TS/TR

Question 1

The tricuspid valve (TV) has a saddle shape because of anterior and posterior high points and mid septal and lateral wall low points.

T or F ?

Answer 1

T

Question 2

Tricuspid Valve

The largest leaflet is _________ & the smallest leaflet is ________

Answer 2

anterior

posterior

Question 3

Tricuspid Valve

Septal leaflet is connected to the ___________

Answer 3

wall of the IVS

Question 4

Tricuspid Valve

How many pap muscles does TV have?

Answer 4

3

Question 5

Tricuspid Valve

Compared to MV, TV is positioned slightly ______ than MV

Answer 5

inferior

Question 6

Tricuspid Stenosis

Definition

Answer 6

TS is a narrowing /thickening/obstruction of the TV that impedes diastolic flow traveling from the RA, though the TV, into the RV

Question 7

Tricuspid Stenosis

Murmur

Answer 7

a diastolic rumble that varies with respiration and has an opening snap

*may be accentuated with inspiration

Question 8

Tricuspid Stenosis

cause

Answer 8

• RHD: most common cause; however, TS rarely occurs alone, and typically AV and MV are affected prior to TV
• Congenital TS such as Ebstein anomaly
• Carcinoid heart disease with TV involvement: also causes TR, PS, and PR *TV leaflets are thick and rigid with no change in position from diastole to systole
• Secondary TS due to intracardiac wires/pacemaker, RA clot.tumor, or TV vegetation (from endocarditis) that physically obstruct the TV
• Secondary TS due to other medical condition: Systemic Lupus Erythematosus
• Prosthetic valve dysfunction

Question 9

Tricuspid Stenosis

Complications

Answer 9

• TS is usually not an isolated disease state and associated with other conditions
• increased risk of infective endocarditis
• increased risk of embolization in the event of a clot or tumor

Question 10

What is Ebstein anomaly?

Answer 10

• rare congenital heart defect
• TV is in the wrong position and leaflets are malformed leading to TR
• often associated with ASD and heart rhythm abnormalities

In people with Ebstein anomaly, the leaflets are placed deeper into the right ventricle instead of the normal position. The leaflets are often larger than normal. The defect most often causes the valve to work poorly, and blood may go the wrong way. Instead of flowing out to the lungs, the blood flows back into the right atrium. The backup of blood flow can lead to heart enlargement and fluid buildup in the body. There may also be narrowing of the valve that leads to the lungs (pulmonary valve).

Question 11

Tricuspid Stenosis

signs and symptoms

Answer 11

• ascites
• abdominal swelling
• jaundice
• peripheral edema
• right upper quadrant pain

Question 12

Tricuspid Stenosis

Increased RA pressure eventually leads to RA enlargement and signs of _______

Answer 12

right heart failure

Question 13

Tricuspid Stenosis

clinical presentation

physical findings

Answer 13

• Jagular venous distention with cannon “a” waves
• hepatomegaly
• ascites
• peripheral edema without pulmonary congestion

Question 14

Tricuspid Stenosis

2D echo findings

Answer 14

• thickened TV leaflets with restricted motion
• diastolic doming of the TV leaflets best detected from the PLAX or 4C
• decreased TV orifice due to tethered leaflets
• RA enlargement due to volume and pressure overload
• dilated IVC (normal: 1.2-2.1cm) due to the backup of blood and RA enlargement

Question 15

Tricuspid Stenosis

M-mode findings

Answer 15

• thickened TV leaflets
• multiple echoes may be visible
• decreased TV leaflet mobility causes a decreased EF slope. The RV fills slower when TS is present; therefore, the valve is help open by an elevated RAP
• anterior motion of the posterior TV leaflet due to tethered TV leaflet tips

Question 16

Tricuspid Stenosis

Quantification

views used to acquire sample volume?

