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Tricuspid Valve Flashcards

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1
Q

What are the four components of the TV?

A
  • fibrous annulus
  • leaflets (three)
  • papillary muscles
  • chordal attachments
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2
Q

What is the normal shape of the tricuspid annulus?

What happens when to size when functional dilation occurs?

A
  • triangular and saddle shaped
  • becomes cicrular and planar
    • owing to greater enlargement of the anteroposterior over the medolateral dimensions
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3
Q

What are the 3 leaflets of the tricuspid valve?

Explain differences in size and location.

A
  • anterior
    • largest in size
  • posterior
  • septal
    • smallest in size
    • most medial
    • inserted apically into the interventricular septum
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4
Q

Describe papillary muscles in relation to the TV

A
  • Two discrete papillary muscles (anterior, posterior)
  • Anterior
    • provides chordae to the anterior and posterior leaflets
  • Posterior
    • provides chordae to all three leaflets
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5
Q

What structures (in addition to papillary muscles) provide TV support?

A
  • Septum
    • No formal septal papillary muscle –> septum gives chordae to the anterior and septal leaflets
  • RV free wall
    • may provide chordal attachments
  • Moderator band
    • may provide chordal attachments
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6
Q

What is the most common cause of TS?

A
  • Rhuematic disease
    • accounts for 90% of TS cases
    • only 8% of rheumatic patients will develop TS
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7
Q

What are causes of TS?

A
  • Rheumatic (MCC ~ 90% of cases)
  • Carcinoid (always combined with TR)
  • SLE
  • Pacemaker-induced adhesions
  • Radiation therapy
  • Congenital malformations
  • Obstruction
    • RA tumors
    • Infection/vegetations
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8
Q

What are the clinical features/PE findings of TS?

A
  • Right sided pressure increase
    • peripheral edema
    • hepatomegaly
    • ascites
    • fatigue (out of proportion to the degree of dyspnea)
  • PE
    • JVP (with giant A wave)
    • mid-diastolic rumble, that augments on inspiration, best heard in the tricuspid area
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9
Q

What are signs of chronic pressure overload associated with TS?

A

RA and IVC ( >2.1 cm) enlargement

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10
Q

What are common findings of Carcinoid syndrome on 2D Echo?

A
  • severely thickened leaflets
  • immobile leaflets (“frozen leaflets”)
  • combination of TS and TR are present
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11
Q

What views are best to obtain tricuspid inflow velocity?

A
  • PS RV inflow
  • A4C
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12
Q

What is a good cut off for TV inflow velocity to rule out TS?

A

rarely exceeds 0.7 m/s

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13
Q

When is TS considered severe (in the evaluation of TS) on TV inflow velocity?

A
  • Diastolic gradient > 5 mmHg
  • TVA < 1.0 cm2
    • ​calculated via continuity equation
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14
Q

What are the specific findings of significant TS on Echo?

Supportive findings?

A
  • MG > 5 mmHg
  • TV VTI (inflow time) > 60 cm
  • PHT > 190 ms
  • TVA (by continuity equation) < 1.0 cm2
  • Enlarged RA > moderate
  • Dilated IVC ( > 2.1 cm)
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15
Q

Why is PHT assessment of valve area different with the TV and MV?

A
  • may be less accurate
  • due to differences in:
    • AV compliance between the right and left heart
    • influence of respiration and TR on this measurement
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16
Q

What are two factors that will affect assessment of the TV?

A
  • HR > 100 bpm
    • should ideally be 70-80 bpm
    • affect the interpretation of PHT
  • concomitant TR
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17
Q

When should TV (inflow velocity) assessment be obtained in relation to the cardiac cycle?

A

End of respiratory cycle (at end expiration, while patient holding there breath)

or

Averaged throughout respiratory cycle

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18
Q

What is the rule for obtaining TV (inflow velocity, VTI) in the setting of A-fib?

A
  • Measurements taken from a minimum of five cardiac cycles
  • must be averaged
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19
Q

Describe the picture

A
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20
Q

What are the class I indications for TV replacement surgery (in TS)?

A
  • Severe TS + at time of operation for left-sided valve disease
  • Isolated, severe, symptomatic TS
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21
Q

What are potential complications of TV surgery?

