Brief Tweetorial on Hepatic Vein Doppler in patients with Tricuspid Regurgitation. Two days ago I asked this question, most answered "B" which is what you would usually expect on severe TR (1/13)
Normal HV doppler has 3 (or 4) waves. 1) S wave: during systole, corresponds to x descent of RAP; 2) V wave: late systole (not always seen) 3) D wave: during diastole, (y descent of RAP) 4) A wave: during atrial contraction. S and D are antegrade. A and V are retrograde (2/13) 
Large TR causes a large V wave on RAP and thus the Hepatic Vein shows reversal of the systolic wave. **Antegrade flow (from liver to heart) is shown below the baseline while retrograde flow (heart to liver) is show above the baseline. Example from some of my patients: (3/13)
So back to the original Tweet: This patient has severe TR. The severity is suggested by just looking at the color jet, Pt also had formal echo that measured a vena contracta of 9 mm. Also look at the density of the CW doppler: Definitely severe TR (4/13)
So one should expect a reverse systolic wave on HV doppler, however.... surprise: This is the actual HV doppler from this patient: It looks fairly normal. (5/13)
Part of the explanation: This pt has Chronic Group 1 pulmonary hypertension and has had time to adapt via a large RA with high compliance (6/13)
This from the Comprehensive textbook of echocardiography chapter on HV doppler: (7/13)
However, I believe there is more to this story. Look at this patients JVP at 30°: (8/13)
Also look at this patient intra-renal venous doppler which shows a biphasic flow. (I also throw in a nice graph on how to interpret). So: How Come the kidneys and the jugular vein show severe congestion but not the liver??? (9/13)
The answer might lie in the patients chart: Besides having Group 1 PH, this patient also has advanced liver cirrhosis from Hepatitis C. Have a look at her liver with #POCUS (10/13)
Liver disease results in decreased HV compliance (11/13)
This also applies to portal vein. In this study, out of 37 patients with severe TR, 6 (16%) did not show portal vein pulsatility, most of them had liver biopsy and it showed severe fibrosis in every case! This case in previous post shows that: (12/13)
In conclusion: Despite this patients severe TR, I believe her large and compliant RA + advanced liver fibrosis helps explain why the Hepatic Vein doppler does not show systolic reversal. (13/13)
