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Echocardiography 5 minutes before starting  



Examples of pathological findings

—Echocardiographic examinations

—Cardiac function and PA pressure

—Examples of pathological
findings


Valvular heart disease
Intracardiac masses
Pericardial disease
Cardiomyopathies
Aortic dissection
Congenital heart disease
echo|case



Valvular heart disease


Mitral valve stenosis | Valvular regurgitation | Signs of severe aortic regurgitation | Severe mitral regurgitation


The EAE/ASE recommendations for the evaluation of valvular stenosis can be downloaded directly from the ASE: Echocardiographic assessment of valve stenosis, 2009.



Aortic valve stenosis

1. ACC/AHA 1998 guidelines for grading an aortic valve stenosis






* information not available (Bonow et al. Circulation 1998;98:1949-1984)

PPG = peak pressure gradient, MPG = mean pressure gradient



2. Continuity equation: standard method to calculate valvular opening area. Systolic velocities in left ventricular
outflow track (LVOT) and on the aortic valve, as well as LVOT area must be assessed.




A2 = aortic stenosis area, V2 = aortic stenosis velocity time integral (VTI, obtained with CW-Doppler), A1 = LVOT area and V1 = LVOT VTI (obtained with PW-Doppler).

Calculation of the continuity equation can be usually made in every echomachine, but in case this is not possible, hier an online calculator of the Canadian Society of Echocardiography.

Pitfalls in the assessment of a severe aortic stenosis are: the low-output low-gradient aortic stenosis and the pinhole stenosis. In case of the presence of morphologic criteria for severe aortic stenosis (thickened aortic valve with important decrease of leaflets separation, severe left ventricular hypertrophy) examination ends first after assessment of maximal velocities from standard views, as well as from the subcostal, suprasternal and right parasternal views.

A transesophageal examination should be considered in difficult cases, maximal velocities can be obtained here from the transgastric five-chamber view.


Left: assessment of valvular morphology ist the first step to a correct diagnosis of valvular heart disease. Here a cross sectional view of the aortic valve from the parasternal short axis view.

Right: the aortic valve is thickened, calcified and with severely reduced leaflet separa- tion, as seen from the apical five-chamber view.

Left: color Doppler helps to CW-Doppler beam positioning. Pin hole stenoses are very difficult to examine, fact that can lead to important underestimation of velocities.

Right: maximal velocities from 4.5 m/s or above (peak pressure gradient aprox. 80 mmHg) can be considered as a thumb rule for severe aortic stenosis.



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Mitral valve stenosis

Correct assessment of the pressure half time (PHT) is decisive for calculating mitral valvular opening area, correspondingly its stenosis degree. This can be difficult in case of atrial fibrillation, since Doppler profile inclination varies with the duration of diastole.







Left: a dilated left atrium is a common occurrence to a signi- ficant mitral stenosis.

Right: the degree of thickness, calcification and movement limitation of the whole mitral valve apparatus are important parameters for decision to a percutaneous valvuloplasty (Wilkins-Score, online calculator from the Canadian Society of Echocardiography).

Left: a concurrent mitral valve regurgitation must be included in the evaluation before valvulo- plasty.

Right: different values of PHT can be obtained in case of atrial fibrillation, according to diastole length. It is importante to find a mean value, that correlate to measured values of transmitral gradients.



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Valvular regurgitation

1. Overview


All valvular regurgitations have three components: PISA (proximal isovelocity surface area), vena contracta and regurgitation jet. PISA can be spontaneously seen when regurgitation is already significant. Vena contracta plays a more important role for assessment of degree of regurgitation than regurgitation jet.





A vena contracta with an area larger than 50 % of LVOT, with a regurgitation jet deceleration >3 m/s² and a diastolic retrograde flow in the descendant aorta can be consistent with the diagnosis of a severe aortic regurgitation.

A wide vena contracta with a v-shaped regurgitation jet (CW-Doppler), PISA and systolic retrograde flow into the pulmonary veins can be consistent with the diagnosis of a severe mitral regurgitation. A TEE examination to exclude e.g. partial ruptured chordae tendineae can be necessary in this case, especially in presence of an eccentric mitral regurgitation.

A retrograde flow into the hepatic veins together with the afore mentioned parameters lead to the diagnosis of a severe tricuspid regurgitation.



2. Parameters for quantitative assessment: EROA, regurgitation volumen, regurgitation fraction


New "high-end" echomachines simplify the assessment of the effective regurgitation orifice area (EROA), regurgitation volume and fraction.

Assessment of EROA can be carried out with the continuity equation, where A1 (PISA area), V1 (PISA Nyquist-limit) and V2 (regurgitation VTI) are the known variables, and A2 (EROA) the variable to be calculated.


EROA = (PISA area x PISA Nyquist-limit) / regurgitation VTI

Regurgitation volume = SVreg - SVnorm

SVreg: Stroke volume measured at the regurgitating valve
SVnorm: Stroke volume measured at a valve without regurgitation


Regurgitation fraction = Regurgitation volume / SVreg

SV (Stroke volume) = CSA (cross sectional area, valve annulus) x VTI



3. Aortic valve regurgitation





4. Mitral valve regurgitation







Calculations with the PISA method can usually be made directly in the echomachine, alternatively here an online calculator from the Canadian Society of Echocardiography. Excentric regurgitations may produce inaccurate results.

