First week - Valvular Regurgitation

Murmur characteristics PI

• Low pitched

• Diastolic

• Increased with inspiration

PI w/ Pulm HTN murmur is called a

Graham Steel Murmur (Board question)

systolic murmurs are heard when there’s regurgitation with

Atrioventricular valves

diastolic murmurs are heard when there’s regurgitation with

Semilunar valves

Acute regurgitation always results in

pressure overload

Etiology (causes) PI (6)

• Pathologic PI is not frequent

• MOST COMMONLY caused by pulmonary HTN

  • Leads to Annular dilation

• Endocarditis

• Rheumatic Heart Disease

• Tetralogy of Fallot

• Carcinoid

% of people with normal PI

40-87%

Pathologic PI

NOT FREQUENT

• This valve usually doesn’t have a lot of problems

Why is it difficult to see the valve cusps on a 2D echo

Pulmonic valve leaflets are very thin

Pulmonic insufficiency directed towards the Tricuspid leaflet causes:

Diastolic fluttering on M-Mode

RV Volume overload on M-Mode causes (2)

RV Enlargement and paradoxical septal motion

Evaluate _______ & ________ of the PI Color doppler jet

EXTENT & AREA

Assess CW Spectral doppler jet _______ for _______

assess CW spectral doppler jet DENSITY for SEVERITY

Severe PI causes

Rapid equalization of RV and Pulmonary artery pressures

(2)

Regurgitation for PI is above the baseline and SEVERE PI IS DAGGER SHAPED

• Rapid reversal

• rapid desceleration

• BAD BAD BAD!

Murmur - TV (2)

• holosystolic

• increase with respiration

Etiology (causes) TR (10)

• Pulmonary HTN

  • Due to RV enlargement and Annular Dilation

  • can be caused by MV Disease or Pulmonary HTN

• Rheumatic Heart Disease

• Triscupid valve prolapse

  • Often associated with Mitral valve prolapse

• RV Failure

• RV MI

• Carcinouid

  • TV is most affected by radiation

  • CHD

    • Marfans sydrome - poor connective tissue

• Ebstein Anomoly

  • CHD

• Trauma

• Endocarditis

• Pacerwire

  • Goes through the TV

Ebstein anomoly

Assessment of TR

• CW (3)

• PW

• Extent, area, direction of TR Jet

• PW of hepatic vein in SUBC

Views for assessing TR (6)

• RVIT

• PSAX

• A4C

• SUBC

• RT FOCUSED A4C

• A3C RT HEART VIEWS

Is PISA used often for TR

Nah bruh (rarely)

Vena contracta width severe for TR when its over

0.7 cm (7mm) SEVERE

Use TR peak velocity to assess

PAP

Severe TR

• vena contracta

• spectral waveform

• hep vein

• PISA

• Vena contracta >0.7 cm wide

• Dense spectral doppler waveform

  • early peaking

  • triangular shaped

• Hepatic vein

  • Blunted systolic wave, systolic flow reversal

• PISA Radius > 0.9 cm

RV Volume overload

Right ventricular englargement

Pardoxical septal motion

PISA Radius width TR

• mild

• moderate

• severe

Mild: <or= 0.5 cm

Moderate: 0.6-0.9 cm

Severe: >0.9 cm

what does this show and why

MILD TR

• Small color jet

• round CW doppler

• Systolic dominance in Hep vein

  • because LV is pushing blood through it

What is this and why

SEVERE TR

• Big color jet

• Steep and sharp reguritant CW Wwaveform

• systolic flow reverasal in PW Hep vein

• Dagger shaped high pressure that drops off quick

TR Due to RV enlargement and annular dilation common in what patient

IV Drug users because the dirty drugs hit the TV first

Severe TR is when there is more __________ flow than __________ flow

Severe TR is when there is more retrograde flow than antegrade flow

MODERATE TR

Systole and Diastole velocities are similiar

normal hepatic vein PW

• Systolic is larger than diastolic

Hepatic vein FLOW REVERSAL

• Look at systole! ITS GOING BACKWARDS BC PULMONARY PRESSURES ARE SO HIGH!!!

TR will causes a greater velocity in what part of diastole

TR = INCREASED E VELOCITY

Obtain peak CW TR for (2)

• PAP

• PISA Measurement

See what leaflets in these views

• RVIT:

• A4C

• PSAX

TV

RVIT: Posterior & anterior

PSAX: Anterior & septal

A4C: Anterior & septal

primary regurgiation

Problem with the leaflets

secondary regurgitation

problem with the valve appartatus

examples of secondary regurtation TR (4)

cor pulmonal

• RT HF (W/ Embolos usually)

• RV MI

• Pacemaker wires going through TV

• Pulmonary HTN

  • RV Enlargement

  • annular dilation

  • leaflets fail to coapt

right sided failure will lead to

left sided failure

which dysfuction usually leads to the other

• systolic = diastolic?

• diastolic = systolic?

Systolic = diastolic