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Tricuspid Valve Flashcards

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USMLE® Step 1 flashcards
1
Q

What are the four components of the TV?

A
  • fibrous annulus
  • leaflets (three)
  • papillary muscles
  • chordal attachments
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2
Q

What is the normal shape of the tricuspid annulus?

What happens when to size when functional dilation occurs?

A
  • triangular and saddle shaped
  • becomes cicrular and planar
    • owing to greater enlargement of the anteroposterior over the medolateral dimensions
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3
Q

What are the 3 leaflets of the tricuspid valve?

Explain differences in size and location.

A
  • anterior
    • largest in size
  • posterior
  • septal
    • smallest in size
    • most medial
    • inserted apically into the interventricular septum
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4
Q

Describe papillary muscles in relation to the TV

A
  • Two discrete papillary muscles (anterior, posterior)
  • Anterior
    • provides chordae to the anterior and posterior leaflets
  • Posterior
    • provides chordae to all three leaflets
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5
Q

What structures (in addition to papillary muscles) provide TV support?

A
  • Septum
    • No formal septal papillary muscle –> septum gives chordae to the anterior and septal leaflets
  • RV free wall
    • may provide chordal attachments
  • Moderator band
    • may provide chordal attachments
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6
Q

What is the most common cause of TS?

A
  • Rhuematic disease
    • accounts for 90% of TS cases
    • only 8% of rheumatic patients will develop TS
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7
Q

What are causes of TS?

A
  • Rheumatic (MCC ~ 90% of cases)
  • Carcinoid (always combined with TR)
  • SLE
  • Pacemaker-induced adhesions
  • Radiation therapy
  • Congenital malformations
  • Obstruction
    • RA tumors
    • Infection/vegetations
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8
Q

What are the clinical features/PE findings of TS?

A
  • Right sided pressure increase
    • peripheral edema
    • hepatomegaly
    • ascites
    • fatigue (out of proportion to the degree of dyspnea)
  • PE
    • JVP (with giant A wave)
    • mid-diastolic rumble, that augments on inspiration, best heard in the tricuspid area
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9
Q

What are signs of chronic pressure overload associated with TS?

A

RA and IVC ( >2.1 cm) enlargement

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10
Q

What are common findings of Carcinoid syndrome on 2D Echo?

A
  • severely thickened leaflets
  • immobile leaflets (“frozen leaflets”)
  • combination of TS and TR are present
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11
Q

What views are best to obtain tricuspid inflow velocity?

A
  • PS RV inflow
  • A4C
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12
Q

What is a good cut off for TV inflow velocity to rule out TS?

A

rarely exceeds 0.7 m/s

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13
Q

When is TS considered severe (in the evaluation of TS) on TV inflow velocity?

A
  • Diastolic gradient > 5 mmHg
  • TVA < 1.0 cm2
    • ​calculated via continuity equation
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14
Q

What are the specific findings of significant TS on Echo?

Supportive findings?

A
  • MG > 5 mmHg
  • TV VTI (inflow time) > 60 cm
  • PHT > 190 ms
  • TVA (by continuity equation) < 1.0 cm2
  • Enlarged RA > moderate
  • Dilated IVC ( > 2.1 cm)
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15
Q

Why is PHT assessment of valve area different with the TV and MV?

A
  • may be less accurate
  • due to differences in:
    • AV compliance between the right and left heart
    • influence of respiration and TR on this measurement
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16
Q

What are two factors that will affect assessment of the TV?

A
  • HR > 100 bpm
    • should ideally be 70-80 bpm
    • affect the interpretation of PHT
  • concomitant TR
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17
Q

When should TV (inflow velocity) assessment be obtained in relation to the cardiac cycle?

A

End of respiratory cycle (at end expiration, while patient holding there breath)

or

Averaged throughout respiratory cycle

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18
Q

What is the rule for obtaining TV (inflow velocity, VTI) in the setting of A-fib?

A
  • Measurements taken from a minimum of five cardiac cycles
  • must be averaged
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19
Q

Describe the picture

A
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20
Q

What are the class I indications for TV replacement surgery (in TS)?

