How to Evaluate Valvular Stenosis and Regurgitation: Whatкод для вставки
How to Evaluate Vavlvular Stenosis and Regurgitation: What Numbers Really Matter Margaret Park, BS, RVT, RDCS, FASE How to Evaluate Valvular Stenosis and Regurgitation: What Numbers Really Matter Margaret M. Park, BS, RVT, RDCS, FASE Cleveland Clinic Heart and Vascular Institute Objectives As a result of this presentation, the attendee should be able to: 1. 2. 3. 4. 5. Apply a logical approach to imaging patients with valvular stenosis and regurgitation. Describe the various quantitative parameters that can be obtained by 2D Doppler echocardiography in the evaluation of valve stenosis and/or regurgitation. Discuss parameters useful for the quantification of valvular regurgitation such as aortic pressure half time and aortic flow reversal. Implement the proximal flow convergence method and understand how it can be simplified. Apply technical tips to your everyday analysis of valvular disease. ASE Guidelines and Standards Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice, Baumgartner et al, Journal American Society of Echocardiography, January 2009 firstname.lastname@example.org ASE Guidelines and Standards Recommendations for the Evaluation of the Severity of Native Valvular Regurgitation with Two-dimensional and Doppler Echocardiography, Zoghbi et al, Journal American Society of Echocardiography 2003;16:777-802 email@example.com Evaluation of Valvular Stenosis Narrowing of the valve orifice вЂў Aortic valve stenosis (AS) вЂў Pulmonic valve stenosis (PS) вЂў Mitral valve stenosis (MS) вЂў Tricuspid valve stenosis (TS) Evaluation of Valvular Stenosis вЂў вЂў вЂў вЂў вЂў Thickening/calcification Restricted leaflet mobility(opening) Underlying etiology Comprehensive Doppler exam Utilize ALL available Doppler windows Evaluation of Valvular Stenosis вЂў вЂў вЂў вЂў вЂў вЂў Correct measurement requires parallel beam alignment to flow Accurate pressure gradients depend on accurate velocity data Bernoulli equation (modified) Pressure gradient = 4 x V2 Imaging Probe/color flow Doppler Non-imaging probe Aortic Valve stenosis вЂў Determine etiology вЂў Degenerative вЂ“ senile вЂў Congenital вЂ“ bicuspid aortic valve вЂў Rheumatic вЂ“ (post inflammatory) вЂў Classification вЂ“ level of obstruction вЂў Valvular вЂў Subvalvular вЂў Supravalvular Aortic Valve Stenosis 2D Evaluation вЂў Number of cusps вЂў Thickness and calcification вЂў Leaflet mobility вЂў Cooptation lines, Y, inverted Mercedes Benz sign вЂў LV function вЂў Other valve abnormalities Aortic valve stenosis Echo-Doppler assessment вЂў Maximal Velocity Gradient вЂў Mean Velocity Gradient вЂў Valve area (continuity Equation) вЂў LVOT diameter вЂў LVOT velocity Measurement of LVOT diameter Image modified from ASE Guidelines and standards; Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice , Baumgartner et al Repeat three times and use the largest diameter вЂўInner edge to inner edge вЂўSeptum to MV leaflet вЂўParallel to AV вЂў.5 - 1.0 cm from valve Pulsed wave (PW) of LVOT Image modified from ASE Guidelines and standards; Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice , Baumgartner et al Place sample volume(SV) at same point as diameter measurement вЂўApical 5 chamber or long axis views вЂўAvoid high PRF вЂўLaminar flow curve вЂўLow wall filter Doppler