Triscuspid valve study facts Flashcards
Signs of tricuspid regurgitation
Increased jugular venous pressure with a prominent V wave
Peripheral edema and ascites
Pan-systolic murmur prominent at the left sternal edge, increased with inspiration
3rd hear sound (gallop rhythm)
Right ventricular heave
Jaundice secondary to hepatic congestion in severe TR
What are causes of Tricuspid Stenosis
Rheumatic fever
Carcinoid heart disease
Congenital triscupid stenosis
What are surgical options for tricuspid valve annular dilation
De Vega annuloplasty
Ring annuloplasty
Bicuspidisation/plication–running suture along the posterior TV annulus to shorten or eliminate the posterior leaflet resulting in a bicuspid valve
What structures are at risk during triscuspid valve surgery
Coronary sinus
Right coronary artery
Atrioventricular nodal artery
aortic valve (non-coronary cusp)
Bundle of HIS (at the apex of the triangle of koch)
Atriventricular node (at the center of the triangle of koch)
How do you size a triscuspid valve ring
Based on the length of the base of the septal leaflet (intertrigonal length)
How you place your sutures for tricuspid annuloplasty
Mattress sutures are placed circferentially, wider on the annulus.
avoid the AV bundle at apex of triangle of koch
What are tricuspid surgery options for endocarditis
Tricuspid excision if pulmonary pressure are not elevated if endocarditis is very extensive in IV drug abusers where the dependence is not controlled Tricuspid valve replacement Limited valve excision and repair replacement with homograft
What are causes of organic TR
Carcinoid heart disease Post radiation Diet drug heart disease pace maker/AICD didease Trauma Endocarditis
What are quantitative methods for measuring TR
ERO > 0.4cm2
regurgitant volume > 45ml/beat
Vena contracta > 0.7 cm
Systolic flow reversal in hepatic veins
What is important intra-operative assess of TR
measure the annular assessment. Recurrent if septal anterior annulus is > 7- mm
What are risk factors for recurrence of TR
No ring used severe of baseline TR residual TR at first OR Persistent pulmonary hypertension residual left sided lesions
How does carcinoid syndrome present
Related to inappropriate and excessive release of serotonin and bradykinin
Tachycardia
Hot flashes
Violacious skin changes
What are the cardiac manifestations of carcinoid
50% develop valve disease
Primary lesion is located in the small intestine
Mainly right sided lesion
Usually TR or TS
plaques are on the downstream of the valves leading to adherence of the leaflet on the underlying structures
Regurgitation
May constrict the annulus leading to stenosis
What is management of Carcinoid syndrome
Tricuspid valve is replaced
Pulmonary valve is valvectomy
Octreotide perioperatively
to manage vasodilatio related to release of hormones
What are other associated lesions with ebstein’s
rhythm disturbances including supraventricular tachycardia, ventricular tachycardia, and WPW
What are symptoms of TR
dyspnea and fatigue
peripheral edema and ascites due to back pressure on the systemic venous circulation
What are signs of TR
increased jugular venous pressure with prominent v wave
peripheral edema and ascites
janudice secondary to hepatic congestion in severe TR
3rd heart sound
right ventricular heave
pan-systolic murmur prominent at the left sternal edge, increased with inspiration
How is severe TS quantified
tricuspid valve area < 1cm2
mean tricuspid diastolic pressure gradient can also be used to quantify TS
What are IIa indications for surgery in severe TR
tricuspid annulus size > 40 mm,
right ventricular function and size
pulmonary hypertension size > 50 mmHg at rest and 60 mmHg on exercise
right atrial size and the presence of atrial fibrillation
What are the surgical options for tricuspid valve annular dilation
DeVega annuloplasty
Right annuloplasty
Bicuspidisation/plication of the tricuspid valve
List structures at risk during tricuspid valve surgery
Coronary sinus Right coronary artery aortic valve (non-coronary cusp) atriventricular nodal artery atrioventricular node
Describe a De Vega annuloplasty
two arms of a running suture weaving along the TV annulus from the anteroseptal to posteroseptal commissure. First arm starts at the anterorspetal commiusre and goes clockwise to the posteroseptal commissure(secured with a teflon suture) and then weaved back counter clockwise.
tied over a hagar dilator
What leaflet is the smallest and biggest in tricuspid position?
Septal is smallest
Anterior is biggest
How does annulus increase
The circumference of the annulus lengths primarily onlg the attachmets of the anterior and posterior leaflet.
Septal leaflet is fixed between the fibrous trigones–preventing it from lengthening
How does Marfan lead to tricuspid dysfunction
lead to prolapsing leaflets
elongation of chardae
chordal rupture
What do guidelines say about pacemaker or defibrillator leads causing TR
Do NOT replace lead.
Makes things worse by taking it out and placing an epicardial lead.
What are right sided heart failure signs
Ascites congestive heptosplenomegaly pulsatile liver pleural effusions and periheral edema Late stages a. wasted pts with cachexia, cyanosis, and jaundice, and hepatic cirrhosis.
What is SVG for a bioprosthetic valve in the tricuspid position
Longer duration of freedom from SVD compared to mitral
18 years 63% freedom from SVD
always possible to place a large (27 have no problem)
What is Ebstein’s anomaly
Dysplasia of the tricuspid valve leaflets resulting in
1) fused, perforated or absent leaflets with abnormal chordae
2) apical displacement of the septal leaflet into the body of the right ventricle
3) a thin atrialised portion of the right ventricle
4) severe right ventricular dysfunction and dilation
5) tricuspid regurgitation
6) right ventricular outflow tract obstruction causes by displaced leaflets
Associated with rhythm disturbances including supraventricular tachycardia, ventricular tachycardia and WPW
