echocardiographic assessment of stenotic valvular lesions
DESCRIPTION
Echocardiographic assessment of stenotic valvular lesions. Dr Nithin P G. Layout of seminar. Basic considerations Volumetric flow calculations Continuity equation Bernoulli equation & Pressure Gradients Pressure Half Time & Deceleration time Proximal Isovelocity Surface Area method - PowerPoint PPT PresentationTRANSCRIPT
Echocardiographic assessment of stenotic
valvular lesions
Dr Nithin P G
Layout of seminar
• Basic considerations• Volumetric flow calculations• Continuity equation• Bernoulli equation & Pressure Gradients• Pressure Half Time & Deceleration time• Proximal Isovelocity Surface Area method
• Assessment of common stenotic lesions• MS• AS• TS• PS
BASIC CONSIDERATION
Volumetric flow calculations
D (h) = v x t D (h) =
D (h) =Area under curve=
VTI
Q= Cross sectional Area x VTI
Volumetric flow calculations
Limitations • Assumptions
– Flow through rigid circular tube [elastic]
– Uniform velocity across the vessel
– Derived CSA is circular [AV valves elliptical]
– CSA constant throughout the flow
– SV remains in constant position throughout
• Errors in VTI measurements– Inadequate beam alignment– Failure to correctly trace the
VTI [ leading edge in A,P modal velocity in M,T]
– 3-5 beats in SR, 8- 10 bts in AF– Incorrect gain settings and
filter settings
• Errors in diameter measurements– Wrong phase of cardiac cycle– Inconsistent annulus
measurement
Continuity equation
• QLVOT= Qthru all chambers
• ALVOT x VTILVOT = Apoint x VTIpoint
• Apoint = ALVOT x VTILVOT
VTIpoint
= p D2 x VTILVOT
4 VTIpoint
= 0.785 D2 x VTILVOT
VTIpoint
•No intracardiac shunts between the two points
•No significant regurgitant flow
Continuity equation
Limitations
• Limitations in measurement of flow
• Intracardiac shunts
• Regurgitation flow
• Low cardiac output
Bernoulli equation
• D P= 4V2
• Peak Pressure Grad = 4 x (Vmax)2
• Mean PG = 4 x (∑V1²+V2²+…Vn²) n MPG=[∆P(max)/1.45 ]+2
MPG=2.4(Vmax)²
P1, v1
P2, v2
Bernoulli equation & Pressure Gradients
Bernoulli equation & Pressure Gradients• Pressure recovery phenomenon
Bernoulli equation & Pressure Gradients
Bernoulli equation & Pressure Gradients
HR=72
HR=100
Pressure Half Time & Deceleration time
Pressure Half Time & Deceleration time
• PHT- time required by the pressure to decay to half its original value [ velocity to V/1.414]
MVA= 220/PHT
• DT- Time taken for peak early diastolic velocity to fall to zero [ PHT= 0.29 x DT]
MVA= 759/DT
Pressure Half Time & Deceleration time
Advantages
• Not affected by low cardiac output
• Not affected by coexisting MR
Limitations• Affected by LV compliance,
Peak Pressure gradients– Post BMV– Severe AR [elev. LVEDP
shortens PHT]– Severe LVH- ↓LV
compliance• Misinterpretation b/w AR
velocity and MS signal [ MS after IVRT]
• Prosthetic mitral valve- not validated
Proximal Isovelocity Surface Area method
• QAlias= AAlias x VAlias
• QAlias= 2pr2 x VN
• QAlias= QOrif = AOrif x VOrif
• AOrif = 2pr2 x VN
VOrif
Stenotic orifice area
Proximal Isovelocity Surface Area method
Angle correction• Flow can only converge
from an angle of a• Corrected Formulae MVA= 2pr2 x VN x a
Vorif 180
Proximal Isovelocity Surface Area method
Advantages
• Mitral valve calcification
• MR/AR
• Accurate and reliable
Disadvantages• Peak velocity (E) rather than
integration of flow over the entire diastolic period
• Vena contracta= effective orifice area < anatomical orifice
• Radius measurement calculation– Accurate measurement
required– Low Aliasing velocity will
reduce accuracy
ASSESSMENT OF COMMON STENOTIC LESIONS
Mitral Stenosis
Mitral Stenosis
RHD
• Commissural fusion doming/bowing⇒
• Chordal thickening abnormal motion⇒
• Progressive fibrosis stiffening calcification⇒ ⇒
• Doming of the mitral valve (hockey stick AML)
• Funnel shaped opening of mitral valves
• Focal thickening and beading of leaflets
• Calcification
M-mode assessment
Decrease in the initial diastolic leaflet closure (E-F slope) [>80mm/s MVA =4-6cm², <15mm/s MVA <1.3cm²]⇒ ⇒
