Lai Echo - TV & RA

TV and RA Echocardiography (Lai13)

TRICUSPID VALVE ANOMALIES

-Tricuspid Stenosis- hypoplastic/thick valve leaflets w decr orifice

-Ebstein Anomaly- displacement of part of the origin of the vlv leaflets fr the AV jct into RV

-usually w malformed TV w TR, ventric dysfx

-?bc of underlying RV morph xx, so incomplete separation of the septal/posterior leaflets so they adhere to RV wall; the ant leaflet dvps separate fr the wall so isn't adherent, but becomes elongated, redundant, fenestrated --> the vlv is rotated R and ant in addition to displaced fwd

-Tricuspid Dysplasia- malformed leaflets

-again bc of undermining of the RV like Ebstein Anomaly; almost always affects septal leaflet, which forms late

-Double Orifice TV- 2 orifices; aka duplication of the TV

-bc of imperfect vlv formation by endocardial cushions; thus assoc w AVSD

-3 types: extra hole in a commisure, in a leaflet, or bc of a fibrous bridge dividing the orifice

-Double Outlet RA- if one orifice straddles the IVS

Anatomy

-septal, ant, post (inf/mural) positioned leaflets

-medial pap muscle supports the zone of apposition bn the septal and ant leaflets

-anterior pap muscle (larger) supports the zone of apposition bn the ant and inf leaflets

-inferior muscle (smaller) or multiple muscles support the zn of app bn inf and septal leaflets

-TV cords fr septal leaflet DO attach to ventric septum

Ebstein Valve:

DDx as Ebstein bc of:

-Septal & post leaflets displaced fwd

-+/- Restricted ant leaflet motion

-atrialized RV w true tricuspid annulus dilation

-+/- myocardial dysfx

-Nl TV is offset at the septal leaflet fr the ant MV leaflet, usually 0.8cm/m2 bn the vlv hinges

-so if >0.8cm/m2, then +Ebstein valve

-some might have only mild displacement, while others have thickened, dysplastic displaced septal/post leaflets w focal muscularization, and only a few chordal attachment; septal leaf might missing, or all 3 leaflets might be adherent to the ventric wall which can --> triscupid sac w/o an orifice

-Ant leaflet not displaced, but is malformed

-RV may become thinner or aneurysmal at diaph wall or RVOT; LV also abNl bc of L ward bowing of IVS

-Assoc xx- MV: cleft, parachute, double orifice

-TV annulus is incomplete fibrous ring, so muscle fr atrium to ventric --> incr risk for WPW...

Imaging

Goals:

[ ] see the TV

[ ] leaflet morph and movement

[ ] check for dysplastic thickened-rolled leaflets, short cords, adhered leaflets, underdvpd paps

[ ] chordae

[ ] pap muscles

[ ] size of the TV annulus

[ ] z-score

[ ] compare relative to MV annulus

[ ] r/o TV clefts

[ ] check for multiple orifices/sizes

[ ] Check for TS

[ ] thick, rolled TV leaflets that dome in diastole, further shortening cords w abNl attchmts

[ ] stenosing membrane within the funnel of the TV--> restricts leaflet opening

[ ] measure Vmax across TV

-Nl 0.8m/s; if >1.3m/s w/o a L to R shunt, then +TS

[ ] calculate max and mean diastolic transvalvar P gradient

[ ] Check for TR (Doppler)

[ ] TR grade of TR jet

[ ] systolic RV-RA P grad; IVC, SVC, CS flow profiles

[ ] dilated R hrt chambers and veins

[ ] Check for Ebstein's

[ ] displaced septal leaflet >0.8cm/m2

[ ] amt of septal/postal leaflet displacement & dysplasia

[ ] RV check

[ ] fractional area change, Tei index

[ ] aneurysmal dilation of RVOT, = if it's 2x Ao root size

[ ] RV thinning or dyskinesis

[ ] LV check

[ ] M mode for SF, diameters at syst/diast

[ ] Assoc lesions

[ ] DDx by r/o other things that cause TR-

-Ebstein, tricuspid dysplasia, ungaurded orifice, TV prolapse, TV annular dilation, 2y annular dilation fr phtn, CM, infarct; RV dysplasia, rh TV disease, carcinoid herat disease, CT dz, endocarditis, trauma

-espec c/s ruptured pap muscle fr ischemic necrosis in newborns

-AP4C- good to check displacement of TV septal leaflet twd apex. Often it's thick/dysplastic w impaired mvmt bc of short cords, or it is absent w just a cauliflower like remnant on the IVS

-PSLA thru RV inflow - see the ant and post (aka inf aka mural) leaflets; note the hingepoints of each leaflet

-PSSA- good to see TV ant leaflet to check its sail-like movement and bulging into RVOT

-SC4C (SA and LA) good to check TV ant and septal leaflets

-by turning transducer 30-45degrees clockwise fr a SC coronal view, you can see all 3 leaflets

-can see the ant leaflet attachments, and see any fenestrations

-TEE can show subvalvar apparatus well

-3D TEE can show post leaflet and degree of tethering