1. Answer: E. In severe tricuspid regurgitation during sinus rhythm, hepatic vein Doppler typically shows a prominent, late peaking systolic flow reversal wave. However, systolic flow reversal may also occur in the setting of right ventricular dysfunction. Of note, blunting of the forward flow systolic wave rather than systolic flow reversal may occur in patients with severe TR and a large, compliant right atrium.

2. Answer: D. A PHT ≥230 ms can identify a stenotic bileaflet tricuspid mechanical valve. However, rounded spectral Doppler contours are not infrequent and PHT cannot be measured in these cases. In the absence of high output states (anemia, hyperthyroidism, sepsis) the elevated mean gradient ≥6 mm Hg and/or an elevated velocity >1.7 m/s are supportive diagnostic parameters of tricuspid prosthetic valve stenosis. No data on TVI_prosthesis/TVI_LVOT ratio are available in current guidelines.

3. Answer: B. Tricuspid E/A ratio >2.1 with a deceleration time <120 ms are consistent with right ventricular restrictive filling in patients with RV disease. Latediastolic antegrade flow in the pulmonary artery also suggests increased right ventricular diastolic pressure.

4. Answer: C. The normal diameter of IVC is ≤2.1 cm and decreases by at least 50% with inspiration during sniffing. Thus patients in choices A and E have the lowest RAP (0-5 mm Hg). When the IVC is dilated but collapses by at least 50%, RAP is estimated at 5-10 mm Hg. In the presence of a normal diameter but with less than 50% collapse (assuming good effort during sniffing), RAP is usually between 10 and 15 mm Hg. When the IVC is both dilated with less than 50% collapse, RAP is estimated at 15-20 mm Hg (Table 28-1).

5. Answer: A. In this cardiomyopathy, there are frequent abnormalities in RV regional and global function. The regional dysfunction is commonly noted in the RVOT, apex, and basal RV free wall in the region of the “triangle of dysplasia.” RV dilatation and depressed global systolic function also occur, though not in all patients early on. In one study, dilatation of the RVOT was noted in all patients with ARVD and may occur as an isolated finding. Other abnormalities include abnormally bright moderator band, RV sacculations (or diastolic outpouchings), aneurysm (systolic outpouchings), and trabecular derangements. LV EF is characteristically normal in most patients with ARVD although infrequently a left-sided cardiomyopathy may occur. Given the presence of RV systolic dysfunction, PA pressures are usually normal and not elevated. Therefore, a peak TR velocity of 3.6 m/s is not consistent with ARVD.

6. Answer: B. RV systolic and diastolic functions are depressed in patients with pulmonary hypertension. Because of the RV contribution to septal function, both septal systolic and diastolic mitral annulus tissue Doppler velocities are reduced. Likewise, tricuspid annulus velocities at the lateral side of the tricuspid annulus are reduced in these patients. On the other hand, LV function is preserved, and early-diastolic velocities at the lateral side of the mitral annulus are usually normal.

7. Answer: D. The flow in the hepatic veins is largely determined by RAP during the cardiac cycle (see Table 28-1). In normal subjects, antegrade flow from the hepatic veins to the RA occurs in systole (S) and diastole (D). With RA contraction, brief retrograde late-diastolic flow (Ar), as well as late systole flow (Vr), occurs into the hepatic veins. It is feasible to record high-quality signals by transthoracic imaging from the subcostal window in most ambulatory patients. Hepatic vein flow velocities can be used to asses RAP. In general, a lower proportion of forward systolic flow is indicative of increased RAP, except in healthy young subjects where this finding is normal. Similar to mitral inflow, young subjects have an E/A ratio that is >1 with a short deceleration time (DT), and reduced RA contribution to RV filling.

8. Answer: D. There are limitations to using hepatic venous flow to predict RAP. These include the presence of tricuspid valve stenosis or regurgitation, pericardial compression syndromes, high-grade AV block, and heart transplants. The presence of a restrictive cardiomyopathy is not a limitation. Option A is consistent with tricuspid stenosis/regurgitation. Option B is consistent with a postoperative pericardial compression syndrome. The patient in option C has high-grade heart block, and option E is a heart transplant. The presentation in D is consistent with amyloid where the patient has cardiac disease and peripheral neuropathy.

9. Answer: E. With advanced RV disease in patients with cardiac amyloidosis, RV free wall thickness is >7 mm, and tricuspid inflow shows a restrictive filling pattern. Hepatic venous flow at this stage is characterized by reduced forward systolic flow, increased forward diastolic flow, and inspiratory diastolic atrial flow reversal.

10. Answer: C. PA systolic pressure is given by 4(V_TR)² + RAP. A jugular venous pressure of 15-cm water corresponds to 15 × 0.7 or 10-11 mm Hg, since 1-cm water corresponds to 0.7 mm Hg. Accordingly, PA systolic pressure is given by 4(3)² + 10, or 46 mm Hg.

