Exam #3 Right Heart Valves Flashcards
Views for TV (4)
- RV inflow
- parasternal short-axis at the base
- apical 4 chamber
- subcostal 4 chamber
Causes of Tricuspid Stenosis (6)
- rheumatic heart disease (90%)
- systemic lupus erythmatosus
- carcinoid heart disease
- loefller’s endocarditis
- metastatic melanoma
- congenital heart disease
Rheumatic MV disease can have associated ________________ involvement.
tricuspid valve
This almost never occurs.
ISOLATED rheumatic TV stenosis
If TV Stenosis is undetected, it can (3)
- increase operative morbidity and mortality in patients having left heart valve disease
- chronic elevation of RA pressure
- low cardiac output even if left heart valves are repaired
What does M-mode for rheumatic TV stenosis look like? (3)
- diminished EF slope
- anterior displacement of posterior leaflet
- thickening of valve leaflets and apparatus
Associated findings with tricuspid stenosis (5)
- RAE
- IAS bows to the left from high RA pressure
- Dilated IVC
- Pulmonary hypertension
- right ventricular hypertrophy
can cause diminished EF slope
pulmonary hypertension and right ventricular hypertrophy
what is the 2D criteria for TV stenosis (4)
- 2D criteria more reliable
- doming of TV leaflets in diastole, more toward the tips of leaflets
- thickening and reduced excursion of the posterior or septal leaflets, or both
- reduced tricuspid orifice diameter relative to annulus diameter in same plane
What can obstruct RV inflow and mimic TV stenosis? (3)
- RA tumors
- Large vegetations
- Large atrial thrombus - can be result of embolization from venous bed
Describe Doppler of TS
- Higher diastolic velocity than normal
- Decreased EF slope
- Turbulent flow
- Prolonged reduction in velocity throughout diastole
- Increased “a” wave on hepatic vein flow
Describe TV Velocities (2)
- With TR, TV velocities usually not higher than 0.7 m/sec
- With TV stenosis the velocities are > 1.0 m/sec
What is the only proven quantifiable data for grading TV stenosis?
Quantifiable data - peak velocities, peak gradient, mean gradient
(Can’t get planimetry and PHT number validity has not been proven)
If you were using PHT to grade TV Stenosis, the formula for TVA would be
190 / PHT
carcinoid heart disease results from what. These are found where?
results from the presence of carcinoid tumors, tumors are found mostly in the GI tract
carcinoid tumors produce something particular. what is it?
produce vasoactive substance that causes endothelial damage to right side of heart
6 characteristics of carcinoid tumors/heart disease
- primary tumors can be small
- can involve heart and cause liver mets
- heart is affected late in the disease progression
- half of patients with carcinoid syndrome have cardiac involvement
- elevated venous pressure
- systolic and diastolic murmurs
6 clinical symptoms of carcinoid heart disease
- facial flushing with stimuli
- abdominal pain
- diarrhea
- renal failure
- hepatic failure
- hepatomegaly in later stages
*pulsing jugular veins in neck is REALLY BAD… LOOK at your patients!
