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Echo 2 > Module 8 : Tricuspid and Pulmonary Stenosis > Flashcards

Module 8 : Tricuspid and Pulmonary Stenosis Flashcards

1
Q

what 5 things does the tricuspid valve complex include

A
  • TV annulus
  • three leaflets (septal, anterior, posterior)
  • chordae tendinae
  • two discrete pap muscles and one rudimentary pap (moderator band)
  • RV myocardium
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2
Q

what are the three TV commissures

A
  • the anteroseptal commissure = between anterior and septal
  • the anteroposterior = between anterior and posterior leaflets
  • the posteroseptal commissure = between posterior and septal leaflet
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3
Q

definition of TV stenosis

A
  • obstruction of blood flow from the RA across the tricuspid valve into the RV
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4
Q

what are the two different aetiologies of TV stenosis

A
  • congenital or acquired
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5
Q

what are the congenital causes of TS associated with and what does it include

A
  • associated with other congenital cardiac defects

- various malformation of TV valve complex

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6
Q

what are 4 examples of congenital causes of TS

A
  • mal developed leaflets
  • shortened chordae tendinae
  • annular hypoplasia
  • abnormalities of pap muscles
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7
Q

what are 2 acquired causes of TS

A
  • rheumatic vale disease

- carcinoid heart disease

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8
Q

what is the most common acquired cause of TS

A
  • rheumatic valve disease
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9
Q

when does rheumatic valve disease occur

A
  • several years after the initial beta-hemolytic streptococcus infection as an autoimmune response
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10
Q

what do the changes look like with rheumatic valve disease of the TV

A
  • resemble MS
  • thickened, fibrotic, fused leaflets and chordae
  • diastolic doming of leaflets
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11
Q

what is carcinoid heart disease caused by

A
  • rare MALIGNANT NEUROENDOCRINE TUMOR
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12
Q

how does the carcinoid tumour damage the valves

A
  • tumor secretes serotonin which damages both the tricuspid and pulmonary valve
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13
Q

what does carcinoid heart disease look like and what does the plaque cause

A
  • milky white plaque deposits on endocardial surfaces and myocardium
  • causes valves and chordae to become thickened, retracted and rigid
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14
Q

if you see a stenotic PV and TV what is the most likely cause

A
  • carcinoid heart disease
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15
Q

with carcinoid TV stenosis will there be stenosis or regurge

A
  • both
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16
Q

what are 4 other causes of TS

A
  • cor triatriatum dexter (perforates membrane in RA)
  • large TV vegetation
  • right heart thrombus
  • right heart tumors
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17
Q

what is the pathophysiology of TS

A
  • 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
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18
Q

what are 4 clinical manifestations of TS

A
  • systemic venous congestion
  • jugular venous distention (elevated jugular venous pulse)
  • ascites
  • peripheral edema
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19
Q

what are 3 symptoms of TS

A
  • fatigue
  • abdominal discomfort
  • abdominal swelling
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20
Q

what are the 6 jobs of echo with TS

A
  • determine etiology
  • asses RA size
  • asses RV size and function
  • estimate severity and stenosis
  • estimate RVSP
  • identify associated valve lesions
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21
Q

how do you determine between an etiology of carcinoid heart disease and rheumatic heart disease as TS

A
  • carcinoid HD often involves pulmonary valve
  • rheumatic heart disease always involves the MV
  • carcinoid will never involve the MV
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22
Q

what does chronic elevation of RA pressure lead to

A
  • dilation of RA
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23
Q

what is normal RA area

A

< 18 cm ^2

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24
Q

what is normal RA length

A

< 5.3cm

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25
Q

what is normal RA width

A

< 4.4cm

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26
Q

normal female RAVI

A

< 27 ml/m^2

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27
Q

normal male RAVI

A

< 32 ml/M^2

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28
Q

what is normal RV base

A

< 41mm

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29
Q

what is normal RV mid

A

< 35mm

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30
Q

what is normal RV length

A

< 86mm

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31
Q

what is normal TAPSE

A

> 17mm

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32
Q

what is normal S’ for RV

A

> 9.5cm/s

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33
Q

what is normal RV FAC

A

> 35%

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34
Q

what is normal RIMP

A

< 0.44

35
Q

what are the 3 measurements of RV size

A
  • RV base
  • RV mid
  • RV length
36
Q

what are the 4 measurements of RV function

A
  • TAPSE
  • S prime
  • FAC
  • RIMP
37
Q

what are the 4 methods to assess TS severity with doppler

A
  • mean TV pressure gradient
  • tricuspid inflow velocity time integral
  • TV pressure half time
  • tricuspid valve area
38
Q

which view is the mean TV pressure gradient measured

A
  • measured from the view which is most parallel to TV inflow jet
    + PLAX RVIT
39
Q

what does tracing the TB inflow envelope give us

A
  • VTI

- mean gradient

40
Q

is the mean or peak velocity more useful

A
  • mean gradient
41
Q

what are the 2 reasons that mean gradient is better than peak velocity

A
  • more than 1 peak during diastolic cycle

- diastolic cycle is longer than systolic cycle

42
Q

what does the diastolic slope represent on the spectral trace

A
  • PG between the R and RA during diastole
43
Q

what is the TV pressure half time a measurement of

A
  • time it takes for the early diastolic pressure gradient to fall to half its original value
44
Q

what is a limitation to P 1/2 T

A

tachycardia (E and A waves fuse)

