Cardiac Measurements Guidelines

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The following types of measurements are commonly included in a comprehensive echocardiography report.

1) Left Ventricle:a) Size: Dimensions or volumes, at end-systole and end-diastoleb) Wall thickness and/or mass: Ventricular septum and left ventricular posterior wall thicknesses (at end-systole and end-diastole) and/or mass (at end-diastole)c) Function: Assessment of systolic function and regional wall motion. Assessmentof diastolic function2) Left Atrium:• Size: Area or dimension3) Aortic Root:• Dimension4) Right Ventricle:a)Size: Dimensions b)Function: Systolic and diastolic functionc)RV & pulmonary hemodynamics5) Right Atrium:a) Size: Dimensions, areab) RA pressure

The following cardiac and vascular structures are generally be evaluated as part of acomprehensive adult transthoracic echocardiography report:

1) Left Ventricle (LV)2) Left Atrium (LA)3) Right Atrium (RA)4) Right Ventricle (RV)5) Aortic Valve (AV)6) Mitral Valve (MV)7) Tricuspid Valve (TV)8) Pulmonic Valve (PV)9) Pericardium 10) Aorta (Ao)11) Pulmonary Artery (PA)12) Inferior Vena Cava (IVC) and Pulmonary Veins

6) Valvular Stenosis:a) Valvular Stenosis: Assessment of severity, including trans-valvular gradient and area.

b) Subvalvular Stenosis: Assessment of severity, Including subvalvular gradient.

7) Valvular Regurgitation: Assessment of severity with semi-quantitative descriptive statements and/or quantitative measurements

8) Cardiac Shunts: Assessment of severity. Measurements of QP:QS (pulmonary-to systemic flow ratio) and/or orifice area or diameter of the defect are often helpful.

9) Prosthetic Valves:a) Transvalvular gradient and effective orifice area

b) Description of regurgitation, if present

The following types of measurements are commonly included in a comprehensive echocardiography report.

① This icon identifies the level 1 measurements according to ASE’s standard guidelines

② This icon identifies the level 2 measurements according to ASEstandard Guidelines

Clarification

Left Ventricle (LV)

LV Dimensions, wall thickness, LV mass: 2D Mode

Input: - IVSd - Interventricular septal tickness at end-diastole(green) - LVEDD - LV End-Diastolic dimension (yellow)- PWd - PW thickness at End-Diastolic (red)- LVESD – LV End-Systolic dimension (right image)

Output:- LVEF % - LVFS (Fractional Shortening )- LV Mass-LVMI - LV Mass Index -RWT - Relative wall thickness

①

LV Dimensions, wall thickness, LV mass: M-Mode (sax or plax)

Input:- IVSd (yellow)- LVIDd – LV Internal diameter diastole (EDD)- LVPWd – LV Posterior wall diastole (green)- IVSs - Interventricular Septum systole (red) - LVIDs - LV Internal diameter systole (ESD)- LVPWs End-systolic diameter(blue)

Output:- LV EF - (Teichholz formula)- LV FS - (Fractional Shortening) - LVVd - Diastolic Volume- LVVs - Systolic Volume- SV - Stroke Volume- SI - Stroke index- Sept Thickening %- PW Thickening %- LV Mass- LVMI - LV Mass Index

Left Ventricle (LV) ①

The most commonly used 2D methods for measuring LV mass are based on the area-length formula and the truncated ellipsoid model, as described in detail in the 1989 ASE document on LV quantitation. Both methods rely on measurements of myocardial area at the midpapillary muscle level. The epicardium is traced to obtain the total area (A1) and the endocardium is traced to obtain the cavity area (A2). Myocardial area (Am) iscomputed as the difference: Am = A1 - A2.

Left Ventricle (LV)LV Mass: 2D Mode (A-L and Truncated ellipsoid method)

Input:A1 – Area1 Pericardial border A2 – Area 2 Endocardial border

A-L : LV length

Output:LV MassLVMI – LV Mass index

①

LV Volumes & systolic function: Simpson methodThe most commonly used 2D measurement for volume measurements is the biplane method of disks (modified Simpson’s rule) and is the currently recommended method of choice by consensus of the proper ASE committee. The total LV volume is calculated from the summation of a stack of elliptical disks. The height of each disk is calculated as a fraction (usually 1/20) of the LV long axis based on the longer of the two lengths from the 2- and 4- chambers view. Papillary muscles should be excluded from the cavity in the tracing.

Input:LV EDD – LV End-diastolic dimension (A4C) LV ESD – LV End-systolic dimension (A4C)LV EDD – LV End-diastolic dimension (A2C)LV ESD – LV End-systolic dimension (A2C)

Output:EDV – End-diastolic volume (mL)ESV - End-systolic volume (mL)LVDVI – LV Diastolic volume index (mL/m²) LVSVI – LV Systolic volume index (mL/m²)LVEF – LV Ejection fraction %SV – Stroke Volume (mL)SI - Stroke Index

Left Ventricle (LV) ①

LV Volumes & systolic function (A-L)As an alternative method to calculate the LV Vol when apical endocardial definition precludes accurate tracing is the area-length where the LV is assumed to be Bullet-shaped. The mid-LV cross-sectional area is computed by planimetry in the parasternal short-axis view and the length of the ventricle taken from the midpoint of the annulus to the apex in A4C view. This measurements are repeated in end-diastole and end-systole. The most widely used parameter for indexing volumes is the Body Surface Area (BSA) in square meters.

