1. Atrioventricular valve dysfunction: evaluation by doppler and cross-sectional ultrasound 
Norman H Silverman, MD, Doff B McElhinney, MD 
The Annals of Thoracic Surgery 
Volume 66, Issue 2, Pages (August 1998)
DOI: /S (98)

2. Fig 1
(A) This diagram demonstrates the features of jet physics, which are important in the assessment of atrioventricular valve regurgitation. The jet in the lower part of the diagram can be seen to have multiple velocities in aliasing. Its length over its width is a constant of 6.3. The jet has a central core and has entrainment of mass as it decelerates (arrows). Proximal to the jet, the flow velocity accelerates along an isovelocity line related to the first alias. The area of the hemisphere formed by the isovelocity line of the first alias (2πr2), multiplied by the velocity of the Nyquist limit in cm/s (in this example, 38 cm/s), multiplied by 60 and divided by 1,000 to bring the equation to L/min, yields the volume flow of the regurgitant jet. Centerline velocities are the velocities along the jet length, which diminish with continuing entrainment of the jet. (B) An example of centerline velocities. It is known that a turbulent jet expands laterally as it flows because of surrounding fluid entrainment, which slows the jet velocity along its centerline relationship. Vo = velocity at the orifice of the jet; D = diameter of the orifice; Vm = centerline velocity at a given point X; and 6.3 = the constant relating the maximal jet width to length. The flow of the jet can then be related to the velocity measured in the centerline at a given position from the jet’s orifice divided by a constant, multiplied by the velocity at the orifice of the jet. (Top right) We can see the potential core decay for velocities beginning at 1 mm (A) and 2 mm (B and C), their decay levels at velocities starting off initially at 2 (A and B) and 4 m/s (C), respectively. (Bottom left) The relationship of the distal velocity to the orifice velocity at a given position related to the orifice diameter is equivalent for all curves (a, b, and c). (Bottom right) The reciprocal of this relationship, the relationship of the velocity at the orifice over the velocity distally, can be seen to exhibit a linear pattern for all different kinds of curves (a, b, and c). Thus, if one knows the distal velocity at any given relationship distance, one can calculate the flow through the orifice.
The Annals of Thoracic Surgery  , DOI: ( /S (98) )

3. Fig 2
Apical four-chamber view in a patient with pulmonary hypertension. (Left) The right atrium (RA) and right ventricle (RV) are enlarged. (Middle) Doppler color-flow map with the flow disturbance in the atrium caused by the regurgitation. The velocity signal obtained axial to the jet velocity through the central core is 5.13 m/s, equivalent to a pressure difference between the right atrium and ventricle of 105 mm Hg. (LA = left atrium; LV = left ventricle.)
The Annals of Thoracic Surgery  , DOI: ( /S (98) )

4. Fig 3
These series of figures demonstrate the variability of mapping jet size based on changes in various Doppler settings in the same patient as in Figure 2. (A) This figure shows different velocity maps of tricuspid regurgitation. In all of these examples, the Nyquist limit is set at 61, but different maps define different aspects. (Top left) A standard velocity map. (Top right) A velocity plus variance map. (Bottom left) A simple red-blue velocity map. (Bottom right) A different velocity variance map. Note particularly the isovelocity change proximal to the tricuspid regurgitation, which is not substantially altered with the respective maps. What appears to be altered is the distal processing of the jet in the atrium. (B) In this same patient, the standard velocity variance map is used, but the Nyquist limit is changed from 61 (top left) to 39 (top right) to 23 (bottom left) to 17 (bottom right). Note that not only does the jet broaden in the right atrium, but also the size of the alias boundary increases progressively.
The Annals of Thoracic Surgery  , DOI: ( /S (98) )

5. Fig 3
These series of figures demonstrate the variability of mapping jet size based on changes in various Doppler settings in the same patient as in Figure 2. (A) This figure shows different velocity maps of tricuspid regurgitation. In all of these examples, the Nyquist limit is set at 61, but different maps define different aspects. (Top left) A standard velocity map. (Top right) A velocity plus variance map. (Bottom left) A simple red-blue velocity map. (Bottom right) A different velocity variance map. Note particularly the isovelocity change proximal to the tricuspid regurgitation, which is not substantially altered with the respective maps. What appears to be altered is the distal processing of the jet in the atrium. (B) In this same patient, the standard velocity variance map is used, but the Nyquist limit is changed from 61 (top left) to 39 (top right) to 23 (bottom left) to 17 (bottom right). Note that not only does the jet broaden in the right atrium, but also the size of the alias boundary increases progressively.
The Annals of Thoracic Surgery  , DOI: ( /S (98) )

6. Fig 4
(A) Diagramatic representation of an apical four-chamber image in a patient with transposition of the great arteries and substantial tricuspid regurgitation before pulmonary artery banding. (Left) The dilated right ventricle with tricuspid regurgitation related to chordal position change. (Right) After the band is applied, the left and right ventricular areas change and the ventricular septal configuration is altered, shifting the location and orientation of the subvalvar apparatus of the tricuspid valve and also altering the zone of apposition of the tricuspid valvar leaflets. As a result, tricuspid valve regurgitation diminishes. (B) A series of four-chamber transesophageal views showing gradual tightening of the pulmonary artery band (from left to right and top to bottom) in a patient with right ventricular dysfunction and severe tricuspid regurgitation late after atrial repair of transposition of the great arteries. Note the shift in the position of the ventricular septum. (C) Doppler color-flow images in the same patient demonstrate a marked change in the tricuspid regurgitant velocity during the tightening of the band, as well as a significant decrease in tricuspid regurgitation. Left ventricular pressure was monitored to test the adequacy of the band from 40% to 90% of left ventricular pressure. (LV = left ventricle; PA = pulmonary artery; PVA = pulmonary venous atrium; RV = right ventricle; SVA = systemic venous atrium.)
The Annals of Thoracic Surgery  , DOI: ( /S (98) )