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Echo 2 > C11: TV And PV Regurg > Flashcards

C11: TV And PV Regurg Flashcards

1
Q

3 subgroups of TR

A
  1. Functional or secondary
  2. Organic or primary causes
  3. Mechanical causes
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2
Q

How do functional causes of TR cause regurg

what can cause this

A

by causing annular dilation, usually the TV leaflets have normal structure

dilated cardiomyopathy
ASDs
pulmonary hypertension

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3
Q

How do organic causes of TR cause regurgitation

A

By causing disorders of the TV complex

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4
Q

Possible causes of mechanical TR

A

Pacemaker leads

Implantable cardioverter debrillator leads

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5
Q

If rheumatic is affecting the TV, are other valves often affected

Which other valves are usually affected

A

Yes, it rarely occurs it isolation w/ only the TV

MV and/or the AV

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6
Q

US appearance of TV w/ rheumatic

Where does the thickened go start

A

Thickened and retraction of TV leaflets
TV diastolic doming (stenosis)
Dilation of the TV annulus (causes regurgitation)

Leaflet tips

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7
Q

Describe TR due to carcinoid HD

Causes

A

Rare malignant neuroendocrine tumor that secretes excessive amount of serotonin w/ damages right heart valves

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8
Q

US of TV w/ carcinoid

A

TV becomes thickened, retracted and rigid

You’ll see both stenosis and regurg…. value remains in a fixed, semi-open position, throughout the cardiac cycle

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9
Q

Key difference b/w carcinoid and rheumatic

A

Involvement of the MV/AV w/ rheumatic…. with carcinoid the PV will be involved and left heart if not effected

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10
Q

Why is the TV more susceptible to injury than the MV

A

RV is easier to compress making the Tv more susceptible

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11
Q

What type of TR does trauma cause

A

Acute TR

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12
Q

Describe TV prolapse

A

Systolic bowing of the belly of the leaflets into the RA during systole

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13
Q

TVP usually occurs with what other pathology of the L heart

A

MVP

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14
Q

Describe Ebsteins anomaly

4 main characteristics

A

A congenital malformation of the TV leaflets

  1. Adhesion of the septal and post leaflets to the myocardium
  2. Exaggerated apical displacement of the septal leaflet
  3. Atrialization and dilation of a portion of the RV inflow tract
  4. Small functional RV
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15
Q

What does exaggerated apical displacement of the TV septal leaflet cause

A

Leaflets cant coapt which leads to TR

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16
Q

Ebsteins anomaly is associated w/ which other abnormalities

A
  • PFO or ASD
  • Congenitally corrected transposition of great vessels
  • VSDs
  • hypoplastic pulmonary artery
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17
Q

How can Ebsteins affect the development of conduction pathways

What can this lead to

A

May lead to maldevelopment of the conduction pathway from the atria to the ventricles…..

… Wolfe-Parkinson White syndrome

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18
Q

What is Wolfe-Parkinson White syndrome

A

Early scoop of the QRS complex

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19
Q

Criteria for diagnosing Ebsteins anomally

To which insertion point should you compare it

A

TV septal leaflet displaced apical >2 cm

MV in the A4CH view

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20
Q

How can Ebsteins affect the movement and appearance of the anterior and septal TV leaflets

A

Anterior may have restricted motion

Septal may have whip-like motion and be longer w/ redundant tissue?

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21
Q

what should you always assess for w/ spectral doppler if the patient has ebsteins

A

ASD or PFO w/ colour and PW

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22
Q

if theres an IAS w/ ebsteins, how might the direction be different

what is this called

A

shunt direction may be from right to left instead of left to right due to increased right heart press from TR

Eisenemnger’s

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23
Q

w/ ebsteins how will the bowing of the IVS change

A

will be to the LV…. the L heart will look squished

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24
Q

common causes of annular dilation of the TV leading to functional TR

A

dilated cardiomyopathy
ASDs
pulmonary hypertension

ASD can cause pulmonary hypertension

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25
Q

how do large ASDs affect the right heart

A

larger ASDs can have significant shunts of > 50% to the R heart which causes the R heart chambers to dilate

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26
Q

chronic, severe pulmonary hypertension (PHT) is associated w/ dilation of which structures

A

RV and TV annulus

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27
Q

what happens to the TV leaflets as the pap muscles in the RV migrate away from the TV annulus

A

tenting and lack of coaptation

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28
Q

does TR peak velocity reflect the severity of the TR?