Input: LV diastolic CSA – Cross sectional area LV diastolic length – A4CLV systolic CSA LV systolic length – A4C

Left Ventricle (LV) ②

Output:EDV – End-diastolic volume (mL)ESV - End-systolic volume (mL)LVDVI – LV Diastolic volume index (mL/m²) LVSVI – LV Systolic volume index (mL/m²)LVEF – LV Ejection fraction %SV – Stroke Volume (mL)SI - Stroke Index

LV Systolic function: Stroke Volume (SV), Cardiac output (CO)

CO (LV) is the volume of blood being pumped by the left ventricle in the time interval of one minute.In order to obtain CO we need to measure the LVOT diameter in PLAX view zoomed image (left) in systole and the Velocity Time Integral in Pulsed wave mode of the LVOT in apical 5 chamber view (left down).

Formula: SV = π x (LVOT / 2)² x VTI₁

CO= (SV x HR) / 1000

Input:LVOT – LV outflow tract diameter (mm) LVOT VTI - Subvalvular Velocity Time integral (cm)R-R interval (HR) (Red doted line)

Output:SV - Stroke Volume CO - Cardiac output SI – Stroke Index CI - Cardiac Index

Left Ventricle (LV) ①

LV Systolic function: MPI LV (Myocardial Performance Index)Also known as the Tei index. It is an index that incorporates both systolic and diastolic time intervals in expressing global systolic and diastolic ventricular function. Systolic dysfunction prolongs prejection (isovolumic contraction time, IVCT) and a shortening of the ejection time (ET). Both systolic and diastolic dysfunction result in abnormality in myocardial relaxation which prolongs the relaxation period (isovolumic relaxation time, IVRT).

Input: MCOT - Mitral valve closure to opening time (orange) LVET - LV Ejection time (blue lines)

Output:LV MPI – LV Myocardial performance index

Formula:LV MPI= (IVCT + IVRT) / LVET = (MCOT – LVET) / LVET

Left Ventricle (LV) ①

LV Systolic function: dP/dt (LV Contractility)

Peak dP/dt is one of the most commonly used indexes for assessing left ventricular function. Continuous wave Doppler determination of the velocities of a mitral insufficiency jet should allow calculation of instantaneous pressure gradients between the left ventricle and left atrium. The rising segment of the mitral insufficiency velocity curve should reflect left ventricular pressure elevation. The LV contractility dP/dt can be estimated by using time interval between 1 and 3 cm/sec on MR velocity CW spectrum during isovolumetric contraction, i.e. before aortic valve opens when there is no significant change in LA pressure.

Formula:dP/dt= 32/T

Input: T - Time between 1 and 3 cm/sec

Output: dP/dt (mmHg/s)

Left Ventricle (LV) ①

Systolic myocardial velocity (S’) atthe lateral mitral annulus is a measure of longitudinal systolic function and is correlated with measurements of LV ejection fraction and peak dP/dt. A reduction in S’ (Systolic velocity annulus) velocity can be detected within 15 seconds of the onset of ischemia, and regional reductions in S’ are correlated with regional wallmotion abnormalities. Incorporation of TDI measures of systolic function in exercise testing to assess for ischemia, viability, and contractile reserve has been suggested because peak S’ velocity normally increases with dobutamine infusion and exercise and decreases with ischemia. *

* A Clinician's Guide to Tissue Doppler Imaging Carolyn Y. Ho and Scott D. Solomon Circulation. 2006;113:e396-e398

LV Systolic function: TDI

Input: S – Systolic velocity in lateral wall A4C (red)

Left Ventricle (LV) ②

LV Wall motion score

Left Ventricle (LV)

LV Diastolic function

- PW mitral inflow IVRT (Isovolumic relaxation time)- DTI (e ) (Tissue doppler)′- PV (Pulmonary vein) flow - Mitral inflow propagation- LA volume- PCWP by E/e’ (mean Pulmonary Capillary Wedge Pressure by E/e’) (Nagueh)

Left Ventricle (LV)

Input:-E-wave - Peak early filling velocity (Yellow)-A-wave - Late diastolic filling velocity (green)-DT - Deceleration time (Blue)-IVRT – Isovolumic relaxation time (red)-A duration – (orange)

LV diastolic function: PW mitral inflowThe mitral inflow velocity profile is used to initially characterize LV filling dynamics. The E velocity (E) represents the early mitral inflow velocity and is influenced by the relative pressures between the LA and LV, which, in turn, are dependent on multiple variables including LA pressure, LV compliance, and the rate of LV relaxation. The A velocity (A) represents the atrial contractile component of mitral filling and is primarily influenced by LV compliance and LA contractility. The deceleration time (DT) of the E velocity is the interval from peak E to a point of intersection of the deceleration of flow with the baseline and it correlates with time of pressure equalization between the LA and LV.

