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Guidelines
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1) Left Ventricle:
a) Size: Dimensions or volumes, at end-systole and end-diastole
b) Wall thickness and/or mass: Ventricular septum and left ventricular posterior wall
thicknesses (at end-systole and end-diastole) and/or mass (at end-diastole)
c) Function: Assessment of systolic function and regional wall motion. Assessment
of diastolic function
2) Left Atrium:
• Size: Area or dimension
3) Aortic Root:
• Dimension
4) Right Ventricle:
a) Size: Dimensions
b) Function: Systolic and diastolic function
c) RV & pulmonary hemodynamics
5) Right Atrium:
a) Size: Dimensions, area
b) RA pressure
The following cardiac and vascular structures are generally be evaluated as
part of a
comprehensive adult transthoracic echocardiography report:
6) Valvular Stenosis:
a) Valvular Stenosis: Assessment of severity, including trans-valvular gradient and area.
b) Subvalvular Stenosis: Assessment of severity, Including subvalvular gradient.
7) Valvular Regurgitation: Assessment of severity with semi-quantitative descriptive
statements and/or quantitative measurements
8) Cardiac Shunts: Assessment of severity. Measurements of QP:QS (pulmonary-to
systemic flow ratio) and/or orifice area or diameter of the defect are often helpful.
9) Prosthetic Valves:
a) Transvalvular gradient and effective orifice area
b) Description of regurgitation, if present
Clarification
Input: Output:
- IVSd - Interventricular septal tickness at end- - LVEF %
diastole(green) - LVFS (Fractional Shortening )
- LVEDD - LV End-Diastolic dimension (yellow) - LV Mass
- PWd - PW thickness at End-Diastolic (red)
- LVESD – LV End-Systolic dimension (right image)
- LVMI - LV Mass Index
- RWT - Relative wall thickness
Left Ventricle (LV) ①
LV Dimensions, wall thickness, LV mass: M-Mode (sax or plax)
Output:
- LV EF - (Teichholz formula)
Input: - LV FS - (Fractional Shortening)
- IVSd (yellow) - LVVd - Diastolic Volume
- LVIDd – LV Internal diameter diastole (EDD) - LVVs - Systolic Volume
- LVPWd – LV Posterior wall diastole (green) - SV - Stroke Volume
- IVSs - Interventricular Septum systole (red) - SI - Stroke index
- LVIDs - LV Internal diameter systole (ESD) - Sept Thickening %
- LVPWs End-systolic diameter(blue) - PW Thickening %
- LV Mass
- LVMI - LV Mass Index
Left Ventricle (LV) ①
LV Mass: 2D Mode (A-L and Truncated ellipsoid method)
Input: Output:
A1 – Area1 Pericardial border LV Mass
A2 – Area 2 Endocardial border LVMI – LV Mass index
A-L : LV length
Left Ventricle (LV) ①
Output:
Input:
EDV – End-diastolic volume (mL)
LV EDD – LV End-diastolic dimension (A4C) ESV - End-systolic volume (mL)
LV ESD – LV End-systolic dimension (A4C) LVDVI – LV Diastolic volume index (mL/m²)
LV EDD – LV End-diastolic dimension (A2C) LVSVI – LV Systolic volume index (mL/m²)
LV ESD – LV End-systolic dimension (A2C) LVEF – LV Ejection fraction %
SV – Stroke Volume (mL)
SI - Stroke Index
Left Ventricle (LV) ②
LV Volumes & systolic function (A-L)
As an alternative method to calculate the
LV Vol when apical endocardial definition
precludes accurate tracing is the area-
length where the LV is assumed to be
Bullet-shaped. The mid-LV cross-sectional
area is computed by planimetry in the
parasternal short-axis view and the
length of the ventricle taken from the
midpoint of the annulus to the apex in
A4C view. This measurements are
repeated in end-diastole and end-systole.
The most widely used parameter for
indexing volumes is the Body Surface
Area (BSA) in square meters.
