TV, PV, RVOT Flashcards
What is the General anatomy of the PV?
Three cusps, semilunar
What forms the RVOT?
The area in the ventricle just prior to the valves
How many cusps are seen in 2D?
Usually only 2 cusps seen
How does the AO and PA develop?
The AO and PA arise in a parallel fashion. Then rotate such that the RVOT, PV, and proximal PA wrap around the AO and ascending AO.
What views are used to evaluate the PA?
Which view can the bifurcation of the PA be seen
PLAX
PSAX at base optimal - bifurcation
Subcostal Short and Long.
How many cusps are imaged in M-Mode?
What views are used in M-mode
one leaflet
M-mode can only intersect one of the leaflets in the PLAX & PSAX views
what does each PV waveform looks like on M-Mode?
Normal, Stenotic, HTN, infundibular obstruction, idiopathic dilation
normal valve straight Stenotic: valve thick HTN: valve W shape infundibular obstruction: large spikes idiopathic dilation; small spikes
What is the line placement for spectral Doppler of the PA when you use PW vs CW?
What view is this measurement taken at?
What is the difference between the CW & PW wave characteristics?
CW - Line should go through the tips of the leaflets
PW- Area immediately prior to flow out the RVOT (prior to annulus
View: Parasternal at the base
Wave is below the baseline
CW: has the highest velocity – no envelope
PW: should have an envelope
What measurements can be taken of the PA in spectral doppler?
Acceleration Time: from beginning of wave to peak
VTI: trace wave
What happen to the peak when when pulmonary pressure and pulmonary vascular resistance are high?
the peak will occur earlier.
What are normal pulmonary outflow tract velocity ranges
from 1 to 1.5 m/sec.
What is Acceleration time and what causes it to decrease?
What are the normal values?
the time in milliseconds from the onset of ejection to peak systolic velocity.
In normal individuals, acceleration time exceeds 140 milliseconds and progressively shortens with increasing degrees of pulmonary hypertension
What is the relationship between the pulmonary acceleration time and pulmonary artery systolic, diastolic, and mean pressures.
They are inversely related
What is an acceleration time of less than 70 to 90 milliseconds is typically indicative of?
pulmonary artery systolic pressures ≥70 mmHg.
What is pulmonary velocity acceleration time (PVAT).
What is the normal value?
It is the interval between the onset of flow and peak flow.
The normal PVAT is > 130 msec.
Normal PAP time
borderline
Mildly elevated
severely elevated
Severity PVAT Normal PAP >130 msec Borderline PAP 100-130 msec Mildly elevated 80-100 Severely elevated less than 80
What is PI?
How is it detected?
What view do we use to assess it?
Pulmonary Insufficiency – also known as regurgitation
Use Color doppler
Subcostal PSAX at base view
Where is PI located?
They are usually Central or peripherally located on the valve
What can PI be confused with?
When is it seen?
What needs to be recognized to avoid any confusion?
communication between AO and PA
Only seen in diastole
recognition exclusive diastolic flow
What are the differential for PI? Direct and indirect
Jet size, depth of penetration into the right ventricle
width of the Vena contracta
Its overall width in relation to the RVOT
Indirect evidence:
Ventricular dilation
Right ventricular overload pattern
What causes Pulmonary regurgitation?
Everyone has a little PAV and tricuspid regurgitation
stenosis
dilation of annulus (idiopathic or due to pulmonary artery dilation as a consequence of PHT)
congenital absence of one or more pulmonary valve cusps
How is Pulmonary regurgitation (PI) detected?
color Doppler -detects a diastolic retrograde jet
PW -detect a retrograde spectral profile
What type of grading is used to grade PI?
Subjective grading
Mild, moderate, severe, ect.
If it can be seen, measure the Vena Contracta (diameter of jet at narrowest point in relation to RVOT diameter)
Which is more validated the severity of pulmonary valve regurgitation or AO regurgitation?
PV regurgitation is less well validated than of AO regurgitation, in large part due to the lack of reliable standards for comparison
What is a known cause of PV stenosis?