Answer 16

• RV inflow
• PSAX
• A4C
• Subcostal SAX

*sample volume at tips of TV leaflets

Question 17

Tricuspid Stenosis

Quantification

Explain how to obtain pressure half time and TVA

Answer 17

• Compare PLAX RVIT, PSAX RVIT, A4C, A3C RVIT (modified view), Subcostal 4C/SAX if necessary
• Optimize Doppler angle
• CWD focus within the TV leaflets
• increase sweep speed to 100 mm/s
• Acquire the peak TS waveform, freeze, and measure from the peak velocity down to the deceleration slope *average 3+ waveforms
• The machine will calculate the P½t and TVA once the slope is acquired

Question 18

Tricuspid Stenosis

TVA equation

Answer 18

TVA = 190/pressure half time

*190 is constant

Question 19

Tricuspid Stenosis

Similar to MS, TS has an ______ peak velocity (E), _______ EF slope, and _____ A wave that assessed via the pressure half time

Answer 19

increased

flattened

absent

Question 20

Tricuspid Stenosis

Explain how to obtain mean PG

Answer 20

• Trace the peak waveform, start and finish at ) baseline
• the machine will calculate the mean PG

Question 21

Tricuspid Stenosis

severity scale: TVA

normal?

severe?

Answer 21

7-9 cm²

≤ 1.0 cm²

Question 22

Tricuspid Stenosis

severity scale: P½t

severe?

Answer 22

≥190 m/s

Question 23

Tricuspid Stenosis

severity scale: mean PG

severe?

Answer 23

≥ 5 mmHg

Question 24

Tricuspid Regurgitation

definition

Answer 24

the result of an incompetent TV that permits backward systolic from the RV, through the TV (while it is closed), into the RA

Question 25

_Tricuspid Regurgitation_ murmur

Answer 25

a holosystolic murmur that increases with inspiration

Question 26

_Tricuspid Regurgitation_ causes

Answer 26

* majority of normal patients (75%) have trace/mild TR * mosrt common cause of TR is secondary or functional TR due to: * annulr dilatation from RA/RV enlargement * associated with left heart disease * RV dysfunction * PH * myxomatous degeneration - most common cause of primary TR * Rheumatic TR - usually associated with TS * TV prolapse \*seen in 20% of cases with concominant MVP (**mid-to-late systolic or holosystolic)** * incomplete closure of TV due to: * pacemaker wire * tumor * RV infarct * pap muscle dysfunction * ruptured TV chordae * secondary TR due to frail leaflets (closed chest trauma, biopsy, vegetation) * carcinoid heart disease * congenital TR (Ebstein anomaly) * prosthetic valve disease

Question 27

_Tricuspid Stenosis_ severity: inflow time-velocity integral

Answer 27

> 60cm

Question 28

_Tricuspid Stenosis_ severity: supportive findings

Answer 28

enlarged RA ≥ moderate; dilated IVC

Question 29

_Tricuspid Regurgitation_ cause

Answer 29

* **secondary** or **functional TR** due to _annular dilatation_ from RA and/or RV enlargement, may be associated with _left heart disease, RV dysfunction, or PH_ \***most common cause** * **Myxomatous degeneration** is _the most common cause_ of **primary TR** * **Rheumatic TR** is usually associated with **Rheumatic TS** * **TR due to TV prolapse**. **_TVP_** _is seen in_ **_20%_** _of cases with concomitant (associated/accompanied) MVP_ and is diagnosed with excessive billowing of ½/3 TV leaflets into the RA. Similar to MVP, TVP can be mid-to-late systolic or holosystolic * incomplete closure of TV due to pacemaker wire, tumor, RV infarct, pap muscle dysfunction, ruptured TV chordae * **Secondary TR due to flail leaflets** (closed chest trauma or biopsy), vegetation etc * Carcinoid heart disease with TV involvement. TV leaflets are thick and rigid with no change in position from diastole to systole. Additional findings incluude TS, PS, and PR * Congenital TR such as Ebstein anomaly * Prosthetic valve dysfunction

Question 30

_Tricuspid Regurgitation_ The majority of normal patients \_\_\_\_% have trace/mild TR (functional TR)

Answer 30

75

Question 31

_Tricuspid Regurgitation_ Functional TR caused by:

Answer 31

* left heart disease (LV dysfunction or valve disease resulting in PH) * primary PH * secondary PH due to: chronic lung disease, **pulmonary thromboembolism (DVT)**, left-to-right shunt (ASD/VSD), **AFib** * cardiac tumors

Question 32

_Tricuspid Regurgitation_ TR due to Structural Abnormality of TV Cause?

