INTRODUCTION

The aim of this session is to explain the theory underlying the quantitative and semiquantitative methods used in TEE. Most quantitative methods use algebra, geometry and physics. The information obtained by TEE should always be interpreted on the basis of clinical profile of the patient.

WHY?

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Hemodynamic instability encompasses hypotension, low/high cardiac output, and abnormal filling pressures. Evaluation of hemodynamic instability include Hemodynamic parameters. Preload and fluid responsiveness. LV afterload. Ventricular function. Valvular function. LVOT obstruction Cardiac Tamponade.

BASIC CONCEPTS
Blood is a fluid capable of flowing form one place to another by a force. Pressure is force acting on an unit area. Pressure and flow are integrally related because fluid flows down a pressure gradient. Neither flow nor pressure can be measured directly from TEE, but velocity of blood can be estimated by Doppler echocardiography.

Dimensions of cardiac structures can be evaluated from 2D TEE. From the above information, volumes and flows can be derived.

JETS
As blood flowing down a pressure gradient approaches a narrow orifice, it speeds up. This produces a characteristic appearance proximal and distal to the orifice. Proximal to the orifice, depending on its size, the pressure gradient and PISA may be visible on color Doppler. The dimensions of PISA can be used to assess the size of valvular orifice.

The narrowest point of flow occurs just distal to the orifice and is called vena contracta. The width of VC can be used to grade the severity of regurgitant lesions. Distal to the VC, a jet is formed. Here the blood velocity decreases, but its volume increases in accordance with the principle of momentum.

The area of a jet, on color Doppler is usually assumed to be proportional to its volume. Therefore jet area may be an index of lesion severity. But it has to noted that jets are usually 3D and their cross section varies from plane to plane. Free jets are those that flow into the center of a large chamber (eg: LA)

Confined jets are limited by the boundaries of the chamber (eg: AS or eccentric MR) and are thus modified by the Coanda effect. Dual jet interaction tends to attenuate the size of jets if they are in the opposite direction and accentuate the size if in the same direction.

VELOCITY TO CALCULATE FLOW AND VALVE AREAS

Consider a rigid cylinder of radius r, through which blood flows. Assuming flow to be constant and laminar with a flat/blunt velocity profile. If the blood moves a distance s over time t, then velocity V will be

V=s/t

Flow Q, will be the product of velocity and the cylinders cross sectional area (CSA)

Q = V x CSA

Due to the difficulty in obtaining a CSA of cardiac structures, certain shapes have been attributed to particular structures.
STRUCTURE LVOT PISA MV ANNULUS AV ASSUMED SHAPE CIRCLE HEMISPHERE ELLIPSE/CIRCLE EQUILATERAL TRIANGLE FORMULA FOR AREA r2 2r2 r1r2 0.433 s2

The assumption that flow is laminar with a flat profile is reasonable in LVOT and across the normal cardiac valves. It may not be true for ascending aorta due to its curvature producing a parabolic flow, making it unfavorable for measuring SV. CSA changes as blood progresses through the heart and great vessels leading to a change in velocity to maintain constant flow.

Blood flow is pulsatile, which is represented by velocity-time curves on Doppler displays. Hence mean velocities have to used i.e velocities obtained over one pulse period have to be employed. s = V mean / t This distance is the area under the velocity time curve and is called Velocity Time Integral (VTI).

In the absence of valvular regurgitation, the total volume passing through a structure during systole or diastole is the stroke volume (SV ).

Q max = CSA x V max Q mean = CSA x V mean SV = Q mean x t = CSA x V mean x t SV = CSA x VTI

The dimensions of MV change throughout diastole and TR is found in 90% of individuals, so SV estimation is unreliable from MV and TV. In the absence of regurgitation, cardiac output (CO) CO = SV x Heart rate Cardiac index (CI) = CO / BSA. CO estimation by using PW across LVOT, CW across AV and PW across MV have shown correlation with PAC derived CO.

Eg : The diameter of LVOT from ME AV LAX is approx 2.4 cm. The VTI across LVOT measures20 cm from TG/Deep TG LAX views by PW Doppler and HR = 70 beats/min. CSA LVOT =r2 = 4.5 cm2

SV = 4.5 X 20 = 90 ml CO = 90 x 70 = 6300 ml/min

PRINCIPLE OF CONTINUITY OF FLOW

By principle of continuity, in the absence of shunts and under stable hemodynamics, net forward SV at any one part of circulation must equal forward SV at another point, provided blood is neither removed nor added to the system. This can be used to calculate orifice area of stenotic or regurgitant valves in three distinct settings.

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3.

