Sonopath Forum

Tricuspid Regurgitation

6 year old FN Basset with a new finding of a grade 3/6 right sided murmur on routine check up.
I think there is tricuspid regurgitation and right ventricular dilation, also mild mitral regurgitation.

6 year old FN Basset with a new finding of a grade 3/6 right sided murmur on routine check up.
I think there is tricuspid regurgitation and right ventricular dilation, also mild mitral regurgitation.
The mitral valves were thickened but the tricuspid valves did not look that abnormal to me.
How do I differentiate between tricuspid valve degeneration (or dysplasia if not obvious) and pulmonary hypertensin causing tricuspid regurgitation please?

Comments

August 10, 2017 at 2:16 pm -

The TV looks a bit vegetative

The TV looks a bit vegetative to me but the good thing about right heart disease is they can deal with it better than left sided disease. Check the abdominal cvc/ao ratio and hepatic veins if congested and need a TR jet to assess level of pht if present. If the TV looks good with solid apposition but the TR jet is in PHT range > 3 m/sec then this is secondary PHT but with valvular pathology it can be primary or secondary… at least thats how I learned it.

Peter

August 10, 2017 at 6:56 pm -

I completely agree with Eric.

I completely agree with Eric. The TV seems to be a bit degenerated. Yet, the right heart is far away from causing right heart failure. The TI gradient is sth around 50 mm Hg – so there is some mild PHT present.

The differentiation between secondary TI due to PHT and TV degeneration (degenerative valve disease) is only based on the morphology of the valve and the relation between the degree of TI and PHT. In your case the PHT is mild and would (given that the TI jet has been aligned correnctly) not cause moderate TI, if there was not an underlying valvular disease present…

Peter

veteurope1

August 10, 2017 at 9:35 pm -

Thank you both for clearing
Thank you both for clearing that up. Would you say the right ventricle is dilated? How does this occur without right atrial dilation? If PTH would you expect hypertrophy?

gadams

August 11, 2017 at 2:19 am -

Taking advantage of the topic

Taking advantage of the topic to get a ride! :)

– Any tricuspid regurgitation above 30mmHg can I classify as pulmonary hypertension?

- Regurgitation in tricuspid only by degeneration of the valve but with a pressure gradient above 30mmHg i can 
classify as pulmonary hypertension as well?

- If you have tricuspid regurgitation with high blood pressure in the right atrium, can you find a pulmonary valve/artery 
without regurgitation and with a pressure gradient within normality, as in my figures?

Those questions are pounding in my head this week!

Regards,
Adams.

randyhermandvm

August 11, 2017 at 4:22 am -

I have not attached this

I have not attached this paper I made to help me when I was going for my certification. I find it helpful.

Peter

August 11, 2017 at 7:38 pm -

Hi
its not always black or

its not always black or white of course. PA pressures can also rise when the animal is very excited.

Basically, in your images, the RA is dilated since it has the same size as the left atrium. Dogs with TV degeration can have PHT as well! Think of DMVD patients with tricuspid involvement and secondary PHT.

Not all dogs with PHT have significant pulmonic valve insufficiency.

Sometimes it is difficult to align the jet properly with the doppler beam which leads to underestimation of the pressure gradients.

Re hypertrophy: the more acute the disease the less concentric hypertrophy. Means dogs with acute PHT like thrombembolism usually have only dilated right hearts while dogs with chronic PHT (e.g. lung fibrosis) have much more concentric hypertrophy (thichened right ventricle)

Hope that helps

Regards

Peter

August 11, 2017 at 8:03 pm -

To sildenafil or not to

To sildenafil or not to sildenafil? That is the question:) This is by no means studied and will get cardiologists animated like during an acei discussion at acvim but I can only say what I do right or wrong it has worked for me for years in the “value perception” studies in New Jersey and elsewhere:

The way I work through it is: CF over the TV and if there is regurg then duplex the pw over the CF turbulent flow and if aliasing then CW duplex over the CF. Then measure the cleanest and highest jet. If > 3 m/sec but < 3.5 that is mild pHT but careful if systemic hypertension is present then this may be elevating the TR jet too… in fact I have found that tx for systemic HT may drop the TR jet so watch for this change. Then is the PHT clinically significant if present? Usually in my experience clinical signs may start when PHT TR velocity is > 3.5 m/sec but most are not clinical… i.e. ex intollerance usually…. but if approaching severe PHT > 4 m/sec Im going to sildenafil…. for the dog, not for me 🙂

Regardless with PHT and hepatic vein dilation or elevated CVC/AO ratio at the abdominal diaphragm I’m watching for clinical signs and emerging right chf (PHT is not Right CHF but one may lead to the other) assuming they are not sedated especially dex domitor which will dilate HV and CVC.

Now the right heart may not necessarily show the typical eccentric or then dilatative right sided in enlargement even with PHT and the TR jet may be lower than what you would think in light of HC/CVC dilation or even ascites and even wet right CHF so dont go by TR jet alone.

Hope this helps on TR jet 101 from a “spotty” but experienced mind:)

veteurope1

August 11, 2017 at 8:11 pm -

This post has cleared up a

This post has cleared up a lot for me thank you!

August 11, 2017 at 10:32 pm -

Glad to be of help

Glad to be of help

gadams

August 15, 2017 at 10:19 pm -

Thanks veteurope1 for the

Thanks veteurope1 for the post, randyhermandvm for the file, Peter and Eric for the answers!

I always learn a lot from all of you.

Regards,
Adams.