Severity of MS
• The normal adult mitral valve area (MVA) is 4 to 6 cm² in CSA
• Severe MS when,MVA of < 1.0 cm²- severe MSPHT> 220Mean Gradient >10
Mild Moderate Severe
Assessment of severity
I. 2D-Planimetry
• 2D short axis imaging of diastolic orifice-planimetry
• Smallest orifice at the leaflet tips
• Inner edge of the black/white interface traced
• Correlates well with hemodynamic assessment
Assessment of severity1. Funnel-shaped- Actual limiting
orifice at the tip
2. Instrumentation setting- ‘’blooming” of the echoes due to increased gain [operator—dependent]
3. Proper alignment of the imaging plane relative to valve orifice is critical
4. The orifice should be measured during initial diastole when the valve is maximally distended
5. Appropriate receiver gain settings are necessary
6. The orifice should appear fish mouthed
7. Good lateral resolution is necessary to identify the medial and lateral margins correctly.
8. Planimetry has decreased accuracy in the setting of valvular thickening and calcification, chest deformity and previous commissurotomy
Assessment of severity
Method for determining the correct level for planimetry
Step 1- Direct the scan plane to the level of papillary muscle
Step 2- Angle the transducer slightly medially & tilt superiorly until the tips of mitral leaflets are identified [ corres. to the smallest MVA]
Step 3- Freeze the image in early diastole
Step 4- Trace the MVA along the inner margins of the leaflets
Assessment of severity
Method for calculating the MVA by PHT & DT
Step 1- Optimize the CW Doppler Signal through the mitral valve [usually the best from apical window, colour flow imaging]
Step 2- Measure the peak E velocity [Vpeak]
Step 3- Determine the PHT point on the EF slope where V becomes Vpeak / 1.414
Step 4- Draw vertical lines from baseline to Vpeak & PHT point
Step 5- Measure the time interval between the vertical lines [= PHT]
Step 6- Trace the EF slope till it touches the baseline, measure the time interval from Vpeak to this point [=DT]
Step 7- Calculate MVA [220/PHT or 759/DT]
II. PHT or DT
Assessment of severity
PHT or DT TracingA normal range of PHT is 20 – 60msec
MS have PHT > 90msec
Assessment of severity
Method for calculating the MVA by PISA
Step 1- Zoom the area of the mitral valve from the apical four-chamber view.
Step 2- Use colour flow imaging of the mitral stenosis jet and upward shift of the zero baseline for colour map (30- to 45-cm/s aliasing velocity).
Step 3- Freeze colour flow images in a cine loop and identify an optimal frame to measure radius (r) of PISA in the LA.
Step 4- Determine the angle (a) between two mitral leaflets at the atrial surface and use the following formula: MVA= 2pr2 x VN x a Vpeak 180
III. PISA
Assessment of severity
Adjusting Aliasing velocity
Assessment of severity
Method for calculating the MVA by Continuity Equation
Step 1-Measure the CSA in cm2 of LVOT [ from PLAX view measure the LVOT Dia., during systole, inner edge to inner edge; CSA= 0.785 x D2]
Step 2- Measure VTI of LVOT [ from A5C view, PW doppler, SV just proximal to aortic valve, systole, trace leading edge velocity for VTI ]
Step 3- Measure VTI of MS [from A4C view, CW doppler, trace modal velocity VTI]
Step 4- Calculate MVA using the following formula: CSALVOT x VTILVOT
VTIMS
IV. Continuity Equation
Assessment of severity
Method for calculating the MV Gradients
Step 1-Optimize the CW Doppler Signal through the mitral valve [usually the best from apical window, colour flow imaging]
Step 2- Measure the peak E velocity [Vpeak]. Peak PG= 4 Vpeak2
Step 3- Trace the velocity signal of MS to get the mean PG.
Step 4- Mention the heart rate at which measurement taken
V. Pressure Gradients
TECHNIQUE METHOD REMARKS
Planimetry Measurement in short axis view
Operator dependent, decreased accuracy in setting of calcification or prev. commisurotomy
Pressure half time (Pt½ ) MVA= 220/ Pt½ where Pt½ =0.29 x Deceleration time
Unreliable in conditions with elevated LVEDP (MR, AI, recent PBMV)
Continuity Equation MVA=D2 LVOT x 0.785x TVI LVOT /TVI MV
In regurgitant lesions reliability decreases
PISA (Proximal Iso -velocity Surface Area)
MVA= 2πr2 x V Very reliable, operator dependent
Assessment of severity
Secondary features of MS
• LA dilation
• AF
• Spontaneous echo contrast
• LA thrombus
• Secondary pulmonary HTN-TR
Echo approach to MS
• Valve morphology, etiology
• Exclude other causes of clinical presentation
• MS severity Peak & Mean PG 2D valve area MVA by PHT, Continuity, PISA
• Assosiated MR
• LA enlargement/ clots
• Pulmonary art pressure
• Co-existing TR severity
• Assessment for BMV
Individuals with score≤8 –excellent for BMV
Those with score 12-less satisfactory results≧
Tricuspid Stenosis
• Normal inflow velocity < 0.5-1m/sec, mean gradient < 2 mm Hg.
