1. What are the 3 TV leaflets and commissures? 2. What are the RV pap muscles?

1. Leaflets = Anterior, posterior and septal Commissures = Anteroseptal, anteroposterior, posteroseptal 2. Two discrete pap muscles and one rudimentary (moderator band)

Tricuspid And Pulmonary Stenosis Flashcards by Julianna Small

What are the 3 TV leaflets and commissures?

2. What are the RV pap muscles?

Leaflets = Anterior, posterior and septal

Commissures = Anteroseptal, anteroposterior, posteroseptal

Two discrete pap muscles and one rudimentary (moderator band)

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Etiology of tricuspid stenosis may be of what two origins?

Congenital

2. Acquired

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What is congenital TS associated with?

Almost always associated with other congenital cardiac defects

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What are some examples of congenital TS? (3)

Cor Triatriatum Dexter (Septation in the RA that is perforate - netting)
Malformed leaflets, chordae or paps
Annular hypoplasia

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What is the most common acquired cause of TS?

Rheumatic (beta-hemolytic strep infection that causes fibrosis)

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What is Carcinoid heart disease?

Acquired cause of TS:

Rare, malignant neuroendocrine tumor that secretes serotonin and covers valve in milky plaque that causes thickening

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What views best show the TV?

A4C
Subcostal RVOT (4 or 5 chamber)
PLAX RVIT
PSAX RVOT

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What does carcinoid heart disease damage?

Tricuspid and pulmonary valves

NEVER left heart

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Other than rheumatic and carcinoid, what are other causes of acquired TS? (3)

Large TV vegetation
Rt heart tumours
Rt heart thrombus

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In order to maintain cardiac output in the presence of TS, what must the RA pressure do?

Increase

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As the RA pressure increased, where does it work its way to?

Backward into the systemic veins

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Rheumatic TS usually occurs in conjunction with what?

Rheumatic MS and dyspnea

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What are the clinical manifestations of TS?

Systemic venous congestion, jugular venous distention, ascites, peripheral edema

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What are the symptoms of TS?

Fatigue, abdominal discomfort and swelling

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How can you tell the diff between rheumatic causing TS or carcinoid causing TS?

If it’s rheumatic the MV will be affected as well

If it’s carcinoid the PV will be affected as well

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How can we assess TS? (5)

Assess RA size (for dilation)
Assess RV size and function
Estimate stenosis severity (using colour, mean pressure gradient, VTI, P1/2T and TVA)
Estimate the RV systolic pressure
Identify valve lesions and determine cause

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What is normal RA area?

<18cm2

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What is normal RA length and width?

Length: <5.3 cm

Width: <4.4 cm

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What is the normal RA volume index for Males and Females?

Male: < 32 ml/m2

Female <27 ml/m2

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What are the normal RV measurements?

Base: < 4.1 cm

Mid: < 3.5 cm

Length < 8.6 cm

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What is the normal TAPSE value?

> 17mm

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What is the normal s’ value for RV function? (TDI)

> 9.5cm/s

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What is the normal FAC for RV function?

> 35%

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What is the normal RIMP for RV function?

Study These Flashcards

<0.44

How do we assess TS with echo? (4)

1. Use colour to see aliasing in RV during diastole 2. Trace the TV inflow (jet) to measure: - Mean pressure gradient to see if it's high - VTI to see if it's high 3. Assess pressure half time by measuring the downslope to see if it takes a long time for blood to move through valve 4. Calculate the TV Area with the continuity principal

Which is more useful, mean gradient or peak velocity for asessing TS and why?

Mean gradient Because: - More than one peak during diastole - Diastole is longer than systole

What is TV pressure half time measurement?

Measures the time it takes for the early diastolic pressure gradient between the RA and RV to fall to half it's original value (will be fast in a normal (wide) TV)

How is TVA area assessed?

By comparing the SV of the TV with the SV of another valve using the continuity equation (assuming SV should be the same in all normal valves)

What is a limitation of pressure half time with TV?

Tachycardia as the E and A waves are fused

What is a normal TVA?

6-7cm2

When can TVA not be calculated?

In the presence of signficant TR coexisting with TS because the SV is altered

What is the formula for tricuspid valve area?

TVA = (CSAlvot x VTIlvot) ÷ VTItv

How is severity of TS rated?

Signficant or insignificant

What is a significant TS mean gradient?

≥5mmHg

What is a significant TS inflow VTI?

>60 cm

What is a significant TS pressure half time?

>190 ms

What is a significant TS tricuspid valve area?

≤1.0cm2

What are two supportive findings that are seen with significant stenosis?

Enlarged RA and dilated IVC

What are treatments for TS? (3)

- Surgical debulking/repair of tumor/vegetation - Transvenous balloon valvuloplasty - Diuretics or nitrates to relieve venous congestion

What are the names of the pulmonary valve cusps?

Anterior, right and left posterior

The PV is not continuous with the IVS and instead has a muscular ridge called what?

The infundibulum

The anatomy of the pulmonary root is the same as what?

Aortic root

Where can RVOT obstruction occur?

Subvalvular (infundibular), valvular, supravalvular, branch

PS is almost always caused by what?

Congenital

What are the 3 types of congenital PS?

1. Dome shaped (reduced orifice) 2. Dysplastic (severe thickening) 3. Unicuspid or bicuspid (bicuspid assc. W/ tetrology of fallot

Acquired causes of PS? (5)

Rare (usually PS is congenital) 1. Rheumatic 2. Carcinoid - Sinus or IVS aneurysmy - Hypertrophic CMO - Post ross procedure/surgeries - Thrombus/tumors/vegetations

What is a normal RV thickness?

3-5mm

What are the 2 criteria used to assess the severity of PS?

1. Peak PV velocity 2. Maximum gradient (NOT PVA - as recommended by ASE)

What is the peak velocity for mild and severe PS?

Mild: < 3 Severe: > 4 (Same as aortic)

What is the Max Gradient value for mild and severe PS?

Mild: < 36 Severe: > 64

How can you determine the maximum gradient of PS if you have the peak velocity?

By using bernoulli's equation (4Vsq)

What is the procedure of choice for severe congenital pulmonary stenosis?

PV valvuloplasty

Where is the PV annulus best measured and why is it done?

PSAX view of the RVOT Done to select correct size of balloon for valvuloplasty

In the absence of PS or an RVOT obstruction, it is assumed that the RVSP is equal to what?

Pulmonary artery systolic pressure

When a mild or moderate RVOT obstruction is present, what does the PASP formula become?

PASP = RVSP - mean PGpv

When a severe or critical obstruction is present in the RVOT what formula is used for sPAP?

PASPc = RVSP - MIPGpv | Max Instantaneous

What does mild vs critical PS look like on CW Doppler?

Mild has early peaking and is v-shaped, critical is more parabolic and somewhat flattened

How does echo assess PS? (4)

1. RV size and function 2. Severity of PS (using peak vel and max gradient) 3. Measure PV annulus 4. Estimate pulm pressures

Tricuspid And Pulmonary Stenosis Flashcards

(58 cards)