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

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Presentation on theme: "DOPPLER IN REGURGITANT LESIONS. Regurg Lesions…..Doppler  Indirect  Semiquantitative….jet area ratios  Quantitative…RVol,RF,EROA."— Presentation transcript:

1 DOPPLER IN REGURGITANT LESIONS

2 Regurg Lesions…..Doppler  Indirect  Semiquantitative….jet area ratios  Quantitative…RVol,RF,EROA

3 INDIRECT INDICATORS Doppler ParameterSignificant regurg Forward flow velocitiesIncreased Intensity of regurg signalStrong (compared to forward flow signal) Shape of regurg signalRapid drop-off of signal Duration of regurg signalShortened (finishes prior to end of diastole) Flow reversalsSystolic  veins entering atrium (MR/TR) Diastolic  in DA & Abd aorta

4 Shape of regurg signal : “V” cut-off sign (AV valves) Shortened PHT or DS (semilunar valves) Mild AV valve reg…Pr gradient is high & remains relatively constant through out the entire systole…symmetrical U shaped doppler velocity curve….. In Severe …Gradient initaially high,but decreases towards the latter half of systole….rapid & asymmetric V shaped doppler V” cut-off sign : d/t rapid equalisation (cross over) of LA & LV pressures

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6 Shortened PHT in semil valves… Larger the reg orifice,the greater the rate of decline of diast pr gradient b/w aorta & LV. So PHT decreases in severe DS (V peak/DT) increases in severe

7 Flow reversal velocities : TR….hepatic veins MR…Pulmonary veins AR…DA & Abd aorta Syst to diast PV flow velocity ratio [VTIs/VTI D ] in MR MRVTIs/VTIDSensitivitySpecificity Mild>184 Moderate0.5-1.05781 Moderately Severe0.0-0.53385 Severe<0.05296

8 Flow reversal in semil valve regurg : velocity & duration during diastole…index of severity Pandiast flow reversal in DA…at least moder AR Pandiast flow reversal in Abd A…extremely sensitive (100%) & specific (97%) for severe AR End diastolic flow velocity>18cm/s..predict moderate to severe AR sensitivity (88%) & specificity (92%)

9 Limitations of flow reversal: Coex L-R shunt or aortic anomalies Arrythmias Poor setting of wall filters Resp Variation LA compliance & pressures Eccentric jets

10 COLOUR FLOW DOPPLER (1)Vena Contracta :  narrowest portion of a jet that occurs at or just downstream from the orifice.  high velocity, laminar flow and is slightly smaller than the anatomic regurgitant orifice due to boundary effects transducer needs to be angulated It is preferable to use a zoom mode The color flow sector should also be as narrow as possible,

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12 2)AR jet ht & JH/LVOT diameter ratio 3)Regurgitant jet area & Regurgitant jet area to receiving chamber area ratio 4)PISA method JH : significant overlap >8 mm.. To discriminate b/w grades 1-2 vs 3-4 JH/LVOH >40%.. To discriminate b/w grades 1-2 vs 3-4 ; <25%..mild AR JH/LVOH…. Best indicator for predicting the severity of AR

13 JH : max AP diameter of the regurg jet just below AV in PLAX LVOT : measured @ end diastole at the same location

14 IN AR RJA : PSAX @ LVOT level LVOA :@ end diastole @ same location RJA : >8 cm2  i/o severe MR (sens/specif…82/94)/ TR(71/91) InAR, RJA/LVOA of 25% …mild-moderate vs moderately severe to severe AR

15 ARRJA/LVOA % Sensitivity % Specificity % Mild<480100 Moderate4-2410095 Moderately Severe 25-59100 Severe>60100

16 RJA & LAA … from multiple orthogonal planes including A4C, PLAX, PSA MR severityRJA/LAA (%) SensitivitySpecificity Mild<2073-9492-100 Moderate20-409495 Severe>4065-9495-96

17 Limitations of CFDI in Regurg assessmnt Wall jets.. Underestimates jet size Coexistent Jets…MS/Prosthetic MV Instrument factors … Gain settings ; PRF ; Incident angle ; Driving pressure, Receiving chamber size & compliance, regurg volume,size & shape of regurg orifice.

18 Regurgitant Volume : Rvol = SV RV – SV CV Regurg Fraction : R vol ÷ SV forward x 100

19 Calculation of RV & RF Method 1 SV LVOT = CSA (cm2) x VTI (cm) LVOT….diameter …PLAX…@ aortic annulus…from inner edge to inner edge of aortic cuspal insertion. CSA LVOT= 0.785xD 2 VTI of LVOT … from A5C.. PWD sample volume in centre of LVOT proximal to aortic valve

20 SV MV = CSA MV x VTI MV MV annulus diameter ….from A4C … mid diastole…from inner edge to inner edge VTI…from A4C…PwD sample vol at MV annulus So for MR RV = SV MV - SV LVOT RF = SV MV - SV LVOT / SV MV = RV/SV MV AR : RV =SV LVOT – SV MV RF = SV LVOT – SV MV / SV LVOT = RV/SV LVOT Considered as the the most accurate method for calculating RV & RF

21 ( 2)SV LV by 2d echo … Simpsons biplane method LV EDV-LVESV In MR … RV = SV(2D) – SV LVOT RF = SV(2D) – SV LVOT / SV2D =RV/SV2D In AR.. RV = SV(2D) – SV MV RF= SV(2D) – SV MV/SV(2D) = RV/SV2D Less accurate Used when it is difficult to measure mitral annulus diameter or LVOT diameter

