Module 8 : Tricuspid and Pulmonary Stenosis Flashcards
what 5 things does the tricuspid valve complex include
- TV annulus
- three leaflets (septal, anterior, posterior)
- chordae tendinae
- two discrete pap muscles and one rudimentary pap (moderator band)
- RV myocardium
what are the three TV commissures
- the anteroseptal commissure = between anterior and septal
- the anteroposterior = between anterior and posterior leaflets
- the posteroseptal commissure = between posterior and septal leaflet
definition of TV stenosis
- obstruction of blood flow from the RA across the tricuspid valve into the RV
what are the two different aetiologies of TV stenosis
- congenital or acquired
what are the congenital causes of TS associated with and what does it include
- associated with other congenital cardiac defects
- various malformation of TV valve complex
what are 4 examples of congenital causes of TS
- mal developed leaflets
- shortened chordae tendinae
- annular hypoplasia
- abnormalities of pap muscles
what are 2 acquired causes of TS
- rheumatic vale disease
- carcinoid heart disease
what is the most common acquired cause of TS
- rheumatic valve disease
when does rheumatic valve disease occur
- several years after the initial beta-hemolytic streptococcus infection as an autoimmune response
what do the changes look like with rheumatic valve disease of the TV
- resemble MS
- thickened, fibrotic, fused leaflets and chordae
- diastolic doming of leaflets
what is carcinoid heart disease caused by
- rare MALIGNANT NEUROENDOCRINE TUMOR
how does the carcinoid tumour damage the valves
- tumor secretes serotonin which damages both the tricuspid and pulmonary valve
what does carcinoid heart disease look like and what does the plaque cause
- milky white plaque deposits on endocardial surfaces and myocardium
- causes valves and chordae to become thickened, retracted and rigid
if you see a stenotic PV and TV what is the most likely cause
- carcinoid heart disease
with carcinoid TV stenosis will there be stenosis or regurge
- both
what are 4 other causes of TS
- cor triatriatum dexter (perforates membrane in RA)
- large TV vegetation
- right heart thrombus
- right heart tumors
what is the pathophysiology of TS
- TS reduces area of conduit between the RA and RV
- in order to maintain cardiac output the RA pressure rises
- this increases driving pressure across the valve
- this increase in pressure works its way backward into systemic veins
what are 4 clinical manifestations of TS
- systemic venous congestion
- jugular venous distention (elevated jugular venous pulse)
- ascites
- peripheral edema
what are 3 symptoms of TS
- fatigue
- abdominal discomfort
- abdominal swelling
what are the 6 jobs of echo with TS
- determine etiology
- asses RA size
- asses RV size and function
- estimate severity and stenosis
- estimate RVSP
- identify associated valve lesions
how do you determine between an etiology of carcinoid heart disease and rheumatic heart disease as TS
- carcinoid HD often involves pulmonary valve
- rheumatic heart disease always involves the MV
- carcinoid will never involve the MV
what does chronic elevation of RA pressure lead to
- dilation of RA
what is normal RA area
< 18 cm ^2
what is normal RA length
< 5.3cm
what is normal RA width
< 4.4cm
normal female RAVI
< 27 ml/m^2
normal male RAVI
< 32 ml/M^2
what is normal RV base
< 41mm
what is normal RV mid
< 35mm
what is normal RV length
< 86mm
what is normal TAPSE
> 17mm
what is normal S’ for RV
> 9.5cm/s
what is normal RV FAC
> 35%
what is normal RIMP
< 0.44
what are the 3 measurements of RV size
- RV base
- RV mid
- RV length
what are the 4 measurements of RV function
- TAPSE
- S prime
- FAC
- RIMP
what are the 4 methods to assess TS severity with doppler
- mean TV pressure gradient
- tricuspid inflow velocity time integral
- TV pressure half time
- tricuspid valve area
which view is the mean TV pressure gradient measured
- measured from the view which is most parallel to TV inflow jet
+ PLAX RVIT
what does tracing the TB inflow envelope give us
- VTI
- mean gradient
is the mean or peak velocity more useful
- mean gradient
what are the 2 reasons that mean gradient is better than peak velocity
