The Right Heart Flashcards
(132 cards)
1
Q
What view is this?
What tricuspid valve leaflets are shown?
A
Mid-esophageal 4 chamber with focus on the RV
Tricuspid Valve: septal (STVL) + anterior (ATVL) leaflets
Septal = Medial leaflet
2
Q
RV regional wall motion abnormalities that involve the base of the RV with sparing of the RV apex are particularly suggestive of:
1. What pathology?
2. What sign?
A
Pulmonary Embolism
McConnell Sign
3
Q
What view of this?
What is the valve shown here?
What is 1?
What is 2?
A
Deep TG of tricuspid valve
1 = Posterior Valve
2 = Anterior or Septal Valve
4
Q
What view?
What are leaflets 3 and 4?
A
Tricuspid Valve of ME RV inflow/Outflow
3 = Anterior or septal
4 = Posterior
5
Q
What view of the RV under TEE is correlated best with MRI resolution RV Ejection Fraction?
A
Mid-esophageal 4 chamber
6
Q
What is TAPSE?
A
Tricuspid annular plane systolic excursion (TAPSE)
7
Q
What TEE view is best used to calculate TAPSE?
A
Midesophageal 4 chamber view
8
Q
What are all the views to assess the RV?
A
ME-4 chamber
ME - RV inflow-outflow
ME Asc Aorta Short Axis
ME Bicaval view (modified bicaval) (Doppler of Tricuspid insufficiency jet to calculate RVSP)
Upper Esophageal Aortic Arch Shot Axis
TG Short Axis
TG RV inflow (TGSAx then change sector to 90 degrees)
Deep TG RV outflow (Angle for tissue doppler for Syst and diast)
9
Q
What are the two views you can use to calculate RVSP?
A
Mid esophageal RV inflow-outflow to get RVSP
Mid Esophageal Bicaval Modified to get RVSP
10
Q
What views can you align a doppler along the pulmonic valve parallel to blood flow?
A
Mid Esophageal Ascending Aortic Short Axis
Upper Esophageal Aortic Arch Short Axis
(Images 1 and 3 in photo)
11
Q
What is the arrow pointing at?
A
Left Atrium
12
Q
What is the arrow pointing at?
Which coronary cusp?
A
Aortic Valve
Specifically, the non-coronary cusp
13
Q
What is the arrow pointing at?
Which coronary cusp?
A
Aortic Valve
Right Coronary Cusp
14
Q
What cusp is to the right of the arrow?
A
Left Coronary Cusp of the Aortic Valve
15
Q
What is the green arrow pointing at?
A
Coronary Sinus
(Probe turned to the right and advanced slightly from your 4 chamber view)
16
Q
In the modified Bicaval View listed
What is the top left arrow? (Teal)
What is the top right arrow? (White)
What is the bottom right arrow? (Green)
A
Teal = Coronary Sinus
White = SVC
Green = Right Atrial Appendage
17
Q
What view do we see here?
What is the arrow pointing to?
A
Transgastric Mid Papillary Short Axis View
Arrow = Moderator Band
18
Q
What view is seen here?
A
Transgastric RV inflow view
19
Q
What view is this?
Label:
Pink
Teal
Green
A
Deep Transgastric RV outflow
Pink = TV
Teal= RA
Green = AV
20
Q
What is seen in green?
A
Pulmonic Valve
21
Q
What view is seen?
What is the dotted line?
Label
Green
Teal
BLue
A
Upper Esophageal Aortic Arch Short Axis
Dotted line = Parallel Continuous Wave Doppler on Pulmonic Valve
Green = Pulmonary Valve
Teal = Aortic Valve
Blue = Innominate Vein
22
Q
What view is seen here?
Label the major vessels here
A
23
Q
What is the structure labeled “Z”?
A
Pulmonary Artery Catheter
24
Q
What view is this?
A
Midesophageal Bicaval View (Modified)
25
What is the formula to calculate RVSP?
RVSP = 4 (Velocity of TR peak)2 + Right Atrial Pressure
26
What physics principle is used to come up with the RVSP equation?
Bernoulli
27
How does the RSVP equation change if you have pulmonic stenosis?