• Respiratory variation in inflow velocity [ increased during inspiration]. Best measured with breath held in expiration
• 2D-Planimetry cannot be used
• Severe when mean PG > 7 mm Hg or PHT > 190 msec
Trileaflet valve
Normal valve area-3-4 cm²
Severity of Aortic Stenosis
AORTIC VALVE
Mild Moderate Severe
AVA-Direct planimetry
• Rarely are all 3 leaflets imaged perpendicular
• Triangular shape- measurement error
• Deformities & irregularities- further exacerbates
• AoV- superior-inferior rapid moments
Assessment of severity
Method for calculating the MVA by Continuity Equation
Step 1-Measure the CSA in cm2 of LVOT [ from PLAX view measure the LVOT Dia., during systole, inner edge to inner edge; CSA= 0.785 x D2]
Step 2- Measure VTI of LVOT [ from A5C view, PW doppler, SV just proximal to aortic valve, systole, trace leading edge velocity for VTI ]
Step 3- Measure VTI of AS [from multiple views , A5C view, CW doppler, trace modal velocity VTI]
Step 4- Calculate MVA using the following formula: CSALVOT x VTILVOT
VTIAS
I. Continuity Equation
Assessment of severity
Method for calculating the Pressure Gradients
Step 1-Optimize the CW Doppler Signal through the aortic valve [usually from apical 5C window, colour flow imaging]
Step 2- Measure the peak velocity [Vpeak]. Peak PG= 4 Vpeak2
Step 3- Trace the velocity signal of AS to get the mean PG.
Step 4- Mention the heart rate at which measurement taken
II. Pressure Gradients
Assessment of Severity
Discrepancies
– Technically poor doppler recording
– Non parallel interrogation angle
– Pressure gradients depends on HR, flow rate & valve narrowing –AR/LV dysfunction
Assessment of Severity
Dobutamine Echo
• Aortic valve area depends on Aortic flow rate
• Distinguish- true severe valvular stenosis vs mild to mod stenosis with LV dysfunction
• Stepwise infusion of dobutamine(5—30µg/kg/min)
• Lack of contractile reserve- Failure of LVEF to ↑ by 20% is a poor prognostic sign
Normal LV , AS
Abnormal LV , AS
Assessment of Severity
Maximal aortic cusp separation (MACS) on M-mode
Vertical distance between RCC and NCC during systole
Stenotic Aortic Valve → decreased MACS
Limitations– Single dimension– Asymmetrical AV involvement– Calcification / thickness– ↓ LV systolic function– ↓ CO status
AVA MACS
N > 2cm2 N > 15 mm
< 0.75 cm2 < 8 mm
> 1 cm2 > 12 mm
gray area 8 – 12 mm
Assessment of Severity
• Ao valve resistance-Has a good correlation with AVA for a given aortic velocity. Resistance=28/ AVA x √gradient( mean) =(∆P/∆Q)mean x1333
• Dimensionless index [DI] DI =VTILVOT / VTIAortic
If DI < 0.25 for native valve, then critical stenosis
Discrepancies in AS severity assessment
AS by gradient
Gradient lower than expected– Reduced EF– Significant MR
Gradient higher than expected– Significant AR– High Output states like
anemia, fever
AS by continuity Equation
• Associated subvalvular obstruction [higher LVOT velocities, abnormal measurements]; [AR not C.I.]
• LVOT TVI- SV -just behind AoV
• Suboptimal LVOT measurements
• Low Trans Aortic flow rate Low EF Small ventricular chamber Mod-severe MR
Echo approach to AS
• Valve anatomy, etiology
• Exclude other LVOTO
• Stenosis severity
– jet velocity
– mean pressure gradient
– AVA – continuity equation
• LV
Dimensions/ hypertrophy/ EF/
diastolic fn
• Aorta
Aortic diameter/ annulus
diameter/ assess COA
• AR – quantification if more
than mild
• Associated MR- mechanism
& severity
• Pulmonary artery pressure
Pulmonary stenosis
• Isolated or associated with other congenital lesions
• Jet velocity > 4 m/sec or maximum gradient > 60 mm Hg
• Prominent a waves in M-mode tracing
P V Pressure gradient A wave amplitude
Nil 2-7 mm
< 50 mm Hg 2-10 (6) mm
>50 mm Hg 6-18 (10) mm
Thank you