Tricuspid, Pulmonic, and Mixed Valve Disease Flashcards
What are the two classifications of tricuspid regurgitation (TR)?
Primary and secondary
Primary indicates intrinsic valve pathology, while secondary indicates that right ventricular pressure or volume overload has caused the normal tricuspid valve to leak.
What is the most common cause of secondary tricuspid regurgitation?
Left heart failure
Increased left ventricular filling pressure leads to increased right ventricular systolic pressure, causing secondary TR.
List three primary causes of tricuspid regurgitation.
- Trauma
- Ebstein’s Anomaly
- Congenital Tricuspid Hypoplasia
List three secondary causes of tricuspid regurgitation.
- Left Heart Failure
- Parenchymal Lung Disease
- Pulmonary Vascular Disease
True or False: Secondary tricuspid regurgitation is less common than primary disease.
False
Secondary TR is far more common than primary disease.
What happens to the right ventricle (RV) during primary tricuspid regurgitation?
It experiences volume overload, leading to or exacerbating right heart failure.
What is the main diagnostic tool for tricuspid regurgitation?
Echocardiography
Standard 2-D echocardiography estimates right atrial and right ventricular volumes.
What is the typical sound of a tricuspid regurgitation murmur?
Holosystolic
The murmur is heard best along the right sternal border.
Fill in the blank: The tricuspid regurgitant jet helps estimate _____ pressure.
Right ventricular
The jet provides key information regarding RV pressure overload.
What is the modified Bernoulli equation used for in the context of tricuspid regurgitation?
To estimate the pressure gradient between the right ventricle and right atrium.
What does a vena contracta width greater than 7 mm indicate?
Severe tricuspid regurgitation.
What symptom may indicate severe tricuspid regurgitation?
Ascites
This is due to high right atrial pressure.
What does jugular venous pulsation indicate in the context of tricuspid regurgitation?
It may indicate elevated right atrial pressure.
What is TAPSE and its relevance in assessing right ventricular function?
Tricuspid annular plane systolic excursion; its role in assessing RV function in the presence of TR is uncertain.
Describe the hemodynamic effect of pulmonary embolism related to tricuspid regurgitation.
It often causes TR sufficient to estimate RV pressure but rarely leads to severe TR.
What are the signs of right heart failure associated with tricuspid regurgitation?
- Dyspnea
- Edema
- Anorexia
- Right upper quadrant pain
What is the role of right heart catheterization in tricuspid regurgitation?
It can provide hemodynamic information supportive of the diagnosis.
What happens to the right ventricular function in the presence of tricuspid regurgitation?
Estimation of RV volume and function becomes complicated.
What is indicated by systolic reversal in the hepatic veins on pulsed Doppler examination?
It indicates a complication in estimating right ventricular (RV) volume and function.
What is the premise of measuring tricuspid annular plane systolic excursion (TAPSE)?
It measures RV long axis shortening and thus measures contraction in that plane.
True or False: TAPSE and right ventricular strain are independent of load conditions.
False
What is recommended when there is progressive deterioration in RV function or progressive RV dilatation?
Correction of primary severe tricuspid regurgitation (TR).
Which imaging technique is most accurate for assessing changes in RV volume and function over time?
Cardiac MRI.
What is the standard therapy for most cases of secondary TR?
Treatment of the left heart or lung disease responsible for causing the TR.
How does improving lung function affect RV size and TR?
It reduces pulmonary vascular resistance, thereby reducing pulmonary artery and RV pressure, which improves secondary TR.
What are the common causes of primary tricuspid regurgitation?
- Deceleration injuries from motor vehicle accidents
- Penetrating chest wounds
- Interference from pacemaker leads
- Infective endocarditis
- Accidental damage during RV biopsy
- Carcinoid syndrome or serotonergic-like drugs
What does the presence of TR negatively affect?
Prognosis.
What is the class I indication for mechanical therapy in tricuspid regurgitation?
To treat severe TR during left-sided surgery.
Fill in the blank: The preferred mechanical therapy for isolated TR is _______.
[uncertain]
What is the most common cause of tricuspid stenosis in adults worldwide?
Rheumatic heart disease.
What symptoms are primarily caused by tricuspid stenosis?
Right atrial and systemic venous hypertension symptoms such as congestion, ascites, and edema.
True or False: A trans-tricuspid valve gradient of 5 mmHg results in an RA pressure of 10–12 mmHg.