You must substract the PA pressure across the valve
28
Label teal arrow
Label White arrow
Label Green arrow
Teal = Coronary SInus
White = SVC
Green = Right atrial appendage
29
How do you tell a difference in the IVC vs. Coronary sinus in the bicaval view?
**IVC** is larger, and more "flat"
**Coronary Sinus** is smaller and angled more vertical "up" on the screen
30
What % of CPB circ failure is due to RV failure?
20%
31
Why doesn't retrograde cardioplegia protect the Right heart well?
1. Right heart drains into Thebesian Veins, which drain into the right ventricle (Not into the coronary sinus)
2. When ice is placed on the heart, doesn't cool the right heart as much
3. Air shoots down the RCA is air embolism occurs
32
What % of patients have severe refractory RV failure in:
1. Cardiotomy?
2. Heart Transplantation?
3. LVAD?
0.1% cardiotomy
2-3% of heart transplantation
20-30% of patients receiving LVAD
33
Mechanically, how does an LVAD make RV function worse?
LVAD sucks the septum towards the device and the septum no longer participates in RV contraction
34
How does an IABP cause RV dysfunction?
IABP Causes decrease in RV afterload
Due to RV afterload reduction, septum shifts toward LV
RV can then not help as much participate in contraction
35
Comment on the **Compliance**, **Resistance** and **Loading conditions** pertaining to the right heart.
**Compliance** = High
**Resistance** = Low
**Loading conditions** = Sensitive to
36
What are the 4 quantititative measures of RV function?
**RVFAC** (RV Fractional Area Change)
**RVEF**
**TAPSE** - Tricuspid Annular Plane Systolic Excursion
**IVA** = Isovolumetric Acceleration
37
What is the normal values of RVFAC (RV Fractional Area Change)?
RVFAC (RV Fractional Area Change)
## Footnote
**\>/= 32%**
38
What is the normal Values of RVEF?
RVEF
## Footnote
**\>/- 45%**
39
What are the normal values for TAPSE?
TAPSE
Normal = Anything above 17
**\>17 mm (Cutoff for nomal)**
**Anything below this is abnormal**
**TAPSE doesn't stratify low normal vs. normal**
40
What is the normal value for IVA?
IVA = Isovolumetric Acceleration
## Footnote
***_1.4 +/- 0.5 m/s_2***
**(Lower range of normal, 2.2 in other studies)**
41
Why is RVEF approx \>45 % and LVEF \>55-65%?
**RV end-systolic and end-diastolic volumes are higher** than LVESV and LVEDV
42
What is the **TV S' (S Prime)** for the lower range of normal?
**\<10**
**(I've read \<9.5 cm/sec in TTE guidelines)**
43
How do we measure TAPSE?
You are looking at the **"swinging" of the lateral tricuspid annulus toward the apex**
## Footnote
**A - B = TAPSE**
44
What is the equation to IVA (Isovolumetric acceleration)?
Vt / (Delta) t
45
What is the formula for RV FAC?
## Footnote
***_Which TEE view would be ideal?_***
[_End Diastolic Area - End Systolic Area_] / [_End Diastolic Area}_
## Footnote
**_View = Mid esophageal 4 chamber view_**
46
What view is this?
What is the arrow pointing at? (Purple arrow)
**Mid Esophageal RV Inflow Outflow**
Eustachian Valve
47
What view is this?
What is the arrow pointing to?
What is this arrowed structure attached to?
Transgastric Mid Papillary Short Axis View
Moderator Band
Moderator Band attached to anterior papillary muscle
48
What view is seen here?
Transgastric RV inflow view
49
What happens to the septum with volume overload?
**Late diastolic septal motion to the left**
(IN late diastole, that is when RV volume is the highest)
Left to Right shows progression of RV dysfunction
50
What are the etiologies that are possible with volume overload where you have flattening of the septum?
**Pulmonary insufficiency (PI)**
**Atrial Septal Defect (ASD)**
**Tricuspid Regurgitation**
51
What is the eccentricity index?
A / B (Measure anterior and posterior index)
Quantifies how much septal bowing you have
52
How does your eccentricity index change with worsening RV failure?
**A \> B** as the RV turns into a "D" shape and your **eccentricity index will rise**
53
What will you see in isolated pressure overload of the RV?