①

Output:-E/A ratio

The IVRT is the time interval between aortic valve closure and mitral valve opening. The transducer is placed in the apical position with either a pulsed or continuous wave Doppler sample placed between the aortic and mitral valves. A normal IVRT is approximately 70 to 90 ms. The IVRT will lengthen with impaired LV relaxation and shorten when LV compliance is decreased and LV filling pressures are increased.

IVRT - measurement from the Ao valve closure (yellow)And Mitral valve opening (green)

LV diastolic function: IVRT (Isovolumic relaxation time)

Left Ventricle (LV) ①

Currently, the most sensitive and widely used technique for LVDF is TDI.Diastolic dysfunction is directly related to the reduction in early LV relaxation compromising the effective transfer of the blood from the atrial reservoir into the LV cavity. The reduction in LV relaxation may be characterized through the evaluation of mitral annular motion, generally with Doppler tissue imaging, which can resolve subtle changes in LV relaxation by identifying a low septal annular early diastolic mitral annular motion (e’) velocity.For the assessment of global LV diastolic function, it is recommended to acquire and measure tissue Doppler signals at leastat the septal and lateral sides of the mitral annulus and their average, given the influence of regional function on these velocities and time intervals.

Input:s: Systolic annular velocity (blue)e’: early diastolic annular velocity (yellow)a’: late diastolic velocity (green)Output: E/e’ ratioe’/a’ ratio

Left Ventricle (LV)

LV diastolic function: Tissue doppler image

①

LV diastolic function: Pulmonary veins

PW Doppler of pulmonary venous flow is performed in the apical 4-chamber view and aids in the assessment of LV diastolic function. If the mitral inflow velocityprofile indicates a predominant relaxation abnormality with a low E/e= ratio (normal mean LA pressure), a pulmonary vein flow duration greater than mitral inflow duration at atrial contraction may indicate an earlier stage of reduced LV compliance as well as increased LV end-diastolic pressure.PV flow is better

Input: S - Peak systolic vel D - Peak diastolic vel Ar - Reverse vel in late diatole Ar duration Ar - A - Time difference between Ar duration and mitral A-wave duration

Left Ventricle (LV) ①

Output:S/D Ratio

LV diastolic function: Mitral Inflow Propagation

Acquisition is performed in the apical 4-chamber view, using color flow imaging with a narrow colorsector, and gain is adjusted to avoid noise. The M-mode scan line is placed through the center of the LV inflow blood column from the mitral valve to the apex. Then the color flow baseline is shifted tolower the Nyquist limit so that the central highest velocity jet is blue. Flow propagation velocity (Vp) is measured as the slope of the first aliasing velocity during early filling, measured from the mitral valve plane to 4 cm distally into the LV cavity. Alternatively, the slope of the transition from no color to color is measured. Vp 50 cm/s is considered normal. During heart failure and during myocardial ischemia, there is slowing of mitral-to-apical flow propagation, consistent with a reduction of apical suction.

Input:Vp - Flow propagation velocity (doted whiteLine) (cm/s)

Left Ventricle (LV) ①

LV diastolic function: Left Atrium (LA) Volume

Left atrial volume is regarded as a “barometer” of the chronicity of diastolic dysfunction; with the most accurate measurements obtained using the apical 4-chamber and 2-chamber views (Biplane areal-length or Simpson). This assessment is clinically important, because there is a significant relation between LA remodeling and echocardiographic indices of diastolic function. However, Doppler velocities and time intervals reflect filling pressures at the time of measurement, whereas LA volume often reflects the cumulative effects of filling pressures over time.

Input: A1 – Max planimetry LA area - A4CA2 – Max planimetry LA area – A2CL - Length

Left Ventricle (LV) ①

Output: LA Volume – Left atrial volumeLAVI – LA volume index

Left Ventricle (LV)LV diastolic function: PCWP (Mean capilary wedge pressure) by E/e’

We can use the average e’ velocity obtained from the septal and lateral sides of the mitral annulus for prediction of LV filling pressures. E/e’ ratio < 8 is usually associated with normal LV filling pressures (PCWP < 15 mmHg) while a ratio > 15 is associated with increased filling pressures (PCWP > 15 mmHg). Between 8 ans 15 there is a gray zone with overlapping of values for filling pressures.

Input: E: Mitral inflow E velocitye’ (lateral) e’ (septal)

Output: e’ (Average) - of the lateral and septal e’ values (m/s)E/e’: ratioPCWP - Mean Pulmonary capillary wedge pressure (mmHg)

Formulas:e’ = (e’ lateral + e’ septal) / 2

PCWP = 1.24 * (E/e’) + 1.9

①

Left Atrium (LA)

When LA size is measured in clinical practice, volume determinations are preferred over linear dimensions because they allow accurate assessment of the asymmetric remodeling of the LA chamber. In thearea-length formula the length is measured in both the 4- and 2-chamber views and the shortest of these2 length measurements is used in the formula.