Answer 32

* **25%** of TR patients * **Rheumatic** * **Prolapse** * **Congenital:** Ebstein anomaly, TV displasia, TV hypoplasia, TV cleft, double-orifice TV, _unguarded TV orifice (_most extreme form) * **Endocarditis** * **Endomyocardial fibrosis** (an idiopathic disorder of the tropical and subtropical regions of the world that is characterized by the development of restrictive cardiomyopathy and fibrotic changes in the endocardium, usually limited to the cardiac apex.) * **Carcinoid disease** * **Traumatic** (blunt chest injury, laceration) * **iatrogenic**: pacemaker/defibrillator lead interference, RV biopsy, drug exposure to _fenfluramine-phentamine_ (The drug combination fenfluramine/phentermine, usually called **fen-phen**, was an anti-obesity treatment that utilized two anorectics) or methysergide, radiation

Question 33

_Tricuspid Regurgitation_ Backward flow of blood through incompetent TV during ventricular systole. Progressive increase in degree of TR leading to \_\_\_\_\_\_\_\_

Answer 33

RV volume overload

Question 34

_Tricuspid Regurgitation_ Impaired forward cardiac output due to volume of regurgitant flow. Heart compensates for volume overload with ______ and \_\_\_\_\_\_

Answer 34

RV dilatation hypertrophy

Question 35

_Tricuspid Regurgitation_ Increased RA pressure causes\_\_\_\_\_\_\_ and the process eventually leads to \_\_\_\_\_

Answer 35

RA dilatation RHF

Question 36

_Tricuspid Regurgitation_ clinical presentation What are the signs & symptoms?

Answer 36

* usually asymptomatic for a long period * weakness * fatigue * findings of heart failure

Question 37

_Tricuspid Regurgitation_ What are the physical findings?

Answer 37

* Jagular venous distention with prominent “v” wave * hepatomegaly * pulsatile liver * hepatojugular reflux * peripheral edema * ascites * AFib * hyperdynamic RV impulse

Question 38

_Tricuspid Regurgitation_ treatment options

Answer 38

* TR is usually a secondary problem * annuloplasty * valve replacement

Question 39

_Tricuspid Regurgitation_ complications

Answer 39

enlargement of the: * RA and RV which leads to AFib * IVC * hepatic veins * SVC * neck veins

Question 40

_Tricuspid Regurgitation_ patient may experience:

Answer 40

* leg and abdominal edema * liver enlargement * portal hypertension due to increased BP returning from the venous circulation

Question 41

_Tricuspid Regurgitation_ 2D echo findings

Answer 41

\*anatomic basis/defect that prevent coaptation: * **RA enlargement** with dilated annulus * thickened TV leaflets, particularly if there is a history of RHD * **TVP,** best detected from the PLAX RVIT, 4C, or Sub \***diastolic flutter of the TV leaflets** secondary to trauma or endocarditis \*_RV volume overload pattern_: **RV dilatation with paradoxical septal motion** - note: chronic, severe TR usually leads to RA/RV dilatation; whereas, normal chamber volume are **_unusua_**l with chronic, severe TR \*dilated IVC (normal: 1.2 - 2.1 cm) \*dilated HV (normal: 0.5 - 1.1 cm) * trauma * endocarditis

Question 42

_Tricuspid Regurgitation_ Doppler evaluation hepatic vein evaluation with PWD to check\_\_\_\_\_

Answer 42

hepatic vein flow reversal by aligning insonation beam with the flow in the HV \*note: may not be reliable in patients with Afib, paced rhythm with retrograded atrial conduction

Question 43

_Tricuspid Regurgitation_ CW Doppler evaluation What are the disadvantages?