45
Q

what is normal velocity floe profile for the TV

A
  • low velocity profile

- rapid short deceleration time

46
Q

what is the TVA equation

A

TVA = (CSAlvot x VTIlvot) / VTItv

47
Q

what is normal TVA

A

6-7cm^2

48
Q

what are 3 limitations to the TVA

A
  • 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
49
Q

what measurement of mean gradient represents severe TS

A

> /= 5mmHg

50
Q

what measurement of inflow VTI represents severe TS

A

> 60cm

51
Q

what measurement of pressure half time represents severe TS

A

> 190ms

52
Q

what measurement of TVA represents severe TS

A

= 1cm^2

53
Q

what are 2 supportive findings of severe TS

A
  • enlarged RA

- dilated IVC

54
Q

does TR affect preload

A
  • yes

- will alter continuity equation

55
Q

what is the treatment for TS

A
  • surgical debunking of tumor or vegetation
  • diuretics, nitrates to relieve venous congestion
  • transvenous balloon valvuloplasty
56
Q

what are the components of the PV

A
  • annulus
  • cusps
  • commisures
  • interleaflet triangles
57
Q

what are the names of the PV cusps and what do they correspond too

A
  • left
  • right
  • anterior
58
Q

what is the infundibulum

A
  • PV not supported by IVS (not in fibrous continuity) but has a muscular ring
59
Q

what are the components of the pulmonary root

A
  • annulus
  • sinus
  • STJ
  • main PA
60
Q

where does the main PA lie in relation to the aorta

A
  • anterior and bifurcates into left and right 4-5cm distal to PV
61
Q

what are the 4 levels of the PV that can become obstructed

A
  • subvalvular (infundibular)
  • valvular
  • supravalvular
  • LPA or RPA
62
Q

what is the usual etiology of PS

A
  • almost always congenital
63
Q

what are the three types of congenital PS

A
  • typical domed shape PV
  • dysplastic PV
  • unicuspid or bicuspid PV
64
Q

what is typical domed shaped PV

A
  • preserved valve mobility with reduced central orifice
65
Q

what is dysplastic PV

A
  • trileaflet valve with severe thickening and reduced mobility
  • noonans syndrome
66
Q

what is unicuspid or bicuspid PV

A
  • fusion at commisures

- bicuspid may be associated with tetralogy of fallout

67
Q

what are the 8 causes of acquired PS

A
  • rheumatoid HD
  • carcinoid HD
  • extraneous TV tissue
  • PV sinus of valsalva aneurysm
  • IVS aneurysm
  • hypertrophic cardiomyopathy
  • tumors, trombus, vegatation
  • post ross procedure
68
Q

what are the 6 roles of echo in PS

A
  • determine site of obstruction
  • assess valve morphology
  • assess RV function and size
  • estimate severity of PS
  • measure PV annulus
  • estimate pulmonary artery pressures
69
Q

what should we look for other than just the measurements when assessing RV size with PS

A
  • look for hypertrophy from high afterload
70
Q

what are the 2 criteria used to assess severity

A
  • peak PV velocity

- maximum gradient

71
Q

what peak velocity indicates mild PS

A

< 3 m/s

72
Q

what peak velocity indicates moderate PS

A

3-4 m/s

73
Q

what peak velocity indicates severe PS

A

> 4 m/s

74
Q

what maximum gradient indicates mild PS

A

< 36mmHg

75
Q

what maximum gradient indicates moderate PS

A

36-64 mmHg

76
Q

what maximum gradient indicates severe PS

A

> 64 mmHg

77
Q

what is the relationship between peak velocity and max gradient with PS

A

max gradient increases peak velocity increases

78
Q

what view is the best for measuring PV annulus

A

PSAX RVOT

  • use color to help see borders
79
Q

in the absence of an RVOT obstruction what pressure is the RVSP pressure equal to

A

pulmonary artery systolic pressure

PASP

80
Q

if there is an RVOT obstruction which pressure will be higher

A

RVSP> PASP

81
Q

what is the formula to calculate PASP in the presence of a mild or moderate RVOT obstruction

A

PASP = RVSP - mPG pv

82
Q

what is the formula to calculate PASP in the presence of a critical RVOT obstruction

A

PASP = RVSP - MIPG pv

83
Q

what shape will the spectral trace have with mild PS

A

v shaped

- early peaking

84
Q

what shape with the spectral trace have with critical PS

A
  • rounded parabolic shape

Echo 2 (18 decks)

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