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Cardiac Measurements

Guidelines

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The following types of measurements are commonly included in a
comprehensive echocardiography report.

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:

1) Left Ventricle (LV)


2) Left Atrium (LA)
3) Right Atrium (RA)
4) Right Ventricle (RV)
5) Aortic Valve (AV)
6) Mitral Valve (MV)
7) Tricuspid Valve (TV)
8) Pulmonic Valve (PV)
9) Pericardium
10) Aorta (Ao)
11) Pulmonary Artery (PA)
12) Inferior Vena Cava (IVC) and Pulmonary Veins
The following types of measurements are commonly included in a
comprehensive 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

This icon identifies the level 1 measurements according to ASE’s


① standard guidelines

This icon identifies the level 2 measurements according to ASE


② standard Guidelines
Left Ventricle (LV) ①

LV Dimensions, wall thickness, LV mass: 2D Mode

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)

The most commonly used 2D methods for


measuring LV mass are based on the area-
length formula and the truncated ellipsoid
model, as described in detail in the 1989 ASE
document on LV quantitation. Both methods
rely on measurements of myocardial area at
the midpapillary muscle level. The epicardium
is traced to obtain the total area (A1) and the
endocardium is traced to obtain the cavity
area (A2). Myocardial area (Am) is
computed as the difference: Am = A1 - A2.

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

LV Volumes & systolic function: Simpson method


The most commonly used 2D measurement
for volume measurements is the biplane
method of disks (modified Simpson’s rule) and
is the currently recommended method of
choice by consensus of the proper ASE
committee. The total LV volume is calculated
from the summation of a stack of elliptical
disks. The height of each disk is calculated as a
fraction (usually 1/20) of the LV long axis
based on the longer of the two lengths from
the 2- and 4- chambers view. Papillary muscles
should be excluded from the cavity in the
tracing.

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)

CO (LV) is the volume of blood being pumped by the


left ventricle in the time interval of one minute.
In order to obtain CO we need to measure the LVOT
diameter in PLAX view zoomed image (left) in systole
and the Velocity Time Integral in Pulsed wave mode
of the LVOT in apical 5 chamber view (left down).

Formula:
SV = π x (LVOT / 2)² x VTI₁

CO= (SV x HR) / 1000

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)

Peak dP/dt is one of the most commonly used


indexes for assessing left ventricular function.
Continuous wave Doppler determination of the
velocities of a mitral insufficiency jet should
allow calculation of instantaneous pressure
gradients between the left ventricle and left
atrium. The rising segment of the mitral
insufficiency velocity curve should reflect left
ventricular pressure elevation. The LV
contractility dP/dt can be estimated by using
time interval between 1 and 3 cm/sec on MR
velocity CW spectrum during isovolumetric
contraction, i.e. before aortic valve opens when
there is no significant change in LA pressure.
Input: Formula:
T - Time between 1 and 3 cm/sec
dP/dt= 32/T
Output:
dP/dt (mmHg/s)
Left Ventricle (LV) ②
LV Systolic function: TDI Systolic myocardial velocity (S’) at
the lateral mitral annulus is a measure
of longitudinal systolic function and is
correlated with measurements of LV
ejection fraction and peak dP/dt. A
reduction in S’ (Systolic velocity annulus)
velocity can be detected within 15
seconds of the onset of ischemia, and
regional reductions in S’ are correlated
with regional wallmotion abnormalities.
Incorporation of TDI measures of
systolic function in exercise testing to
assess for ischemia, viability, and
contractile reserve has been suggested
because peak S’ velocity normally
increases with dobutamine infusion and
exercise and decreases with ischemia. *
Input:
S – Systolic velocity in lateral wall A4C (red)

* 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)

The IVRT is the time interval between aortic


valve closure and mitral valve opening. The
transducer is placed in the apical position
with either a pulsed or continuous wave
Doppler sample placed between the aortic
and mitral valves. A normal IVRT is
approximately 70 to 90 ms. The IVRT will
lengthen with impaired LV relaxation and
shorten when LV compliance is decreased
and LV filling pressures are increased.