A
  • injury to adjacent structures:
    • RCA
    • AV node
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22
Q

When is percutaneous balloon commissurotomy considered in TS?

A

isolated, symptomatic, severe TS without accompanying TR (class IIb)

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23
Q

What is the most common cause of TR?

A

functional (or secondary) regurgitation

  • secondary to annular dilatation from RA or RV enlargement, Pulmonary hypertension
  • accounts for 80% of cases of severe TR
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24
Q

What are acquired causes of primary TR?

A
  • Myxomatous/Degenerative (most common)
  • Rheumatic
  • Carcinoid
  • Endocarditis
  • Endomyocardial fibrosis
  • Toxins
  • Trauma
  • Iatrogenic
    • Pacemaker lead impingement
    • Endomyocardial (RV) biopsy complication
  • Ischemic papillary muscle rupture
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25
What are the pathophysiologic mechnisms for TR (functional)?
* annular dilation * papillary muscle displacement * chordal tethering * leaflet malcoaptation
26
What is the most common cause of primary TR?
myxomatous/degenerative disease
27
What are congenital causes of primary TR?
* Congenitally corrected transposition of the great arteries * Other (giant right atrium) * Repaired Tetralogy of Fallot * Ebstein's anomaloy * TV dysplasia * TV tethering * associated with perimembranous VSD and VS aneurysm
28
What are the clinical/PE features of significant TR?
* Right sided volume overload (ascites, peripheral edema, abdominal discomfort, hepatomegaly, fatigue) * Murmur is difficult to detect on PE (very soft) * pansystolic murmurm * best heard in tricuspid area * increases in intensity: * inspiration * S3 may be present * Elevated JVP with large cv wave
29
What are the causes/mechanisms of secondary (functional) TR?
* Left heart disease (LV dysfunction or valve disease) * RV dysfunction * RV ischemia * RV volume overload * RV cardiomyopathy * Pulmonary hypertension * chronic lung disease * pulmonary thromboembolism * left-to-right shunt * RA abnormalities * A-fib
30
Describe the algorithm for TR evaluation
31
Describe views and the leaflet anatomy
32
Describe the findings in the image
* Ebstein's anomaly * apical displacement of the septal leaflet and associated severe TR
33
Describe the findings in the image
34
Describe the findins in the image
* Carcinoid heart disease (of the TV) * severe RA dilation * severe thickening, shortening and retraction of the TV leaflets * leads to incomplete leaflet coaptation and severe TR
35
What leaflets (of the TV) are visualized in the RV inflow view?
* Nearfield * **anterior leaflet (blue) is always visualized** * Farfield * may be septal (yellow) or posterior (green) * wide range of variability
36
What leaflets (of the TV) are visualized in the SAX view?
* SAX (level of Aortic Valve) * anterior leaflet (blue) is always visible and adjacent to the aorta * posterior leaflet (green) sometimes visible and adjacent to RV free wall * SAX (level of LVOT) * all three leaflets visible
37
What leaflets (of the TV) are visualized in the A4C view?
*
38
When is 3D Echo most useful for the TV assessment?
* Pacemaker wire impingement * Tethering of leaflets * Traumatic TR * assessment of valve damage/surgical planning
39
Describe the findings
* CW Doppler demonstrating severe TR * traingular-shaped, early peaking jet contour
40
Describe the findings
* "Sine Wave" appearance on CW doppler of the TV * very severe TR with normal RV pressure * represents equal forward and backward flow across a severely incompetent valve
41
What are the structural parameters used to assess TR severity?
* TV morphology * severe = severe valve lesions (flail leaflet, severe retraction, large perforation) * RV size * RA size * IVC diameter * \< 2 cm = normal-mild * \> 2.5 cm = severe
42
What are the qualitative parameters used to assess TR severity?
* Color flow jet area * Flow convergence zone * severe = large, throughout systole * CWD jet
43
What are the semi-quantitative parameters used to assess TR severity?
