Right heart valve disease (CV) Flashcards
What is tricuspid stenosis defined by?
Rare condition defined by an abnormally elevated pressure gradient across the tricuspid valve during diastolic filling of the RV
What does tricuspid stenosis rarely occur in the absence of?
Associated rheumatic mitral and/or aortic disease
What is a cause of tricuspid stenosis?
Rheumatic fever - which almost always occurs with mitral or aortic valve disease
What is tricuspid regurgitation?
When blood flows backwards through the tricuspid valve - majority during systole, but severely elevated RV filling pressure can be associated with diastolic TR
Who can mild/moderate tricuspid regurgitation affect?
Mild/moderate tricuspid regurgitation without abnormal valve anatomy, ventricular function, or pulmonary artery pressure is not necessarily abnormal and is estimated to be present in >50% of asymptomatic young adults (incidental findings)
What is the most important form of tricuspid regurgitation clinically?
Secondary to left-sided cardiac disease, with tricuspid annular dilation
How can tricuspid regurgitation be classified? (2)
- primary TR - abnormal valve morphology
- secondary TR - normal valve morphology
What are some causes of tricuspid regurgitation? (6)
- functional: RV dilatation e.g. due to pulmonary hypertension
- rheumatic fever (recent sore throat, chorea, polyarthralgia, erythema marginatum)
- infective endocarditis in IVDU
- congenital (e.g. Ebstein’s anomaly - malpositioned tricuspid valve)
- drugs e.g. ergot-derived dopamine agonists
- other: carcinoid syndrome, trauma, cirrhosis, iatrogenic
What are the features of rheumatic fever (valve disease)? (4)
- recent sore throat
- chorea - sudden uncontrollable jerky movements of arms, legs, facial muscles
- polyarthralgia - pain in multiple joints
- erythema marginatum
What is pulmonary stenosis?
Obstruction of blood flow from RV into pulmonary bed, resulting in a pressure gradient >10mmHg across the pulmonary valve during systole
What is a cause of pulmonary stenosis?
Usually congenital e.g. Tetralogy of Fallot
Associated with carcinoid heart disease (Hedinger syndrome)
What is pulmonary regurgitation?
Leakage of blood from pulmonary artery back into RV - rare and infrequently symptomatic
What causes pulmonary regurgitation?
Any cause of pulmonary hypertension / increased pulmonary artery pressure
What are the clinical features of tricuspid stenosis? (2)
- fatigue
- dyspnoea
What might you find on examination of tricuspid stenosis?
- elevated JVP with prominent a-wave + jugular pulsations
- abdominal swelling and discomfort
- cyanosis or hypoxaemia
- ascites, hepatomegaly, oedema
- mid-diastolic murmur at left lower sternal border, louder during inspiration
What murmur would you hear in tricuspid stenosis?
Mid-diastolic murmur - at left lower sternal border, louder during inspiration
What are the clinical features of tricuspid regurgitation? (10)
- fatigue
- dyspnoea/breathlessness
- lower limb oedema
- palpitations
- headaches
- nausea
- anorexia
- epigastric pain - worse on exercise
- jaundice
- ascites
What might you see on examination in tricuspid regurgitation?
- pulse - irregularly irregular if AF
- inspection - raised JVP with giant v-waves (which may oscillate earlobes) - caused by transmission of high RV pressures into great veins
- palpation - parasternal heave
- auscultation - pansystolic murmur (best heard at lower left sternal edge on inspiration - Carvallo sign) + loud P2 component of second heart sound
- chest examination - signs of pleural effusion, causes of pulmonary hypertension
- abdominal examination - palpable liver (tender, smooth, pulsatile), ascites, jaundice
- legs - pitting oedema
What murmur would you hear in tricuspid regurgitation?
Pansystolic murmur - left lower sternal edge (4th intercostal left parasternal region) on inspiration
What are the clinical features of pulmonary stenosis? (6)
- fatigue
- dyspnoea
- chest pain
- ascites
- oedema
- ejection systolic murmur
What murmur would you hear in pulmonary stenosis?
