Tricuspid and Pulmonary Valve Disease
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1 Tricuspid and Pulmonary Valve Disease Lawrence Rudski MD FRCPC FACC FASE Professor of Medicine Director, Division of Cardiology Jewish General Hospital McGill University
2 Question 1 All of the following are compatible with severe Tricuspid Regurgitation except: A RV basal dimension measuring 50mm B Flow reversal in the hepatic veins after the P wave C PISA radius of 10 mm at an aliasing velocity of 30 cm/s D Non-parabolic TR CW Doppler signal with an early peak
3 Question 2 All of the following are true except: A) The simplified Bernoulli equation is not valid B) The septum is D-shaped in diastole C) The PAP may be overestimated due to the presence of laminar flow D) The RA pressure is likely > 15 mmhg
4 Question 3 Which of the following is least likely A) A diastolic rumble will be heard over the apex B) The IVC will be markedly dilated C) Mitral inflow pulsed Doppler will demonstrate E:A reversal D) The RV systolic pressure will be significantly elevated
5 Right Sided Failure Edema Gut congestion Atrial fibrillation Tricuspid Regurgitation DEATH associated with increased risk of death So What? Dyspnea!!! Little TR OK (useful for us, in fact) Lots of TR - BAD
6
7 TR predicts survival (n=5,223) EF 50% SPAP<40mmHg EF<50% SPAP 40mmHg Nath et al (VA, Palo Alto), JACC 2004
8 Complex Anatomy (literally) Leaflet(s) One continuous leaflet with indentations into Anterior, Septal, Posterior Annulus D-shaped, with flatter portion along the central fibrous body - contractile Chordae Papillary muscles usually 3 Underlying Right Ventricular Myocardium
9 View from Above Septal Anterior Posterior
10 Tricuspid Valve Anatomy - TTE
11 Tricuspid Valve Anatomy - TEE
12
13 Why is this important?
14
15 Leaky What Can Go Wrong? Stretched Infected, with long-term sequelae Perforated Skewered Ripped Narrowed Rheumatic Evil Humors
16 Etiologies of TR Functional TR PAH Vol. Overload e.g. ASD Cor Pulmonale Left heart Disease RV myocardial Disease RV dysplasia RV ischemia Post-transplant Primary TR Rheumatic Myxomatous Ebstein s Anomaly Endocarditis Carcinoid/Infiltrative Traumatic anterior structure-mva Iatrogenic Pacer/ICD wires RV biopsy No reason why Carpentier s Classification can t apply
17 Primary or Secondary? PA Pressure - As a general rule In setting of severe TR, PAPs > 55 mmhg is often associated with anatomically normal tricuspid valves, while PAPs < 55 mmhg usually associated with an abnormality of the tricuspid valve apparatus.
18 Tricuspid Valve Assessment Leaflets Thickening, doming, restriction Coaptation Flail Annulus diameter Mean gradient TR severity RA + RV dilatation, septal flattening RV systolic function PA pressure
19 Leaflets
20
21 Bicuspid TV Valve Courtesy of Dr. Roberto Lang
22 Pacemaker Lead Impingement Courtesy of Dr. Roberto Lang
23 Not TV Dinner, but TV Kebab R. Al-Bawardy et al: TR in patients with pacemakers and ICDs Clin. Cardiol. 36, 5, (2013) (a) Valve obstruction caused by lead placed in between leaflets. (b) Lead adherence due to fibrosis and scar formation to valve causing incomplete closure. (c) Lead entrapment in the tricuspid valve apparatus (d) Valve perforation or laceration. (e) Annular dilatation.