①Quantification of the Left Atrial size: LA Volume (Biplane)

Input: A1 – Max planimetry LA area - A4CA2 – Max planimetry LA area – A2CL - Length

Output: LA Diameter – (cm)LA diameter index – cm/m² LA Volume – Left atrial volume (mL)LAVI – LA volume index (mL/m²)

Quantification of the Left Atrial size: M-Mode

The LA size is measured at the end-ventricular systole when the LA chamber is at its greatest dimension, care should be taken to avoid foreshortening of the LA. The base of the LA should be at its largest size indicating that the imaging plane passes through the maximal shortening area. The LA length should be also maximized ensuring alignment along the true long axis of the LA. The confluences of the pulmonary veins, and LA appendage should be excluded. AP linear dimensions of the LA as the sole measure of LA size may be misleading and should be accompanied by LA volume determination in both clinical practice and research.

Left Atrium (LA)

Input: LAD – Left atrium diameter (cm)

②

Aortic root

Aortic root dimension

Figure 19 Measurement of aortic root diameter at sinusesof Valsava from 2-dimensional parasternal long-axis image.Although leading edge to leading edge technique is shown,some prefer inner edge to inner edge method. TTE imaging.

Figure 18 Measurement of aortic root diameters at aorticvalve annulus (AV ann) level, sinuses of Valsalva (SinusVal), and sinotubular junction (ST Jxn) from midesophageallong-axis view of aortic valve, usually at angle ofapproximately 110 to 150 degrees. Annulus is measured byconvention at base of aortic leaflets. Although leading edgeto leading edge technique is demonstrated for the Sinus Valand ST Jxn, some prefer inner edge to inner edge method.TEE imaging.

①

Input: AV Ann – Aortic valve annulus (TEE)Sinus Val – Sinuses of Valsalva (TEE)ST Jxn – Sinotubular junction (TEE)Ao – Aortic root diameter (TTE)

Right Ventricle (RV)RV segments & coronary supply

Segmental nomenclature of the right ventricular walls, along with their coronary supply. Ao, Aorta; CS, coronary sinus; LA, left atrium; LAD, left anterior descending artery; LV, left ventricle; PA, pulmonary artery; RA, right atrium; RCA, right coronary artery;RV, right ventricle; RVOT, right ventricular outflow tract.

Right Ventricle (RV)RV Size: RV linear dimension

Using 2D echocardiography, RV size can be measured from a 4-chamber view obtained from the apical window at end-diastole. Although quantitative validation is lacking, qualitatively, the right ventricle should appear smaller than the left ventricle and usually no more than two thirds the size of the left ventricle in the standard apical 4-chamber view. If the right ventricle is larger than the left ventricle in this view, it is likely significantly enlarged.RV dimension is best estimated at end-diastole from a right ventricle–focused apical 4-chamber view.Input:

RV Basal - RV Basal diameter (mm)RV mid - RV Mid diameter (mm) RV long - RV Longitudinal diameter (mm)

①

Right Ventricle (RV)RV size: RVOT Dimensions

The RVOT is generally considered to include the subpulmonary infundibulum,or conus, and the pulmonary valve. The RVOT is best viewed from the left parasternal and subcostal windows. The size of the RVOT should be measured at end-diastole on the QRS deflection.

A) PLAX view, a portion of the proximal RVOT can be measuredB) PSAX view, proximal RVOT measurementC) PSAX view, Distal RVOT measurement (preferred site for RVOT linear measurement)

Input:RVOT proximal (mm)RVOT Distal (mm)

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Right Ventricle (RV)RV size: RV Wall thickness

(A) Subcostal 2-dimensional image of right ventricular wall.(B) Zoom of region outlined in (A) with right ventricular wall thickness indicated by arrows. (C) M-mode image corresponding to arrowsin (B). (D) Zoom of region outlined in (C) with arrows indicating wall thickness at end-diastole.

RV wall thickness is a useful measurement for RVH, usually the result of RVSP overload. RV free wall thickness can be measured at end-diastole by M-mode or 2D echocardiography from the subcostal window, preferably at the level of the tip of the anterior tricuspid leaflet or left parasternal windows. Excluding RV trabeculations and papillary muscle from RV endocardial border is critical for accurately measuring the RV wall thickness.When image quality permits, fundamental imaging should be used to avoid the increased structure thickness seen with harmonic imaging.

