TS/TR Flashcards
The tricuspid valve (TV) has a saddle shape because of anterior and posterior high points and mid septal and lateral wall low points.
T or F ?
T
Tricuspid Valve
The largest leaflet is _________ & the smallest leaflet is ________
anterior
posterior
Tricuspid Valve
Septal leaflet is connected to the ___________
wall of the IVS
Tricuspid Valve
How many pap muscles does TV have?
3
Tricuspid Valve
Compared to MV, TV is positioned slightly ______ than MV
inferior
Tricuspid Stenosis
Definition
TS is a narrowing /thickening/obstruction of the TV that impedes diastolic flow traveling from the RA, though the TV, into the RV
Tricuspid Stenosis
Murmur
a diastolic rumble that varies with respiration and has an opening snap
*may be accentuated with inspiration
Tricuspid Stenosis
cause
- RHD: most common cause; however, TS rarely occurs alone, and typically AV and MV are affected prior to TV
- Congenital TS such as Ebstein anomaly
- Carcinoid heart disease with TV involvement: also causes TR, PS, and PR *TV leaflets are thick and rigid with no change in position from diastole to systole
- Secondary TS due to intracardiac wires/pacemaker, RA clot.tumor, or TV vegetation (from endocarditis) that physically obstruct the TV
- Secondary TS due to other medical condition: Systemic Lupus Erythematosus
- Prosthetic valve dysfunction
Tricuspid Stenosis
Complications
- TS is usually not an isolated disease state and associated with other conditions
- increased risk of infective endocarditis
- increased risk of embolization in the event of a clot or tumor
What is Ebstein anomaly?
- rare congenital heart defect
- TV is in the wrong position and leaflets are malformed leading to TR
- often associated with ASD and heart rhythm abnormalities
In people with Ebstein anomaly, the leaflets are placed deeper into the right ventricle instead of the normal position. The leaflets are often larger than normal. The defect most often causes the valve to work poorly, and blood may go the wrong way. Instead of flowing out to the lungs, the blood flows back into the right atrium. The backup of blood flow can lead to heart enlargement and fluid buildup in the body. There may also be narrowing of the valve that leads to the lungs (pulmonary valve).
Tricuspid Stenosis
signs and symptoms
- ascites
- abdominal swelling
- jaundice
- peripheral edema
- right upper quadrant pain
Tricuspid Stenosis
Increased RA pressure eventually leads to RA enlargement and signs of _______
right heart failure
Tricuspid Stenosis
clinical presentation
physical findings
- Jagular venous distention with cannon “a” waves
- hepatomegaly
- ascites
- peripheral edema without pulmonary congestion
Tricuspid Stenosis
2D echo findings
- thickened TV leaflets with restricted motion
- diastolic doming of the TV leaflets best detected from the PLAX or 4C
- decreased TV orifice due to tethered leaflets
- RA enlargement due to volume and pressure overload
- dilated IVC (normal: 1.2-2.1cm) due to the backup of blood and RA enlargement
Tricuspid Stenosis
M-mode findings
- thickened TV leaflets
- multiple echoes may be visible
- decreased TV leaflet mobility causes a decreased EF slope. The RV fills slower when TS is present; therefore, the valve is help open by an elevated RAP
- anterior motion of the posterior TV leaflet due to tethered TV leaflet tips
Tricuspid Stenosis
Quantification
views used to acquire sample volume?
- RV inflow
- PSAX
- A4C
- Subcostal SAX
*sample volume at tips of TV leaflets
Tricuspid Stenosis
Quantification
Explain how to obtain pressure half time and TVA
- Compare PLAX RVIT, PSAX RVIT, A4C, A3C RVIT (modified view), Subcostal 4C/SAX if necessary
- Optimize Doppler angle
- CWD focus within the TV leaflets
- increase sweep speed to 100 mm/s
- Acquire the peak TS waveform, freeze, and measure from the peak velocity down to the deceleration slope *average 3+ waveforms
- The machine will calculate the P½t and TVA once the slope is acquired
Tricuspid Stenosis
TVA equation
TVA = 190/pressure half time
*190 is constant
Tricuspid Stenosis
Similar to MS, TS has an ______ peak velocity (E), _______ EF slope, and _____ A wave that assessed via the pressure half time
increased
flattened
absent
Tricuspid Stenosis
Explain how to obtain mean PG
- Trace the peak waveform, start and finish at ) baseline
- the machine will calculate the mean PG
Tricuspid Stenosis
severity scale: TVA
normal?
severe?
7-9 cm2
≤ 1.0 cm2
Tricuspid Stenosis
severity scale: P½t
severe?
≥190 m/s
Tricuspid Stenosis
severity scale: mean PG
severe?
