valvular stenosis

Valvular StenosisValvular Stenosis

Susan A. Raaymakers, MPAS, PA-C, RDCS (AE)(PE)Susan A. Raaymakers, MPAS, PA-C, RDCS (AE)(PE)

Radiologic and Imaging Sciences - EchocardiographyRadiologic and Imaging Sciences - Echocardiography

Grand Valley State University, Grand Rapids, MichiganGrand Valley State University, Grand Rapids, Michigan

[email protected]@gvsu.edu

Basic PrinciplesBasic PrinciplesApproach to Evaluation Valvular StenosisApproach to Evaluation Valvular Stenosis

Complete echocardiographic evaluationComplete echocardiographic evaluation Diagnostic imaging of the valve to define the etiology of Diagnostic imaging of the valve to define the etiology of

stenosisstenosis

Quantification of stenosis severityQuantification of stenosis severity

Evaluation of coexisting valvular lesionsEvaluation of coexisting valvular lesions

Assessment of left ventricular systolic functionAssessment of left ventricular systolic function

Response to chronic pressure overload of other upstream Response to chronic pressure overload of other upstream cardiac chambers, and the pulmonary vascular bedcardiac chambers, and the pulmonary vascular bed

Echocardiographic information integration with pertinent Echocardiographic information integration with pertinent clinical dataclinical data

Fluid Dynamics of Valvular StenosisFluid Dynamics of Valvular StenosisHigh Velocity JetHigh Velocity Jet

Characterized by formation of a laminar, Characterized by formation of a laminar, high velocity jet in the narrowed orificehigh velocity jet in the narrowed orifice Flow profile in cross section of origin is flat Flow profile in cross section of origin is flat

(blunt) – (blunt) – Remains blunt as the jet reaches the narrowest cross-Remains blunt as the jet reaches the narrowest cross-

sectional area in the vena contractasectional area in the vena contracta

Physiologic cross-sectional area < anatomic cross-Physiologic cross-sectional area < anatomic cross-sectional areasectional area

Fluid Dynamics of Valvular StenosisFluid Dynamics of Valvular StenosisHigh Velocity JetHigh Velocity Jet

Length of high velocity jet is dependent on:Length of high velocity jet is dependent on: Orifice geometryOrifice geometry

Examples:Examples: Very short jet across a deformed, irregular Very short jet across a deformed, irregular

calcified aortic valvecalcified aortic valve Longer jet along smoother tapering symmetric Longer jet along smoother tapering symmetric

rheumatic mitral valverheumatic mitral valve

Rheumatic Heart DiseaseRheumatic Heart Disease Heart valves are damaged by a disease process that Heart valves are damaged by a disease process that

begins with a sore throat from streptococcal begins with a sore throat from streptococcal infection. infection.

Untreated, the streptococcal infection can develop into acute Untreated, the streptococcal infection can develop into acute rheumatic fever.rheumatic fever.

Rheumatic fever is an inflammatory disease that can affect many Rheumatic fever is an inflammatory disease that can affect many connective tissues of the body, especially those of the heart, joints, connective tissues of the body, especially those of the heart, joints, brain or skin. brain or skin.

Who is at risk of rheumatic heart disease?Who is at risk of rheumatic heart disease? Anyone can get acute rheumatic fever, but it usually occurs in children Anyone can get acute rheumatic fever, but it usually occurs in children

five to fifteen years old. The resulting rheumatic heart disease can last five to fifteen years old. The resulting rheumatic heart disease can last for life. for life.

What are the symptoms of rheumatic heart disease?What are the symptoms of rheumatic heart disease? The symptoms vary greatly from person to person. Often the damage The symptoms vary greatly from person to person. Often the damage

to heart valves is not immediately noticeable.to heart valves is not immediately noticeable. A damaged heart valve either does not completely close or does not A damaged heart valve either does not completely close or does not

completely open.completely open.

Rheumatic Heart DiseaseRheumatic Heart Disease Mitral Mitral stenosisstenosis

Progressive fibrosisProgressive fibrosis Thickening and calcification of valveThickening and calcification of valve

Enlargement of LAEnlargement of LA Formation of mural thrombiFormation of mural thrombi Funnel shaped Funnel shaped “fish-mouthed” mitral valve“fish-mouthed” mitral valve MS and MRMS and MR AS and AIAS and AI

Non-dynamic images

Fluid Dynamics of Valvular StenosisFluid Dynamics of Valvular Stenosis Relationship between Pressure Gradient and Relationship between Pressure Gradient and

VelocityVelocity Simply stated: Simplified Bernoulli Simply stated: Simplified Bernoulli

equationequation

4V4V22

Fluid Dynamics of Valvular StenosisFluid Dynamics of Valvular Stenosis Distal Flow DisturbanceDistal Flow Disturbance

Distal to stenotic jetDistal to stenotic jet Flowstream becomes disorganized w/multiple Flowstream becomes disorganized w/multiple

blood flow velocities and directionsblood flow velocities and directions Distance that flow disturbance propagates Distance that flow disturbance propagates

downstream is related to stenosis severitydownstream is related to stenosis severity

Aortic proximal flow patternsAortic proximal flow patterns Proximal to a stenotic valveProximal to a stenotic valve

Flow is smooth and laminar (organized) with normal Flow is smooth and laminar (organized) with normal flow velocityflow velocity

““Flat” flow profileFlat” flow profile


Mitral valve proximal velocitiesMitral valve proximal velocities Left atrial to left ventricular pressure Left atrial to left ventricular pressure

gradient drives flow passively from gradient drives flow passively from the left atrium abruptly across the the left atrium abruptly across the stenotic orificestenotic orifice

Proximal flow acceleration is Proximal flow acceleration is prominent over a large region of the prominent over a large region of the left atriumleft atrium

3D velocity profile is curved: flow 3D velocity profile is curved: flow velocities are velocities are

Faster adjacent to and in the center of Faster adjacent to and in the center of a line continuous with the jet direction a line continuous with the jet direction through the narrowed orifice through the narrowed orifice

Slower at increasing radial distances Slower at increasing radial distances from the valve orificefrom the valve orifice

Hemi-elliptical in comparison to a Hemi-elliptical in comparison to a stenotic semilunar valvestenotic semilunar valve


Take home messageTake home message Stroke volumeStroke volume

Calculated proximal to a Calculated proximal to a stenotic valvestenotic valve

Based on knowledge of Based on knowledge of cross-sectional area of cross-sectional area of flow and spatial mean flow and spatial mean flow velocity over a flow velocity over a period of flowperiod of flow