IVRT - measurement from the Ao valve closure (yellow)


And Mitral valve opening (green)
Left Ventricle (LV) ①
LV diastolic function: Tissue doppler image
Currently, the most sensitive and widely
used technique for LVDF is TDI.
Diastolic dysfunction is directly related to the
reduction in early LV relaxation
compromising the effective transfer of the
blood from the atrial reservoir into the LV
cavity. The reduction in LV relaxation may be
characterized through the evaluation of
mitral annular motion, generally with
Doppler tissue imaging, which can resolve
subtle changes in LV relaxation by identifying
a low septal annular early diastolic mitral
annular motion (e’) velocity.
For the assessment of global LV diastolic
Input: function, it is recommended to acquire and
s: Systolic annular velocity (blue) measure tissue Doppler signals at least
e’: early diastolic annular velocity (yellow) at the septal and lateral sides of the mitral
a’: late diastolic velocity (green) annulus and their average, given the
Output: influence of regional function on these
E/e’ ratio velocities and time intervals.
e’/a’ ratio
Left Ventricle (LV) ①
LV diastolic function: Pulmonary veins
PW Doppler of pulmonary venous flow is
performed in the apical 4-chamber view
and aids in the assessment of LV diastolic
function. If the mitral inflow velocity
profile indicates a predominant
relaxation abnormality with a low E/e=
ratio (normal mean LA pressure), a
pulmonary vein flow duration greater
than mitral inflow duration at atrial
contraction may indicate an earlier stage
of reduced LV compliance as well as
increased LV end-diastolic pressure.
PV flow is better
Input: Output:
S - Peak systolic vel
S/D Ratio
D - Peak diastolic vel
Ar - Reverse vel in late diatole
Ar duration
Ar - A - Time difference between Ar duration and
mitral A-wave duration
Left Ventricle (LV) ①
LV diastolic function: Mitral Inflow Propagation
Acquisition is performed in the apical 4-chamber
view, using color flow imaging with a narrow color
sector, and gain is adjusted to avoid noise. The M-
mode scan line is placed through the center of the
LV inflow blood column from the mitral valve to the
apex. Then the color flow baseline is shifted to
lower the Nyquist limit so that the central highest
velocity jet is blue. Flow propagation velocity (Vp)
is measured as the slope of the first aliasing
velocity during early filling, measured from the
mitral valve plane to 4 cm distally into the LV cavity.
Alternatively, the slope of the transition from no
color to color is measured. Vp 50 cm/s is
considered normal. During heart failure and during
Input: myocardial ischemia, there is slowing of mitral-to-
Vp - Flow propagation velocity (doted white apical flow propagation, consistent with a
Line) (cm/s) reduction of apical suction.
Left Ventricle (LV) ①
LV diastolic function: Left Atrium (LA) Volume
Left atrial volume is regarded as a “barometer”
of the chronicity of diastolic dysfunction; with
the most accurate measurements obtained
using the apical 4-chamber and 2-chamber
views (Biplane areal-length or Simpson). This
assessment is clinically important, because
there is a significant relation between LA
remodeling and echocardiographic indices of
diastolic function. However, Doppler velocities
and time intervals reflect filling pressures at the
time of measurement, whereas LA volume
often reflects the cumulative effects of filling
pressures over 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

PCWP = 1.24 * (E/e’) + 1.9



Left Atrium (LA)
Quantification of the Left Atrial size: LA Volume (Biplane)

When LA size is measured in clinical practice,


volume determinations are preferred over
linear dimensions because they allow
accurate assessment of the asymmetric
remodeling of the LA chamber. In the
area-length formula the length is measured
in both the 4- and 2-chamber views and the
shortest of these
2 length measurements is used in the
formula.

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

The LA size is measured at the end-ventricular


systole when the LA chamber is at its greatest
dimension, care should be taken to avoid
foreshortening of the LA. The base of the LA
should be at its largest size indicating that the
imaging plane passes through the maximal
shortening area. The LA length should be also
maximized ensuring alignment along the true
long axis of the LA. The confluences of the
pulmonary veins, and LA appendage should be
excluded. AP linear dimensions of the LA as the
sole measure of LA size may be misleading and
should be accompanied by LA volume
determination in both clinical practice and
Input: research.
LAD – Left atrium diameter (cm)
Aortic root ①
Aortic root dimension

