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PTE Masters Ravi > The Right Heart > Flashcards

The Right Heart Flashcards

1
Q

What view is this?

What tricuspid valve leaflets are shown?

A

Mid-esophageal 4 chamber with focus on the RV

Tricuspid Valve: septal (STVL) + anterior (ATVL) leaflets

Septal = Medial leaflet

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2
Q

RV regional wall motion abnormalities that involve the base of the RV with sparing of the RV apex are particularly suggestive of:

1. What pathology?

2. What sign?

A

Pulmonary Embolism

McConnell Sign

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3
Q

What view of this?

What is the valve shown here?

What is 1?

What is 2?

A

Deep TG of tricuspid valve

1 = Posterior Valve

2 = Anterior or Septal Valve

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4
Q

What view?

What are leaflets 3 and 4?

A

Tricuspid Valve of ME RV inflow/Outflow

3 = Anterior or septal

4 = Posterior

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5
Q

What view of the RV under TEE is correlated best with MRI resolution RV Ejection Fraction?

A

Mid-esophageal 4 chamber

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6
Q

What is TAPSE?

A

Tricuspid annular plane systolic excursion (TAPSE)

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7
Q

What TEE view is best used to calculate TAPSE?

A

Midesophageal 4 chamber view

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8
Q

What are all the views to assess the RV?

A

ME-4 chamber

ME - RV inflow-outflow

ME Asc Aorta Short Axis

ME Bicaval view (modified bicaval) (Doppler of Tricuspid insufficiency jet to calculate RVSP)

Upper Esophageal Aortic Arch Shot Axis

TG Short Axis

TG RV inflow (TGSAx then change sector to 90 degrees)

Deep TG RV outflow (Angle for tissue doppler for Syst and diast)

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9
Q

What are the two views you can use to calculate RVSP?

A

Mid esophageal RV inflow-outflow to get RVSP

Mid Esophageal Bicaval Modified to get RVSP

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10
Q

What views can you align a doppler along the pulmonic valve parallel to blood flow?

A

Mid Esophageal Ascending Aortic Short Axis

Upper Esophageal Aortic Arch Short Axis

(Images 1 and 3 in photo)

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11
Q

What is the arrow pointing at?

A

Left Atrium

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12
Q

What is the arrow pointing at?

Which coronary cusp?

A

Aortic Valve

Specifically, the non-coronary cusp

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13
Q

What is the arrow pointing at?

Which coronary cusp?

A

Aortic Valve

Right Coronary Cusp

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14
Q

What cusp is to the right of the arrow?

A

Left Coronary Cusp of the Aortic Valve

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15
Q

What is the green arrow pointing at?

A

Coronary Sinus

(Probe turned to the right and advanced slightly from your 4 chamber view)

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16
Q

In the modified Bicaval View listed

What is the top left arrow? (Teal)

What is the top right arrow? (White)

What is the bottom right arrow? (Green)

A

Teal = Coronary Sinus

White = SVC

Green = Right Atrial Appendage

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17
Q

What view do we see here?

What is the arrow pointing to?

A

Transgastric Mid Papillary Short Axis View

Arrow = Moderator Band

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18
Q

What view is seen here?

A

Transgastric RV inflow view

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19
Q

What view is this?

Label:

Pink

Teal

Green

A

Deep Transgastric RV outflow

Pink = TV

Teal= RA

Green = AV

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20
Q

What is seen in green?

A

Pulmonic Valve

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21
Q

What view is seen?

What is the dotted line?

Label

Green

Teal

BLue

A

Upper Esophageal Aortic Arch Short Axis

Dotted line = Parallel Continuous Wave Doppler on Pulmonic Valve

Green = Pulmonary Valve

Teal = Aortic Valve

Blue = Innominate Vein

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22
Q

What view is seen here?

Label the major vessels here

A
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23
Q

What is the structure labeled “Z”?

A

Pulmonary Artery Catheter

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24
Q

What view is this?

A

Midesophageal Bicaval View (Modified)

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25
Q

What is the formula to calculate RVSP?

A

RVSP = 4 (Velocity of TR peak)2 + Right Atrial Pressure

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26
Q

What physics principle is used to come up with the RVSP equation?

A

Bernoulli

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27
Q

How does the RSVP equation change if you have pulmonic stenosis?