True
What is the effect of exercise on right atrial pressure in the context of tricuspid stenosis?
It may cause very high RA pressure due to the squared relationship with cardiac output.
What is the role of diuretics in primary tricuspid regurgitation?
To lower right atrial pressure and relieve venous congestion.
What is the significance of mechanical management of primary TR?
There is no evidence that it improves outcomes.
What does the ACC/AHA Guidelines recommend for treating asymptomatic severe TR?
To address it at the time of left-sided valve surgery.
What is the expected outcome of tricuspid repair during left-sided valve surgery?
Reduced risk of TR progression.
What is the relationship between tricuspid regurgitation and heart failure?
The presence of TR can lead to right heart failure.
What are the common outcomes from tricuspid valve replacement with bioprostheses compared to mechanical valves?
- Structural valve deterioration more common with bioprostheses
- Thromboembolic/hemorrhagic complications more common with mechanical valves.
What does the literature suggest about the timing of tricuspid surgery in relation to left-sided surgeries?
It suggests that addressing more than mild TR is preferred during left-sided valve surgery.
Fill in the blank: The symptoms of tricuspid stenosis primarily stem from _______ and systemic venous hypertension.
[right atrial pressure]
What is the primary cause of symptoms in tricuspid stenosis (TS)?
Right atrial (RA) and systemic venous hypertension
A trans-tricuspid valve gradient of 5 mmHg can result in an RA pressure of 10–12 mmHg, leading to right-sided congestion, ascites, and edema.
What type of murmur is typically heard in tricuspid stenosis (TS)?
A diastolic rumble accentuated by inspiration
The murmur may be very soft due to relatively low right-sided pressures.
What does elevated neck veins with a prominent a wave indicate in TS?
Right atrial pressure increase
The blunted y descent is also noted in the physical examination.
What is the mainstay of diagnosis for valve diseases including TS?
Imaging
Special care must be taken to obtain all views and calculate the trans-tricuspid gradient.
What is the preferred treatment for severe tricuspid stenosis (TS)?
Surgical intervention at the time of left-sided valve operations
Valve repair is preferred to valve replacement.
What is the typical etiology of pulmonic stenosis (PS)?
Congenital fusion of the valve leaflets
Most PS cases are addressed by balloon valvotomy in childhood.
What symptoms may indicate severe pulmonic stenosis (PS)?
Dyspnea on exertion, fatigue, and chest pain
Overt right-sided heart failure causing ascites and edema is rare.
What physical examination finding is characteristic of pulmonic stenosis (PS)?
A systolic ejection murmur heard in the pulmonic area
The murmur is often preceded by an ejection click.
What is used to gauge the severity of pulmonic stenosis (PS)?
Peak gradient
Symptom-free survival worsens when the peak gradient exceeds 50 mmHg.
What imaging modality demonstrates doming of the valve in systole for PS?
Echocardiography
Doppler interrogation determines jet velocity from which the transvalvular gradient is obtained.
What is the gold standard of care for severe pulmonic regurgitation (PR)?
Surgical pulmonary valve replacement
If PR is secondary to a failed pulmonary conduit, it can be treated with percutaneous valve replacement.
What is a common finding in patients with severe PR during physical examination?
Dyspnea on exertion and fatigue
The murmur is a high pitched diastolic blowing sound heard best in the pulmonic area.
What is the typical cause of clinically important primary pulmonic regurgitation (PR)?
Previous correction of congenital heart disease
This can occur from balloon valvotomy for PS or from failure of valved conduits.
True or False: Most patients with PR are symptomatic.
False
Most patients with PR are asymptomatic.
What issue complicates the management of severe PR?
Progressive decline in RV function or increased RV size
The exact triggers for intervention in terms of RV volume or ejection fraction have not been delineated.
What is the relationship between aortic stenosis (AS) and mitral regurgitation (MR)?
AS may be accompanied by MR due to ventricular remodeling
Secondary MR represents advanced disease and is associated with worse prognosis compared to isolated AS.
Fill in the blank: The pressure overload of AS typically results in _______.
Concentric hypertrophy or concentric remodeling
What is one reason why secondary MR may not improve following aortic valve replacement (AVR)?
Persistent atrial fibrillation
Atrial remodeling can perpetuate annular dilatation and MR.
What can low initial aortic gradient indicate after AVR?
Less decrease in LV pressure driving MR
Low aortic gradient AS is usually due to LV dysfunction that may persist post AVR.
