Right Heart Assessment Flashcards
1
Q
The right atrium receives venous blood via which three vessels?
A
The SVC, IVC and Coronary Sinus.
2
Q
What are the three normal variants seen within the RA?
A
The Eustachian valve, Chiari Network and the crista terminalis.
3
Q
What are the common causes of RA dilatation?
A
- RA pressure overload; pHTN, restrictive cardiomyopathy and tricuspid stenosis - 2. RA volume overload; tricuspid regurgitation and ASD and 3. Chronic atrial fibrillation.
4
Q
What can be used to determine RAP?
A
The assessment of JVP (jugular venous pressure) or IVC.
5
Q
An IVC ≤2.1cm which collapses by >50% on inspiration/sniff indicates a normal RA pressure of what?
A
0-5mmHg.
6
Q
An IVC >2.1cm which collapses by <50% on inspiration/sniff indicates a high RA pressure of what?
A
15mmHg.
7
Q
An IVC ≤2.1cm which collapses by <50% on inspiration/sniff OR >2.1cm with >50% collapse indicates an intermediate RA pressure of what?
A
5-10mmHg.
8
Q
When RAP rise, the RA becomes dilated. What else becomes increasingly dilated?
A
The hepatic veins.
9
Q
In fetal life, what is the purpose of the Eustachian Valve?
A
It directs oxygenated blood away from the tricuspid valve and towards the foramen ovale.
10
Q
The chiari network appears as what on echocardiography?
A
A web-like structure.
11
Q
The chiari network is present in what percentage of population?
A
Around 2%.
12
Q
Usually the chiari network/eustachian valve are of no clinical significance, however either remnant in combination with a PFO may increase the risk of what?
A
Paradoxical embolism (right-to-left).
13
Q
The tricuspid valve has how many cusps; and what are they called?
A
Three; anterior, posterior and septal cusps.
14
Q
In order of decreasing size, name the three tricuspid cusps.
A
Anterior, septal and posterior cusps.
15
Q
True or false; with regards to the tricuspid valve, there are a variable number of papillary muscles of different sizes and positions.
A
True.
16
Q
Which has the larger annulus and is the more apically positioned valve, the tricuspid or mitral valve?
A
The tricuspid valve.
17
Q
Tricuspid stenosis is most commonly a consequence of what?
A
Rheumatic fever.
18
Q
True or false; rheumatic thickening of the tricuspid valve tends to be subtler than that of the mitral valve.
A
True.
19
Q
Apart from rheumatic fever; what are other causes of tricuspid stenosis?
A
Carcinoid Syndrome, Ebstein’s Anomaly or “Functional” Stenosis as a result of obstruction by a large RA tumour, thrombus of vegetation.
20
Q
In the RV inflow view, which tricuspid leaflets are seen?
A
The anterior leaflet (on the RHS) and, when the inferior RV wall is in view, the posterior leaflet is seen. But if the septum remains in view, the septal leaflet is seen.
21
Q
What three parameters are used in the assessment of tricuspid stenosis?
A
Mean PG, Valve Area and Inflow VTI.
22
Q
A VTI of what indicates severe tricuspid stenosis?
A
> 60cm.
23
Q
A mean PG of what indicates severe tricuspid stenosis?
A
≥5mmHg.
24
Q
A valve area of what indicates severe tricuspid stenosis?
A
<1cm*2.
25
How can Tricuspid valve area be calculated from PHT?
TVA = 190/PHT
26
A trace of Tricuspid regurgitation is a common finding in up to what percentage of "normal" individuals?
Up to 70%.
27
What are the common causes of tricuspid regurgitation?
Rheumatic valve disease, carcinoid syndrome, infective endocarditis, tricuspid valve prolapse, Ebstein's anomaly, the presence of a pacing wire and tricuspid annular dilatation.
28
What parameters are used to quantify tricuspid regurgitation severity?
EROA, Regurgitant Volume, PISA and Vena Contracta
29
An EROA of what indicates severe TR?
≥0.4cm*2
30
A regurgitant volume of what indicates severe TR?
≥45mL/beat
31
A VC of what indicates severe TR?
>0.7cm.
32
How does CW Doppler tracings differ between mild, moderate and severe TR (including acute severe TR)?
Mild TR has a soft jet density and a parabolic contour. Severe TR has a dense CW Jet. In acute severe, or torrential TR the CW envelope is early peaking and triangular in shape.