A
  • Severe TS + at time of operation for left-sided valve disease
  • Isolated, severe, symptomatic TS
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21
Q

What are potential complications of TV surgery?

A
  • injury to adjacent structures:
    • RCA
    • AV node
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22
Q

When is percutaneous balloon commissurotomy considered in TS?

A

isolated, symptomatic, severe TS without accompanying TR (class IIb)

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23
Q

What is the most common cause of TR?

A

functional (or secondary) regurgitation

  • secondary to annular dilatation from RA or RV enlargement, Pulmonary hypertension
  • accounts for 80% of cases of severe TR
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24
Q

What are acquired causes of primary TR?

A
  • Myxomatous/Degenerative (most common)
  • Rheumatic
  • Carcinoid
  • Endocarditis
  • Endomyocardial fibrosis
  • Toxins
  • Trauma
  • Iatrogenic
    • Pacemaker lead impingement
    • Endomyocardial (RV) biopsy complication
  • Ischemic papillary muscle rupture
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25
Q

What are the pathophysiologic mechnisms for TR (functional)?

A
  • annular dilation
  • papillary muscle displacement
  • chordal tethering
  • leaflet malcoaptation
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26
Q

What is the most common cause of primary TR?

A

myxomatous/degenerative disease

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27
Q

What are congenital causes of primary TR?

A
  • Congenitally corrected transposition of the great arteries
  • Other (giant right atrium)
  • Repaired Tetralogy of Fallot
  • Ebstein’s anomaloy
  • TV dysplasia
  • TV tethering
    • associated with perimembranous VSD and VS aneurysm
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28
Q

What are the clinical/PE features of significant TR?

A
  • Right sided volume overload (ascites, peripheral edema, abdominal discomfort, hepatomegaly, fatigue)
  • Murmur is difficult to detect on PE (very soft)
    • pansystolic murmurm
    • best heard in tricuspid area
    • increases in intensity:
      • inspiration
    • S3 may be present
  • Elevated JVP with large cv wave
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29
Q

What are the causes/mechanisms of secondary (functional) TR?

A
  • Left heart disease (LV dysfunction or valve disease)
  • RV dysfunction
    • RV ischemia
    • RV volume overload
    • RV cardiomyopathy
  • Pulmonary hypertension
    • chronic lung disease
    • pulmonary thromboembolism
    • left-to-right shunt
  • RA abnormalities
    • A-fib
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30
Q

Describe the algorithm for TR evaluation

A
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31
Q

Describe views and the leaflet anatomy

A
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32
Q

Describe the findings in the image

A
  • Ebstein’s anomaly
    • apical displacement of the septal leaflet and associated severe TR
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33
Q

Describe the findings in the image

A
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34
Q

Describe the findins in the image

A
  • Carcinoid heart disease (of the TV)
    • severe RA dilation
    • severe thickening, shortening and retraction of the TV leaflets
    • leads to incomplete leaflet coaptation and severe TR
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35
Q

What leaflets (of the TV) are visualized in the RV inflow view?

A
  • Nearfield
    • anterior leaflet (blue) is always visualized
  • Farfield
    • may be septal (yellow) or posterior (green)
    • wide range of variability
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36
Q

What leaflets (of the TV) are visualized in the SAX view?

A
  • SAX (level of Aortic Valve)
    • anterior leaflet (blue) is always visible and adjacent to the aorta
    • posterior leaflet (green) sometimes visible and adjacent to RV free wall
  • SAX (level of LVOT)
    • all three leaflets visible
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37
Q

What leaflets (of the TV) are visualized in the A4C view?

A

*

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38
Q

When is 3D Echo most useful for the TV assessment?

A
  • Pacemaker wire impingement
  • Tethering of leaflets
  • Traumatic TR
    • assessment of valve damage/surgical planning
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39
Q

Describe the findings

A
  • CW Doppler demonstrating severe TR
    • traingular-shaped, early peaking jet contour
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40
Q

Describe the findings

A
  • “Sine Wave” appearance on CW doppler of the TV
    • very severe TR with normal RV pressure
    • represents equal forward and backward flow across a severely incompetent valve
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41
Q

What are the structural parameters used to assess TR severity?

