The prognostic value of tricuspid valve annular motion in large malignant pericardial effusions

Background and objectives: Although collapsing of the right atrium (RA) and/or right ventricle (RV), as far as flow velocity paradox through the tricuspid valve (TV), are common findings in the echocardiogram (ECHO) of threatened tamponade, their prognostic value remains controversial. We investigated whether an interrogation of the TV annular motion offers any additional prognosticators in cases of large malignant pericardial effusions (PE). Subjects and methods: 96 patients with newly diagnosed lung cancer and neoplastic PE, not in clinical tamponade, underwent a respirophasic conventional and tissue Doppler imaging (TDI) of the TV annulus. Ra and RV collapsing, TV flow velocity paradox, TV annular plane systolic excursion (TAPSE), and TV annular velocities Sa, Ea, Aa were assessed. In a period of one month, 37 patients (group A) developed clinical tamponade, versus 59 patients (group B) who did not. The independent value of each ECHO parameter in predicting tamponade was estimated by univariate and multivariate analysis. Results: Collapsing of Ra and RV were more frequent in group A (84% vs 69% and 41% vs 20% respectively), whereas the trans-tricuspid flow velocity paradox was similar in both groups. TAPSE and Sa were higher in group A (p < 0.001). The velocities Ea and Aa demonstrated an excessive respirophasic fluctuation (ΔEa and ΔAa), with inspiratory increase and expiratory decrease. ΔEa and ΔAa were higher in group A (p < 0.001). In multivariate analysis, TAPSE, expiratory Ea and Aa, as well as ΔAa, were independent predictors of tamponade. Conclusion: Large neoplastic PE manifest an enhanced longitudinal motility of TV annulus. Early progression to tamponade is likely, and parameters deriving from the TDI of the RV free wall present considerable predictive value.