A complete description of all criteria for the assessment of valvular regurgitation can be downloaded from the American Society of Echocardiography: Recommendations for Evaluation of the Severity of Native Valvular Regurgitation, 2003.



Left: color Doppler settings must be correctly adjusted for the PISA method. The Nyquist-limit should be placed around 50-60 cm/s.

Right: afterwards, base line should be shifted in the direction of the regurgitation jet, until a well-defined hemisphere appears.

Left: to calculate VTI of regurgi- tation jet, CW-Doppler profile area should be delineated.

Right: by measuring PISA radius it is important to hit correctly the limit ot the hemisphere. Small errors can produce important variations.

Left: furthermore, it is very im- portant to define the cause of the valvular regurgitation. Here a TEE examination of partial ruptured chordae tendineae of the posterior mitral leaflet.

Right: a severe, excentric mitral regurgitation can be verified with color Doppler.



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30 signs of severe aortic regurgitation

The following morphofunctional parameters of severe aortic regurgitation are in part historic, in part very much up-to-date. Most of them can be documented in a (standard) routine examination, only a few demand additional especial views and machine settings.

In case of suspicion of a sever aortic regurgitation, the examiner has the task to observe and document them, as well as to derive the corresponding interpretation. The echocardiography report can help on the decision about the urgency of an invasive examination and the subsequent surgical correction. A comprehensive assessment of valve morphology can be achieved with a TEE examination.


2D-Echo

1. Significant annuloaortic ectasia with incomplete coaptation of aortic cusps
2. Prolaps of one (or more) aortic cusp/s (with or without dissection of the aortic root)
3. Aortic cusp perforation
4. LVEDD > 60 mm (> 35 mm/m²)
5. LVESD > 50 mm (> 25 mm/m²)
6."Reversed doming" of the anterior mitral leaflet
7. Dilated left atrium
8. Strong pulsating aortic arch (suprasternal view)
9. Strong pulsating abdominal aorta (subxyphoid view)

M-Mode

10. Premature mitral valve closure
11. High frecuency diastolic vibration of the anterior mitral leaflet
12. High frecuency diastolic vibration of the interventricular septum

Color Doppler

13. Vena contracta > 6 mm
14. Regurgitation jet > 50 % of LVOT diameter or LVOT surface (short axis view)
15. Coanda effekt
16. Extremely short jet, as braked in LVOT

CW Doppler

17. High density of regurgitation envelope
18. Steep decline of regurgitation envelope profile
19. PHT < 200 ms
20. Deceleration of regurgitation profile > 3m/s²

PISA (color and CW Doppler)

21. EROA > 0,4 cm²
22. Regurgitation volumen > 60 mL

PW Doppler

23. Diastolic flow reversal in the descending aorta (suprasternal view) > 25% of the diastole
24. Diastolic flow reversal in the abdominal aorta (subxyphoid view)

Additional functional parameters

25. LV-EF < 55 %
26. DT-E < 150 ms
27. E/E' (lateral) > 15
28. PVF-s/PVF-d < 0,5
29. Vp < 45 cm/s
30. PASP > 35 mmHg



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23 signs of severe mitral regurgitation

The following morphofunctional parameters of severe mitral regurgitation can be documented in a (standard) routine examination, only a few demand additional especial views and machine settings.

In case of suspicion of a sever aortic regurgitation, the examiner has the task to observe and document them, as well as to derive the corresponding interpretation. The echocardiography report can help on the decision about the urgency of an invasive examination and the subsequent surgical correction. A comprehensive assessment of valve morphology can be achieved with a TEE examination.


2D-Echo

1. Dilated mitral annulus with incomplete valvular coaptation
2. Mitral valve prolapse or leaflet segment prolapse (with or without rupture of chordae tendineae)
3. Papillary muscle dysfunction (with or without rupture)
4. Mitral leaflet perforation
5. Functional classification Carpentier type IIIb
6. Dilated LA
7. LVEDD > 60 mm (> 35 mm/m²)
8. LVESD > 35 mm (> 20 mm/m²)

Color Doppler

9. Vena contracta > 7 mm
10. Coanda effect
11. Extremely short jet, as braked in LA

CW Doppler

12. High density of regurgitation envelope
13. "V-Wave cutoff" sign
14. Slow systolic peak velocities (e.g. 4 m/s)

PISA (Color and CW Doppler)

15. EROA > 0,3 cm²
16. Regurgitation volumen > 60 mL

PW Doppler

17. Systolic reversed flow in the pulmonary veins

Additional functional parameters

18. LV-EF < 55 %
19. DT-E < 150 ms
20. E/E' (lateral) > 15
21. PVF-s/PVF-d < 0,5
22. Vp < 45 cm/s
23. PASP > 35 mmHg



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