A

no

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29
Q

what does TR peak velocity reflect

A

press difference b/w the RV and RA during systole

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30
Q

does severe TR usually have a high or low velocity jet

A

usually low, because of the larger opening of the TV which will lower the PG b/w the RV and RA

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31
Q

w/ RV volume overload, when will you see the “D” sign of the LV is short axis

A

only during systole

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32
Q

w/ RV pressure overload, when will you see the “D” sign of the LV is short axis

common cause of press overload

A

throughout the entire cardiac cycle

lung damage

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33
Q

does volume overload often lead to press overload

A

yes

34
Q

severe/progressive TR will show what signs

A 
signs of RHF:
increased JVP
hepatomegaly
peripheral edema
ascites
35
Q

3 ways we indirectly estimate the severity of TR w/ colour doppler

A
  1. colour jet are
  2. vena contracta width
  3. flow convergence radio (PISA)
36
Q

4 ways we indirectly estimate the severity of TR w/ spectral doppler

A
  1. TV inflow (PW)
  2. hepatic vein profile (reversal during systole)
  3. Intensity of TR signal
  4. TR jet contour
37
Q

2 quantitative parameters to assess severity of TR

A
  1. regurgitant volume
  2. effective regurg orifice area

BOTH USING PISA TR

38
Q

limitations of colour doppler for TR severity

A
  • overestimation of TR jet:
  • jet displaces blood already sitting in the chamber…. trace only the aliased area
  • over gained
  • underestimation of TR jet:
  • occurs w/ eccentric jets which hug the atrial wall
  • severe lack of coaptation leads to huge hole in the TV and leads to only dark blue colour jet due to lower velocity (wont be aliased)
39
Q

what is it called when an eccentric jet hugs the atrial wall

A

coanda effect

40
Q

how do we determine the TR jet area

A

trace around the aliased part of the jet in systole, dont not trace any dark blue (represents the displaced blood)

41
Q

value for mild TR jet area

severe

A

Mild: < 5 cm^2

severe: >10 cm^2

42
Q

value for mild TR vena contracta

severe

A

mild: < 3mm (use MR value)
severe: > 7 mm

43
Q

can you use the vena contracta and PISA method when there are multiple jets

A

no

44
Q

in which views can you measure vena contracta for TR

A

RVIT or 4CH

should zoom

45
Q

in which views can you measure PISA for TR

how do you do it

A

A4CH

zoom and lower colour scale to 28 cm/s

46
Q

value for PISA for mild TR

severe

A

mild: = 0.5 mm
severe: >/= 9 mm

47
Q

how will the TV inflow change w/ TR

velocity over what value could indicate severe TR

A

velocity of the inflow will increase, as well as volume since the volume from the TR is also going through the valve

> 1 m/s for the E wave: called E wave dominant

48
Q

how will the HV flow profile change with TR

A

you will see reversal in later systole… w/ at least moderate TR, and the flow becomes diastolic dominant

49
Q

is reversal in the HV sensitive or specific to severe TR

A

sensitive…. b/c there are other causes of HV systolic flow reversal

50
Q

why does the liver get enlarged w/ TR

A

theres less forward flow in the the IVC, blood backs up into the liver

51
Q

technical factors that limit the accuracy of TR CW brightness to determine severity

A
  1. gain -over-gaining or under-gaining… use inflow as control
  2. doppler angle, get as aligned as possible
52
Q

shape of mild TR w/ CW

why

A

parabolic

b/c the press gradient b/w the RV and RA is maintained throughout all of systole

53
Q

shape of severe TR w/ CW

why

A

triangular with an early peak

the press gradient drops off rapidly throughout systole due to a quick rise in pressure in the RA from the regurg volume.

