Set 5 Flashcards
An 18 year old male complains of palpitations. His chest x-ray reveals cardiomegaly and as a result, an echocardiogram is ordered. The echo reveals right atrial and ventricular enlargement. The tricuspid valve appears abnormally displaced towards the apex. What is this patients most probable cardiac abnormality?
This patient probably has Ebstein’s anomaly. Often patients with Ebstein’s anomaly are asymptomatic and this finding is a surprise when an echocardiogram is performed for something like evaluating a murmur
What additional test should be performed in the echo lab for a patient with Ebstein’s anomaly?
A microcavitation (saline bubble or contrast) study should be performed to identify the presence of absence of an associated atrial septal defect
What are the main echocardiographic findings associated with chronic tricuspid regurgitation?
Mild chronic tricuspid regurgitation may yield normal echo findings.
In contrast, Moderate to Severe regurgitation causes right ventricular volume overload.
The right ventricle becomes dilated and flattening of the interventricular septum in diastole may be evident.
Due to increased volume and pressure, the right atrium is dilated and the vena cava is distended
What are the main echocardiographic findings associated with acute tricuspid regurgitation?
Mild acute tricuspid regurgitation may yield normal echo findings. More likely, however, the echo will show some evidence of valvular diseases (such as trauma related prolapse, other valvular disruptions, or vegetative lesions)
Moderate to Severe acute tricuspid regurgitations may cause hyperdynamic motion and mild dilatation of the right ventricle. The right ventricle does not have time to enlarge, as it does in chronic regurgitation. The right atrium is slightly dilated and the IVC is distended
What happens during a Ross Procedure?
During a Ross Procedure, the patients pulmonic valve is surgically moved to the aorta (coronaries need to be detached and reattached) and then a homograft prosthetic valve is put in the pulmonary position.
This surgery is usually performed for congenital aortic stenosis. Sometimes called a Double Valve Surgery
How is tricuspid regurgitation quantified by color flow Doppler imaging?
Color flow Doppler imaging “maps” the area of regurgitant flow.
Unlike the pulsed Doppler approach, color flow imaging shows the regurgitant jet within a single cardiac cycle
The larger the jet, the more severe the regurgitation. In determining the severity of tricuspid regurgitation, the examiner must take into account the total size, length, duration, and width of the jet as well as the patients pulmonary pressures
How does tricuspid regurgitation affect the atria?
Tricuspid regurgitation causes right atrial enlargement
The degree of such enlargement is usually proportional to the severity of regurgitation. Trivial or mild regurgitation rarely results in atrial enlargement.
Unlike tricuspid stenosis, in which atrial enlargement is due to increased pressure, tricuspid regurgitation causes atrial enlargement via volume overload.
How does tricuspid regurgitation affect the ventricles?
Mild tricuspid regurgitation does not noticeably affect either ventricle.
Moderate to severe regurgitation results in volume overload of the right ventricle. The right ventricle becomes dilated and hypercontractile in the absence of systolic dysfunction.
The left ventricle is not usually affected
If you already know the peak tricuspid regurgitation velocity, how can you calculate the right ventricular systolic pressure (RVSP)?
To calculate the RVSP, add the tricuspid regurgitation (TR) gradient (converted from the velocity to mmHg by 4V squared) and the estimated right atrial (RA) pressure (from IVC size and collapsibility)
The equation is:
RVSP = TR gradient + RA pressure
What is the significance of the RVSP calculation?
This calculation is a means of non invasively calculating the pulmonary artery pressure.
In the absence of pulmonic stenosis, the pulmonary artery pressure will be the same as the right ventricular systolic pressure.
What is carcinoid syndrome?
Carcinoid syndrome is associated with carcinoid tumors of the intestinal tract or pancreas.
Such tumors release serotonin, an acidic “tar-like” compound that is deposited on the endocardial walls and valvular surfaces
How does carcinoid syndrome cause tricuspid regurgitation?
Serotonin deposits build up on the tricuspid or pulmonic leaflets, causing them to become thickened and immobile so that they cannot coapt properly.
This often results in moderate to severe regurgitation.
In some patients the valves become immobile in the closed position creating stenosis.
