Right-Sided Valvular Disease

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4 Right-Sided Valvular Disease

Rebecca A. Schroeder, Jonathan B. Mark, Atilio Barbeito

Background

Tricuspid Valve Structure and Function

• The tricuspid valve (TV) is the largest cardiac valve (normal area 7-9 cm2).
• It has a large anterior and smaller septal (medial) and posterior leaflets.
• There is great variability in leaflet and commissural morphology, chordal, and papillary muscle support.
• The anterior papillary muscle is the largest and arises from the moderator band in the right ventricle (RV).
• The tricuspid annulus is apically displaced relative to the mitral valve. It is supported medially by the right fibrous trigone and is thinner posteriorly and laterally.
• Tricuspid annular plane systolic excursion (TAPSE) toward the RV apex is reflective of right ventricular (RV) systolic function (normal 23 mm, range 15-31 mm).
• The tricuspid annulus shows horizontal, sphincter-like systolic motion during RV systole, reducing its area approximately 33%. Tricuspid annulus fractional shortening (TAFS) is indicative of RV systolic function.

Pulmonic Valve Structure and Function

• The pulmonic valve (PV) is similar to the aortic valve in its semilunar structure and area (normal area 2-4 cm2), with lunula, nodulus of Arantii, and associated sinuses of Valsalva and sinotubular junction.
• Typically, the PV has thinner leaflets, which are termed anterior, left posterior, and right posterior.
• The PV annulus is thinner, less clearly defined, and more distensible than the aortic valve annulus, and it is attached to RV muscle.

Overview of Echocardiographic Approach

• Right-sided valvular assessment uses a similar echocardiographic approach to that used for assessment of the mitral and aortic valves.
• The echocardiographic modalities include

• Two-dimensional (2D) imaging.
• Color flow (CF) Doppler mapping.
• Spectral Doppler imaging, including pulsed wave (PW) Doppler and continuous wave (CW) Doppler.
• Three-dimensional (3D) imaging.

• The most efficient examination strategy begins with 2D imaging (structure), followed by CF Doppler mapping (flow, function), followed by PW or CW Doppler (quantitation).
• 3D data sets (including color flow) are easily acquired in real time, but best manipulated after examination or off-line.

• 3D zoom mode is preferable for assessment of TV and PV leaflets.
• 3D full-volume mode is probably better for assessment of tricuspid regurgitation (TR) and TV supporting structures.

• Structures to examine include

• TV.
• PV.
• RV.
• Right atrium (RA).
• Interatrial septum (IAS) and interventricular septum (IVS)
• Superior (SVC) and inferior (IVC) venae cavae.
• Hepatic veins (HVs).
• Pulmonary artery (PA).

• Compared with left-sided valvular assessment, imaging may be more difficult owing to more anterior (far-field) location of right-sided valves and acoustic shadowing from calcified or prosthetic aortic and mitral valves (Box 4-1).

Box 4-1 Standard Scan Planes for Tricuspid and Pulmonic Valves

• ME four-chamber view
• ME RV inflow-outflow view
• Modified ME bicaval view
• TG RV midpapillary short axis view
• TG RV inflow view
• TG RV outflow view
• Deep TG four-chamber view
• TG hepatic vein view
• ME aortic valve short axis view
• ME ascending aortic short axis view
• UE aortic arch short axis view

ME, midesophageal; RV, right ventricular; TG, transgastric; UE, upper esophageal.

Anatomic Imaging

Standard Scan Planes for Tricuspid and Pulmonic Valves

• Midesophageal (ME) four-chamber view allows assessment of TV and RA, RV, IAS, IVS, and adjacent left heart structures (Figure 4-1).

