DK2985_C000 1..28 - AlSharqia Echo Club

456 Transesophageal EchocardiographyTable 19.2 Echocardiographic and Doppler Parameters Used in the Evaluation of Tricuspid Regurgitation Severity: Utility, Advantages,and LimitationsParameter Utility/advantages LimitationsRV/RA/IVC sizeEnlargement sensitive forEnlargement seen in other conditionschronic significant TRNormal size virtually excludesMay be normal in acute significant TRsignificant chronic TRTV leaflet alterationsFlail valve specific for significant Other abnormalities do not imply TRsignificant TRParadoxical septal motion Simple sign of severe TR Not specific for TR(volume overload pattern)Jet area—color flow Simple, quick screen for TR Subject to technical and hemodynamic factors.Underestimates severity in eccentric jetsVena contracta widthSimple, quantitative, separatesIntermediate values require further confirmationmild from severe TRPISA method Quantitative Validated in only a few studiesFlow quantitation—PWD Quantitative Not validated for determining TR regurgitant fractionJet profile—CWD Simple, readily available Qualitative, complementary dataPeak tricuspid E velocity Simple, usually increased insevere TRDepends on RA pressure and RV relaxation, TV area,and atrial fibrillation; Complementary data onlyHepatic vein flow Simple Influenced by RA pressure, atrial fibrillationSystolic flow reversal is sensitivefor severe TRNote: CWD, continuous-wave Doppler; EROA, effective regurgitant orifice area; IVC, inferior vena cava; PISA, proximal isovelocity surface area;PWD, pulsed-wave Doppler; RA, right atrium; RV, right ventricle; TV, tricuspid valve; TR, tricuspid regurgitation. [With permission of Zoghbi WA (20).]include leaflet destruction or perforation, abnormalcoaptation from chordal or papillary muscle rupture (9). Avegetation size .10 mm is associated with an increasedlikelihood of pulmonary emboli (24).Infection of indwelling central venous cathetersand permanent pacemakers also occasionally leads toright-sided endocarditis, which occurs in the face ofvalvular microtrauma caused by catheters, followedTable 19.3Echocardiographic and Doppler Parameters Used in Grading Tricuspid Regurgitation SeverityParameter Mild Moderate SevereTricuspid valve Usually normal Normal or abnormal Abnormal/flail leaflet/poorcoaptationRV/RA/IVC size Normal a Normal or dilated Usually dilated bJet area—central jets (cm 2 ) c ,5 5–10 .10VC width (cm) d Not defined Not defined, but ,0.7 .0.7PISA radius (cm) e ,0.5 0.6–0.9 .0.9Jet density and contour—CW Soft and parabolic Dense, variable contour Dense, triangular with earlypeakingHepatic vein flow f Systolic dominance Systolic blunting Systolic reversala Unless there are other reasons for RA or RV dilation. Normal 2D measurements from the apical four-chamber view: RV mediolateral end-diastolicdimension ,4.3 cm, RV end-diastolic area ,35.5 cm 2 , maximal RA mediolateral and superoinferior dimensions ,4.6 and 4.9 cm respectively,maximal RA volume ,33 mL/m 2 (21).b Exception: acute TR.c At a Nyquist limit of 50–60 cm/sec. Not valid in eccentric jets. Jet area is not recommended as the sole parameter of TR severity due to its dependence onhemodynamic and technical factors.d At a Nyquist limit of 50–60 cm/sec.e Baseline shift with Nyquist limit of 28 cm/sec.f Other conditions may cause systolic blunting (e.g. atrial fibrillation, elevated RA pressure).Note: CWD, continuous-wave Doppler; IVC, inferior vena cava; RA, right atrium; RV, right ventricle; VC, vena contracta width. [With permission ofZoghbi WA (20).]