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Echo 2 > Module 9 : Tricuspid and Pulmonary Regurgitation > Flashcards

Module 9 : Tricuspid and Pulmonary Regurgitation Flashcards

1
Q

what is the definition of tricuspid regurgitation

A
  • backward flow of blood from the RV to the RA during systole
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2
Q

what are the 3 groups of etiology of TR

A
  • functional (primary)
  • organic (secondary)
  • mechanical
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3
Q

what are functional causes of TR

A
  • ANNULAR DILATION
  • afib
  • ASD
  • DCMO
  • PHTN, PR
  • RV dysplasia
  • RV CHF
  • RV infarct
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4
Q

what are the organic causes of TR

A
  • DISORDERS OF THE TV COMPLEX
  • cancer
  • congenital
  • connective tissue disorder
  • iatrogenic
  • infective endocarditis
  • TVP
  • radiation
  • rheumatic TV disease
  • RV infarct
  • trauma
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5
Q

what are the mechanical causes of TR

A
  • pacemaker leads

- implantable caradioverter defibrillator

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6
Q

what are the characteristics of rheumatic TV disease

A
  • thickened and retracted TV leaflets
  • diastolic doming of the TV
  • dilation of the TV annulus (regurge)
  • incomplete leaflet coaptation
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7
Q

what is carcinoid heart disease caused by

A
  • rare, malignant neuroendocrine tumor that secretes excessive amounts of serotonin which damages right heart valves
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8
Q

what are the characteristics of Carcinoid heart disease TR

A
  • TV becomes thickened retracted and rigid
  • TV becomes both stenotic and rigid
  • valve remains in fixed semi open position
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9
Q

what can causes traumatic TV rupture

A
  • violent external compression puts extreme pressure of the chordae of the TV
  • may lead to chordae rupture or flail leaflet
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10
Q

what is TVP and what does it occur with

A
  • systolic bowing of the belly of the leaflets into the RA during systole
  • MVP
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11
Q

what is ebsteins anomaly

A
  • malformation of the TV leaflets during development
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12
Q

what are the 4 main characteristics of ebsteins anomaly

A
  • adhesion of the septal and posterior leaflet to the underlying myocardium
  • exaggerated apical displacement of the septal leaflet
  • atrialization and dilation of a portion of the RV inflow tract
  • small functional RV
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13
Q

what can ebsteins lead to

A
  • maldevelopment of the conduction pathway from atria to ventricle
    + Wolfe-parkinson white syndrome
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14
Q

what must the measurement of the septal leaflet displacement be to diagnose ebsteins

A
  • > 20mm
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15
Q

what will the leaflet motion be with ebteins

A
  • ATV restricted motion

- septal TV whip like motion

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16
Q

what will color look like with ebsteins

A
  • some degree of TR
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17
Q

what should we assess for with spectral with ebsteins

A
  • ASD or PFO
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18
Q

what way will the shunt be directed with ebsteins anomaly in a ASD

A
  • right to left not left to right

+ AKA eisenemngers syndrome

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19
Q

are the leaflets structurally normal with annular dilation of the TV

A
  • yes

- just have incomplete coaptation due to dilated annulus

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20
Q

what are 3 common causes of annular dilation

A
  • dilated cardiomyopathy
  • ASD
  • pulmonary hypertension
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21
Q

what is chronic severe pulmonary HTN associated with

A
  • RV and TV dilation
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22
Q

what will happen to the pap muscles with annular dilation

A
  • pap muscles migrate away from the TV annulus as the RV dilates
  • this leads to functional TR
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23
Q

does TR peak velocity reflect the severity of the TR if not what does it represent

A
  • no

- pressure difference between the RV and RA during systole

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24
Q

what sign is caused from RV volume overload

A
  • D sign only during diastole
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25
Q

what sign is caused from RV pressure overload

A
  • D sign throughout entire cycle
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26
Q

is TR usually well tolerated

A
  • yes
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27
Q

what signs will be seen with severe/progressive TR

A 
- right heart failure 
  \+ increased JVP
  \+ hepatomegaly 
  \+ peripheral edema 
  \+ ascites
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28
Q

what are the 5 roles of echo

A
  • determine etiology of the lesion
  • assess RA size
  • assess RV size and function
  • estimate severity of the regurgitation
  • estimate right heart pressure
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29
Q

what does chronic elevation of RA pressure lead to

A
  • dilation of the RA
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30
Q