A

You must substract the PA pressure across the valve

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28
Q

Label teal arrow

Label White arrow

Label Green arrow

A

Teal = Coronary SInus

White = SVC

Green = Right atrial appendage

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29
Q

How do you tell a difference in the IVC vs. Coronary sinus in the bicaval view?

A

IVC is larger, and more “flat”

Coronary Sinus is smaller and angled more vertical “up” on the screen

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30
Q

What % of CPB circ failure is due to RV failure?

A

20%

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31
Q

Why doesn’t retrograde cardioplegia protect the Right heart well?

A
  1. Right heart drains into Thebesian Veins, which drain into the right ventricle (Not into the coronary sinus)
  2. When ice is placed on the heart, doesn’t cool the right heart as much
  3. Air shoots down the RCA is air embolism occurs
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32
Q

What % of patients have severe refractory RV failure in:

  1. Cardiotomy?
  2. Heart Transplantation?
  3. LVAD?
A

0.1% cardiotomy

2-3% of heart transplantation

20-30% of patients receiving LVAD

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33
Q

Mechanically, how does an LVAD make RV function worse?

A

LVAD sucks the septum towards the device and the septum no longer participates in RV contraction

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34
Q

How does an IABP cause RV dysfunction?

A

IABP Causes decrease in RV afterload

Due to RV afterload reduction, septum shifts toward LV

RV can then not help as much participate in contraction

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35
Q

Comment on the Compliance, Resistance and Loading conditions pertaining to the right heart.

A

Compliance = High

Resistance = Low

Loading conditions = Sensitive to

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36
Q

What are the 4 quantititative measures of RV function?

A

RVFAC (RV Fractional Area Change)

RVEF

TAPSE - Tricuspid Annular Plane Systolic Excursion

IVA = Isovolumetric Acceleration

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37
Q

What is the normal values of RVFAC (RV Fractional Area Change)?

A

RVFAC (RV Fractional Area Change)

>/= 32%

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38
Q

What is the normal Values of RVEF?

A

RVEF

>/- 45%

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39
Q

What are the normal values for TAPSE?

A

TAPSE

Normal = Anything above 17

>17 mm (Cutoff for nomal)

Anything below this is abnormal

TAPSE doesn’t stratify low normal vs. normal

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40
Q

What is the normal value for IVA?

A

IVA = Isovolumetric Acceleration

1.4 +/- 0.5 m/s2

(Lower range of normal, 2.2 in other studies)

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41
Q

Why is RVEF approx >45 % and LVEF >55-65%?

A

RV end-systolic and end-diastolic volumes are higher than LVESV and LVEDV

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42
Q

What is the TV S’ (S Prime) for the lower range of normal?

A

<10

(I’ve read <9.5 cm/sec in TTE guidelines)

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43
Q

How do we measure TAPSE?

A

You are looking at the “swinging” of the lateral tricuspid annulus toward the apex

A - B = TAPSE

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44
Q

What is the equation to IVA (Isovolumetric acceleration)?

A

Vt / (Delta) t

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45
Q

What is the formula for RV FAC?

Which TEE view would be ideal?

A

[End Diastolic Area - End Systolic Area] / [End Diastolic Area}

View = Mid esophageal 4 chamber view

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46
Q

What view is this?

What is the arrow pointing at? (Purple arrow)

A

Mid Esophageal RV Inflow Outflow

Eustachian Valve

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47
Q

What view is this?
What is the arrow pointing to?

What is this arrowed structure attached to?

A

Transgastric Mid Papillary Short Axis View

Moderator Band

Moderator Band attached to anterior papillary muscle

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48
Q

What view is seen here?

A

Transgastric RV inflow view

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49
Q

What happens to the septum with volume overload?

A

Late diastolic septal motion to the left

(IN late diastole, that is when RV volume is the highest)

Left to Right shows progression of RV dysfunction

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50
Q

What are the etiologies that are possible with volume overload where you have flattening of the septum?

A

Pulmonary insufficiency (PI)

Atrial Septal Defect (ASD)

Tricuspid Regurgitation

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51
Q

What is the eccentricity index?

A

A / B (Measure anterior and posterior index)

Quantifies how much septal bowing you have

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52
Q

How does your eccentricity index change with worsening RV failure?

A

A > B as the RV turns into a “D” shape and your eccentricity index will rise

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53
Q

What will you see in isolated pressure overload of the RV?

