PS/PR Flashcards
Pulmonary Valve
PV has 3 leaflets and sits at the junction of the _____ and _______
RVOT & main PA
Pulmonary Valve
What are the name of each cusp?
AC (anterior)
LC (left)
RC (right)
*note: anterior is the largest
Pulmonary Stenosis
Definition?
narrowing/thickening/obstruction of the PV that impedes systolic flow traveling fro the RV, though the PV, into the PA. Similar to AS
Pulmonary Stenosis
Types of PS?
- subvalvular (infundibular) PS: an obstruction of the RVOT (below the valve)
- valvular PS: an obstruction of the PV cusps
- supravalvular PS: an obstruction in the PA (above the valve)
Pulmonary Stenosis
Causes?
- congenital (mainly): the stenotic PV can be trileaflet, bicuspid, or dysplastic
- a part of more complex congenital anomaly (frequently): Tetralogy of Fallot, atrioventricular canal, double outlet RV etc)
- carcinoid heart disease: most common form of acquired PS
- subvalvular PS: *caused by sinus of Valsalva aneurysm which protrudes into the RVOT and obstruct flow
- Functional PS: tumor that compress the RVOT
- RHD: possible but uncommon
Pulmonary Stenosis
murmur?
harsh systolic ejection murmur heard at the left upper sternal border; a thrill may also be present
Pulmonary Stenosis
complication?
- dyspnea on exertion (*physical/mental effort)
- Jagular venous distension (enlargement)
- RVH, eventually RV dilatation & RA enlargement
- associated congenital anomalies
Pulmonary Stenosis Grading
peak Doppler velocity
mild?
severe?
mild: < 3 m/s
severe: > 4 m/s
Pulmonary Stenosis Grading
peak Doppler gradient
mild?
severe?
mild: < 36 mmHg
severe: > 64mmHg
Pulmonary Stenosis Grading
mean Doppler gradient
severe?
>40mmHg
Pulmonary Stenosis Grading
Always check tricuspid regurgitation gradient to rule out overestimation of PS gradient.
T or F ?
T
What is tetralogy of Fallot?
Tetralogy of Fallot is a birth defect that affects normal blood flow through the heart. It happens when a baby’s heart does not form correctly as the baby grows and develops in the mother’s womb during pregnancy.
A heart defect that features four problems.
They are:
- a hole between the lower chambers of the heart (atrioventricular canal/ASD/VSD)
- an obstruction from the heart to the lungs (PS)
- The aorta lies over the hole in the lower chambers
- RV hypertrophy
Pulmonary Stenosis
What are the echo findings?
- thickening if the PV leaflets with systolic doming
- RV hypertrophy due to RV pressure overload = increased afterload
- flattening if the IVS due to the RV pressure overload *D shaped LV (can be visualized in PSAX)
- RA enlargement
- RV failure in the later stages of PS
- post-stenotic dilatation of the MPA due to the high velocity PS jet striking the PA wall *similar to AS
Pulmonary Stenosis
What are the M-mod findings?
“a” wave dip of the right posterior PV cusp
*normal range: 2-3 mm in depth
*severe: > or = 8mm in depth
Pulmonary Stenosis
Explain how to assess with Doppler
similar to AS, assess:
- peak velocity
- max & mean PG
- PVA
via the continuity equation
- CW focus in the PV; acquire the PV peak velocity & the VTI
- PW gate in the RVOT; acquire the RVOT peak velocity & VTI
*For a quick PG, utilize the modified Bernouli’s equation: PG = 4V2
Pulmonary Stenosis
PVA equation?
PVA = (VTI RVOT) (CSA RVOT) / (VTI PV)
*acquire the RVOT diameter just proximal to the PV
Pulmonary Stenosis
what is the normal range of RVOT proximal?
21-35mm
Pulmonary Stenosis
The Gorlin Formula can be used to calculate the PVA.
T or F ?
T
Pulmonary Stenosis
What views can be used for PV Doppler assessment?