• The TV septal leaflet is seen medially, with either the anterior or the posterior leaflet seen laterally.
• Transesophageal echocardiography (TEE) probe insertion, which brings the coronary sinus into view, most likely displays the posterior TV leaflet.
• TEE probe withdrawal, which brings the RA appendage into view, most likely displays the anterior TV leaflet.
• Clockwise TEE probe rotation helps center the TV and right heart structures in the image display.
• The tricuspid annular dimension can be measured in this view (normal 28 mm, range 20-40 mm). TAFS and TAPSE can be measured to assess RV function.
• RA and RV size and function can be evaluated.
• CF Doppler allows assessment of a TR jet in the RA. However, the interrogation angle between the direction of the regurgitant jet and the ultrasound beam is often large, making this view suboptimal for spectral Doppler measurements.
• ME RV inflow-outflow view displays RA, TV, RV, PV, and PA, all “wrapping around” a centered aortic valve, seen in short axis (Figure 4-2).

• The TV anterior leaflet appears medially and the TV posterior leaflet appears laterally, but there is some variability to this typical pattern.
• The PV leaflets are seen between the RV and the proximal PA, generally in long axis, in the far right portion of the video display. The leaflets are often not distinctly seen.
• CF Doppler allows assessment of a TR jet in the RA or a pulmonic regurgitation (PR) jet in the RV.
• Spectral Doppler assessment of a TR jet is often better in this view, owing to a more parallel alignment with the ultrasound beam.
• Spectral Doppler assessment of a PR jet and PV flow may be performed in this view, but the interrogation angle is often too large for accurate measurement.
• Modified ME bicaval view displays the TV in addition to the RA, LA, IAS, SVC, and coronary sinus (Figure 4-3).

• This view is seen with slight counterclockwise probe rotation and a TEE probe angle greater than that needed for the bicaval view (typically 100-140 degrees).
• The SVC-RA junction is often seen, along with the origin of the coronary sinus in the RA.
• CF Doppler allows assessment of a TR jet in the RA.
• Spectral Doppler assessment of a TR jet and TV flow is often best in this view, owing to parallel alignment with the ultrasound beam.
• Transgastric (TG) RV Midpapillary short axis view is acquired with counterclockwise probe rotation beginning with a transgastric LV midpapillary short axis view. It often demonstrates the leaflets of the TV when the TEE probe is withdrawn or anteflexed slightly (Figure 4-4).

• In this view, the large, redundant anterior TV leaflet appears to the left of the screen with the much smaller septal and posterior leaflets appearing to the right and in the near field, respectively.
• TG RV inflow view displays the TV in long axis as well as portions of the RA and the RV (Figure 4-5).

• This view provides the best view of TV support structures.
• The RV is seen to the left side of the display and the RA to the right.
• This view is usually obtained with the probe turned slightly to the patient’s right (clockwise) and a probe angle of 90 to 110 degrees.
• The inferior free wall appears in the near field of the display and the anterior free wall is seen in the far field.
• Because TV flow is perpendicular to the ultrasound beam in this view, spectral Doppler measurements are generally impossible.
• TG RV outflow view displays the PV in long axis, with the TV, RV, RA, LA, and proximal PA in other orientations (Figure 4-6).

• This view is acquired by slight counterclockwise probe rotation and using a probe angle of 130 to 145 degrees.
• The right ventricular outflow tract (RVOT) and PV appear in the mid-far field, usually parallel to the ultrasound beam.
• Measurements of PV annular dimensions in this view correlate best with intraoperative surgical measurements.
• Deep TG four-chamber view displays the RV and the other three cardiac chambers, much like the ME four-chamber view (Figure 4-7).

• Beginning with a deep TG four-chamber view, clockwise probe rotation will often show the RV, RA, and TV in the center of the image display.
• Alignment of a TR jet with the ultrasound beam is variable in this view.
• Clear images and alignment of the RV and TV make this view useful for measurement of TAPSE.
• TG HV view can be acquired from a TG probe location and allows measurement of HV flow velocity with PW Doppler, which is useful for TR quantification (Figure 4-8).

• Often best imaged from the RV short axis views by turning the probe to the right (clockwise), identifying an HV, and adjusting the multiplane angle to optimally align the direction of flow with the ultrasound beam.
• PW Doppler analysis yields patterns analogous to pulmonary venous flow patterns.
• ME aortic valve short axis view displays long axis views of the PV and proximal PA.
• ME ascending aortic short axis view is acquired with slight TEE probe withdrawal (Figure 4-9).

