Transcript DOPPLER IN REGURGITANT LESIONS Regurg Lesions…..Doppler  Indirect  Semiquantitative….jet area ratios  Quantitative…RVol,RF,EROA.

DOPPLER IN REGURGITANT
LESIONS
Regurg Lesions…..Doppler
 Indirect
 Semiquantitative….jet area ratios
 Quantitative…RVol,RF,EROA
INDIRECT INDICATORS
Doppler Parameter
Significant regurg
Forward flow velocities
Increased
Intensity of regurg signal
Strong (compared to forward
flow signal)
Shape of regurg signal
Rapid drop-off of signal
Duration of regurg signal
Shortened (finishes prior to end of
diastole)
Flow reversals
Systolic veins entering atrium
(MR/TR)
Shape of regurg signal :
“V” cut-off sign (AV valves)
Shortened PHT or DS (semilunar valves)
Mild AV valve reg…Pr gradient is high & remains
relatively constant through out the entire
systole…symmetrical U shaped doppler velocity
curve…..
In Severe …Gradient initaially high,but decreases
towards the latter half of systole….rapid &
asymmetric V shaped doppler
V” cut-off sign : d/t rapid equalisation (cross over) of
LA & LV pressures
Shortened PHT in semil valves…
Larger the reg orifice,the greater the rate of decline of
diast pr gradient b/w aorta & LV .
So PHT decreases in severe
DS (V peak/DT) increases in severe
Flow reversal velocities :
TR….hepatic veins
MR…Pulmonary veins
AR…DA & Abd aorta
Syst to diast PV flow velocity ratio [VTIs/VTID] in MR
MR
VTIs/VTID
Sensitivity
Specificity
Mild
>1
84
84
Moderate
0.5-1.0
57
81
Moderately Severe
0.0-0.5
33
85
Severe
<0.0
52
96
Flow reversal in semil valve regurg :
velocity & duration during diastole…index of severity
Pandiast flow reversal in DA…at least moder AR
Pandiast flow reversal in Abd A…extremely sensitive
(100%) & specific (97%) for severe AR
End diastolic flow velocity>18cm/s..predict moderate
to severe AR sensitivity (88%) & specificity (92%)
Limitations of flow reversal:
Coex L-R shunt or aortic anomalies
Arrythmias
Poor setting of wall filters
Resp Variation
LA compliance & pressures
Eccentric jets
COLOUR FLOW DOPPLER
(1)Vena Contracta :
narrowest portion of a jet that occurs at or just
downstream from the orifice.
high velocity, laminar flow and is slightly smaller
than the anatomic regurgitant orifice due to
boundary effects
•transducer needs to be angulated
•It is preferable to use a zoom mode
•The color flow sector should also be as narrow as
possible,
2)AR jet ht & JH/LVOT diameter ratio
3)Regurgitant jet area & Regurgitant jet area to
receiving chamber area ratio
4)PISA method
JH : significant overlap
>8 mm .. To discriminate b/w grades 1-2 vs 3-4
JH/LVOH >40% .. To discriminate b/w grades 1-2 vs
3-4 ; <25% ..mild AR
JH/LVOH…. Best indicator for predicting the severity
of AR
JH : max AP diameter of the regurg jet just below AV in PLAX
LVOT : measured @ end diastole at the same location
IN AR
RJA : PSAX @ LVOT level
LVOA :@ end diastole @ same location
RJA : >8 cm2  i/o severe MR
(sens/specif…82/94)/ TR(71/91)
InAR, RJA/LVOA of 25% …mild-moderate vs
moderately severe to severe AR
AR
RJA/LVOA
%
Sensitivity
%
Specificity
%
Mild
<4
80
100
Moderate
4-24
100
95
Moderately
Severe
25-59
100
100
Severe
>60
100
100
RJA & LAA … from multiple orthogonal planes
including A4C , PLAX, PSA
MR severity
RJA/LAA
(%)
Sensitivity
Specificity
Mild
<20
73-94
92-100
Moderate
20-40
94
95
Severe
>40
65-94
95-96
Limitations of CFDI in Regurg assessmnt
Wall jets .. Underestimates jet size
Coexistent Jets…MS/Prosthetic MV
Instrument factors … Gain settings ; PRF ;
Incident angle ;
Driving pressure,
Receiving chamber size & compliance,
regurg volume,size & shape of regurg orifice.
Regurgitant Volume :
Rvol = SV RV – SV CV
Regurg Fraction : Rvol ÷ SV forward x 100
Calculation of RV & RF
Method 1
SV LVOT = CSA (cm2) x VTI (cm)
LVOT….diameter …PLAX…@ aortic annulus…from
inner edge to inner edge of aortic cuspal insertion.
CSA LVOT= 0.785xD2
VTI of LVOT … from A5C .. PWD sample volume in
centre of LVOT proximal to aortic valve
SVMV = CSAMV x VTIMV
MV annulus diameter ….from A4C … mid diastole…from
inner edge to inner edge
VTI…from A4C…PwD sample vol at MV annulus
So for MR
RV = SVMV - SV LVOT
RF = SVMV - SV LVOT / SVMV =
RV/SVMV
AR :
RV =SV LVOT – SV MV
RF = SV LVOT– SV MV / SV LVOT = RV/SV LVOT
Considered as the the most accurate method for calculating
RV & RF
(2)SV LV by 2d echo … Simpsons biplane method
LV EDV-LVESV
In MR …
RV = SV(2D) – SV LVOT
RF = SV(2D) – SV LVOT / SV2D =RV/SV2D
In AR ..