Aortic StenosisAortic Stenosis

Classified as Three TypesClassified as Three Types

1.1. ValvularValvular

2.2. SubaorticSubaortic

3.3. Supra-valvularSupra-valvular

Diagnostic Imaging of the Aortic Diagnostic Imaging of the Aortic ValveValve

Aortic stenosis most often due to:Aortic stenosis most often due to: Calcific aortic stenosisCalcific aortic stenosis Congenital valve disease (most often Congenital valve disease (most often

bicuspid. In rare instances or bicuspid. In rare instances or unicuspid or quadracuspid)unicuspid or quadracuspid)

Rheumatic valve diseaseRheumatic valve disease

Diagnostic Imaging of the Aortic Diagnostic Imaging of the Aortic ValveValve

Calcific Aortic StenosisCalcific Aortic Stenosis Most common etiology of aortic Most common etiology of aortic

stenosisstenosis Degenerative age related calcificationDegenerative age related calcification Occurs slowly over many yearsOccurs slowly over many years

Initially presents as “sclerosis” area of Initially presents as “sclerosis” area of increased echogenicity typically at base increased echogenicity typically at base of valve leaflets sans significant of valve leaflets sans significant obstruction to left ventricular outflowobstruction to left ventricular outflow

Aortic StenosisAortic StenosisCalcific/DegenerativeCalcific/Degenerative

Mean age 60 – 70 Mean age 60 – 70 Clinically significant obstruction occurs Clinically significant obstruction occurs

typically from age 70-85 years oldtypically from age 70-85 years old Most common cause of aortic stenosisMost common cause of aortic stenosis

10-007 Feigenbaum

Pathologic specimen of a severely stenotic Pathologic specimen of a severely stenotic trileaflet aortic valve, which demonstrates trileaflet aortic valve, which demonstrates

gross nodular athero-calcific changes on the gross nodular athero-calcific changes on the aortic side ofaortic side ofthe leaflets.the leaflets.


Systolic leaflet excursion of less than 15 mm by Systolic leaflet excursion of less than 15 mm by 2D or M-mode2D or M-mode Severe obstruction is reliably excludedSevere obstruction is reliably excluded

Again 10-007 Feigenbaum


Planimetry of aortic valve is possible Planimetry of aortic valve is possible in some patientsin some patients Interpretation with caution due to Interpretation with caution due to

complex 3D anatomy of the orifice in complex 3D anatomy of the orifice in calcific degenerative stenosiscalcific degenerative stenosis

Ensure image plane is aligned at Ensure image plane is aligned at narrowest orifice of the valvenarrowest orifice of the valve

2D represents anatomic valve area – 2D represents anatomic valve area – Doppler data reflects functional valve Doppler data reflects functional valve areaarea

PlanimetryPlanimetry

10-006b Feigenbaum

Aortic Stenosis - Bicuspid ValveAortic Stenosis - Bicuspid Valve

Severe calcification: difficult to Severe calcification: difficult to differentiate between bicuspid and differentiate between bicuspid and tricuspid aortic valvetricuspid aortic valve

http://info.med.yale.edu/intmed/cardio/echo_atlas/entities/aortic_stenosis_senile.html

Aortic Stenosis - Bicuspid ValveAortic Stenosis - Bicuspid Valve

Average age of onset of calcific Average age of onset of calcific stenosis symptom is younger: usually stenosis symptom is younger: usually 45 to 65 years old45 to 65 years old

http://info.med.yale.edu/intmed/cardio/echo_atlas/entities/aortic_stenosis_senile.html

Aortic Stenosis - Bicuspid ValveAortic Stenosis - Bicuspid Valve Can be identified best in parasternal Can be identified best in parasternal

short-axis viewshort-axis view Football shaped openingFootball shaped opening

Long-axis: “dome-like” appearanceLong-axis: “dome-like” appearance Typically leaflets are unequal in sizeTypically leaflets are unequal in size

If anterior-posterior opening: anterior leaflet is If anterior-posterior opening: anterior leaflet is largerlarger

If lateromedial opening: rightward leaflet is If lateromedial opening: rightward leaflet is largerlarger

Aortic Stenosis - Bicuspid ValveAortic Stenosis - Bicuspid Valve Often have raphae (seam-like line or ridge) Often have raphae (seam-like line or ridge)

in the larger leaflet: closed valve appears in the larger leaflet: closed valve appears trileaflettrileaflet Identify as trileaflet only in systoleIdentify as trileaflet only in systole

18-34a & b Feigenbaum

Aortic Stenosis – Unicuspid Aortic Stenosis – Unicuspid ValveValve

http://www.med.yale.edu/intmed/cardio/chd/c_unic_aov/index.html

Aortic Stenosis - RheumaticAortic Stenosis - Rheumatic Rheumatic valvular disease preferentially involves Rheumatic valvular disease preferentially involves

mitral valvemitral valve Rheumatic aortic stenosis occurs concurrently with Rheumatic aortic stenosis occurs concurrently with

rheumatic mitral valve diseaserheumatic mitral valve disease

Results in commissural fusion of the aortic leaflets Results in commissural fusion of the aortic leaflets similar to rheumatic mitral diseasesimilar to rheumatic mitral disease

Appears similar to calcific aortic stenosis (if mitral Appears similar to calcific aortic stenosis (if mitral involved suspect aortic stenosis due to rheumatic involved suspect aortic stenosis due to rheumatic disease)disease)

SummarySummary

Aortic Stenosis - CongenitalAortic Stenosis - Congenital Usually diagnosed at childhoodUsually diagnosed at childhood

May not become symptomatic until young May not become symptomatic until young adulthoodadulthood

May be resultant from re-stenosis after surgical May be resultant from re-stenosis after surgical valvotomyvalvotomy

Aortic StenosisAortic StenosisDifferential DiagnosisDifferential Diagnosis

Left ventricular outflow tract obstructionLeft ventricular outflow tract obstruction Fixed valvular obstructionFixed valvular obstruction

Subaortic membrane or a muscular subaortic Subaortic membrane or a muscular subaortic stenosisstenosis

Dynamic subaortic obstructionDynamic subaortic obstruction Hypertrophic cardiomyopathyHypertrophic cardiomyopathy

Supravalvular stenosisSupravalvular stenosis


Fixed valvular obstructionFixed valvular obstruction Subaortic membraneSubaortic membrane

Suspect when valve anatomy is not clearly Suspect when valve anatomy is not clearly stenotic even though Doppler velocity and stenotic even though Doppler velocity and color flow indicates stenosiscolor flow indicates stenosis

