Echocardiographic assessment of tricuspid and pulmonary valves.pptx

Echo Assessment of Tricuspid valve and pulmonic valve

1. Echocardiographic assessment of tricuspid and pulmonary valves By- Dr Aman Kedia Under the guidance of – Dr SS Kothari sir , Dr Sibasis Sahoo sir , Dr Hasit Joshi sir , Dr Pratik Raval sir , Dr Spandan Sir.

2. Anatomy of Tricuspid valve The right atrioventricular valve complex is made up of 3 valve leaflets , annulus , supporting chordae tendineae , and the papillary muscle Tricuspid valve consists of anterior , septal and posterior leaflets . The anterior leaflet is the most anatomically constant echo feature , and septal and posterior leaflets being variable in size and position. The normal tricuspid valve thickness is < 3 mm , valve area is 4- 6 sq cm The location of tricuspid valve as the most rightward valve places it at or just beneath the sternal edge and requires the ultrasound beam to be angled sharply rightward while maintaining transducer contact with chest wall . Anatomically , it is the most complex of the four cardiac valves . The 3 tricuspid valve leaflets are attached around the tricuspid annulus , which has more variable geometry than does relatively circular mitral valve annulus . Anterior (or lateral ) leaflet typically being substantially larger than the septal and posterior leaflets . Septal leaflet is smaller than the other two and inserts in a more apical position compared with anterior leaflets of mitral valve . During diastole , the major cusps ( anterior and posterior ) move like sails and meet to join the smaller septal leaflet

3. Anatomy of tricuspid valve The tricuspid subvalvular apparatus consists of anterior , posterior and septal papillary muscles and their true chordae tendineae . False chordae can connect 2 papillary muscles , connect a papillary muscle to the ventricular wall or connect points on ventricular walls . The true chordae typically originates from the apical third of the papillary muscle but can originate from ventricular walls as in the case of septal leaflet . The anterior papillary muscle is the largest and the septal smallest Because of the variable size of each of the three tricuspid leaflets , it is difficult to ascertain the independent location , size , and motion of any tricuspid leaflet

4. Echocardiographic assessment of tricuspid valve The tricuspid valve can be visualized from multiple transthoracic and transoesophageal imaging planes . From the parasternal transducer position , the tricuspid valve is well visualized from the right ventricular inflow tract view , obtained by medial angulation of the transducer such that the ultrasound beam is directed beneath the sternum . In this view , the right atrium , right ventricle , coronary sinus and occasionally the ivc with an associated Eustachian valve are clearly viscualized . The posterior and anterior leaflets of the tricuspid valve can be clearly seen . In PSAX view at the base of the heart , tricuspid valve can be seen at 9 o clock position in relation to the aorta , septal and anterior leaflets are visualized

5. Tricuspid valve apical four chamber view From an apical four chamber view , the septal and anterior leaflets of the tricuspid valve are clearly visualized . Because the tricuspid valve is complex both in its anatomy and motion , M – mode echo plays little role in identification of tricuspid valve pathology . When employed , it can demonstrate a two phase opening pattern of the tricuspid valve , similar to mitral valve .

6. TEE of tricuspid valve Using tee , tricuspid valve can be imaged from multiple imaging planes . The incremental yield of tee over tte is often less for tricuspid valve . Valve can be visualized in the four chamber equivalent view from behind the left atrium , in which case its appearance is similar to that noted for a tte 4 chamber view. Also well visualized at the base of the heart in an 80 to 110 degree view . From a midoesophageal transducer position , a short axis view of the tricuspid valve can also be obtained . The deeper gastric view in a longitudinal plane often provide superb visualization of tv

7. TEE Views for TV ME 4C 0 – 90 degree RV inflow outflow Modified bicaval view Trans gastric

8. Doppler evaluation of the tricuspid valve Because the EOA of the tricuspid valve is greater than that of mitral valve , the inflow velocities are lower than for mitral valve at any given flow volume , as for the mitral valve , normal pattern consists of relatively higher early inflow (E) and a lower velocity flow concordant with atrial systole ( A) . In absence of significant pathology , tricuspid valve E/A typically exceeds 1

9. Tricuspid stenosis Infrequently encountered Causes include : rheumatic heart disease ( in which case mitral stenosis will invariably be present ), carcinoid , IE , Ra myxoma , congenital tricuspid atresia Severe TS : mean gradient > 5mmhg , pressure t1/2 > 190 ms , Valve area <= 1 cm2 TVA = 190/PHT Dilated RA , Dilated Ivc , tv doming

10. Tricuspid regurgitation Unlike TS , TR is common Etiology : functional (m/c) , primary disease of the tricuspid valve ( infective endocarditis , trauma , myxomatous , post ppi ) The severity of functional TR is related to the degree of apical tethering of the tricuspid leaflets , quantified as tethering area or height , which in addition to providing mechanistic insight , may predict success of tricuspid valve repair .

