Doppler Echocardiography: Theory, Instrumentation, Technique, and Application  RICK A. NISHIMURA, M.D., FLETCHER A. MILLER, M.D., MARK J. CALLAHAN, M.D.  Mayo Clinic Proceedings  Volume 60, Issue 5, Pages 321-343 (May 1985) DOI: 10.1016/S0025-6196(12)60540-0 Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 1 Schematic representation of error introduced into determination of blood flow velocity by angulation between Doppler beam and maximal velocity vector axis. The maximal velocity vector axis of blood flow is shown in the ascending aorta. Various Doppler beam vectors and resultant errors in calculation of blood flow velocity are demonstrated. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 2 Diagram of optimal transducer position for evaluation of mitral stenosis. Transducer is placed at cardiac apex and angulated superiorly, posteriorly, and toward the right. When the jet of mitral stenosis is reached, an increased velocity during diastole will be noted above the baseline. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 3 Diagram of recommended transducer location for evaluation of mitral regurgitation (similar to that for mitral stenosis). Lower right diagram shows pulsed-wave Doppler recording of mitral regurgitation; a holosystolic velocity is evident above and below the baseline, representing an aliased signal. Extent of area of systolic turbulence in left atrium gives a semiquantitative assessment of degree of mitral regurgitation: 1 = trivial; 2 = mild; 3 = moderate; and 4 = severe. Upper left diagram shows continuous-wave Doppler recording, illustrating that mitral incompetence can occasionally be detected from suprasternal position and should not be confused with signal for aortic stenosis. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 4 Doppler echocardiographic tracings of mitral valve (MV). Top, Normal mitral flow pattern (pulsed-wave recording on an expanded scale). There is a low diastolic flow (less than 1.0 m/s), with an early diastolic peak, rapid decline of velocity during mid-diastole, and end-diastolic peak corresponding to atrial “kick.” Normally, no systolic flow is present, ecg = electrocardiographic tracing. Center, Mitral stenosis (MS). At left, during diastole, initial velocity is increased (1.8 m/s) and typical “M” configuration is still evident. This tracing depicts mild mitral stenosis; atrial kick remains as patient is still in normal sinus rhythm. At right, this tracing represents more severe stenosis. Atrial kick is absent because patient is in atrial fibrillation. See text for discussion of diastolic half time. Bottom, At left, continuous-wave Doppler recording shows combined MS and mitral regurgitation (MR). Note typical MS pattern of slow rate of decline of pressure gradient and resultant slow decline of diastolic slope. MR pattern consists of high systolic velocity in opposite direction of normal diastolic mitral valve flow pattern. At right, pure MR is present. Because of high systolic left ventricular pressure, as compared with left atrial pressure, velocity signal frequently exceeds 5 m/s. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 5 Diagrams depicting multiple transducer positions and angulations for evaluation of aortic stenosis. Conventional position isfrom cardiac apex with transducer directed superiorly, anteriorly, and medially from familiar “M” pattern of diastolic mitral flow until a systolic aortic velocity below the baseline is obtained. In aortic stenosis, the highest velocity jet may be eccentric; thus, multiple transducer positions (apical, right and left sternal borders [at multiple interspaces], suprasternal, supraclavicular, and subcostal) must be used to find the highest systolic velocity. Top, Most frequently encountered jet direction (central and rightward), with optimal transducer positions (apical and right parasternal). Center, Jet direction central and anterior, with optimal transducer positions (apical, right parasternal, supraclavicular, and suprasternal). Bottom, Jet direction leftward, with optimal transducer position (left parasternal). Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 6 Diagram depicting transducer positions for evaluation of aortic regurgitation. Apical position is most commonly used. In addition, aortic regurgitation may be detected from right parasternal or suprasternal position. From apical position with use of pulsed-wave Doppler mode, aortic regurgitation is displayed as a holodiastolic signal above and below the baseline, representing an aliased signal. Extent of diastolic turbulence in left ventricle gives a semiquantitative assessment of degree of aortic regurgitation: 1 = trivial; 2 = mild; 3 = moderate; and 4 = severe. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 7 Doppler echocardiographic tracings of aortic valve from apical position. Top, Normal aortic flow pattern (pulsed-wave recording) consists of systolic flow below the baseline with a systolic velocity of less than 1.5 m/s. Center, Continuous-wave recording of combined aortic stenosis and aortic incompetence. Peak systolic velocity is 4.2 m/s, and peak systolic gradient is 70 mm Hg. Aortic insufficiency is also present, as indicated by prominent diastolic flow above the baseline. Phonocardiographic tracing (Phono) demonstrates a systolic murmur (SM), and carotid pulse tracing (CAR) shows delay of carotid upstroke and a systolic shudder. A2 and P2 = aortic and pulmonic second sounds, respectively; ecg = electrocardiogram; S1 = first heart sound. Bottom, Typical tracings of aortic stenosis: mild (at left; 1.7 m/s; gradient 12 mm Hg), moderate (center; 3.2 m/s; gradient 41 mm Hg), and severe (at right; 4.4 m/s; gradient 77 mm Hg). Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 8 Doppler echocardiographic tracings of aortic valve (AV) from suprasternal or right parasternal position. Top, Normal aortic flow signal (pulsed-wave recording) from suprasternal position demonstrates systolic pattern above the baseline and a peak systolic velocity of less than 1.5 m/s. Center, Isolated aortic insufficiency from suprasternal notch position. Diastolic flow signal is below the baseline. CAR = carotid pulse tracing; ecg = electrocardiogram. Bottom, Typical tracings of aortic stenosis: moderate (at left; 3.3 m/s; gradient 44 mm Hg) and severe (at right; 4.5 m/s; 81 mm Hg). In tracing at right, phonocardiogram demonstrates a long systolic murmur with a central peak (S1 and S2 = first and second heart sounds, respectively), and analog tracing shows aortic valve opening (A.O.) and closure (A.C.). Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 9 Diagram depicting transducer positions and angulation for evaluation of tricuspid regurgitation. With use of apical position, transducer is tilted rightward and anteriorly from left ventricular outflow tract. For evaluation of tricuspid valve flow, transducer can be placed close to left sternal border with beam directed posteriorly. Tricuspid regurgitation with use of pulsed-wave Doppler mode is detected as holosystolic velocity above and below the baseline. Extent of tricuspid regurgitation in right atrium gives a semiquantitative assessment of degree of regurgitation: 1 = trivial; 2 = mild; 3 = moderate; and 4 = severe. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 10 Dopplere chocardiographic tracings of tricuspid valve. Top, Normal tricuspid valve flow shows low-velocity M-shaped configuration during diastole. Center, Continuous-wave recording of tricuspid regurgitation (TR). Peak systolic velocity of 4 m/s corresponds to right ventricular minus right atrial pressure gradient of 64 mm Hg (moderate to severe pulmonary hypertension). Jugular venous pulse (JUG) demonstrates a large V wave of tricuspid regurgitation with rapid Y descent. Phonocardiogram (Phono) shows systolic murmur. ecg = electrocardiogram; S1 and S2 = first and second heart sounds, respectively. Bottom, Tricuspid regurgitation associated with mild (at left) and moderate to severe (at right) pulmonary hypertension (see text). R AVV = right atrioventricular valve. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 11 Diagram depicting transducer position and angulation for evaluation of pulmonic valve. Transducer is placed at upper left sternal border and directed posteriorly until a systolic velocity below the baseline is found. In some patients, transducer must be placed in a lower intercostal space and tilted superiorly. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 12 Doppler echocardiographic tracings of pulmonic valve. Top, Pulsed-wave recording of normal pulmonic flow, consisting of systolic velocity of less than 1.2 m/s below the baseline. Center, Continuous-wave recording of pulmonic insufficiency (PI), demonstrating diastolic flow above the baseline. A high velocity is sustained throughout diastole, an indication of severe pulmonary hypertension. Bottom, Flows in main pulmonary artery (MPA) consistent with mild (left) and severe (right) pulmonic stenosis. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 13 Diagram depicting transducer positions for determination of cardiac output from ascending aorta (Ao). M-mode transducer is placed at left parasternal border in order to obtain the smallest ascending aortic diameter (D). Doppler transducer is placed in suprasternal notch and directed inferiorly and to the right until maximal velocity is obtained. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 14 Comparison of Doppler-derived cardiac output with simultaneous measurement of cardiac output by thermodilution. r = correlation coefficient; SEE = standard error of the estimate. (From Nishimura and associates.6) Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 15 Color-flow mapping of a normal heart. Upper Panel, Two-dimensional long-axis views during diastole (at left) and during systole (at right). Lower Panel, Color flow of left ventricular inflow (orange) and left ventricular outflow (blue) at left and right, respectively. AV = aortic valve; LA = left atrium; LV = left ventricle; RV = right ventricle; vs = ventricular septum. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 16 Color-flow mapping demonstrating tricuspid regurgitation. Upper, Two-dimensional modified four-chamber view. Lower Left, Tricuspid inflow demonstrated by orange color flow into right ventricle. Lower Right, Tricuspid regurgitation demonstrated by blue color flow into right atrium during systole. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle; VS = ventricular septum. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 17 Color-flow mapping of mitral regurgitation. Left, Two-dimensional long-axis view. Right, Mitral regurgitation demonstrated by blue flow into left atrium. Ao = aorta; LA = left atrium; LV = left ventricle; RV = right ventricle; VS = ventricular septum. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 18 Color-flow mapping of aortic regurgitation. Left, Two-dimensional long-axis view. Right, Aortic regurgitation demonstrated by diastolic color flow into left ventricle. The high velocities of the regurgitant jet result in a blue-orange mosaic color. Ao = aorta; AV = aortic valve; LA = left atrium; LV = left ventricle; LVO = left ventricular outflow; PW = posterior wall; RV = right ventricle; vs = ventricular septum. Mayo Clinic Proceedings 1985 60, 321-343DOI: (10.1016/S0025-6196(12)60540-0) Copyright © 1985 Mayo Foundation for Medical Education and Research Terms and Conditions