Tricuspid valve
Functional means the valve is normal but has
TR
What can you find in 2d m-mode of TR dilated:
TV Annulus IVC greater 1.7cm with lack of respiratory collapse Hepatic Vein Coronary Sinus SVC
What are leaflets in carcinoid disease look like?
TV leaflets are thick and rigid with no change in position from diastole to systole.
What are the 2D echo findings with TS?
Thickened Tricuspid Valve Leaflets with restricted motion. Diastolic doming of the Tricuspid Valve with commissural fusion. Right Atrial Dilatation. Dilated IVC, Hepatic Veins. Leftward protrusion of the Interatrial Septum. Pulmonary Hypertension due to coexisting MV disease.
M-mode echocardiography of TS
Thickened leaflets Decreased E-F slope of the anterior TV leaflet. Anterior motion of the Posterior TV leaflet. IN RVIT Mode
Tricuspid is larger and thinner than Mitral valve?
True
What are differential diagnosis of dilated RV with paradoxical Septal Motion that causes RV volume overload:
ASD Partial Anomalous Pulmonary Venous return Pressure overload due to Pulmonic Valve Disease Pulmonary Hypertension due either to left-sided heart disease or intrinsic lung disease D-shaped LV will be throughout Systole and Diastole (pressure overload)
What are 2D and M-Mode echo evaluation of TR
Anatomic basis for the presence of Tricuspid Regurgitation Right Atrial Dilatation Right Ventricular Dilatation Right Ventricular Volume overload pattern Globular Right Ventricle which may form the cardiac Apex Dilated M-Mode: RV volume Overload Pattern
Which Leaflets is most common followed by Septal and Posterior Leaflet Prolapse?
Anterior Leaflet Prolapse
What is the second most common disease for TS?
Carcinoid disease
Secondary TS
Due to a RA clot or tumor dropping down into the TV during diastole Vegetations Systemic Lupus Erythematosus Prosthetic Valve Dysfucntion Intracardiac wires/ pacemakers that obstruct the TV flow
The pressure Half Time is obtained by measuring the Deceleration Slope from _to_ on the peak TS waveforms.
E-F
Anatomic basis for the presence of TR
Ebstein's Anomaly Carcinoid TV Vegetation Ruptured Chordae Tendinae
Murmur of Tricuspid Regurgitation
Holosystolic murmur Increases in intensity with inspiration
What is RAP indicated by?
IVC
What does decreased E-F slope of Tricuspid Inflow Doppler tracing tell you?
Indicates increased deceleration time and an increased pressure half-time
What TV prolapse associated with?
MVP
Where is TV Prolapse common in?
Marfan's syndrome, Secundum ASD, and Ebstein's Anomaly
Which typically valves are associated with heart disease prior to the TV?
Mitral and Aortic Valve
What equals RVSP?
PAP ( pulmonary artery pressure)
How do you measure area of TV?
Pressure Half Time (PHT)
What is most common functional cause of TR due to left heart failure?
Pulmonary Hypertension
other causes of functionally TR
Pulmonary hypertension Mitral stenosis Mitral Regurgitation LV systolic/diastolic dysfunction Congenital lesions RV infarction RT Heart Pathology Constrictive Pericarditis
What is RV volume Overload Pattern:
RV Dilatation D-shpaed LV during ventricualr diastole (volume overload) Paradoxial Septal motion which is an abnormal septal motion characterized on M-mode recording by posterior motion of the septum in diastole which is volume overload and anterior motion of the septum
Which views do we see TR severity in?
RVIT AP4C VIEW PSAX of aortic view
carcinoid DIsease in RVIT
RVIT in systole showing thickened, immobile and retracted Anterior and Posterior Leaflets of TV
Anatomic casue of TR (primary, abnormal TV apparatus)
Rheumatic Heart Disease Infective Endocarditis latrogenic (pace wire, prosthetic valve) Ebstein's anomaly Marfan's Syndrome Carcinoid Heart disease Trauma Cardiac Transplantation TV Prolapse Systemic Lupus Erythematous (SLE)
What is the first affect from TR?
Right Atrial Dilatation
What equals RVSP in absence of RVOT obstruction?
