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Tricuspid and pulmonic valves 2011

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Echo Review of Evaluation of Tricuspid and Pulmonic Valves

Published in: Health & Medicine

Tricuspid and pulmonic valves 2011

  1. 1. Tricuspid and Pulmonic Valves: The forgotten valves Michael G. Katz, MD Fellow in Cardiovascular Disease August 10, 2012
  2. 2. Normal TV1. TV annulus is non-planar2. Unequal leaflet size3. Direct chordae attachment into septum4. Small or absent papillary muscle
  3. 3. TR: Role of Echo• Assessment of TR etiology• Assessment of hemodynamic burden – IVC, RA, RV size – RV function • Visual assessment, dp/dt, RIMP • Annular DTI, TAPSE – LV size and function• Measure RV and PA pressures
  4. 4. Functional TRTricuspid regurgitation that is at least moderate or greater inseverity is most frequently “functional” in nature • not related to specific tricuspid leaflet pathology • right ventricular dilatation, distortion of the subvalvular apparatus, tricuspid annular dilatation, or all three
  5. 5. Causes of Functional (non-organic) TR
  6. 6. Functional TR• Normal TV leaflets except for mild thickening• Progressive RV enlargement • Annular dilatation • Asymmetric geometrical alterations • Malaligned papillary muscles • Tethering of the TV leaflets • Tenting of the TV leaflets • Incomplete coaptation • Tricuspid regurgitation• Significant impact on survival in severe HF
  7. 7. Organic TR• Degenerative • Radiation Rx• Endocarditis • Carcinoid• Traumatic • Hypereosinophilia• Congenital • Drug induced – (Ebstein anomaly) – (ergots, anorectics)• Rheumatic • PPM or ICD lead
  8. 8. Qualitative Evaluation
  9. 9. Clinical and Echo features of ORGANIC TR
  10. 10. PASPPASP = tricuspid regurgitation gradient + RA-pressure (RAP)PASP = 4(Vmax² ) + RAP
  11. 11. RA pressure 5 mmHg 10 mmHgNormal Size/>50% Collapse Normal Size/<50% Collapse 15 mmHg 20 mmHgDilated IVC/Minimal Collapse Dilated IVC/No Collapse
  12. 12. Significant TRSystolic PAP > Systolic PAP < 55 mm Hg 40 mm Hg TV likely Primary TV lesion likely normal (exceptions: RV(functional) infarct, ASD) Circulation 2006;114;450-527
  13. 13. Color DopplerTR jet area measurement • Best done at Nyq~50-70 cm/s • Underestimate eccentric TR • Overestimate central jet
  14. 14. CW Doppler Mild
  15. 15. Both examples of Severe“dagger-shaped” earlypeaking tricuspid regurgitantjetprofile due to earlyequilibration of pressuresbetween the right atriumand right ventricle
  16. 16. Normal HV flow
  17. 17. Semi-Quantitative Analysis• All valvular regurgitations have three components: 1. PISA (proximal isovelocity surface area), 2. vena contracta, and 3. regurgitation jet
  18. 18. Tricuspid Stenosis• Rheumatic fever – Thick leaflets/ restricted motion – Fusion, shortening of chordae – Reduced separation of leaflet tips• Isolated TV congenital malformations rare• Carcinoid heart disease• Impedance of flow by RA tumor, TV vegetation, or• Other structures• Prosthetic valve degeneration or thrombosis
  19. 19. Qualitative 2D• valve thickening and/or calcification,• Restricted mobility with diastolic doming,• reduced leaflet separation at peak opening, and• right atrial enlargement
  20. 20. Quantitative CW Doppler• Mean gradient – < 2 mm Hg is normal – > 7 mm Hg is severe – Measure in held expiration or average of >= 5 cycles• PHT >= 190 msec is severe• TVA = 190/PHT
  21. 21. Caveats to CW analysis• PHT is not reliable when there is significant RV dysfunction or PR• Significant TR will increase mean gradient
  22. 22. Pulmonic Stenosis• 95% of cases are congenital• may also occur as part of more complex congenital lesions such as tetralogy of Fallot, complete atrioventricular canal, double outlet RV, and univentricular heart• Peripheral pulmonary artery stenosis may co-exist with valvular pulmonary stenosis such as in Noonan’s syndrome and Williams syndrome.
  23. 23. Pulm HTN : Loss ofpulmonic A wave and mid-systolic notching.
  24. 24. PS: thickenedvalve withaccentuated Awave > 6 mm
  25. 25. AT < 70 to 90 msec c/w PASP >70 mm HgNormal: > 140 msec
  26. 26. Pulmonary Regurgitation
  27. 27. PHT < 100 c/w significant PRPADP = RVEDP + deltaPpv
  28. 28. Virtual RHC when there’s no PS Mean PA = VTITR + RAP PAEDP = 4(PREDV)2 + RAP RVSP = PASP = 4(Vmax² ) + RAP J Am Soc Echocardiogr 2009;22:814-819
  29. 29. PCWP
  30. 30. J Am Soc Echocardiogr 2009;22:814-819

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