- PLAX RVOT
- PSAX RVOT
- Subcostal base
Pulmonic Regurgitation
definition
the backward or regurgitant flow of blood through the PV into the RV during ventricular diastole; may be acute or chronic
Pulmonic Regurgitation
etiology
- incomplete PV closure due to PH (high pressure pulmonary disease): causes PA/PV annulus dilatation *most common cause
- infective endocarditis/vegetation *second most common
- RHD: uncommon; usually affect MV, AoV prior to PV
- Myxomatous (non cancerous tumor) degeneration
- Connective tissue disorder e.g. Marfan’s syndrome
- Congenital anomalies: Tetralogy of Fallot, VSD, valvular PS, absence of the PV etc
- iatrogenic: relating to illness caused by medical examination or treatment e.g. post surgical repair
- PA catheter
- Carcinoid heart disease
- Syphillis
- Tuberculosis
- chest trauma
- prosthetic heart valve
- physiologic
Pulmonary Regurgitation
symptoms & signs
- asymptomatic; may be tolerated for years due solely to PR is rare
- dyspnea
- fatigue
- palpable RV impulse along left sternal border
- systolic/diastolic thrills (a vibratory movement or resonance) at the left upper sternal border
Pulmonary Regurgitation
murmur
a low-pitched diastolic murmur that may increase with inspiration
right-sided Austin Flint murmur: low frequency presystolic murmur
Graham-Steele murmur: a high-pitched blowing diastolic murmur may be heard when PH is present with PR
Pulmonary Regurgitation
treatment
- PR usually well tolerated
- endocarditis prophylaxis (prevention)
- Digitalis (Digitalis medicines strengthen the force of the heartbeat by increasing the amount of calcium in the heart’s cells) for RHF
- valvuloplasty/valve replacement
Pulmonary Regurgitation
Trivial/mild PR is present in up to ____% of patient
87
Pulmonary Regurgitation
M-mode findings
- RV dilatation
- RV dilatation with paradoxical (seemingly absurd or self-contradictory) septal motion - due to RV vol overload
- premature opening of the PV due to severe, acute PR that increases the RVED pressure
- fine diastolic flutter of the TV
- diastolic flutter of the pulmonic valve
Pulmonary Regurgitation
2D echo findings
- PH (common cause)
- anatomic basis/defect that prevents coaptation: annulus dilatation, PA dilatation, infective endocarditis, RHD, carcinoid heart disease, PS etc
- RA dilatation
- RV dilatation with paradoxical septal motion due to vol overload pattern
- D-shaped LV
- determine RV dimensions, volumes and EF
Pulmonary Regurgitation
Doppler assessment
acquire the end-diastolic pulmonic regurgitation (EDPR) velocity and calculate the EDPR gradient with modified Bernouli’s equation = 4V2
Pulmonary Regurgitation
Doppler assessment
What is the normal range?
0-5 mHg
Pulmonary Regurgitation
Doppler Assessment
PR grade
mild
Pulmonary Regurgitation
Doppler Assessment
PR grade
severe
Pulmonary Regurgitation
Doppler Assessment
PR grade
trivial
Pulmonary Regurgitation
Doppler Assessment
PR grade
mild
Pulmonary Regurgitation
Doppler Assessment
PR grade
moderate
Pulmonary Regurgitation
Doppler Assessment
PR grade
severe
Pulmonary Regurgitation
Color Doppler Assessment
physiologic regurgitation: _____ in length and not holodiastolic in duration with normal PA pressure
let area/width _____ RVOT diameter
< 1 cm
< ⅓
Pulmonary Regurgitation
Color Doppler Assessment
Borderline regurgitation: _____ in length and holodiastolic in duration
jet area/width: _____ RVOT diameter
1-2 cm
>⅓ and < ⅔
Pulmonary Regurgitation
Color Doppler Assessment
clinically significant: ____ in length with peak velocity _____ and holodiastolic in duration
jet area/width: _____RVOT diameter
> 2cm> or = 1.5 m/s> ⅔
PH is an elevation in the pressure of the PAs caused by another disease such as diastolic heart failure or left heart disease.