1. Paradoxical Septal Motion
2. Late systolic Septum --\> Left
3. RVH = Thickness \> 5mm
54
How do you differentiate between isolated pressure overload vs. isolated volume overload in regard to septal shifting of the RV?
**Volume Overload** = Max septal shift in late diastole
**Pressure overload** = Max septal shift in late systole
55
What is apex forming?
**When the RV forms the apex image of the heart, you have RV dysfunction**
(Normal = LV forms your apex)
56
What will you see during pulmonary embolism on the mid-esophageal 4 chamber?
## Footnote
**What is this called?**
Apex of the RV moves, but the base of the RV doesn't move?
## Footnote
**McConnell Sign**
57
Label this entire image
1. Valves first
2. Cusps top valve
3. Cusps right valve
Top = Pulmonic Valve
Aortic Valve = Center
Mitral Valve = Left
Tricuspid Valve = Right
58
In the 4 chamber mid esophageal view, what tricuspid leaflets are seen?
If you are seeing **anterior** structures (Aortic Valve, LVOT), then you are seeing **anterior** leaflet *_on the Left._*
If you are seeing **posterior** structure (Coronary Sinus), then you are seeing **posterior** leaflet *_on the left._*
*_The right side is always showing the septal leaflet_*
59
What is the structure seen in green?
## Footnote
*_What tricuspid leaflets are seen here?_*
**Coronary sinus**
*_Posterior (left) and Septal (Right)_*
60
What leaflets of the tricuspid valve seen here?
**Anterior** (Left) and **Septal** (Right)
because we are in ME-5 chamber and its looking at more anterior structutres
61
What valves of the tricuspid valves are seen here?
Left = Posterior
Right = Anterior/Septal Leaflet
62
In the transgastric mid papillary short axis, label the triscupid valve leaflets.
63
In the TG RV view, what tricuspid leaflets are seen here?
Top = Posterior
Bottom = Anterior or Septal
64
What is the type of TR that develops with normal valve leaflets?
**Functional TR**
65
What happens to the triscupid valve with a PA catheter?
**Mild TR**
66
What are some other etiologies of TR outside of functional TR (Normal valves) and PA-Catheter induced mild TR?
1. Annular Dilation
2. Papillary muscle dysfunction
3. Pressure / Volume overload
67
What is the term for TR due to abnormal valve leaflets?
**Structural TR**
68
What are some etiologies of abnormal valve leaflets (Structural TR)
1. Rheumatic
2. Myxomatous Degeneration
3. Ebstein's Anomaly
4. Carcinoid Heart Syndrome
5. Endocarditis (IVDU)
69
What is the most common cause of triscupid stenosis?
**Rheumatic Heart Disease**
70
Rheumatic Heart Disease is more likely to cause TS or TR?
**TR \> TS**
71
Rheumatic Heart Disease affects which valves most commonly (List stenosis vs. regurgitation).
1. Mitral Valve
2. Mitral Valve and Aortic
3. Mitral, Aortic and Tricuspid (20-30%)
4. Aortic Valve alone (\<5%)
72
What occurs with the leaflets with Ebstein's Anomaly?
**Large "sail-like" anterior leaflet** (Left side of image)
Anterior leaflet attaches to the TV annulus
TV is funnel shaped and incompentent
73
What happens to the RV in ebstein's anomaly?
**Atrialization of the part of the RV**
74
What two conditions is Ebstein Anomaly associated with?
1. ASD
2. SVT (Wolff-Parkinson-White (WPW) syndrome)
75
Why is serotonin only affecting right sided heart valves?
Serotonin is degraded by **monoamine oxidases** in the **lungs**
76
What is the classic sign of Carcinoid Syndrome?
**Thickening and fibrosis of the TV and PV**
Can cause stenosis or regurgitation of both left sided valves
77
When can you have carcinoid syndrome affecting the left heart?
**PFO**
78
With carcinoid syndrome, is stenosis or regurgitation more common?
Which leaflets are involved?
Regurgitation more common
**Septal** and **Anterior** Leaflets
79
How do you grade Triscupid Regurgitation in terms of mild, moderate and severe?