A
  • TV morphology
    • severe = severe valve lesions (flail leaflet, severe retraction, large perforation)
  • RV size
  • RA size
  • IVC diameter
    • < 2 cm = normal-mild
    • > 2.5 cm = severe
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42
Q

What are the qualitative parameters used to assess TR severity?

A
  • Color flow jet area
  • Flow convergence zone
    • severe = large, throughout systole
  • CWD jet
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43
Q

What are the semi-quantitative parameters used to assess TR severity?

A
  • Color flow jet area (cm2)
  • VC (cm)
  • PISA radius (cm)
  • Hepatic vein flow
  • Tricuspid inflow
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44
Q

What are the quantitative parameters used to assess TR severity?

A
  • EROA (cm2)
  • RV (mL)
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45
Q

What jet area is consistent with severe TR?

What factors can affect appearance of the jet?

A
  • > 10 cm2
  • > 50% of RA area
  • Jet area factors:
    • several Echo machine settings can affect teh appearance of the jet
      • Pulse repetition frequency
    • eccentric or wall impinging jet –> underestimation of severity when using color doppler alone
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46
Q

Describe VC severity scale in TR assessment

A
  • Mild < 0.30 cm
  • Moderate 0.30 - 0.69 cm
  • Severe > 0.70 cm
    • > 0.40 cm2 (on 3D Echo)
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47
Q

What are the specific criteria for Severe TR (inital evaluation)?

A
  • Dilated annulus with no valve coaptation or flail leaflet
  • Dilated RV with preserved function
  • Dense, triangular CW jet or sine wave pattern
  • Systolic reversal of Hepatic vein flow
  • Large central jet > 50% of RA
  • VC width > 0.7cm
  • PISA radius > 0.9cm (at Nyquist 30-40 cm/s)
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48
Q

Describe the EROA scale in TR assessment?

A
  • Mild < 0.2 cm2
  • Moderate 0.2-0.4 cm2
  • Severe > 0.4 cm2
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49
Q

Describe the RVol scale in TR assessment?

A
  • Mild < 30 mL
  • Moderate 30-44 mL
  • Severe > 45 mL
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50
Q

What are the specific criteria for Mild TR (inital evaluation)?

A
  • Incomplete or faint CW jet
  • Thin, small central color jet
  • Tricuspid A-wave dominant inflow
  • Systolic dominant Hepatic vein flow
  • VC < 0.3 cm
  • PISA radius < 0.4 cm (at Nyquist 30-40 cm/s)
  • Normal RV/RA
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51
Q

What clinical scenario is TEE indicated in addition to TTE for thorough evaluation?

A
  • Suspected PM endocarditis

Not indicated for

  • PA pressure in primary pulmonary hypertension
  • IVC thrombus
  • RV function
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52
Q

What is the cause of severe TR (regurgitant velocity 1 m/s) with reduced RV function post-transplant?

A
  • Flail TV leaflet
    • common with valvular (usually septal) leaflet/chordae damage due to repeated endomyocardial biopsies following transplantation
    • results in laminar rather than turbulent flow
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53
Q

What is the etiology of McConnell sign?

Describe the pathophysiology?

A
  • Acute PE
    • regional RV dysfunction with apical sparing of RV function
    • may be seen in acute PE
    • Senstivity 70%, specificity 30%, PPV 67%, NPV 33%
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54
Q

How is RVSP calculated with TR?

When can this not be utilized?

A
  • RVSP = 4v2 + RAP
  • Laminar flow (not turbulent) flow through the valve renders the Bernoulli equation inaccurate
55
Q

What is the PA systolic pressure? Is Pulmonary Hypertension present?