Figure 18 Measurement of aortic root diameters at aortic


valve annulus (AV ann) level, sinuses of Valsalva (Sinus
Figure 19 Measurement of aortic root diameter at sinuses
Val), and sinotubular junction (ST Jxn) from midesophageal
of Valsava from 2-dimensional parasternal long-axis image.
long-axis view of aortic valve, usually at angle of
Although leading edge to leading edge technique is shown,
approximately 110 to 150 degrees. Annulus is measured by
some prefer inner edge to inner edge method.
convention at base of aortic leaflets. Although leading edge
TTE imaging.
to leading edge technique is demonstrated for the Sinus Val
and ST Jxn, some prefer inner edge to inner edge method.
TEE imaging.
Input:
AV Ann – Aortic valve annulus (TEE)
Sinus Val – Sinuses of Valsalva (TEE)
ST Jxn – Sinotubular junction (TEE)
Ao – Aortic root diameter (TTE)
Right Ventricle (RV)
RV segments & coronary supply

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.

A) PLAX view, a portion of the proximal RVOT can be measured


B) PSAX view, proximal RVOT measurement
C) PSAX view, Distal RVOT measurement (preferred site for RVOT linear measurement)

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.

(A) Subcostal 2-dimensional image of right ventricular wall.


Input: (B) Zoom of region outlined in (A) with right ventricular wall thickness indicated by arrows.
RV Wall thickness (mm) (C) M-mode image corresponding to arrows
in (B).
(D) Zoom of region outlined in (C) with arrows indicating wall thickness at end-diastole.
Right Ventricle (RV) ①
RV systolic function: TAPSE (Tricuspid Annular Plane Systolic Excursion)
The systolic movement of the base
of the RV free wall provides one of
the most visibly obvious movements
on normal echocardiography. TAPSE
or TAM is a method to measure the
distance of systolic excursion of the
RV annular segment along its
longitudinal plane, from a standard
apical 4-chamber window. It is
inferred that the greater the descent
of the base in systole, the better the
RV systolic function. TAPSE is usually
acquired by placing an M-mode
cursor through the tricuspid annulus
Input: and measuring the amount of
TAPSE – Tricuspid Annular Plane Excursion mm longitudinal motion of the
annulus at peak systole
Right Ventricle (RV) ①
RV systolic function: FAC (Fractional Area Change)

The percentage RV FAC, defined as (end-diastolic


area end-systolic area)/end-diastolic area 100, is
a measure of RV systolic function that has been
shown to correlate with RV EF by magnetic
resonance
imaging (MRI). FAC is obtained by tracing the RV
endocardium both in systole and diastole from
the annulus, along the free wall to the
apex, and then back to the annulus, along the
interventricular septum. Care must be taken to
trace the free wall beneath the
Trabeculations. Two-dimensional Fractional Area
Change is one of the recommended methods of
quantitatively estimating RV function, with a
Input: Output: lower reference value
ED area - End-diastolic Area FAC % for normal RV systolic function of 35%.
ES area - End-systolic Area
Right Ventricle (RV) ①
RV systolic function: RV S’ (Systolic excursion velocity)

Among the most reliably and reproducibly


imaged regions of the right ventricle are the
tricuspid annulus and the basal free wall
segment. These regions can be assessed by
pulsed tissue Doppler and color-coded tissue
Doppler to measure the longitudinal velocity
+ of excursion. This velocity has been termed
the RV S’ or systolic excursion velocity. To
perform this measure, an apical 4-chamber
window is used with a tissue Doppler mode
region of interest highlighting the RV free
wall. The pulsed Doppler sample volume is
placed in either the tricuspid annulus or the
middle of the basal segment of the RV free
wall.
Input:
S’ – Systolic excursion velocity
Right Ventricle (RV) ②
RV systolic function: MPI RV - Myocardial Performance Index RV
The MPI, also known as the RIMP or Tei index, is a
global estimate of both systolic and diastolic
function of the right ventricle. It is based on the
relationship between ejection and nonejection work
of the heart. The MPI is defined as the ratio of
isovolumic time divided by ET, or [(IVRT +
IVCT)/ET]. The right-sided MPI can be obtained by
two methods: the pulsed Doppler method and the
tissue Doppler method: In the pulsed Doppler
method (A), the ET is measured with pulsed
Doppler of Rv outflow (time from the onset to the
cessation of flow), and the tricuspid (valve) closure-
opening time is measured with either pulsed
Doppler of the tricuspid inflow (time from the end of
the transtricuspid A wave to the beginning of the
transtricuspid E wave) or continuous Doppler
of the TR jet (time from the onset to the cessation of
the jet). In the tissue Doppler method (B), all time
intervals are measured from a single beat by
pulsing the tricuspid annulus (left)