• This view displays the proximal ascending aorta in short axis, the adjacent proximal PA, its bifurcation, and the right PA.
• Alignment is ideal for spectral Doppler analysis of proximal PA flow or PV flow, especially when the valve is seen clearly.
• This is a useful view for assessment of pulmonary emboli in the main PA and its proximal branches.
• Upper esophageal (UE) aortic arch short axis view allows visualization of the PV in long axis as well as a significant portion of the main PA (Figure 4-10).

• This view of the PV may be improved by turning the probe slightly to the left (counterclockwise) and retroflexing the tip.
• This view also offers excellent alignment between flow and the ultrasound beam for accurate spectral Doppler assessment of flow across the PV.
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Figure 4-1 ME four-chamber view with the probe turned slightly clockwise to center the TV and display the RA, RV, LA, and left ventricle (LV) during systole (A) and diastole (B).

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Figure 4-2 ME inflow-outflow view displays the aortic valve (AV) in the center of the image with the right-sided chambers wrapping around from left to right. Prox PA, proximal pulmonary artery.

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Figure 4-3 Modified bicaval view with the LA at the apex of the display, the RA near the center, and the TV appearing in the far left portion of the image. A, This view provides excellent alignment of the ultrasound beam with the direction of a regurgitant jet through the TV. B, Slight counterclockwise rotation brings the coronary sinus (CS) into view. SVC, superior vena cava.

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Figure 4-4 TG short axis view of the TV shows the leaflets approximated in systole (A) and open in diastole (B). Note the dominance of the large, redundant anterior leaflet (AL) compared with the small posterior (PL) and septal (SL) leaflets.

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Figure 4-5 TG RV inflow view shows the RA and RV in long axis as well as the tricuspid leaflets in diastole (A) and systole (B). Given that flow across the TV is perpendicular to the ultrasound beam in this view, spectral Doppler measurements are not possible.

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Figure 4-6 TG RV outflow view shows the RV and the RVOT, the PV, and the main pulmonary artery (mPA). This view is an excellent choice for Doppler interrogation of flow through the PV owing to alignment of the ultrasound beam and the direction of blood flow.

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Figure 4-7 Deep TG four-chamber view shows the RA, LA, RV and LV. This view may be useful for Doppler analysis of a tricuspid regurgitant jet, especially in cases in which ME views are inadequate or poorly aligned.

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Figure 4-8 PW Doppler analysis of HV flow from the TG position with the probe turned slightly to the right (clockwise rotation). The antegrade S- and D-waves, as well as the retrograde A- and V-waves are labeled. The V-wave is not uniformly present.

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Figure 4-9 UE aortic short axis view demonstrates the main PA and its bifurcation into the right and left pulmonary arteries (R Pa). The PV leaflets are not uniformly seen as clearly as in this image.

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Figure 4-10 A, UE aortic arch short axis view shows the aortic arch (Ao Arch) in cross section and the RVOT, the PV, and the main PA in continuity. This image provides excellent positioning for CF (B) and spectral (C) Doppler analysis of RVOT or PV flow for estimation of pulmonary arterial mean or diastolic pressure, or assessment of severity of PS.

Tricuspid Valve

Step-by-Step Examination

Step 1: 2D Examination

• Standard 2D views for TV examination include the ME four-chamber view (see Figure 4-1), the ME inflow-outflow view (see Figure 4-2), the modified ME bicaval view (see Figure 4-3), and the TG RV inflow view (see Figure 4-5). TG windows are very helpful for examination of the TV leaflets in short axis, although these are not uniformly obtainable. Other supplementary views described previously may be helpful in difficult cases.
• Characteristics to examine include the general appearance of the TV annulus and leaflets, annular size (diameter), leaflet thickness and motion (restricted, excessive, coordinated, flail), leaflet coaptation, pathologic masses (e.g., vegetation or thrombus), and annular or leaflet calcification. In addition, RA, RV, and vena caval dimensions should be noted.
• Careful TEE 2D imaging is particularly important for the diagnosis of endocarditis. It is the most sensitive method to visualize vegetations, perivalvular abscesses, and leaflet perforations (Figure 4-11).
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Figure 4-11 CF Doppler image demonstrates leaflet perforations of the TV secondary to infective endocarditis.

