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ECHO 325 > Tricuspid And Pulmonary Stenosis > Flashcards

Tricuspid And Pulmonary Stenosis Flashcards

1
Q
  1. What are the 3 TV leaflets and commissures?

2. What are the RV pap muscles?

A
  1. Leaflets = Anterior, posterior and septal

Commissures = Anteroseptal, anteroposterior, posteroseptal

  1. Two discrete pap muscles and one rudimentary (moderator band)
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2
Q

Etiology of tricuspid stenosis may be of what two origins?

A
  1. Congenital

2. Acquired

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3
Q

What is congenital TS associated with?

A

Almost always associated with other congenital cardiac defects

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4
Q

What are some examples of congenital TS? (3)

A
  • Cor Triatriatum Dexter (Septation in the RA that is perforate - netting)
  • Malformed leaflets, chordae or paps
  • Annular hypoplasia
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5
Q

What is the most common acquired cause of TS?

A

Rheumatic (beta-hemolytic strep infection that causes fibrosis)

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6
Q

What is Carcinoid heart disease?

A

Acquired cause of TS:

Rare, malignant neuroendocrine tumor that secretes serotonin and covers valve in milky plaque that causes thickening

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7
Q

What views best show the TV?

A
  1. A4C
  2. Subcostal RVOT (4 or 5 chamber)
  3. PLAX RVIT
  4. PSAX RVOT
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8
Q

What does carcinoid heart disease damage?

A

Tricuspid and pulmonary valves

NEVER left heart

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9
Q

Other than rheumatic and carcinoid, what are other causes of acquired TS? (3)

A
  • Large TV vegetation
  • Rt heart tumours
  • Rt heart thrombus
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10
Q

In order to maintain cardiac output in the presence of TS, what must the RA pressure do?

A

Increase

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11
Q

As the RA pressure increased, where does it work its way to?

A

Backward into the systemic veins

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12
Q

Rheumatic TS usually occurs in conjunction with what?

A

Rheumatic MS and dyspnea

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13
Q

What are the clinical manifestations of TS?

A

Systemic venous congestion, jugular venous distention, ascites, peripheral edema

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14
Q

What are the symptoms of TS?

A

Fatigue, abdominal discomfort and swelling

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15
Q

How can you tell the diff between rheumatic causing TS or carcinoid causing TS?

A

If it’s rheumatic the MV will be affected as well

If it’s carcinoid the PV will be affected as well

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16
Q

How can we assess TS? (5)

A
  1. Assess RA size (for dilation)
  2. Assess RV size and function
  3. Estimate stenosis severity (using colour, mean pressure gradient, VTI, P1/2T and TVA)
  4. Estimate the RV systolic pressure
  5. Identify valve lesions and determine cause
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17
Q

What is normal RA area?

A

<18cm2

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18
Q

What is normal RA length and width?

A

Length: <5.3 cm

Width: <4.4 cm

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19
Q

What is the normal RA volume index for Males and Females?

A

Male: < 32 ml/m2

Female <27 ml/m2

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20
Q

What are the normal RV measurements?

A

Base: < 4.1 cm

Mid: < 3.5 cm

Length < 8.6 cm

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21
Q

What is the normal TAPSE value?

A

> 17mm

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22
Q

What is the normal s’ value for RV function? (TDI)

A

> 9.5cm/s

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23
Q

What is the normal FAC for RV function?

A

> 35%

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24
Q

What is the normal RIMP for RV function?

A

<0.44

25
Q

How do we assess TS with echo? (4)

A
  1. Use colour to see aliasing in RV during diastole
  2. Trace the TV inflow (jet) to measure:
    - Mean pressure gradient to see if it’s high
    - VTI to see if it’s high
  3. Assess pressure half time by measuring the downslope to see if it takes a long time for blood to move through valve
  4. Calculate the TV Area with the continuity principal
26
Q

Which is more useful, mean gradient or peak velocity for asessing TS and why?

A

Mean gradient

Because:

  • More than one peak during diastole
  • Diastole is longer than systole
27
Q

What is TV pressure half time measurement?