11. Endocardial Fibroelastosis Marked inflammatory response in the endocardium that extends to the chordae and subsequently interferes with normal valve coaptation . Leaflets will appear to be restricted and bound down towards the ventricular wall . Often seen in a/w obliteration of RV apex due to inflammatory tissue and secondary thrombosis .

12. Ebsteins anomaly Apical displacement of the septal leaflet(by > 8 mm/ m2 ) as well as tethering of the lateral leaflet to the ventricular wall ( apical 4 chamber view ) resulting in coaptation of the tricuspid leaflets in a position displaced toward the right ventricular apex and creates an atrialized portion of the right ventricle . Dilated RV with visualization of tv tissue in what would have anticipated to be the right ventricular outflow tract If actual leaflet coaptation cannot be identified , color Doppler demonstrating TR with an apically displaced convergence zone provides a clue

13. Anatomy of pulmonary valve 3 cusp structure Inserts into pulmonary annulus distal to rvot When viewed with 2d echo typically only one or two cusps are simultaneously visualized , specialized imaging may allow visualization of pv in its short axis , however the relatively thin , highly pliable leaflets are often not visualized in their entirety .

14. Echocardiographic assessment of pulmonic valve TTE : begins with PSAX view at the level of the aortic valve , where pulmonic valve anatomy cane be examined for thickening , doming or vegetation Although the apical and subcostal views can be useful in imaging the right ventricle as it relates to the pulmonic valve and arteries , it is often difficult to adequately image the pulmonary arterial system in these views

15. TEE of pulmonic valve PV can be imaged from several views . The views that maximize visualization of pulmonary valve includes imaging at the level of aorta in a 40 to 60 degree plane and in the horizontal ( o degree plane ) at relatively shallow depths (typically 25 to 30 cm from incisors) with counterclockwise rotation of the probe . In this view , the bifurcation of the pulmonary artery is typically seen and PV can be likewise visualized In deep gastric imaging plane , with clockwise rotation of the transducer , the entire sweep of the right ventricular inflow and outflow tracts can often be obtained and simultaneous visualization of the RA , TV , RVOT , PV , proximal pulmonary artery

16. M mode echo for Pulmonic valve From parasternal approach , motion of pulmonary valve can be recorded . Typically only one leaflet will be intersected by the M mode beam . There are several components to normal pulmonary valve motion . The first is pre systolic A wave motion away from the transducer , which is due to relative low amplitude excursion ( < 6 mm ) of the pulmonary valve with atrial systole , This phenomenon is dependant on mechanical atrial systole and is also dependant on relatively low pulmonary artery diastolic pressure so that atrial contraction creates driving force for partial opening of pulmonary valve

17. Doppler echocardiography Normal pulmonary outflow tract velocity ranges from 1 to 1.5 m /s Time velocity integral of this valve can be determined and in combination with outflow tract dimension can be used to calculate volumetric flow .Multiplying this value by HR provides CO in L /min Acceleration time : Time in ms from onset of ejection to peak systolic velocity , normally > 140 ms and progressively shortens with increasing degree of pulmonary hypertension , there is inverse relationship between AT and PA systolic , PA diastolic and mpap .An AT < 70 to 90 ms is indicative of PA systolic pressure > 70 mmhg , this assessment has been largely replaced by the more direct Doppler assessment of RVSP from TR signal . On occasion one encounters a patient without a measurable TR velocity and a short AT may be the only evidence of Phtn PA mean = 79 – 0.45*PA acceleration time

18. Pulmonary valve stenosis Virtually always congenital Thickening and systolic doming of the pulmonary valve cusps 2d echo : RVH , systolic valve doming , valve thickening , post stenotic dilation of the mpa Color Doppler : aliased flow CW Doppler : peak flow velocity across the valve is measured and converted to peak pressure gradient by Bernoulli equation Severe PS : Peak velocity > 4 m/s and mean gradient > 35 mm hg M mode : Exaggerated A wave during diastole

19. Pulmonary valve regurgitation Causes : Dilatation of PV annulus ( idiopathic , PAH ) , congenital absence of one or more pulmonary valve cusps , IE , carcinoid 2d echo : look for thickening , vegetation or prolapse , presence of vegetation Color Doppler : Examination of antegrade and retrograde flow in the short axis view across the pulmonic valve with visualization of both the RVOT and proximal pulmonary artery gives the most information about PR Vena contracta , Volume of RVOT occupied with regurgitation and percentage of time in diastole occupied with regurgitation ( severe will have a dense jet that rapidly decelerates so that flow ends around mid diastole while mild to moderate persists throughout diastole PHT< 100 , Jet length >10 mm….Severe PR By contrast velocity of flow is not proportional to severity of regurgitation Indirect markers such as RV dilatation and RV volume overload pattern

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