Step 2: CF Doppler

• CF Doppler examination of the TV should be performed in the ME four-chamber view (Figure 4-12A), the ME inflow-outflow view (see Figure 4-12B), and the modified ME bicaval view (see Figure 4-12C). The TG RV inflow view is not as useful for Doppler analysis owing to the large angle between the direction of flow and the direction of the ultrasound beam.
• The nature of flow (turbulent vs. laminar) as well as the magnitude and direction of antegrade and retrograde flow should be noted. In addition, eccentric CF Doppler signals that may indicate leaflet perforations or septal defects should also be noted.
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Figure 4-12 CF Doppler images demonstrate severe TR in the ME four-chamber (A), ME inflow-outflow (B) and modified bicaval (C) views. It is important to examine the extent of regurgitant flow in as many views as possible in order to completely assess the regurgitant jet and select the best view for spectral Doppler measurements.

Step 3: Spectral PW Doppler and CW Doppler

• The choice of views in which to perform spectral Doppler analysis of the TV must be guided by which views yield adequate 2D and CF Doppler images of the valve. It is crucial that the direction of the flow be optimally aligned with the direction of the ultrasound beam.
• Estimation of peak RV pressure requires an adequate TR jet as well as alignment between the regurgitant jet and the interrogating beam. Inadequate alignment (>20-30 degrees) results in underestimation of peak velocity and errors in calculated pressure gradient.
• The modified ME bicaval view is often the best view in which to perform spectral Doppler analysis of a TR jet. Measurement of the pressure gradient across a stenotic TV may be best in the ME four-chamber view, the ME RV inflow-outflow view, or the modified ME bicaval view (Figure 4-13).
• Pitfall to avoid: The TV spectral Doppler trace may be contaminated by abnormal flow profiles across the aortic or mitral valves. CF Doppler mapping before spectral Doppler analysis should identify these other abnormal flow velocities.
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Figure 4-13 CW Doppler analysis of a TR jet in the modified bicaval view with calculation of peak right ventricular systolic pressure (RVSP) by the simplified Bernoulli equation. In this case, estimated RVSP is 60 mm Hg.

• HV flow velocity (see Figure 4-8)

• The HVs may be imaged from the TG TEE probe position. The probe angle is adjusted to identify a long axis view of a large HV and align the direction of flow with the direction of the ultrasound beam.
• Normal HV flow velocity consists of an antegrade systolic (S) and diastolic (D) wave and a small retrograde atrial (A) wave resulting from end-diastolic atrial contraction. In patients with slow heart rates, another small retrograde wave (V) may be seen at end-systole.
• Survey for associated (secondary) clinical findings

• The RV, RA, IVS, and IAS are important structures that may be affected by primary TV pathology or cause or exacerbate TR as a result of changes in normal chamber pressures and gradients.

• Alternative diagnostic techniques

• The proximal isovelocity surface area (PISA) technique may be used to quantify TR severity but is not commonly used in the perioperative setting. A TR jet PISA radius greater than 9 mm indicates severe TR.
• The pressure half-time (PHT) method may be used to quantify tricuspid stenosis (TS) severity (as with mitral stenosis), but it is not frequently performed with TEE or in the perioperative setting.
• 3D imaging may be used to obtain a more accurate assessment of the valve before possible repair or removal of a vegetation. However, 3D imaging of the TV is not as reliable as 3D imaging of the mitral valve.

Key Points

• Standard views for 2D TV imaging include ME four-chamber, inflow-outflow, modified bicaval views and TG RV inflow view.
• TG RV inflow view is not optimal for Doppler assessment owing to the poor alignment between the ultrasound beam and the direction of blood flow.
• Optimal views for spectral Doppler analysis are guided by the 2D and CF Doppler examination.
• Inadequate alignment between the ultrasound beam and the direction of flow (in excess of 20-30 degrees) yields falsely low velocity measurements.
• Contamination of the TV spectral Doppler traces may occur from eccentric flow through the aortic or mitral valves.

