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DMST 283 ECHO 2 > Tricuspid Regurgitation > Flashcards

Tricuspid Regurgitation Flashcards

1
Q

What is involved in the tricuspid valve complex?

A
  1. TV annulus
  2. Three leaflets
  3. Chordae tendinae
  4. 2 discrete pap muscles
  5. RV myocardium
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2
Q

What are the three leaflet tips of the tricuspid valve?

A
  1. Septal
  2. Anterior
  3. Posterior
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3
Q

What are the three TV commissures?

A
  1. Anteroseptal commissures
  2. Anteriorposterior commissures
  3. Posteroseptal Commisure
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4
Q

Where is the anterioseptal commissures located?

A

Between the anterior and septal leaflets

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5
Q

Where is the anteroposterior commissure located?

A

Lies between the anterior and posterior leaflets

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6
Q

Where is the posteroseptal commissures located?

A

Lies between the posterior and septal leaflets

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7
Q

What are some clinical features of TR?

A
  1. Usually well tolerated
  2. Severe/ progressive TR may show signs of right sided heart failure
  3. May show clinical features of underlying cardiac conditions
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8
Q

What are some clinical features of ECG/ EXR for TR?

A
  1. RA enlargement
  2. A-Fib
  3. RBBB
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9
Q

What are some clinical features of auscultation for TR?

A

Holosystolic murmur along LT sternal border

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10
Q

What is the role of echo to assess TR?

A
  1. Determine etiology of the lesion
  2. Assess RA size
  3. Assess RV size and function
  4. Estimate severity of the regurgitation
  5. Estimate right heart pressures
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11
Q

What is tricuspid regurgitation?

A

The backward flow of blood from the RV and the RA during systole due to an incompetent TV

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12
Q

Etiology of TR can be divided into 3 subgroups, what are they?

A
  1. Functional (secondary) causes
  2. Organic primary causes
  3. Mechanical causes
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13
Q

As with MR, TR may occur due to what?

A

Disorders affecting any part of the TV complex

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14
Q

What are some examples of functional causes of TR?

A
  1. Atrial fibrillation
  2. Atrial septal defect
  3. Pulmonary hypertension
  4. Dilated cardiomyopathy
  5. RV CHF
  6. RV infarction
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15
Q

What are functional causes?

A

Any thing that causes annular dilation

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16
Q

What are organic causes?

A

Disorders of the TV complex

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17
Q

What are some organic causes examples?

A
  1. Carcinoid heart disease
  2. Infective endocarditis
  3. Epstein anomaly
  4. Trauma
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18
Q

What are some examples of mechanical causes?

A

Pacemaker leads

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19
Q

Rheumatic TV disease almost never occurs when/ where?

A

In isolation

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20
Q

What is almost always involved with rheumatic TV disease?

A

MV

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21
Q

Rheumatic TV disease is characterized by what?

A

Thickened and retracted TV leaflets

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22
Q

What is seen with the TV in 2D when there is rheumatic TV disease?

A

Diastolic doming

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23
Q

Besides the thickened and retracted TV leaflets what else may happen to the annulus?

A

Dilation May occur

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24
Q

What is a carcinoid heart disease?

A

When there is a rare malignant tumour which damages right heart valves

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25
Q

What happens to the TV with carcinoid heart disease?

A

The TV becomes thickened, retracted and rigid

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26
Q

What does carcinoid heart disease lead to?

A

TS and TR

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27
Q

With carcinoid heart disease, how is the valve of the TV?

A

The valve remains in a fixed semi-open position throughout the cardiac cycle

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28
Q

What is the key difference between carcinoid and rheumatic heart disease?

A

The involvement of the MV/AV with Rheumatic

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29
Q

What does aliasing during systole and diastole indicative of during carcinoid HD?

A

MS and MR

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30
Q

What disease has thickened, retracted TV leaflets and normal MV mobility?

A

Carcinoid HD TR

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31
Q

What happens with traumatic TV rupture?

A

Trauma puts extreme pressure on the TV chordae

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32
Q

The RV is more easily what? What does this lead to?