A
  1. Paradoxical Septal Motion
  2. Late systolic Septum –> Left
  3. RVH = Thickness > 5mm
54
Q

How do you differentiate between isolated pressure overload vs. isolated volume overload in regard to septal shifting of the RV?

A

Volume Overload = Max septal shift in late diastole

Pressure overload = Max septal shift in late systole

55
Q

What is apex forming?

A

When the RV forms the apex image of the heart, you have RV dysfunction

(Normal = LV forms your apex)

56
Q

What will you see during pulmonary embolism on the mid-esophageal 4 chamber?

What is this called?

A

Apex of the RV moves, but the base of the RV doesn’t move?

McConnell Sign

57
Q

Label this entire image

  1. Valves first
  2. Cusps top valve
  3. Cusps right valve
A

Top = Pulmonic Valve

Aortic Valve = Center

Mitral Valve = Left

Tricuspid Valve = Right

58
Q

In the 4 chamber mid esophageal view, what tricuspid leaflets are seen?

A

If you are seeing anterior structures (Aortic Valve, LVOT), then you are seeing anterior leaflet on the Left.

If you are seeing posterior structure (Coronary Sinus), then you are seeing posterior leaflet on the left.

The right side is always showing the septal leaflet

59
Q

What is the structure seen in green?

What tricuspid leaflets are seen here?

A

Coronary sinus

Posterior (left) and Septal (Right)

60
Q

What leaflets of the tricuspid valve seen here?

A

Anterior (Left) and Septal (Right)

because we are in ME-5 chamber and its looking at more anterior structutres

61
Q

What valves of the tricuspid valves are seen here?

A

Left = Posterior

Right = Anterior/Septal Leaflet

62
Q

In the transgastric mid papillary short axis, label the triscupid valve leaflets.

A
63
Q

In the TG RV view, what tricuspid leaflets are seen here?

A

Top = Posterior

Bottom = Anterior or Septal

64
Q

What is the type of TR that develops with normal valve leaflets?

A

Functional TR

65
Q

What happens to the triscupid valve with a PA catheter?

A

Mild TR

66
Q

What are some other etiologies of TR outside of functional TR (Normal valves) and PA-Catheter induced mild TR?

A
  1. Annular Dilation
  2. Papillary muscle dysfunction
  3. Pressure / Volume overload
67
Q

What is the term for TR due to abnormal valve leaflets?

A

Structural TR

68
Q

What are some etiologies of abnormal valve leaflets (Structural TR)

A
  1. Rheumatic
  2. Myxomatous Degeneration
  3. Ebstein’s Anomaly
  4. Carcinoid Heart Syndrome
  5. Endocarditis (IVDU)
69
Q

What is the most common cause of triscupid stenosis?

A

Rheumatic Heart Disease

70
Q

Rheumatic Heart Disease is more likely to cause TS or TR?

A

TR > TS

71
Q

Rheumatic Heart Disease affects which valves most commonly (List stenosis vs. regurgitation).

A
  1. Mitral Valve
  2. Mitral Valve and Aortic
  3. Mitral, Aortic and Tricuspid (20-30%)
  4. Aortic Valve alone (<5%)
72
Q

What occurs with the leaflets with Ebstein’s Anomaly?

A

Large “sail-like” anterior leaflet (Left side of image)

Anterior leaflet attaches to the TV annulus

TV is funnel shaped and incompentent

73
Q

What happens to the RV in ebstein’s anomaly?

A

Atrialization of the part of the RV

74
Q

What two conditions is Ebstein Anomaly associated with?

A
  1. ASD
  2. SVT (Wolff-Parkinson-White (WPW) syndrome)
75
Q

Why is serotonin only affecting right sided heart valves?

A

Serotonin is degraded by monoamine oxidases in the lungs

76
Q

What is the classic sign of Carcinoid Syndrome?

A

Thickening and fibrosis of the TV and PV

Can cause stenosis or regurgitation of both left sided valves

77
Q

When can you have carcinoid syndrome affecting the left heart?

A

PFO

78
Q

With carcinoid syndrome, is stenosis or regurgitation more common?

Which leaflets are involved?

A

Regurgitation more common

Septal and Anterior Leaflets

79
Q

How do you grade Triscupid Regurgitation in terms of mild, moderate and severe?

CWD Jet Density

Jet Area

Vena Contracta

Hepatic Venous Flow

A
80
Q

What are the waves in Hepatic Vein Velocity?