Tricuspid Regurgitation

• General Comments

• “Normal” TR velocity is 2 to 2.5 m/s and is present in 65% of the general population and 93% of patients older than 70 years of age.
• Pitfall to avoid: TR jet velocity is related to the pressure gradient between the RV and the RA and is NOT indicative of the severity of TR.
• With more severe degrees of TR and resultant increases in baseline RA pressure, peak jet velocity may decrease due to decreasing pressure gradient between the RV and the RA.
• The TR jet may be laminar (not turbulent) in cases of severe TR.
• In cases of severe TR, there will be increased total flow through the TV. This may result in increases in peak antegrade velocities in the absence of valvular obstruction (≥1.0 m/s).
• Other ancillary signs consistent with severe TR include

• A large CF Doppler TR jet area (>10 cm2) in the RA (Figure 4-14).
• A TR jet with a large vena contracta width (>7 mm).
• An HV flow velocity pattern showing S-wave reversal (Figure 4-15).
• A TR CW Doppler spectral trace showing a low-velocity, dense, triangular, early peaking jet, with a spectral trace density equal to that of the antegrade TV flow velocity (Figure 4-16). The triangular shape of the CW Doppler trace indicates the “V-wave cutoff” resulting from the elevated systolic RA pressure.
• Accompanying signs resulting from volume overload of the right heart chambers include enlargement of the RA, RV, and IVC. The IAS may show systolic displacement toward the left atrium (LA). The IVS will show diastolic flattening and abnormal systolic motion toward the RV.
• Pitfall to avoid: Catheters or wires that cross the TV do not generally cause significant regurgitation in the absence of preexisting valvular pathology.

• Specific diagnoses (Box 4-2)

• Endocarditis.

• Vegetations typically attach to the atrial side of the TV and are often larger than left-sided lesions.
• TEE has greater sensitivity than transthoracic echocardiography (TTE) for detection of vegetations and diagnosis of endocarditis.
• Large obstructing vegetations are more common on the TV than on other valves, with Staphylococcus aureus being one of the most common causative organisms.
• Intravenous drug abuse and presence of indwelling catheters and wires are significant risk factors for TV endocarditis (Figure 4-17).

• Ebstein’s anomaly.

• This congenital disorder involves apical displacement of the septal insertion of the TV leaflet (>8 mm/m2 body surface area) with associated RV dysfunction, severe TR, annular dilatation, and dilatation of an “atrialized” portion of the RV (Figure 4-18).
• The anterior TV leaflet is large, deformed, and described as “sail-shaped” or “curtain-like.”
• There may be an associated large atrial septal defect in many cases.
• Although most patients with this disorder present in childhood, some with milder forms may not present until much later in life.

• Carcinoid heart disease. Circulating vasoactive amines in patients with carcinoid tumors lead to fibrosis and neovascularization of valve surfaces, with the right-sided valves almost exclusively affected (Figure 4-19).

• Lesions occur on the ventricular side of the TV and affect up to 50% of patients with carcinoid tumors.
• Regurgitation is usually due to restricted leaflet closure, with short, thickened, and retracted valve leaflets that become immobile and often fixed in the open position.
• Surgical intervention for the valvular dysfunction is often indicated owing to the rapidly progressive nature of the valve involvement and the indolent nature of the primary tumors.
• Rheumatic heart disease.

• Characteristic 2D findings include leaflet doming, thickening, and restricted motion. TR is a more common manifestation than TS.
• Rheumatic involvement of the mitral and aortic valves is seen more often than TV disease and may result in secondary TR related to pulmonary hypertension.
• Associated commissural fusion, calcification, and thickening of the subvalvular apparatus are often best seen in TG long and short axis views.

• Functional TR.