11. Answer: A. Pulmonary vascular resistance (PVR) is derived invasively as: (mean PA pressure – wedge pressure)/cardiac output. It can be estimated noninvasively by using the ratio between peak velocity of TR jet (as a surrogate of PA pressure), and time velocity integral of RVOT systolic flow (as a surrogate of cardiac output). Options A and C have the highest peak velocity, while option A has the least time velocity integral of RVOT systolic flow.

12. Answer: C. Mean PA pressure is given by PA diastolic pressure + 1/3 pulse pressure or (PA systolic pressure + 2 × PA diastolic pressure)/3. This patient has a PA systolic pressure of 4(3)² + 10 or 46 mm Hg. PA diastolic pressure = 4(2)² + 10 or 26 mm Hg. Pulse pressure is given by 46 – 26 or 20 mm Hg. Accordingly, mean PA pressure = 26 + (20/3), or 33 mm Hg. Mean PA pressure can also be estimated using the regression equation: 80 – 0.5 (acceleration time) of the RVOT pulsed Doppler velocity.

13. Answer: C. RV systolic pressure is given by 4(V_TR)² + RAP, where V_TR is the peak velocity of the TR jet. Therefore, RV systolic pressure = 64 + 10, or 74 mm Hg. The gradient between RV systolic pressure and PA systolic pressure is given by RV systolic pressure – PV systolic pressure = 4(V_PV)², where V_PV is the peak velocity across the pulmonary valve. Therefore, PA systolic pressure = 74 – 36, or 38 mm Hg.

14. Answer: C. Mean PA pressure can be estimated using the regression equation: 80 – 0.5 (acceleration time). Therefore, the patient in option A is predicted to have a mean PA pressure of 20 mm Hg, which is normal. Mean PA pressure can also be estimated using the peak velocity of PR to which an estimate of right ventricular end-diastolic pressure (RVEDP), or RAP, is added. Therefore, the mean PA pressure in option B can be predicted to be: 4(1.5)² + 5 or 14 mm Hg, which is normal. In option C, the peak systolic pressure is at least: 4(3.5)², or 49 mm Hg, which is consistent with pulmonary hypertension. With increased RV systolic pressure, a D-shaped septum is present in both systole and diastole, and not only during diastole.

15. Answer: C. The hepatic venous flow shows holosystolic reversal compatible with severe TR, as in the setting of infective endocarditis of the tricuspid valve. A patient with controlled blood pressure has normal RA pressure and predominant forward systolic flow, not systolic reversal. In the setting of RV infarction and acute inferior wall MI, RV filling pressures are increased and there is predominant forward diastolic flow in the hepatic veins. Systolic flow is reduced, but not reversed in atrial fibrillation.

16. Answer: D. The hepatic venous flow shows a large Ar signal compatible with normal RA systolic function in the presence of increased RVEDP. In early stages of RV diastolic dysfunction, RVEDP is increased, whereas mean RAP is normal. This hemodynamic finding is compatible with option D. Systemic congestion occurs with increased RA mean pressure and predominant forward diastolic flow in all other choices.

17. Answer: A. The patient has a wide regurgitant jet of pulmonic regurgitation (PR) by color Doppler and normal right ventricular systolic function with normal cardiac output. Spectral Doppler with a short deceleration time of PR may also occur due to an abnormally elevated right ventricular end-diastolic pressure. A wide color Doppler jet can differentiate severe pulmonic regurgitation from a nonsignificant regurgitant lesion. Normal RV systolic function with normal cardiac output in the presence of a short PR deceleration time supports the diagnosis of severe PR as opposed to a noncompliant RV. A noncompliant RV typically occurs in patients with an enlarged RV with reduced systolic function.

18. Answer: E. TAPSE assumes that the tricuspid annulus displacement represents RV global systolic function. In reality, TAPSE reflects best longitudinal as opposed to global RV systolic function. The lower range for normal TAPSE is 16 mm.

19. Answer: B. The 4-chamber view demonstrates the presence of prominent thickening and retraction of septal and anterior tricuspid leaflets with annular dilatation, characteristic findings of carcinoid heart disease. Ebstein anomaly is characterized by apical displacement of the septal leaflet and an elongated anterior leaflet in that view. Rheumatic tricuspid valve disease is usually accompanied by mitral valve rheumatic disease in patients with a history of rheumatic fever. The pathologic characteristic is commissural fusion of the leaflets with diffuse thickening and resultant stenosis and regurgitation.

20. Answer: B. The PR signal is steep indicating rapid equilibration of pressure between the PA and the RV. When RV stiffness is increased, RV diastolic pressure rises rapidly leading to a PR signal that is similar to that seen in this case. This patient has increased RVEDP and RAP. Tricuspid inflow is characterized by predominant early filling with an E/A ratio >1, and a steep deceleration time of tricuspid E velocity. Hepatic venous flow shows predominant forward flow in diastole (not systolic reversal).