Output:
Input: EDV – End-diastolic volume (mL)
LV diastolic CSA – Cross sectional area ESV - End-systolic volume (mL)
LV diastolic length – A4C LVDVI – LV Diastolic volume index (mL/m²)
LVSVI – LV Systolic volume index (mL/m²)
LV systolic CSA LVEF – LV Ejection fraction %
LV systolic length – A4C SV – Stroke Volume (mL)
SI - Stroke Index
Left Ventricle (LV) ①
LV Systolic function: Stroke Volume (SV), Cardiac output (CO)
Formula:
SV = π x (LVOT / 2)² x VTI₁
Input:
LVOT – LV outflow tract diameter (mm)
LVOT VTI - Subvalvular Velocity Time integral (cm)
R-R interval (HR) (Red doted line)
Output:
SV - Stroke Volume
CO - Cardiac output
SI – Stroke Index
CI - Cardiac Index
Left Ventricle (LV) ①
LV Systolic function: MPI LV (Myocardial Performance Index)
Also known as the Tei index. It is an index
that incorporates both systolic and
diastolic time intervals in expressing
global systolic and diastolic ventricular
function. Systolic dysfunction prolongs
prejection (isovolumic contraction time,
IVCT) and a shortening of the ejection
time (ET). Both systolic and diastolic
dysfunction result in abnormality in
myocardial relaxation which prolongs the
relaxation period (isovolumic relaxation
time, IVRT).
Formula:
LV MPI= (IVCT + IVRT) / LVET = (MCOT – LVET) / LVET
Output:
Input:
LV MPI – LV Myocardial performance index
MCOT - Mitral valve closure to opening time (orange)
LVET - LV Ejection time (blue lines)
Left Ventricle (LV) ①
LV Systolic function: dP/dt (LV Contractility)
* A Clinician's Guide to Tissue Doppler Imaging Carolyn Y. Ho and Scott D. Solomon Circulation. 2006;113:e396-e398
Left Ventricle (LV)
LV Wall motion score
LV Diastolic function
- PW mitral inflow
IVRT (Isovolumic relaxation time)
- DTI (e′) (Tissue doppler)
- PV (Pulmonary vein) flow
- Mitral inflow propagation
- LA volume
- PCWP by E/e’ (mean Pulmonary
Capillary Wedge Pressure by E/e’) (Nagueh)
Left Ventricle (LV) ①
LV diastolic function: PW mitral inflow
The mitral inflow velocity profile is used to
initially characterize LV filling dynamics. The E
velocity (E) represents the early mitral inflow
velocity and is influenced by the relative
pressures between the LA and LV, which, in turn,
are dependent on multiple variables including LA
pressure, LV compliance, and the rate of LV
relaxation. The A velocity (A) represents the
atrial contractile component of mitral filling and
is primarily influenced by LV compliance and LA
contractility. The deceleration time (DT) of the E
velocity is the interval from peak E to a point of
intersection of the deceleration of flow with the
baseline and it correlates with time of pressure
equalization between the LA and LV.
Input:
- E-wave - Peak early filling velocity (Yellow) Output:
- A-wave - Late diastolic filling velocity (green) - E/A ratio
- DT - Deceleration time (Blue)
- IVRT – Isovolumic relaxation time (red)
- A duration – (orange)
Left Ventricle (LV) ①
LV diastolic function: IVRT (Isovolumic relaxation time)
Input: Output:
A1 – Max planimetry LA area - A4C LA Volume – Left atrial volume
A2 – Max planimetry LA area – A2C LAVI – LA volume index
L - Length
Left Ventricle (LV) ①
LV diastolic function: PCWP (Mean capilary wedge pressure) by E/e’
We can use the average e’ velocity obtained
from the septal and lateral sides of the mitral
annulus for prediction of LV filling pressures.
E/e’ ratio < 8 is usually associated with normal
LV filling pressures (PCWP < 15 mmHg) while a
ratio > 15 is associated with increased filling
pressures (PCWP > 15 mmHg). Between 8 ans
15 there is a gray zone with overlapping of
values for filling pressures.
Input: Output:
E: Mitral inflow E e’ (Average) - of the lateral and
velocity septal e’ values (m/s)
e’ (lateral) E/e’: ratio
e’ (septal) PCWP - Mean Pulmonary capillary
wedge pressure (mmHg)
Formulas:
e’ = (e’ lateral + e’ septal) / 2
Output:
Input: LA Diameter – (cm)
A1 – Max planimetry LA area - A4C LA diameter index – cm/m²
A2 – Max planimetry LA area – A2C LA Volume – Left atrial volume (mL)
L - Length LAVI – LA volume index (mL/m²)
Left Atrium (LA) ②
Quantification of the Left Atrial size: M-Mode
Segmental nomenclature of the right ventricular walls, along with their coronary supply.
