Module 9 : Tricuspid and Pulmonary Regurgitation Flashcards
what is the definition of tricuspid regurgitation
- backward flow of blood from the RV to the RA during systole
what are the 3 groups of etiology of TR
- functional (primary)
- organic (secondary)
- mechanical
what are functional causes of TR
- ANNULAR DILATION
- afib
- ASD
- DCMO
- PHTN, PR
- RV dysplasia
- RV CHF
- RV infarct
what are the organic causes of TR
- DISORDERS OF THE TV COMPLEX
- cancer
- congenital
- connective tissue disorder
- iatrogenic
- infective endocarditis
- TVP
- radiation
- rheumatic TV disease
- RV infarct
- trauma
what are the mechanical causes of TR
- pacemaker leads
- implantable caradioverter defibrillator
what are the characteristics of rheumatic TV disease
- thickened and retracted TV leaflets
- diastolic doming of the TV
- dilation of the TV annulus (regurge)
- incomplete leaflet coaptation
what is carcinoid heart disease caused by
- rare, malignant neuroendocrine tumor that secretes excessive amounts of serotonin which damages right heart valves
what are the characteristics of Carcinoid heart disease TR
- TV becomes thickened retracted and rigid
- TV becomes both stenotic and rigid
- valve remains in fixed semi open position
what can causes traumatic TV rupture
- violent external compression puts extreme pressure of the chordae of the TV
- may lead to chordae rupture or flail leaflet
what is TVP and what does it occur with
- systolic bowing of the belly of the leaflets into the RA during systole
- MVP
what is ebsteins anomaly
- malformation of the TV leaflets during development
what are the 4 main characteristics of ebsteins anomaly
- 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
what can ebsteins lead to
- maldevelopment of the conduction pathway from atria to ventricle
+ Wolfe-parkinson white syndrome
what must the measurement of the septal leaflet displacement be to diagnose ebsteins
- > 20mm
what will the leaflet motion be with ebteins
- ATV restricted motion
- septal TV whip like motion
what will color look like with ebsteins
- some degree of TR
what should we assess for with spectral with ebsteins
- ASD or PFO
what way will the shunt be directed with ebsteins anomaly in a ASD
- right to left not left to right
+ AKA eisenemngers syndrome
are the leaflets structurally normal with annular dilation of the TV
- yes
- just have incomplete coaptation due to dilated annulus
what are 3 common causes of annular dilation
- dilated cardiomyopathy
- ASD
- pulmonary hypertension
what is chronic severe pulmonary HTN associated with
- RV and TV dilation
what will happen to the pap muscles with annular dilation
- pap muscles migrate away from the TV annulus as the RV dilates
- this leads to functional TR
does TR peak velocity reflect the severity of the TR if not what does it represent
- no
- pressure difference between the RV and RA during systole
what sign is caused from RV volume overload
- D sign only during diastole
what sign is caused from RV pressure overload
- D sign throughout entire cycle
is TR usually well tolerated
- yes
what signs will be seen with severe/progressive TR
- right heart failure \+ increased JVP \+ hepatomegaly \+ peripheral edema \+ ascites
what are the 5 roles of echo
- determine etiology of the lesion
- assess RA size
- assess RV size and function
- estimate severity of the regurgitation
- estimate right heart pressure
what does chronic elevation of RA pressure lead to
- dilation of the RA
what is normal RA area
< 18 cm^2
what is normal RA length
< 5.3 cm
what is normal RA width
< 4.4cm
what is normal male RAVI
32 ml/m^2
what is normal female RAVI
27 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 prime
> 9.5cm/s
what is normal RV FAC
> 35%
what is normal RIMP
< 0.44
what are 3 indirect signs of regurge with color
- color jet area
- vena contracta width
- flow convergence radius
what are 4 indirect signs of regurge with spectral
- tricuspid inflow (PW)
- hepatic vein profile (PW)
- intensity of TR signal (CW)
- TR jet contour (CW)
what are 2 quantitative parameters of regurge
- regurgitant volume (RV)
- effective orifice area (EROA)
what are 2 limitations to color doppler estimation of regurge severity
- overestimation of the TR jet
- underestimation
when does an overestimation of the TR jet occur
- jet tend to displace blood already sitting int the chamber
- trace only aliased jet to correct for this
when does underestimation of the TR jet occur
- occur when there is an eccentric jet
- jet will tend to hug atria wall
- coanda effect
what color will flow be with a large TV whole
- lower velocity through valve so more dark blue flow
what measurement of TR jet area indicates mild regurge
< 5 cm^2
what measurement of t TR jet area indicates moderate regurge
5-10 cm^2
what measurement of TR jet area indicates severe regurge
> 10 cm^2
what vena contracta measurement indicates moderate regurge
< 7mm
what vena contracta measurement indicates severe regurge
> /= 7mm
what PISA radius indicates mild regurge
+ 5mm
what PISA radius indicates moderate regurge
