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RV/PAH Flashcards

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USMLE® Step 1 flashcards
1
Q

What will Hepatic vein Doppler show in severe TR (in sinus rhythm)?

A

Prominent, late peaking systolic flow reversal wave

  • blunting of the forward flow systolic wave rather than flow reversal may occur in patients with severe TR and a large, compliant RA

****Systolic flow reversal may also occur in the setting of RV dysfunction

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2
Q

What Doppler parameters are supportive of tricuspid mechanical valve stenosis?

A
  • PHT > 230 ms
    • ​can identify a stenotic bileaflet tricuspid mechanical valve
  • Elevated MG ≥ 6 mmHg
  • Elevated TVV > 1.7 m/s
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3
Q

What findings are supportive of severe RV diastolic dysfunction?

A
  • E/A > 2.1
  • DT < 120 ms
  • Late diastolic antegrade flow in the pulmonary artery
    • suggest increased RV diastolic pressure
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4
Q

Describe the calculation for RAP

A
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5
Q

Describe the relationship to RAP / IVC collapse / Hepatic Vein Doppler flow

A
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6
Q

What is a characteristic of RV structure and function in patients with longstanding arrhythmogenic RV dysplasia (ARVD)?

A

RV regional dysfunction in RVOT and apical segments

  • Regional dysfunction is commonly noted in the RVOT, apex and basal RV free wall in the region of the “triangle of dysplasia”
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7
Q

Describe blood flow and velocities in the hepatic vein / RA

A
  • Antegrade flow from the hepatic veins –> RA occurs in systole (S) and diastole (D)
  • RA contraction –> brief retrograde late-diastolic flow (Ar), as well as late systole flow (Vr), occurs into the hepatic veins
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8
Q

What are the limitations to using hepatic venous flow to predict RAP?

A
  • TS or TR
  • Pericardial compression syndromes
  • High-grade AV block
  • Heart transplants
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9
Q

This finding is consistent with advanced RV disease in patients with cardiac amyloidosis?

A

Inspiratory hepatic venous atrial flow reversals

​

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10
Q

What are signs of advanced disease in the RV in cardiac amyloidosis?

A
  • RV free wall thickness > 7 mm
  • Tricuspid inflow –> restrictive filling pattern
  • Hepatic venous flow
    • reduced forward systolic flow
    • increased forward diastolic flow
    • inspiratory diastolic atrial flow reversal
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11
Q

Describe formula for calculating PASP

  • peak TR velocity 3 m/s
  • JVP 15 cm
A
  • PASP = 4 (TRVmax)2 + RAP
  • PASP = 36 + RAP
    • RAP = JVP x 0.7
      • since 1 cm water corresponds to 0.7 mmHg
  • PASP = 36 + 10
  • PASP = 46 mmHg
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12
Q

Calculate PVR:

  • TRpeak velocity = 3.6 m/s
  • RVOTVTI = 13 cm
A
  • PVR = (mPAP - PCWP) / CO
    • use TRpeak velocity (4V2) as a surrogate of mPAP
    • use RVOT VTI as a surrogate of CO
  • PVR = 36 mmHg - PCWP / 13

****Highest TR velocity and lowest VTI (CO) is the answer

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13
Q

What are the fomulas for PVR?

A

PVR = (mPAP - PCWP) / CO

or

PVR = 10 x (TRpeak systolic velocity / RVOT VTI) + 0.16

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14
Q

What is the mean PA pressure?

  • TRpeak velocity = 3 m/s
  • PRend-diastolic velocity = 2 m/s
  • RAP = 10 mmHg
A
  • mPAP = 1/3 PASP + 2/3 PADP
  • PASP = 4 (3)2 + 10 = 46
  • PADP = 4 (2)2 + 10 = 26
  • mPAP = 1/3 (46) + 2/3 (26)
  • mPAP = 15 + 17 = 32 mmHg
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15
Q

What are the formulas for mPAP?

A

mPAP = 1/3 PASP + 2/3 PADP

mPAP = 4(PRpeak velocity)2 + RAP

mPAP = Mean ΔP(RV-RA) + RAP

mPAP = 80 - (0.5 x RVOT AcT)

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16
Q

Caculate mPAP:

  • RVOT AcT = 120ms
A
  • mPAP = 80 - (0.5 x RVOT AcT)
  • mPAP = 80 - (0.5 x 120)
  • mPAP = 20 mmHg
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17
Q

Describe the findings and diagnosis

A

25 year old with recurrent septic PE

  • Hepatic venous flow –> holosystolic reversal
  • Severe TR
    • in the setting of endocarditis of the tricuspid valve
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18
Q

What are the findings on hepatic venous flow in the setting of RV infarction / acute infer wall MI?

