Thread by @ArgaizR

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)

https://twitter.com/ArgaizR/status/1200829902318186501?s=20

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)

https://twitter.com/ArgaizR/status/1200829885381586949?s=20

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)

https://twitter.com/ArgaizR/status/1179569341874003970?s=20

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)

Tagging some sonofile fiends:
@khaycock2 @ThinkingCC @siddharth_dugar @msiuba
@PittIMPOCUS @westernsono @iceman_ex @load_dependent @Thind888 @NephroP @curromir @cmbuendia @Wilkinsonjonny @ICUnephroSuarez @JCHCheung @RogerAlvarezDO