Answer 43

* qualitative * perfectly central jets may appear denser than eccentric jets of higher severity * overlap between moderate and severe TR

Question 44

_Tricuspid Regurgitation_ CFD evaluation

Answer 44

* jet size and configuration - jet area to RA area comparison * direction and eccentricity of jet * color M-mode to establish timing \***Vena contracta** * narrowest portion of jet that occurs at or just downstream from the orifice, measured at the time of its largest diameter * _not valid_ in presence of multiple jets * **width \> 0.7** = severe TR \*PISA * validated only in small studies * rarely needed clinically

Question 45

_Tricuspid Regurgitation_ Doppler evaluation PWD

Answer 45

\*Tricuspid inflow E wave velocity * predominant early filling with severe TR * “E” velocity \> 1.0 m/s consistent with severe TR in the absence of severe diastolic dysfunction * must rule out co-existing stenosis \*Hepatic vein abnormalities * Diminished systolic forward flow occurs with increasing severity of TR * High RA pressure and AFib may also cause diminished systolic forward flow * severe TR may cause systolic flow reversal

Question 46

_Tricuspid Regurgitation_ TR severity scale

Answer 46

* RVSP/SPAP * CWD spectral strength and shape * CFD regurgitant jet area/RA area * PWD mapping technique

Question 47

_Tricuspid Regurgitation_ CFD severity?

Answer 47

mild

Question 48

_Tricuspid Regurgitation_ CFD severity?

Answer 48

moderate

Question 49

_Tricuspid Regurgitation_ CFD severity?

Answer 49

severe

Question 50

_Tricuspid Regurgitation_ CFD severity?

Answer 50

massive

Question 51

_Tricuspid Regurgitation_ CWD evaluation Use RV inflow, PSAX, A4C view and evaluate the RA just below the valve leaflets to assess presence of systolic flow disturbance. T or F ?

Answer 51

T

Question 52

_Tricuspid Regurgitation_ CWD evaluation Density of CW Doppler signal is proportional to regurgitant volume. T or F ?

Answer 52

T

Question 53

_Tricuspid Regurgitation_ CWD evaluation Velocity of TR is NOT related to severity of TR. T or F ?

Answer 53

T

Question 54

_Tricuspid Regurgitation_ CWD evaluation Duration of TR signal is typically holosystolic. T or F ?

Answer 54

T

Question 55

_Tricuspid Regurgitation_ CWD shape of TR symmetrical shape reflects _____ TR asymmetrical shape reflects _____ TR

Answer 55

mild severe \*due to rapid increase in RA pressure

Question 56

_Tricuspid Regurgitation_ CWD evaluation Use of Bernoulli equation to assess RVSP may be unreliable if the regurgitant orifice is not “restrictive” T or F ?

Answer 56

T

Question 57

_Tricuspid Regurgitation_ CWD evaluation: Systolic flow reversal in the _____ vein as viewed in the subcostal LAX of the IVC indicates severe TR

Answer 57

left hepatic

Question 58

_Tricuspid Regurgitation_ CWD evaluation: CW Doppler from A4C may allow determination of \_\_\_\_\_\_

Answer 58

RVSP (RV systolic pressure)

Question 59

_Tricuspid Regurgitation_ CWD evaluation RVSP = _____ pressure

Answer 59

systolic PA \***RVSP = SPAP**

Question 60

_Tricuspid Regurgitation_ CWD evaluation: RVSP equation?

Answer 60

RVSP = TR jet gradient + RA pressure

Question 61

_Tricuspid Regurgitation_ RVSP/SPAP is dependent upon age, weight, SV, and BP T or F ?

Answer 61

T

Question 62

_Tricuspid Regurgitation_ In the absence of RVOT obstruction, the peak TR velocity (peak TRV) and mean RAP are used to estimate the RVSP T or F?

Answer 62

T

Question 63

_Tricuspid Regurgitation_ Even though the sonographer and/or the TR can over/underestimate the values, the RVSP/SPAP has a strong correlation with the noninvasively acquired LAP; therefore, the TR & RVSP/SPAP calculation are used to acquire an indirect estimate of the LAP T or F?

Answer 63

T

Question 64

_Tricuspid Regurgitation_ The RVSP/SPAP calculation is useful in the diagnosis and assessment of PH T or F?