Input:RV Wall thickness (mm)

①

Right Ventricle (RV)RV systolic function: TAPSE (Tricuspid Annular Plane Systolic Excursion)

The systolic movement of the base of the RV free wall provides one of the most visibly obvious movements on normal echocardiography. TAPSE or TAM is a method to measure the distance of systolic excursion of the RV annular segment along its longitudinal plane, from a standard apical 4-chamber window. It is inferred that the greater the descent of the base in systole, the better the RV systolic function. TAPSE is usuallyacquired by placing an M-mode cursor through the tricuspid annulusand measuring the amount of longitudinal motion of theannulus at peak systole

Input:TAPSE – Tricuspid Annular Plane Excursion mm

①

Right Ventricle (RV)RV systolic function: FAC (Fractional Area Change)

The percentage RV FAC, defined as (end-diastolic area end-systolic area)/end-diastolic area 100, is a measure of RV systolic function that has been shown to correlate with RV EF by magnetic resonanceimaging (MRI). FAC is obtained by tracing the RV endocardium both in systole and diastole from the annulus, along the free wall to theapex, and then back to the annulus, along the interventricular septum. Care must be taken to trace the free wall beneath theTrabeculations. Two-dimensional Fractional Area Change is one of the recommended methods of quantitatively estimating RV function, with a lower reference valuefor normal RV systolic function of 35%.

Input: ED area - End-diastolic AreaES area - End-systolic Area

Output: FAC %

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Right Ventricle (RV)

Input: S’ – Systolic excursion velocity

RV systolic function: RV S’ (Systolic excursion velocity)

Among the most reliably and reproduciblyimaged regions of the right ventricle are the tricuspid annulus and the basal free wall segment. These regions can be assessed by pulsed tissue Doppler and color-coded tissue Doppler to measure the longitudinal velocity of excursion. This velocity has been termed the RV S’ or systolic excursion velocity. To perform this measure, an apical 4-chamber window is used with a tissue Doppler mode region of interest highlighting the RV free wall. The pulsed Doppler sample volume is placed in either the tricuspid annulus or the middle of the basal segment of the RV free wall.

+

①

Right Ventricle (RV)RV systolic function: MPI RV - Myocardial Performance Index RV

The MPI, also known as the RIMP or Tei index, is a global estimate of both systolic and diastolic function of the right ventricle. It is based on the relationship between ejection and nonejection work of the heart. The MPI is defined as the ratio of isovolumic time divided by ET, or [(IVRT + IVCT)/ET]. The right-sided MPI can be obtained by two methods: the pulsed Doppler method and the tissue Doppler method: In the pulsed Doppler method (A), the ET is measured with pulsed Doppler of Rv outflow (time from the onset to the cessation of flow), and the tricuspid (valve) closure-opening time is measured with either pulsed Doppler of the tricuspid inflow (time from the end of the transtricuspid A wave to the beginning of the transtricuspid E wave) or continuous Dopplerof the TR jet (time from the onset to the cessation of the jet). In the tissue Doppler method (B), all time intervals are measured from a single beat by pulsing the tricuspid annulus (left)

Output: IVCT (Isovolumic Contraction Time)IVRT (Isovolumic Relaxation Time)MPI RV

Input: ET - Ejection TimeTCO - Tric. Closure-Opening Time)

②

Right Ventricle (RV)RV systolic function: RV dP/dt

RV dP/dt can be accurately estimated from the ascending limb of the TR continuous-wave Doppler signal. Is commonly calculated by measuring the time required for the TR jet to increase in velocity from 1 to 2 m/s. Using the simplified Bernoulli equation, this represents a 12 mm Hg increase inpressure. The dP/dt is therefore calculated as 12 mm Hg divided by this time (in seconds), yielding a value in millimeters of mercury per second.

Because of the lack of data in normalsubjects, RV dP/dt cannot be recommended for routine uses. It can be considered in subjects with suspected RV dysfunction. RV dP/dt < approximately 400 mm Hg/s is likely abnormal.

Point 1 represents the point at which the tricuspid regurgitation(TR) signal meets the 1 m/s velocity scale marker,while point 2 represents the point at which the TR signal meetsthe 2 m/s velocity scale marker. Point 3 represents the time requiredfor the TR jet to increase from 1 to 2 m/s. In this example,this time is 30 ms, or 0.03 seconds. The dP/dt is therefore 12mmHg/0.03 seconds, or 400 mm Hg/s.

②

Right Ventricle (RV)RV systolic function: RV IVA (Myocardial Acceleration During Isovolumic Contraction)

Isovolumetric acceleration (IVA) is a novel tissue Doppler parameter for the assessment of systolic function. Myocardial acceleration during isovolumic contraction is defined as the peak isovolumic myocardial velocity divided by time to peak velocity and is typically measured for the right ventricle by Doppler tissue imaging at the lateral tricuspid annulus. For the calculationof IVA, the onset of myocardial acceleration is at the zero crossing point of myocardial velocity during isovolumic contraction. In studies in patients with conditions affected by RV function, RV IVA may be used, and when used, it should be measured at the lateral tricuspid annulus. RV IVA is not recommended as a screening parameter for RV systolic function in the general echocardiographylaboratory population.