2D appearance of carcinoid heart disease (6)
- RVE
- Abnormal septal motion indicating RVVO
- thickened TV leaflets that are retracted
- foreshortened chordae
- thickened retracted PV cusps
- TV leaflets don’t coast completely and remain open throughout cardiac cycle - resulting in STENOSIS and HUGE regurg
Doppler signs of carcinoid heart disease (4)
- TR (most prevalent finding)
- increased diastolic TV velocities
- increased diastolic PV velocities
- pulmonary insufficiency
Echo findings of carcinoid heart disease (2)
- similar to rheumatic TV stenosis
- rheumatic disease would have left sided valvular involvement, carcinoid disease will not
TR is caused by 2 mechanisms:
- secondary to right heart chamber abnormalities (RAE, RVE, RV infarction)
- actual tricuspid valve disease
Abnormal right heart - right atrial enlargement (2)
- dilation of tricuspid valve annulus
- prevents complete leaflet closure
Abnormal right heart - right ventricular enlargement (2)
- associated with CONDITIONS that cause RV volume / pressure overload such as
- aortic valve disease
- mitral valve disease: especially MV stenosis because it causes left sided pressure increase resulting in pulmonary hypertension
TR Causes (4)
- pacer wire in the right heart
- cardiac transplant
- tricuspid valve disease
- Right ventricle infarction
tricuspid regurgitation caused by right ventricle dilatation, caused by (2)
- congenital heart disease such as partial anomalous venous return
- RVVO which alters TV apparatus
tricuspid regurgitation caused by right ventricle infarction (1)
- involves posterior papillary muscle - attaches to posterior and septal leaflets of TV, affecting 2 leaflets
tricuspid valve disease (7)
- rheumatic tricuspid valve disease
- tv prolapse
- endocarditis
- ruptured papillary muscles or chordae
- carcinoid heart disease
- trauma
- congenital defects of TV - TV dysplasia or Ebstein’s anomaly
Ebstein’s Anomaly is
displacement of the attachment of the TV leaflets toward the apex
Physical findings with tricuspid regurgitation (4)
- jugular venous distention with prominent v wave
- jaundice
- thrill (lower left sternal border)
- hyper dynamic RV impulse along left sternal border
color assessment of tricuspid regurg
1/3 into RA = mild TR (1+)
2/3 into RA = moderate TR (2+)
fills RA = severe TR (3+)
all the way to back wall (4+)
**assessment is the ratio of RA area to the jet area
hepatic vein and IVC flow
- flows into RA during systole
- pressure falls with atrial relaxation
Color Doppler shows what characteristics in severe TR?
- retrograde flow in hepatic veins and IVC
- systolic flow reversal
TR severity… what are the reasons for determining tricuspid regurg severity? (2)
- deciding to repair or replace TV in patients having other cardiac surgeries
- determining systolic pulmonary pressures (THE MOST COMMON REASON)
SPAP = RSVP as long as
NO STENOSIS on PV
(SPAP is systolic PA pressures)
(RVSP is right ventricular systolic pressure)
For pressure gradients at TV (2)
- Use CW in presence of high velocities or aliasing
- calculate pressure using Bernoulli equation (4V2)
SPAP or RVSP values (4)
- add RA pressure (which is equal to jugular venous pressure) to peak TR gradient
- normal RA pressures range from 10-14 mmHg
What is the caval index?
the maximum diameter - minimum diameter DIVIDED BY maximum diameter = percent of change
**It is how much the IVC collapses
alternate calculation method for systolic PA pressure
(TV PG x 25% + TR gradient)
TV prolapse (3)
- buckles into RA
- common to see with MVP
- use RV inflow view or apical 4-chamber to visualize
TV endocarditis (2)
- rare… veggies are rare here too
- usually seen with IV drug use, alcoholism, congenital defects (ex VSD)
Clinical SBE findings (3)
- temperature > 100 degrees
- murmurs of TR and PI
- positive blood cultures (usually staph)
2D SBE findings (4)
- dense mass
- highly mobile
- shaggy appearance of entire valve
- polypoid structure attached to single leaflet
differential diagnosis for TV SBE
- myxoma - attach to IAS by stalk
- vegetations - move with valve during cardiac cycle
difference between myxoma and vegetations
vegetations move with valve during cardiac cycle
Complications of SBE (2)
- TR
- Flail tricuspid valve
Pulmonic valve disease best seen from (2)
left parasternal short axis view
subcostal short-axis view
3 types of pulmonic valve stenosis
valvular
supravalvular
subvalvular
2 major forms of pulmonic valve stenosis
- bicuspid pulmonary valves
- dysplastic pulmonary valve (didn’t form properly)
Congential PV Stenosis - bicuspid valve (4)
- doming of the valve in systole
- fusion of the raphe
- usually post stenotic dilation of the PA
- balloon valvuloplasty can correct
Dysplastic pulmonary valve (3)
- severely thickened valve tissue
- immobile cusps from thickened myxomatous tissue
- associated with Noonan’s syndrome which includes dysmorphic features (PEDS)
Supravalvular pulmonary stenosis of (3)
- occur in any part of the PA
- stenotic segment may be localized or diffuse and may involve multiple areas
- can be difficult to diagnose with TTE if peripheral arteries are involved
Subvalvular pulmonary stenosis (3)
- occurs at infundibular level
- usually part of a more complex congenital disease
- isolated subvalvular stenosis may occur from obstruction of a windsock VSD bulging into RVOT
or SOV aneurysm
Pulmonic regurgitation (2)
- turbulent flow into RVOT during diastole
- clinical significance is not known