**CWD Jet Density**
**Jet Area**
**Vena Contracta**
**Hepatic Venous Flow**
80
What are the waves in Hepatic Vein Velocity?
A
S
V
D
81
What do the A, S, V, and D waves of HV Velocity? correlate to on the CVP tracing
A = a waves
S = x descent
V = v wave
D = y descent
82
What is the CVP pattern and HV pattern seen with Tricuspid insufficiency?
C and V wave
A wave and V wave present but "retrograde flow" seen instead of S wave.
83
What is seen in the image below?
**Holosystolic HVF reversal seen in severe Tricuspid insufficiency.**
Note: The Pulse Wave doppler is seen through the hepatic vein
88
Why is Tricuspid Stenosis very rare?
**The annulus is very large**, so hard to get a stenotic valve
89
What is the most common cause of Tricuspid stenosis?
**Rheumatic Disease**
(Although TR is more common than TS with Rheumatic disease)
90
What are the two other most common etiologies to TS other than rheumatic disease?
1. Carcinoid Syndrome
2. Congenital Abnormalities
91
What is the normal peak TV velocity?
**30 - 70 cm/sec**
92
Name all the valves and label each cardiac valves
93
What pulmonic **leaftlets** are seen in the ME RV inflow outflow tract?
"Top" = R/L
Bottom = Anterior
94
When we grade TS, do we use mean or peak gradients?
Mean
95
What quantitative value of mean Peak gradient is used to define severe TS?
**\>5 mmHg**
96
Gradients used to evaluate TS are dependent on what two variables?
**1. HR**
HR increase (Decreases diastolic filling time therefore increased gradient)
**2. Flow**
Decreased flow = Decreased gradient
97
Label:
Green
Teal
Blue
**Green** = Pulmonic Valve
**Teal** = Aorta
**Blue** = Innominate Vein
98
**Label the image regarding Pulmonary Valve**
Systolic Ejection
Early Velocity
Late Velocity
99
When you use continuous pulse wave doppler on the pulmonic valve, you see this.
What is it?
**Holodiastolic Flow Reversal**
**Indicates severe pulmonary insufficiency**
100
How many cusps are on the pulmonic valve?
What are they?
3
## Footnote
**1. Anterior**
**2. Right**
**3. Left**
103
How do we obtain a PA systolic pressure from RVSP and pulmonic stenosis?
**1. Calculate RVSP** (RVSP = 4 (Velocity of TR Peak)2 + RAP
**2. Subtract Max Gradient** from **RVSP**
104
What are the 4 aspects of Tetrology of Fallot?
1. VSD
2. Overriding Aorta
3. Pulmonic Obstruction (No flow = No grow)
4. RVH
105
Significant PI is usually what etiology?
**Congenital**
106
What are the etiologies of acquired pulmonic insufficiency?
1. **Carcinoid**
2. **Endocarditis** (Least common valve infected by this pathology)
3. **Pulmonary Hypertension**
4. **Myxomatous Disease**
5. **Radiation to the Thorax**
107
What are the 3 objective criteria to determine pulmonic insufficiency?
1. **Jet area**
2. **Jet width**
3. **Holodiastolic Flow reversal in the main PA**
111
What is the etiology of pulmonic stenosis?
**Congenital**
112
How do you assess pulmonic stenosis gradient?
**Peak** and **Mean** Gradient with CWD
113
How do we obtain RVSP with pulmonic stenosis?
Hint: Equation
CWD on the tricuspid valve
**Change in Pressure** = 4 (**Velocity of TR Peak**)2 + **RAP**
**Note: The velocity is in meters/sec**
114
You have a patient with pulmonic stenosis. What is the most critical component of their management?
**Do not allow their aortic diastolic pressure to drop**
115
What is Arrow 1?
What is Arrow 2?
Arrow 1 = D wave
Arrow D = S wave
116
What is #7?
What is #8?
