DOPPLER IN REGURGITANT LESIONS

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

INDIRECT INDICATORSDoppler Parameter Significant regurg

Forward flow velocities Increased

Intensity of regurg signal Strong (compared to forward flow signal)

Shape of regurg signal Rapid drop-off of signal

Duration of regurg signal Shortened (finishes prior to end of diastole)

Flow reversals Systolic veins entering atrium (MR/TR)Diastolicin DA & Abd aorta

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 dopplerV” cut-off sign : d/t rapid equalisation (cross over) of LA & LV pressures

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

Flow reversal velocities : TR….hepatic veins MR…Pulmonary veins AR…DA & Abd aortaSyst to diast PV flow velocity ratio [VTIs/VTID] in MR

MR VTIs/VTID Sensitivity Specificity

Mild >1 84 84

Moderate 0.5-1.0 57 81

Moderately Severe

0.0-0.5 33 85

Severe <0.0 52 96

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%)

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

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,

2)AR jet ht & JH/LVOT diameter ratio3)Regurgitant jet area & Regurgitant jet area to receiving chamber area ratio4)PISA method

JH : significant overlap >8 mm .. To discriminate b/w grades 1-2 vs 3-4JH/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

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

IN ARRJA : PSAX @ LVOT levelLVOA :@ 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

AR RJA/LVOA %

Sensitivity%

Specificity%

Mild <4 80 100

Moderate 4-24 100 95

Moderately Severe

25-59 100 100

Severe >60 100 100

RJA & LAA … from multiple orthogonal planes including A4C , PLAX, PSA

MR severity

RJA/LAA (%)

Sensitivity Specificity

Mild <20 73-94 92-100

Moderate 20-40 94 95

Severe >40 65-94 95-96

Limitations of CFDI in Regurg assessmntWall jets .. Underestimates jet sizeCoexistent Jets…MS/Prosthetic MVInstrument factors … Gain settings ; PRF ; Incident angle ;Driving pressure,Receiving chamber size & compliance,regurg volume,size & shape of regurg orifice.

Regurgitant Volume : Rvol = SV RV – SV CV

Regurg Fraction : Rvol ÷ SV forward x 100

Calculation of RV & RF

Method 1SV LVOT = CSA (cm2) x VTI (cm)

LVOT….diameter …PLAX…@ aortic annulus…from inner edge to inner edge of aortic cuspal insertion.CSA LVOT= 0.785xD2 VTI of LVOT … from A5C .. PWD sample volume in centre of LVOT proximal to aortic valve

SVMV = CSAMV x VTIMV

MV annulus diameter ….from A4C … mid diastole…from inner edge to inner edgeVTI…from A4C…PwD sample vol at MV annulus

So for MR RV = SVMV - SV LVOT

RF = SVMV - SV LVOT / SVMV = RV/SVMV

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

(2)SV LV by 2d echo … Simpsons biplane method LV EDV-LVESVIn MR … RV = SV(2D) – SV LVOT RF = SV(2D) – SV LVOT / SV2D =RV/SV2DIn AR .. RV = SV(2D) – SV MV RF= SV(2D) – SV MV/SV(2D) = RV/SV2D

Less accurateUsed when it is difficult to measure mitral annulus diameter or LVOT diameter

(3)RF in ARMeasure syst , diast diameter of aorta (@ top of aort arch)From suprasternal long axis viewSystolic VTI … PwD sample vol is positioned proximal to head & neck vesselsDiastolic VTI … PwD sample vol is placed just distal to left subclavian artery with in Desc.aortaCalculate Syst SV & Diast reversed SVRF= SV diast/SV systRarely used..as imaging of aorta in suprasternal notch is challenging

Limitations of RV & RF calculations

Assumptions of SV calculationErrors in diameter measurementsErrors in VTIPresence of multivalv lesions/intracardiac shunts

Valv lesion Total SV Forward SV

MR without AR CSAMV x VTIMV CSALVOT x VTILVOT

MR with AR (no intracardiac shunt)