T or F?
T
Echo provides a noninvasive assessment of PH and an accurate systolic PA pressure.
T or F?
T
______ is the most common cause of PS
congenital heart disease
PS creates a harsh diastolic ejection murmur and a thrill may also be present
T or F?
F
*harsh systolic ejection murmur not diastolic
echo findings include a PV “a” wave of 10mm; what is most likely the diagnosis?
- severe PH
- severe PR
- severe PS
- all of the above
severe PS
The patient presents with congenital PS with a peak velocity of 3.5 m/s; what is most likely the diagnosis?
- normal PV
- peak PG = 14 mmHg, mild PS
- peak PG = 49 mmHg, moderate PS
- peak PG = 52 mmHg, severe PS
moderate PS
______ is an indication of PS?
- LVH with flattening of the IVS
- post-stenotic dilatation of the aorta
- thickening of the pulmonic leaflets with systolic doming
- all of the above
thickening of the pulmonic leaflets with systolic doming
A Graham-Steele murmur is a high-pitched blowing diastolic murmur may that may be heard in case of PS with PH
T or F?
F
Graham-Steele murmur (a high-pitched blowing diastolic murmur) is present with PR & PH
Calculate the ______ with the end-diastolic PR velocity and Bernoulli equation
- EDPR gradient
- RVEDP
- RVSP
- all of the above
EDPR gradient
The pulmonary valve has 3 leaflets and sits at the junction of the LV outflow tract (LVOT) and the main pulmonary artery (PA)
T or F ?
Structural abnormalities are the cause of tricuspid regurgitation at least 25% of the time. Please list at least 4
Severe hemodynamic changes due solely to pulmonary regurgitation is rare
T or F ?
List 5 clinical symptoms associated with Right Heart Failure
A progressive increase in degree of TR can lead to RV volume overload
T or F ?
Always check tricuspid regurgitation gradient to rule out overestimation of pulmonary stenosis gradient
T or F ?
Up to 87% of normal patients appear to have PR
T or F ?
For cases of tricuspid stenosis, our Doppler finding would demonstrate a spectral wave form similar to the waveform demonstrated with this finding _________________.
The pulmonic valve (PV) has a saddle shape because of anterior and posterior high points and mid septal and lateral wall low points
T or F ?
List 5 causes of pulmonary regurgitation (PI)
Signs and symptoms of Pulmonic stenosis include: Dyspnea, Fatigue, Right Upper quadrant abdominal pain
T or F ?
Describe the TS (tricuspid stenosis) murmur
List 4 causes of TS (tricuspid stenosis)
Functional Tricuspid Regurgitation occurs 75% of the time. Please list 4 causes.
- Left heart disease (left ventricular dysfunction or valve diseases) resulting in pulmonary hypertension
- Primary pulmonary hypertension
- Secondary pulmonary hypertension (e.g. chronic lung disease, pulmonary thromboembolism, left-to-right shunt)
- Atrial fibrillation
- Cardiac tumors (particularly right atrial myxomas
What do the following statements describe?
Low-pitched, diastolic murmur, usually best heard along the third or fourth intercostal spaces adjacent to the left sternal border (accentuated with inspiration)
Low frequency presystolic murmur (right-sided Austin Flint)
List 3 M-Mode findings for Pulmonary Regurgitation (PI)
- RV dilatation
- Right ventricular volume overload pattern (right ventricular dilatation withparadoxical septal motion)
- Fine diastolic flutter of theTricuspid valve
- Diastolic flutter of the pulmonic valve
How many papillary muscles does the tricuspid valve have?
3
Hepatojugular reflux, Peripheral edema, Ascites, Atrial fibrillation, and Hyperdynamic RV impulse are considered physical findings associated with PR
T or F ?
