The Right Heart Flashcards
What view is this?
What tricuspid valve leaflets are shown?
Mid-esophageal 4 chamber with focus on the RV
Tricuspid Valve: septal (STVL) + anterior (ATVL) leaflets
Septal = Medial leaflet
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?
Pulmonary Embolism
McConnell Sign
What view of this?
What is the valve shown here?
What is 1?
What is 2?
Deep TG of tricuspid valve
1 = Posterior Valve
2 = Anterior or Septal Valve
What view?
What are leaflets 3 and 4?
Tricuspid Valve of ME RV inflow/Outflow
3 = Anterior or septal
4 = Posterior
What view of the RV under TEE is correlated best with MRI resolution RV Ejection Fraction?
Mid-esophageal 4 chamber
What is TAPSE?
Tricuspid annular plane systolic excursion (TAPSE)
What TEE view is best used to calculate TAPSE?
Midesophageal 4 chamber view
What are all the views to assess the RV?
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)
What are the two views you can use to calculate RVSP?
Mid esophageal RV inflow-outflow to get RVSP
Mid Esophageal Bicaval Modified to get RVSP
What views can you align a doppler along the pulmonic valve parallel to blood flow?
Mid Esophageal Ascending Aortic Short Axis
Upper Esophageal Aortic Arch Short Axis
(Images 1 and 3 in photo)
What is the arrow pointing at?
Left Atrium
What is the arrow pointing at?
Which coronary cusp?
Aortic Valve
Specifically, the non-coronary cusp
What is the arrow pointing at?
Which coronary cusp?
Aortic Valve
Right Coronary Cusp
What cusp is to the right of the arrow?
Left Coronary Cusp of the Aortic Valve
What is the green arrow pointing at?
Coronary Sinus
(Probe turned to the right and advanced slightly from your 4 chamber view)
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)
Teal = Coronary Sinus
White = SVC
Green = Right Atrial Appendage
What view do we see here?
What is the arrow pointing to?
Transgastric Mid Papillary Short Axis View
Arrow = Moderator Band
What view is seen here?
Transgastric RV inflow view
What view is this?
Label:
Pink
Teal
Green
Deep Transgastric RV outflow
Pink = TV
Teal= RA
Green = AV
What is seen in green?
Pulmonic Valve
What view is seen here?
Label the major vessels here
What is the structure labeled “Z”?
Pulmonary Artery Catheter
What view is this?
Midesophageal Bicaval View (Modified)
What is the formula to calculate RVSP?
RVSP = 4 (Velocity of TR peak)2 + Right Atrial Pressure
What physics principle is used to come up with the RVSP equation?
Bernoulli
How does the RSVP equation change if you have pulmonic stenosis?
You must substract the PA pressure across the valve
Label teal arrow
Label White arrow
Label Green arrow
Teal = Coronary SInus
White = SVC
Green = Right atrial appendage
How do you tell a difference in the IVC vs. Coronary sinus in the bicaval view?
IVC is larger, and more “flat”
Coronary Sinus is smaller and angled more vertical “up” on the screen
What % of CPB circ failure is due to RV failure?
20%
Why doesn’t retrograde cardioplegia protect the Right heart well?
- Right heart drains into Thebesian Veins, which drain into the right ventricle (Not into the coronary sinus)
- When ice is placed on the heart, doesn’t cool the right heart as much
- Air shoots down the RCA is air embolism occurs
What % of patients have severe refractory RV failure in:
- Cardiotomy?
- Heart Transplantation?
- LVAD?
0.1% cardiotomy
2-3% of heart transplantation
20-30% of patients receiving LVAD
Mechanically, how does an LVAD make RV function worse?
LVAD sucks the septum towards the device and the septum no longer participates in RV contraction
How does an IABP cause RV dysfunction?
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
Comment on the Compliance, Resistance and Loading conditions pertaining to the right heart.
Compliance = High
Resistance = Low
Loading conditions = Sensitive to
What are the 4 quantititative measures of RV function?
RVFAC (RV Fractional Area Change)
RVEF
TAPSE - Tricuspid Annular Plane Systolic Excursion
IVA = Isovolumetric Acceleration
What is the normal values of RVFAC (RV Fractional Area Change)?
RVFAC (RV Fractional Area Change)
>/= 32%
What is the normal Values of RVEF?
RVEF
>/- 45%
What are the normal values for TAPSE?
TAPSE
Normal = Anything above 17
>17 mm (Cutoff for nomal)
Anything below this is abnormal
TAPSE doesn’t stratify low normal vs. normal
What is the normal value for IVA?
IVA = Isovolumetric Acceleration
1.4 +/- 0.5 m/s2
(Lower range of normal, 2.2 in other studies)
Why is RVEF approx >45 % and LVEF >55-65%?
RV end-systolic and end-diastolic volumes are higher than LVESV and LVEDV
What is the TV S’ (S Prime) for the lower range of normal?
<10
(I’ve read <9.5 cm/sec in TTE guidelines)
How do we measure TAPSE?
You are looking at the “swinging” of the lateral tricuspid annulus toward the apex
A - B = TAPSE
What is the equation to IVA (Isovolumetric acceleration)?
Vt / (Delta) t
What is the formula for RV FAC?
Which TEE view would be ideal?
[End Diastolic Area - End Systolic Area] / [End Diastolic Area}
View = Mid esophageal 4 chamber view
What view is this?
What is the arrow pointing at? (Purple arrow)
Mid Esophageal RV Inflow Outflow
Eustachian Valve
What view is this?
What is the arrow pointing to?
What is this arrowed structure attached to?
Transgastric Mid Papillary Short Axis View
Moderator Band
Moderator Band attached to anterior papillary muscle
What view is seen here?
Transgastric RV inflow view
What happens to the septum with volume overload?
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
What are the etiologies that are possible with volume overload where you have flattening of the septum?
Pulmonary insufficiency (PI)
Atrial Septal Defect (ASD)
Tricuspid Regurgitation
What is the eccentricity index?
A / B (Measure anterior and posterior index)
Quantifies how much septal bowing you have
How does your eccentricity index change with worsening RV failure?
A > B as the RV turns into a “D” shape and your eccentricity index will rise
What will you see in isolated pressure overload of the RV?
- Paradoxical Septal Motion
- Late systolic Septum –> Left
- RVH = Thickness > 5mm