TTE vs TEETTE vs TEE10-027 Feigenbaum

Subaortic Membrane – Fixed Subaortic Membrane – Fixed Subvalvular StenosisSubvalvular Stenosis

18-30 Feigenbaum

Dynamic Subvalvular Dynamic Subvalvular StenosisStenosis

19-29a Feigenbaum

Supravalvular stenosis in a 30 year old with Supravalvular stenosis in a 30 year old with familial hypercholesterolemiafamilial hypercholesterolemia

Non-dynamic

Aortic StenosisAortic StenosisQuantitation of Stenosis SeverityQuantitation of Stenosis Severity

Measurement of maximum aortic jet velocityMeasurement of maximum aortic jet velocity Calculation of mean and maximum gradientCalculation of mean and maximum gradient Determination of continuity equation valve areaDetermination of continuity equation valve area Ratio of outflow tract to aortic jet velocityRatio of outflow tract to aortic jet velocity


Dependence of pressure gradients on Dependence of pressure gradients on volume flow ratevolume flow rate Coexisting aortic regurgitation = high Coexisting aortic regurgitation = high

transaortic pressure gradient transaortic pressure gradient Depressed ejection fraction/coexisting mitral Depressed ejection fraction/coexisting mitral

regurgitation = low transaortic pressureregurgitation = low transaortic pressure Coexisting conditions common in adults with Coexisting conditions common in adults with

aortic stenosisaortic stenosis


Continuity EquationContinuity Equation Stroke volume proximal to valve = Stroke volume proximal to valve =

transvalvular stroke volumetransvalvular stroke volume CSA CSA LVOTLVOT X VTI X VTI LVOTLVOT = CSA = CSA AoAo X VTI X VTI AoAo

Aortic StenosisAortic StenosisAortic Valve IndexAortic Valve Index

Effect of body size into accountEffect of body size into account

AVA index = AVA/BSAAVA index = AVA/BSA

Aortic StenosisAortic StenosisTechnical Considerations and Technical Considerations and

PitfallsPitfalls Continuity equation valve areas: well Continuity equation valve areas: well

validated in comparison with Gorlin validated in comparison with Gorlin formulaformula

Continuous wave Doppler needed d/t high Continuous wave Doppler needed d/t high velocitiesvelocities Use of non-imaging transducer learning curveUse of non-imaging transducer learning curve Parallel to flow: utilize several windowsParallel to flow: utilize several windows

Outflow tract diameter: measure in mid-Outflow tract diameter: measure in mid-systole (inner edge to leading edge)systole (inner edge to leading edge)

Aortic StenosisAortic StenosisCoexisting Valvular DiseaseCoexisting Valvular Disease

Approximately 80% of patients with Approximately 80% of patients with predominate aortic stenosis have predominate aortic stenosis have coexisting aortic regurgitationcoexisting aortic regurgitation

Regurgitation does not alter Regurgitation does not alter continuity calculation valve area continuity calculation valve area calculationscalculations

Aortic StenosisAortic StenosisResponse of the Left Ventricle to Valvular Aortic Response of the Left Ventricle to Valvular Aortic

StenosisStenosis

Chronic overloadChronic overload Concentric left ventricular Concentric left ventricular

hypertrophyhypertrophy LV systolic function typically LV systolic function typically

preserved until late in disease coursepreserved until late in disease course Dysfunction due to increased afterload Dysfunction due to increased afterload

and often reversible post repairand often reversible post repair

Aortic StenosisAortic StenosisResponse of the Left Ventricle to Valvular Aortic Response of the Left Ventricle to Valvular Aortic

StenosisStenosis

Female vs. maleFemale vs. male Female: Female:

More hypertrophyMore hypertrophy Smaller ventricles Smaller ventricles Preserved systolic functionPreserved systolic function

Male:Male: Less hypertrophyLess hypertrophy More left ventricular dilationMore left ventricular dilation Higher prevalence of systolic dysfunctionHigher prevalence of systolic dysfunction

Aortic StenosisAortic StenosisClinical Applications in Specific Patient PopulationsClinical Applications in Specific Patient Populations

Symptomatic Aortic StenosisSymptomatic Aortic Stenosis

Doppler evaluationDoppler evaluation Aortic jet maximum velocity: simplest and Aortic jet maximum velocity: simplest and

most quantitativemost quantitative >4 m/sec considered surgical>4 m/sec considered surgical

May have >4 m/sec and coexisting MR = not surgicalMay have >4 m/sec and coexisting MR = not surgical <3 m/sec significant aortic stenosis unlikely; <3 m/sec significant aortic stenosis unlikely;

valve replacement unnecessaryvalve replacement unnecessary Caution: parallel to flow and systolic dysfunctionCaution: parallel to flow and systolic dysfunction


Asymptomatic Aortic Stenosis: Disease Asymptomatic Aortic Stenosis: Disease Progression and PrognosisProgression and Prognosis

ReproducibilityReproducibility Recording variabilityRecording variability

Intercept angle, wall filters, signal strength, acoustic Intercept angle, wall filters, signal strength, acoustic windowwindow

Measurement variabilityMeasurement variability Identification of the maximum velocity, outflow tract Identification of the maximum velocity, outflow tract

diameterdiameter Physiologic variabilityPhysiologic variability

Interim changes in heart rate, stroke volume, or Interim changes in heart rate, stroke volume, or pressure gradientpressure gradient


Asymptomatic Aortic Stenosis: Disease Progression Asymptomatic Aortic Stenosis: Disease Progression and Prognosisand Prognosis

Doppler echocardiographyDoppler echocardiography Prognosis depends o presence or absence of clinical Prognosis depends o presence or absence of clinical

symptoms and not on hemodynamics severitysymptoms and not on hemodynamics severity Rate of hemodynamic progression is variable from Rate of hemodynamic progression is variable from

patient to patientpatient to patient On average: On average:

Increase of 0.3 m/sec per yearIncrease of 0.3 m/sec per year Increase of mean pressure of 7 mmHg per yearIncrease of mean pressure of 7 mmHg per year Valvular size decrease of 0.1 cmValvular size decrease of 0.1 cm22 per year per year

Concurrent decrease in volume flow rate may obscure Concurrent decrease in volume flow rate may obscure disease progression resulting in no change in jet velocitydisease progression resulting in no change in jet velocity

Aortic StenosisAortic Stenosis2D Criteria2D Criteria Systolic “doming” and diastolic prolapse represent Systolic “doming” and diastolic prolapse represent

congenital featurescongenital features Usually thickened valve leaflets with restricted motion. Usually thickened valve leaflets with restricted motion.

