Tricuspid Regurgitation Flashcards
(105 cards)
1
Q
What is involved in the tricuspid valve complex? 5
A
- TV annulus
- Three leaflets
- Chordae tendinae
- 2 discrete pap muscles
- RV myocardium
2
Q
What are the three leaflet tips of the tricuspid valve? 3
A
- Septal
- Anterior
- Posterior
3
Q
What are the three TV commissures? 3
A
- Anteroseptal commissures
- Anteriorposterior commissures
- Posteroseptal Commisure
4
Q
Where is the anterioseptal commissures located?
A
Between the anterior and septal leaflets
5
Q
Where is the anteroposterior commissure located?
A
Lies between the anterior and posterior leaflets
6
Q
Where is the posteroseptal commissures located?
A
Lies between the posterior and septal leaflets
7
Q
What are some clinical features of TR? 3
A
- Usually well tolerated
- Severe/ progressive TR may show signs of right sided heart failure
- May show clinical features of underlying cardiac conditions
8
Q
What are some clinical features of ECG/ EXR for TR? 3
A
- RA enlargement
- A-Fib
- RBBB
9
Q
What are some clinical features of auscultation for TR?
A
Holosystolic murmur along LT sternal border
10
Q
What is the role of echo to assess TR? 5
A
- Determine etiology of the lesion
- Assess RA size
- Assess RV size and function
- Estimate severity of the regurgitation
- Estimate right heart pressures
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
12
Q
Etiology of TR can be divided into 3 subgroups, what are they? 3
A
- Functional (secondary) causes
- Organic primary causes
- Mechanical causes
13
Q
As with MR, TR may occur due to what?
A
Disorders affecting any part of the TV complex
14
Q
What are some examples of functional causes of TR? 6
A
- Atrial fibrillation
- Atrial septal defect
- Pulmonary hypertension
- Dilated cardiomyopathy
- RV CHF
- RV infarction
15
Q
What are functional causes?
A
Any thing that causes annular dilation
16
Q
What are organic causes?
A
Disorders of the TV complex
17
Q
What are some organic causes examples? 4
A
- Carcinoid heart disease
- Infective endocarditis
- Epstein anomaly
- Trauma
18
Q
What are some examples of mechanical causes?
A
Pacemaker leads
19
Q
Rheumatic TV disease almost never occurs when/ where?
A
In isolation
20
Q
What is almost always involved with rheumatic TV disease?
A
MV
21
Q
Rheumatic TV disease is characterized by what?
A
Thickened and retracted TV leaflets
22
Q
What is seen with the TV in 2D when there is rheumatic TV disease?
A
Diastolic doming
23
Q
Besides the thickened and retracted TV leaflets what else may happen to the annulus?
A
Dilation May occur
24
Q
What is a carcinoid heart disease?
A
When there is a rare malignant tumour which damages right heart valves
25
What happens to the TV with carcinoid heart disease?
The TV becomes thickened, retracted and rigid
26
What does carcinoid heart disease lead to?
TS and TR
27
With carcinoid heart disease, how is the valve of the TV?
The valve remains in a fixed semi-open position throughout the cardiac cycle
28
What is the key difference between carcinoid and rheumatic heart disease?
The involvement of the MV/AV with Rheumatic
29
What does aliasing during systole and diastole indicative of during carcinoid HD?
MS and MR
30
What disease has thickened, retracted TV leaflets and normal MV mobility?
Carcinoid HD TR
31
What happens with traumatic TV rupture?
Trauma puts extreme pressure on the TV chordae
32
The RV is more easily what? What does this lead to?
Compressed than LV, making TV more susceptible to rupture
33
Traumatic TV rupture may lead to what?
Chordal rupture or flail leaflet
34
What would be an example of acute TR with flail?
Traumatic TV rupture
35
What is TVP or Tricuspid valve prolapse?
Systolic bowing of the belly of the leaflets into the RA during systole?
36
What does TVP normally occur with?
In association with MVP
37
What is Epstein anomaly?
Malformation of the TV leaflets during development leading to them being placed higher up on the RV
38
What are the four major characteristics of Ebstein anomaly? 4
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
39
What is ebstein anomaly associated with? 4
1. PFO/ ASD
2. L-TGA
3. VSD
4. Hypoplastic pulmonary artery
40
Epstein may lead to maldevelopment of what?
The conduction pathway from atria to ventricle.
41
What syndrome may ebstein lead to eventually?
Wolfe-Parkinson’s white syndrome
42
What view should we use to view ebstein anomaly?
A4C view
43
Ebstein s can be diagnosed when the septal TV leaflet is displaced how much apically?
>2cm
44
During Ebstein anomaly, which leaflet may have restricted motion?
The anterior TV leaflet
45
Which leaflet may have a whiplike motion and be longer with redundant tissue, in terms of Ebstein anomaly?
Septal TV leaflet
46
When we assess ebstein with colour, how will it present? why?
There will invariably be some degree of TR due to lack of coaptation
47
When we use spectral doppler to interrogate Ebstein what might we see? 2
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
What is eisenmenger’s syndrome?
When the shunt direction reverses from being left to right to right to left
49
What does PFO stand for?