6-9mm
what PISA radius indicates severe regurge
> 9mm
can vena contract and Pisa be used when there are multiple jets
nope
what should the color baseline be set too when measuring the PISA radius in A4C
28 cm/s
what velocity of TV E and A wave indicates severe TR
> 1.0m/s
what can happen when a large RV displaces blood backward that was in the RA
- blood pushed back into the IVC and hepatic veins
is pulsing the hepatic vein sensitive and specific to TR
- sensitive but not specific
what should a normal hepatic vein doppler flow look like
- inverted pulmonary vein flow
what happens to the hepatic vein doppler flow with severe TR
- systolic flow reversal
what can happen to the liver when less forward flow gets from the IVC to the heart
- liver engorgment
what does intensity of TR signal dependant of
= number of RBCS
what does a brighter TR signal mean
- more RBCs
- more TR
what does a faint TR signal mean
- less RBCs
- less TR
what 2 technical factors effect the doppler signal brightness
- gain
- doppler angle
what is the doppler flow shape of mild TR and what causes it
- when there is mild TR the high pressure gradient is maintains
- leads to parabolic TR
what is the doppler flow shape of severe TR and what causes it
pressure gradient reduces as the TR enters the RA throughout systole
- triangular shape (V cut OFF)
what do both calculations of TR use
PISA TR
what is the PISA radius
- 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
what is the EROA tr equation
( 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
what measurement of RV indicates mild TR
< 30 mL
what measurement of RV indicates moderate TR
30-44mL
what measurement of RV indicates severe TR
> /= 45mL
what measurement of EROA indicates mild TR
< 0.2cm^2
what measurement on EROA indicates moderate TR
0.2-0.39 cm^2
what measurement of EROA indicates severe TR
> /= 0.4
definition of PR
- backward flow from the PA to the RV during diastole
what are the 2 aetiologies of PR
- functional (secondary)
- organic (primary)
what does organic PR refer to
- abnormality of the cusps
what does functional PR refer to
- causes which cause annular dilation which leads to poor cusp caption in an otherwise normal valve
what are symptoms of PR due to
- due to RV volume overload and varying levels of right heart failure with severe PR
what are 5 symptoms of PR
- dyspnea
- peripheral edema
- fatigue
- increased JVP
- liver engorgement
what are the functional causes of PR
- ANNULAR DILATION
- congenital heart disease
- PA dilation
- pulmonary HTN
- RV CMO
- RV infarct
what are the organic causes of PR
- DISORDERS OF PULMONARY VALVE
- carcinoid
- congenital lesions
- latrogenic
- rheumatic valve disease
- trauma
what are the 4 roles fo echo in PR
- determine the etiology of PR
- assess RV size and function
- estimate severity of regurge
- estimate PA pressures
what are the 6 qualitative parameters in assessing PR
- jet width
- flow reversal in branch pulmonary arteries
- PR jet width ratio
- intensity of PR signal
- PR pressure half time
- PR index
what is the 1 quantitative parameters in assessing PR
- regurgitant volume
what level of severity is indicated by PR in right or left PA branches
- severe PR
if PR is seen more distally what does that indicate about the level of PR
- more severe
what is the PR jet width ratio
- ratio of the width of the PR jet compared to that od the RVOT diameter
what is the PR jet width ratio equation
PR jet width / RVOTd
what measurement of PR jet width ratio indicates severe PR
> 0.7
what should we compare the intensity of the PR jet signal to
- antegrade signal
the steeper the PR slope indicates what level of PR
steeper = more severe
what type of deceleration time indicates severe PR
- short deceleration time that ends before the end of diastole
what measurement of P 1/2 T indicates moderate PR
> 100ms
what measurement of P 1/2 T indicates severe PR
< 100ms
what are the 2 reasons that the PR velocity declines
- 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
what is the pulmonary regurgitation index PRI
- measure of the ration of the duration of the PR signal to the Toal diastolic duration
what should the PRI ratio be when mild PR signal continues. throughout all of diastole
1
when does pre systolic forward flow out the PV occur
- severe PR
- RV diastolic dysfunction
- very stiff RV and non compliant
what 2 pressures cane calculated when PR is present
- PAEDP
- mPAP
what is the equation for PAEDP
PAEDP = 4Vpr-ed^2 + RVEDP
in the absence fo tricuspid stenosis what pressure is equal to RVEDP
RAP
what is the equation for PAEDP with RAP instead
PAEDP = 4 Vpr-ed ^2 + RAP
would they rather repair or replace a valve
repaired
what criteria of valves will be replaced or repaired
- all severe stenotic or regurgitant
what valve disorder is well suited for repair
MVP
what are the 2 reasons a valve may be replaced or repaired before severe stage
- patient meets surgical criteria for other pathology
- permanent damage being done to other organs due to the stenosis or regurge
