RV/PAH Flashcards
What will Hepatic vein Doppler show in severe TR (in sinus rhythm)?
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
What Doppler parameters are supportive of tricuspid mechanical valve stenosis?
-
PHT > 230 ms
- can identify a stenotic bileaflet tricuspid mechanical valve
- Elevated MG ≥ 6 mmHg
- Elevated TVV > 1.7 m/s
What findings are supportive of severe RV diastolic dysfunction?
- E/A > 2.1
- DT < 120 ms
- Late diastolic antegrade flow in the pulmonary artery
- suggest increased RV diastolic pressure
Describe the calculation for RAP
Describe the relationship to RAP / IVC collapse / Hepatic Vein Doppler flow
What is a characteristic of RV structure and function in patients with longstanding arrhythmogenic RV dysplasia (ARVD)?
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”
Describe blood flow and velocities in the hepatic vein / RA
- 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
What are the limitations to using hepatic venous flow to predict RAP?
- TS or TR
- Pericardial compression syndromes
- High-grade AV block
- Heart transplants
This finding is consistent with advanced RV disease in patients with cardiac amyloidosis?
Inspiratory hepatic venous atrial flow reversals
What are signs of advanced disease in the RV in cardiac amyloidosis?
- 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
Describe formula for calculating PASP
- peak TR velocity 3 m/s
- JVP 15 cm
- PASP = 4 (TRVmax)2 + RAP
- PASP = 36 + RAP
- RAP = JVP x 0.7
- since 1 cm water corresponds to 0.7 mmHg
- RAP = JVP x 0.7
- PASP = 36 + 10
- PASP = 46 mmHg
Calculate PVR:
- TRpeak velocity = 3.6 m/s
- RVOTVTI = 13 cm
- 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
What are the fomulas for PVR?
PVR = (mPAP - PCWP) / CO
or
PVR = 10 x (TRpeak systolic velocity / RVOT VTI) + 0.16
What is the mean PA pressure?
- TRpeak velocity = 3 m/s
- PRend-diastolic velocity = 2 m/s
- RAP = 10 mmHg
- 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
What are the formulas for mPAP?
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)
Caculate mPAP:
- RVOT AcT = 120ms
- mPAP = 80 - (0.5 x RVOT AcT)
- mPAP = 80 - (0.5 x 120)
- mPAP = 20 mmHg
Describe the findings and diagnosis
25 year old with recurrent septic PE
- Hepatic venous flow –> holosystolic reversal
- Severe TR
- in the setting of endocarditis of the tricuspid valve
What are the findings on hepatic venous flow in the setting of RV infarction / acute infer wall MI?
- RV filling pressures are increased
- Predominant forward diastolic flow in the hepatic veins
Describe the findings and diagnosis
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
42 year old woman with RV dilatation, what finding can estable the definitive diagnosis?
CW Doppler at the pulmonic valve is shown:
Color Doppler
- Wide color Doppler jet can differentiate severe PR from a nonsignificant regurgitant lesion
What is the diagnosis:
- Normal RV systolic function
- Normal CO
- Short PR DT
Severe PR (more likely)
Noncompliant RV (less likely)
What views can be utilized to assess RV function?
- RV inflow (anterior and inferior walls)
- A4C (free wall)
- PLA RVOT view / PSA basal view (RVOT)
What are the linear measurements of the RV body in assessment of RV chamber size?
- RV basal dimension
- RV mid dimension
- RV longitudinal dimension
- RVOT PLAX diameter
- RVOT proximal diameter
When are all RV linear dimensions measured?
end-diastole
What are the abnormal values for RV Quantitative Dimensions?
What are abnormal values for RV end-diastolic area?
RV end-diastolic area (men) > 25 cm2
RV end-diastolic area (women) > 20 cm2
What is the general rule for RV / LV size?
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
What views is RV wall thickness assessed in?
Parasternal views (RVOT) and Subcostal view (lateral wall)
What is the cutoff for RV hypertrophy?
> 5 mm at end-diastole
- wall thickness has low sensitivity and specificity for identifying RV hypertrophy
What are the quantitative parameters to evaluate RV systolic function?
Abnormal values?
- 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%
These findings or RV function are associated with a poor prognosis in patients with CHF and Pulmonary Hypertension?
Abnormal TAPSE and Strain
Define TAPSE
How is it measured?
- 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
What are some limitations to TAPSE and Tricuspid Annular Velocity (S’)?
- 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
Define Fractional Area Change (FAC)
- 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
What is the formula for RV FAC?
FAC = [(RVend diastolic area - RVend systolic area) / RVend diastolic area] x 100
Abnormal values < 35%
Define RV Myocardial Performance Index (RIMP) / Tei index
- 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
What is normal 3D RVEF?
RVEF > 45%
Describe the findings and diagnosis
- 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
Describe the findings and diagnosis in a patient with Pulmonary Hypertension
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
Describe the findings and diagnosis in this patient with Pulmonary Hypertension
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
What is McConnell sign?
- Echo finding in acute PE
- Akinesia of the mid-RV free wall and a spared normally functioning RV apex
What is the PASP in this patient?
- TRpeak velocity 2.8 m/s
- Hepatic venous flow - S/D ratio - 0.35
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
Describe findings of Hepatic Doppler flow in relation to respiration
Phase 1 - Inspiration
- Augmentation in forward flow velocities
- Expiration –> decreased in forward flow velocities with increase in diastolic flow reversal velocity (not seen)
What are characteristics of severe TR on CW Doppler?
dense, triangular shaped, early peaking signal
- Peak velocity = 160 ms
- holosystolic, hepatic venous flow reversal
Describe the findings and relationship to RV pressure
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
What is important in the assessment of PASP, patients with severe TR and small systolic transvalvular pressure gradients?
- 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
Common finding in patient’s with Ebstein’s anomaly that can lead to neurologic sequelae?
Interatrial shunting via PFO or ASD
What is true concerning the TR jet and pulmonary venous flow signals?
Septal systolic velocity by TDI is probably reduced
- Severe TR (peak velocity 4 m/s) with PASP 64 mmHg
Describe the findings and diagnosis
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
*
Describe findings related to CW doppler recorded at RVOT in this patient
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
When is a D-shaped septum seen?
- Significant Pulmonary Stenosis
- secondary to increased RV systolic pressure / RV hypertrophy
- occurs in both systole and diastole
How can RV diastolic dysfunction be identified?
Increased AR velocity and duration in Hepatic venous flow
Describe the findings and diagnosis
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)
What are features of severe PR on 2D Echo and CW Doppler?
- 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
