cardiac measurements guidelines | aha and eae

8/12/2019 Cardiac Measurements Guidelines | AHA and EAE

http://slidepdf.com/reader/full/cardiac-measurements-guidelines-aha-and-eae 1/80

Cardiac MeasurementsGuidelines

Powered byMyLab Alpha eHD/Crystaline MyLab Seven eHD/Crystaline MyLab Class C

w: www.mideas.si

m: 00386 40 771 779

e: [email protected]

http://www.mideas.si/mylab-alpha.html

http://www.mideas.si/mylab-seven.html

http://www.mideas.si/mylab-classc.html

http://www.mideas.si/mylab-classc.html

http://www.mideas.si/mylab-seven.html

http://www.mideas.si/mylab-alpha.html

http://www.mideas.si/

http://www.esaote.com/



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: Dimensionsb) 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) Pericardium10) Aorta (Ao)

11) Pulmonary Artery (PA)

12) Inferior Vena Cava (IVC) and Pulmonary Veins



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

The following types of measurements are commonly included in a

comprehensive echocardiography report.



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

standard guidelines

② This icon identifies the level 2 measurements according to ASEstandard Guidelines

Clarification



Left Ventricle (LV)

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

Input:

- IVSd - Interventricular septal tickness at end-

diastole(green)

- LVEDD - LV End-Diastolic dimension (yellow)

- PWd - PW thickness at End-Diastolic (red)

- LVESD – LV End-Systolic dimension (right image)

Output:

- LVEF %

- LVFS (Fractional Shortening )

- LV Mass

- LVMI - LV Mass Index

- RWT - Relative wall thickness

①



LV Dimensions, wall thickness, LV mass: M-Mode (sax or plax)

Input:- IVSd (yellow)

- LVIDd – LV Internal diameter diastole (EDD)

- LVPWd – LV Posterior wall diastole (green)

- IVSs - Interventricular Septum systole (red)

- LVIDs - LV Internal diameter systole (ESD)

- LVPWs End-systolic diameter(blue)

Output:

- LV EF - (Teichholz formula)

- LV FS - (Fractional Shortening)- LVVd - Diastolic Volume

- LVVs - Systolic Volume

- SV - Stroke Volume

- SI - Stroke index

- Sept Thickening %

- PW Thickening %

- LV Mass- LVMI - LV Mass Index

Left Ventricle (LV) ①



The most commonly used 2D methods formeasuring 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 epicardiumis 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.

Left Ventricle (LV)LV Mass: 2D Mode (A-L and Truncated ellipsoid method)

Input:

A1 – Area1 Pericardial border

A2 – Area 2 Endocardial border

A-L : LV length

Output:

LV Mass

LVMI – LV Mass index

①



LV Volumes & systolic function: Simpson method

The most commonly used 2D measurementfor 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 ellipticaldisks. 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.

Input:

LV EDD – LV End-diastolic dimension (A4C)

LV ESD – LV End-systolic dimension (A4C)

LV EDD – LV End-diastolic dimension (A2C)

LV ESD – LV End-systolic dimension (A2C)

Output:

EDV – End-diastolic volume (mL)

ESV - End-systolic volume (mL)

LVDVI – LV Diastolic volume index (mL/m²)

LVSVI – LV Systolic volume index (mL/m²)

LVEF – LV Ejection fraction %

SV – Stroke Volume (mL)SI - Stroke Index




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.

Input:

LV diastolic CSA – Cross sectional area

LV diastolic length – A4C

LV systolic CSA

LV systolic length – A4C

Left Ventricle (LV) ②

Output:

EDV – End-diastolic volume (mL)

ESV - End-systolic volume (mL)

LVDVI – LV Diastolic volume index (mL/m²)

LVSVI – LV Systolic volume index (mL/m²)

LVEF – LV Ejection fraction %

SV – Stroke Volume (mL)SI - Stroke Index

①



LV Systolic function: Stroke Volume (SV), Cardiac output (CO)

CO (LV) is the volume of blood being pumped by theleft 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 IndexCI - Cardiac Index


①



LV Systolic function: MPI LV (Myocardial Performance Index)

Also known as the Tei index. It is an index

that incorporates both systolic anddiastolic 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 diastolicdysfunction result in abnormality in

myocardial relaxation which prolongs the

relaxation period (isovolumic relaxation

time, IVRT).

