Methods

The study subjects were selected from healthy patients referred to our cardiology service for evaluation of a heart murmur or a family history of heart disease. The study group consisted of 860 pediatric patients (431 males and 429 females) with normal echocardiographic findings. For the purposes of the present study, only echocardiograms with completely normal findings, with the exception of a patent foramen ovale with a diameter of ≤2 mm and trivial left/right shunting, were accepted. All patients with congenital heart disease, acquired heart disease, or chromosomal syndromes were excluded from the analysis. The subjects were examined in an at rest state without previous sedation. The infants were allowed to be bottle fed during the examination.

Echocardiography was performed using a commercially available echocardiographic system (Sonos iE33, Philips, Andover, Massachusetts) with transducers of 5-1, 8-3, and 12-4 MHz, depending on patient size. The images were recorded digitally and later analyzed by 1 of us (M.K.) using off-line software (Xcelera Echo, Philips Medical Systems, Eindhoven, The Netherlands).

Pulsed wave-TDI of the lateral tricuspid annulus was performed using transducer frequencies of 2.5 to 3.5 MHz, with spectral Doppler filters adjusted to a Nyquist limit of 15 to 20 cm/s. The minimal optimal gain setting was used. Doppler measurements were acquired with the subjects in the left lateral decubitus position during shallow respiration. Guided by the 4-chamber view, a 5-mm sample volume was placed at the lateral corner of the tricuspid annulus at the attachment of the anterior leaflet of the tricuspid valve. Care was taken to obtain an ultrasound scan as parallel as possible to the direction of the tricuspid annular motion. The peak annular velocities during systole were recorded and analyzed off-line. The resulting velocities were recorded for 3 to 5 cardiac cycles and averaged.

TAPSE was measured using 2-dimensional echocardiographically guided M-mode recordings from the apical 4-chamber view with the cursor placed at the free wall of the tricuspid annulus, as previously described. Care was taken to align the sample volume as vertically as possible with respect to the cardiac apex. Angle correction and respiratory gating were not used. The maximum TAPSE was determined by the total excursion of the tricuspid annulus from its highest position after atrial ascent to the lowest point of descent during ventricular systole. Portions of the TAPSE values used in the present analysis were included in a previous study. The investigation of both TAPSV and TAPSE was performed with the subject in a quiet state.

All data were measured from 3 well-trained observers (M.K., B.H., and B.N.) from 5 consecutive beats and averaged, as previously recommended. For data analysis, the Statistical Package for Social Sciences, version 18 (SPSS, Chicago, IL) was used. The data are presented as the mean ± 2 SD. In a first step, the correlation structure among age, BSA, and TAPSV was analyzed with Pearson’s correlation coefficient. A stepwise linear multiple regression analysis was used to estimate the TAPSV from the age, BSA, and gender. The inter- and intraobserver variability were computed for TAPSV, with an intraclass correlation coefficient of 0.97 (95% confidence interval 0.94 to 0.99; p <0.001) and 0.98 (95% confidence interval 0.96 to 0.99; p >0.001). Our intraobserver and interobserver variability were similar to those reported for TAPSV.

The present study complied with all institutional guidelines related to patient confidentiality and research ethics, including institutional review board approval (EK-Nr 23-048, ex. 10/11). There were no financial or other potentially conflicting relations to report.

Results

A representative image of the TAPSV in a neonate and a 15-year-old adolescent, respectively, with normal RV and left ventricular function is shown in Figure 1 . The study group encompassed neonates to adolescents (age 1 day to 18 years; BSA 0.14 to 2.30 m ² ), including 83 newborns and 255 infants.

Apical 4-chamber view. White broken line indicates M-mode cursor placement at tricuspid lateral annulus. Representative image of TDI-measured TAPSV in neonate (A), 15-year-old adolescent (B), and M-mode measured TAPSE (C) in 16-year-old adolescent, with normal RV and left ventricular function. Red line indicates absolute longitudinal displacement measure; yellow arrow marks upper and lower measure points in centimeters (C) .