Ao, Aorta; CS, coronary sinus; LA, left atrium; LAD, left anterior descending artery;
LV, left ventricle; PA, pulmonary artery; RA, right atrium; RCA, right coronary artery;
RV, right ventricle; RVOT, right ventricular outflow tract.
Right Ventricle (RV) ①
RV Size: RV linear dimension
Using 2D echocardiography, RV size can
be measured from a 4-chamber view
obtained from the apical window at
end-diastole. Although quantitative
validation is lacking, qualitatively, the
right ventricle should appear smaller
than the left ventricle and usually no
more than two thirds the size of the left
ventricle in the standard apical 4-
chamber view. If the right ventricle is
larger than the left ventricle in this view,
it is likely significantly enlarged.
RV dimension is best estimated at end-
diastole from a right ventricle–focused
Input: apical 4-chamber view.
RV Basal - RV Basal diameter (mm)
RV mid - RV Mid diameter (mm)
RV long - RV Longitudinal diameter (mm)
Right Ventricle (RV) ①
RV size: RVOT Dimensions
The RVOT is generally considered to include the subpulmonary infundibulum,
or conus, and the pulmonary valve. The RVOT is best viewed from the left parasternal
and subcostal windows. The size of the RVOT should be measured at end-diastole on
the QRS deflection.
Input:
RVOT proximal (mm)
RVOT Distal (mm)
Right Ventricle (RV) ①
RV size: RV Wall thickness
RV wall thickness is a useful measurement for RVH, usually the result of RVSP overload. RV free wall thickness
can be measured at end-diastole by M-mode or 2D echocardiography from the subcostal window, preferably at
the level of the tip of the anterior tricuspid leaflet or left parasternal windows. Excluding RV trabeculations and
papillary muscle from RV endocardial border is critical for accurately measuring the RV wall thickness.When
image quality permits, fundamental imaging should be used to avoid the increased structure thickness seen with
harmonic imaging.
Input: Output:
ET - Ejection Time IVCT (Isovolumic Contraction Time)
TCO - Tric. Closure-Opening Time) IVRT (Isovolumic Relaxation Time)
MPI RV
Right Ventricle (RV) ②
RV systolic function: RV dP/dt
Input: Output:
PR PHT (yellow) PA Reg PHT (ms)
PR Vmax – Pulmonary regurgitation PA peak diastolic gradient
max velocity (red) dPAP (end diastolic gradient)
PR end Vmax - Pulmonary mPAP (mean Pulmonary
regurgitation end max velocity Artery pressure)
(green)
Right Ventricle (RV) ①
RV hemodynamics: mPAP (mean Pulmonary artery pressure)
AT method
Once systolic and diastolic pressures
are known, mean pressure may be
estimated by the standard formula
mean PA pressure = 1/3(SPAP) +
2/3(PADP). Mean PA pressure may
also be estimated by using pulmonary
AT measured by pulsed Doppler of the
pulmonary artery in systole, whereby
mean PA pressure = 79 (0.45 AT).
Generally, the shorter the AT
(measured from the onset of the Q
wave on electrocardiography to the
Input: Output:
PA TVI - (Time velocity PA AT (acceleration time) onset of peak pulmonary flow
Integral) (yellow) mPAP velocity), the higher the PVR
mPAP (mean Pulmonary
Artery pressure) (Pulmonary Vascular Resistance) and
hence the PA pressure.
Right Atrium (RA) ①
Right atrium size
Input:
RA End-Systolic Area (cm ²)
RA Major Dimension (mm)
RA Minor Dimension (mm)
Right Atrium (RA) ①
Inferior Vena Cava: RA pressure
The subcostal view is most useful for imaging
the IVC, with the IVC viewed in its long axis.
The measurement of the IVC diameter should
be made at end-expiration and just proximal
to the junction of the hepatic veins that lie
approximately 0.5 to 3.0 cm proximal to the
ostium of the right atrium. To accurately
assess IVC collapse, the change in diameter of
the IVC with a sniff and also with quiet
respiration should be measured, ensuring that
the change in diameter does not reflect a
translation of the IVC into another plane.
The measurements are done at end-diastole.