A

Compressed than LV, making TV more susceptible to rupture

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33
Q

Traumatic TV rupture may lead to what?

A

Chordal rupture or flail leaflet

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34
Q

What would be an example of acute TR with flail?

A

Traumatic TV rupture

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35
Q

What is TVP or Tricuspid valve prolapse?

A

Systolic bowing of the belly of the leaflets into the RA during systole?

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36
Q

What does TVP normally occur with?

A

In association with MVP

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37
Q

What is Epstein anomaly?

A

Malformation of the TV leaflets during development leading to them being placed higher up on the RV

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38
Q

What are the four major characteristics of Ebstein anomaly?

A
  1. Apical displacement of the septal leaflet
  2. Atrialization and dilation of a portion of the RV inflow tract
  3. Small functional RV
  4. “Struck” septal/posterior leaflets
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39
Q

What is ebstein anomaly associated with?

A
  1. PFO/ ASD
  2. L-TGA
  3. VSD
  4. Hypoplastic pulmonary artery
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40
Q

Epstein may lead to maldevelopment of what?

A

The conduction pathway from atria to ventricle.

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41
Q

What syndrome may ebstein lead to eventually?

A

Wolfe-Parkinson’s white syndrome

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42
Q

What view should we use to view ebstein anomaly?

A

A4C view

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43
Q

Ebstein s can be diagnosed when the septal TV leaflet is displaced how much apically?

A

> 2cm

44
Q

During Ebstein anomaly, which leaflet may have restricted motion?

A

The anterior TV leaflet

45
Q

Which leaflet may have a whiplike motion and be longer with redundant tissue, in terms of Ebstein anomaly?

A

Septal TV leaflet

46
Q

When we assess ebstein with colour, how will it present? why?

A

There will invariably be some degree of TR due to lack of coaptation

47
Q

When we use spectral doppler to interrogate Ebstein what might we see?

A
  1. ASD or PFO with colour in colour or pulsed wave doppler
  2. Shunt direction being right to left instead of left to right
48
Q

What is eisenmenger’s syndrome?

A

When the shunt direction reverses from being left to right to right to left

49
Q

What does PFO stand for?

A

Patent foramen ovale

50
Q

What is a functional cause of TR?

A

Annular dilatation

51
Q

What is ASD or atrial septal disease?

A

A birth defect of the heart in which there is a hole in the wall (septum) that divides the chambers (atria) of the heart

52
Q

Why do we have have TR with annular dilation?

A

The atria gets so big that the leaflets can’t touch.

53
Q

How are the TV leaflets with annular dilation?

A

They are normal and fully functional

54
Q

What are common causes of annular dilation?

A
  1. Dilated cardiomyopathy
  2. Atrial septal defect
  3. Pulmonary hypertension
55
Q

How does Pulmonary hypertension lead to functional TR?

A

PHTN leads to RV dilation then functional TR

56
Q

How does RV dilation affect the TV?

A
  1. Incomplete coaptation of the TV leaflets
  2. Pap muscles pulled artery from TV
57
Q

TR peak velocity does not reflect on what?

A

The velocity of the TR but simply the pressure difference between RV and RA during systole

58
Q

With pulmonary hypertension, What does TR look like?

A
  1. Mild TR with high jet velocity
  2. Severe TR with Low jet velocity
59
Q

What does paradoxical septal motion look like with PAH and TR?

A

The IVS looks flat because the high RV pressure is pushing it to the LT side in a “shape”

60
Q

PAH and TR can be caused by what two things?

A
  1. RV volume overload
  2. RV pressure overload
61
Q

What does a RV volume overload look like

A

D sign only during diastole

62
Q

What does RV pressure overload look like?

A

D sign throughout the entire cycle

63
Q

How do we determine the RA size?

A

RA volume index

64
Q

What is the RA volume index numbers for Male and female?

A
  1. Male: 32 ml/m
  2. Female 27ml/m
65
Q

What is the normal range for TAPSE

A

> 17mm

66
Q

What is the S prime normal value?

A

> 9.5 cm/s

67
Q

What normal FAC ranges?

A

> 35%

68
Q

What is normal RIMP values?