Peak or maximum Continuous wave (CW) jet velocity CW, suprasternal notch Use all available windows, align jet parallel to flow вЂўApical вЂўRight sternal border вЂўSuprasternal notch вЂўSubcostal Aortic valve Area (AVA) Continuity Equation - simplified вЂў вЂў вЂў AVA = CSA (LVOT) x TVI (LVOT) / TVI (AS) CSA = 3.14 x r2 Radius (r) = ВЅ measured diameter (radius is squared to determine area) Area = CSA (LVOT) x V (LVOT) / V (AS) Area = cm2 AVA Calculation Continuity Equation Using Velocity time integral (VTI) AVA= .785 x (LVOT)2 x LVOT (VTI) / AV (VTI) AVA= .785 x (2.0 cm)2 x 11.0 cm / 59cm AVA= .6cm2 AVA Calculation Simplified Continuity Equation Using peak (max) velocity AVA= .785 x (LVOT)2 x (V) LVOT / (V)AV AVA= .785 x (2.0 cm)2 x 56.0 cm/s / 288 cm/s AVA= .6cm2 AS Severity Scale Normal Mild Moderate Severe Mean 0 Gradient(mm Hg) <25 25-40 >40 Peak Gradient (mm Hg) <35 35-60 >60 1.6-3.0 1.0-1.5 <1.0 0 Valve Area (cm2) 3.0-4.0 FeigenbaumвЂ™s Echocadiography , Seventh edition , William Armstrrong and Tom Ryan, 2010 Dimensionless Index вЂў вЂў вЂў вЂў Useful when LVOT cannot be measured Velocity ratio = V (LVOT) / V (AS) Severe = .25 or less Corresponds to a valve area of 25% of normal AVA Planimetry Insert your slide text in this area. вЂўBullet вЂўBullet вЂўBullet Planimetry by 2D echo вЂў вЂў вЂў вЂў вЂў TTE, TEE, 3D echo Anatomic (geometric) cross sectional area measured freehand from 2D or 3D echo Difficult to perform accurately Useful if Doppler not available TEE best Mitral Stenosis вЂў вЂў вЂў вЂў вЂў вЂў вЂў Valve anatomy Commissural fusion- Psax Leaflet thickening, calcification- Plax Valve mobility- Plax Annular calcification Rheumatic vs degenerative Congenital- subvalvular apparatus Mitral Stenosis вЂў вЂў вЂў вЂў вЂў Doppler diastolic pressure gradient Bernoulli equation, change pressure =4V2 Apical window parallel alignment of beam to MV flow, continuous wave Mean pressure gradient derived from MV trace Atrial fibrillation requires average ~ 5 MV Pressure Gradient Mean pressure gradient 6-12 moderate, >12 mmHg severe Mitral Stenosis вЂў вЂў вЂў вЂў вЂў MV area, planimetry Direct measure of MV area Psax, measure at leaflet tips Scan from base to apex to find largest area Mid-diastole, cineloop through frozen image MVA by Planimetry Mitral Stenosis вЂў вЂў вЂў вЂў вЂў Doppler - Pressure Half time Deceleration slope of MV inflow MVA = 220 / pressure half time Atrial fibrillation average of 5 Avoid short diastole during selection Mitral Stenosis вЂў вЂў Pressure half time (PHT) (t ВЅ) MVA= 220 / t ВЅ DT= time from peak velocity to zero baseline PHT proportionally related to DT PHT is always 29% of the DT T1/2 =DT x 0.29 Mitral Valve Severity вЂў Cut off point for MVA <1.5 cm with symptoms Pulmonary Artery Systolic Pressure вЂў Continuous Wave Doppler jet velocity пЃ„P=4x(4.6)2 пЃ„P=85 mmHg RVSP=85 RVSP=85 mmHg+RAP (RAP (RAP is estimated) Right Atrial Pressure Estimation Brief sniff IVC SIZE Diameter decrease Estimated RAP < 1.7cm > 50% 0-5 mmHg > 1.7cm > 50% 6-10 mmHg >1.7 cm < 50% 10-15 mmHg >1.7 cm No change, 0% > 15 mmHg Tricuspid Valve Stenosis вЂў вЂў вЂў вЂў вЂў Similar to mitral valve stenosis methods Respiratory variation on Doppler especially with inspiration Anatomical assessment of valve Thickness, calcification Mobility, diastolic doming, reduced leaflet mobility