IVC diameter ≤ 2.1 cm that collapses >50% with a sniff suggests a normal RA pressure of 3 mm Hg (range, 0-5 mmHg)
IVC diameter > 2.1 cm that collapses <50% with a sniff suggests a high RA pressure of 15 mm Hg (range, 10-20 mmHg)
In indeterminate cases in which the IVC diameter and collapse do not fit this paradigm, an intermediate value
of 8 mm Hg (range, 5-10 mm Hg) may be used
Valvular stenosis ①
Aortic stenosis: AS jet velocity
AS jet velocity (Antegrade Systolic Velocity) is
defined as the highest velocity signal obtained from
any window after a careful examination; lower values
from other views are not reported.The antegrade
systolic velocity across the narrowed aortic valve, or
aortic jet velocity, is measured using continuous-
wave (CW) Doppler (CWD) ultrasound. A dedicated
small dual-crystal CW transducer is recommended
both due to a higher signal-to-noise ratio and to allow
optimal transducer positioning and angulation,
particularly when suprasternal and right parasternal
windows are used. However, when stenosis is only
mild (velocity 3 m/s) and leaflet opening is well seen,
a combined imaging-Doppler transducer may be
adequate.
Input: Output:
AS jet velocity (m/s) Mean gradient (mmHg)
VTI – Velocity Time
integral
Valvular stenosis ①
Aortic stenosis: AVA (Continuity equation VTI)
Aortic valve area can be calculated by using
the principle of conservation of mass –
“What comes in must go out”.
AVA indexed to BSA should be considered
for the large and small extremes of body
surface area.
Left ventricular outflow tract diameter is
measured in the parasternal long-axis view
in mid-systole from the white–
black interface of the septal endocardium to
the anterior mitral leaflet, parallel to the
aortic valve plane and within 0.5–1.0 cm
of the valve orifice.
Input: Output:
LVOT diameter (mm) AVA (cm²) AVA = (CSALVOT x VTILVOT) / VTIAV
VTI1 (Subvalvular VTI) (cm) AVAI (Indexed to BSA)
VTI2 (Max VTI across the valve (cm²/m²)
(cm)
Valvular stenosis ②
Aortic stenosis: AVA (Continuity equation Vmax)
Input: Output:
LVOT diameter (mm) AVA (cm²)
V1 (Subvalvular Velocity) (m/s) AVAI (Indexed to BSA)
V2 (Max velocity across the valve) (cm²/m²)
(m/s)
Valvular stenosis ②
Aortic stenosis: Velocity ratio
Input: Output:
V1 (Subvalvular Velocity) (m/s) VR - Velocity Ratio
V2 (Max velocity across the valve)
(m/s)
Valvular stenosis ②
Aortic stenosis: Planimetry of anatomic valve area
Input: Output:
AV planimetry AVA (cm²)
Valvular stenosis ①
Mitral stenosis: MVA Planimetry
MV planimetry has been shown to have the best correlation with anatomical valve area as assessed on explanted valves.
For these reasons, planimetry is considered as the reference measurement of MVA. Planimetry measurement is obtained
by direct tracing of the mitral orifice, including opened commissures, if applicable, on a parasternal short-axis view. The
optimal timing of the cardiac cycle to measure planimetry is mid-diastole. This is best performed using the cineloop mode
on a frozen image.
A) Mitral stenosis. Both commissures are fused. Valve area is 1.17 cm2.
B) Unicommissural opening after balloon mitral commissurotomy. The postero-medial commissure is opened. Valve area
is 1.82 cm2.
C) Bicommissural opening after balloon mitral commissurotomy. Valve area is 2.13 cm2.
Valvular stenosis ①
Mitral stenosis: PHT (Pressure Half-time)
Input: Output:
2 × π × r2 : Proximal isovelocity hemispheric surface area at a radial VFR (Volume flow rate) (cc)
distance r from the orifice.
MVA (cm²)
Vr : Aliasing velocity at the radial distance r (cm/s)
Vmax : Peak mitral stenosis velocity by CW (m/s)
α : Angle between two mitral leaflets on the atrial side (degree0)
Valvular stenosis ①
Tricuspid stenosis: CWD hemodynamic evaluation
Tricuspid stenosis (TS) is currently the least common of
the valvular stenosis lesions given the low incidence of
rheumatic heart disease. As with all valve lesions, the
initial evaluation starts with an anatomical assessment
of the valve by 2D echocardiography using multiple
windows such as parasternal right ventricular inflow,
parasternal short axis, apical four-chamber and
subcostal four-chamber. The evaluation of stenosis
severity is primarily done using the hemodynamic
information provided by CWD. Because tricuspid inflow
velocities are affected by respiration, all measurements
taken must be averaged throughout the respiratory
cycle or recorded at end-expiratory apnea. In theory,
the continuity equation should provide a robust method
for determining the effective valve area as SV divided
by the tricuspid inflow VTI as recorded with CWD. In
the absence of significant TR, one can use the SV
obtained from either the left or right ventricular
outflow; a valve area of 1 cm2 is considered indicative
of severe TS.