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

RV dP/dt can be accurately estimated from the


ascending limb of the TR continuous-wave Doppler
signal. Is commonly calculated by measuring the
time required for the TR jet to increase in velocity
from 1 to 2 m/s. Using the simplified Bernoulli
equation, this represents a 12 mm Hg increase in
pressure. The dP/dt is therefore calculated as 12
mm Hg divided by this time (in seconds), yielding a
value in millimeters of mercury per second.

Because of the lack of data in normal


subjects, RV dP/dt cannot be recommended for
routine uses. It can be considered in subjects with
suspected RV dysfunction. RV dP/dt <
approximately 400 mm Hg/s is likely abnormal.
Point 1 represents the point at which the tricuspid regurgitation
(TR) signal meets the 1 m/s velocity scale marker,
while point 2 represents the point at which the TR signal meets
the 2 m/s velocity scale marker. Point 3 represents the time required
for the TR jet to increase from 1 to 2 m/s. In this example,
this time is 30 ms, or 0.03 seconds. The dP/dt is therefore 12mm
Hg/0.03 seconds, or 400 mm Hg/s.
Right Ventricle (RV) ②
RV systolic function: RV IVA (Myocardial Acceleration During
Isovolumic Contraction)
Isovolumetric acceleration (IVA) is a novel
tissue Doppler parameter for the assessment
of systolic function. Myocardial acceleration
during isovolumic contraction is defined as the
peak isovolumic myocardial velocity divided by
time to peak velocity and is typically measured
for the right ventricle by Doppler tissue
imaging at the lateral tricuspid annulus. For
the calculation
of IVA, the onset of myocardial acceleration is
at the zero crossing point of myocardial
velocity during isovolumic contraction. In
studies in patients with conditions affected by
RV function, RV IVA may be used, and when
Pulsed wave tissue Doppler imaging of the RV free used, it should be measured at the lateral
wall of a control subject. 1: peak myocardial systolic tricuspid annulus. RV IVA is not recommended
velocity (Sm), 2: peak early diastolic velocity (Em), 3: as a screening parameter for RV systolic
peak late diastolic velocity (Am) 4: isovolumetric function in the general echocardiography
contraction time (IVCT), 5: ejection time (ET), 6: peak
laboratory population.
myocardial isovolumetric contraction velocity (IVV),
acceleration time (AT), isovolumetric acceleration (IVA)
(red).
Right Ventricle (RV) ①
RV diastolic function: PW Tricuspid inflow

From the apical 4-chamber view, the Doppler beam


should be aligned parallel to the RV inflow. Proper
alignment may be facilitated by displacing the
transducer medially toward the lower parasternal
E
region.
The sample volume should be placed at the tips of
the tricuspid leaflets. With this technique,
measurement of transtricuspid flow velocities can
be achieved in most patients, with low
interobserver and intraobserver variability. Care
must be taken to measure at held end-expiration
and/or take the average of ≥ 5 consecutive beats.
The presence of moderate to severe TR or atrial
fibrillation could confound diastolic parameters,
Input: Output: and most studies excluded such patients.
Tricuspid Flow Profile (red) E wave velocity
A wave velocity
E/A ratio
Tricuspid E/e’
DT - Deceleration time (ms)
Right Ventricle (RV) ②
RV diastolic function: Tissue doppler imaging