* Color flow jet area (cm2) * VC (cm) * PISA radius (cm) * Hepatic vein flow * Tricuspid inflow
44
What are the quantitative parameters used to assess TR severity?
* EROA (cm2) * RV (mL)
45
What jet area is consistent with severe TR? What factors can affect appearance of the jet?
* \> 10 cm2 * \> 50% of RA area * Jet area factors: * several Echo machine settings can affect teh appearance of the jet * Pulse repetition frequency * eccentric or wall impinging jet --\> underestimation of severity when using color doppler alone
46
Describe VC severity scale in TR assessment
* Mild \< 0.30 cm * Moderate 0.30 - 0.69 cm * Severe \> 0.70 cm * \> 0.40 cm2 (on 3D Echo)
47
What are the specific criteria for Severe TR (inital evaluation)?
* Dilated annulus with no valve coaptation or flail leaflet * Dilated RV with preserved function * Dense, triangular CW jet or sine wave pattern * Systolic reversal of Hepatic vein flow * Large central jet \> 50% of RA * VC width \> 0.7cm * PISA radius \> 0.9cm (at Nyquist 30-40 cm/s)
48
Describe the EROA scale in TR assessment?
* Mild \< 0.2 cm2 * Moderate 0.2-0.4 cm2 * Severe \> 0.4 cm2
49
Describe the RVol scale in TR assessment?
* Mild \< 30 mL * Moderate 30-44 mL * Severe \> 45 mL
50
What are the specific criteria for Mild TR (inital evaluation)?
* Incomplete or faint CW jet * Thin, small central color jet * Tricuspid A-wave dominant inflow * Systolic dominant Hepatic vein flow * VC \< 0.3 cm * PISA radius \< 0.4 cm (at Nyquist 30-40 cm/s) * Normal RV/RA
51
What clinical scenario is TEE indicated in addition to TTE for thorough evaluation?
* Suspected PM endocarditis Not indicated for * PA pressure in primary pulmonary hypertension * IVC thrombus * RV function
52
What is the cause of severe TR (regurgitant velocity 1 m/s) with reduced RV function post-transplant?
* Flail TV leaflet * common with valvular (usually septal) leaflet/chordae damage due to repeated endomyocardial biopsies following transplantation * results in laminar rather than turbulent flow
53
What is the etiology of McConnell sign? Describe the pathophysiology?
* Acute PE * regional RV dysfunction with apical sparing of RV function * may be seen in acute PE * Senstivity 70%, specificity 30%, PPV 67%, NPV 33%
54
How is RVSP calculated with TR? When can this not be utilized?
* RVSP = 4v2 + RAP * Laminar flow (not turbulent) flow through the valve renders the Bernoulli equation inaccurate
55
What is the PA systolic pressure? Is Pulmonary Hypertension present? * Pulmonary valve stenosis * PG 20 mmHg across pulmonary valve * TR * regurgitant velocity 3 m/s * RA and IVC (good collapsibility on sniffing) normal in size
* RVSP = 4v2 + estimated RA pressure * V = 3 m/s * estimated RA pressure * normal size \< 2.1 with sniffing collapse = 3 mmHg (5mmHg is prior number) * RVSP = 36 mmHg + 3 mmHg (5 mmHg) = 39/41 mmHg * PA systolic pressure = RVSP - PG (across valve) * PASP = 39/41 mmHg - 20 mmHg = 19/21 mmHg * PA systolic pressure = 19/21 mmHg --\> normal PA systolic pressures and thus no PH
56
What is a Gerbode defect?
* communication between the RA and LV * often iatrogenic after sugery on the AV valves or following endocarditis of these valves
57
What is the PHT formula for TVA in TS assessment?
TVA = 190 / PHT
58
What is the best view to obtain planimetry of the TV (in TS assessment)?
* 3D TTE or 3D TEE * difficult to obtain short axis view on regular TTE
59
What jet's can be utilized to estimate Pulmonary artery pressures?
* TR jet * 4 TR Vmax2 + RAP = RVSP/PASP * PI jet * 4 PI Vmax2 + RAP = Mean PASP * 4 PI Vend-diastolic2 + RAP = diastolic pulmonary artery pressures * VSD jet (only if jet can be obtained coaxial with direction of flow) * SBP - 4 VVSD2 = RVSP/PASP * RVOT jet * 79 - (0.45 x RVOT AT) = mean pulmonary artery pressure * acceleration time
60
Describe how to calculate PASP/RVSP using TR jet?
4 (TR Vmax)2 + RAP = RVSP/PASP
61
Describe how to calculate PASP/RVSP using PI jet?
* 4 (PI Vmax)2 + RAP = Mean PASP * 4 (PI Vend-diastolic)2 + RAP = diastolic pulmonary artery pressures
62
Describe how to calculate PASP/RVSP using VSD jet?
* SBP - 4 VVSD2 = RVSP/PASP * can only be obtained if doppler can be aligned with jet, coaxial with direction of flow
