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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 Moderate Moderately Severe Severe<

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 : end diastole at the same location

14 IN AR RJA : LVOT level LVOA end 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< Moderate Moderately Severe Severe>60100

16 RJA & LAA … from multiple orthogonal planes including A4C, PLAX, PSA MR severityRJA/LAA (%) SensitivitySpecificity Mild< Moderate Severe>

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 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 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< MOD MOD Severe Severe> TR Severe28>

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)< >0.7 R Vol (ml/beat)< >60 RF (%)< >50 EROA (cm2)< >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 Steep <200 Jet densityIncomplete or faintDense Diastolic flow reversal in DA–PW Brief, early diastolic Intermediate Prominent holodiastolic Jet /LVOT width, % < >65 VC width (cm)< >0.6 R Vol (ml/beat)< >60 RF (%)< >50 Jet CSA/LVOT CSA, % <5< >60 EROA (cm2)< >0.30

37 TR MILDMODSEVERE Jet area<55-10>10 VC widthNot definedNot defined; but <0.7 >0.7 PISA radius< >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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