  • Pulmonary valve stenosis
    • PG 20 mmHg across pulmonary valve
  • TR
    • regurgitant velocity 3 m/s
  • RA and IVC (good collapsibility on sniffing) normal in size
A
  • RVSP = 4v2 + estimated RA pressure
    • V = 3 m/s
    • estimated RA pressure
      • normal size < 2.1 with sniffing collapse = 3 mmHg (5mmHg is prior number)
    • RVSP = 36 mmHg + 3 mmHg (5 mmHg) = 39/41 mmHg
    • PA systolic pressure = RVSP - PG (across valve)
      • PASP = 39/41 mmHg - 20 mmHg = 19/21 mmHg
  • PA systolic pressure = 19/21 mmHg –> normal PA systolic pressures and thus no PH
56
Q

What is a Gerbode defect?

A
  • communication between the RA and LV
  • often iatrogenic after sugery on the AV valves or following endocarditis of these valves
57
Q

What is the PHT formula for TVA in TS assessment?

A

TVA = 190 / PHT

58
Q

What is the best view to obtain planimetry of the TV (in TS assessment)?

A
  • 3D TTE or 3D TEE
    • difficult to obtain short axis view on regular TTE
59
Q

What jet’s can be utilized to estimate Pulmonary artery pressures?

A
  • TR jet
    • 4 TR Vmax2 + RAP = RVSP/PASP
  • PI jet
    • 4 PI Vmax2 + RAP = Mean PASP
    • 4 PI Vend-diastolic2 + RAP = diastolic pulmonary artery pressures
  • VSD jet (only if jet can be obtained coaxial with direction of flow)
    • SBP - 4 VVSD2 = RVSP/PASP
  • RVOT jet
    • 79 - (0.45 x RVOT AT) = mean pulmonary artery pressure
      • acceleration time
60
Q

Describe how to calculate PASP/RVSP using TR jet?

A

4 (TR Vmax)2 + RAP = RVSP/PASP

61
Q

Describe how to calculate PASP/RVSP using PI jet?

A
  • 4 (PI Vmax)2 + RAP = Mean PASP
  • 4 (PI Vend-diastolic)2 + RAP = diastolic pulmonary artery pressures
62
Q

Describe how to calculate PASP/RVSP using VSD jet?

A
  • SBP - 4 VVSD2 = RVSP/PASP
    • can only be obtained if doppler can be aligned with jet, coaxial with direction of flow
63
Q

Describe how to calculate PASP/RVSP using RVOT jet?

A

79 - (0.45 x RVOT AT) = mean pulmonary artery pressure

64
Q

What jet cannot be utilized to calculate RVSP/PASP?

A

ASD jet

65
Q

What is consistent with a diagnosis of severe PS?

A
  • PV > 4 m/s
  • elevated RVSP
    • PASP is usually normal in the setting of severe PS
  • RV hypertrophy (wall thickness > 0.4cm)
  • Post-stenotic dilatation
66
Q

Describe the peak velocity scale in the assessment of PS

A
  • Mild < 3 m/s
  • Moderate 3-4 m/s
  • Severe > 4 m/s
67
Q

What are the criteria (PV and MG) for mild PS?

A
  • PV < 3 m/s
  • MG < 36 mmHg
68
Q

When is severe pulmonary insufficiency commonly seen?

A
  • Treatment of congenital heart disease
    • prior surgery of RVOT or pulmonary valve
69
Q

What type of velocity is most commonly associated with severe pulmonary insufficiency?

A
  • Laminar rather than turbulent velocity
    • associated with high end-diastolic pressure and reduced pressure gradient across the pulmonic valve
70
Q

What can pulmonary insufficiency jet be used to obtain?

A
  • PA diastolic pressures
    • utilizing end-diastolic velocity

****Cannot be utilized to estimate PA systolic pressure

71
Q

What is the is the optimal Nyquist limit for assessing PI?

A

Nyquist limi 50-60 cm/s

72
Q

What are qualitative parameters used in the assessment of PI?

A
  • Abnormal pulmonic valve morphology
  • Large jet with a wide origin
  • Dense jet (by CW doppler)
    • with steep deceleration/early termination of diastolic flow
  • Pulmonic flow > aortic flow (by PW doppler)
73
Q

What is the most common cause of a mobile mass on the TV?