Pulsed wave tissue Doppler imaging of the RV free wall of a control subject. 1: peak myocardial systolic velocity (Sm), 2: peak early diastolic velocity (Em), 3: peak late diastolic velocity (Am) 4: isovolumetric contraction time (IVCT), 5: ejection time (ET), 6: peak myocardial isovolumetric contraction velocity (IVV), acceleration time (AT), isovolumetric acceleration (IVA) (red).

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Right Ventricle (RV)RV diastolic function: PW Tricuspid inflow

From the apical 4-chamber view, the Doppler beam should be aligned parallel to the RV inflow. Proper alignment may be facilitated by displacing the transducer medially toward the lower parasternal region.The sample volume should be placed at the tips of the tricuspid leaflets. With this technique, measurement of transtricuspid flow velocities can be achieved in most patients, with low interobserver and intraobserver variability. Care must be taken to measure at held end-expiration and/or take the average of ≥ 5 consecutive beats.The presence of moderate to severe TR or atrial fibrillation could confound diastolic parameters, and most studies excluded such patients.Input:

Tricuspid Flow Profile (red)

Output: E wave velocityA wave velocityE/A ratioTricuspid E/e’DT - Deceleration time (ms)

E

①

Right Ventricle (RV)RV diastolic function: Tissue doppler imaging

Input: S’ Systolic velocityE’ velovity A’ velocity

Output: E’/A’ ratioE/E’ ratio

②

Among the most reliably and reproduciblyimaged regions of the right ventricle are the tricuspid annulus and the basal free wall segment. These regions can be assessed by pulsed tissue Doppler and color-coded tissue Doppler to measure the longitudinal velocity of excursion. S’ is systolic velocity, E’ is early diastolic velocity and A’ is late diastolic velocity. To perform this measure, an apical 4-chamber window is used with a tissue Doppler mode region of interest highlighting the RV free wall. The pulsed Doppler sample volume is placed in either the tricuspid annulus or the middle of the basal segment of the RV free wall.

Right Ventricle (RV)RV hemodynamics: sPAP (Systolic pulmonary artery pressure)

SPAP can be estimated using TR velocity, and PADP can be estimated from the end-diastolic pulmonary regurgitation velocity. Mean PA pressure can be estimated by the PA acceleration time (AT) or derived from the systolic and diastolic pressures. RVSP can be reliably determined from peak TR jet velocity, using the simplified Bernoulli equation and combining this value with an estimate of the RA pressure: RVSP = 4 (V) ² + RA pressure, where V is the peak velocity (in meters per second) of the tricuspid valve regurgitant jet, and RA pressure is estimated from IVC diameter and respiratory changes. Because velocity measurements are angle dependent,it is recommended to gather TR signals from several windows and to use the signal with the highest velocity.

Input: TR Jet velocityPAP mmHg (depending on IVC collapsability on sniff)

Output: TR velocitysPAPRV Systolic pressure

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RV hemodynamics: dPAP (Diastolic Pulmonary artery pressure)mPAP (mean Pulmonary Artery Pressure)

Right Ventricle (RV)

dPAP can be estimated from the velocity of the end-diastolic pulmonary regurgitant jet using the modified Bernoulli equation: [PADP = 4 (end-diastolic pulmonary regurgitant velocity)² + RA pressure]. Mean PA pressure correlates with 4 x (early PI velocity) ² + estimated RAP .

Input: PR PHT (yellow)PR Vmax – Pulmonary regurgitation max velocity (red)PR end Vmax - Pulmonary regurgitation end max velocity (green)

Output: PA Reg PHT (ms) PA peak diastolic gradientdPAP (end diastolic gradient)mPAP (mean Pulmonary Artery pressure)

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Right Ventricle (RV)RV hemodynamics: mPAP (mean Pulmonary artery pressure) AT method

Once systolic and diastolic pressures are known, mean pressure may be estimated by the standard formula mean PA pressure = 1/3(SPAP) + 2/3(PADP). Mean PA pressure may also be estimated by using pulmonary AT measured by pulsed Doppler of the pulmonary artery in systole, whereby mean PA pressure = 79 (0.45 AT). Generally, the shorter the AT (measured from the onset of the Qwave on electrocardiography to the onset of peak pulmonary flow velocity), the higher the PVR (Pulmonary Vascular Resistance) and hence the PA pressure.

Input: PA TVI - (Time velocityIntegral) (yellow)

Output:PA AT (acceleration time)mPAPmPAP (mean Pulmonary Artery pressure)

①

Right Atrium (RA)

The primary transthoracic window for imaging the right atrium is the apical 4-chamber view. From this window, RA area is estimated by planimetry. The maximal long-axis distance of the right atrium is from the center of the tricuspid annulus to the center of the superior RA wall, parallel to the interatrial septum. A mid-RA minor distance is defined from the mid level of the RA free wall to the interatrial septum, perpendicular to the long axis. RA area is traced at the end of ventricular systole (largest volume) from the lateral aspect of the tricuspid annulus to the septal aspect, excluding the area between the leaflets and annulus, following the RA endocardium, excluding the IVC and superior vena cava and RA appendage

Right atrium size

Input: RA End-Systolic Area (cm ²)RA Major Dimension (mm)RA Minor Dimension (mm)

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Right Atrium (RA)

Inferior Vena Cava: RA pressure The subcostal view is most useful for imaging the IVC, with the IVC viewed in its long axis. The measurement of the IVC diameter should be made at end-expiration and just proximal to the junction of the hepatic veins that lie approximately 0.5 to 3.0 cm proximal to the ostium of the right atrium. To accurately assess IVC collapse, the change in diameter of the IVC with a sniff and also with quiet respiration should be measured, ensuring that the change in diameter does not reflect a translation of the IVC into another plane.The measurements are done at end-diastole.