Adjacent structures during the same phase of cardiac cycle ( AV and LVOT ) Non adjacent structures on the same side of the height during different phases of cardiac cycle ( MV in diastole and AV in systole) Structures on opposite side of the heart (PA and MV)

Adjacent structures during the same phase of cardiac cycle

Flow through a stenotic valve (AV) must equal the flow proximal to the valve (LVOT). This holds for maximum flow or SV and SV is a function of VTI. So in systole, CSA AV x VTI AV = CSA LVOT x VTI LVOT CSA AV = CSA LVOT x (VTI AV /VTI LVOT)

The ratio of the maximum velocity in LVOT and that of the AV is called Doppler Velocity Index. It has been used as an index of severity of AS. A ratio less than 0.25 suggests severe stenosis. This can be extrapolated to the PV and RVOT, but obtaining the views are cumbersome, and pulmonary stenosis is rare in adults.

Non adjacent structures on the same side of the height during different phases of cardiac cycle

At steady state, the same amount of blood must enter a given cardiac chamber as leaves it. Thus LV inflow in diastole must be equal to outflow in systole. Assuming no shunts or regurgitation

CSA MV x VTI MV (diastole) = CSA LVOT x VTI LVOT (systole)

This method can be employed to calculate the MV orifice area, but for assessing the AV area the former method is preferable. Multiple measurements have to be made to reduce errors in the measurement. If both the valves are incompetent, mitral inflow and AR in diastole must equal the MR and aortic outflow in systole rendering the equation meaningless.

But, if one valve is incompetent then an equation applies in which EROA can be employed to calculate the orifice area. This equation reflects that SV ejected from LV must now contain not just the blood entering LV through MV in diastole but also the blood entering through the AR or MR.

In MR,

CSA MV x VTI MV (diastole) = CSA LVOT x VTI LVOT + ERO MV x VTI MR (systole)
In AR,

CSA MV x VTI MV + ERO AV x VTI AR (diastole) = CSA LVOT x VTI LVOT(systole)

The regurgtitant volume (V reg) in isolated MR or AR is the difference between mitral inflow and aortic outflow V reg jet = SV reg valve SV normal valve This is typically used to assess MR/AR, but not TR/PR. The regurgtitant fraction (RF) can be calcuated by RF = V reg jet / SV reg valve

Structures on opposite side of the heart

The PA diameter and VTI can be used to estimate SV in the evaluation of MS and in LR shunts, the Qp/Qs can be calculated by measuring the SV across PA and LVOT separately. It is necessary to take an average of 5-10 measurements to allow for left to right respiratory variation in SV.

Qp / Qs = SV right heart / SV left heart.

Proximal Isovelocity Surface Area

As blood flow converges towards a narrow orifice, it accelerates. Imagine a series of hemispheres of radius r, centered on the orifice. The velocity at all points on the surface of any one of these hemispheres will be constant. Each of these surfaces is called PISA. PISA becomes evident with CFD at every point where the velocity exceeds Nyquist Limit.

When PISA assumes a contour of a hemisphere, then CSA PISA = 2r2 If the Nyquist limit produces a flat PISA, then the area will be over-estimated and if a tall PISA is produced, then area is underestimated. The morphology of the valve also alters the PISA. In MR the base of PISA will be flat due to closure of the valve during PISA formation.

In MS, the base will be cone shaped, as the valve is partially open. So in MS, an angle of correction () will be required where is the angle between the two leaflets. CSA PISA = 2r2 x /180

Valve area by PISA

The velocity at the outermost PISA associated with aliasing is the NL which is operator dependant. Flow through this PISA equals the surface area multiplied by NL. PISA and valve orifice are adjacent structures in the same phase of the cardiac cycle.

CSA valve x V max-valve = CSA PISA x NL CSA valve = (CSA PISA x NL) / Vmax-valve

This equation can be used for MS in diastole , MR or TR in systole, AR in diastole.

USING VELOCITY TO ESTIMATE PRESSURE GRADIENTS AND PRESSURES

Flow, when laminar is function of pressure gradient and resistance

P1-P2 = QR
If R=0, then P1=P2, which is true for widely open heart valves. So pressures in LV and aorta are the same during systole, and that in LA and LV in diastole, in the absence of stenosis.

Bernoulli equation
This is based on the principle of conservation of energy. For a given volume, the work done by pressure in moving an incompressible fluid from one point to another along a rigid pipe is related to gain in KE, the change in PE and the work done overcoming viscous resistance. If P1, V1 and P2, V2 are proximal and distal pressures and velocities respectively then,

P1- P2 = x 4 (V22-V12)

The density of blood is taken as 1, so for maximum velocities, the equation is reduced to

P1- P2 = 4 (V22-V12)

If the proximal velocity is small comparatively then we can simplify it to P1- P2 (P) = 4V2

This does not apply to normal valves (R=0) and to stenotic valves (friction loss is significant). In severe anemia, reduced blood viscosity results in over-estimation of pressure gradients, making this equation meaningless. It becomes unreliable in PHV and valvular stenosis where continuity equation is preferable to calculate the orifice area as CO affects the gradient across MS/AS.