A

fibroelastoma

74
Q

Define Chiari network

A
  • fenestrated membranous structure
  • originates at the orifice of the IVC
  • embryologic remnant
  • may rarely float through the TV but usually confied to the RA and is not attached to the TV
75
Q

Describe Ebstein’s anomaly effect on TV leaflets

A
  • apical displacement of the septal leaflet of the TV
    • does not involve the PV
76
Q

What is often a concomitant finding in infundibular stenosis?

A
  • Pulmonary insufficiency
    • may cause a high-velocity jet that impinges on the PV
77
Q

What are causes/etiologies of infundibular stenosis?

A
  • Congenital heart disease (TOF)
  • HOCM
  • Tumors of RVOT
  • Infiltrative disorders
78
Q

What is the best view for imaging infundibular stenosis?

A

PSAX or Subcostal

79
Q

Describe the image

A

Ebstein’s anomaly

80
Q

What are common associations in Ebstein’s anomaly?

A
  • Rhythm abnormalities
    • accelerated conduction via accessory pathways (WPW)
  • ​Severe TR
  • Intracardiac shunt
  • Atrialization of a portion of the RV
81
Q

What is the common finding in Uhl syndrome?

What does this predispose to?

A
  • Parchment-like RV wall
  • Ventricular arrhythmias
82
Q

Describe the findings

A
  • Severe TR
  • Systolic Flow reversal of the Hepatic vein (on PW doppler)
83
Q

What are alternative methods to quantify TR?

A
  • TEE
  • Cardiac MRI
    • can provide RV and RF
84
Q

Describe the findings

A
  • TEE transgastric basal SAX view of the tricuspid valve
85
Q

What are the indications for TV Repair in Progressive functional TR (Stage B) at the time of left sided valve surgery?

A
  • TA (tricuspid annulus) dilation (Class IIa)
    • > 40 mm on TTE (21 mm/m2)
    • > 70 mm on direct intraoperative measurement
  • PHTN without TA dilation (Class IIb)
86
Q

What are the treatment options for Asymptomatic, severe TR (Stage C)?

A
  • Functional + At the time of left-sided valve surgery –>
    • TV Repair or TVR (Class I)
  • Primary + Progressive RV dysfunction –>
    • TV Repair or TVR (Class IIb)
87
Q

What are the treatment options for Symptomatic, severe TR (Stage D)?

A
  • Reoperation + Preserved RV function and PHTN not severe
    • TV repair or TVR (Class IIb)
  • Functional + At time of left-sided valve surgery
    • TV Repair or TVR (Class I)
  • ​Primary
    • TV Repair or TVR (Class IIa)
88
Q

Describe the findings

A

Severe PR likely as a result of prior surery on his pulmonary valve or RV outflow tract

  • proximal flow convergence on PA side of the valve
  • Flail leaflet
  • RV dilation and RV dysfunction
89
Q

What is the most common cause of severe PR?

A

Prior surgery for congenital heart disease involving the pulmonary valve or RVOT

90
Q

Explain how intraoperative TEE differs from an ambulatory assessment

A
  • Intraoperative TEE will underestimate severity (of TR)
    • decreased intravascular volume
    • change in loading conditions, consequent to anesthesia and mechanical ventilation
91
Q

Describe the findings

A
  • Severe TR
    • High-velocity systolic rversal in the hepatic veins
    • Gives rise to large “v” waves in the JVP
92
Q

What is pulsus paradoxus?

When is it commonly seen?

A
  • abnormally large reduction in SBP > 10 mmHg during inspiration
  • Cardiac tamponade (with a pericardial effusion the sensitivity is > 80%)
93
Q

What is Kussmaul sign?

When is it commonly seen?

A
  • Increase in venous pressure on inspiration
  • Constrictive pericarditis
94
Q

What is pulsus alternans?

When is it commonly seen?

A
  • alternating strong and weak peripheral pulses
  • End stage LV systolic dysfunction
95
Q

What is pulsus bisferiens?

