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Valvular Heart Disease > Tricuspid, Pulmonic, and Mixed Valve Disease > Flashcards

Tricuspid, Pulmonic, and Mixed Valve Disease Flashcards

1
Q

What are the two classifications of tricuspid regurgitation (TR)?

A

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.

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2
Q

What is the most common cause of secondary tricuspid regurgitation?

A

Left heart failure

Increased left ventricular filling pressure leads to increased right ventricular systolic pressure, causing secondary TR.

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3
Q

List three primary causes of tricuspid regurgitation.

A
  • Trauma
  • Ebstein’s Anomaly
  • Congenital Tricuspid Hypoplasia
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4
Q

List three secondary causes of tricuspid regurgitation.

A
  • Left Heart Failure
  • Parenchymal Lung Disease
  • Pulmonary Vascular Disease
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5
Q

True or False: Secondary tricuspid regurgitation is less common than primary disease.

A

False

Secondary TR is far more common than primary disease.

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6
Q

What happens to the right ventricle (RV) during primary tricuspid regurgitation?

A

It experiences volume overload, leading to or exacerbating right heart failure.

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7
Q

What is the main diagnostic tool for tricuspid regurgitation?

A

Echocardiography

Standard 2-D echocardiography estimates right atrial and right ventricular volumes.

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8
Q

What is the typical sound of a tricuspid regurgitation murmur?

A

Holosystolic

The murmur is heard best along the right sternal border.

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9
Q

Fill in the blank: The tricuspid regurgitant jet helps estimate _____ pressure.

A

Right ventricular

The jet provides key information regarding RV pressure overload.

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10
Q

What is the modified Bernoulli equation used for in the context of tricuspid regurgitation?

A

To estimate the pressure gradient between the right ventricle and right atrium.

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11
Q

What does a vena contracta width greater than 7 mm indicate?

A

Severe tricuspid regurgitation.

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12
Q

What symptom may indicate severe tricuspid regurgitation?

A

Ascites

This is due to high right atrial pressure.

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13
Q

What does jugular venous pulsation indicate in the context of tricuspid regurgitation?

A

It may indicate elevated right atrial pressure.

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14
Q

What is TAPSE and its relevance in assessing right ventricular function?

A

Tricuspid annular plane systolic excursion; its role in assessing RV function in the presence of TR is uncertain.

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15
Q

Describe the hemodynamic effect of pulmonary embolism related to tricuspid regurgitation.

A

It often causes TR sufficient to estimate RV pressure but rarely leads to severe TR.

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16
Q

What are the signs of right heart failure associated with tricuspid regurgitation?

A
  • Dyspnea
  • Edema
  • Anorexia
  • Right upper quadrant pain
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17
Q

What is the role of right heart catheterization in tricuspid regurgitation?

A

It can provide hemodynamic information supportive of the diagnosis.

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18
Q

What happens to the right ventricular function in the presence of tricuspid regurgitation?

A

Estimation of RV volume and function becomes complicated.

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19
Q

What is indicated by systolic reversal in the hepatic veins on pulsed Doppler examination?

A

It indicates a complication in estimating right ventricular (RV) volume and function.

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20
Q

What is the premise of measuring tricuspid annular plane systolic excursion (TAPSE)?

A

It measures RV long axis shortening and thus measures contraction in that plane.

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21
Q

True or False: TAPSE and right ventricular strain are independent of load conditions.

A

False

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22
Q

What is recommended when there is progressive deterioration in RV function or progressive RV dilatation?

A

Correction of primary severe tricuspid regurgitation (TR).

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23
Q

Which imaging technique is most accurate for assessing changes in RV volume and function over time?

A

Cardiac MRI.

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24
Q

What is the standard therapy for most cases of secondary TR?

A

Treatment of the left heart or lung disease responsible for causing the TR.

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25
Q

How does improving lung function affect RV size and TR?

A

It reduces pulmonary vascular resistance, thereby reducing pulmonary artery and RV pressure, which improves secondary TR.

26
Q

What are the common causes of primary tricuspid regurgitation?

A
  • 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
27
Q

What does the presence of TR negatively affect?

A

Prognosis.

28
Q

What is the class I indication for mechanical therapy in tricuspid regurgitation?

A

To treat severe TR during left-sided surgery.

29
Q

Fill in the blank: The preferred mechanical therapy for isolated TR is _______.

A

[uncertain]

30
Q

What is the most common cause of tricuspid stenosis in adults worldwide?

A

Rheumatic heart disease.

31
Q

What symptoms are primarily caused by tricuspid stenosis?

A

Right atrial and systemic venous hypertension symptoms such as congestion, ascites, and edema.