what is normal RA area

A

< 18 cm^2

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31
Q

what is normal RA length

A

< 5.3 cm

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32
Q

what is normal RA width

A

< 4.4cm

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33
Q

what is normal male RAVI

A

32 ml/m^2

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34
Q

what is normal female RAVI

A

27 ml/m^2

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35
Q

what is normal RV base

A

< 41mm

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36
Q

what is normal RV mid

A

< 35mm

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37
Q

what is normal RV length

A

< 86mm

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38
Q

what is normal TAPSE

A

> 17mm

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39
Q

what is normal S prime

A

> 9.5cm/s

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40
Q

what is normal RV FAC

A

> 35%

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41
Q

what is normal RIMP

A

< 0.44

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42
Q

what are 3 indirect signs of regurge with color

A
  • color jet area
  • vena contracta width
  • flow convergence radius
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43
Q

what are 4 indirect signs of regurge with spectral

A
  • tricuspid inflow (PW)
  • hepatic vein profile (PW)
  • intensity of TR signal (CW)
  • TR jet contour (CW)
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44
Q

what are 2 quantitative parameters of regurge

A
  • regurgitant volume (RV)

- effective orifice area (EROA)

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45
Q

what are 2 limitations to color doppler estimation of regurge severity

A
  • overestimation of the TR jet

- underestimation

46
Q

when does an overestimation of the TR jet occur

A
  • jet tend to displace blood already sitting int the chamber
  • trace only aliased jet to correct for this
47
Q

when does underestimation of the TR jet occur

A
  • occur when there is an eccentric jet
  • jet will tend to hug atria wall
  • coanda effect
48
Q

what color will flow be with a large TV whole

A
  • lower velocity through valve so more dark blue flow
49
Q

what measurement of TR jet area indicates mild regurge

A

< 5 cm^2

50
Q

what measurement of t TR jet area indicates moderate regurge

A

5-10 cm^2

51
Q

what measurement of TR jet area indicates severe regurge

A

> 10 cm^2

52
Q

what vena contracta measurement indicates moderate regurge

A

< 7mm

53
Q

what vena contracta measurement indicates severe regurge

A

> /= 7mm

54
Q

what PISA radius indicates mild regurge

A

+ 5mm

55
Q

what PISA radius indicates moderate regurge

A

6-9mm

56
Q

what PISA radius indicates severe regurge

A

> 9mm

57
Q

can vena contract and Pisa be used when there are multiple jets

A

nope

58
Q

what should the color baseline be set too when measuring the PISA radius in A4C

A

28 cm/s

59
Q

what velocity of TV E and A wave indicates severe TR

A

> 1.0m/s

60
Q

what can happen when a large RV displaces blood backward that was in the RA

A
  • blood pushed back into the IVC and hepatic veins
61
Q

is pulsing the hepatic vein sensitive and specific to TR

A
  • sensitive but not specific
62
Q

what should a normal hepatic vein doppler flow look like

A
  • inverted pulmonary vein flow
63
Q

what happens to the hepatic vein doppler flow with severe TR

A
  • systolic flow reversal
64
Q

what can happen to the liver when less forward flow gets from the IVC to the heart

A
  • liver engorgment
65
Q

what does intensity of TR signal dependant of

A

= number of RBCS

66
Q

what does a brighter TR signal mean

A
  • more RBCs

- more TR

67
Q

what does a faint TR signal mean

A
  • less RBCs

- less TR

68
Q

what 2 technical factors effect the doppler signal brightness

A
  • gain

- doppler angle

69
Q

what is the doppler flow shape of mild TR and what causes it

A
  • when there is mild TR the high pressure gradient is maintains
  • leads to parabolic TR
70
Q

what is the doppler flow shape of severe TR and what causes it

A

pressure gradient reduces as the TR enters the RA throughout systole
- triangular shape (V cut OFF)