Among the most reliably and reproducibly


imaged regions of the right ventricle are the
tricuspid annulus and the basal free wall
segment. These regions can be assessed by
pulsed tissue Doppler and color-coded tissue
Doppler to measure the longitudinal velocity
of excursion. S’ is systolic velocity, E’ is early
diastolic velocity and A’ is late diastolic
velocity. To perform this measure, an apical
4-chamber window is used with a tissue
Doppler mode region of interest highlighting
the RV free wall. The pulsed Doppler sample
volume is placed in either the tricuspid
annulus or the middle of the basal segment
of the RV free wall.
Input: Output:
S’ Systolic velocity E’/A’ ratio
E’ velovity E/E’ ratio
A’ velocity
Right Ventricle (RV) ①
RV hemodynamics: sPAP (Systolic pulmonary artery pressure)
SPAP can be estimated using TR velocity, and
PADP can be estimated from the end-diastolic
pulmonary regurgitation velocity. Mean PA
pressure can be estimated by the PA
acceleration time (AT) or derived from the
systolic and diastolic pressures. RVSP can be
reliably determined from peak TR jet velocity,
using the simplified Bernoulli equation and
combining this value with an estimate of the
RA pressure: RVSP = 4 (V) ² + RA pressure,
where V is the peak velocity (in meters per
second) of the tricuspid valve regurgitant jet,
and RA pressure is estimated from IVC
diameter and respiratory changes. Because
Input: Output: velocity measurements are angle dependent,
TR Jet velocity TR velocity it is recommended to gather TR signals from
PAP mmHg sPAP several windows and to use the signal with the
(depending on RV Systolic pressure highest velocity.
IVC collapsability on sniff)
Right Ventricle (RV) ①
RV hemodynamics: dPAP (Diastolic Pulmonary artery pressure)
mPAP (mean Pulmonary Artery Pressure)

dPAP can be estimated from the velocity


of the end-diastolic pulmonary
regurgitant jet using the modified
Bernoulli equation: [PADP = 4 (end-
diastolic pulmonary regurgitant velocity)²
+ RA pressure]. Mean PA pressure
correlates with 4 x (early PI velocity) ² +
estimated RAP .

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

The primary transthoracic window for imaging the


right atrium is the apical 4-chamber view. From this
window, RA area is estimated by planimetry. The
maximal long-axis distance of the right atrium is
from the center of the tricuspid annulus to the
center of the superior RA wall, parallel to the
interatrial septum. A mid-RA minor distance is
defined from the mid level of the RA free wall to the
interatrial septum, perpendicular to the long axis.
RA area is traced at the end of ventricular systole
(largest volume) from the lateral aspect of the
tricuspid annulus to the septal aspect, excluding the
area between the leaflets and annulus, following
the RA endocardium, excluding the IVC and superior
vena cava and RA appendage

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)

The simplified continuity equation is based


on the concept that in native aortic valve
stenosis the shape of the velocity curve in
the outflow tract and aorta is similar so that
the ratio of LVOT to aortic jet VTI is nearly
identical to the ratio of the LVOT to aortic jet
maximum velocity (V). This method is less
well accepted because some experts are
concerned that results are more variable
than using VTIs in the equation.

AVA = CSALVOT x VLVOT / VAV

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

Another approach to reducing error related to


LVOT diameter measurements is removing CSA from
the simplified continuity equation. This dimensionless
velocity ratio expresses the size of the valvular
effective area as a proportion of the CSA of the
LVOT. Substitution of the time-velocity integral can
also be used as there was a high correlation
between the ratio using time–velocity integral and
the ratio using peak velocities. In the absence of
valve stenosis, the velocity ratio approaches 1, with
smaller numbers indicating more severe stenosis.
Severe stenosis is present when the velocity ratio is
0.25 or less, corresponding to a valve area 25% of
normal.

Velocity ratio = VLVOT / VAV

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

Multiple studies have evaluated the method


of measuring anatomic (geometric) AVA by
direct visualization of the valvular orifice,
either by 2D or 3D TTE or TEE. Planimetry
may be an acceptable alternative when
Doppler estimation of flow velocities is
unreliable. However, planimetry may be
inaccurate when valve calcification causes
shadows or reverberations limiting
identification of the orifice.