A
  • RV filling pressures are increased
  • Predominant forward diastolic flow in the hepatic veins
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19
Q

Describe the findings and diagnosis

A

65 year old woman with hypertrophic cardiomyopathy and RV hypertrophy

  • Hepatic venous flow
    • large AR signal –> normal RA systolic function in the presence of increased RVEDP
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20
Q

42 year old woman with RV dilatation, what finding can estable the definitive diagnosis?

CW Doppler at the pulmonic valve is shown:

A

Color Doppler

  • Wide color Doppler jet can differentiate severe PR from a nonsignificant regurgitant lesion
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21
Q

What is the diagnosis:

  • Normal RV systolic function
  • Normal CO
  • Short PR DT
A

Severe PR (more likely)

Noncompliant RV (less likely)

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22
Q

What views can be utilized to assess RV function?

A
  • RV inflow (anterior and inferior walls)
  • A4C (free wall)
  • PLA RVOT view / PSA basal view (RVOT)
23
Q

What are the linear measurements of the RV body in assessment of RV chamber size?

A
  • RV basal dimension
  • RV mid dimension
  • RV longitudinal dimension
  • RVOT PLAX diameter
  • RVOT proximal diameter
24
Q

When are all RV linear dimensions measured?

A

end-diastole

25
Q

What are the abnormal values for RV Quantitative Dimensions?

A
26
Q

What are abnormal values for RV end-diastolic area?

A

RV end-diastolic area (men) > 25 cm2

RV end-diastolic area (women) > 20 cm2

27
Q

What is the general rule for RV / LV size?

A

RV should be no larger than 2/3’s the size of the LV in the A4C view

  • RV = LV size –> moderate RV dilation
  • RV > LV –> significant RV dilation
    • also considered with “apex-forming” RV
28
Q

What views is RV wall thickness assessed in?

A

Parasternal views (RVOT) and Subcostal view (lateral wall)

29
Q

What is the cutoff for RV hypertrophy?

A

> 5 mm at end-diastole

  • wall thickness has low sensitivity and specificity for identifying RV hypertrophy
30
Q

What are the quantitative parameters to evaluate RV systolic function?

Abnormal values?

A
  • TAPSE < 17 mm
  • Tricuspid annular velocity (S’) < 9.5 cm/s
  • RV 2D Fractional area change (FAC) < 35%
  • RV free wall strain < - 20% (more positive numbers)
  • RV index of myocardial performance
    • > 0.43 for PW
    • > 0.54 for TDI
  • 3D RVEF < 45%
31
Q

These findings or RV function are associated with a poor prognosis in patients with CHF and Pulmonary Hypertension?

A

Abnormal TAPSE and Strain

32
Q

Define TAPSE

How is it measured?

A
  • measure of longitudinal motion of the RV annulus
    • represents the distance that the annulus has travelled between the beginning and end of systole –> larger values represent greater RV annular function
  • measured in A4C, by placing cursor through the lateral TV annulus
33
Q

What are some limitations to TAPSE and Tricuspid Annular Velocity (S’)?

A
  • May not accurately reflect global RV function - remainder of RV could be functional/dysfunctional
    • PH –> preserved annular function but remainder of RV is dysfunctional
    • Post-cardiac surgery –> diminished TAPSE with normal global RV function
  • Angle-depdendent
    • incorrect measurements may be made if the cursor is not parallel to the longitudinal motion of the annular RV
34
Q

Define Fractional Area Change (FAC)

A
  • 2D surrogate for RVEF
  • Calculates the percent change in the RV area between systole and diastole
  • Reflects both longitudinal shortening and radial thickening of the RV inflow and RV body
  • Measured by tracing the endocardial contour of the “compacted” RV myocardium in systole and diastole from the A4C view
35
Q

What is the formula for RV FAC?

A

FAC = [(RVend diastolic area - RVend systolic area) / RVend diastolic area] x 100

Abnormal values < 35%

36
Q

Define RV Myocardial Performance Index (RIMP) / Tei index

A
  • Basis of the measurement is that a normal RV should spend more of the cardiac cycle ejecting blood than it spends in an isovolumetric state
  • Reflects both systolic and diastolic RV function
  • Lower values –> normal function
  • Measured by PW or tissue Doppler
37
Q

What is normal 3D RVEF?

