Tricuspid Stenosis/Tricuspid Regurgitation WK 5

How many leaflets does the AO have?

3. Anterior leaflet

   Posterior leaflet

   Septal leaflet

Where is the tricuspid valve located in this image?

What is TV stenosis?

A condition in which the valve between RA and LA are not functioning properly. Tricuspid stenosis often occurs with other heart valve problems.

A narrowing of the tricuspid valve orrifice that impedes diastolic flow traveling from RA>TV>RV

Tricuspid Stenosis

Tricuspid stenosis causes a

reduction of blood from the RA into the RV

Tricuspid Valve Stenosis causes the______to become enlarged, decreasing the amount of blood entering the _____.

RA/RV

Atrisia is?

Absent

What is ebstein?

displacement of the tricuspid valve leaflets downward into the right ventricle, leading to a functional stenosis.

the most common cause of tricuspid valve disease

Rheumatic fever

________(always combined with TR)

Carcinoid

Etiology of the Tricuspid stenosis

Congenital heart problems

Heart attack or coronary heart disease

Congestive heart failure

Endocarditis—heart infection

  or inflammation

Trauma to the heart

Secondary aka functional TS

Signs and Symptoms of TS

Ascites

Abdominal swelling

jaundice

Peripheral edema

RUQ pain

Complications of TS

-usually not an isolated disease state. Evaluate other valves for stenosis.

-Increased risk IE

-If clot/tumor, increased risk of embolization

-Decreased Cardiac output

What is Tricuspid Atresia?

is a condition present at birth (congenital heart disease), a solid wall of tissue blocks the blood flow between your right heart chambers.

Ebstein's anomaly

is a condition in which a malformed tricuspid valve sits lower than normal in the right ventricle, causing blood to flow back into the right atrium (TR).

Carcinoid heart disease  

is a consequence of the effects of excess hormone production. Serotonin in high concentrations entering the heart from the liver causes fibrosis, particularly in the tricuspid and pulmonic valves, resulting in right-sided heart failure. 

Nearly ____ of patients exhibiting the _______ will develop carcinoid heart disease (CHD) with fibrotic endocardial plaques and associated heart valve dysfunction that classically involves the ______.

40%/carcinoid syndrome/tricuspid valve

On an echocardiogram this presents a thickening and retraction of the tricuspid valve leaflets during systole. The right-sided image demonstrated severe tricuspid valve regurgitation.

Carcinoid heart Disease

What can be heard during auscultation?

With tricuspid stenosis a mid diastolic murmur can be heard during auscultation

What does TS creates?

TS creates diastolic rumble with an opening snap that varies with respiration

Asses RVIT

Asses apical 4

Asses RVOT in SAX

asses in Spectral doppler

Tv Inflow (PW)

RV inflow pattern

PWD gate at tips of TV leaflets 

Normal Flow is Antegrade

Use TV package (E/A velocity)

Measure peak E velocity and Decel slope

>1 m/s suggestive of high velocity

2. Measure peak A wave

TV stenosis (CW)

DECREASED E-F SLOPE

OBTAIN TVA USING

PHT METHOD

NORMAL TVA 7-9 CM

TRACE E & A WAVE TO OBTAIN MEAN PG

Severity Scale

Tricuspid Regurgitation

is leakage of blood backwards from the right ventricle into the right atrium during systole; may be acute, chronic or intermittent.

What happens during Tricuspid Regurgitation?

As the right ventricle contracts to pump blood forward to the lungs, some blood leaks backward into the right atrium, increasing the volume of blood in the atrium.

As a result of TR..

As a result, the right atrium can enlarge, which can change the pressure in the nearby chambers and blood vessels.

Causes of TR

Carcinoid Heart Disease (HD) with TR

Carcinoid heart disease (HD) occurs when large amounts of vasoactive substances such as serotonin, tachykinins, and prostaglandins reach the right side of the heart, consequent to reduced hepatic metabolism from extensive metastatic liver involvement of the carcinoid tumor.