A

A

S

V

D

81
Q

What do the A, S, V, and D waves of HV Velocity? correlate to on the CVP tracing

A

A = a waves

S = x descent

V = v wave

D = y descent

82
Q

What is the CVP pattern and HV pattern seen with Tricuspid insufficiency?

A

C and V wave

A wave and V wave present but “retrograde flow” seen instead of S wave.

83
Q

What is seen in the image below?

A

Holosystolic HVF reversal seen in severe Tricuspid insufficiency.

Note: The Pulse Wave doppler is seen through the hepatic vein

88
Q

Why is Tricuspid Stenosis very rare?

A

The annulus is very large, so hard to get a stenotic valve

89
Q

What is the most common cause of Tricuspid stenosis?

A

Rheumatic Disease

(Although TR is more common than TS with Rheumatic disease)

90
Q

What are the two other most common etiologies to TS other than rheumatic disease?

A
  1. Carcinoid Syndrome
  2. Congenital Abnormalities
91
Q

What is the normal peak TV velocity?

A

30 - 70 cm/sec

92
Q

Name all the valves and label each cardiac valves

A
93
Q

What pulmonic leaftlets are seen in the ME RV inflow outflow tract?

A

“Top” = R/L

Bottom = Anterior

94
Q

When we grade TS, do we use mean or peak gradients?

A

Mean

95
Q

What quantitative value of mean Peak gradient is used to define severe TS?

A

>5 mmHg

96
Q

Gradients used to evaluate TS are dependent on what two variables?

A

1. HR

HR increase (Decreases diastolic filling time therefore increased gradient)

2. Flow

Decreased flow = Decreased gradient

97
Q

Label:

Green

Teal

Blue

A

Green = Pulmonic Valve

Teal = Aorta

Blue = Innominate Vein

98
Q

Label the image regarding Pulmonary Valve

Systolic Ejection

Early Velocity

Late Velocity

A
99
Q

When you use continuous pulse wave doppler on the pulmonic valve, you see this.

What is it?

A

Holodiastolic Flow Reversal

Indicates severe pulmonary insufficiency

100
Q

How many cusps are on the pulmonic valve?

What are they?

A

3

1. Anterior

2. Right

3. Left

103
Q

How do we obtain a PA systolic pressure from RVSP and pulmonic stenosis?

A

1. Calculate RVSP (RVSP = 4 (Velocity of TR Peak)2 + RAP

2. Subtract Max Gradient from RVSP

104
Q

What are the 4 aspects of Tetrology of Fallot?

A
  1. VSD
  2. Overriding Aorta
  3. Pulmonic Obstruction (No flow = No grow)
  4. RVH
105
Q

Significant PI is usually what etiology?

A

Congenital

106
Q

What are the etiologies of acquired pulmonic insufficiency?

A
  1. Carcinoid
  2. Endocarditis (Least common valve infected by this pathology)
  3. Pulmonary Hypertension
  4. Myxomatous Disease
  5. Radiation to the Thorax
107
Q

What are the 3 objective criteria to determine pulmonic insufficiency?

A
  1. Jet area
  2. Jet width
  3. Holodiastolic Flow reversal in the main PA
111
Q

What is the etiology of pulmonic stenosis?

A

Congenital

112
Q

How do you assess pulmonic stenosis gradient?

A

Peak and Mean Gradient with CWD

113
Q

How do we obtain RVSP with pulmonic stenosis?

Hint: Equation

A

CWD on the tricuspid valve

Change in Pressure = 4 (Velocity of TR Peak)2 + RAP

Note: The velocity is in meters/sec

114
Q

You have a patient with pulmonic stenosis. What is the most critical component of their management?

A

Do not allow their aortic diastolic pressure to drop

115
Q

What is Arrow 1?

What is Arrow 2?

A

Arrow 1 = D wave

Arrow D = S wave

116
Q

What is #7?

What is #8?

A

7 = Posterior

8 = Anterior

Tricuspid Valve

117
Q

Holodisatolic Flow reversal in the main PA may result from?

A. Severe PI

B. PDA

  1. Aortopulmonary Window

D. Severe TR

E. A, B, C

F. All of the above

A

Answer = A, B, C

118
Q

The intensity of the TV regurgitant signal relative to the intensity of the antegrade flow signal on the CWD spectal profile reflects which of the following?