Input:

MCOT - Mitral valve closure to opening time (orange)

LVET - LV Ejection time (blue lines)

Output:

LV MPI – LV Myocardial performance index

Formula:

LV MPI= (IVCT + IVRT) / LVET = (MCOT – LVET) / LVET


①



LV Systolic function: dP/dt (LV Contractility)

Peak dP/dt is one of the most commonly usedindexes 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 mitralinsufficiency 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 whenthere is no significant change in LA pressure.

Formula:

dP/dt= 32/T

Input:

T - Time between 1 and 3 cm/sec

Output:

dP/dt (mmHg/s)


②



Systolic myocardial velocity (S’) at

the lateral mitral annulus is a measure

of longitudinal systolic function and iscorrelated 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 correlatedwith 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. *

* A Clinician's Guide to Tissue Doppler Imaging Carolyn Y. Ho and Scott D. Solomon Circulation. 2006;113:e396-e398

LV Systolic function: TDI

Input:

S – Systolic velocity in lateral wall A4C (red)

Left Ventricle (LV) ②



LV Wall motion score

Left Ventricle (LV)



LV Diastolic function

- PW mitral inflowIVRT (Isovolumic relaxation time)

- DTI (e′) (Tissue doppler)

- PV (Pulmonary vein) flow- Mitral inflow propagation

- LA volume

- PCWP by E/e’ (mean PulmonaryCapillary Wedge Pressure by E/e’) (Nagueh)

①



Left Ventricle (LV)

Input:

- E-wave - Peak early filling velocity (Yellow)

- A-wave - Late diastolic filling velocity (green)

- DT - Deceleration time (Blue)

- IVRT – Isovolumic relaxation time (red)

- A duration – (orange)

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 theatrial 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 pressureequalization between the LA and LV.

①

Output:

- E/A ratio

①



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 aorticand 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)

LV diastolic function: IVRT (Isovolumic relaxation time)


①



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 ofmitral 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 diastolicfunction, it is recommended to acquire and

measure tissue Doppler signals at least

at the septal and lateral sides of the mitral

annulus and their average, given the

influence of regional function on these

velocities and time intervals.

Input:

s: Systolic annular velocity (blue)

e’: early diastolic annular velocity (yellow)

a’: late diastolic velocity (green)

Output:

E/e’ ratio

e’/a’ ratio

Left Ventricle (LV)

LV diastolic function: Tissue doppler image

①

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 greaterthan 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:

S - Peak systolic vel

D - Peak diastolic vel

Ar - Reverse vel in late diatole

Ar duration

Ar - A - Time difference between Ar duration and

mitral A-wave duration


Output:

S/D Ratio

①



LV diastolic function: Mitral Inflow Propagation

Acquisition is performed in the apical 4-chamberview, 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 highestvelocity 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 isconsidered normal. During heart failure and during

myocardial ischemia, there is slowing of mitral-to-

apical flow propagation, consistent with a

reduction of apical suction.

Input:

Vp - Flow propagation velocity (doted white

Line) (cm/s)


( ) 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 ofdiastolic 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:

A1 – Max planimetry LA area - A4C

A2 – Max planimetry LA area – A2C

L - Length


Output:

LA Volume – Left atrial volume

LAVI – LA volume index

f l ( ) ①



Left Ventricle (LV)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 mitralannulus 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 ofvalues for filling pressures.

Input:

E: Mitral inflow E

velocity

e’ (lateral)

e’ (septal)

Output:

e’ (Average) - of the lateral and

septal e’ values (m/s)

E/e’: ratio

PCWP - Mean Pulmonary capillarywedge pressure (mmHg)

Formulas:

e’ = (e’ lateral + e’ septal) / 2

PCWP = 1.24 * (E/e’) + 1.9

①

①



Left Atrium (LA)

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 measuredin both the 4- and 2-chamber views and the

shortest of these

2 length measurements is used in the

formula.

