Spotting tricuspid and pulmonary valve disease

In this video from our Echocardiography Essentials course, you'll learn how to recognize hemodynamically significant tricuspid and pulmonary valve disease using transthoracic echo.

After completing this course, you’ll be able to perform a basic transthoracic echo (TTE) exam without the help of a more senior colleague. Using practical demonstrations, we'll teach you echo anatomy and show you how to operate the machine, obtain the standard TTE views, differentiate normal from abnormal, and confidently assess and report on anything you find!

[00:00:00] Most right-sided valve disease you're going to see is going to be tricuspid regurgitation. So, mild tricuspid regurgitation is normal but we can have tricuspid regurgitation because of an abnormality in the valve itself, so it's rheumatic or it's prolapsing or it's endocarditis. But we can also have tricuspid regurgitation because of an abnormality of the right ventricle or if there's pulmonary hypertension. And sometimes the pacing lead through the tricuspid valve can disrupt it such as it becomes regurgitant.

[00:00:30] So, this is severe tricuspid regurgitation. Look here, at the neck of this jet, up at the tricuspid valve. You can see how broad that is. So, there are some other things we can do to assess the severity of the tricuspid regurgitation. So, here, we've put a continuous wave Doppler through the TR jet and we're going to look at the characteristics of this jet, here. Now, we need to remember that the velocity of the jet isn't giving us any information about severity. It's just telling us about the gradient between the right ventricle and the

[00:01:00] right atrium. So instead, we're going to look at whether this wave form, here, is complete like it is here, we got a whole signal. And we're going to look how bright it is, here and compare it to forward flow. So, I think I've got a complete signal. I think it's pretty intense. I'm suspecting this is probably going to be severe TR. The shape of it is still quite U shaped. Sometimes when we get very severe TR, you get a triangular shape. This is still fairly U shaped but I think this is probably going to prove severe, but we'll keep looking.

[00:01:30] So, this is a subcostal image, where we're focusing on the IVC in the hepatic vein. So, here, you can see the IVC and this is the hepatic vein draining into the IVC. This is the right atrium, here. And when we look on color, we can see there's a really broad severe jet of tricuspid regurgitation and it's so severe that it's actually going backwards, up the hepatic vein. And we can see that because we're scanning from up here, so we know the flow towards our probe is going

[00:02:00] to be red. And we get this red flash, here, which we call reversal in the hepatic vein. So, we're going to use the information we've got to decide how severe our TR is. We had a very broad jet in the neck width, looked much more than 7 mm. Our signal was pretty dense. It wasn't triangular but I think the intensity was more than moderate and we had a quite obvious systolic reversal in the hepatic vein. So, I'm quite confident that I can call this TR severe. So now, let's think about tricuspid

[00:02:30] stenosis. It's very rare but not only is it rare, it's actually really difficult to spot as well. It's mostly going to be rheumatic but you don't get the thickening on the tricuspid valve that you see on the mitral valve. So, if you have rheumatic mitral stenosis, don't forget to check the tricuspid valve quite carefully. Occasionally, a pacing lead through the tricuspid valve can become enmeshed in it and cause the valve to become stenotic. So, suspect tricuspid stenosis, if your forward jet on color

[00:03:00] looks narrow and if the mean gradient is more than two when you trace around the forward signal. Pulmonary stenosis is usually congenital and we often see it with other congenital abnormalities. I think it's easiest to spot using color Doppler. So, here, we've got color with the pulmonary valve and you can just see the bifurcation, here and then the main pulmonary artery is, here. And what we've got is a lot of turbulent color in the main pulmonary artery. If we put a continuous wave Doppler through this, we get this signal, which is about 2.5 meters

[00:03:30] per second so it is raised but it's suggesting there's only mild pulmonary stenosis and I think if you look really carefully, it actually looks like the stenosis is above the valve. Most of the turbulent flow and flow acceleration is actually starting about, here, but this is only mild. If the peak velocity was four or more, we would consider it severe and if it's between three and four, we would report it as moderate. It's really important to remember that if you’ve got pulmonary stenosis at any level, whether it's at the valve or above it or before it. You can no longer use your tricuspid regurgitant jet

[00:04:00] to help you estimate pulmonary artery systolic pressures. So, this is pulmonary regurgitation and we've got a parasternal short-axis view and we've got a red jet backwards up the PA. So, we're scanning, up here, so any flow towards the transducer in red is our pulmonary regurgitant jet. I'm looking in the jet, here, in the main PA and I'm looking to see how much of it fills, so it's almost all of it actually. This is probably about 80% of the diameter of the PA,

[00:04:30] plus this regurgitant jet. They are quite easy to miss because the velocities are low. There isn't a turbulent flow that we will see within the regurgitant jet for another valve. So, this low red signal, here, can be quite easy to miss so we can do some other things to make sure we don't do that. And we can put a continuous wave Doppler through that signal and we can see, here, our forward flow through the valve and this is our PR. And if we measure the pressure half time of our regurgitant jet and it's over 100 milliseconds, it suggests our PR

[00:05:00] is severe. So, the right-sided valve disease isn't as common as left but don't forget to look for it because it's actually missed more often.