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)

Is the time interval in milliseconds between the


maximum mitral gradient in early diastole and the
time point where the gradient is half the maximum
initial value. The decline of the velocity of diastolic
transmitral blood flow is inversely proportional to
valve area (cm2), and MVA is derived using the
empirical formula: MVA = 220 ⁄ T1⁄2.
T1/2 is obtained by tracing the deceleration slope of
the E-wave on Doppler spectral display of
transmitral flow and valve area is automatically
calculated by the integrated software of currently
used echo machines. The Doppler signal used is the
same as for the measurement of mitral gradient.
Input: Output:
MV PHT MV PHT (ms)
MVA (cm ²)
Valvular stenosis ①
Mitral stenosis: Pressure gradient
Mitral stenosis is the most frequent valvular
complication of rheumatic fever. Even in
industrialized countries, most cases remain of
rheumatic origin as other causes are rare. The
estimation of the diastolic pressure gradient is
derived from the transmitral velocity flow curve
using the simplified Bernoulli equation ΔP = 4v ².
The use of CWD is preferred to ensure maximal
velocities are recorded. Doppler gradient is
assessed using the apical window in most cases as
it allows for parallel alignment of the ultra sound
beam and mitral inflow.
Input: Output:
MV Flow profile MV Peak Velocity
MV Peak GP (mmHg)
MV mean Velocity
MV Mean GP (mmHg)
Valvular stenosis ②
Mitral stenosis: Continuity equation

As in the estimation of AVA, the


continuity equation is based on the
conservation of mass, stating in this
case that the filling volume of diastolic
mitral flow is equal to aortic SV. The
accuracy and reproducibility of the
continuity equation for assessing MVA
are hampered by the number of
measurements increasing the impact of
errors of measurements. The continuity
equation cannot be used in cases of
atrial fibrillation or associated significant
MR or AR.

MVA = (CSALVOT x VTIAortic) / VTIMitral


Input: Output:
LVOT (cm) MVA (cm²)
VTI Ao (cm)
VTI Mitral (cm)
Valvular stenosis ②
Mitral stenosis: PISA method
The proximal isovelocity surface area method is
based on the hemispherical shape of the
convergence of diastolic mitral flow on the atrial
side of the mitral valve, as shown by colour Doppler.
It enables mitral volume flow to be assessed and,
thus, to determine MVA by dividing mitral volume
flow by the maximum velocity of diastolic mitral flow
as assessed by CWD. This method can be used in
the presence of significant MR.
However, it is technically demanding and requires
multiple measurements. Its accuracy is impacted
upon by uncertainties in the measurement of the
radius of the convergence hemisphere, and the
opening angle.

MVA = 2 x π x r² x (Vr / Vmax) x (α⁰ / 180°)

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)

The rate of deceleration of the diastolic regurgitant


jet and the derived pressure half-time reflect the
rate of equalization of aortic and LV diastolic
pressures. With increasing severity of AR, aortic
diastolic pressure decreases more rapidly. Pressure
half-time is easily measured if the peak diastolic
velocity is appropriately recorded. A pressure half-
time 500 ms is usually compatible with mild AR
whereas a value 200 ms is considered consistent
with severe AR.
CW Doppler of the AR jet should be routinely
recorded but only utilized if a complete signal is
obtained. The PHT is influenced by chamber
compliance and pressure, for this reason it serves
only as a complementary finding for AR severity
assessment.

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

In most patients, maximum MR velocity is 4 to 6 m/s


due to the high systolic pressure gradient between
the LV and LA.
The velocity itself does not provide useful information
about the severity of MR. However, the contour
of the velocity profile and its density are useful. A
truncated, triangular jet contour with early peaking
of the maximal velocity indicates elevated LA
pressure or a prominent regurgitant pressure wave in
the LA. The density of the CW Doppler signal is a
qualitative index of MR severity. A dense signal that
approaches the density of antegrade flow suggests
significant MR, whereas a faint signal, with or without
an incomplete envelope represents mild or trace
MR. Using CW Doppler, the tricuspid regurgitation jet
should be interrogated in order to estimate
pulmonary artery systolic pressure. The presence of
Input: Output: pulmonary hypertension provides another indirect
MR VTI MR Peak velocity (m/s) clue as to MR severity and compensation to the
volume overload.
Valvular regurgitation ②
Mitral regurgitation: Mitral to Aortic TVI ratio
In the absence on mitral stenosis, the increase in
transmitral flow that occurs with increasing MR
severity can be detected as higher flow velocities
during early sistolic filling (increased E velocity). In
the absence of mitral stenosis, peak E velocity > 1.5
m/s suggest severe MR. Conversely, a dominant A
wave (Atrial contraction) basically excludes severe
MR. The PW doppler mitral to aortic TVI ratio is also
used as an easily measured index for the
quantification of the isolated pure organic MR. Mitral
inflow doppler tracings are obtaines at the mitral
leaflet tips and aortic flow at the annulus level in the
apical four-chamber view. A TVI ratio > 1.4 strongly
suggest severe MR whereas a TVI ratio < 1 is in
favor of mild MR.
Both the pulsed Doppler mitral to aortic TVI ratio and
the systolic pulmonary flow reversal are specific for
severe MR. They represent the strongest additional
parameters for evaluating MR severity.
Input: Output:
Mitral VTI Mitral to Aortic VTI ratio
Aortic VTI
Valvular regurgitation ②
Mitral regurgitation: Pulmonary venous flow