32
Q

True or False: A trans-tricuspid valve gradient of 5 mmHg results in an RA pressure of 10–12 mmHg.

A

True

33
Q

What is the effect of exercise on right atrial pressure in the context of tricuspid stenosis?

A

It may cause very high RA pressure due to the squared relationship with cardiac output.

34
Q

What is the role of diuretics in primary tricuspid regurgitation?

A

To lower right atrial pressure and relieve venous congestion.

35
Q

What is the significance of mechanical management of primary TR?

A

There is no evidence that it improves outcomes.

36
Q

What does the ACC/AHA Guidelines recommend for treating asymptomatic severe TR?

A

To address it at the time of left-sided valve surgery.

37
Q

What is the expected outcome of tricuspid repair during left-sided valve surgery?

A

Reduced risk of TR progression.

38
Q

What is the relationship between tricuspid regurgitation and heart failure?

A

The presence of TR can lead to right heart failure.

39
Q

What are the common outcomes from tricuspid valve replacement with bioprostheses compared to mechanical valves?

A
  • Structural valve deterioration more common with bioprostheses
  • Thromboembolic/hemorrhagic complications more common with mechanical valves.
40
Q

What does the literature suggest about the timing of tricuspid surgery in relation to left-sided surgeries?

A

It suggests that addressing more than mild TR is preferred during left-sided valve surgery.

41
Q

Fill in the blank: The symptoms of tricuspid stenosis primarily stem from _______ and systemic venous hypertension.

A

[right atrial pressure]

42
Q

What is the primary cause of symptoms in tricuspid stenosis (TS)?

A

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.

43
Q

What type of murmur is typically heard in tricuspid stenosis (TS)?

A

A diastolic rumble accentuated by inspiration

The murmur may be very soft due to relatively low right-sided pressures.

44
Q

What does elevated neck veins with a prominent a wave indicate in TS?

A

Right atrial pressure increase

The blunted y descent is also noted in the physical examination.

45
Q

What is the mainstay of diagnosis for valve diseases including TS?

A

Imaging

Special care must be taken to obtain all views and calculate the trans-tricuspid gradient.

46
Q

What is the preferred treatment for severe tricuspid stenosis (TS)?

A

Surgical intervention at the time of left-sided valve operations

Valve repair is preferred to valve replacement.

47
Q

What is the typical etiology of pulmonic stenosis (PS)?

A

Congenital fusion of the valve leaflets

Most PS cases are addressed by balloon valvotomy in childhood.

48
Q

What symptoms may indicate severe pulmonic stenosis (PS)?

A

Dyspnea on exertion, fatigue, and chest pain

Overt right-sided heart failure causing ascites and edema is rare.

49
Q

What physical examination finding is characteristic of pulmonic stenosis (PS)?

A

A systolic ejection murmur heard in the pulmonic area

The murmur is often preceded by an ejection click.

50
Q

What is used to gauge the severity of pulmonic stenosis (PS)?

A

Peak gradient

Symptom-free survival worsens when the peak gradient exceeds 50 mmHg.

51
Q

What imaging modality demonstrates doming of the valve in systole for PS?

A

Echocardiography

Doppler interrogation determines jet velocity from which the transvalvular gradient is obtained.

52
Q

What is the gold standard of care for severe pulmonic regurgitation (PR)?

A

Surgical pulmonary valve replacement

If PR is secondary to a failed pulmonary conduit, it can be treated with percutaneous valve replacement.

53
Q

What is a common finding in patients with severe PR during physical examination?

A

Dyspnea on exertion and fatigue

The murmur is a high pitched diastolic blowing sound heard best in the pulmonic area.

54
Q

What is the typical cause of clinically important primary pulmonic regurgitation (PR)?

A

Previous correction of congenital heart disease

This can occur from balloon valvotomy for PS or from failure of valved conduits.

55
Q

True or False: Most patients with PR are symptomatic.

A

False

Most patients with PR are asymptomatic.

56
Q

What issue complicates the management of severe PR?

A

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.

57
Q

What is the relationship between aortic stenosis (AS) and mitral regurgitation (MR)?

A

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.

58
Q

Fill in the blank: The pressure overload of AS typically results in _______.

A

Concentric hypertrophy or concentric remodeling

59
Q

What is one reason why secondary MR may not improve following aortic valve replacement (AVR)?

A

Persistent atrial fibrillation

Atrial remodeling can perpetuate annular dilatation and MR.

60
Q

What can low initial aortic gradient indicate after AVR?

A

Less decrease in LV pressure driving MR

Low aortic gradient AS is usually due to LV dysfunction that may persist post AVR.

Valvular Heart Disease (13 decks)

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