The most common cause of TR

The most common cause of TR is Secondary (functional)

An increase in size of the right atrium or right ventricle, causing annular dilatation

Secondary causes of TR

Tricuspid valve regurgitation often _____ cause signs or symptoms until the condition is ______. You may be diagnosed with this condition when having tests for other conditions

Doesn’t/ Severe

Symptoms of TR ex)

Noticeable signs and symptoms of tricuspid valve regurgitation may include:

Fatigue

Declining exercise capacity

Swelling in your abdomen, legs, or veins in your neck

Abnormal heart rhythms

Pulsing in your neck

Shortness of breath with activity

You may also notice signs or symptoms of the underlying condition that's causing tricuspid valve regurgitation, such as ________.

Pulmonary Hypertension

How does The Murmur sound with TR

-Holosystolic Murmur

-Increases with Inspiration

-tricuspid regurgitate murmur that is more easily heard with inspiration.

Rivero-Carvellos Sign

-tricuspid regurgitate murmur that is more easily heard with inspiration.

Treatment Options For TR

Usually, secondary problem

-Annuloplasty

-Tricuspid Valve replacement

Complications and signs of TR

-Enlarged RA, RV, IVC, Hepatic veins, SVC & Neck veins

-leg & abdominal swelling

-liver enlargement & portal HTN

Right Ventricular Systolic Pressure (RVSP) is used to

RVSP is used to estimate right side pressures in the vessels leading to the lungs. This is used to determine pulmonary hypertension.

TR Vmax + RAP= RVSP

Pulmonary Hypertension (PHTN)

PAP elevation

caused by another disease

not a disease of pulmonary vessels

identified by:

elevated SPAP

elevated PVR (The resistance the RV must overcome

Pulmonary Atrial Hypertension (PAH)

Chronic, an incurable subgroup of PH

PAP elevation

Caused by pulmonary vessel disease

Identified by:

elevated SPAP (> 25 mmHg at rest or > 30 mmHg with exercise)

How to obtain the rsvp/spap

1. Place the CW cursor through the                              TR color jet

2. Measure the tricuspid regurgitant waveform to achieve the tr velocity

3. The machine will use the TR Vmax velocity and turn it into a pressure gradient. This is done by using the Bernoulli equation

If TR= 42MMHg+________

IVC=2.2

Add Sniff

=57

Ex? Since anything over 2.1 is abnormal and there was a sniff we add The high of 15. So 42+15= 57. If there was no sniff or the Ivc was 2.1 we would have added an 8 instead.

RVSP / Systolic pulmonary artery pressure  (SPAP) determined by the TR

TR Max PG + RAP = RVSP/SPAP

Tricuspid Regurgitation Color Jet

Assess TR jet width and length in all views.  Adjust color gain, scale, and color box

Views in RVIT, SAX AO, A4C

Normal hepatic vein flow travels _____ from the transducer towards the IVC and is encoded in _____

away/ blue.

TR flowing into the IVC & Hepatic veins will flow ______ the transducer during systole and is encoded in _____

towards/red

On the spectral waveform, this systolic flow will appear _____ the baseline (______)

(color & spectral flow reversal of the hepatic veins)

above/ antegrade

The hepatic vein waveform can be reflective of the ______

severity of TR present.

The more severe the regurgitation, the more _______ the hepatic waveform becomes.

pulsatile

anything above baseline means flow reversal

How to prove severe TR

Tricuspid valve prolapse is an ______ echocardiographic finding that is most commonly associated with ______.

Infrequent/ Mitral Valve Prolapse

(TV FLAIL) TR caused by flail leaflets is most often_____, is caused by_______endocarditis or is a consequence of a ________.

Post traumatic/Endocarditis/myxomatously degenerated valve

The clinical presentation is________ with TV flail.

The clinical presentation is severe and is characterized by excess mortality and high morbidity.

Quantification of TR

Can you asses RVSP if a patient is on a Ventilator?

No because the ventilator is breathing for you.