• The most common cause of TR is annular dilatation secondary to pulmonary hypertension and RV dilatation from a variety of other primary processes.
• Leaflet morphology is typically normal, and suture or ring annuloplasty is the standard treatment for severe functional TR (Figure 4-20).

• Assessment of severity (Table 4-1).
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Figure 4-14 CF Doppler image, in which the area of the tricuspid regurgitant jet (TR jet) exceeds 10 cm2, meeting criteria for severe TR.

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Figure 4-15 PW Doppler analysis of HV flow shows reversal of the S-wave in a patient with severe TR.

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Figure 4-16 CW Doppler analysis of a tricuspid regurgitant jet shows a low peak velocity, and a dense, triangular, early peaking jet, all consistent with severe TR.

Box 4-2 Tricuspid Regurgitation

Etiology

• Annular dilatation (secondary to pulmonary hypertension, constrictive pericarditis, pulmonic stenosis, RV ischemia or infarction)
• Rheumatic heart disease
• Endocarditis (infectious or noninfectious)
• Carcinoid heart disease
• Tumor (primary papillary fibroelastoma, secondary to obstructing atrial myxoma or renal cell carcinoma)
• Endomyocardial fibrosis
• Trauma (blunt chest trauma, iatrogenic secondary catheters or wires)
• Congenital anomalies (Ebstein’s anomaly, tricuspid atresia)
• Tricuspid valve prolapse (associated with Ehlers-Danlos or Marfan’s syndromes, Ebstein’s anomaly, or septum secundum ASD)

ASD, atrial septal defect; RV, right ventricle.

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Figure 4-17 ME four-chamber view of the RA and RV shows a large vegetation arising from the leaflets of the TV.

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Figure 4-18 ME four-chamber view of the right-sided chambers in a patient with Ebstein’s anomaly. Note that the TV annulus is in a more apical position than the mitral, separating the RV from its “atrialized” portion.

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Figure 4-19 CF Doppler analysis of regurgitant flow through a deformed TV with leaflet fusion caused by carcinoid disease. Note that the regurgitant flow is laminar, indicating severe TR.

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Figure 4-20 Modified bicaval view of the TV after bioprosthetic valve replacement. Note that the leaflets appear to open completely during diastole (A) and that flow through the prosthetic valve is laminar (B).

TABLE 4-1 TRICUSPID REGURGITATION: GRADING SEVERITY

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Key Points

• The best views in which to perform spectral Doppler analysis of the TR jet are the modified ME bicaval view and the ME RV inflow-outflow view.
• The views that provide optimal alignment for spectral Doppler analysis of the PV are the TG RV outflow view, the UE aortic arch short axis view, and the ME ascending aortic short axis view.
• 3D zoom mode is preferable for valve leaflet examination whereas 3D full-volume is probably better for assessment of subvalvular structures and TR jet analysis.
• TR jet velocity is determined by the pressure gradient across the TV and compliance of the RA and RV. Laminar jets with low peak velocity may indicate severe TR of long standing.
• Increasing total flow across the valve in the setting of severe TR may result in increased antegrade peak velocity in the absence of valvular obstruction.
• Many pathologic processes that result in stenosis of the TV also result in significant TR.
• TEE has the greatest sensitivity and specificity for diagnosis of right-sided endocarditis, especially in the presence of indwelling lines or catheters (Figure 4-21).
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Figure 4-21 ME four-chamber view, the best single scan plane for assessment of TR.

Tricuspid Stenosis

• General Comments (Figure 4-22).

• Because the TV has the greatest cross-sectional area, flow velocities across the valve are lowest (<0.7 m/s).
• Significant TS is suggested when peak flow velocity exceeds 1.5 m/s.
• Many conditions that cause TS also result in significant TR (Box 4-3).
• Measurement of peak gradients with spectral Doppler is heavily dependent on loading conditions, the compliance of the RA and RV, and the correct alignment of the ultrasound beam with the direction of antegrade blood flow.
• TV leaflets affected by carcinoid disease are often fixed and retracted whereas those involved in rheumatic disease demonstrated characteristic commissural fusion and doming during diastole.
• Assessment of severity (Table 4-2).
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Figure 4-22 ME four-chamber view shows TV stenosis. Note the semiclosed position of the leaflet during diastole, as well as severe enlargement of the RA.