Input: Output: However, as severity of TR increases, valve area is
TV Flow profile Peak diastolic velocity progressively underestimated by this method.
Mean gradient (mmHg)
PHT (pressure half-time)
mmHg
Valvular stenosis ①
Pulmonic stenosis: Pressure gradient
Pulmonary stenosis is almost always congenital in
origin. The normal pulmonary valve is trileaflet. The
congenitally stenotic valve may be trileaflet,
bicuspid, unicuspid, or dysplastic. Acquired stenosis
of the pulmonary valve is very uncommon.
Quantitative assessment of pulmonary stenosis
severity is based mainly on the transpulmonary
pressure gradient. The estimation of the systolic
pressure gradient is derived from the
transpulmonary velocity flow curve using
the simplified Bernoulli equation ΔP = 4 (V) ². This
estimation is reliable, as shown by the good
correlation with invasive measurement using
cardiac catheterization. Continuous-wave Doppler
is used to assess the severity when even mild
stenosis is present. It is important to line up the
Doppler sample volume parallel to the flow with the
aid of colour flow mapping where appropriate. In
Input: Output: adults, this is usually most readily performed from a
Peak velocity (m/s) Peak Gradient (mmHg) parasternal short-axis view.
Valvular regurgitation ①
Aortic regurgitation: Jet diameter/LVOT diameter ratio %
Imaging of the regurgitant jet is used in all
patients with AR because of its simplicity
and real time availability.The parasternal
views are preferred over apical views
because of better axial resolution. The
recommended measurements are those of
maximal proximal jet width obtained from
the long-axis views and its ratio to the LV
outflow tract diameter. Similarly, the cross-
sectional area of the jet from the
parasternal short-axis view and its ratio to
the LV outflow tract area can also be used.
The criteria to define severe AR are ratios
of ≥ 65% for jet width and ≥ 60% for jet
area.
Is possible to use the CSA instead width
Input: Output: for both Jet and LVOT.
Jet Width (red) Jet width/LVOT Width ratio (%)
LVOT Width (yellow)
Valvular regurgitation ①
Aortic regurgitation: VC (Vena contracta)
The Vena contracta is the narrowest portion of the
regurgitant jet downstream from the regurgitant
orifice. It is sligtly smaller than the anatomic
regurgitant orifice due to boundary effect. For AR,
imaging of the VC is obtained from the PLAX view.
To properly identify the VC the three components of
the regurgitant jet should be visualized (flow
convergence zone, vena contracta, jet turbulence).
A narrow colour sector scan coupled with the zoom
mode is recommended to improve measurement
accuracy. It provides thus an estimation of the size
of the EROA (Estimated regurgitant orifice area)
and is smaller that the regurgitant jet width in the
LVOT. Using a Nyquist limit of 50-60 cm/s, a vena
contracta width of < 3mm correlates with mild AR,
whereas a width > 6mm indicates severe AR.
When feasible the measurement of VC width is
recommended to quantify AR severity. Intermediate
VC values (3-6 mm) needs confirmation by a more
quantitative method.
Input:
AR VC width – Aortic regurgitation Vena Contracta width (cm)
Valvular regurgitation ①
Aortic regurgitation: PISA (Proximal Isovolumetric Surface Area)
The assessment of the flow convergence zone has
been less extensively performed in AR than in MR.
The colour flow velocity scale is shifted towards the
direction of the jet (downwards or upwards in the
left parasternal view depending on the jet
orientation and upwards in the apical view).
1- Color Doppler settings must be correctly
adjusted for the PISA method. The Nyquist-limit
should be placed around 50-60 cm/s.
2- Afterwards, base line should be shifted in the
direction of the regurgitation jet, until a well-defined
hemisphere appears.
3- To calculate VTI of regurgitation jet, CW-Doppler
profile area should be delineated.
4- By measuring PISA radius it is important to hit
correctly the limit ot the hemisphere. Small errors
can produce important variations.