IVC diameter ≤ 2.1 cm that collapses >50% with a sniff suggests a normal RA pressure of 3 mm Hg (range, 0-5 mmHg)IVC diameter > 2.1 cm that collapses <50% with a sniff suggests a high RA pressure of 15 mm Hg (range, 10-20 mmHg)In indeterminate cases in which the IVC diameter and collapse do not fit this paradigm, an intermediate valueof 8 mm Hg (range, 5-10 mm Hg) may be used

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Valvular stenosis

Aortic stenosis: AS jet velocity

AS jet velocity (Antegrade Systolic Velocity) is defined as the highest velocity signal obtained from any window after a careful examination; lower values from other views are not reported.The antegrade systolic velocity across the narrowed aortic valve, or aortic jet velocity, is measured using continuous-wave (CW) Doppler (CWD) ultrasound. A dedicated small dual-crystal CW transducer is recommended both due to a higher signal-to-noise ratio and to allow optimal transducer positioning and angulation, particularly when suprasternal and right parasternal windows are used. However, when stenosis is only mild (velocity 3 m/s) and leaflet opening is well seen, a combined imaging-Doppler transducer may be adequate.

Input: AS jet velocity (m/s)VTI – Velocity Time integral

Output: Mean gradient (mmHg)

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Valvular stenosis

Aortic stenosis: AVA (Continuity equation VTI)

Aortic valve area can be calculated by using the principle of conservation of mass – “What comes in must go out”. AVA indexed to BSA should be considered for the large and small extremes of body surface area.Left ventricular outflow tract diameter is measured in the parasternal long-axis view in mid-systole from the white–black interface of the septal endocardium to the anterior mitral leaflet, parallel to the aortic valve plane and within 0.5–1.0 cmof the valve orifice.Input:

LVOT diameter (mm) VTI1 (Subvalvular VTI) (cm) VTI2 (Max VTI across the valve (cm)

Output: AVA (cm²)AVAI (Indexed to BSA) (cm²/m²)

AVA = (CSALVOT x VTILVOT) / VTIAV

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Valvular stenosis

Aortic stenosis: AVA (Continuity equation Vmax)

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The simplified continuity equation is based on the concept that in native aortic valve stenosis the shape of the velocity curve in the outflow tract and aorta is similar so that the ratio of LVOT to aortic jet VTI is nearly identical to the ratio of the LVOT to aortic jet maximum velocity (V). This method is less well accepted because some experts are concerned that results are more variable than using VTIs in the equation.

AVA = CSALVOT x VLVOT / VAVInput: LVOT diameter (mm) V1 (Subvalvular Velocity) (m/s)V2 (Max velocity across the valve)(m/s)

Output: AVA (cm²)AVAI (Indexed to BSA) (cm²/m²)

Valvular stenosisAortic stenosis: Velocity ratio

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Another approach to reducing error related toLVOT diameter measurements is removing CSA from the simplified continuity equation. This dimensionless velocity ratio expresses the size of the valvular effective area as a proportion of the CSA of the LVOT. Substitution of the time-velocity integral can also be used as there was a high correlation between the ratio using time–velocity integral andthe ratio using peak velocities. In the absence of valve stenosis, the velocity ratio approaches 1, with smaller numbers indicating more severe stenosis. Severe stenosis is present when the velocity ratio is0.25 or less, corresponding to a valve area 25% of normal.

Velocity ratio = VLVOT / VAV

Input: V1 (Subvalvular Velocity) (m/s)V2 (Max velocity across the valve)(m/s)

Output: VR - Velocity Ratio

Valvular stenosis

Aortic stenosis: Planimetry of anatomic valve area

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Multiple studies have evaluated the method of measuring anatomic (geometric) AVA by direct visualization of the valvular orifice, either by 2D or 3D TTE or TEE. Planimetry may be an acceptable alternative when Doppler estimation of flow velocities is unreliable. However, planimetry may be inaccurate when valve calcification causes shadows or reverberations limiting identification of the orifice.

Input: AV planimetry

Output: AVA (cm²)

Valvular stenosisMitral stenosis: MVA Planimetry

MV planimetry has been shown to have the best correlation with anatomical valve area as assessed on explanted valves. For these reasons, planimetry is considered as the reference measurement of MVA. Planimetry measurement is obtained by direct tracing of the mitral orifice, including opened commissures, if applicable, on a parasternal short-axis view. The optimal timing of the cardiac cycle to measure planimetry is mid-diastole. This is best performed using the cineloop mode on a frozen image.