RV = SV(2D) – SV MV
RF= SV(2D) – SV MV/SV(2D) = RV/SV2D
Less accurate
Used when it is difficult to measure mitral annulus
diameter or LVOT diameter
(3)RF in AR
Measure syst , diast diameter of aorta (@ top of aort
arch)
From suprasternal long axis view
Systolic VTI … PwD sample vol is positioned
proximal to head & neck vessels
Diastolic VTI … PwD sample vol is placed just distal
to left subclavian artery with in Desc.aorta
Calculate Syst SV & Diast reversed SV
RF= SV diast/SV syst
Rarely used..as imaging of aorta in suprasternal notch
is challenging
Limitations of RV & RF calculations
Assumptions of SV calculation
Errors in diameter measurements
Errors in VTI
Presence of multivalv lesions/intracardiac
shunts
Valv lesion
MR without AR
MR with AR (no
intracardiac shunt)
Total SV
CSAMV x VTIMV
CSAMV x VTIMV
Forward SV
CSALVOT x VTILVOT
CSARVOT x VTIRVOT
AR without MR
CSALVOT x VTILVOT
CSAMV x VTIMV
AR with MR(no
intracardiac shunt)
CSALVOT x VTILVOT
CSARVOT x VTIRVOT
AR (using the forward CSAAO-diast x VTIAO-diast CSAAO-syst x VTIAO-syst
& reverse flows from
aortic arch)
The flow rate proximal to a narrowed orifice is
the product of the hemisheric flow convergent
area & the velocity of that isovelocity shell
Q=2 π r2Vr
Bld flow thru hemishere must pass thru the
orifice ;So
2 π r2Vr = Ao x Vo
Ao = 2 π r2 Vr / Vo
EROA= 2 π r2 VN / VR
Rvol=EROA x VTIRJ
EROA
(1)Spectral doppler techniq .. Principle of
conservation of mass
Calculated from the premise that RV thru an
incomp valve is equal to flow @ the regurg
orifice
Rvol=EROAxVTI RJ
EROA=Rvol/VTI RJ
(2)PISA method : variation in the application of
the cont equation.
EROA =2 π r2Vn/Vr
Simplified method for MR Rvol…when appropriate CW D MR jet
cannot be obtained…the ratio b/w the max mitral reg velocity &
VTIRJ is a constant of 3.25 (Rossi et al.)
Rvol= 2 π r2 VN /3.25 (ie 2 π r2 VN/VR x VTIRJ)
Tricuspid EROA = (2 π r2 VN /VR-VN) (α/180)
After 2 corrections for
(1)flattening of PISA close to the reg orifice (corrected by
multiplying flow rate by (VR/VR-VN)
(2)Distorted reg orificesmall isovelocity contours…corrected by
multiplying 2 π by α/180
Simplified method for evaluating MR/TR using
the flow convergence region prox to the regurg
orifice…measures the radius of PISA dome…
Valve/severity
Aliased
velocity (cm/s)
PISA
radius(mm)
Sensitvty
Specif
38
<3.5
63
70
MR
MILD
MOD
3.5-7.5
MOD Severe
7.5-14.5
Severe
>14.5
85
63
>8.5
76
91
TR
Severe
28
MITRAL REGURGITATION
Mild
Moderate
Severe
Jet area
Small, central jet
(usually 4 cm2 or
20% of LA area)
Variable
Large central jet (10
cm2 or 40% of LA or
variable size wall
impinging
jet swirling in LA
Mitral inflow
A wave dominant
Variable
E wave dominant
(E usually 1.2 m/s)
Jet density
Incomplete or faint
Dense
Dense
Jet contour
Parabolic
PV flow
Systolic dominance
Parabolic
Systolic blunting
Syst flow reversal
VC width (cm)
<0.3
R Vol (ml/beat)
<30
30-44
45-59
>60
RF (%)
<30
30-39
40-49
>50
EROA (cm2)
<0.20
0.3-0.69
Early peaking–
triangular
0.20-0.29 0.30-0.39
>0.7
>0.40
Trace MR…40% healthy indiv….elderly
3 methods…color flow Doppler mapping:
regurgitant jet area,vena contracta, and flow
convergence (PISA).
AORTIC REGURGITATION
Jet width in
LVOT
Jet deceleration
rate
(PHT, ms)
Jet density
Diastolic flow
reversal in
DA–PW
Mild
Moderate
Severe
Small in central jets
Intermediate
Large in central jets;
variable in eccentric jets
Slow >500
Medium 500-200
Steep <200
Incomplete or faint
Dense
Dense
Brief, early
diastolic
Intermediate
Prominent
holodiastolic
25-45
46-64
>65
Jet /LVOT width,
%
<25
VC width (cm)
<0.3
R Vol (ml/beat)
<30
30-44
45-59
>60
RF (%)
<30
30-39
40-49
>50
Jet CSA/LVOT
<5
5-20
21-59
>60
0.3-0.6
>0.6
TR
MILD
MOD
SEVERE
Jet area
<5
5-10
>10
VC width
Not defined
Not defined; but >0.7
<0.7
PISA radius
<0.5
0.6-0.9
>0.9
Jet density &
contour
Soft and
parabolic
Dense, variable
contour
Hepatic vein
flow
Syst dominance
Syst blunting
Dense,
triangular with
early peaking
Syst reversal
PULMONARY REGURG
MILD
MOD
Jet size
Thin (usually
Intermediate
<10 mm
in length) with a
narrow origin
Jet density &
decel rate
Soft; Slow
deceleration
Pulmonic
Slightly
systolic flow
increased
compared
to systemic flow
Dense; variable
deceleration
Intermediate
SEVERE
Usually large,
with a wide
origin; May be
brief in
duration
Dense; steep
deceleration,
early
termination of
diastolic flow
Greatly
increased