Input: Output: When feasible, the PISA method is highly
PISA Radius AR EROA (Effective Regurgitant recommended to assess the severity of AR. It can
AR VTI Orifice Area) cm ² be used in both central and eccentric jets. The
AR R Vol (regurgitant volume) window recommended is PLAX view for flow
mL/beat convergence.
Valvular regurgitation ①
Aortic regurgitation: Jet deceleration rate (PHT)
Input:
AR PHT - Aortic reg Pressure half-time (ms)
Valvular regurgitation ②
Aortic regurgitation: Flow quantitation - PW
Quantitation of flow with pulsed Doppler for the
assessment of AR is based on comparison of
measurement of aortic stroke volume at the
LVOT with mitral or pulmonic stroke volume.
Total stroke volume (aortic stroke volume) can
also be derived from quantitative 2D
measurements of LV end-diastolic and end-
systolic volumes. EROA can be calculated from
the regurgitant stroke volume and the
regurgitant jet velocity time integral by CW
Doppler. As with the PISA method, a regurgitant
volume ≥60 ml and EROA ≥0.30 cm2 are
consistent with severe AR. The quantitative
Doppler method cannot be used if there is more
than mild mitral regurgitation, unless the
pulmonic site is used for systemic flow
calculation. In general, a RF > 50 % indicates
severe AR. Volumetric measurements with PW
are Time consuming, and requires multiple
Input: Output: measurements, so the source of errors are
LVOT PW profile (A5C) EROA higher.
LVOT diameter (PLAX) R Vol.
Mitral inflow profile PW (A4C) RF (Regurgitant Fraction ) %
Mitral annulus diameter (max
opening MV (A4C)
Valvular regurgitation ①
Aortic regurgitation: Aortic diastolic flow reversal PW
It is normal to observe a brief diastolic flow reversal
in the aorta. The flow reversal is best recorded in the
upper descending aorta at the aortic isthmus level
using a suprasternal view, or in the lower descending
aorta using a longitudinal subcostal view. With
increasing aortic regurgitation both the duration and
the velocity of the reversal increase. Therefore, a
holodiastolic reversal is usually a sign of at least
moderate aortic regurgitation. A prominent
holodiastolic reversal with a diastolic time integral
similar to the systolic time integral is a reliable
qualitative sign of severe AR. However, reduced
compliance of the aorta seen with advancing age
may also prolong the normal diastolic reversal in the
absence of significant AR. In general, an end-
diastolic flow velocity > 20 cm/s is indicative of
severe AR.
Input:
End-diastolic velocity (cm/s)
Valvular regurgitation ①
Mitral regurgitation: Vena Contracta (VC)
The vena contracta should be imaged in high-
resolution, zoom views for the largest obtainable
proximal jet size for measurements. The examiner
must search in multiple planes perpendicular to the
commissural line (such as the parasternal long-axis
view), whenever possible. The width of the neck or
narrowest portion of the jet is then measured. The
regurgitant orifice in MR may not be circular, and is
often elongated along the mitral coaptation line. The
two-chamber view, which is oriented parallel to the
line of leaflet coaptation, The width of the vena
contracta in long-axis views and its cross-sectional
area in short-axis views can be standardized from the
parasternal view.s A vena contracta 0.3 cm
usually denotes mild MR where as the cut-off for
severe MR has ranged between 0.6 to 0.8 cm.
Input:
MR VC width (cm)
Valvular regurgitation ①
Mitral regurgitation: PISA
Most of the experience with the PISA method for
quantitation of regurgitation is with MR. Qualitatively,
the presence of PISA on a routine examination (at
Nyquist limit of 50-60 cm/s) should alert to the
presence of significant MR. Several clinical studies
have validated PISA measurements of regurgitant
flow rate and EROA. This methodology is more
accurate for central regurgitant jets than eccentric
jets, and for a circular orifice than a noncircular
orifice. Flow convergence should be optimized from
the apical view, usually the fourchamber view, using
a zoom mode. For determination of EROA, it is
essential that the CW Doppler signal be well aligned
with the regurgitant jet. Poor alignment with an
eccentric jet will lead to an underestimation of
velocity and an overestimation of the EROA.
Generally, an EROA 0.4 cm2 is consistent with
severe MR, 0.20-0.39 cm² moderate, and 0.20 cm²
mild MR.