Usually always congenital
What is the hallmark of congenital pulmonic stenosis?
thickening and systolic doming of the pulmonary valve cusps
What are the findings of PV stenosis in M-mode echocardiography?
accentuated A-wave amplitude (>6 mm) with thickening of the leaflet.
What is the origin of the accentuated A wave?
relatively elevated RV pressure in comparison with the PA diastolic pressure
What does stenosis look like in the various modes?
Calcification and Thickening of valves Leaflets grow together (can see commissural but don’t see it open) May form bicuspid or uni-cuspid valve Restrict flow systolic doming of the PV cusps
How is stenosis detected in spectral doppler?
CW – VTI, Max velocity
What is a Vena Contracta and how do you measure it?
Convergence point
The narrowest central flow region of a jet that occurs at, or just downstream to, the orifice of a regurgitant valve
The narrowest portion of the color jet
What parameters of color Doppler do you have to consider when evaluating a PV regurgitation jet?
Optimize the color to avoid overcalling jet
Avoid having too much gain
What other things can be present on a valve? And how do you tell the difference?
(PV)
infectious Endocarditis – Less common with this valve (inflammation of the endocardium)
Vegetations may occur (bacteria or fungal growth) - oscillating appearance
Fibroma or papilloma – spherical mass attached by small stalk
Possibility of having a thrombus attached to it
What areas do we use PW vs CW?
PW- RVOT & LVOT
CW – PV & AOV
What is the anatomical makeup of the RVOT?
What type of tissue?
The portion of the RV extending from crista supraventricularis to the pulmonary annulus
It is relatively trabeculated
May be dilated
May see congenital abnormalities
What causes sub-valvular stenosis?
Elevated pulmonary pressure from stenosis causes hypertrophy
What the best view for the RVOT?
Parasternal views are best, but can be seen from the subcostal view
What demographic are idiopathic dilation of the pulmonary artery typically seen in?
elderly female patients
.
What does idiopathic dilation of the pulmonary artery frequently result in?
what are two more additional findings?
- secondary pulmonary valve regurgitation
- high-frequency oscillation of the pulmonary valve leaflets noted best with M-mode echocardiography.
3 .occasional isolated aneurysms of the PA
What is the area of the RVOT?
the portion of the RV extending from the crista supraventricularis to the PA annulus
What disease cause hypertrophy of the RVOT?
diseases that elevate right ventricular pressure, such as pulmonary hypertension or
pulmonary valve stenosis,
What type of motion of the RVOT can be seen on M-mode?
coarse fluttering of the pulmonary valve
What is the Anatomy of the TV?
Which leaflet is the smallest? Which is the largest?
Most complex of the valves Three leaflets of differing size Anterior leaflet is largest septal is smallest Posterior in between
What are landmarks of the Right heart?
Moderator bad and the TV tricuspid
What is the position of the TV in relation to MV?
What is the max normal distance between the TV annulus and the MV annulus?
What view is this best measured at?
Closers to the ventricular apex. Located further into the ventricle than the MV annular location.
They should not be more than 7mm apart from one another
Apical 4CH
What use does 3D have in evaluating the TV?
for surgical planning
evaluate the tricuspid valve in cases such as Ebstein anomaly
quantifying functional tricuspid regurgitation
What is Ebsteins Anomaly?
The TV is formed in the right ventricle making the right atrium appear large.
No more than 7mm between the MV annulus and the TV annulus.
Measure in Apical 4CH
TV prone to severe leaking, which causes a dilated heart
Causes high right heart pressure
What views are used for doppler of the TV? Which is the optimal view?
PLAX, PSAX and A4CH
Apical optimal view
Recognize the views with TTE and TEE
RV Inflow tract, PSAX at the base, Apical 4Ch, subcostal 4Ch,
TEE- 60o base, horizontal left atrial 4ch, gastic 1200, Bicaval view
Compared to MV what do the Doppler signals look like?