22 (3)RF in AR Measure syst, diast diameter of aorta (@ top of aort arch) From suprasternal long axis view Systolic VTI … PwD sample vol is positioned proximal to head & neck vessels Diastolic VTI … PwD sample vol is placed just distal to left subclavian artery with in Desc.aorta Calculate Syst SV & Diast reversed SV RF= SV diast/SV syst Rarely used..as imaging of aorta in suprasternal notch is challenging

23 Limitations of RV & RF calculations Assumptions of SV calculation Errors in diameter measurements Errors in VTI Presence of multivalv lesions/intracardiac shunts

24 Valv lesionTotal SVForward SV MR without ARCSA MV x VTI MV CSA LVOT x VTI LVOT MR with AR (no intracardiac shunt) CSA MV x VTI MV CSA RVOT x VTI RVOT AR without MRCSA LVOT x VTI LVOT CSA MV x VTI MV AR with MR(no intracardiac shunt) CSA LVOT x VTI LVOT CSA RVOT x VTI RVOT AR (using the forward & reverse flows from aortic arch) CSA AO-diast x VTI AO- diast CSA AO-syst x VTI AO-syst

25 The flow rate proximal to a narrowed orifice is the product of the hemisheric flow convergent area & the velocity of that isovelocity shell Q=2 π r 2 Vr Bld flow thru hemishere must pass thru the orifice ;So 2 π r 2 Vr = Ao x Vo Ao = 2 π r 2 Vr / Vo EROA= 2 π r 2 V N / V R Rvol=EROA x VTI RJ

26 EROA (1)Spectral doppler techniq.. Principle of conservation of mass Calculated from the premise that RV thru an incomp valve is equal to flow @ the regurg orifice Rvol=EROAxVTI RJ EROA=Rvol/VTI RJ

27 (2)PISA method : variation in the application of the cont equation.

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29 EROA =2 π r2Vn/Vr

30 Simplified method for MR Rvol…when appropriate CW D MR jet cannot be obtained…the ratio b/w the max mitral reg velocity & VTI RJ is a constant of 3.25 (Rossi et al.) Rvol= 2 π r 2 V N /3.25 (ie 2 π r 2 V N /VR x VTI RJ ) Tricuspid EROA = (2 π r 2 V N /V R -V N ) (α/180) After 2 corrections for (1)flattening of PISA close to the reg orifice (corrected by multiplying flow rate by (VR/VR-VN) (2)Distorted reg orifice  small isovelocity contours…corrected by multiplying 2 π by α/180

31 Simplified method for evaluating MR/TR  using the flow convergence region prox to the regurg orifice…measures the radius of PISA dome… Valve/severityAliased velocity (cm/s) PISA radius(mm) SensitvtySpecif MR MILD38<3.56370 MOD3.5-7.5 MOD Severe7.5-14.5 Severe>14.58563 TR Severe28>8.57691

32 MITRAL REGURGITATION MildModerateSevere Jet areaSmall, central jet (usually 4 cm2 or 20% of LA area) VariableLarge central jet (10 cm2 or 40% of LA or variable size wall impinging jet swirling in LA Mitral inflowA wave dominantVariableE wave dominant (E usually 1.2 m/s) Jet densityIncomplete or faintDense Jet contourParabolic Early peaking–triangular PV flowSystolic dominance Systolic bluntingSyst flow reversal VC width (cm)<0.3 0.3-0.69>0.7 R Vol (ml/beat)<3030-44 45-59>60 RF (%)<3030-39 40-49>50 EROA (cm2)<0.200.20-0.29 0.30-0.39>0.40

33 Trace MR…40% healthy indiv….elderly 3 methods…color flow Doppler mapping: regurgitant jet area,vena contracta, and flow convergence (PISA).

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36 AORTIC REGURGITATION MildModerateSevere Jet width in LVOT Small in central jets Intermediate Large in central jets; variable in eccentric jets Jet deceleration rate (PHT, ms) Slow >500 Medium 500-200 Steep <200 Jet densityIncomplete or faintDense Diastolic flow reversal in DA–PW Brief, early diastolic Intermediate Prominent holodiastolic Jet /LVOT width, % <25 25-45 46-64 >65 VC width (cm)<0.30.3-0.6>0.6 R Vol (ml/beat)<3030-44 45-59>60 RF (%)<3030-39 40-49>50 Jet CSA/LVOT CSA, % <5<5 5-20 21-59 >60 EROA (cm2)<0.100.10-0.19 0.20-0.29>0.30

37 TR MILDMODSEVERE Jet area<55-10>10 VC widthNot definedNot defined; but <0.7 >0.7 PISA radius<0.50.6-0.9>0.9 Jet density & contour Soft and parabolic Dense, variable contour Dense, triangular with early peaking Hepatic vein flow Syst dominanceSyst bluntingSyst reversal

38 PULMONARY REGURG MILDMODSEVERE Jet sizeThin (usually <10 mm in length) with a narrow origin IntermediateUsually large, with a wide origin; May be brief in duration Jet density & decel rate Soft; Slow deceleration Dense; variable deceleration Dense; steep deceleration, early termination of diastolic flow Pulmonic systolic flow compared to systemic flow Slightly increased IntermediateGreatly increased

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