Patent foramen ovale
50
What is a functional cause of TR?
Annular dilatation
51
What is ASD or atrial septal disease?
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
Why do we have have TR with annular dilation?
The atria gets so big that the leaflets can’t touch.
53
How are the TV leaflets with annular dilation?
They are normal and fully functional
54
What are common causes of annular dilation? 3
1. Dilated cardiomyopathy
2. Atrial septal defect
3. Pulmonary hypertension
55
How does Pulmonary hypertension lead to functional TR?
PHTN leads to RV dilation then functional TR
56
How does RV dilation affect the TV? 2
1. Incomplete coaptation of the TV leaflets
2. Pap muscles pulled artery from TV
57
TR peak velocity does not reflect on what?
The velocity of the TR but simply the *pressure difference* between RV and RA during systole
58
With pulmonary hypertension, What does TR look like? 2
1. Mild TR with high jet velocity
2. Severe TR with Low jet velocity
59
What does paradoxical septal motion look like with PAH and TR?
The IVS looks flat because the high RV pressure is pushing it to the LT side in a “shape”
60
PAH and TR can be caused by what two things? 2
1. RV volume overload
2. RV pressure overload
61
What does a RV volume overload look like
D sign only during diastole
62
What does RV pressure overload look like?
D sign throughout the entire cycle
63
How do we determine the RA size?
RA volume index
64
What is the RA volume index numbers for Male and female? 2
1. Male: 32 ml/m
2. Female 27ml/m
65
What is the normal range for TAPSE
>17mm
66
What is the S prime normal value?
>9.5 cm/s
67
What normal FAC ranges?
>35%
68
What is normal RIMP values?
<0.44
69
What are three ways to estimate severity of Regurgitation? 3
1. Qualitative assessment
2. Semi-qualitative assessment
3. Quantitative assessment
70
What are some examples of qualitative assessment? 3
1. Colour jet area
2. Vena Contracta width
3. Flow convergence radius
71
What are some examples of semi-qualitative assessment? 4
Spectral doppler
1. Tricuspid inflow PW
2. Hepatic vein profile PW
3. Intensity of TR signal CW
4. TR jet contour CW
72
What quantitative assessment examples? 2
1. Regurgitation volume (RV)
2. Effective Regurgitant orifice area (EROA)
73
What the Mild, moderate, severe values for TR jet area measurement? 3
1. Mild <5cm
2. Moderate 5-10cm
3. Severe >10cm
74
How often is TR jet area measurements taken?
Still performed in some labs but not common
75
How do we get TR jet area measurements?
Trace around the aliased portion of the TR jet only using the calc package.
*trace only the aliased jet to avoid overestimation*
76
How many planes should we use for TR jet area measurement?
Multiple planes
77
Label the regurgitation? 3
1. Mild central
2. Several Central
3. Severe Eccentric
78
When do we have an underestimation of TR jets?
When there is an eccentric jet
79
What does the Coanda effect?
When there is an eccentric jet that will hug the atrial wall
80
What happens when there is a severe lack of TV coaptation?
A huge hold in the TV during systole is formed
81
When there is a huge hole in the TV during systole due to a lack of TV coaptation, is there Aliasing and why?
No aliasing due to the low velocity of the TR jet.
82
What does TR jet velocity represent?
The pressure gradient between RV and RA
83
Label the image?
84
What are the valves for Vena contracta and PISA radius? **Know the PISA radius numbers VC is a bonus**
Same as MR
85
Can we use Vena contracta and PISA if there are multiple jets?
No
86
What is a tip for measuring Vena contracta?
Zoom on any window
87
PISA should be measured in which view?
A4C with zoom
88
What should the Nyquist limit be set for PISA radius?
20-40 cm/s
89
In terms of TV inflow pulsed wave doppler, the E and A wave velocity should be lower than what?
MV
90
What might >1.0 m/s indicate when interrogating for a TV inflow PW doppler?
Severe TR
91
What should Normal TV flow be?
0.7 m/s
92
When two volumes are combined what happens in the TV?
Regurgitant volume increases, but for this to happen more flow must travel through the TV
93
What happens when there is less forward flow into the IVC due to TR?
The liver becomes engorged
94
TR signal intensity depends on what?
The number of RBCs moving in the same direction
95
More/ Less RBCs mean what in terms of waveform?
More = brighter TR signal and vice versa
96
What re some technical factors we might need to consider when looking at the intensity of TR doppler signals? 2
1. Gain
2. Doppler angle
97
What do we need to compare in terms of TR brightness when adjust gain?
Antegrade flow
98
Label the image
99
With Mild TR, The high PG is affected how?
It is maintained throughout systole
100
What is the appearance of mild TR?
Parabolic appearance
101
What is the appearance of significant TR?
Triangular cutoff or V cut off
102
With significant TR, The PG does what?
Reduces as the TR enters the RA during systole
103
What happens in the Hepatic vein when there is severe TR?
Systolic reversal
104
What are the two main methods used to quantify the amount of regurgitation using the PISA principle? 2
1. Regurgitant volume
2. EROA (effective Regurgitant orifice area)
105
What are ways we can estimate right heart pressures? 4
1. RVSP
2. PAT
3. mPAP
4. PAEDP