CSAMV x VTIMV CSARVOT x VTIRVOT

AR without MR CSALVOT x VTILVOT CSAMV x VTIMV

AR with MR(no intracardiac shunt)

CSALVOT x VTILVOT CSARVOT x VTIRVOT

AR (using the forward & reverse flows from aortic arch)

CSAAO-diast x VTIAO-

diast

CSAAO-syst x VTIAO-syst

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 r2Vr

Bld flow thru hemishere must pass thru the orifice ;So 2 π r2Vr = Ao x Vo Ao = 2 π r2 Vr / VoEROA= 2 π r2 VN / VR

Rvol=EROA x VTIRJ

EROA (1)Spectral doppler techniq .. Principle of conservation of massCalculated from the premise that RV thru an incomp valve is equal to flow @ the regurg orifice

Rvol=EROAxVTI RJ

EROA=Rvol/VTI RJ

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

EROA =2 π r2Vn/Vr

Simplified method for MR Rvol…when appropriate CW D MR jet cannot be obtained…the ratio b/w the max mitral reg velocity & VTIRJ is a constant of 3.25 (Rossi et al.)

Rvol= 2 π r2 VN /3.25 (ie 2 π r2 VN/VR x VTIRJ)

Tricuspid EROA = (2 π r2 VN /VR-VN) (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 orificesmall isovelocity contours…corrected by multiplying 2 π by α/180

Simplified method for evaluating MR/TR using the flow convergence region prox to the regurg orifice…measures the radius of PISA dome…

Valve/severity

Aliased velocity (cm/s)

PISA radius(mm)

Sensitvty Specif

MR

MILD 38 <3.5 63 70

MOD 3.5-7.5

MOD Severe 7.5-14.5

Severe >14.5 85 63

TR

Severe 28 >8.5 76 91

MITRAL REGURGITATIONMild Moderate Severe

Jet area Small, central jet (usually 4 cm2 or 20% of LA area)

Variable Large central jet (10 cm2 or 40% of LA or variable size wall impingingjet swirling in LA

Mitral inflow A wave dominant Variable E wave dominant(E usually 1.2 m/s)

Jet density Incomplete or faint

Dense Dense

Jet contour Parabolic Parabolic Early peaking–triangular

PV flow Systolic dominance

Systolic blunting

Syst flow reversal

VC width (cm)

<0.3 0.3-0.69 >0.7

R Vol (ml/beat)

<30 30-44 45-59

>60

RF (%) <30 30-39 40-49

>50

EROA (cm2) <0.20 0.20-0.29 0.30-0.39

>0.40

Trace MR…40% healthy indiv….elderly

3 methods…color flow Doppler mapping: regurgitant jet area,vena contracta, and flow convergence (PISA).

AORTIC REGURGITATIONMild Moderate Severe

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 density Incomplete or faint

Dense Dense

Diastolic flow reversal inDA–PW

Brief, early diastolic

Intermediate Prominent holodiastolic

Jet /LVOT width, %

<25 25-45 46-64

>65

VC width (cm)

<0.3 0.3-0.6 >0.6

R Vol (ml/beat)

<30 30-44 45-59 >60

RF (%) <30 30-39 40-49 >50

Jet CSA/LVOT CSA, %

<5 5-20 21-59 >60

EROA (cm2) <0.10 0.10-0.19 0.20-0.29

>0.30

TRMILD MOD SEVERE

Jet area <5 5-10 >10

VC width Not defined Not defined; but <0.7

>0.7

PISA radius <0.5 0.6-0.9 >0.9

Jet density & contour

Soft and parabolic

Dense, variable contour

Dense, triangular with early peaking

Hepatic vein flow

Syst dominance

Syst blunting Syst reversal

PULMONARY REGURGMILD MOD SEVERE

Jet size Thin (usually <10 mmin length) with anarrow origin

Intermediate Usually large, with a wideorigin; May be brief induration

Jet density & decel rate

Soft; Slow deceleration

Dense; variabledeceleration

Dense; steep deceleration,early termination ofdiastolic flow

Pulmonic systolic flow comparedto systemic flow

Slightly increased

Intermediate Greatly increased