The TAPSV ranged from a mean of 7.2 cm/s (z score ± 2: 4.8 to 9.5 cm/s) in the newborn to 14.3 cm/s (z score ± 2: 10.6 to 18.6 cm/s) in the 18-year-old adolescent. Significant correlations were found between TAPSV and age (r = 0.700, p <0.001; Figure 2 ) and TAPSV and BSA (r = 0.720, p <0.001; Figure 3 ) . The TAPSV values increased from neonates to adolescents nonlinearly. The stepwise multiple regression analysis revealed that 64.9% of the variance in TAPSV could be explained by age alone. The addition of BSA (p = 0.003, partial correlation r = 0.10) allowed for 65.3% of the variance in TAPSV to be predicted. These results showed that adding BSA resulted in only a minor increase in the explained variance (0.4%). No additional information was found by adding gender (p = 0.960, partial correlation r = −0.002). The regression equation relating age and TAPSV is as follows:

Age versus mean TAPSV value ± 2 SD and ± 3 SD z scores for age versus TAPSV. Black solid line indicates mean; black dashed line with circles and black dashed line with squares indicate z score ± 2 SD and z score ± 3 SD, respectively.

BSA versus mean TAPSV value ± 2 SD and 3 SD z scores for BSA versus TAPSV. Black solid line indicates mean; black dashed line with circles and black dashed line with squares indicate z score ± 2 SD and z score ± 3 SD, respectively.

To calculate the z scores, the residual SD of 1.57 was used. Age-related z scores ± 2 SD and ± 3 SD for TAPSV are listed in Table 1 . Graphs demonstrating the mean value ± 2 SD and ± 3 SD z scores for TAPSV versus age and TAPSV versus BSA are presented in Figures 2 and 3 , respectively.

Table 1

Classification table for TAPSV values of our healthy subjects

Age	Subjects (n)	TAPSV					BSA
		Mean	−2 SD	+2SD	−3 SD	+3 SD	Mean	Minimum	Maximum
1 month	83	7.2	4.8	9.5	3.6	10.7	0.22	0.14	0.34
2 months	34	8.5	6.5	10.5	5.5	11.5	0.25	0.22	0.31
3 months	18	8.7	6.3	11	5.1	12.2	0.27	0.19	0.33
4 months	28	9.1	6.3	11.8	4.9	13.2	0.29	0.19	0.37
5 months	11	9.8	6.4	13.2	4.7	14.9	0.32	0.24	0.38
6 months	9	9.1	7.5	10.6	6.7	11.4	0.31	0.27	0.4
7 months	18	9.5	7.3	11.8	6.1	12.9	0.35	0.28	0.41
8 months	8	9.7	6.4	12.9	4.7	14.6	0.37	0.32	0.45
9 months	9	9.9	6.4	13.4	4.7	15.1	0.39	0.34	0.44
10 months	13	10.6	8.1	13.1	6.9	14.4	0.4	0.28	0.48
11 months	11	11.1	8.1	14.1	6.6	15.6	0.37	0.24	0.47
12 months	13	11	7.7	14.4	6	16.1	0.39	0.3	0.47
2 years	55	11.4	8.7	14	7.4	15.4	0.51	0.37	1.02
3 years	34	11.7	8.3	15.1	6.6	16.9	0.58	0.47	0.7
4 years	38	12.2	9.3	15	7.9	16.4	0.64	0.4	0.82
5 years	43	12.3	9.4	15.2	8	16.6	0.72	0.56	0.84
6 years	43	12.4	9.6	15.3	8.2	16.7	0.79	0.67	1
7 years	33	12.6	9.7	15.4	8.3	16.8	0.87	0.67	1.18
8 years	40	12.7	9.8	15.6	8.3	17	0.95	0.74	1.39
9 years	25	12.5	9.5	15.5	8	17.1	1.02	0.77	1.47
10 years	23	12.8	10.4	15.2	9.2	16.4	1.22	1.08	1.47
11 years	28	13.1	10.3	15.9	9	17.3	1.31	1	2
12 years	33	12.9	9.9	16.4	7.6	18.2	1.42	1.03	1.75
13 years	25	13.2	10.7	15.8	9.4	17.1	1.51	1.06	1.87
14 years	29	13.3	10	17.7	6.6	19.9	1.57	0.83	1.98
15 years	37	13.8	10.5	17.1	8.9	18.8	1.66	1.37	2.07
16 years	37	14.1	10.1	18.1	8.1	20.1	1.7	1.3	2.06
17 years	43	14	10.1	17.9	8.2	19.8	1.79	1.45	2.3
18 years	39	14.3	10.7	17.9	8.9	19.8	1.71	1.4	2.05

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