24 Annular Dimension 40 mm 70 mm Dreyfus G and al. Ann Thorac Surg 2005;79:127 32
25 Annulus Diameter 40 mm or 21 mm/m2
26 Quantitation?
27
28 Quantification of TR by Color Doppler Simplest and quickest way to evaluate TR severity but limitations and uncertainties Analogous to MR Assessment by color Doppler A large color jet represents more significant tricuspid regurgitation than a small jet Visualisation of the color jet depends on: Hemodynamic/Loading Conditions Hyper/Hypotension RA Pressure and pressure gradient between RV-RA RA size and capacitance Phase of respiration Cause of regurgitation Excentric Jet (Coanda effect)-use multiple views Vs. Central Jet Technical Limitations Sub-optimal views Gain settings
29
30 Quantitation Vena Contracta cm/s cm/s Severe : VC > 0.7 cm Nyquist cm/s
31 TR by PISA Set Nyquist Limit to aliasing velocity of 28 cm/s A Radius of > 9mm correlates with severe TR 6-9mm moderate TR < 5mm, usually with mild TR
32 EOA = 2 R 2 X V alias / V max Nyquist Radius cm/sec cm cm cm cm cm cm
33 Hepatic Vein Reversal
34 TR signal density and shape
35 Effect on RV (and vice versa)
36 Paradoxical Septum D-Diastole
37 RA Size
38 *
39 Tricuspid Stenosis Etiology Rheumatic Infiltration Carcinoid Compression Rare external (clot/tumor)/aorta
40 TS Gradients and TV Area VTI cm TVA cm 2 = 190/PHT
41 Calculation of TVA A1 = LVOT CSA or RVOT CSA V1 = LVOT V1 or RVOT V1 (PW) V2 = Vmax of Tricuspid Inflow by CW Doppler
42
43 Pulmonic Valve << Tricuspid Valve Stenosis Valvar, Sub-, Supra Congenital Infiltrative Iatrogenic post Ross e.g. Regurgitation PH Congenital Surgery Repaired Tetralogy Endocarditis Infiltrative
44 Normal PV
45 PS
46 Pulmonic Valve Disease- Carcinoid
47
48 PR Severity
49
50 Not many numbers RV enlargement with PR jet and not much else Very broad vena contracta Short PHT
51 Impact Same as for TR Assess RV size, RA size, RV function PAP Calculation Caveat Subtract the PS Gradient** SPAP = (TR gradient + RAP) PV PG = ( ) 32 = 26 mmhg
52 Summary More than eyeball of color jet Tricuspid Morphology, Degree of dysfunction, Impact on cardiac size and function Pulmonic Same as above Implications for Clinical therapy When to intervene in primary and secondary TR, PR When to intervene for TS and PS
53 CMR So 1990 s MRI Echo Echo, echocardiography; RAP, right atrial pressure; TR, tricuspid regurgitation. Watch RAP!
54 Images can be deceptive! Integrate detail with the BIG PICTURE
55 Question 1 All of the following are compatible with severe Tricuspid Regurgitation except: A RV basal dimension measuring 50mm B Flow reversal in the hepatic veins after the P wave C PISA radius of 10 mm at an aliasing velocity of 30 cm/s D Non-parabolic TR CW Doppler signal with an early peak
56 Answer - B The flow reversal representing severe TR is after the QRS i.e. in systole
57 Question 2 All of the following are true except: A) The simplified Bernoulli equation is not valid B) The septum is D-shaped in diastole C) The PAP may be overestimated due to the presence of laminar flow D) The RA pressure is likely > 15 mmhg
58 Answer - C Laminar flow is likely to underestimate severity of TR. The Simplified Bernoulli equation is predicated on turbulent flow
59 Question 3 Which of the following is least likely A) A diastolic rumble will be heard over the apex B) The IVC will be markedly dilated C) Mitral inflow pulsed Doppler will demonstrate E:A reversal D) The RV systolic pressure will be significantly elevated
60 Answer - C This patient has rheumatic TS, and therefore likely also has rheumatic mitral valve disease There is severe RA enlargement and therefore likely marked elevation of RA pressure The patient is in atrial fibrillation, so there will not be much of an A wave present
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