63
Describe how to calculate PASP/RVSP using RVOT jet?
79 - (0.45 x RVOT AT) = mean pulmonary artery pressure
64
What jet cannot be utilized to calculate RVSP/PASP?
ASD jet
65
What is consistent with a diagnosis of severe PS?
* **PV \> 4 m/s** * elevated RVSP * PASP is usually normal in the setting of severe PS * RV hypertrophy (wall thickness \> 0.4cm) * Post-stenotic dilatation
66
Describe the peak velocity scale in the assessment of PS
* Mild \< 3 m/s * Moderate 3-4 m/s * Severe \> 4 m/s
67
What are the criteria (PV and MG) for mild PS?
* PV \< 3 m/s * MG \< 36 mmHg
68
When is severe pulmonary insufficiency commonly seen?
* Treatment of congenital heart disease * prior surgery of RVOT or pulmonary valve
69
What type of velocity is most commonly associated with severe pulmonary insufficiency?
* Laminar rather than turbulent velocity * associated with high end-diastolic pressure and reduced pressure gradient across the pulmonic valve
70
What can pulmonary insufficiency jet be used to obtain?
* PA diastolic pressures * utilizing end-diastolic velocity \*\*\*\*Cannot be utilized to estimate PA systolic pressure
71
What is the is the optimal Nyquist limit for assessing PI?
Nyquist limi 50-60 cm/s
72
What are qualitative parameters used in the assessment of PI?
* Abnormal pulmonic valve morphology * Large jet with a wide origin * Dense jet (by CW doppler) * with steep deceleration/early termination of diastolic flow * Pulmonic flow \> aortic flow (by PW doppler)
73
What is the most common cause of a mobile mass on the TV?
fibroelastoma
74
Define Chiari network
* fenestrated membranous structure * originates at the orifice of the IVC * embryologic remnant * may rarely float through the TV but usually confied to the RA and is not attached to the TV
75
Describe Ebstein's anomaly effect on TV leaflets
* apical displacement of the septal leaflet of the TV * does not involve the PV
76
What is often a concomitant finding in infundibular stenosis?
* Pulmonary insufficiency * may cause a high-velocity jet that impinges on the PV
77
What are causes/etiologies of infundibular stenosis?
* Congenital heart disease (TOF) * HOCM * Tumors of RVOT * Infiltrative disorders
78
What is the best view for imaging infundibular stenosis?
PSAX or Subcostal
79
Describe the image
Ebstein's anomaly
80
What are common associations in Ebstein's anomaly?
* Rhythm abnormalities * accelerated conduction via accessory pathways **(WPW)** * **​**Severe TR * Intracardiac shunt * Atrialization of a portion of the RV
81
What is the common finding in Uhl syndrome? What does this predispose to?
* Parchment-like RV wall * Ventricular arrhythmias
82
Describe the findings
* Severe TR * Systolic Flow reversal of the Hepatic vein (on PW doppler)
83
What are alternative methods to quantify TR?
* TEE * Cardiac MRI * can provide RV and RF
84
Describe the findings
* TEE transgastric basal SAX view of the tricuspid valve
85
What are the indications for TV Repair in Progressive functional TR (Stage B) at the time of left sided valve surgery?
* TA (tricuspid annulus) dilation (Class IIa) * \> 40 mm on TTE (21 mm/m2) * \> 70 mm on direct intraoperative measurement * PHTN without TA dilation (Class IIb)
86
What are the treatment options for Asymptomatic, severe TR (Stage C)?
* **Functional** + At the time of left-sided valve surgery --\> * TV Repair or TVR (Class I) * **Primary** + Progressive RV dysfunction --\> * TV Repair or TVR (Class IIb)
87
What are the treatment options for Symptomatic, severe TR (Stage D)?
* **Reoperation** + Preserved RV function and PHTN not severe * TV repair or TVR (Class IIb) * **Functional** + At time of left-sided valve surgery * TV Repair or TVR **(Class I)** * **​**Primary * TV Repair or TVR (Class IIa)
88
Describe the findings
Severe PR likely as a result of prior surery on his pulmonary valve or RV outflow tract * proximal flow convergence on PA side of the valve * Flail leaflet * RV dilation and RV dysfunction
89
What is the most common cause of severe PR?
Prior surgery for congenital heart disease involving the pulmonary valve or RVOT