33
The peak velocity of the TR jet reflects what?
RVSP.
34
How does systolic hepatic vein flow differ between mild, moderate and severe tricuspid regurgitation?
Mild; systolic dominance, Moderate; systolic blunting and Severe; systolic reversal.
35
Vena contracta width should be measured at a Nyquist limit of what?
50-60cm/s.
36
TR PISA should be measured at a Nyquist limit of what?
28cm/s.
37
Why might hepatic vein flow be blunted (other than because of moderate TR)?
Because of AF or raised RA pressures.
38
How is PISA calculated?
PISA = 2πr*2
39
How is regurgitant flow rate calculated?
Regurgitant flow rate = PISA x Aliasing Velocity.
40
A PISA radius of what indicates mild, moderate and severe TR?
Mild; <0.5cm, Moderate; 0.5-0.9cm and Severe; >0.9cm.
41
True or false; PISA should not be obtained for eccentric TR jets.
True.
42
What other chambers are usually dilated in the presence of severe TR?
RA/RV/IVC
43
Treatment with what can provide symptomatic relief for patients with symptoms of fluid overload secondary to TR?
Diuretics.
44
When should RA area be measured?
At the end of ventricular systole on the frame just prior to TV opening.
45
Why does acute severe or torrential TR CW Doppler show an early peaking triangular shape?
Because of rapid equalisation of RV and RA pressure.
46
When can TR velocity be underestimated?
In severe/free-flowing TR (which will show a triangular low-velocity jet).
47
Tricuspid inflow velocities vary with what (therefore averaging should be performed over 5beats)?
Respiration.
48
How is carcinoid heart disease caused?
By metastatic carcinoid tumour to the liver, secreting 5-HT or serotonin products that affect right heart valves.
49
Why does carcinoid heart disease not affect left-sided valves?
Because the 5-HT or serotonin products that are secreted are degraded in the lungs.
50
When might carcinoid heart disease affect left-sided valves?
In the presence of a right-left shunt.
51
How is the TV affected by carcinoid heart disease?
It's thickened and immobile.
52
True or false; right-sided heart valves are more at risk of endocarditis in IV drug abusers.
True.
53
Apart from hepatic vein flow reversal, severe TR can also cause flow reversal where?
In the SVC and IVC.
54
True or false; the IVC enters the RA inferior to the coronary sinus.
True
55
What is the Crista Terminalis?
A ridge of myocardium within the right atrium that extends along the wall of the RA between the orifice of the SVC and IVC.
56
The Chiari network is essentially an extension of what?
The eustachian valve.
57
The presence of a Chiari network is associated with an increased risk of what?
ASD/PFO.
58
What is Lushka's muscles?
An accessory papillary muscle of the septal leaflet sometimes seen in the RVOT.
59
Pulmonary stenosis is most commonly due to what?
A congenital defect.
60
What are other causes of pulmonary stenosis (apart from congenital)?
Previous rheumatic fever or from carcinoid syndrome.
61
Which wall of the RVOT can be assessed for RWMAs in the pLAX view?
The anterior wall.
62
All RV measurements/diameters should be taken at what part of the cardiac cycle?
At end-diastole.
63
What is considered "normal" for RVOT PLAX in males and females?
≤ 43mm (in males) or ≤ 40mm (in females).
64
In the PLAX RV inflow view, which RV walls are visualised?
The anterior and inferior walls.
65
In order to visualise the true inferior wall in the RV inflow view, what must be ensured?
The ventricular septum must be excluded (and the diaphragm and liver must come into view).
66
In the PSAX view (at the base and mid level), what RV walls can be seen (in a clockwise manner).
The inferior, lateral and anterior walls.
67
In what view should the eccentricity index be measures?
In the pSAX view, at the mid-level.
68
For the eccentricity index, measurements should be taken at end-systole and end-diastole. A left-ventricular eccentricity index of what is considered abnormal?
(D2/D1) > 1.1
69
RV volume overload causes eccentricity in what part of the cardiac cycle?
In diastole only.
70
RV pressure overload causes eccentricity in what part of the cardiac cycle?
In diastole and systole.
71
In the PSAX view (at the apex), what RV walls can be seen (in a clockwise manner).
The inferior and superior walls.
72
Which wall of the RVOT can be assessed for RWMAs in the pSAX view?
The anterior wall.
73
Which view is more reproducible for RVOT measurements, the pLAX or the pSAX view?
The pSAX view.