- more than 1 peak during diastolic cycle
- diastolic cycle is longer than systolic cycle
what does the diastolic slope represent on the spectral trace
- PG between the R and RA during diastole
what is the TV pressure half time a measurement of
- time it takes for the early diastolic pressure gradient to fall to half its original value
what is a limitation to P 1/2 T
tachycardia (E and A waves fuse)
what is normal velocity floe profile for the TV
- low velocity profile
- rapid short deceleration time
what is the TVA equation
TVA = (CSAlvot x VTIlvot) / VTItv
what is normal TVA
6-7cm^2
what are 3 limitations to the TVA
- suboptimal alignment to the jet direction
- improper LVOT diameter or VTI measurement
- when significant TR coexists with TS the SV is altered therefore TVA cannot be calculated
what measurement of mean gradient represents severe TS
> /= 5mmHg
what measurement of inflow VTI represents severe TS
> 60cm
what measurement of pressure half time represents severe TS
> 190ms
what measurement of TVA represents severe TS
= 1cm^2
what are 2 supportive findings of severe TS
- enlarged RA
- dilated IVC
does TR affect preload
- yes
- will alter continuity equation
what is the treatment for TS
- surgical debunking of tumor or vegetation
- diuretics, nitrates to relieve venous congestion
- transvenous balloon valvuloplasty
what are the components of the PV
- annulus
- cusps
- commisures
- interleaflet triangles
what are the names of the PV cusps and what do they correspond too
- left
- right
- anterior
what is the infundibulum
- PV not supported by IVS (not in fibrous continuity) but has a muscular ring
what are the components of the pulmonary root
- annulus
- sinus
- STJ
- main PA
where does the main PA lie in relation to the aorta
- anterior and bifurcates into left and right 4-5cm distal to PV
what are the 4 levels of the PV that can become obstructed
- subvalvular (infundibular)
- valvular
- supravalvular
- LPA or RPA
what is the usual etiology of PS
- almost always congenital
what are the three types of congenital PS
- typical domed shape PV
- dysplastic PV
- unicuspid or bicuspid PV
what is typical domed shaped PV
- preserved valve mobility with reduced central orifice
what is dysplastic PV
- trileaflet valve with severe thickening and reduced mobility
- noonans syndrome
what is unicuspid or bicuspid PV
- fusion at commisures
- bicuspid may be associated with tetralogy of fallout
what are the 8 causes of acquired PS
- rheumatoid HD
- carcinoid HD
- extraneous TV tissue
- PV sinus of valsalva aneurysm
- IVS aneurysm
- hypertrophic cardiomyopathy
- tumors, trombus, vegatation
- post ross procedure
what are the 6 roles of echo in PS
- determine site of obstruction
- assess valve morphology
- assess RV function and size
- estimate severity of PS
- measure PV annulus
- estimate pulmonary artery pressures
what should we look for other than just the measurements when assessing RV size with PS
- look for hypertrophy from high afterload
what are the 2 criteria used to assess severity
- peak PV velocity
- maximum gradient
what peak velocity indicates mild PS
< 3 m/s
what peak velocity indicates moderate PS
3-4 m/s
what peak velocity indicates severe PS
> 4 m/s
what maximum gradient indicates mild PS
< 36mmHg
what maximum gradient indicates moderate PS
36-64 mmHg
what maximum gradient indicates severe PS
> 64 mmHg
what is the relationship between peak velocity and max gradient with PS
max gradient increases peak velocity increases
what view is the best for measuring PV annulus
PSAX RVOT
- use color to help see borders
in the absence of an RVOT obstruction what pressure is the RVSP pressure equal to
pulmonary artery systolic pressure
PASP
if there is an RVOT obstruction which pressure will be higher
RVSP> PASP
what is the formula to calculate PASP in the presence of a mild or moderate RVOT obstruction
PASP = RVSP - mPG pv
what is the formula to calculate PASP in the presence of a critical RVOT obstruction
PASP = RVSP - MIPG pv
what shape will the spectral trace have with mild PS
v shaped
- early peaking
what shape with the spectral trace have with critical PS
- rounded parabolic shape