Doming during early systole.Doming during early systole. Concentric left ventricular hypertrophy with normal LV Concentric left ventricular hypertrophy with normal LV

cavity size. LA size will be increased (late in course of cavity size. LA size will be increased (late in course of AS)AS)

http://www.med.yale.edu/intmed/cardio/chd/e_as/index.html

Aortic StenosisAortic StenosisDobutamine EchocardiographyDobutamine Echocardiography

Dobutamine is a drug used to increase stroke volume Dobutamine is a drug used to increase stroke volume across the stenotic valve. across the stenotic valve.

Mild to moderate stenosis valve leaflets will open wider Mild to moderate stenosis valve leaflets will open wider with increase in stroke volume. with increase in stroke volume.

True severe stenosisTrue severe stenosis Valve will not open wider Valve will not open wider Dobutamine infusion will increase the maximum Dobutamine infusion will increase the maximum

velocity of both the outflow tract and the jet velocity of both the outflow tract and the jet proportionally. proportionally.

In milder forms of stenosis, increase in velocity of the left In milder forms of stenosis, increase in velocity of the left ventricular outflow tract will be much greater than that of ventricular outflow tract will be much greater than that of the jet (due to the increase in valve area)the jet (due to the increase in valve area)

Limitation of zero change in velocity resultsLimitation of zero change in velocity results

Aortic StenosisAortic StenosisDobutamine Stress EchocardiographyDobutamine Stress Echocardiography

10-022 Feigenbaum

Additional InformationAdditional Information

http://www.echo-web.com/asp/http://www.echo-web.com/asp/samples/sample5.aspsamples/sample5.asp

Mitral StenosisMitral Stenosis

Mitral StenosisMitral StenosisDiagnostic Imaging of the Mitral Diagnostic Imaging of the Mitral

ValveValveEvaluate:Evaluate: Valve anatomy, mobility and Valve anatomy, mobility and

calcificationcalcification Mean transmitral pressure gradientMean transmitral pressure gradient 2D echo mitral valve area2D echo mitral valve area Doppler pressure half-time areaDoppler pressure half-time area Pulmonary artery pressuresPulmonary artery pressures Coexisting mitral regurgitationCoexisting mitral regurgitation

Technical ConsiderationsTechnical Considerations Accurate pressure gradient calculations Accurate pressure gradient calculations

depend on accurate velocity measurementsdepend on accurate velocity measurements

PW Doppler signals may show better PW Doppler signals may show better definition of the maximum velocity and definition of the maximum velocity and early diastolic slope than CW Dopplerearly diastolic slope than CW Doppler Better signal-to-noise ratioBetter signal-to-noise ratio

Mitral Valve Area-2DMitral Valve Area-2D Simpler planimetry than with aortic valveSimpler planimetry than with aortic valve

Well validated compared with valve area at Well validated compared with valve area at surgery and catheterization-determined valve surgery and catheterization-determined valve areasareas

Shape of inflow region similar to a funnelShape of inflow region similar to a funnel Important to perform planimetry at leaflet tipsImportant to perform planimetry at leaflet tips

Begin at apex and scan toward leaflet tips and low gainBegin at apex and scan toward leaflet tips and low gain

Technical ConsiderationsTechnical Considerations Direct planimetry of mitral valve area Direct planimetry of mitral valve area

on 2D shown to be a valid technique on 2D shown to be a valid technique in most clinical situationsin most clinical situations Size may be underestimated if gain is Size may be underestimated if gain is

too low (and vice versa)too low (and vice versa) Image at leaflet tipsImage at leaflet tips

Mitral Valve AreaMitral Valve AreaPressure Half-TimePressure Half-Time

Rate of pressure decline across the stenotic mitral Rate of pressure decline across the stenotic mitral orifice is determined by the cross-sectional area orifice is determined by the cross-sectional area of the orificeof the orifice Smaller the orifice, the slower the rate of declineSmaller the orifice, the slower the rate of decline

Image right: maximum velocity and diastolic slope are identified. Pressure half-time of 226 ms corresponds to valve area of 1 cm2. No a-wave d/t atrial fibrillation

Mitral Valve AreaMitral Valve AreaPressure Half-TimePressure Half-Time

Influence of atrial and ventricular Influence of atrial and ventricular compliance is assumed to be negligiblecompliance is assumed to be negligible Assumption not always warranted especially Assumption not always warranted especially

after percutaneous commissurotomyafter percutaneous commissurotomy

Mitral StenosisMitral StenosisDifferential DiagnosisDifferential Diagnosis

Includes other grounds of pulmonary Includes other grounds of pulmonary congestioncongestion

Standard echocardiography evaluationStandard echocardiography evaluation LV systolic functionLV systolic function Aortic valve diseaseAortic valve disease Presence of mitral regurgitationPresence of mitral regurgitation Diastolic LV functionDiastolic LV function Rare case of atrial myxoma or other atrial tumor Rare case of atrial myxoma or other atrial tumor

obstruction to LV inflowobstruction to LV inflow Rare case of cor triatriatumRare case of cor triatriatum

Mitral StenosisMitral StenosisRheumatic DiseaseRheumatic Disease

Predominately affects mitral valvePredominately affects mitral valve Most common cause of mitral Most common cause of mitral

stenosisstenosis Characterized by commissural fusionCharacterized by commissural fusion

Results in bowing or doming of the valve Results in bowing or doming of the valve leaflets in diastoleleaflets in diastole

Base and midsections of leaflets Base and midsections of leaflets move toward ventricular apexmove toward ventricular apex

Rheumatic Heart DiseaseRheumatic Heart Disease

Mitral StenosisMitral StenosisRheumatic Disease - continuedRheumatic Disease - continued

Motion of the leaflet tips is restricted Motion of the leaflet tips is restricted due to fusion of the anterior and due to fusion of the anterior and posterior leaflets along the medial posterior leaflets along the medial and lateral commissuresand lateral commissures

Thickening of leaflet tips occurs Thickening of leaflet tips occurs frequentlyfrequently

May have normal thickening of base May have normal thickening of base and midportionsand midportions

Often calcification and fibrosis of Often calcification and fibrosis of chordae tendinaechordae tendinae

Mitral StenosisMitral StenosisRheumatic DiseaseRheumatic Disease

11-011 Feigenbaum

Mitral Annular Calcification Mitral Annular Calcification (MAC)(MAC)

Common finding in elderly patientsCommon finding in elderly patients Mild MAC appearanceMild MAC appearance