When is it commonly seen?

A
  • characteristic pulse felt in the setting of both significant AS and AR and HOCM
96
Q

Describe the findings

A
  • Pulmonary hypertension
    • 50% of cases associated with abrupt midsystolic closure of the pulmonary valve
    • appearance is thouh to occur from transient reversal of the PA-RV outflow tract gradient due to impaired PA compliance
97
Q

Describe the findings

A
  • Fibroelastoma
    • well-circumscribed oval mass
    • heterogenous with areas of echolucency
    • 3rd most common primary tumor of the heart
98
Q

Where are cardiac myxomas usually found?

A
  • left atrium
  • originate from the interatrial septum
99
Q

Where are cardiac fibromas usually found?

A
  • Ventricular myocardium (septum)
    • almost always single
    • often with central calcificaiton
100
Q

Describe the findings

A
  • Prosthetic valve endocarditis - aortic vavle position with aortic root abscess
    • Long axis view: thickened leaflets with mobile target
    • Periaortic thickening between the aorta and the left atrium –> aortic root abscess
  • Shadow artifact of the bioprosthetic aortic valve struts
101
Q

Describe the findings

A

Severe Aortic Regurgitation

  • premature closure of the mitral valve (MV), with closure of the MV well before the R wave
102
Q

Describe the findings

A

HOCM with dynamic LVOTO

  • CW from the apical approach
  • typical late-peaking, high-belocity signal during systole
  • shape of curve corresponds to LV to aortic pressure gradient
103
Q

Explain the differences in CW signal between HOCM/LVOTO and SAM/MR

A
  • SAM/MR
    • typically starts earlier and ends later in systole
    • higher velocity through ejection (early)
    • higher peak velocity
  • HOCM/LVOTO
    • low velocity in early systole
    • peaks near end-systole
104
Q

What is the most common cardiac abnormality seen in Noonan syndrome?

A

Pulmonic stenosis (25%)

105
Q

What is the most common cause of acquired PS?

A

Cardcinoid disease

106
Q

Describe congenital valvular PS

A
  • fibrosis and fusion of the commissures –> bicuspid valve
  • restricted leaflets typically have a conical or dome-shaped appearance through systole
107
Q

What is the preferred view for doppler assessment of pulmonic valve?

A
  • PS SAX (with slight angulation)
  • Subcostal or Suprasternal views
    • can be alternatives in patients with dilated pulmonary artery and anterior displacement of the valve
108
Q

What are the PV and PG which correlate with severe PS?

A
  • PV > 4 m/s
  • PG > 64 mmHg
109
Q

When is RVSP not equal to PASP?

A

PS or any gradient across pulonic valve

110
Q

When may balloon valvotomy be recommended in PS patients?

A
  • Symptomatic patients with:
    • PG > 50 mmHg or MG > 30 mmHg
  • Asymptomatic patients with:
    • PG > 60 mmHg or MG > 40 mmHg
111
Q

What are several contraindications to balloon valvotomy in PS patients?

A
  • Moderate or greater PR
  • Dysplastic PV (associated with Noonan syndrome)
112
Q

When does mild-moderate PR (asymptomatic patients) require follow up or intervention?

A

abnormal RV size or function

113
Q

What is the most common cause of severe PR?

A
  • Iatrogenic (congenital heart disease)
    • prior surgery on RVOT or PV in setting of CHD
    • after balloon valvotomy
114
Q

Pulmonic valve is rarely affected by these disease processes?

A
  • Infective endocarditis
  • Rheumatic heart disease

*****Carcinoid disease does affect PV

115
Q

Why is TTE preferred (over TEE) for evaluation of the PV?

A

due to the anterior-superior position (to the aortic valve) in the chest

116
Q

What additional evaluation shoudl be performed when assessing PR severity?

A
  • Right heart
    • RV
    • RVOT
    • pulmonary annulus
    • pulmonary arteries
  • Doppler findings
117
Q
A
118
Q

What are the specific criteria for mild PR?