Pulsed Doppler evaluation of pulmonary venous flow


pattern is another aid for grading the severity of MR.
In normal individuals, a positive systolic wave (S)
followed by a smaller diastolic wave (D) is classically
seen in the absence of diastolic dysfunction. With
increasing severity of MR, there is a decrease of the
S wave velocity. In severe MR, the S wave becomes
frankly reversed if the jet is directed into the sampled
vein. As unilateral pulmonary flow reversal can occur
at the site of eccentric MR jets, sampling through all
pulmonary veins is recommended, especially during
transoesophageal echocardiography. Although,
evaluation of right upper pulmonary flow can often be
obtained using TTE, evaluation is best using TEE
with the pulse Doppler sample placed about 1 cm
Pulmonary venous flow is a qualitative deep into the pulmonary vein.
parameter, no measurements have to be Both the pulsed Doppler mitral to aortic TVI ratio and
done. the systolic pulmonary flow reversal are specific for
severe MR. They represent the strongest additional
parameters for evaluating MR severity.
Valvular regurgitation ②
Mitral regurgitation: Flow quantitation - PW
Pulsed Doppler tracings at the mitral leaflet tips
are commonly used to evaluate LV diastolic
function. Patients with severe MR often
demonstrate a mitral inflow pattern with a
dominant early filling (increased E velocity) due
to increased diastolic flow across the mitral
valve, with or without an increase in left atrial
pressure. In severe mitral regurgitation without
stenosis, the mitral E velocity is higher than the
velocity during atrial contraction (A velocity),
and usually greater than 1.2 m/sec. For these
reasons, a mitral inflow pattern with an A- wave
dominance virtually excludes severe MR.
Volumetric measurements with PW are Time
consuming and not recommended as first level
method to quantify MR severity.

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)

The vena contracta of the TR is typically


imaged in the apical four-chamber view
using the same settings as for MR.
Averaging measurements over at least two
to three beats is recommended. A vena
contracta ≥7 mm is in favour of severe TR
although a diameter <6 mm is a strong
argument in favour of mild or moderate TR.
Intermediate values are not accurate at
distinguishing moderate from mild TR. As for
MR, the regurgitant orifice geometry is
complex and not necessarily circular. When
feasible, the measurement of the vena
contracta is recommended to quantify TR.

Input:
TR VC width (cm)
Valvular regurgitation ①
Tricuspid regurgitation: Flow convergence (PISA)

Although providing quantitative assessment, clinical


practice reveals that the flow convergence method is
rarely applied in TR. This approach has been
validated in small studies. The apical four-chamber
view and the parasternal long and short axis views
are classically recommended for optimal visualization
of the PISA. The area of interest is optimized by
lowering imaging depth and the Nyquist limit to ∼15–
40 cm/s. The radius of the PISA is measured at mid-
systole using the first aliasing. Qualitatively, a TR
PISA radius >9 mm at a Nyquist limit of 28 cm/s
alerts to the presence of significant TR whereas a
radius <5 mm suggests mild TR. An EROA ≥ 40 mm2
or a R Vol of ≥45 mL indicates severe TR.
When feasible, the PISA method is reasonable to
quantify the TR severity. An EROA ≥ 40 mm2 or a R
Vol ≥ 45 mL indicates severe TR.

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

CW Doppler is frequently used to measure


the end-diastolic velocity of PR and thus
estimate pulmonary artery end-diastolic
pressure. However, there is no clinically
accepted method of quantifying pulmonary
regurgitation using CW Doppler. Similar to
AR, the density of the CW signal provides
a qualitative measure of regurgitation. A
rapid deceleration rate, while consistent
with more severe regurgitation, is
influenced by several factors including RV
diastolic properties and filling pressures.
A pressure half-time < 200 ms is
consistent with severe PR.