Isolated area of calcification on the left ventricular side of the posterior Isolated area of calcification on the left ventricular side of the posterior annulus, near the base of the posterior mitral leafletannulus, near the base of the posterior mitral leaflet

Area of fibrous continuity between aortic root and anterior mitral leaflet Area of fibrous continuity between aortic root and anterior mitral leaflet is rarely involvedis rarely involved

MAC may result in mid-to-moderate MR d/t increased rigidity of mitral MAC may result in mid-to-moderate MR d/t increased rigidity of mitral annulusannulus

Occasionally MAC extends into based of mitral leaflets resulting in functional Occasionally MAC extends into based of mitral leaflets resulting in functional mitral stenosis (MS) due to narrowing of inflow areamitral stenosis (MS) due to narrowing of inflow area

Mitral Annular CalcificationMitral Annular Calcification

Degenerative process seen frequently Degenerative process seen frequently in older patientsin older patients

MAC can vary from very mild to very MAC can vary from very mild to very severesevere

Precise cause of MAC is not fully Precise cause of MAC is not fully knownknown

Mitral Annular CalcificationMitral Annular Calcification

TheoryTheory Natural step in the degeneration of the Natural step in the degeneration of the

cardiovascular fibrous tissue that occurs cardiovascular fibrous tissue that occurs in the older populationin the older population

Predisposing factors include: Advanced Predisposing factors include: Advanced Age, Female Gender, Diseases that Age, Female Gender, Diseases that Increase Stress on Mitral Valve ApparatusIncrease Stress on Mitral Valve Apparatus

Mitral Annular Calcification Mitral Annular Calcification

MAC May Contribute MAC May Contribute to the Following:to the Following:

Conduction Conduction DisturbancesDisturbances

StrokeStroke

Infective Infective EndocarditisEndocarditis

11-089 Feigenbaum

Mitral Stenosis: Mitral Stenosis: Left Atrial Enlargement and Left Atrial Enlargement and

ThrombusThrombus Chronic pressure overload Chronic pressure overload

Gradual enlargement of left atrium Gradual enlargement of left atrium Stasis of blood due to low volume rate Stasis of blood due to low volume rate

Results in thrombiResults in thrombi Preferential to left atrial appendagePreferential to left atrial appendage May occur in body of atrium as protruding or as May occur in body of atrium as protruding or as

laminated thrombus along atrial wall or interatrial laminated thrombus along atrial wall or interatrial septumseptum

Most often occurs in conjunction with atrial fibrillation Most often occurs in conjunction with atrial fibrillation but may occur in NSRbut may occur in NSR

Br Heart J. 1975 December; 37(12): 1281–1285


ThrombusThrombus TTE TTE

High specificity for detection of left atrial High specificity for detection of left atrial thrombusthrombus

Low sensitivity <50%Low sensitivity <50% Challenge is imaging left atrial Challenge is imaging left atrial

appendageappendage TEETEE

High specificity >99%High specificity >99% High sensitivity >99%High sensitivity >99%

Non-dynamic

Mitral Stenosis: Mitral Stenosis: Left Atrial Enlargement and ThrombusLeft Atrial Enlargement and Thrombus

21-40a Feigenbaum


ThrombusThrombus

21-41 Feigenbaum

Pulmonary HypertensionPulmonary Hypertension Left atrial Left atrial

pressure pressure leads toleads to Pulmonary Pulmonary

venous venous hypertension hypertension leads toleads to

Pulmonary Pulmonary artery artery hypertensionhypertension

Pulmonary HypertensionPulmonary Hypertension ChronicChronic

Irreversible changes in the pulmonary Irreversible changes in the pulmonary vascular bed occurvascular bed occur

Elevated pulmonary vascular resistance and Elevated pulmonary vascular resistance and persistence of pulmonary hypertension even persistence of pulmonary hypertension even after relief of mitral stenosisafter relief of mitral stenosis

Pulmonary HypertensionPulmonary Hypertension Suspect pulmonary hypertension in mitral Suspect pulmonary hypertension in mitral

stenosis when there is existing:stenosis when there is existing: Mid-systolic partial closure (“notching” of Mid-systolic partial closure (“notching” of

pulmonic valve m-modepulmonic valve m-mode Short interval between onset of flow and Short interval between onset of flow and

maximum velocitymaximum velocity Severe pulmonary hypertensionSevere pulmonary hypertension

2D echocardiographic finding2D echocardiographic finding RVH and RVERVH and RVE Paradoxic septal motionParadoxic septal motion Tricuspid regurgitation secondary to annular dilationTricuspid regurgitation secondary to annular dilation

Mitral Stenosis with Mitral Mitral Stenosis with Mitral RegurgitationRegurgitation

Coexisting regurgitation common in Coexisting regurgitation common in patients with mitral stenosispatients with mitral stenosis

Mitral regurgitation will be covered in Mitral regurgitation will be covered in next lecture materialnext lecture material

Mitral Stenosis with Co-Mitral Stenosis with Co-Existing Other Valvular Existing Other Valvular

DiseaseDisease Rheumatic disease may also affect Rheumatic disease may also affect

Aortic valve (second in frequency to mitral Aortic valve (second in frequency to mitral valve)valve)

Stenosis and/or regurgitationStenosis and/or regurgitation Aortic regurgitation may complicate assessment of Aortic regurgitation may complicate assessment of

mitral stenosis due to merging of two diastolic jetsmitral stenosis due to merging of two diastolic jets Tricuspid valve (less commonly)Tricuspid valve (less commonly)

Tricuspid stenosis due to rheumatic disease difficult Tricuspid stenosis due to rheumatic disease difficult to appreciate on 2D imagingto appreciate on 2D imaging

TR may also be caused by mitral stenosis resultant TR may also be caused by mitral stenosis resultant pulmonary hypertensionpulmonary hypertension

Mitral Stenosis –Left Mitral Stenosis –Left Ventricular ResponseVentricular Response

Left ventricleLeft ventricle Small with normal wall thickness and Small with normal wall thickness and

normal systolic functionnormal systolic function Diastolic dysfunction is impaired due to Diastolic dysfunction is impaired due to

mitral inflow restrictionmitral inflow restriction Presence of dilation suggests coexistentPresence of dilation suggests coexistent

Mitral or aortic regurgitationMitral or aortic regurgitation Primary myocardial dysfunction Primary myocardial dysfunction

(cardiomyopathy or ischemic disease)(cardiomyopathy or ischemic disease)