F
- Jugular venous distention with prominent “v” wave
- Hepatomegaly
- Pulsatile liver
- Hepatojugular reflux
- Peripheral edema
- Ascites
- Atrial fibrillation
- Hyperdynamic RV impulse
These are all the clinical presentation of TR
A patient with Pulmonary Regurgitation my exhibit systolic/diastolic thrills at the left upper sternal border
T or F ?
T
Also, palpable right ventricular impulse along left sternal border is present
Signs and symptoms of PS:
Dyspnea, fatigue, RUQ abdominal pain
T or F ?
F
*Dyspnea, Fatigue, Right Upper quadrant
abdominal pain are signs of TS
The pulmonary valve has 3 leaflets and sits at the junction of the LV outflow tract (LVOT) and the main pulmonary artery (PA).
T or F ?
False
The pulmonary valve has 3 leaflets and sits at the junction of the RVOT and the main pulmonary artery
Structural abnormalities are the cause of tricuspid regurgitation at least 25% of the time. Please list at least 4.
Rheumatic, endocarditis, traumatic (blunt chest injury, laceration), congenital, prolapse, carcinoid disease, endomyocardial fibrosis
Severe hemodynamic changes due solely to pulmonary regurgitation is rare.
T or F ?
T
List 5 clinical symptoms associated with Right Heart Failure.
A progressive increase in degree of TR can lead to RV volume overload.
T or F ?
T
Always check tricuspid regurgitation gradient to rule out overestimation of pulmonary stenosis gradient.
T or F ?
T
Up to 87% of normal patients appear to have PR.
T or F ?
T
For cases of tricuspid stenosis, our Doppler finding would demonstrate a spectral wave form similar to the waveform demonstrated with this finding _________________.
For cases of tricuspid stenosis, our Doppler finding would demonstrate a spectral wave form similar to the waveform demonstrated with this finding _________________.
The pulmonic valve (PV) has a saddle shape because of anterior and posterior high points and mid septal and lateral wall low points.
T or F ?
T
List 5 causes of pulmonary regurgitation (PI).
- Incomplete PV closure (pulmonary hypertension causes pulmonary artery and PV annulus dilatation)
- Infective endocarditis/ veg
- Rheumatic heart disease, although it usually attacks the mitral valve and AOV prior to the PV
- Congenital anomalies (tetrafallot of fallot, ventricular septal defect, valvular pulmonic stenosis)
- Carcinoid heart disease
Signs and symptoms of Pulmonic stenosis include: Dyspnea, Fatigue, Right Upper quadrant abdominal pain.
T or F ?
Describe the TS (tricuspid stenosis) murmur.
High pitched diastolic rumble that varies with respiration and has an opening snap
List 4 causes of TS (tricuspid stenosis).
Rheumatic heart disease
Congenital TS (Ebstein anomaly)
Carcinoid heart disease
Secondary TS due to intracardiac wires/pacemaker, right atrial clot/tumor, or TV veg
Secondary TS due to other medical conditions (systemic Lupus Erythematosus)
Prosthetic valve dysfunction
Functional Tricuspid Regurgitation occurs 75% of the time. Please list 4 causes.
- Left heart disease (left ventricular dysfunction or valve diseases) resulting in pulmonary hypertension
- Primary pulmonary hypertension
- Secondary pulmonary hypertension (e.g. chronic lung disease, pulmonary thromboembolism, left-to-right shunt)
- A fib
- Cardiac tumor (right atrial myxomas)
What do the following statements describe?
Low-pitched, diastolic murmur, usually best heard along the third or fourth intercostal spaces adjacent to the left sternal border (accentuated with inspiration)
Low frequency presystolic murmur (right-sided Austin Flint)
List 3 M-Mode findings for Pulmonary Regurgitation (PI).
How many papillary muscles does the tricuspid valve have?
Hepatojugular reflux, Peripheral edema, Ascites, Atrial fibrillation, and Hyperdynamic RV impulse are considered physical findings associated with PR.
T or F ?