Estimating pressure gradients across a stenotic valve

In AS, maximum and mean PG by TEE correlate well with catheterization data. If the velocity of LVOT is more than 1.5m/s then it should not be neglected during the calculation of PG. P max= 4 x V max 2 P max = 4 x (V max- AV - V max LVOT)2 P mean = 2.4 x V max 2 The same principle applies to MS, PS, TS.

Estimating unknown pressures from known pressures

RV and PASP from TR jet and RAP. 2. PAP using the PR jet and RVP. 3. RV and PASP from VSD jet and LVP. 4. LAP from MR jet and LVSP. 5. LAP from ASD jet and RAP. 6. LVEDP from AR jet and ADP.
1.

RV and PASP from TR jet and RAP

In systole, the gradient across TR can be used to calculate RVSP assuming RAP is known P RV-RA = 4 (V TR )2 P RVS = P RA + P RV-RA If PV is normal, then R=0 and PAP will be equal to RVSP. But if PS is present, then the equation is modified into, P PA-RV = 4 (V PV )2 P PAS = P RVS + P PA-RV

PAP using the PR jet and RVP

In diastole, RVP will equal RA if TV is normal. On CWD of PR jet, a shoulder can be identified late in diastole. For mPAP, the early peak diastolic velocity is used and for PADP, the late peak is used. P mPAP = P RA + P PA-RV early diastolic P PADP = P RA + P PA-RV late diastolic

RV and PASP from VSD jet and LVP

The Bernoulli equation can be used to calculate the PG across VSD and thereby estimate the RVSP and PASP from LVSP which is equal to ASP. However it may be difficult to sometimes align the Doppler beam to get a good signal.

LAP from MR jet and LVSP P LV-LA = 4 (V MR )2 P LA = P LVS + P LV-LA LAP from ASD jet and RAP P LA-RA = 4 (V ASD )2 P LA = P RA + P LA-RA LVEDP from AR jet and ADP P aorta-LV = 4 (V AR )2 LVEDP = P aorta diastolic P aorta-LV

Using pressure acceleration and deceleration to estimate systolic function and PAP and valve area
Pressure acceleration and systolic function If MR is present, the rate at which its flow increases during IVCT provides an estimate of LV systolic function. A reduction in this rate reflects reduction in function

dP/dt = 32 mm Hg/ t
where t is the time taken for the flow velocity to increase from 1 to 3 m/s. Normally values are more than 1200, values below 800 reflect severe LV dysfunction.

Pressure acceleration and PAP The pulmonary acceleration time is the time to peak velocity of systolic ejection in RVOT. This is an inverse function of mPAP. Values less than 80-100 msec indicate PAP >20mm Hg.

Pressure deceleration and pressure half time During diastole, the rate of decrease in PG between the LA and LV or between aorta and LV is a function of severity of lesion. The time from maximum to zero velocity on the velocity-time curve is called deceleration time (DT). In AR, as the lesion becomes more severe and EROA increases, DT decreases. The opposite occurs in MS.

However, deceleration of PG is preferable over DT as it is less dependant on flow. PG deceleration is quantified as time in ms for gradient to fall from P to P/2, called half time. As pressure is related to the square of velocity, the velocity associated with P/2 is obtained by multiplying P with 0.7 i.e (P x 2/2). The pressure half time is therefore defined as time between V max and 0.7 V max.

In MS, Pt1/2 indicates severity of lesion.

CSA MV = 220 / Pt1/2

Factors which affect the usefulness of Pt1/2 are increased CO, raised LVEDP, heart rate, diastolic dysfunction. In AR, the validation is less secure than MS. A value more than 220 ms in MS and 250 ms in AR indicate severe lesion. Raised SVR and reduced LV compliance affect Pt1/2 in AR.

CALCULATION SV of left heart AV for continuity equations SV of right heart

MEASUREMENT VTI (systole) CSA (early systole)

SITE LVOT/AV LVOT AV RVOT/PA

TEE VIEW TGLAX/Deep TG LAX ME AV LAX ME AV SAX ME AA SAX

VTI (systole) CSA (early systole)

MV for continuity equations

VTI (diastole) CSA (early diastole)

ME 4C ME 4C

Pressure gradients

VTR VMR VAR VPR

TV MV AV PV

ME inflow-outflow ME 4C TGLAX/Deep TG LAX TG RVIO/UE AA SAX

CONCLUSION
Multiple views recommended for all measurements. For a dimension the average has to be taken. 3-5 cardiac cycles needed (more in AF). Precise orientation of the Doppler beam with the desired structure is necessary.