Box 4-3 Tricuspid Stenosis

Etiology

• Rheumatic heart disease
• Congenital anomalies
• Endocarditis
• Methysergide toxicity
• Carcinoid heart disease
• Endomyocardial fibrosis

TABLE 4-2 TRICUSPID STENOSIS: GRADING SCALES

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Pulmonic Valve

Step-by-Step Examination

Step 1: 2D Examination

• Characteristics to examine include the general appearance of the annulus and the leaflets, annular size (diameter), leaflet thickness, and motion (restricted, excessive, coordinated, flail).
• Standard 2D views for PV examination include the UE ascending aortic short axis (see Figure 4-9), UE aortic arch short axis view (Figure 4-23A), ME inflow-outflow (Figure 4-24A), and TG RV outflow views (see Figure 4-6).
• Initial evaluation of the valve should focus on the structure (hypoplasia, dysplasia, absence), leaflet motion (doming or prolapse), and the presence of masses. The diameter of the PA should also be noted.

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Figure 4-23 2D (A), CF Doppler (B), and CW Doppler (C) recordings of a pulmonic regurgitation jet imaged from the UE aortic arch short axis position. The spectral Doppler trace shows antegrade flow (above the baseline) and retrograde flow (below the baseline), the latter resulting from PR. Ao Arch, aortic arch.

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Figure 4-24 2D (A) and CF Doppler (B) images of the PV in the ME inflow-outflow view. The regurgitant jet is consistent with moderate PR.

Step 2: CF Doppler

• CF Doppler may be performed in any of the views mentioned previously (see Figures 4-23B and 4-24B).
• The CF Doppler jet characteristics, including length, width, duration, and turbulent or laminar pattern, should be assessed.

Step 3: Spectral PW Doppler and CW Doppler

• The UE aortic arch or TG RV outflow views usually provide the most favorable alignment of the ultrasound beam with the PV flow vector (see Figure 4-23C).
• Indicators of PR severity include the density of the CW Doppler signal, the flow deceleration rate, and flow duration in relation to the electrocardiogram (ECG).
• When pressure gradients are derived from CW Doppler velocity measurements, mean gradients (as opposed to peak gradients) correlate best with catheter-based measurements.
• Survey for associated (secondary) clinical findings

• Both the RV and the PA should be assessed. PV disease and dysfunction may be a consequence of or result in dilatation of proximate structures (PA and RV, respectively).

Pulmonic Regurgitation

• General comments

• Trace or mild PR is very common in healthy individuals.
• The most common cause of significant PR in the adult is primary or secondary pulmonary hypertension.
• Initial evaluation of the valve should focus on cusp number (quadricuspid or bicuspid valves), structure (hypoplasia, dysplasia, absence), and leaflet motion (restriction, doming or prolapse).
• There are no validated, quantitative TEE methods for grading PR severity. As such, a qualitative approach that takes into account a variety of parameters is suggested (Table 4-3).
• Other ancillary signs consistent with severe PR include

• Holodiastolic PA flow reversal.
• Laminar, low-velocity PR flow detected by PW Doppler.
• Premature opening of the PV (caused by atrial contraction at the end of diastole).
• Premature closure if the TV (caused by rapid filling of the RV and equilibration of right atrial [RA] and RV pressures).
• Low peak velocity of the PR jet by CW Doppler (<0.8 m/s).

TABLE 4-3 PULMONIC REGURGITATION: GRADING SEVERITY

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Key Points

• There is no validated grading schema for PR. Rather, a qualitative approach is recommended incorporating RV size, PV appearance, jet characteristics, vena contracta width, and spectral Doppler parameters.
• Although trace or mild PR is extremely common in older adults, pulmonary hypertension is the most likely cause of pathologic PR.
• Compression of the RVOT by extrinsic masses or dynamic obstruction in hypovolemic patients may mimic pulmonic stenosis (PS).