Pre- and Postpercutaneous CommissurotomyPre- and Postpercutaneous Commissurotomy

Balloon mitral balloon valvotomy/ Balloon mitral balloon valvotomy/ commissurotomycommissurotomy Echo Doppler evaluation important for Echo Doppler evaluation important for

patient selection in terms of patient selection in terms of Predicted hemodynamic resultsPredicted hemodynamic results Risk of procedural complicationsRisk of procedural complications

May use qualitative assessment, an May use qualitative assessment, an additive scoring system or quantitative additive scoring system or quantitative measurements of leaflet mobility measurements of leaflet mobility (see (see Textbook written by Otto on Valvular Textbook written by Otto on Valvular Stenosis)Stenosis)

Best hemodynamic resultsBest hemodynamic results Thin, mobile leaflets that have commissural fusion but Thin, mobile leaflets that have commissural fusion but

little calcification or subchordal thickeninglittle calcification or subchordal thickening

Patients with most heavily calcified and Patients with most heavily calcified and deformed valvesdeformed valves More likely to suffer procedure-related morbidity and More likely to suffer procedure-related morbidity and

mortalitymortality

Contraindicated in conjunction with moderate or Contraindicated in conjunction with moderate or severe mitral regurgitationsevere mitral regurgitation

Left atrial thrombi dislodgement by catheters Left atrial thrombi dislodgement by catheters during procedure possibilityduring procedure possibility TEE indicated prior to procedureTEE indicated prior to procedure


Post procedurePost procedure Echo identification of complications Echo identification of complications

and baseline for future assessmentsand baseline for future assessments ComplicationsComplications

Increase in severity of mitral regurgitaitonIncrease in severity of mitral regurgitaiton Presence of an atrial septal defect at the Presence of an atrial septal defect at the

transseptal catheter puncture sitetransseptal catheter puncture site


Symptoms due to MS often initially Symptoms due to MS often initially occur during pregnancy due tooccur during pregnancy due to Increased metabolic demands and Increased metabolic demands and

volume flow ratevolume flow rate

Mitral Stenosis and PregnancyMitral Stenosis and Pregnancy

Tricuspid Valve StenosisTricuspid Valve Stenosis

Tricuspid StenosisTricuspid StenosisNarrowing of the Tricuspid Valve Narrowing of the Tricuspid Valve

OrificeOrifice

Uncommon in adultsUncommon in adults

Tricuspid Valve Stenosis Tricuspid Valve Stenosis

<2.0 cm<2.0 cm22 : severe tricuspid : severe tricuspid stenosisstenosis

Tricuspid Stenosis - Tricuspid Stenosis - EtiologiesEtiologies

Rheumatic Heart Disease – nearly all cases Rheumatic Heart Disease – nearly all cases in association with rheumatic mitral in association with rheumatic mitral involvementinvolvement

Systemic lupus erythematosusSystemic lupus erythematosus Loeffler’s endocarditisLoeffler’s endocarditis Metastatic melanomaMetastatic melanoma Congenital heart diseaseCongenital heart disease CarcinoidCarcinoid Right atrial tumor/thrombusRight atrial tumor/thrombus Whipple’s DiseaseWhipple’s Disease Fabry’s DiseaseFabry’s Disease Infective EndocarditisInfective Endocarditis Endocardial fibroelastosisEndocardial fibroelastosis Methysergide therapyMethysergide therapy Prosthetic valveProsthetic valve

SymptomsSymptoms

DyspneaDyspnea FatigueFatigue Right upper quadrant painRight upper quadrant pain

Physical ExaminationPhysical Examination

Jugular venous distentionJugular venous distention Quiet precordiumQuiet precordium HepatomegalyHepatomegaly AscitiesAscities JaundiceJaundice Peripheral edema without pulmonary Peripheral edema without pulmonary

congestioncongestion Signs and symptoms of mitral stenosisSigns and symptoms of mitral stenosis

Carvallo’s SignCarvallo’s SignJose’ Manuel Rivero Carvallo (Mexican cardiologist 1905-1993)Jose’ Manuel Rivero Carvallo (Mexican cardiologist 1905-1993)

The increase in the The increase in the intensity of the intensity of the pansystolic murmur of pansystolic murmur of tricuspid regurgitation tricuspid regurgitation during inspiration. during inspiration.

Distinguishes tricuspid Distinguishes tricuspid from mitral involvementfrom mitral involvement

Best heard over left Best heard over left sternal bordersternal border

ComplicationsComplications

Increased risk of infective Increased risk of infective endocarditisendocarditis

Decreased cardiac outputDecreased cardiac output

Cardiac AuscultationCardiac Auscultation Opening snap (may occur later than Opening snap (may occur later than

mitral valve opening snap)mitral valve opening snap)

Diastolic rumble best heard along Diastolic rumble best heard along the lower left sternal borderthe lower left sternal border Higher frequency than mitral stenosis Higher frequency than mitral stenosis

rumblerumble May be accentuated with inspirationMay be accentuated with inspiration

Presystolic click with atrial Presystolic click with atrial contractioncontraction

Both the opening snap and the Both the opening snap and the diastolic rumble may be diastolic rumble may be accentuated with inspirationaccentuated with inspiration

Absence of normal respiratory Absence of normal respiratory splitting of S2splitting of S2

Tricuspid regurgitation murmurTricuspid regurgitation murmur

Chest X-Ray (CXR)Chest X-Ray (CXR) Right atrial enlargementRight atrial enlargement Biatrial enlargementBiatrial enlargement Atrial fibrillationAtrial fibrillation Right ventricular hypertrophy Right ventricular hypertrophy

Suggests coexisting mitral stenosis with Suggests coexisting mitral stenosis with pulmonary hypertensionpulmonary hypertension

Cardiac CatheterizationCardiac Catheterization Increased mean diastolic pressure Increased mean diastolic pressure

gradient between the right atrium and gradient between the right atrium and right ventricle right ventricle Increases with inspirationIncreases with inspiration Increased right atrial pressureIncreased right atrial pressure Persistence of end diastolic gradient Persistence of end diastolic gradient

between right atrium and right ventriclebetween right atrium and right ventricle Aids in differentiating tricuspid stenosis from Aids in differentiating tricuspid stenosis from

tricuspid regurgitationtricuspid regurgitation

M-Mode Criteria for Tricuspid M-Mode Criteria for Tricuspid StenosisStenosis

Thickened tricuspid valve Thickened tricuspid valve leafletsleaflets

Decreased EF slope of the Decreased EF slope of the anterior tricuspid leafletanterior tricuspid leaflet

Anterior motion of the Anterior motion of the posterior valve leafletposterior valve leaflet