71
Q

what do both calculations of TR use

A

PISA TR

72
Q

what is the PISA radius

A
  • flow convergence zone is comprised of a series of hemispheric shells of uniform velocity
  • as Flo gets closer to the hole area of each hemispheric shell decreases while the velocity. of each shell increases
73
Q

what is the EROA tr equation

A

( 2ii r^2. x Vn) / V tr

  • r = convergence radius proximal to TV
  • Vn = color nyquist limit at the radial distance of the hemispheric shell (25-30cm/s)
  • Vtr = peak velocity of the TR jet
74
Q

what measurement of RV indicates mild TR

A

< 30 mL

75
Q

what measurement of RV indicates moderate TR

A

30-44mL

76
Q

what measurement of RV indicates severe TR

A

> /= 45mL

77
Q

what measurement of EROA indicates mild TR

A

< 0.2cm^2

78
Q

what measurement on EROA indicates moderate TR

A

0.2-0.39 cm^2

79
Q

what measurement of EROA indicates severe TR

A

> /= 0.4

80
Q

definition of PR

A
  • backward flow from the PA to the RV during diastole
81
Q

what are the 2 aetiologies of PR

A
  • functional (secondary)

- organic (primary)

82
Q

what does organic PR refer to

A
  • abnormality of the cusps
83
Q

what does functional PR refer to

A
  • causes which cause annular dilation which leads to poor cusp caption in an otherwise normal valve
84
Q

what are symptoms of PR due to

A
  • due to RV volume overload and varying levels of right heart failure with severe PR
85
Q

what are 5 symptoms of PR

A
  • dyspnea
  • peripheral edema
  • fatigue
  • increased JVP
  • liver engorgement
86
Q

what are the functional causes of PR

A
  • ANNULAR DILATION
  • congenital heart disease
  • PA dilation
  • pulmonary HTN
  • RV CMO
  • RV infarct
87
Q

what are the organic causes of PR

A
  • DISORDERS OF PULMONARY VALVE
  • carcinoid
  • congenital lesions
  • latrogenic
  • rheumatic valve disease
  • trauma
88
Q

what are the 4 roles fo echo in PR

A
  • determine the etiology of PR
  • assess RV size and function
  • estimate severity of regurge
  • estimate PA pressures
89
Q

what are the 6 qualitative parameters in assessing PR

A
  • jet width
  • flow reversal in branch pulmonary arteries
  • PR jet width ratio
  • intensity of PR signal
  • PR pressure half time
  • PR index
90
Q

what is the 1 quantitative parameters in assessing PR

A
  • regurgitant volume
91
Q

what level of severity is indicated by PR in right or left PA branches

A
  • severe PR
92
Q

if PR is seen more distally what does that indicate about the level of PR

A
  • more severe
93
Q

what is the PR jet width ratio

A
  • ratio of the width of the PR jet compared to that od the RVOT diameter
94
Q

what is the PR jet width ratio equation

A

PR jet width / RVOTd

95
Q

what measurement of PR jet width ratio indicates severe PR

A

> 0.7

96
Q

what should we compare the intensity of the PR jet signal to

A
  • antegrade signal
97
Q

the steeper the PR slope indicates what level of PR

A

steeper = more severe

98
Q

what type of deceleration time indicates severe PR

A
  • short deceleration time that ends before the end of diastole
99
Q

what measurement of P 1/2 T indicates moderate PR

A

> 100ms

100
Q

what measurement of P 1/2 T indicates severe PR

A

< 100ms

101
Q

what are the 2 reasons that the PR velocity declines

A
  • PA pressure falls due to forward run off to the lungs as well as regurgitation back into the RV
  • RV diastolic pressure rises due to normal tricuspid inflow as well as PR volume back into the RV
102
Q

what is the pulmonary regurgitation index PRI

A
  • measure of the ration of the duration of the PR signal to the Toal diastolic duration
103
Q

what should the PRI ratio be when mild PR signal continues. throughout all of diastole

A

1

104
Q

when does pre systolic forward flow out the PV occur

A
  • severe PR
  • RV diastolic dysfunction
  • very stiff RV and non compliant
105
Q

what 2 pressures cane calculated when PR is present

A
  • PAEDP

- mPAP

106
Q

what is the equation for PAEDP

A

PAEDP = 4Vpr-ed^2 + RVEDP

107
Q

in the absence fo tricuspid stenosis what pressure is equal to RVEDP

A

RAP

108
Q

what is the equation for PAEDP with RAP instead

A

PAEDP = 4 Vpr-ed ^2 + RAP

109
Q

would they rather repair or replace a valve

A

repaired

110
Q

what criteria of valves will be replaced or repaired

A
  • all severe stenotic or regurgitant
111
Q

what valve disorder is well suited for repair

A

MVP

112
Q

what are the 2 reasons a valve may be replaced or repaired before severe stage

A
  • patient meets surgical criteria for other pathology

- permanent damage being done to other organs due to the stenosis or regurge

Echo 2 (18 decks)

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