Much lower velocities due to size
E/A typically exceeds 1.0
How do we evaluate TR?
Color Doppler most common method for TR evaluation
How does TR change with age?
TR increases with age and virtually everyone has TR
What causes TV stenosis and how common is it?
Infrequent occurrence
Stenosis is caused from congenital origin, rheumatic heart disease or carcinoid syndrome
What causes TR?
Very common
Dilation of RV caused from PHT
rupture of cords from blunt trauma or papillary muscle infarction
simple prolapse- slip back a little bit, but not flail which is when the tips pointing back in the wrong direction.
What causes severe TR?
tethering of valves with cordae (causing them to be restricted and unable to shut properly (coaptation)).
How do foreign objects affect the Tricuspid Valve?
Catheters, pacemaker leads
leakage and prevent from squeezing down all the way and getting good coaptation
thickening and scarring of leaflets
Inflammation process initiates damaging the leaflet
Found in 20% of individuals with implanted device have some process going on that is affecting the valves
How is the Tricuspid Valve effected by Ischemic Heart Disease?
Almost always associated with inferior wall (RCA)
Causes remodeling of RV
causing outward dilation of lateral wall and consequently TR
How do you grade TR?
Trace, Mild, Moderate and Severe
If significant TR, can see reverse flow in IVC and Hepatic Veins
PW sample looking at S,D, A reversal- normally downward
A will be upward – S will be significantly depressed/smaller or reversed.
Reversal indicates greater significance of TR
If using contrast, you can see bubbles confined in RA or back flowing into IVC
What is RVSP and how do we determine it?
Right ventricular systolic pressure (RVSP)
Use TR jet and measure the peak velocity. (Normal 3-4m/sec)
Plug into Bernoulli equation to get pressure.
In addition you will add the right atrial pressure from the sniff test of the IVC
5-10mmHg
Bernoulli Equation P=4V2
TR jet velocity acquired pressure + RA pressure from IVC = RVSP
What is Carcinoid Heart Disease?
What effect does it have on the right and right heart?
occurs when a neuroendocrine secreting tumor releases high levels of serotonin and metabolites are released into the bloodstream.
These cause inflammation of the endothelial surface of the valves and endocardium.
They are deactivated by lung therefore only the right heart is affected
May affect the left if there is a shunt allowing bypass of lungs
What is fibrosis?
formation of the elastic fibers of the endocardium
It is seen in a variety of diseases including hyperesoinophila syndrome and tropical forms of endocardial fibroelastosisFiber
What does Endocardial Fibroelastosis do to the TV?
Affects the chordae and valve leaflets via inflammation process
Leaflets appear “bound down” to the ventricular wall (tethered to the wall, fibers won’t let leaflets close all the way because they are holding them back)
Associated with the obliteration of the RV apex due to inflammation and secondary thrombosis – particularly associated with hypereosinophilia
LV and MV are similarly involved
What effect does persistent elevation of right heart pressure have on the IVC?
(due to TR)
THe IVC dilates and loses its normal respiratory variation in size.
What is Ebstein Anomaly? what do we see in echo?
Congenital defect causing apical displacement of the Tricuspid valve. TV valve form in RV, cause appearance of a large atrium
Causes severe TR
Valves get tethered to the RV wall
What is valve resection and how does it affect the valve?
Why and When was valve resection a popular treatment and what are is the current results?
Any kind of resection will cause the valve to scar and not function as it should
Resection is usually done due to bacterial endocarditis (usually vegetations or masses)
Many patients in the late 1970’s and early 1980’s had removal of a tricuspid valve leaflet
Obviously severe TR
Now they have significant right heart failure
What effect does the complete absence of the TV tissue of on TR?
There is no organized flow from the RV to the RA and no increase in velocity or organize jet. . This results in the absence of a convergence zone
When would a biopsy be done on the TV?
Biopsies done after transplant to make sure it is not experiencing rejection
What types of primary tumors can arise on the TV?
How often is this seen?
myxomas and occasional fibroelastoma
Rarely