Ejection-systolic murmur with or without a systolic click - loudest over left upper sternal border
Severe/critical PS - long and harsh murmur peaking later in systole
Critical PS - may be soft due to poor cardiac output
What murmur would you hear in pulmonary regurgitation?
Early diastolic murmur (low-pitched decrescendo along left sternal border)
What is the RILE acronym for heart murmurs?
- Right-sided murmurs louder on Inspiration
- Left-sided murmurs louder on Expiration
How can we remember where to auscultate different murmurs?
A Place To Meet 22:45
- Aortic - right 2nd ICS sternal border
- Pulmonary - left 2nd ICS sternal border
- Tricuspid - left 4th/5th ICS sternal border
- Mitral - left 5th ICS, MCL
What are some risk factors for tricuspid stenosis? (5)
- 40-59 years
- Group A Streptococcal (GAS) pharyngitis
- metastatic carcinoid tumours
- artificial tricuspid valve
- IV drug use
What are some risk factors for tricuspid regurgitation? (6)
- left-sided heart failure
- dilated tricuspid annulus
- rheumatic heart disease
- permanent pacemaker
- endocarditis
- carcinoid heart disease
What are the 1st-line investigations for right heart valve disease? (3)
- echocardiogram - transthoracic, with Doppler
- ECG
- CXR
What might you see on 2D/Doppler echocardiogram in tricuspid stenosis?
- thickened, fused and doming valve leaflets with restricted motion
- reduced diameter of valve orifice
- elevated mean tricuspid valve gradient >2mmHg (peak velocity >0.7m/s)
- RA enlargement with dilated systemic and hepatic veins
What would you see in ECG in tricuspid stenosis? (2)
- tall, peaked P-waves in II, III, V1
- AF
What might you see on echocardiogram in tricuspid regurgitation? (3)
- measure extent with Doppler US
- annular diameter to measure severity
- may show valve prolapse and RV dilation
What might ECG show in pulmonary stenosis?
- mild - normal/mild RAD
- moderate - RAD + RV conduction delay
- severe/critical - extreme RAD, R-wave large for age, RA enlargement with tall and peaked P wave in II and V1-V3
What might you see in echocardiogram in pulmonary stenosis?
Increased transvalvular gradient across pulmonary valve during systole (>10mmHg)
What might you see in CXR in pulmonary regurgitation?
- PA dilation with clear lung fields
- RV dilation
What is the general management for tricuspid stenosis? (2)
- diuretics (fluid and sodium restriction + loop diuretic e.g. furosemide)
- surgical repair
What is the specific management for different types of tricuspid stenosis (congenital, carcinoid heart disease, rheumatic fever, IE)?
- congenital - surgery, preoperative alprostadil, postoperative antiplatelet therapy
- carcinoid heart disease - fluid and sodium restriction + loop diuretic (furosemide) + somatostatin analogue + valve replacement surgery or balloon dilatation
- rheumatic fever - fluid and sodium restriction + loop diuretic + surgical repair/replacement (severe)
- infective endocarditis - antimicrobial therapy + surgery
What is the general management for tricuspid regurgitation? (2)
- diuretics (for systemic congestion)
- tricuspid valve repair/annuloplasty or replacement (repair preferred)
How do we manage primary and secondary tricuspid regurgitation?
- primary (mild/moderate) - treat underlying cause + follow up + HF management + risk factor modification
- primary (severe) or secondary - tricuspid valve replacement/annuloplasty, repair if done with mitral valve disease
What is the management for pulmonary stenosis?
- mild - observation
- moderate/severe/critical:
- 1st line - percutaneous balloon pulmonary valvuloplasty
- 2nd line - surgical valvuloplasty
- if respiratory distress/cyanosis - give supplemental oxygen +/- alprostadil first-line
How do we manage pulmonary regurgitation?
- medical management of HF
- severe - inotropic support + pulmonary valve replacement +/- anticoagulation
What are some complications of tricuspid stenosis? (3)
- surgical complications
- bacterial endocarditis
- prosthetic valve failure
What are some complications of tricuspid regurgitation? (6)
- atrial arrhythmia
- advanced liver disease
- AV block
- MI
- prosthetic valve thrombosis
- prosthetic valve endocarditis