A

RVEF > 45%

38
Q

Describe the findings and diagnosis

A
  • PW Doppler PV –> severe PR
    • steep signal indicating rapid equilibration of pressure between the PA and RV
    • RV diastolic pressure rises rapidly in the presence of severe PR and increased RV stiffness
  • Hepatic Doppler flow –> predominant forward flow in diastole
39
Q

Describe the findings and diagnosis in a patient with Pulmonary Hypertension

A

Pulmonary Hypertension - Successful treatment with Bosentan will lead to an increase in mitral E/A ratio

  • Doppler findings –> indicate PH of a noncardiac etiology
    • E/A < 1
    • normal lateral e’
    • reduced septal e’
  • E/e’ < 10 –> normal or reduced LV filling pressures
  • Mitral E/A < 1
    • not due to impaired LV relaxation, but reduced LV filling due to PH and dilated RV
40
Q

Describe the findings and diagnosis in this patient with Pulmonary Hypertension

A

LV relaxation is impaired and LA pressure is increased

  • Grade 2 diastolic dysfunction - Pseudonormal LV filling pattern
  • Decreased lateral e’ velocity –> impaired LV relaxation
  • E/e’ –> increased LV filling pressures
  • Treatment with diuretics –> reduction in LV filling and mitral E/A ratio
41
Q

What is McConnell sign?

A
  • Echo finding in acute PE
  • Akinesia of the mid-RV free wall and a spared normally functioning RV apex
42
Q

What is the PASP in this patient?

  • TRpeak velocity 2.8 m/s
  • Hepatic venous flow - S/D ratio - 0.35
A

PASP = 41-46 mmHg

  • PASP = 4V2 + RAP
  • PASP = 4 (2.8)2 + RAP
    • RAP with predominant forward diastolic flow = RAP 10-15 mmHg
  • PASP = 31 mmHg + 10-15 mmHg
  • PASP = 41-46 mmHg
43
Q

Describe findings of Hepatic Doppler flow in relation to respiration

A

Phase 1 - Inspiration

  • Augmentation in forward flow velocities
  • Expiration –> decreased in forward flow velocities with increase in diastolic flow reversal velocity (not seen)
44
Q

What are characteristics of severe TR on CW Doppler?

A

dense, triangular shaped, early peaking signal

  • Peak velocity = 160 ms
  • holosystolic, hepatic venous flow reversal
45
Q

Describe the findings and relationship to RV pressure

A

RV pressure that is very similar to RA “v” wave pressure

  • dense, triangular shaped, early peaking signal
  • Peak velocity = 160 ms
  • holosystolic, hepatic venous flow reversal
46
Q

What is important in the assessment of PASP, patients with severe TR and small systolic transvalvular pressure gradients?

A
  • Correct estimation of PA systolic pressure is challenging (due to a small systolic transvalvular pressure gradient)
  • highly dependent on the accurate assessment of RAP - not the TR peak velocity
47
Q

Common finding in patient’s with Ebstein’s anomaly that can lead to neurologic sequelae?

A

Interatrial shunting via PFO or ASD

48
Q

What is true concerning the TR jet and pulmonary venous flow signals?

A

Septal systolic velocity by TDI is probably reduced

  • Severe TR (peak velocity 4 m/s) with PASP 64 mmHg
49
Q

Describe the findings and diagnosis

A

PASP is normal

  • SAX –> D-shaped interventricular septum in systole and diastole –> consistent with increased RVSP
  • Color doppler –> flow acceleration across the pulmonic valve = PS
    • mild PR
  • RV hypertrophy is present and cannot be normal in this patient
    *
50
Q

Describe findings related to CW doppler recorded at RVOT in this patient

A

Hepatic veins will have a prominent atrial reversal signal after RA contraction

  • Severe PS
    • Pulmonic valve PV > 6 m/s
  • RV hypertrophy / RV stiffness –> late-diastolic pressures are increased –> prominent AR signal in hepatic venous flow with RA contraction
51
Q

When is a D-shaped septum seen?

A
  • Significant Pulmonary Stenosis
    • secondary to increased RV systolic pressure / RV hypertrophy
    • occurs in both systole and diastole
52
Q

How can RV diastolic dysfunction be identified?

A

Increased AR velocity and duration in Hepatic venous flow

53
Q

Describe the findings and diagnosis

A

Severe PR - CW doppler

  • Increase in velocity across the pulmonic valve is largely due to increased transvalvular flow, and not valve stenosis
  • Severe PR –> steep rise in RV diastolic pressure that leads to rapid equalization of the pressure gradients between the PA and the RV in early diastole
    • PR signal with steep deceleration and short PHT
    • flat septum only noted in diastole (systolic pressures not elevated)
54
Q

What are features of severe PR on 2D Echo and CW Doppler?

A
  • Dilated RV with eccentric hypertrophy
  • Flat septum in diastole
    • IVS motion is characterized by an RV volume overload pattern
  • CW Doppler
    • rapid DT
    • short PHT

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