①

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

Input:

A1 – Max planimetry LA area - A4C

A2 – Max planimetry LA area – A2C

L - Length

Output:

LA Diameter – (cm)

LA diameter index – cm/m²

LA Volume – Left atrial volume (mL)

LAVI – LA volume index (mL/m²)

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 maximalshortening 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

research.

Left Atrium (LA)

Input:

LAD – Left atrium diameter (cm)

②

A ti t ①



Aortic root

Aortic root dimension

Figure 19 Measurement of aortic root diameter at sinuses

of Valsava from 2-dimensional parasternal long-axis image.

Although leading edge to leading edge technique is shown,

some prefer inner edge to inner edge method.

TTE imaging.

Figure 18 Measurement of aortic root diameters at aortic

valve annulus ( AV ann) level, sinuses of Valsalva (Sinus

Val ), and sinotubular junction (ST Jxn) from midesophageal

long-axis view of aortic valve, usually at angle of

approximately 110 to 150 degrees. Annulus is measured by

convention at base of aortic leaflets. Although leading edge

to leading edge technique is demonstrated for the Sinus Val

and ST Jxn, some prefer inner edge to inner edge method.TEE imaging.

①

Input:

AV Ann – Aortic valve annulus (TEE)

Sinus Val – Sinuses of Valsalva (TEE)

ST Jxn – Sinotubular junction (TEE)

Ao – Aortic root diameter (TTE)

Ri h V i l (RV)



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.

Ri ht V t i l (RV) ①



Right Ventricle (RV)

RV Size: RV linear dimension

Using 2D echocardiography, RV size canbe 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 nomore 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

apical 4-chamber view.Input:

RV Basal - RV Basal diameter (mm)

RV mid - RV Mid diameter (mm)

RV long - RV Longitudinal diameter (mm)

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 parasternaland 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)

①

Ri h V i l (RV) ①




RV size: RV Wall thickness

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

(B) Zoom of region outlined in (A) with right ventricular wall thickness indicated by arrows.

(C) M-mode image corresponding to arrows

in (B).

(D) Zoom of region outlined in (C) with arrows indicating wall thickness at end-diastole.

RV wall thickness is a useful measurement for RVH, usually the result of RVSP overload. RV free wall thicknesscan 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:

RV Wall thickness (mm)

①

Ri h V i l (RV) ①




RV systolic function: TAPSE (Tricuspid Annular Plane Systolic Excursion)

The systolic movement of the baseof 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 annulusand measuring the amount of

longitudinal motion of the

annulus at peak systole

Input:

TAPSE – Tricuspid Annular Plane Excursion mm

①




Input:

S’ – Systolic excursion velocity

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 freewall.

+

①

Ri ht V t i l (RV) ②



Right Ventricle (RV)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 therelationship 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 pulsedDoppler 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 timeintervals are measured from a single beat by

pulsing the tricuspid annulus (left)

Output:

IVCT (Isovolumic Contraction Time)

IVRT (Isovolumic Relaxation Time)

MPI RV

Input:

ET - Ejection Time

TCO - Tric. Closure-Opening Time)

②

Ri ht V t i l (RV)

②



Right Ventricle (RV)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.

②

Ri ht V t i l (RV)

②



Right Ventricle (RV)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. Forthe 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 whenused, it should be measured at the lateral

tricuspid annulus. RV IVA is not recommended

as a screening parameter for RV systolic

function in the general echocardiography

laboratory population.

Pulsed wave tissue Doppler imaging of the RV free

wall of a control subject. 1: peak myocardial systolic

velocity (Sm), 2: peak early diastolic velocity (Em), 3:

peak late diastolic velocity (Am) 4: isovolumetric

contraction time (IVCT), 5: ejection time (ET), 6: peak

myocardial isovolumetric contraction velocity (IVV),

acceleration time (AT), isovolumetric acceleration (IVA)(red).

②




Right Ventricle (RV)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

region.