A. The regurgitant volume of blood traversing the valve

B. Parallel alignment of the U/S beam with blood flow

C. The velocity of the tricuspid blood flow

D. The depth of the sample volume

E. The Nyquist limit of the Doppler U/S Beam

A

A = Regurgitant Volume of blood traversing the valve

119
Q

Ebstein Anomaly is most likely associated with which of the following?

A. Dilated PA
B. ASD
C. Small anterior TV leaflet

D. LVOT obstruction

E. Cor triatriatum dexter

F. Supravalvular Aortic Stenosis

A

ASD

120
Q

Which of the following best describes a valvular disorders where one or more of the TV leaflets are displaced from the TV annulus toward the ventricular apex?

A. Rheumatic heart disease

B. Carcinoid

C. Ebstein’s Anomaly

D. Noonan Syndrome

E. Kartagener’s Syndrome

F. Williams Syndrome

A

Ebsteins Anomaly

121
Q

The IV septum flattens and is displaced toward the LV at what point in the cardiac cycle with RV pressure overload?

A. Early Diastole

B. Late diastole

C. Early Systole

D. Late systole

E. This does not occur with RV pressure overload

A

Late Systole

(Max displacement occurs here)

122
Q

The IV septum flattens and is displaced toward the LV at what point in the cardiac cycle with RV volume overload?

A. Early Diastole

B. Late diastole

C. Early Systole

D. Late systole

E. This does not occur with RV pressure overload

A

Late Diastole

123
Q

Which of the following views allows accurate determinations of the instataneous peak pressure gradient across the pulmonic valve by CWD?

A. ME RV inflow outflow

B. TG RV Inflow view

C. ME RV outflow view

D. ME Pulmonic Outflow View

E. Upper esophageal aortic arch short axis view

A

Upper esophageal aortic arch short axis view

124
Q

Which of the following is most likely present in the left atrium?

A. Eustachian valve

B. Crista Terminalis

C. Cor Triatriutum

D. Chiari Network

E. Moderator Band

F. Thesbian Valve

A

Cor Triatriutum

125
Q

Which of the follwoing is most likely present in the RV?

A. Cor Triatriatum

B. Coumadin Ridge

C. Crista Terminalis

D. Moderator Band

E. Chiari Network

F. Thesbian Valve

A

Moderator Band

126
Q

Which of the following structures is most likely present in the RA?

A. Crista Supraventricualris

B. Cor Triatriatum

C. Coumadin Ridge

D. Chiari Network

E. Moderator Band

A

Chiari Network

127
Q

What valvular disorder would most likely be consistent with an abnormal enlargement of the hepatic venous flow wave illustrated with the arrow below?

A. TR

B. MR

C. TS
D. PS

E. MS

A

Triscuspid Stenosis

128
Q

See picture

A

B

129
Q

What view allows us to eval TAPSE?

A

Mid esophageal 4 chamber view

130
Q

What is responsible for rheumatic heart disease?

A

Streptococcal pyogenes M-protein autoantibodies

131
Q

What is responsible for amyloidosis?

A

Infiltration of Beta-Amyloid

132
Q

RV Hypertrophy in adults is defined as what?

A

Wall thickness > 5mm

133
Q

Which of the following is true with regard to the eccentricity index?

A. Normally equals 1 at end-systole and end-diastole

B. Measure of LV systolic function

C. Measure of LV diastolic function.

D. Lowest at end-systole with isolated RV volume overload

E. Lowest at end-diastole with isolated RV pressure overload

A

A

134
Q

Tricuspid Annular Tissue doppler is best assessed from which of the following views?

A

Deep TG RV views

135
Q

Which of the following measures of RV systolic function is least load dependent?

A. RV FAC

B. RV EF
C. TAPSE

D. Tricuspid annular plane max systolic V (S’) (DTI)

E. Isovolumetric acceleration (IVA)

F. RV dp/dt

A

Isovolumetric acceleration

136
Q

What is structure “Z”

A

Right Atrial Appendage

137
Q

Label “Y”

A

Left Atrium

138
Q

Label X

A

IVC

139
Q

What is the labeled structure?

A

Coronary Sinus

140
Q

What is A?

A

Pulmonic Valve

141
Q

What is 2 used to calculate?

What is 3 used to calculate?

A

2 = Early Velocity to calculate PA Mean Pressure

3 = Late velocity to calculate PA diastolic pressure

PTE Masters Ravi (45 decks)

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