74
What is considered "normal" for RVOT1 - proximal (PSAX) in males and females?
≤ 44mm (in males) or ≤ 42mm (in females).
75
What is considered "normal" for RVOT2 - distal (PSAX) in males and females?
≤ 29mm (in males) or ≤ 28mm (in females).
76
The pSAX RVOT2 (distal) view allows regional wall motion analysis of what part of the RV?
The infundibulum.
77
Where should PA dimensions be measured?
End-diastole, halfway between the PV and bifurcation of the main PA, or 1cm distal to the PV.
78
A PA diameter of what is considered abnormal?
>2.5cm.
79
Mild PR is likely when (with regards to colour Doppler)?
If the jet has a narrow origin and is <10mm in length.
80
Severe PR is likely when (with regards to colour Doppler)?
If the jet originates from the bifurcation of the branch of the PA.
81
Severe "free" PR may not easily be seen on colour Doppler, why?
Because it may be laminar (without turbulence).
82
A jet width of what (of the RVOT width) is indicative of severe PR?
>65% (same as AR).
83
VC/PV annulus ratio of greater than what is an indicator of severe PR?
>50%.
84
How might right atrial contraction be seen on the CW Doppler through the RVOT?
As late diastolic forward flow.
85
Right atrial contraction seen on the CW Doppler through the RVOT (as late diastolic forward flow) may be more prominent when?
On inspiration.
86
Right atrial contraction seen on the CW Doppler through the RVOT (as late diastolic forward flow) may a marker of what?
Restrictive RV physiology.
87
How does the CW Doppler envelope differ between mild and severe PR?
Mild PR has a soft Doppler envelope with slow deceleration whereas severe PR has a dense CW envelope with a triangular envelope.
88
A PV max of what indicates mild, moderate and severe pulmonary stenosis?
Mild; <3m/s, Moderate; 3-4m/s and Severe; >4m/s.
89
What is used to differentiate subvalvular, valvular and suprvalvular PS?
PW Doppler (and visual 2D assessment).
90
An EARLY PR velocity of what is a marker of raised mean PA pressure?
>2.2m/s.
91
What can be used to estimate PA diastolic pressure; PR early velocity or PR end-diastolic velocity?
PR end-diastolic velocity.
92
How can PA diastolic pressures be estimated?
```
4 X (PR end-diastolic velocity)*2 + RA pressure.
Same as PASP but by using PR end-diastolic velocity rather than the TR velocity.
```
93
A PHT of what is suggestive of severe PR?
<100ms.
94
A PR index (the duration of the CW PR jet as a proportion of the whole of diastole) of what is suggestive of severe PR?
<0.77.
95
What parameters can be used to assess the severity of PR?
Jet width/RVOT diameter, VC/PV annulus ratio, PHT and PR Index.
96
RVOT acceleration time should be measures with the PW sample volume positioned where?
Just below the pulmonic cusp on the RV side in the RVOT.
97
In which part of respiration should RVOT acceleration time be measured at?
End-expiration.
98
A RVOT acceleration time of what is considered a marker of raised PAP?
<105ms.
99
RA area should be measured when?
At the end of ventricular systole on the frame just prior to TV opening.
100
When is the RA considered dilated (area and indexed area; for male and female)?
Area; Male ≥22cm*2, Female ≥19cm*2.
| Indexed Area; ≥11 (for both).
101
RV/LV basal diameter ratio is measured when?
At end-diastole.
102
A RV/LV basal diameter ratio of what suggests RV dilatation?
>1.
103
Why might RV size be underestimated?
Because of the crescentic RV shape.
104
A basal RV diameter (RVD1) of what is considered normal (in males and females)?
≤ 47mm (in males) and ≤43mm (in females).
105
A mid RV diameter (RVD2) of what is considered normal (in males and females)?
≤ 42mm (in males) and ≤35mm (in females).
106
The mid RV diameter should be measured at what level?
Of the LV papillary muscles.
107
RV length (RVD3) of what is considered normal (in males and females)?
≤ 87mm (in males) and ≤80mm (in females).
108
FAC (fractional area change) of the RV involves manual tracing of the RV endocardial border at end-diastole and end-systole. How has FAC calculated?
FAC = (RVAdiastole - RVAsystole)/RVAdiastole X100.
109
What is a disadvantage of the RV FAC measure?
It neglects the contribution of of the RVOT to overall systolic function.
