Andersons pediatric cardiology 1464

AV,Aorticvalve.

TricuspidValveDisease
TricuspidregurgitationinthesettingofRHDismostcommonlyfunctionaland
istheresultofadvancedleft-sidedpathologyandpulmonaryhypertension.
Organictricuspidvalvediseasethatresultsfromdirectrheumaticinflammation
islesscommon;italmostalwayscoexistswithmitraland/orAVinvolvement
andisconsideredtobeamarkerofseverityofRHD.LiketheMR,tricuspid
valveregurgitationmayalsoprogresstostenosiswithleafletthickening,chordal
shortening,andcommissuralfusion.

PulmonaryValveDisease
PulmonaryvalveinvolvementinRHDisexceptionalbuthasbeendescribed.

GradingofValvarSeverity
Significantlimitationsexistwithregardtogradingtheseverityofrheumatic
valvardysfunctionbyechocardiography.Thisrelatestothefactthatmultivalve
diseaseiscommonandoftenmanifestsasmixedvalvedisease—concomitant
stenosisandregurgitation.EveninthesettingofpureMR,evaluationcanbe
challenging,astheregurgitantjetistypicallyveryeccentricandwallhugging,
andmultiplejetsarecommon.ARoftenarisesasaresultofleafletprolapse,
resultingineccentricregurgitantjets.TheAmericanSocietyof
Echocardiographyrecommendationsforevaluatingtheseverityofnativeaortic
andmitralvalvarregurgitationwithtwo-dimensional(2D)andDoppler
echocardiographyaredetailedinChapters34and44.39Theseguidelines,
however,donotdetailhowtodifferentiatetrivialorphysiologicregurgitation
frommild/pathologicregurgitation,sincethesefindingsindegenerativeor
congenitalheartdiseasehavenoclinicalsignificance.However,inthesettingof
RHD,theprescriptionoflong-termsecondaryprophylaxisintheformofthreeto
fourweeklyintramuscularinjectionsofbenzathinepenicillinmaydependon
whethertheregurgitationistrivialormild.Forthisreason,the2012WorldHeart

Federationechocardiographicdiagnosticcriteriawereestablishedwithanaimto
clearlydefinehowtodifferentiatephysiologicfrommildpathologic
regurgitation(seeBox55.1).22


MonitorProgression/Resolution
Serialechocardiographyallowsforthemonitoringofdiseaseprogressionor
resolution.Inadditiontoassessingvalvarmorphologyandgradingtheseverity
ofvalvardysfunction,serialmeasurementsofleftatrialsize,LVsize,andLV
volumeusing2D(M-mode,area/length,andSimpsonbiplanemethods)ornewer
three-dimensional(3D)modalitiesallowforoptimizingmedicalmanagement
andthetimingofsurgery.Serialassessmentofventricularfunctionand
estimationofpulmonaryarterypressurearerequired.
Itisimportanttonotethatinthesettingofsignificantmitraland/orAR,
fractionalshorteningorejectionfractionarepoorsurrogatesforcardiac
contractilityduetothealteredloadingconditions;thereforetheymay
underestimatecardiacimpairment.Load-independentmeasures,suchasstress
velocityindex,maycorrelatemorecloselywiththestateofcardiaccontractility
inthesecircumstances.12

GuidetotheNatureofCardiosurgical
Intervention
Echocardiographicparametersguidethetimingofsurgeryinacuteandchronic
RHD.Two-dimensionaland3Dimagingcanaccuratelyidentifythemechanism
ofvalvardysfunction;evaluatethepatient'ssuitabilityforpercutaneous
intervention;andguidesurgicalmitral,aortic,andtricuspidvalverepair
strategies(Fig.55.10).


FIG.55.10 Three-dimensionalechocardiographicimageofrheumatic

heartdiseaseofthemitralvalve.