Input: Output:
PISA Radius MR EROA (Effective Regurgitant
MR VTI Orifice Area) cm²
MR R Vol (regurgitant volume)
mL/beat
Valvular regurgitation ①
Mitral regurgitation: Continuous wave doppler
Input: Output:
LVOT PW profile (A5C) MR EROA
LVOT diameter (PLAX) MR R Vol.
Mitral inflow profile PW (A4C) MR RF (Regurgitant Fraction ) %
Mitral annulus diameter (max
opening MV (A4C)
Valvular regurgitation ①
Tricuspid regurgitation: Vena contracta (VC)
Input:
TR VC width (cm)
Valvular regurgitation ①
Tricuspid regurgitation: Flow convergence (PISA)
Input: Output:
TR PISA Radius TR EROA (Effective Regurgitant
TR VTI Orifice Area) cm²
TR R Vol (regurgitant volume)
mL/beat
Valvular regurgitation ②
Tricuspid regurgitation: CW jet velocity
Recording of TR jet velocity provides a
useful method for noninvasive
measurement of RV or pulmonary artery
systolic pressure. It is important to note
that TR jet velocity, similar to velocity of
other regurgitant lesions, is not related to
the volume of regurgitant flow. In fact,
massive TR is often associated with a
low jet velocity ( 2m/s), as there is near
equalization of RV and right atrial
pressures, conversely, mild regurgitation
may have a very high jet velocity, when
pulmonary hypertension is present.
Similar to MR, the features of the TR jet
by CW Doppler that help in evaluating
severity of regurgitation, are the signal
Input: intensity and the contour of the
TR flow profile
velocity curve.
Valvular regurgitation ②
Tricuspid regurgitation: Anterograde velocity of tricuspid inflow
A small degree of tricuspid regurgitation
(TR) is present in about 70% of normal
individuals. Pathologic regurgitation is
often due to right ventricular (RV) and
tricuspid annular dilation secondary to
pulmonary hypertension or RV
dysfunction. Primary causes of TR
include endocarditis, carcinoid heart
disease, Ebstein’s anomaly, and
rheumatic disease.
Similar to MR, the severity of TR will
affect the early tricuspid diastolic filling (E
velocity). In the absence of tricuspid
stenosis, the peak E velocity increases in
proportion to the degree of TR. Tricuspid
Input: inflow Doppler tracings are obtained at
E wave velocity the tricuspid leaflet tips. A peak E velocity
≥1 m/s suggests severe TR
Valvular regurgitation ①
Pulmonary regurgitation: Jet width - CFM
Minor degrees of pulmonary regurgitation
(PR) have been reported in 40-78% of
patients with morphologically normal
pulmonary valves and no other evidence
of structural heart disease Pathologic
regurgitation is infrequent, and should be
diagnosed mainly in the presence of
significant structural abnormalities of the
right heart. Color Doppler flow mapping
is the most widely used method to
identify PR. A diastolic jet in the RV
outflow tract, beginning at the line of
leaflet coaptation and directed toward the
right ventricle is diagnostic of PR.
Although this measurement suffers from
a high inter-observer variability, a jet
Input: Output: width that occupies >65% of the RV
Color Jet width (white) Jet to RVOT width ratio (%) outflow tract width measured in the same
RVOT width (yellow) frame is in favour of severe PR.
Valvular regurgitation ①
Pulmonary regurgitation: Vena contracta (VC)
Although the vena contracta width is
probably a more accurate method than
the jet width to evaluate PR severity by
colour Doppler, it lacks validation studies.
As for other regurgitations, the same
limitations are applicable. The shape of
the vena contracta is complex in most
cases.
Input:
PR VC width (cm)
Valvular regurgitation ②
Pulmonary regurgitation: Jet density and deceleration rate
Input: Output:
PR PHT Deceleration rate (ms)
Cardiac shunts
Qp/Qs: Pulmonary-systemic flow ratio
Input: Output:
LVOT (mm) Qp/Qs
LVOT VTI (cm)
RVOT (mm)
RVOT VTI (cm)
Prosthetic valves
Prosthetic aortic valves: doppler investigation (formulas previously described)
* DVI = VLVO / VPrAV . DVI is the Ratio of respective VTIs, and can
be approximated as the ratio of the respective
peak velocities. (simplified continuity equation)
* DVI = VPrMV / VLVO DVI is the Ratio of respective VTIs, and can
be approximated as the ratio of the respective
peak velocities. (simplified continuity equation)