The sample volume should be placed at the tips of

the tricuspid leaflets. With this technique,

measurement of transtricuspid flow velocities canbe 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,and most studies excluded such patients.Input:

Tricuspid Flow Profile (red)

Output:

E wave velocity

A wave velocity

E/A ratio

Tricuspid E/e’

DT - Deceleration time (ms)

E

①

Right Ventricle (RV) ②



Right Ventricle (RV)RV diastolic function: Tissue doppler imaging

Input:

S’ Systolic velocity

E’ velovity

A’ velocity

Output:

E’/A’ ratio

E/E’ ratio

②

Among the most reliably and reproduciblyimaged 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 segmentof the RV free wall.

Right Ventricle (RV) ①



Right Ventricle (RV)RV hemodynamics: sPAP (Systolic pulmonary artery pressure)

SPAP can be estimated using TR velocity, and

PADP can be estimated from the end-diastolicpulmonary 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

velocity measurements are angle dependent,it is recommended to gather TR signals from

several windows and to use the signal with the

highest velocity.

Input:

TR Jet velocity

PAP mmHg

(depending on

IVC collapsability on sniff)

Output:

TR velocity

sPAP

RV Systolic pressure

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:

PR PHT (yellow)

PR Vmax – Pulmonary regurgitation

max velocity (red)

PR end Vmax - Pulmonary

regurgitation end max velocity

(green)

Output:

PA Reg PHT (ms)

PA peak diastolic gradient

dPAP (end diastolic gradient)

mPAP (mean Pulmonary

Artery pressure)

①




Right Ventricle (RV)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 thepulmonary 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 theonset of peak pulmonary flow

velocity), the higher the PVR

(Pulmonary Vascular Resistance) and

hence the PA pressure.

Input:

PA TVI - (Time velocity

Integral) (yellow)

Output:

PA AT (acceleration time)

mPAP

mPAP (mean Pulmonary

Artery pressure)

①

Right Atrium (RA) ①



Right Atrium (RA)

The primary transthoracic window for imaging the

right atrium is the apical 4-chamber view. From thiswindow, 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 theinteratrial 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

Right atrium size

Input:

RA End-Systolic Area (cm ²)

RA Major Dimension (mm)

RA Minor Dimension (mm)

①

Right Atrium (RA) ①



Right Atrium (RA)

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 ofthe 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

①

Valvular stenosis ①



Valvular stenosis

Aortic stenosis: AS jet velocity

AS jet velocity (Antegrade Systolic Velocity) isdefined 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:

AS jet velocity (m/s)

VTI – Velocity Time

integral

Output:

Mean gradient (mmHg)

①




Valvular stenosis

Aortic stenosis: AVA (Continuity equation VTI)

Aortic valve area can be calculated by usingthe 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 ismeasured 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:

LVOT diameter (mm)

VTI1 (Subvalvular VTI) (cm)

VTI2 (Max VTI across the valve

(cm)

Output:

AVA (cm²)

AVAI (Indexed to BSA)

(cm²/m²)

AVA = (CSALVOT x VTILVOT) / VTIAV

①

Valvular stenosis ②



Valvular stenosis

Aortic stenosis: AVA (Continuity equation Vmax)

②

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 / V AV

Input:

LVOT diameter (mm)

V1 (Subvalvular Velocity) (m/s)

V2 (Max velocity across the valve)

(m/s)

Output:

AVA (cm²)

AVAI (Indexed to BSA)

(cm²/m²)




Valvular stenosis

Aortic stenosis: Velocity ratio

②

Another approach to reducing error related toLVOT 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 andthe 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 / V AV

Input:

V1 (Subvalvular Velocity) (m/s)

V2 (Max velocity across the valve)

(m/s)

Output:

VR - Velocity Ratio




Valvular stenosis

Aortic stenosis: Planimetry of anatomic valve area

②

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 isunreliable. However, planimetry may be

inaccurate when valve calcification causes

shadows or reverberations limiting

identification of the orifice.