A

Measures the time it takes for the early diastolic pressure gradient between the RA and RV to fall to half it’s original value (will be fast in a normal (wide) TV)

28
Q

How is TVA area assessed?

A

By comparing the SV of the TV with the SV of another valve using the continuity equation (assuming SV should be the same in all normal valves)

29
Q

What is a limitation of pressure half time with TV?

A

Tachycardia as the E and A waves are fused

30
Q

What is a normal TVA?

A

6-7cm2

31
Q

When can TVA not be calculated?

A

In the presence of signficant TR coexisting with TS because the SV is altered

32
Q

What is the formula for tricuspid valve area?

A

TVA = (CSAlvot x VTIlvot) ÷ VTItv

33
Q

How is severity of TS rated?

A

Signficant or insignificant

34
Q

What is a significant TS mean gradient?

A

≥5mmHg

35
Q

What is a significant TS inflow VTI?

A

> 60 cm

36
Q

What is a significant TS pressure half time?

A

> 190 ms

37
Q

What is a significant TS tricuspid valve area?

A

≤1.0cm2

38
Q

What are two supportive findings that are seen with significant stenosis?

A

Enlarged RA and dilated IVC

39
Q

What are treatments for TS? (3)

A
  • Surgical debulking/repair of tumor/vegetation
  • Transvenous balloon valvuloplasty
  • Diuretics or nitrates to relieve venous congestion
40
Q

What are the names of the pulmonary valve cusps?

A

Anterior, right and left posterior

41
Q

The PV is not continuous with the IVS and instead has a muscular ridge called what?

A

The infundibulum

42
Q

The anatomy of the pulmonary root is the same as what?

A

Aortic root

43
Q

Where can RVOT obstruction occur?

A

Subvalvular (infundibular), valvular, supravalvular, branch

44
Q

PS is almost always caused by what?

A

Congenital

45
Q

What are the 3 types of congenital PS?

A
  1. Dome shaped (reduced orifice)
  2. Dysplastic (severe thickening)
  3. Unicuspid or bicuspid (bicuspid assc. W/ tetrology of fallot
46
Q

Acquired causes of PS? (5)

A

Rare (usually PS is congenital)

  1. Rheumatic
  2. Carcinoid
  • Sinus or IVS aneurysmy
  • Hypertrophic CMO
  • Post ross procedure/surgeries
  • Thrombus/tumors/vegetations
47
Q

What is a normal RV thickness?

A

3-5mm

48
Q

What are the 2 criteria used to assess the severity of PS?

A
  1. Peak PV velocity
  2. Maximum gradient

(NOT PVA - as recommended by ASE)

49
Q

What is the peak velocity for mild and severe PS?

A

Mild: < 3

Severe: > 4

(Same as aortic)

50
Q

What is the Max Gradient value for mild and severe PS?

A

Mild: < 36

Severe: > 64

51
Q

How can you determine the maximum gradient of PS if you have the peak velocity?

A

By using bernoulli’s equation (4Vsq)

52
Q

What is the procedure of choice for severe congenital pulmonary stenosis?

A

PV valvuloplasty

53
Q

Where is the PV annulus best measured and why is it done?

A

PSAX view of the RVOT

Done to select correct size of balloon for valvuloplasty

54
Q

In the absence of PS or an RVOT obstruction, it is assumed that the RVSP is equal to what?

A

Pulmonary artery systolic pressure

55
Q

When a mild or moderate RVOT obstruction is present, what does the PASP formula become?

A

PASP = RVSP - mean PGpv

56
Q

When a severe or critical obstruction is present in the RVOT what formula is used for sPAP?

A

PASPc = RVSP - MIPGpv

Max Instantaneous

57
Q

What does mild vs critical PS look like on CW Doppler?

A

Mild has early peaking and is v-shaped, critical is more parabolic and somewhat flattened

58
Q

How does echo assess PS? (4)

A
  1. RV size and function
  2. Severity of PS (using peak vel and max gradient)
  3. Measure PV annulus
  4. Estimate pulm pressures

ECHO 325 (19 decks)

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