Input: Output:
PR PHT Deceleration rate (ms)
Cardiac shunts
Qp/Qs: Pulmonary-systemic flow ratio

Qp/Qs can be estimated by using 2D


echo and spectral doppler
measurements in patients who have
intra- or extra- cardiac shunts, e.g. atrial
or ventricular septal defects.
This formula only works in cases where
there is pure left to right shunting.

Qp = RVOT VTI x π x (RVOT / 2)²

Qs = LVOT VTI x π x (LVOT / 2)²

Qp/Qs ratio = Qp/Qs

Input: Output:
LVOT (mm) Qp/Qs
LVOT VTI (cm)
RVOT (mm)
RVOT VTI (cm)
Prosthetic valves
Prosthetic aortic valves: doppler investigation (formulas previously described)

Doppler echocardiography of - Peak velocity gradient


the valve - Mean gradient
- Contour of the jet velocity, AT
(acceleration time)
- DVI (doppler velocity index) *
- EOA (Effective orifice area)
- Presence, location, and
severity of regurgitation

Pertinent cardiac chambers - LV size, function, and Hypertrophy

* 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 = Doppler Velocity Index


VLVO = Subvalvular (LVOT) velocity
VPRAV = Max velocity across the valve
Prosthetic valves
Prosthetic mitral valves: doppler investigation (formulas previously described)

Doppler echocardiography of - Peak early velocity


the valve - Mean gradient
- Heart rate at the time of Doppler
- Pressure half-time
- DVI*: (Doppler velocity index)
- EOA (Effective oriffice area)
- Presence, location, and severity
of regurgitation†

Other pertinent - LV size and function


echocardiographic and doppler - RV size and function
parameters - Estimation of pulmonary artery
pressure

* 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)

VPRMV = Max velocity across the prosthetic mitral valve


Prosthetic valves
Prosthetic pulmonary valves: doppler investigation (formulas previously described)

Doppler echocardiography of - Peak velocity/peak gradient


the valve - Mean gradient
- DVI *
- EOA*
- Presence, location, and severity
of regurgitation

Related cardiac chambers - RV size, function, and hypertrophy


- RV systolic pressure

* Theoretically possible to measure. Few data exist.


Prosthetic valves
Prosthetic tricuspid valves: doppler investigation (formulas previously described)

Doppler echocardiography of - Peak early velocity


the valve - Mean gradient
- Heart rate at time of Doppler
assessment
- Pressure half-time
- VTIPRTV / VTILVO *
- EOA
- Presence, location, and severity of TR

Related cardiac chambers, - RV size and function


inferior vena cava and hepatic - Right atrial size
veins - Size of inferior vena cava and
response to inspiration
- Hepatic vein flow pattern

* Feasible measurements of valve function, similar to mitral prostheses,


but no large series to date.

VTIPRTV: Velocity Time Integral Prosthetic Tricuspid Valve


VTILVO: Velocity Time Integral LVOT
Other abreviations
AT = Acceleration time
EF = Ejection fraction
ET = Ejection time
FAC = Fractional area change
IVA = Isovolumic acceleration
IVC = Inferior vena cava
IVCT = Isovolumic contraction time
IVRT = Isovolumic relaxation time
MPI = Myocardial performance index
MRI = Magnetic resonance imaging
LV = Left ventricle
PA = Pulmonary artery
PADP = Pulmonary artery diastolic pressure
PH = Pulmonary hypertension
PLAX = Parasternal long-axis
PSAX = Parasternal short-axis
PVR = Pulmonary vascular resistance
RA = Right atrium
RIMP = Right ventricular index of myocardial performance
(MPI RV)
RV = Right ventricle
RVH = Right ventricular hypertrophy
RVOT = Right ventricular outflow tract
RVSP = Right ventricular systolic pressure
SD = Standard deviation
SPAP = Systolic pulmonary artery pressure
TAM = Tricuspid annular motion
TAPSE = Tricuspid annular plane systolic excursion
3D = Three-dimensional
TR = Tricuspid regurgitation
2D = Two-dimensional

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