≥ 5 mmHg
Tricuspid Regurgitation
definition
the result of an incompetent TV that permits backward systolic from the RV, through the TV (while it is closed), into the RA
Tricuspid Regurgitation
murmur
a holosystolic murmur that increases with inspiration
Tricuspid Regurgitation
causes
- majority of normal patients (75%) have trace/mild TR
- mosrt common cause of TR is secondary or functional TR due to:
- annulr dilatation from RA/RV enlargement
- associated with left heart disease
- RV dysfunction
- PH
- myxomatous degeneration - most common cause of primary TR
- Rheumatic TR - usually associated with TS
- TV prolapse *seen in 20% of cases with concominant MVP (mid-to-late systolic or holosystolic)
- incomplete closure of TV due to:
- pacemaker wire
- tumor
- RV infarct
- pap muscle dysfunction
- ruptured TV chordae
- secondary TR due to frail leaflets (closed chest trauma, biopsy, vegetation)
- carcinoid heart disease
- congenital TR (Ebstein anomaly)
- prosthetic valve disease
Tricuspid Stenosis
severity: inflow time-velocity integral
> 60cm
Tricuspid Stenosis
severity: supportive findings
enlarged RA ≥ moderate; dilated IVC
Tricuspid Regurgitation
cause
- secondary or functional TR due to annular dilatation from RA and/or RV enlargement, may be associated with left heart disease, RV dysfunction, or PH *most common cause
- Myxomatous degeneration is the most common cause of primary TR
- Rheumatic TR is usually associated with Rheumatic TS
- TR due to TV prolapse. TVP is seen in 20% of cases with concomitant (associated/accompanied) MVP and is diagnosed with excessive billowing of ½/3 TV leaflets into the RA. Similar to MVP, TVP can be mid-to-late systolic or holosystolic
- incomplete closure of TV due to pacemaker wire, tumor, RV infarct, pap muscle dysfunction, ruptured TV chordae
- Secondary TR due to flail leaflets (closed chest trauma or biopsy), vegetation etc
- Carcinoid heart disease with TV involvement. TV leaflets are thick and rigid with no change in position from diastole to systole. Additional findings incluude TS, PS, and PR
- Congenital TR such as Ebstein anomaly
- Prosthetic valve dysfunction
Tricuspid Regurgitation
The majority of normal patients ____% have trace/mild TR (functional TR)
75
Tricuspid Regurgitation
TR due to Structural Abnormality of TV
Cause?
- 25% of TR patients
- Rheumatic
- Prolapse
- Congenital: Ebstein anomaly, TV displasia, TV hypoplasia, TV cleft, double-orifice TV, _unguarded TV orifice (_most extreme form)
- Endocarditis
- Endomyocardial fibrosis (an idiopathic disorder of the tropical and subtropical regions of the world that is characterized by the development of restrictive cardiomyopathy and fibrotic changes in the endocardium, usually limited to the cardiac apex.)
- Carcinoid disease
- Traumatic (blunt chest injury, laceration)
- iatrogenic: pacemaker/defibrillator lead interference, RV biopsy, drug exposure to fenfluramine-phentamine (The drug combination fenfluramine/phentermine, usually called fen-phen, was an anti-obesity treatment that utilized two anorectics) or methysergide, radiation
Tricuspid Regurgitation
What are the physical findings?
- Jagular venous distention with prominent “v” wave
- hepatomegaly
- pulsatile liver
- hepatojugular reflux
- peripheral edema
- ascites
- AFib
- hyperdynamic RV impulse
Tricuspid Regurgitation
Doppler evaluation
hepatic vein evaluation with PWD to check_____
hepatic vein flow reversal by aligning insonation beam with the flow in the HV
*note: may not be reliable in patients with Afib, paced rhythm with retrograded atrial conduction
Tricuspid Regurgitation
CW Doppler evaluation
What are the disadvantages?
- qualitative
- perfectly central jets may appear denser than eccentric jets of higher severity
- overlap between moderate and severe TR
Tricuspid Regurgitation
CFD evaluation
- jet size and configuration - jet area to RA area comparison
- direction and eccentricity of jet
- color M-mode to establish timing
*Vena contracta
- narrowest portion of jet that occurs at or just downstream from the orifice, measured at the time of its largest diameter
- not valid in presence of multiple jets
- width > 0.7 = severe TR
*PISA
- validated only in small studies
- rarely needed clinically
Tricuspid Regurgitation
CFD severity?
mild
Tricuspid Regurgitation
CFD severity?
moderate
Tricuspid Regurgitation
CFD severity?
severe
Tricuspid Regurgitation
CFD severity?
massive
Tricuspid Regurgitation
CWD shape of TR
symmetrical shape reflects _____ TR
asymmetrical shape reflects _____ TR
mild
severe *due to rapid increase in RA pressure
Tricuspid Regurgitation
TR & TVSP/SPAP calculation method
- acquire the peak TRV then calculate the RV-RA pressure gradient using the modifies Bernoulli equation: 4V2 (*V = peak TRV you measured)
- Unless the patient has a central venous line, estimate the mean RAP by using 3/8/15 method based on the IVC diameter & IVC respiratory behavior (collapse)
- IVC < 2.1 cm & collapse > 50% = normal RAP = 3mmHg
- IVC < 2.1 cm & collapse < 50% = normal size/abnormal collapse = intermediate RAP = 8mmHg
- IVC > 2.1 cm & collapse > 50% = abnormal size/normal collapse = intermediate RAP = 8mmHg
- IVC > 2.1 cm & collapse < 50% = abnormal size/abnormal collapse = severe RAP = 15 mmHg
*acquire IVC diameter at the end-expiration, just proximal to the entrance of hepatic vein
