14. RV, RA, Tricuspid and Pulmonic Valve

Question 0

RVH

Answer 0

RV free wall > 5mm

Question 1

Moderator Band

Answer 1

Muscular trabeculation extending from lower interventricular septum to anterior RV free wall
- separates inflow and outflow portions of RV

Question 2

RV dilation

Answer 2

RV cross sectional area to LV
Normal: 60%
Mild dilation: 60-100%
Moderate: 100%
Severe: >100% (RV larger than LV)

** RV makes up portion of apex = abnormal

Question 3

TAPSE

Answer 3

• tricuspid annular plane systolic excursion
• measure of RV systolic function
• measured at free wall (lateral tricuspid annulus)

Normal: 20-25mm

Question 4

RV systolic function and hepatic vein flow

Answer 4

• S wave blunted with decreased RV function

S: fall in atrial pressure caused by atrial relaxation and apically movement of TV during RV systole
D: early ventricular filling
A: atrial contraction
V: small retrograde

Question 5

RV volume overload vs pressure overload

Answer 5

Volume overload:

• 2/2 ASD, VSD, TR, PR
• more consistent dilation of RV
• interventricular septum distortion maximal at end-diastole
• paradoxical septal motion

Pressure overload:

• 2/2 pulmonary hypertension or PS
• hypertrophy of free wall
• peak septal distortion at end-systole or early diastole

Question 6

Eustachian valve and chiari network

Answer 6

• associated with IVC

persistent eustachian valve: result from a failure of regression of right or inferior valve of the sinus venosus

chiari network: strand-like structure within the RA cavity

Question 7

Tricuspid anatomy

Answer 7

• trileaflet: anterior, posterior, septal
• three papillary muscles, each associated with leaflet
  
  • anterior originates from moderator band and is largest
• TV is slightly apically displaced compared to MV
  
  • not present: primum ASD and endocardial cushion defects
  • exaggerated: ebsteins anomaly

Question 8

Tricuspid Regurgitation

Answer 8

• most common right sided lesion
• associated with RV enlargement or pulmonary hypertension

Severe:

• jet fills greater than 50% of RA
• systolic reversal of hepatic vein flow

Question 9

Tricuspid Stenosis

Answer 9

• rheumatic disease is most common cause of TS
  
  • normal has TR as well plus mitral involvement
• flow velocities typically under 0.7m/s in normal valve
• velocity >1.5 m/s in prosthetic tricuspid indicates significant
  stenosis

Question 10

Carcinoid

Answer 10

• tumors in ileum release serotonin, bradykinin, histamine, prostaglandins
• causes mod-severe TR, mild TS and PS
• inactivated by MAO in lungs so left sided valves are unaffected

Question 11

Ebsteins anomaly

Answer 11

• malformed TV displaced into RV
  
  • separation between MV and TV > 8mm
• anterior leaflet least affected, but septal and inferior leaflet rudimentary or absent
• displacement of TV causes part of RV to become atrialized
• associated with:
  
  • impaired RV function
  • conduction delays
  • TR

Question 12

Pulmonic Valve

Answer 12

• trileaflet with anterior, right, left cusps

- leaflets directly connected to musculature of RV (and much thinner than aortic valve)

Question 13

Pulmonic Regurgitation

Answer 13

• either congenital (abnormal cusps) or from pulmonary hypertension
• PA catheter DOES NOT have significant effect on level of TR and PR

Question 14

Pulmonic Stenosis

Answer 14

-normally congenital, but can result from rheumatic, carcinoid, and endocarditis

Question 15

Ross Procedure

Answer 15

• replacement of a patient’s aortic valve with their own native pulmonic valve

Contraindications:

• significant PR
• annular dimension mismatch > 2mm between AV and PR

** dissection and excision of PV may cause inadvertent ligation of septal coronary artery branch cause LV septal regional wall motion abnormality