pHTN and PVS

Question 1

2D pHTN findings

Answer 1

1) Diminished or absent “a” wave of the pulmonary valve
2) Midsystolic closure of the pulmonary valve
3) Enlarged chambers of the right heart
4) D-shaped LV cavity

Question 2

Transtricuspid pressure gradient

Answer 2

4(TRV)^2

Question 3

What does tricuspid regurgitation velocity reflect?

Answer 3

The pressure difference during systole between the RV and the RA.

Question 4

PASP

PA systolic pressure

Answer 4

In the absence of a gradient across the pulmonic valve or RVOT, RVSP is equal to PASP

Question 5

When might the TRV appear low?

Answer 5

In the presence of markedly increased RA pressure due to RV infarct, RV failure, or severe TR.

Question 6

RVSP

Answer 6

RA pressure + peak TR velocity

RA + 4(V)^2

Question 7

How should TR velocity be measured?

Answer 7

Held-expiration, to avoid respiratory variation

Question 8

PAEDP

Answer 8

4(PREDV)^2 + RAP

Question 9

MPAP

Answer 9

4(Peak PRV)^2

or

1/3(PASP) + 2/3(PAEDP)

or

79 - 0.45(AcT) (For RVOT flow velocity)

Question 10

Why is there a dip in the PA-RV pressure gradient?

Answer 10

PRV usually reflects small pressure differences between the PA and the RV, ATRIAL CONTRACTION with increased RV pressure creates a unique DIP in the velocity curve.

NB: When PA pressure is high, RA contraction usually does not make a notable change in the PA-RV pressure gradient. NO DIP!

Question 11

Mahan’s equation for MPAP

Answer 11

MPAP = 79 - 0.45(AcT) (For RVOT flow velocity)

* Dependent on CO and HR, adjust for 100bpm.

Question 12

Acceleration time

Answer 12

The time interval between the beginning of the flow and its peak velocity

Question 13

PVR (Cath Lab)

Answer 13

(MPAP - PCWP)/CO

Question 14

PVR (Doppler)

Answer 14

10 (TRV/RVOT TVI) + 0.16

• A cutoff value of 0.2 for TRV/RVOT TVI separates a group with PVR greater than 2 Wood units

Question 15

How can you assume pHTN is due to a pulmonary process?

Answer 15

If mitral inflow shows a nonrestrictive diastolic filling pattern.

Question 16

What happens to hepatic venous flow in pHTN?

Answer 16

There is prominent atrial flow reversal in the hepatic vein caused by increased diastolic pressure and decreased compliance of the RV.

***There is very little respiratory variation of atrial flow reversal in pHTN, unlike the variation seen in restrictive CM or constrictive pericarditis.

Question 17

How to quantify RV dysfunction?

Answer 17

1) RV dilation
2) Paradoxical septal motion
3) TRV > 2.8m/s

Question 18

Congenital pulmonary veins

Answer 18

From one to all four PVs can be connected with or drain into the right side of the heart.

Best seen with the suprasternal short-axis view

One of the PVs may drain into the VERTICAL VEIN, which connects with the innominate vein.

Question 19

PV Stenosis: Etiology and Rx

Answer 19

May be congenital or due to PVI (catheter ablation)

The best treatment is percutaneous dilatation or stent placement.

Question 20

Causes of increased RV pressure

Answer 20

1) RV infarct
2) pHTN
3) Constrictive pericarditis