SPAP (systolic pulmonary artery pressure)
Rheumatic Tricuspid Stenosis
With thickened valve leaflets and RA Enlargement in the A4C view
tricuspid murmur
a diastolic murmur that varies with respiration and has an opening snap
Ebstein's anomaly of the tricuspid valve
abnormal displacement of the septal leaflet of the tricuspid valve toward the apex of the right ventricle; the right ventricle above this leaflet becomes the "atrialized" chamber
tricuspid stenosis
abnormal narrowing of the opening of the tricuspid valve/ to obstruction o the TV that impedes diastolic blood flow traveling from the RA through the TV, into the TV
What are three leaflets of tricuspid valve?
anterior, posterior, septal
Where is annulus of Tricuspid Valve closer to?
apex of heart
Carcinoid tumor
are slow growing tumors than can arise in several places in the body, mostly GIT( Gastrointenstial tract).
What is considered stenosis in TV?
below 2cm^2
What is moderate regurgitation jet flow?
between 5 and 10 cm^2 of the RA
Where is the tricuspid valve located?
between right atrium and right ventricle
Where is Tricuspid prolapse of leaflets are at?
beyond tv Annulus
What is PHTN?
degree of Pulmonary Hypertension by the RVSP/PAP METHOD
when does volume overload happen during septal motion?
diastole
What is severe regurgitation jet flow?
fills more than 10cm^2 of an enlarged RA
What is mild MPG for TS?
less than 2mmHg
What is Severe valve area?
less then 2cm^2
What is mild jet area?
less then 5cm^2
What is TV Prolaspe associated with?
mild, late systolic TR
What is Severe Jet area?
more than 10 cm^2
What can pressure overload of the RA lead to:
peripheral edema and reduced cardiac output
What does velocity indicate?
pulmonary Hypertension is higher, you can have Mild TR with Severe Pulmonary Hypertension
what does the intensity of CW signals relative to the antegrade flow signal intensity related to?
regurgitant severity
variation with right side is due to
respiration
What is most common cause of TS?
rheumatic heart disease (90%)
What is RAP?
right atrial pressure
How much is mild regurgitation characterized by ?
small systolic to the valve closure plane )jet area of less then 5 cm^2
Severe Tricuspid Regurgitation results in ___________
systolic flow reversal in the IVC and SVC
What anatomic, primary means:
the main reason is in the Valve
How many leaflets does the tricuspid valve have?
three
Carcinoid heart disease (2 main findings)
tricuspid regurgitation, pulmonic stenosis
What do we check for TS?
we must check the other valves fro Rheumatic involvement
TR can be evaluated with color Doppler Imaging to determine the TR jet___________
width, depth and intensity
Is Hepatic flow reversal an indication of severe TR?
yes
What is Normal RVSP/PAP in degree of PHTN?
18-30 mmHg
What is formula for TVA?
190P1/2T (msec)
How many views do you need to diagnose the patient for TV prolapse?
2
What is moderate MPG for TS?
2 to 5 mmHg
What is Normal Right atrial pressure?
2-8 mmHg
Color flow doppler will demonstrate a diastolic jet which is characterized as_____
laminar aliased flow or candle flame-shaped with a mosaic center
What is RAP for IVC greater than 1.7 cm with no inspiratory collapse?
20mmHg which is severe
Mild PHTN RVSP/SPAP
30-40 mmHg
How do you estimatie Right Ventricular Systolic Pressure (RVSP)
4(v)^2+RAP
Moderate PHTN RVSP/SPAP
40-70 mmHg
What is Moderate JET area?
5 to 10cm^2
What is RAP for IVC greater than 1.7 cm and collapses greater than 50% with inspiration?
5mmHg
Normal TV orifice
7-9 cm^2
What is Normal valve area?
7-9 cm^2
how much percentage of patient have trace-to-mild TR?
93%
Severe PHTN RVSP/SPAP
> 70 mmHg
What is RAP for IVC less than 1.7 cm and collapses greater than 50% with inspiration?
15mmHg
Normal TV velocity
0.3-0.7 m/s
What is RAP for IVC greater than 1.7 cm and collapses less than 50% with inspiration?
10mmHg
Tricuspid regurgitation
Backflow of blood through incompetent tricuspid valve into RA during systole
The brighter and more filled in, the higher the_____
intensity of the TR
What is Severe MPG for TS?
greater than 6mmHg
When does pressure overload happen during septal motion?
in systole and diastole
What does Dilated Hepatic Veins with a dilated IVC suggest?
increased RAP
Doppler evaluation of TS
increased Tricuspid Valve E velocity recorded at the TV Leaflet tips (greater 1.0m/s)