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1. PTE Masters > The Right Heart/Tricuspid valve > Flashcards

The Right Heart/Tricuspid valve Flashcards

1
Q

In the ME 4C view, which tricuspid leaflets are visible medially and laterally?

A

Medial = septal
Lateral = anterior or posterior

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2
Q

Why does retrograde cardioplegia not protect the RV as well as the LV?

A

The RV drains into Thebesian veins which do not connect to the coronary sinus, so cardioplegia flowing into the CS will not get to the RV

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3
Q

What are contributors to post-CPB RV failure?

A
  • Inadequate cardioprotection
  • Inadequate cooling
  • Air to the RCA
  • Pulmonary edema/dysfunction
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4
Q

What is the frequency of severe refractory RV failure in:
* all cardiotomy patients
* heart transplants
* LVADs

A

Cardiotomy: 0.1%
Heart transplant: 2-3%
LVAD: 20-30%

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5
Q

Normal TAPSE

A

> 1.7cm (JASE)

2.0-2.5 cm

Note: >1.5cm per Haddad (2009)

In JASE 2010, lower limit of normal 1.6cm, mean 2.3cm, upper limit 3.0cm

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6
Q

How to measure RV Isovolumetric Acceleration

A

In deep TG RV inflow, measure peak isovolumetric velocity (peak between S’ and a’ on TDI of lateral tricuspid annulus) and divide by how long it takes to reach peak velocity

Acceleration = velocity/time

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7
Q

What does the interventircular septum do when there is RV VOLUME overload?

A

Late diastolic flattening or motion towards the left (end diastole is when the RV has the highest volume)

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8
Q

What does the interventricular septum do when there is RV PRESSURE overload?

A

Paradoxical septal motion towards the LV during late systole (when RV pressure is highest)

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9
Q

What is the eccentricity index?

A

A measure of RV function: in TG SAX view, the LV A-P diameter is divided by the septal-lateral diameter. Should be 1 in a normal patient, becomes >1 in RV failure

EI = LV A-P diameter / S-L diameter

(As RV function worsens, septum moves more to the left, the septal-lateral LV diameter shortens)

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10
Q

Wall thickness cutoff for RV hypertrophy

A

> 5mm

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11
Q

What happens to maximal septal shift in
A) RV volume overload
B) RV pressure overload

A

In RV volume overload, maximal septal shift occurs during late DIASTOLE (when RV volume is highest)

In RV pressure overload, maximal septal shift occurs during late SYSTOLE (when RV pressure is highest)

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12
Q

What does an apex-forming RV on ME 4C indicate?

A

RV enlargement (the RV should only take up 60% of the heart in this view)

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13
Q

What is McConnell’s sign?

A

Regional wall motion abnormalities sparing the RV apex; suggests massive PE and poor prognosis

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14
Q

Which tricuspid leaflets do you see in the ME 4C view?

A

Lateral = either Anterior or Posterior

Medial (by septum) = Septal

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15
Q

Which tricuspid leaflets do you see in the ME RV inflow/outflow view?

A

Lateral (by free wall) = posterior

Medial (by AV) = either Septal or Anterior

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16
Q

Which tricuspid leaflets do you see in the TG RV inflow view (90 deg)?

A

Closer to probe = Posterior

Further form probe = Anterior or Septal

17
Q

What are some causes of functional TR?

A
  • Annular dilation
  • Papillary muscle dysfunction
  • Pressure or volume overload
  • PAC
18
Q

What are some causes of structural TR?

A
  • Rheumatic heart disease (most common cause of TS, but is more likely to cause TR)
  • Myxomatous degeneration
  • Ebstein’s anomaly
  • Carcinoid heart disease
  • Endocarditis
19
Q

What is Ebstein’s Anomaly?

A

ANTERIOR leaflet large, APICALIZATION, ASD

  • Large, “sail-like” anterior leaflet
  • Funnel-shaped TV
  • Apical displacement of small septal and posterior leaflets
  • Atrialization of part of the RV
  • Often associated w/ ASD and WPW syndrome
  • RV volume overload, TR
20
Q

What is carcinoid syndrome?

A
  • Metastatic carcinoid cancer releases serotonin, bradykinin, histamine and prostaglandins.
  • Serotonin damages the right-sided valves (thickened, fixed)
  • Lung monamine oxidase protects the LV (unless there is a PFO/ASD)
  • TR more prominent than TS
21
Q

What is normal RV FAC?
(JASE 2010)

A

FAC >35%

22
Q

What is the normal RV EF by MRI?

A

> /= 45%

Note: lower than LV cutoff because RV ESV/EDV are higher than LV ESV/EDV

23
Q

How do you grade TR?

A

Vena contracta: >7mm = severe

Hepatic vein flow: systolic reversal = severe

24
Q

How do you grade TS?

A

TS is usually graded by peak and mean velocities (rather than valve area)

MG >5mmHg = severe TS

25
Q

Which pulmonic valve cusp is closest to the aortic valve?

A

Left cusp

(Pulmonic valve sits anterior and to the left of the AV)

26
Q

What are the three PV cusps?

A

Anterior, Left, Right

27
Q

How to calculate mean PA and PAD pressure from PR jet CWD

A

Use early PR velocity for mean PA and late PR velocity for PA diastolic

28
Q

How to calculate PA systolic pressure when there is PS

A

Calculate RVSP (using CWD through TV and RAP)

Calculate peak gradient across PV (using CWD)

Then subtract peak gradient from RVSP

29
Q

What is the normal TDI S’ for the lateral tricuspid valve annulus?

A

> 10cm/s

(<10 is abnormal in young healthy people)

30
Q

What is the normal RV isovolumic acceleration?

A

> 2.2 m/sec^2

31
Q

What is the normal RV MPI?

A

By blood flow Doppler: <0.4
By TDI: <0.54

32
Q

How do you calculate RV dP/dt? What is the normal value?

A

Time required for the TR jet to increase in velocity from 1m/s to 2m/s

Divide 12mmHg by change in time

Normal >400mmHg/sec

33
Q

Tricuspid annular dilation
- Where to measure
- Cutoff for dilation

A
  • Measure in the 4-chamber RV-focused view during diastole
  • Cutoff is >4cm or 2.1 cm/m2
34
Q

If you are performing left-sided valve surgery, when should you consider placing a tricuspid ring?

A

When the tricuspid annulus is >4cm (or or 2.1 cm/m2)

(even if TR isn’t severe)

35
Q

When in the cardiac cycle should the TR vena contracta be measured?

A

Mid-systole

Note: functional TR is bi-phasic so VC varies throughout cardiac cycle

36
Q

What is the most common cause of primary TR?

A

Myxomatous degeneration

1. PTE Masters (14 decks)

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