54
Q

name for the triangular appearance of severe TR

A

V cut off

55
Q

TR peak velocity w/ massive TR

A

< 2 m/s

56
Q

formula for EROA

A

EROA = (2 x pie x r^2 x Vn) / V of TR

57
Q

what does the 2 x pie x r^2 represent in the EROA

A

surface areA of the hemispheric shell derived from flow convergence radius prox to the TV

58
Q

what does the Vn represent in the EROA

A

colour nyquist limit (what the colour scale is set to below the baseline)

59
Q

formula for the regurg volume using the EROA

A

RV = EROA x VTI of TR

60
Q

value for Regurg volume for mild TR

severe

A

mild: < 30 ml
severe: >/= 45

61
Q

value for EROA for mild TR

severe

A

mild: = 0.20 cm^2
severe: >/= 0.40 cm^2

62
Q

2 general causes of PR

A

functional/secondary: causes that lead to annular dilation, and then poor coaptation of the cusps…. PR valve anatomy is normal

organic/primary: PR due to abnormalities of the cusps

63
Q

clinical manifestation of PR

A

symptoms are due to RV volume overload:

dyspnea
peripheral edema
fatigue
increased JVP
liver engorgement
64
Q

etiology of functional PR

A 
RV cardiomyopathy
RV infarction
PHT
Pulmonary artery dilation
congenital heart disease
65
Q

etiology of organic PR

A 
carcinoid
congenital lesions
iatrogenic
rheumatic valve disease
trauma
66
Q

in which view do you want to measure jet width for PR

A

PSAX RVOT due to lateral resolution

67
Q

when do you start to see flow reversal in the main PA w/ PR

what would be a strong indicator of severe PR

A

moderate PR

seeing PR in the R or L pulmonary artery branches… the more distal, the more severe

68
Q

what is the jet width ratio for PR

formula

A

ratio of the width of the PR jet to the RVOT diameter

PR jet width/RVOTd

69
Q

what does a jet width of 0.7 mean

A

the width of the jet is >/= 70% of the RVOT diameter

70
Q

jet width for severe PR

A

> 0.7

71
Q

how does steepness of the PR slow correlate w/ severity

A

steeper the slope = more severe… short decel time that ends before the end of diastole may be severe

72
Q

value for moderate press 1/2 time

severe

A

mod: > 100 ms
severe: < 100 ms

73
Q

why does the PR velocity slow?

A

PA press falls due to regurg back into the RV and inflow into the RV, which equalizes the press b/w the chambers

74
Q

what is the pulmonary regurg index (PRI)

A

a measure of the ratio of the duration of the PR signal to the total duration of diastole.. the earlier the PR signal ends, the more severe the PR, b/c press is equalizing fast

75
Q

values for mild PRI

severe

A

mild: 1
severe: < 0.77

76
Q

when would pre-systolic flow occur w/ PR and why does it happen

A

w/ severe PR or other conditions like RV diastolic dysfunction (RV very stiff)

when the RVEDP exceeds the PA press, forward flow occurs

77
Q

when there is severe PR and we see forward diastolic floe, what do we assume is the cause

A

severe PR

78
Q

when there is PR present, which pressure should we be calculating instead of RVSP

A

PAEDP and mPAP

79
Q

formula for PAEDP and mPAP

A

PAEDP: 4 (v^2) + RAP

mPAP: 4 (v^2) + RAP

80
Q

where are PAEDP and mPAP located

A

mPAP is at the peak diastolic velocity of the PR

PAEDP is at the lowest diastolic velocity of PR

Echo 2 (15 decks)

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