Decreased/absent A wave of Decreased/absent A wave of the anterior tricuspid valve the anterior tricuspid valve leafletleaflet

Steep A-C slope of the Steep A-C slope of the tricuspid valvetricuspid valve

Pulmonary hypertensionPulmonary hypertension Due to coexisting mitral Due to coexisting mitral

valve diseasevalve disease

2D Criteria for Tricuspid 2D Criteria for Tricuspid StenosisStenosis

Thickened tricuspid valve leaflets, especially at leaflet tips Thickened tricuspid valve leaflets, especially at leaflet tips and chordae tendinae with restricted motionand chordae tendinae with restricted motion

Diastolic “doming” of the tricuspid valve with commissural Diastolic “doming” of the tricuspid valve with commissural fusion of the leafletsfusion of the leaflets

Right atrial dilatationRight atrial dilatation

Dilated inferior vena cava and hepatic veinsDilated inferior vena cava and hepatic veins

Leftward protrusion of the interatrial septumLeftward protrusion of the interatrial septum

Pulmonary hypertension (due to coexisting mitral valve Pulmonary hypertension (due to coexisting mitral valve disease)disease)

TV Stenosis DopplerTV Stenosis Doppler

Surgical TreatmentSurgical Treatment

Surgical/Balloon commisurotomySurgical/Balloon commisurotomy Valve repair/valve replacementValve repair/valve replacement

Stenosis Tricuspid ValveStenosis Tricuspid Valve

Rheumatic Heart DiseaseRheumatic Heart Disease

Rheumatic Tricuspid Rheumatic Tricuspid StenosisStenosis

Isolated rheumatic tricuspid almost never Isolated rheumatic tricuspid almost never occursoccurs

Significant tricuspid stenosis occurs in roughly Significant tricuspid stenosis occurs in roughly 3-5% of patients with rheumatic heart disease3-5% of patients with rheumatic heart disease

Rheumatic fever affecting the tricuspid valve is Rheumatic fever affecting the tricuspid valve is <6% and has a preponderance to females<6% and has a preponderance to females

The tricuspid valve is in rheumatic heart disease The tricuspid valve is in rheumatic heart disease is usually not as thickened or calcified as is usually not as thickened or calcified as compared to mitral valve stenosiscompared to mitral valve stenosis

M-Mode Criteria for M-Mode Criteria for Rheumatic Tricuspid Rheumatic Tricuspid

StenosisStenosis

Diminished EF slopeDiminished EF slope

Anterior displacement of the posterior Anterior displacement of the posterior leafletleaflet

Thickening of valve leaflets and Thickening of valve leaflets and apparatusapparatus

Caveats of M-Mode Criteria Caveats of M-Mode Criteria for Rheumatic Tricuspid for Rheumatic Tricuspid

Valve StenosisValve Stenosis Accuracy is far lower than dx for mitral stenosis Accuracy is far lower than dx for mitral stenosis

with M-modewith M-mode

Frequently concurrent pulmonary hypertension and Frequently concurrent pulmonary hypertension and right ventricular hypertrophy, which also lead to a right ventricular hypertrophy, which also lead to a diminished EF slopediminished EF slope

Anterior displacement of the posterior leaflet Anterior displacement of the posterior leaflet cannot always be well visualized and is therefore cannot always be well visualized and is therefore not a reliable findingnot a reliable finding

Therefore, 2D is a more reliable technique in Therefore, 2D is a more reliable technique in dx of rheumatic tricuspid stenosisdx of rheumatic tricuspid stenosis

2D Criteria for Rheumatic 2D Criteria for Rheumatic Tricuspid Tricuspid

Valve StenosisValve Stenosis Doming of tricuspid valve leaflets in diastole, Doming of tricuspid valve leaflets in diastole,

typically more toward the tips of the leafletstypically more toward the tips of the leaflets

Thickening and reduced excursion of the Thickening and reduced excursion of the posterior or septal leaflets, or bothposterior or septal leaflets, or both

Reduced tricuspid orifice diameter relative to Reduced tricuspid orifice diameter relative to the diameter of the tricuspid annulus in the the diameter of the tricuspid annulus in the same scan planesame scan plane

RVIT Rheumatic StenosisRVIT Rheumatic Stenosis

Note the thickening of the leaflets, which is Note the thickening of the leaflets, which is maximal at the tips and chordae, and the maximal at the tips and chordae, and the preserved mobility of the mid portion of the preserved mobility of the mid portion of the leaflets in the real-time imageleaflets in the real-time image

12-028 Feigenbaum

Tricuspid StenosisTricuspid StenosisImportant to NoteImportant to Note

Tricuspid stenosis is pressure of the right Tricuspid stenosis is pressure of the right atrium, which will eventually produce atrium, which will eventually produce peripheral edema and reduced cardiac peripheral edema and reduced cardiac outputoutput

Tricuspid stenosis almost never occurs as Tricuspid stenosis almost never occurs as an isolated lesion; it generally an isolated lesion; it generally accompanies mitral stenosis, so evaluate accompanies mitral stenosis, so evaluate for mitral, aortic, and pulmonic valve for mitral, aortic, and pulmonic valve disease due to rheumatic feverdisease due to rheumatic fever

Pulmonic StenosisPulmonic Stenosis

Pulmonary StenosisPulmonary StenosisPathophysiologyPathophysiology

Systolic pressure overload leads to RVHSystolic pressure overload leads to RVH

Regional hypertrophy may lead to infundibular Regional hypertrophy may lead to infundibular stenosisstenosis

Commonly associated with other congenital Commonly associated with other congenital malformations (VSDs, ASDs, tetrology of Fallot)malformations (VSDs, ASDs, tetrology of Fallot)

RV chamber size usually normal, RA will enlargeRV chamber size usually normal, RA will enlarge

Increased risk of endocarditisIncreased risk of endocarditis

Pulmonic StenosisPulmonic StenosisEtiologyEtiology

Congenital (most common)Congenital (most common) Rheumatic (rare)Rheumatic (rare) CarcinoidCarcinoid Peripheral (PPS-junction of the R and Peripheral (PPS-junction of the R and

L PAs)L PAs) Infundibular (subvalvular)Infundibular (subvalvular) Prosthetic valve dysfunctionProsthetic valve dysfunction

Physical Signs of PSPhysical Signs of PS Dyspnea on exertionDyspnea on exertion

Systolic ejection murmur (LUSB)Systolic ejection murmur (LUSB)

Pulmonary ejection sound, Pulmonary ejection sound, decreased/delayed Pdecreased/delayed P22

Sustained RV impulse at mid-lower LSBSustained RV impulse at mid-lower LSB

Echo FindingsEcho Findings M-mode may show an increase in the M-mode may show an increase in the

pulmonic “a” dip of more than 7 mm pulmonic “a” dip of more than 7 mm (useful for severe PS only)(useful for severe PS only)

Valvular thickening and systolic doming Valvular thickening and systolic doming (2D)(2D)

Right ventricular hypertrophyRight ventricular hypertrophy

Post-stenotic dilatation of the PAPost-stenotic dilatation of the PA

Narrowing of RVOT in infundibular PSNarrowing of RVOT in infundibular PS

Pulmonary StenosisPulmonary StenosisM-Mode and 2DM-Mode and 2D

Mild pulmonary Mild pulmonary stenosis stenosis No abnormality is No abnormality is

detectable either by M-detectable either by M-mode or two- mode or two- dimensional dimensional echocardiography. echocardiography.