Input:

AV planimetry

Output:

AVA (cm²)



Valvular stenosisMitral 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 ofthe 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:MV PHT

Output:MV PHT (ms)

MVA (cm ²)

①




Valvular stenosis

Mitral stenosis: Pressure gradient

Mitral stenosis is the most frequent valvularcomplication 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:MV Flow profile

Output:MV Peak Velocity

MV Peak GP (mmHg)

MV mean Velocity

MV Mean GP (mmHg)

①




Valvular stenosis

Mitral stenosis: Continuity equation

②

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 MVAare 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) / VTIMitralInput:

LVOT (cm)

VTI Ao (cm)

VTI Mitral (cm)

Output:

MVA (cm²)





The proximal isovelocity surface area method is

based on the hemispherical shape of theconvergence 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°)

Output:

VFR (Volume flow rate) (cc)

MVA (cm²)

Input:

2 × π × r 2 : Proximal isovelocity hemispheric surface area at a radial

distance r from the orifice.

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)

Mitral stenosis: PISA method




Valvular stenosis

Tricuspid stenosis: CWD hemodynamic evaluation

①

Tricuspid stenosis (TS) is currently the least common of

the valvular stenosis lesions given the low incidence ofrheumatic 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 indicativeof severe TS.

However, as severity of TR increases, valve area is

progressively underestimated by this method.Input:

TV Flow profileOutput:

Peak diastolic velocity

Mean gradient (mmHg)

PHT (pressure half-time)

mmHg




Valvular stenosis

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 thetranspulmonary velocity flow curve usingthe 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

adults, this is usually most readily performed from aparasternal short-axis view.

①

Input:

Peak velocity (m/s)Output:

Peak Gradient (mmHg)

Valvular regurgitation ①



Valvular regurgitation

Aortic regurgitation: Jet diameter/LVOT diameter ratio %

①

Imaging of the regurgitant jet is used in all

patients with AR because of its simplicityand 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 LVoutflow 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 jetarea.

Is possible to use the CSA instead width

for both Jet and LVOT.Input:

Jet Width (red)

LVOT Width (yellow)

Output:

Jet width/LVOT Width ratio (%)





Aortic regurgitation: VC (Vena contracta)

The Vena contracta is the narrowest portion of theregurgitant 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 zoommode 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)

①




a u a egu g a o

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.

When feasible, the PISA method is highly

recommended to assess the severity of AR. It can

be used in both central and eccentric jets. The

window recommended is PLAX view for flow

convergence.

Input:

PISA Radius

AR VTI

Output:

AR EROA (Effective Regurgitant

Orifice Area) cm ²

AR R Vol (regurgitant volume)

mL/beat

①


①



g g

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)

①


②



Output:

EROA

R Vol.

RF (Regurgitant Fraction ) %

Aortic regurgitation: Flow quantitation - PW

g g

Quantitation of flow with pulsed Doppler for the

assessment of AR is based on comparison ofmeasurement 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 CWDoppler. 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 % indicatessevere AR. Volumetric measurements with PW

are Time consuming, and requires multiple

measurements, so the source of errors are

higher.Input:

LVOT PW profile (A5C)

LVOT diameter (PLAX)

Mitral inflow profile PW (A4C)

Mitral annulus diameter (max

opening MV (A4C)

②




g g

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 theupper 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.

①

Input:

End-diastolic velocity (cm/s)




g g

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. Thetwo-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)

①




g gMitral 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 fromthe 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 withsevere MR, 0.20-0.39 cm² moderate, and 0.20 cm²

mild MR.

Input:

PISA Radius

MR VTI

Output:

MR EROA (Effective Regurgitant

Orifice Area) cm²

MR R Vol (regurgitant volume)mL/beat

①


①



In most patients, maximum MR velocity is 4 to 6 m/sdue 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 estimatepulmonary artery systolic pressure. The presence of

pulmonary hypertension provides another indirect

clue as to MR severity and compensation to the

volume overload.

g gMitral regurgitation: Continuous wave doppler

Input:

MR VTI

Output:

MR Peak velocity (m/s)

①


②



g gMitral regurgitation: Mitral to Aortic TVI ratio

In the absence on mitral stenosis, the increase in

transmitral flow that occurs with increasing MRseverity 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 forsevere MR. They represent the strongest additional

parameters for evaluating MR severity.

Input:

Mitral VTI

Aortic VTI

Output:

Mitral to Aortic VTI ratio

②


②



g gMitral 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 occurat 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

deep into the pulmonary vein.

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.