Tricuspid Valve Stenosis вЂў вЂў вЂў вЂў вЂў вЂў Mean pressure gradient, > 5 mm Hg Inflow TV (TVI), > 60 cm Valve area by continuity equation< 1cm2 Right atrial enlargement > moderate Dilated IVC Combination lesion- TS/TR Pulmonic Stenosis вЂў вЂў вЂў вЂў вЂў вЂў Transpulmonary pressure gradient Simplified Bernoulli Equation P= 4V2 CW- Parallel to flow Infundibular and subvalvular stenosis may require analysis of full Bernoulli equation PW can help identify jet location Pulmonic Stenosis Pulmonic Valve Stenosis Peak Velocity (m/s) вЂў Mild Moderate Severe <3 3-4 >4 36-64 >64 Enter Objectives here <36 Peak Gradient вЂўRVOT вЂўRVH вЂўRV function/ size Mitral Regurgitation вЂў Determining severity requires multiple methods вЂў Jet Area / Pattern / Characteristics вЂў CW signal strength вЂў Vena Contracta Width вЂў PISA вЂў Pulmonary vein flow вЂў Regurgitant volume / Regurgitant fraction Regurgitation - Jet Area Factors affecting Jet Area вЂў LA pressure/ size вЂў Systemic BP вЂў Jet Direction (eccentricity) вЂў Nyquist limit 50-60 cm вЂў % of jet area/LA area вЂў Mild - severe вЂў <20%, >40% Regurgitation- Vena Contracta вЂў Parasternal long axis вЂў Zoom view вЂў Measure narrowest portion of jet as it emerges from the orifice вЂў Useful with central and eccentric jets вЂў Not useful with multiple jets Vena Contracta Stroke Volume (SV) вЂў CSA LVOT diameter x LVOT VTI = Ao SV вЂў Mitral annulus diameter x MV VTI = MV SV LVOT Diameter x LVOT VTI = SV .785 x (LVOT D)2= CSA Pulsed wave Regurgitant Volume (RV) вЂў Calculating Regurgitant Volume вЂў RV MV = SV (MV) вЂ“ SV (AV) вЂў Calculate Regurgitant Fraction вЂў RF= RV / SV вЂў RF (MV) = RV (MV) / SV (MV) Effective Regurgitant Orifice Area (EROA) вЂў CW Doppler of regurgitation jet (optimal) вЂў Trace jet for VTI вЂў EROA = RV (MV) / VTI (MR) Proximal Isovelocity Surface Area (PISA Method) вЂў Zoomed images of the mitral valve вЂў Color flow Doppler вЂ“ adjust the regurgitant aliasing velocity (baseline shift towards flow direction) down to 30-40 cm/sec range to better define the aliasing velocity вЂ“ Lowering the Nyquist limit will also achieve a well defined PISA hemisphere (lowers wall filter) вЂў Measure PISA radius in peak systole вЂў Note aliasing velocity (Va) вЂў Obtain CW Doppler with cursor parallel in the center of flow. Trace MR envelope for VTI and also mark peak velocity (V) вЂў EROA (cm2) = Flow (cc/sec) / V (cm/sec) вЂў flow= 6.28 x (r 2) x (aliasing velocity) Image Modified from Echo in Context PISA for Evaluation of Mitral Regurgitation PISA is Proximal Isovelocity Surface Area - It is located at the flow convergence of the regugitant valve вЂў Magnify (zoomed) mode вЂў Shift color Doppler baseline вЂў Obtain a PISA with a Nyquist limit at approximately 30- 40 cm/sec PISA for Evaluation of Mitral Regurgitation Apical 4 chamber Capture PISA from the BEST apical view Apical 2 chamber Apical long axis PISA for Evaluation of Mitral Regurgitation Place the CW Doppler cursor parallel in the center of mitral regurgitation Tricuspid Regurgitation Align Doppler parallel to flow Aortic Regurgitation 1. 2. 3. 4. Anatomy of the Aortic valve Mechanism of the leak Left ventricular function PISA Count leaflets 3 2 1 Pressure Half Time Aortic Regurgitation Suprasternal notch, aortic diastolic flow reversal Pulmonic Insufficiency Thank you!