Answer 64

T

Question 65

_Tricuspid Regurgitation_ TR & TVSP/SPAP calculation method

Answer 65

1. acquire the **peak TRV** then calculate the **RV-RA pressure gradient** using the modifies Bernoulli equation: **4V²** (\*V = peak TRV you measured) 2. Unless the patient has a _central venous line_, estimate the **mean RAP** by using **3/8/15 method** based on the _IVC diameter & IVC respiratory behavior (collapse)_ * _IVC \< 2.1 cm & collapse_ **_\>_** _50%_ = **normal RAP** = **3mmHg** * _IVC \< 2.1 cm & collapse_ **_\<_** _50%_ = normal size/**abnorma**l collapse = **intermediate RAP** = **8mmHg** * _IVC_ **_\>_** _2.1 cm & collapse \> 50%_ = **abnormal** size/normal collapse = **intermediate RAP** = **8mmHg** * _IVC \> 2.1 cm & collapse \< 50%_ = **abnormal** size/**abnormal** collapse = **severe RAP** = **15 mmHg** \*acquire _IVC diameter at the end-expiration,_ just proximal to the entrance of hepatic vein

Question 66

_Tricuspid Regurgitation_ RVSP/SPAP equation

Answer 66

RVSP/SPAP = 4V² + RAP

Question 67

_Tricuspid Regurgitation_ IF the peak TRV = 3.2 m/s, and the IVC diameter = 3.2 cm & collapse \< 50% upon inspiration or sniff test, then what is the RVSP/SPAP?

Answer 67

RVSP/SPAP = 4V² + RAP = 4 (3.2)² + 15 = 56 mmHg = moderate PH

Question 68

_Tricuspid Regurgitation_ PH severity scale based on RVSP/SPAP: normal? moderate? severe?

Answer 68

normal: 18-25mmHg moderate: 30-40mmHg severe: \>70mmHg

Question 69

_Grading the severity of chronic TR by echo_ size of IVC normal? normal to mildly dilated? dilated?

Answer 69

normal: \< 2cm normal to mildly dilated: 2.1-2.5 cm dilated: \> 2.5cm

Question 70

What are the reasons that cause a dilated IVC?

Answer 70

* Healthy young athletes may have dilated IVCs in the presence of normal pressures * The IVC is commonly dilated and may not collapse in patients on ventilators * In these cases, the IVC size should not be used to estimate RA pressure

Question 71

_Pulmonary Hypertension_ definition

Answer 71

an elevation in the PAP caused by another disease i.e. obstructive sleep apnea, lung disease, diastolic heart failure, left heart disease. \***It is NOT a disease of the pulmonary vessels themselves**

Question 72

_Pulmonary Hypertension_ PH is identified by:

Answer 72

* elevated SPAP: **\>25mmHg** _at rest_ or **\>30mmHg** _with exercise_ * elevated pulmonary vascular resistance (PVR: the resistance the RV must overcome to pump blood into the PA

Question 73

_PH vs PAH_ What is PAH (pulmonary arterial hypertension)?

Answer 73

a chronic, incurable _subgroup of PH_; it is an _elevation in the PAP_ **caused by pulmonary vessel disease** (the walls of arteries tightens and stiffen)

Question 74

PAH is identified by:

Answer 74

* elevated **SPAP**: \> **25 mmHg** at rest or \> **30 mmHg** with exercise * pulmonary capillary wedge pressure (**PCWP**) **≤ 15 mmH**g, in other words, a _normal left heart pressure_ * elevated **PVR** \*According to AHA, patients with PAH with and elevated RAP, pericardial effusion, and moderate to severe TR, have an elevated mortality risk

Question 75

PH associated echo findings:

Answer 75

* abnormal IVS: PWT ratio (\>1) * diastolic dysfunction (elevated filling pressure by E/e') * dilated IVC with decreased collapsibility * dilated PA * PFO/ASD seen on bubble study * RVH/LVH, RV/LV dilatation and/or dysfunction * pericardial effusion * RAE/LAE * Significant TR, PR, and/or MR * ventricular septal flattening; D shaped LV