• Specific diagnoses

• Primary or secondary pulmonary hypertension generally causes PA and PV annular dilatation, most frequently resulting in mild or moderate degrees of PR with a structurally normal PV.
• Endocarditis. Isolated PV involvement is rare. Predisposing factors include a congenitally abnormal valve, the presence of intracardiac leads or catheters, and intravenous drug abuse (Figure 4-25).
• Rheumatic heart disease. Echocardiographic features of rheumatic valvular disease include leaflet doming, thickening, and restriction. PV involvement in rheumatic disease usually accompanies TV pathology.
• Carcinoid heart disease. Changes in carcinoid heart disease often result in PS with or without PR.
• Congenital abnormalities. Previous PV or RVOT repair, as in tetralogy of Fallot or isolated congenital PS, may result in residual PR.

• Assessment of severity (see Table 4-3).
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Figure 4-25 UE aortic short axis view demonstrates a long, filamentous vegetation in the main PA that arises from the PV. Ao, aorta.

Pulmonic Stenosis

• General comments

• Isolated PS is most commonly seen in neonates and infants and rarely presents in adulthood.
• It may be seen in carcinoid heart disease or recurrent bacterial endocarditis of the PV.
• 2D examination may reveal systolic doming of the valve, leaflet thickening, post-stenotic dilatation of the main PA and its branches, and signs of RV pressure overload (RV hypertrophy, paradoxical IVS motion in systole, varying degrees of TR).
• Subvalvular or supravalvular obstruction needs to be excluded. A variety of conditions, including extrinsic compression of the RVOT by postoperative hematoma, a pericardial cyst, or sarcoma, may mimic PS. Dynamic RVOT obstruction (analogous to dynamic left ventricular outflow tract obstruction) may be seen in hypovolemic postoperative patients treated with inotropic drugs.
• CF Doppler interrogation of the PV will demonstrate turbulent flow in the proximal PA when significant PS is present (Figure 4-26).
• CW Doppler is commonly used to determine the severity of the PS.

• Assessment of severity (Table 4-4).
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Figure 4-26 ME inflow-outflow CF Doppler image shows turbulent flow distal to the PV, consistent with PS. AV, aortic valve.

TABLE 4-4 PULMONIC STENOSIS: GRADING SEVERITY

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Suggested Readings

1 Attenhofer Jost CH, Connolly HM, Dearani JA, et al. Ebstein’s anomaly. Circulation. 2007;115:277-285.

Detailed anatomic descriptions (with nice illustrations) of the pathophysiology of this disease as well as the echocardiographic findings and management guidelines.

2 Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease). J Am Coll Cardiol. 2006;48:e1-e148.

3 Maslow AD, Schwartz C, Singh AK. Assessment of the tricuspid valve: A comparison of four transesophageal echocardiographic windows. J Cardiothorac Vasc Anesth. 2004;18:719-724.

4 Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease). J Am Coll Cardiol. 2006;48:598-675.

This practice guideline and the accompanying detailed executive summary provide up to date criteria for management, including many echocardiographic measures used to determine treatment.

5 Bruce CJ, Connolly HM. Right-sided valve disease deserves a little more RESPECT. Circulation. 2009;119:2726-2734.

Recent summary of tricuspid and pulmonic valve diseases along with current practice guidelines for management and indications for surgical intervention.

6 David TE. Functional tricuspid regurgitation: A perplexing problem. J Am Soc Echocardiogr. 2009;22:904-906.

Insights into the complexity of functional tricuspid regurgitation from the perspective of a renowned cardiac surgeon who specializes in valve repair.

7 Pellikka PA, Tajik AJ, Khandheria BK, et al. Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 patients. Circulation. 1993;87:1188-1196.

One of the most comprehensive reports of carcinoid heart disease, its many forms, and the echocardiographic findings.

8 Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003;16:777-802.

American Society of Echocardiography practice guideline for evaluation of valvular regurgitation, including all modes of echocardiography and criteria for assessing severity.

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