More severe More severe obstruction, obstruction, May be possible to May be possible to

detect right ventricular detect right ventricular hypertrophy, hypertrophy,

Echocardiography is not Echocardiography is not a very sensitive method a very sensitive method for diagnosing this. for diagnosing this.

Pulmonary Stenosis M-ModePulmonary Stenosis M-Mode Another sign that has been Another sign that has been

reported, confined to reported, confined to patients with patients with severe severe obstructionobstruction, is an , is an exaggerated "a-dip" on the exaggerated "a-dip" on the pulmonary valve pulmonary valve echocardiogram.echocardiogram.

““a-dip” or “diving W” a-dip” or “diving W” Hypertrophied right atrium Hypertrophied right atrium

forcefully injects blood into an forcefully injects blood into an already full and stiff right already full and stiff right ventricle during atrial systole. ventricle during atrial systole.

Pulmonary artery pressure is Pulmonary artery pressure is low, low,

Sudden increase in right Sudden increase in right ventricular pressure is sufficient ventricular pressure is sufficient to partially open the pulmonary to partially open the pulmonary valvevalve

Doppler FindingsDoppler Findings Increased velocity and turbulence at level of Increased velocity and turbulence at level of

obstruction (valvular, subvalvular, or obstruction (valvular, subvalvular, or supravalvular)supravalvular)

Use pulsed/color flow Doppler to locate level Use pulsed/color flow Doppler to locate level of obstructionof obstruction

Check for coexisting pulmonic regurgitationCheck for coexisting pulmonic regurgitation Measure peak and mean gradients (PSAX-Ao Measure peak and mean gradients (PSAX-Ao

and RVOT are best)and RVOT are best)

Pulmonic Stenosis DopplerPulmonic Stenosis DopplerCW Doppler spectral recording from PSAX-Ao view in a patient with mild pulmonic stenosis and mild pulmonic stenosis.

Turbulent diastolic and systolic flows are noted with a slight increase in the peak systolic velocity to 1.4 m/s (normal < 1 m/s)

Subvalvular StenosisSubvalvular Stenosis

Note the presence of muscle Note the presence of muscle bundles in the area of the bundles in the area of the right ventricular outflow right ventricular outflow tract (tract (arrowarrow). ).

18-21 Feigenbaum

Pulmonic Valve StenosisPulmonic Valve Stenosis

A basal short-axis view demonstrates A basal short-axis view demonstrates a thickened pulmonary valve (a thickened pulmonary valve (arrowarrow). ).

Doppler imaging demonstrates a peak Doppler imaging demonstrates a peak gradient of 35 mm Hg. gradient of 35 mm Hg.

18-24PV Feigenbaum

Dysplastic Pulmonary Valve Dysplastic Pulmonary Valve StenosisStenosis An example of dysplastic (Any abnormal development of tissues or An example of dysplastic (Any abnormal development of tissues or

organs. In pathology, alteration in size, shape, and organization of organs. In pathology, alteration in size, shape, and organization of adult cells) pulmonary valve stenosis is provided. adult cells) pulmonary valve stenosis is provided.

A:A: The pulmonary valve ( The pulmonary valve (arrowarrow) is markedly thickened and ) is markedly thickened and immobile. Doming during systole is present. immobile. Doming during systole is present.

B:B: A maximal pressure gradient of approximately 65 mm Hg is A maximal pressure gradient of approximately 65 mm Hg is demonstrated. PA, pulmonary artery; RVOT, right ventricular demonstrated. PA, pulmonary artery; RVOT, right ventricular outflow tract. outflow tract.

18-24 Feigenbaum

ComplicationComplicationRight Heart FailureRight Heart Failure

An example of right An example of right ventricular pressure ventricular pressure overload is shown due to overload is shown due to pulmonary hypertension pulmonary hypertension and consequentially and consequentially infundibular hypertrophy. infundibular hypertrophy.

The right heart is The right heart is severely dilated, and severely dilated, and there is global right there is global right ventricular ventricular hypocontractility. hypocontractility.

07-058a Feigenbaum

ComplicationComplicationRight Heart FailureRight Heart Failure

The short-axis view The short-axis view demonstrates demonstrates marked flattening marked flattening of the septum that of the septum that was maintained in was maintained in both systole and both systole and diastole.diastole.

07-058b Feigenbaum

SourcesSources

Feigenbaum H, Armstrong W. (2004). Echocardiography. Feigenbaum H, Armstrong W. (2004). Echocardiography. (6th Edition). Indianapolis. Lippincott Williams & Wilkins. (6th Edition). Indianapolis. Lippincott Williams & Wilkins.

Goldstein S., Harry M., Carney D., Dempsey A., Ehler D., Goldstein S., Harry M., Carney D., Dempsey A., Ehler D., Geiser E., Gillam L., Kraft C., Rigling R., McCallister B., Sisk Geiser E., Gillam L., Kraft C., Rigling R., McCallister B., Sisk E., Waggoner A., Witt S., Gresser C.. (2005). Outline of E., Waggoner A., Witt S., Gresser C.. (2005). Outline of Sonographer Core Curriculum in Echocardiography.Sonographer Core Curriculum in Echocardiography.

Otto C. (2004). Textbook of Clinical Echocardiography. (3rd Otto C. (2004). Textbook of Clinical Echocardiography. (3rd Edition). Elsevier & Saunders.Edition). Elsevier & Saunders.

Reynolds T. (2000). The Echocardiographer's Pocket Reynolds T. (2000). The Echocardiographer's Pocket Reference. (2nd Edition). Arizona. Arizona Heart Institute.Reference. (2nd Edition). Arizona. Arizona Heart Institute.

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