Presentation
Dyspnea
Patient Data
Severe tricuspid regurgitation with peak systolic velocity around 3.00 m/sec during systole.
Enlarged liver reaching 23 cm in Mid-clavicular span suggestive of passive hepatic congestion.
Dilated hepatic veins and IVC reaching 3.1 cm in AP diameter.
Mildly dilated portal vein measuring 13.8 mm in caliber.
A - atrial systole - retrograde wave
S - ventricular systole - antegrade wave
V- opening of tricuspid valve - retrograde wave
D - right ventricular diastolic filling - antegrade wave
The hepatic vein Doppler shows tetraphasic waveform with reduced systolic (S) velocity with a systolic/diastolic (S/D) velocity ratio <1 due to reduction in RV longitudinal motion. This suggests pulmonary hypertension with right ventricular systolic dysfunction.
Note the normal increase in forward flow during inspiration with persistent S/D ratio <1.
The diastolic (D) waveform is prominent despite the presence of pulmonary hypertension.
Case Discussion
Pulmonary hypertension is considered when inferior vena cava is over 2.1 cm at end-expiration with <50% collapse on inspiration (3.2 cm in this case). Also, the prominent pulmonary trunk and its main branches on CT.
Abnormal tricuspid regurgitant jet velocity (TRV) was defined as more than 2.80 m/sec by Doppler echocardiography. A value of 2.90–3.40 m/s indicates intermediate probability for pulmonary hypertension.
Echocardiographers should be familiar with the various hepatic vein Doppler findings in cases of tricuspid regurgitation so as not to miss the diagnosis of associated pulmonary hypertension 1.