110
An RV FAC of what is considered normal (in males and females)?
≥30% (in males) and ≥35% (in females).
111
True of false; TAPSE is an angle dependant measurement.
True.
112
A TAPSE measurement of what is suggestive of RV systolic dysfunction?
≤17mm.
113
Tricuspid inflow velocities are highly sensitive to what?
Preload and afterload.
114
When should tricuspid inflow velocities be interpreted with caution?
In the presence of moderate or severe TR.
115
A TV E wave of what may indicate impaired RV diastolic filling?
<0.35m/s.
116
What is the "normal range" for TV A wave velocity?
21-58cm/s.
117
What is the "normal range" for TV E/A ratio?
0.8-2.1
118
A TV E/A of what may indicate impaired RV relaxation?
<0.8
119
A TV E/A of what may indicate restrictive RV filling?
>2.1
120
What is the "normal range" for TV E wave deceleration time?
120-229ms.
121
A TV EDT of what may indicate impaired RV relaxation?
>229ms.
122
A TV EDT of what may indicate restrictive RV filling?
<120ms.
123
When measuring RV PW Tissue Doppler S', it is important to what?
Ensure the basal RV free wall segment and the lateral tricuspid annulus are aligned with the Doppler cursor.
124
Why is it important to ensure the basal RV free wall segment and the lateral tricuspid annulus are aligned with the Doppler cursor when measuring RV PW Tissue Doppler S'?
To avoid velocity underestimation.
125
True or False; RV S' is closely correlated to TAPSE and the two measures should be concordant if measured correctly.
True.
126
What is a disadvantage of the RV s' measurement?
It assumes that the function of a single segment represents the function of the entire ventricle.
127
An RV S' measurement of what indicates normal RV long-axis systolic function?
≥9cm/s.
128
What is considered normal for RV E' and A'?
E' <8cm/s, A' <7cm/s.
129
An E/e' of what suggests elevated RAP?
>6
130
An RV IVRT of what may indicate impaired RV filling?
>73ms.
131
RIMP, also known as Tei index) is an index of what?
Global RV performance.
132
A RIMP of what indicates RV dysfunction (by PW Doppler and by Tissue Doppler)?
RIMP by PW Doppler >0.43 and by Tissue Doppler >0.54.
133
RIMP derived from Tissue Doppler is preferred (than RIMP derived from PW Doppler), why?
Because it is derived from a single sample.
134
A RIMP of what is associated with a worse prognosis in pHTN?
>0.64
135
IVC diameter should be measured how?
Perpendicular to the IVC long axis, 1-2cm from the RA junction at end-expiration.
136
With regards to IVC diameter/RAP assessment, how can intermediate RA pressure be upgraded to high RA pressure?
If there is minimal IVC collapse with sniff (<35%) and secondary indices of elevated RAP are present.
137
What are the secondary indices of elevated RAP used to upgrade intermediate RAP to high RAP?
Restrictive filling patterns, RV E/e' >6 or diastolic flow reversal in the hepatic veins.
138
With regards to IVC diameter/RAP assessment, how can intermediate RA pressure be downgraded to normal RA pressure?
If no secondary indices are present.
139
RV wall thickness should be measured at what part in the cardiac cycle?
End-diastole.
140
RV wall thickness of what is consistent with RVH?
>5mm.
141
With hepatic vein flow, there is significant respiratory variation. Greater velocities are seen in inspiration or expiration?
Inspiration.
142
What are the main components of the hepatic vein waveform?
The systolic (S) wave, the systolic reversal wave (SR), the diastolic (D) wave and the atrial reversal wave (AR).
143
What does "normal" hepatic vein waveform show?
Systolic dominance.
144
With regards to the hepatic vein waveform, impaired right heart filling manifests what?
S/D reversal and increased reversal wave velocities (particularly during inspiration).
145
An S/D ratio of what may indicate increased RA pressure?
S/D <1
146
How is the HV systolic filling fraction calculated?
HVSFF = S velocity/(S velocity + D velocity) X 100.
147
A HVSFF of what is consistent with increased RA pressure?
<55%.
148
Prominent systolic and/or atrial reversal waves which are amplified during inspiration and in keeping with raised RA pressure. However, in what other setting may this be seen?
Severe tricuspid regurgitation.
149
What values are considered "normal" for RVED area indexed for male and female?
Male; ≤ 13.6cm*2/m*2 and Female; ≤ 12.6cm*2/m*2.