The serotonin is filtered by the lungs so the left sided valves (mitral and aortic) are not usually affected
Define tricuspid valve prolapse
Tricuspid valve prolapse denotes systolic displacement of one or more tricuspid leaflets into the right atrium.
The anterior and septal (medial) tricuspid leaflets prolapse more frequently than the posterior leaflet
What is the relationship between tricuspid valve prolapse and mitral valve prolapse?
Almost 90% of patients with tricuspid valve prolapse also have mitral valve prolapse.
What is the incidence of tricuspid stenosis in rheumatic heart disease?
Approximately 15% of patients with rheumatic heart disease have some degree of tricuspid stenosis
The symptoms of tricuspid stenosis may be masked by mitral stenosis which is almost always present.
Describe the anatomy of the pulmonic valve, including the name and location of each leaflet.
The pulmonic valve is the most anteriorly positioned cardiac valve
It lies within the right ventricular outflow tract, to the left of the aortic valve.
The pulmonic valve has 3 leaflets: the anterior, right (posterior), and left.
The right leaflet is also referred to in M-mode books as the posterior.
What is the primary M-mode finding associated with pulmonic stenosis?
The primary M-mode finding associated with pulmonic (valvular) stenosis is an increase of more than 7 mm in the “a” dip with atrial contraction towards the end of diastole
What are the primary 2D echo findings associated with pulmonic stenosis?
- Valve thickening
- Decreased leaflet excursion
- Systolic doming
- Right ventricular hypertrophy
- Post-stenotic dilatation of the pulmonary artery
When assessing a patient post myocardial infarction (MI), how many wall segments need to be abnormal in order to call a wall motion abnormality?
Having even 1 abnormal wall segments meets the criteria of a wall motion abnormality.
In order to make the diagnosis of Ebstein’s anomaly, how far apically displaced does the tricuspid leaflets have to be from the mitral valve?
In order to make the diagnosis of Ebstein’s anomaly, the tricuspid leaflets need to be more than 10mm (1cm) apically displaced from the insertion of the anterior mitral valve.
What is the most common cause of pulmonic stenosis?
The most common cause of pulmonic stenosis is a congenital abnormality
What are the main echo findings associated with chronic pulmonic regurgitation?
In trivial or mild pulmonic regurgitation, the echo findings may be normal.
Moderate to severe regurgitation is indicated by early right ventricular dilatation, paradoxical septal motion, and hypercontractility.
Later in the disease process, impairment of right ventricular function appears.
What is the most common cause of pulmonic regurgitation?
Pulmonic regurgitation usually affects valves that are otherwise “normal”
About 60% of the general population has some degree of pulmonic regurgitation, probably owing to altered pulmonary artery geometry. (Because the pulmonary artery lies across the aorta, the artery’s shape changes from circular to oblong at this site)
Because pulmonic pressure is normally low, the valve may not close tightly.
How does carcinoid syndrome cause pulmonic stenosis?
Serotonin builds up on the pulmonic and/or tricuspid leaflets, causing them to become thickened and immobile.
If they become fixed in the closed position, stenosis will result.
How does carcinoid syndrome cause pulmonic regurgitation?
If the leaflets become fixed in the open position (as is usually the case), regurgitation will ensue.
How does pulmonary hypertension affect pulmonic regurgitation?
Pulmonic hypertension causes the peak regurgitant velocity to increase.
Normally the regurgitant velocity is about 1 m/sec
In pulmonic hypertension, however, the regurgitant velocity may be greater than 4 m/sec
Describe the typical 2D echo appearance and location of mitral valve vegetations in endocarditis
- Thick, redundant (excessively large or floppy) leaflets
- Mass lesions on the flow (atrial) side of the leaflets
- Mobile masses in the left atrium during systole and in the left ventricle during diastole
Why are intravenous drug abusers at risk for endocarditis involving the right side of the heart?
Intravenous drug abusers are at risk for endocarditis involving the right side of the heart (75% of the time) because they use contaminated needles or syringes to make multiple injections into the venous system
What is the most common organism seen in intravenous drug abusers?
Staphylococcus aureus is the most common organism seen in intravenous drug absuers
