Presentation on theme: "Ali Alshehri, MD DHC, Saudi Aramco Sept, 29th, 2011"— Presentation transcript:
1Ali Alshehri, MD DHC, Saudi Aramco Sept, 29th, 2011 TEE and Aortic valveAli Alshehri, MDDHC, Saudi AramcoSept, 29th, 2011
2Q #1 Gorlin formula has the following limitations except: in AR, the area may be falsely elevatedCO in Afib must be averaged on few beatspeak – peak gradient is requiredSEP must be calculated
3Q #2 All are true about planimetry for AV except ME SAX view is preferredCorrelates well with cath derived AVADepends on adequate COSignificant calcifications decreases the accuracy
4Q# 3 The following is true regarding pressure g across AV Doppler derived MIG approximates catheter MIGPeak to peak gradient is the highest gradientDoppler MIG approximates cath PPGAll true
5Movements of the probeTurning: turning the shaft of the probe to the left or right.Rotating: rotating the transducer forward (towards 180°) or backward (towards 0°).Withdrawing and advancing: moving the probe further out of, or further into, the oesophagus.Anteflexing and retroflexing: moving the tip of the probe forwards or backwards.
23TG long axis viewImage setting: Angledegreessector depth 12 cmprobe adjustment: neutral-leftwardPrimary use: Doppler assessmentof AV, LVEFAV and VOT at 4 o’clockTechnique:from TG 2 chamber , the probe isrotated to 120 degreeswith Lt ward rotation of the probe
25DTG LAX viewImage setting: Angle 0degreesSector depth : 16cmProbe adjustment: AnteflexedPrimary use: AV morphology,LVOTDoppler assessment of AVTechnique:probe advanced to LV apex,anteflexed and slightlywithdrawn with rotation of theprobe to the Lt.
28Assessment of AS 2D assessment of valve morphology, commissures, coaptation point.Doppler interrogation( Bernoulli equation)AVA ( continuity equation)PlanimetryDimensionless Index
29PlanimetryAll planimetric techniques are limited because of an inability to determine whether the actual minimal orifice is being imaged or whether the plain chosen for measurement is at an angle o the true minimal orifice.
31PlanimetryTechnique: 1- all 3 leaflets should be in view 2- use colour doppler with minimal gain to adjust depth and angle 3- gain setting to minimum to show orifice 4- use tracing caliber of machine to trace orifice Aim: get the narrowest orifice reduce the blooming artifact
32PlanimetryThe accuracy of planimetry has been assessed by comparing it to the “ gold standard” reference used in cath lab, The Gorlin equation: AVA = CO/ 44.3(SEP)(HR) MG( square root) so AVA is dependent on CO and mean gradient
33PlanimetryTEE is considered superior to TTE because of it’s higher resolution in measuring the AV orifice more accurately.Stoddard, reported good correlation with TTEand superior correlation with cath .(AHJ 1991)
34Hoffman, showed excellent correlation of TEE with Gorlin formula determined area.(JACC, 1993) Planimetry is not affected by CO changes and is considered by some more accurate in high and low CO.
39Continuity equation AVA= TVI LVOT X AREALVOT/ TVI AV LVOT measured endo-endo at mid systole at insertion point of the leaflets. Usually done in ME ling axis view.LVOT area 3.14X r2= 3.14X(D/2)2Measured with PW at measurement site“Envelope in envelope” method also used
40Continuity equationUnless a clearly defined velocity envelope can be seen, no quantitative estimate of severity should be done.
41Dimensionless Index DI= LVOT TVI/ AV TVI Severe AS< 0.25 Helpful when LVOT measurement is in doubt( disproportionately high or low area to the measured gradient)For follow up of prosthetic aortic valve
43Case presentation History: Mr K, 56y old male, chemical engineer. Newly diagnosed diabetesSeen in ophthalmology clinic for decreased Rt eye vision for 1 week and diagnosed with retinal HeAdmitted 1 week later with fatigability X1month, fever and intermittent memory lapses noted by wife.No recent dental work.
44Exam:BP 140/50. PR 90/min, temp 39.0CNo peripheral sings if IEGrade II diastolic murmur at Rt upper chest
46Further W/UTTETEECT chest:5.1 cm aortic root and ascending aorta.
47TTE:Ejection Fraction = 50-55%. Left ventricular systolic function is normal. There is mild mitral regurgitation. There is a moderate size vegetation or mass on the aortic valve. Aortic valve is thickened looks morphologically Bicuspid and prolapsing in diastole. Moderate to sever aortic regurgitation. There is an eccentric jet of aortic insufficiency directed against the anterior mitral leaflet. The right ventricular systolic function is normal. The left ventricle is severely dilated. Possible mitral vegetation also seen.
48TEE:TEE confirms endocarditis on congenital bicuspid aortic valve The aortic valve is bicuspid. There is a large vegetation or mass o the aortic valve. Moderate aortic regurgitation. Volume overloaded LV due to aortic regurgitation .Vegetation length is approximately 16 mm. There i also significant thickening of the large non coronary cusp which could be a vegetation. No abscess is seen. Possible mitral vegetations also.
49CT chest:5.1 cm aortic root and ascending aorta.
60Back to our patientPatient became a febrile. No heart failure. Memory lapses improved.Referred to KFSH for surgery after completing 3 weeks of IV antibiotics.At surgery, both AV and MV infected with perforation. No abscess seen.29mm carbomedics valved conduit+ MVR doneCompleted another 3 weeks of IV antibiotics.