7 = Posterior
8 = Anterior
**Tricuspid Valve**
117
**Holodisatolic Flow reversal in the main PA may result from?**
A. Severe PI
B. PDA
3. Aortopulmonary Window
D. Severe TR
E. A, B, C
F. All of the above
Answer = A, B, C
118
**The intensity of the TV regurgitant signal relative to the intensity of the antegrade flow signal on the CWD spectal profile reflects which of the following?**
A. The regurgitant volume of blood traversing the valve
B. Parallel alignment of the U/S beam with blood flow
C. The velocity of the tricuspid blood flow
D. The depth of the sample volume
E. The Nyquist limit of the Doppler U/S Beam
A = Regurgitant Volume of blood traversing the valve
119
Ebstein Anomaly is most likely associated with which of the following?
A. Dilated PA
B. ASD
C. Small anterior TV leaflet
D. LVOT obstruction
E. Cor triatriatum dexter
F. Supravalvular Aortic Stenosis
**ASD**
120
Which of the following best describes a valvular disorders where one or more of the TV leaflets are displaced from the TV annulus toward the ventricular apex?
A. Rheumatic heart disease
B. Carcinoid
C. Ebstein's Anomaly
D. Noonan Syndrome
E. Kartagener's Syndrome
F. Williams Syndrome
Ebsteins Anomaly
121
The IV septum flattens and is displaced toward the LV at what point in the cardiac cycle with RV **pressure overload**?
A. Early Diastole
B. Late diastole
C. Early Systole
D. Late systole
E. This does not occur with RV pressure overload
**Late Systole**
| (Max displacement occurs here)
122
The IV septum flattens and is displaced toward the LV at what point in the cardiac cycle with RV **volume overload**?
A. Early Diastole
B. Late diastole
C. Early Systole
D. Late systole
E. This does not occur with RV pressure overload
**Late Diastole**
123
Which of the following views allows accurate determinations of the instataneous peak pressure gradient across the pulmonic valve by CWD?
A. ME RV inflow outflow
B. TG RV Inflow view
C. ME RV outflow view
D. ME Pulmonic Outflow View
E. Upper esophageal aortic arch short axis view
Upper esophageal aortic arch short axis view
124
Which of the following is most likely present in the left atrium?
A. Eustachian valve
B. Crista Terminalis
C. Cor Triatriutum
D. Chiari Network
E. Moderator Band
F. Thesbian Valve
Cor Triatriutum
125
Which of the follwoing is most likely present in the RV?
A. Cor Triatriatum
B. Coumadin Ridge
C. Crista Terminalis
D. Moderator Band
E. Chiari Network
F. Thesbian Valve
Moderator Band
126
Which of the following structures is most likely present in the RA?
A. Crista Supraventricualris
B. Cor Triatriatum
C. Coumadin Ridge
D. Chiari Network
E. Moderator Band
Chiari Network
127
What valvular disorder would most likely be consistent with an abnormal enlargement of the hepatic venous flow wave illustrated with the arrow below?
A. TR
B. MR
C. TS
D. PS
E. MS
Triscuspid Stenosis
128
See picture
B
129
What view allows us to eval TAPSE?
Mid esophageal 4 chamber view
130
What is responsible for rheumatic heart disease?
**Streptococcal pyogenes M-protein autoantibodies**
131
What is responsible for amyloidosis?
**Infiltration of Beta-Amyloid**
132
RV Hypertrophy in adults is defined as what?
**Wall thickness \> 5mm**
133
Which of the following is true with regard to the eccentricity index?
A. Normally equals 1 at end-systole and end-diastole
B. Measure of LV systolic function
C. Measure of LV diastolic function.
D. Lowest at end-systole with isolated RV volume overload
E. Lowest at end-diastole with isolated RV pressure overload
A
134
Tricuspid Annular Tissue doppler is best assessed from which of the following views?
**Deep TG RV views**
135
Which of the following measures of RV systolic function is least load dependent?
A. RV FAC
B. RV EF
C. TAPSE
D. Tricuspid annular plane max systolic V (S') (DTI)
E. Isovolumetric acceleration (IVA)
F. RV dp/dt
**Isovolumetric acceleration**
136
What is structure "Z"
Right Atrial Appendage
137
Label "Y"
Left Atrium
138
Label X
IVC
139
What is the labeled structure?
**Coronary Sinus**
140
What is A?
Pulmonic Valve
141
What is 2 used to calculate?
What is 3 used to calculate?
2 = **Early Velocity** to calculate PA Mean Pressure
3 = **Late velocity** to calculate PA diastolic pressure