A

<0.44

69
Q

What are three ways to estimate severity of Regurgitation?

A
  1. Qualitative assessment
  2. Semi-qualitative assessment
  3. Quantitative assessment
70
Q

What are some examples of qualitative assessment?

A
  1. Colour jet area
  2. Vena Contracta width
  3. Flow convergence radius
71
Q

What are some examples of semi-qualitative assessment?

A

Spectral doppler
1. Tricuspid inflow PW
2. Hepatic vein profile PW
3. Intensity of TR signal CW
4. TR jet contour CW

72
Q

What quantitative assessment examples?

A
  1. Regurgitation volume (RV)
  2. Effective Regurgitant orifice area (EROA)
73
Q

What the Mild, moderate, severe values for TR jet area measurement?

A
  1. Mild <5cm
  2. Moderate 5-10cm
  3. Severe >10cm
74
Q

How often is TR jet area measurements taken?

A

Still performed in some labs but not common

75
Q

How do we get TR jet area measurements?

A

Trace around the aliased portion of the TR jet only using the calc package.

trace only the aliased jet to avoid overestimation

76
Q

How many planes should we use for TR jet area measurement?

A

Multiple planes

77
Q

Label the regurgitation?

A
  1. Mild central
  2. Several Central
  3. Severe Eccentric
78
Q

When do we have an underestimation of TR jets?

A

When there is an eccentric jet

79
Q

What does the Coanda effect?

A

When there is an eccentric jet that will hug the atrial wall

80
Q

What happens when there is a severe lack of TV coaptation?

A

A huge hold in the TV during systole is formed

81
Q

When there is a huge hole in the TV during systole due to a lack of TV coaptation, is there Aliasing and why?

A

No aliasing due to the low velocity of the TR jet.

82
Q

What does TR jet velocity represent?

A

The pressure gradient between RV and RA

83
Q

Label the image?

A
84
Q

What are the valves for Vena contracta and PISA radius? Know the PISA radius numbers VC is a bonus

A

Same as MR

85
Q

Can we use Vena contracta and PISA if there are multiple jets?

A

No

86
Q

What is a tip for measuring Vena contracta?

A

Zoom on any window

87
Q

PISA should be measured in which view?

A

A4C with zoom

88
Q

What should the Nyquist limit be set for PISA radius?

A

20-40 cm/s

89
Q

In terms of TV inflow pulsed wave doppler, the E and A wave velocity should be lower than what?

A

MV

90
Q

What might >1.0 m/s indicate when interrogating for a TV inflow PW doppler?

A

Severe TR

91
Q

What should Normal TV flow be?

A

0.7 m/s

92
Q

When two volumes are combined what happens in the TV?

A

Regurgitant volume increases, but for this to happen more flow must travel through the TV

93
Q

What happens when there is less forward flow into the IVC due to TR?

A

The liver becomes engorged

94
Q

TR signal intensity depends on what?

A

The number of RBCs moving in the same direction

95
Q

More/ Less RBCs mean what in terms of waveform?

A

More = brighter TR signal and vice versa

96
Q

What re some technical factors we might need to consider when looking at the intensity of TR doppler signals?

A
  1. Gain
  2. Doppler angle
97
Q

What do we need to compare in terms of TR brightness when adjust gain?

A

Antegrade flow

98
Q

Label the image

A
99
Q

With Mild TR, The high PG is affected how?

A

It is maintained throughout systole

100
Q

What is the appearance of mild TR?

A

Parabolic appearance

101
Q

What is the appearance of significant TR?

A

Triangular cutoff or V cut off

102
Q

With significant TR, The PG does what?

A

Reduces as the TR enters the RA during systole

103
Q

What happens in the Hepatic vein when there is severe TR?

A

Systolic reversal

104
Q

What are the two main methods used to quantify the amount of regurgitation using the PISA principle?

A
  1. Regurgitant volume
  2. EROA (effective Regurgitant orifice area)
105
Q

What are ways we can estimate right heart pressures?

A
  1. RVSP
  2. PAT
  3. mPAP
  4. PAEDP

DMST 283 ECHO 2 (14 decks)

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