A
  • Small jet, with narrow width
  • Soft or faint CW jet
  • Slow deceleration time
  • Normal RV size
119
Q

What are the specific criteria for severe PR?

A
  • Jet width/Annulus > 70%
  • Early termination of PR flow
  • Dense jet, PHT < 100 ms
  • Diastolic flow reversal in PA branches
  • Dilated RV with normal function
120
Q

What is the next step in evaluation when specific mild/severe PR criteria is not met?

A
  • Moderate PR (likley) –> perform volumetric quantitative methods –> Regurgitant Fraction (RF)
    • ​Mild < 20%
    • Moderate 20-40%
    • Severe > 40%

****RF datea primarily derived from CMR with limited application in Echo

121
Q

What PHT is consistent with severe PR?

A

PHT < 100 ms

122
Q

What PR index is consitent with Moderate/Severe PR?

A

< 0.77

  • PR index: defined as the duration of the PR signal divided by the total duration of diastole
    • this cutoff identifies a CMR derived PR fraction > 25%
123
Q

Describe the findings

A
  • Severe PR
    • impaired RV diastolic compliance on the PR doppler profile
    • as the transmitted RA a-wave creates a brief interruption of the PR flow (the dip in the PR slope)
    • inability of the RV to accept even a small amount of flow simultaneously from the tricuspid inflow and PR
124
Q

Describe the findings

A

Severe PR (on CWD)

125
Q

Describe the findings:

Next step in managment?

A
  • Pacemaker lead endocarditis
    • large mass lesions consistent with vegetations involving the pacing wires, that spare TV
  • Antibiotics, surgical removal of PPM (wires and generator)
126
Q

What is the diagnosis?

Next step in management?

A
  • TV endocarditis (large vegetation)
    • embolic risk less of a consideration with TV endocarditis –> embolization to lungs
    • exception whe R-to-L shunt exists
  • Antibiotic therapy and watchful waiting
    • surgery if worsening destruction of valve or blood cultures fail to clear
127
Q

What are the most important factors when considering TV repair/replacement in Ebstein’s anomaly?

A
  • Tethering of leaflets
  • RV size and function
128
Q

Describe the findings.

Next step in management?

A
  • TV endocarditis
  • BCx, antibiotics, close monitoring of the valve by Echo
129
Q

When is balloon valvuloplasty indicated for severe PS (mean gradient)?

A
  • Asymptomatic - MG > 40 mmHg
  • Symptomatic - MG > 30 mmHg
130
Q

What is the diagnosis? Next step in management?

  • A 42 year old, Indian immigrant presents with RHF
  • Loud first heart sound, apical diastolic murmur
  • RV heave but normal P2
  • PE: JVP shows prominant pulsations that precede systole
A
  • Tricuspid and Mitral stenosis (rheumatic disease)
    • ​JVP: prominant presystole pulsations = “a” wave
    • Loud P2 indicates pulmonary hypertension has not occurred
  • Balloon valvuloplasty of both valves
    • ​Surgery as secondary option if PBV is contraindicated
131
Q

What is the preferred approach to calculate AR RV in this patient?

  • 60 year old woman with RHF with mixed AS/AR, MR, TR and PR.
A
  • Flow convergence method (PISA)
    • presence of AS or regurgitant lesions of other valves does not impact the accurarcy of the flow convergence method
    • Requires:
      • adequate visualization of the AR flow convergence on the aortic aspect of the AVso that PISA radius can be accurately measured
      • high quality, complete CWD profile of the AR flow so that peak AR velocity can be accurately measured
        *
132
Q

What are the most common limitations to the flow convergence method (PISA) in evaluation of AR?

A
  • significant aortic calcification –> shadowing –> inaccurate PISA measurement
  • eccentric AR that results in non-hemispherical flow convergence and/or incomplete AR CW profile
133
Q

What are indicatsons for TEE to diagnose infective endocarditis?

A
  • Moderate-to-high pre test probabily
    • Staph bacteremia
    • Fungemia
    • Prosthetic heart valve
    • Intracardiac device

Medical (69 decks)

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