90
Explain how intraoperative TEE differs from an ambulatory assessment
* Intraoperative TEE will underestimate severity (of TR) * decreased intravascular volume * change in loading conditions, consequent to anesthesia and mechanical ventilation
91
Describe the findings
* Severe TR * High-velocity systolic rversal in the hepatic veins * Gives rise to large "v" waves in the JVP
92
What is pulsus paradoxus? When is it commonly seen?
* abnormally large reduction in SBP \> 10 mmHg during inspiration * Cardiac tamponade (with a pericardial effusion the sensitivity is \> 80%)
93
What is Kussmaul sign? When is it commonly seen?
* Increase in venous pressure on inspiration * Constrictive pericarditis
94
What is pulsus alternans? When is it commonly seen?
* alternating strong and weak peripheral pulses * End stage LV systolic dysfunction
95
What is pulsus bisferiens? When is it commonly seen?
* characteristic pulse felt in the setting of both significant AS and AR and HOCM
96
Describe the findings
* Pulmonary hypertension * 50% of cases associated with abrupt midsystolic closure of the pulmonary valve * appearance is thouh to occur from transient reversal of the PA-RV outflow tract gradient due to impaired PA compliance
97
Describe the findings
* Fibroelastoma * well-circumscribed oval mass * heterogenous with areas of echolucency * 3rd most common primary tumor of the heart
98
Where are cardiac myxomas usually found?
* left atrium * originate from the interatrial septum
99
Where are cardiac fibromas usually found?
* Ventricular myocardium (septum) * almost always single * often with central calcificaiton
100
Describe the findings
* Prosthetic valve **endocarditis** - aortic vavle position with **aortic root abscess** * Long axis view: thickened leaflets with mobile target * Periaortic thickening between the aorta and the left atrium --\> **aortic root abscess** * Shadow artifact of the bioprosthetic aortic valve struts
101
Describe the findings
Severe Aortic Regurgitation * premature closure of the mitral valve (MV), with closure of the MV well before the R wave
102
Describe the findings
HOCM with dynamic LVOTO * CW from the apical approach * typical late-peaking, high-belocity signal during systole * shape of curve corresponds to LV to aortic pressure gradient
103
Explain the differences in CW signal between HOCM/LVOTO and SAM/MR
* SAM/MR * typically starts earlier and ends later in systole * higher velocity through ejection (early) * higher peak velocity * HOCM/LVOTO * low velocity in early systole * peaks near end-systole
104
What is the most common cardiac abnormality seen in Noonan syndrome?
Pulmonic stenosis (25%)
105
What is the most common cause of acquired PS?
Cardcinoid disease
106
Describe congenital valvular PS
* fibrosis and fusion of the commissures --\> bicuspid valve * restricted leaflets typically have a conical or dome-shaped appearance through systole
107
What is the preferred view for doppler assessment of pulmonic valve?
* PS SAX (with slight angulation) * Subcostal or Suprasternal views * can be alternatives in patients with dilated pulmonary artery and anterior displacement of the valve
108
What are the PV and PG which correlate with severe PS?
* PV \> 4 m/s * PG \> 64 mmHg
109
When is RVSP not equal to PASP?
PS or any gradient across pulonic valve
110
When may balloon valvotomy be recommended in PS patients?
* Symptomatic patients with: * PG \> 50 mmHg or MG \> 30 mmHg * Asymptomatic patients with: * PG \> 60 mmHg or MG \> 40 mmHg
111
What are several contraindications to balloon valvotomy in PS patients?
* Moderate or greater PR * Dysplastic PV (associated with Noonan syndrome)
112
When does mild-moderate PR (asymptomatic patients) require follow up or intervention?
abnormal RV size or function
113
What is the most common cause of severe PR?
* Iatrogenic (congenital heart disease) * prior surgery on RVOT or PV in setting of CHD * after balloon valvotomy
114
Pulmonic valve is rarely affected by these disease processes?
* Infective endocarditis * Rheumatic heart disease \*\*\*\*\*Carcinoid disease does affect PV
115