Pulmonary venous flow is a qualitativeparameter, no measurements have to be

done.

Valvular regurgitation ②



Output:

MR EROA

MR R Vol.

MR RF (Regurgitant Fraction ) %

g g

Input:

LVOT PW profile (A5C)

LVOT diameter (PLAX)

Mitral inflow profile PW (A4C)

Mitral annulus diameter (max

opening MV (A4C)

Mitral regurgitation: Flow quantitation - PW

Pulsed Doppler tracings at the mitral leaflet tips

are commonly used to evaluate LV diastolicfunction. 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 thevelocity 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.




①



Tricuspid regurgitation: Flow convergence (PISA)

Although providing quantitative assessment, clinical

practice reveals that the flow convergence method israrely 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:

TR PISA Radius

TR VTI

Output:

TR EROA (Effective Regurgitant

Orifice Area) cm²

TR R Vol (regurgitant volume)

mL/beat

② Valvular regurgitation



Tricuspid regurgitation: CW jet velocity

Recording of TR jet velocity provides a

useful method for noninvasivemeasurement 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 evaluatingseverity of regurgitation, are the signal

intensity and the contour of the

velocity curve.

Input:

TR flow profile


②



Tricuspid regurgitation: Anterograde velocity of tricuspid inflow

A small degree of tricuspid regurgitation

(TR) is present in about 70% of normalindividuals. 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 heartdisease, 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 inproportion to the degree of TR. Tricuspid

inflow Doppler tracings are obtained at

the tricuspid leaflet tips. A peak E velocity

≥1 m/s suggests severe TR

Input:

E wave velocity




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 mappingis 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 froma high inter-observer variability, a jet

width that occupies >65% of the RV

outflow tract width measured in the same

frame is in favour of severe PR.

Input:

Color Jet width (white)

RVOT width (yellow)

Output:

Jet to RVOT width ratio (%)




Pulmonary regurgitation: Vena contracta (VC)

Although the vena contracta width is

probably a more accurate method thanthe 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)


②



Pulmonary regurgitation: Jet density and deceleration rate

CW Doppler is frequently used to measurethe 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:

PR PHT

Output:

Deceleration rate (ms)



Prosthetic valves



Prosthetic aortic valves: doppler investigation (formulas previously described)

Doppler echocardiography of

the valve

- Peak velocity gradient

- 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 respectivepeak velocities. (simplified continuity equation)

DVI = Doppler Velocity Index

VLVO = Subvalvular (LVOT) velocity

VPR AV = Max velocity across the valve

Prosthetic valves




the valve

- Peak early velocity

- Mean gradient

- Heart rate at the time of Doppler

- Pressure half-time

- DVI*: (Doppler velocity index)

- EOA (Effective oriffice area)

- Presence, location, and severityof regurgitation†

Other pertinent

echocardiographic and doppler

parameters

- LV size and function

- RV size and function

- Estimation of pulmonary arterypressure

* DVI = VPrMV / VLVO DVI is the Ratio of respective VTIs, and can

be approximated as the ratio of the respectivepeak velocities. (simplified continuity equation)

Prosthetic mitral valves: doppler investigation (formulas previously described)

VPRMV = Max velocity across the prosthetic mitral valve

Prosthetic valves




the valve

- Peak velocity/peak gradient

- Mean gradient

- DVI *

- EOA*

- Presence, location, and severityof regurgitation

Related cardiac chambers - RV size, function, and hypertrophy

- RV systolic pressure

* Theoretically possible to measure. Few data exist.

Prosthetic pulmonary valves: doppler investigation (formulas previously described)

Prosthetic valves




the valve

- Peak early velocity

- Mean gradient

- Heart rate at time of Doppler

assessment

- Pressure half-time

- VTIPRTV / VTILVO *

- EOA

- Presence, location, and severity of TR

Related cardiac chambers,

inferior vena cava and hepaticveins

- RV size and function

- Right atrial size

- Size of inferior vena cava and

response to inspiration- Hepatic vein flow pattern

Prosthetic tricuspid valves: doppler investigation (formulas previously described)

* 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

cardiac measurements guidelines | aha and eae

Documents