Why is TTE preferred (over TEE) for evaluation of the PV?
due to the anterior-superior position (to the aortic valve) in the chest
116
What additional evaluation shoudl be performed when assessing PR severity?
* Right heart * RV * RVOT * pulmonary annulus * pulmonary arteries * Doppler findings
117
118
What are the specific criteria for mild PR?
* Small jet, with narrow width * Soft or faint CW jet * Slow deceleration time * Normal RV size
119
What are the specific criteria for severe PR?
* Jet width/Annulus \> 70% * Early termination of PR flow * Dense jet, PHT \< 100 ms * Diastolic flow reversal in PA branches * Dilated RV with normal function
120
What is the next step in evaluation when specific mild/severe PR criteria is not met?
* Moderate PR (likley) --\> perform volumetric quantitative methods --\> **Regurgitant Fraction (RF)** * **​Mild \< 20%** * **Moderate 20-40%** * **Severe \> 40%** \*\*\*\*RF datea primarily derived from CMR with limited application in Echo
121
What PHT is consistent with severe PR?
PHT \< 100 ms
122
What PR index is consitent with Moderate/Severe PR?
\< 0.77 * PR index: defined as the duration of the PR signal divided by the total duration of diastole * this cutoff identifies a CMR derived PR fraction \> 25%
123
Describe the findings
* Severe PR * impaired RV diastolic compliance on the PR doppler profile * as the transmitted RA a-wave creates a brief interruption of the PR flow (the dip in the PR slope) * inability of the RV to accept even a small amount of flow simultaneously from the tricuspid inflow and PR
124
Describe the findings
Severe PR (on CWD)
125
Describe the findings: Next step in managment?
* Pacemaker lead endocarditis * large mass lesions consistent with vegetations involving the pacing wires, that spare TV * **Antibiotics, surgical removal of PPM (wires and generator)**
126
What is the diagnosis? Next step in management?
* TV endocarditis (large vegetation) * embolic risk less of a consideration with TV endocarditis --\> embolization to lungs * exception whe R-to-L shunt exists * **Antibiotic therapy and watchful waiting** * surgery if worsening destruction of valve or blood cultures fail to clear
127
What are the most important factors when considering TV repair/replacement in Ebstein's anomaly?
* Tethering of leaflets * RV size and function
128
Describe the findings. Next step in management?
* **TV endocarditis** * **BCx, antibiotics, close monitoring of the valve by Echo**
129
When is balloon valvuloplasty indicated for severe PS (mean gradient)?
* Asymptomatic - MG \> 40 mmHg * Symptomatic - MG \> 30 mmHg
130
What is the diagnosis? Next step in management? * A 42 year old, Indian immigrant presents with RHF * Loud first heart sound, apical diastolic murmur * RV heave but normal P2 * PE: JVP shows prominant pulsations that precede systole
* **Tricuspid and Mitral stenosis (rheumatic disease)** * ​JVP: prominant presystole pulsations = "a" wave * Loud P2 indicates pulmonary hypertension has not occurred * **Balloon valvuloplasty of both valves** * **​**Surgery as secondary option if PBV is contraindicated
131
What is the preferred approach to calculate AR RV in this patient? * 60 year old woman with RHF with mixed AS/AR, MR, TR and PR.
* **Flow convergence method (PISA)** * presence of AS or regurgitant lesions of other valves does not impact the accurarcy of the flow convergence method * Requires: * adequate visualization of the AR flow convergence on the aortic aspect of the AVso that PISA radius can be accurately measured * high quality, complete CWD profile of the AR flow so that peak AR velocity can be accurately measured *
132
What are the most common limitations to the flow convergence method (PISA) in evaluation of AR?
* significant aortic calcification --\> shadowing --\> inaccurate PISA measurement * eccentric AR that results in non-hemispherical flow convergence and/or incomplete AR CW profile
133
What are indicatsons for TEE to diagnose infective endocarditis?
* Moderate-to-high pre test probabily * Staph bacteremia * Fungemia * Prosthetic heart valve * Intracardiac device

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