A) Mitral stenosis. Both commissures are fused. Valve area is 1.17 cm2.B) Unicommissural opening after balloon mitral commissurotomy. The postero-medial commissure is opened. Valve area is 1.82 cm2.C) Bicommissural opening after balloon mitral commissurotomy. Valve area is 2.13 cm2.

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Valvular stenosisMitral stenosis: PHT (Pressure Half-time)

Is the time interval in milliseconds between the maximum mitral gradient in early diastole and the time point where the gradient is half the maximum initial value. The decline of the velocity of diastolic transmitral blood flow is inversely proportional to valve area (cm2), and MVA is derived using the empirical formula: MVA = 220 ⁄ T1⁄2.T1/2 is obtained by tracing the deceleration slope of the E-wave on Doppler spectral display of transmitral flow and valve area is automatically calculated by the integrated software of currently used echo machines. The Doppler signal used is the same as for the measurement of mitral gradient.

Input: MV PHT

Output: MV PHT (ms)MVA (cm ²)

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Valvular stenosis

Mitral stenosis: Pressure gradient

Mitral stenosis is the most frequent valvular complication of rheumatic fever. Even in industrialized countries, most cases remain ofrheumatic origin as other causes are rare. The estimation of the diastolic pressure gradient isderived from the transmitral velocity flow curve using the simplified Bernoulli equation ΔP = 4v ². The use of CWD is preferred to ensure maximal velocities are recorded. Doppler gradient is assessed using the apical window in most cases as it allows for parallel alignment of the ultra sound beam and mitral inflow.

Input: MV Flow profile

Output: MV Peak VelocityMV Peak GP (mmHg)MV mean VelocityMV Mean GP (mmHg)

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Valvular stenosis

Mitral stenosis: Continuity equation

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As in the estimation of AVA, the continuity equation is based on the conservation of mass, stating in this case that the filling volume of diastolic mitral flow is equal to aortic SV. The accuracy and reproducibility of the continuity equation for assessing MVA are hampered by the number of measurements increasing the impact of errors of measurements. The continuity equation cannot be used in cases of atrial fibrillation or associated significant MR or AR.

MVA = (CSALVOT x VTIAortic) / VTIMitralInput: LVOT (cm)VTI Ao (cm)VTI Mitral (cm)

Output: MVA (cm²)

Valvular stenosis ②

The proximal isovelocity surface area method is based on the hemispherical shape of the convergence of diastolic mitral flow on the atrial side of the mitral valve, as shown by colour Doppler. It enables mitral volume flow to be assessed and, thus, to determine MVA by dividing mitral volume flow by the maximum velocity of diastolic mitral flow as assessed by CWD. This method can be used in the presence of significant MR.However, it is technically demanding and requires multiple measurements. Its accuracy is impacted upon by uncertainties in the measurement of the radius of the convergence hemisphere, and the opening angle. MVA = 2 x π x r² x (Vr / Vmax) x (α⁰ / 180°)

Output: VFR (Volume flow rate) (cc)MVA (cm²)

Input: 2 × π × r2 : Proximal isovelocity hemispheric surface area at a radial distance r from the orifice.Vr : Aliasing velocity at the radial distance r (cm/s)Vmax : Peak mitral stenosis velocity by CW (m/s)α : Angle between two mitral leaflets on the atrial side (degree0)

Mitral stenosis: PISA method

Valvular stenosis

Tricuspid stenosis: CWD hemodynamic evaluation

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Tricuspid stenosis (TS) is currently the least common of the valvular stenosis lesions given the low incidence of rheumatic heart disease. As with all valve lesions, the initial evaluation starts with an anatomical assessment of the valve by 2D echocardiography using multiple windows such as parasternal right ventricular inflow, parasternal short axis, apical four-chamber and subcostal four-chamber. The evaluation of stenosis severity is primarily done using the hemodynamic information provided by CWD. Because tricuspid inflow velocities are affected by respiration, all measurements taken must be averaged throughout the respiratory cycle or recorded at end-expiratory apnea. In theory, the continuity equation should provide a robust methodfor determining the effective valve area as SV divided by the tricuspid inflow VTI as recorded with CWD. In the absence of significant TR, one can use the SV obtained from either the left or right ventricularoutflow; a valve area of 1 cm2 is considered indicative of severe TS.However, as severity of TR increases, valve area is progressively underestimated by this method.

Input: TV Flow profile

Output: Peak diastolic velocityMean gradient (mmHg)PHT (pressure half-time) mmHg

Valvular stenosis

Pulmonic stenosis: Pressure gradient Pulmonary stenosis is almost always congenital in origin. The normal pulmonary valve is trileaflet. The congenitally stenotic valve may be trileaflet, bicuspid, unicuspid, or dysplastic. Acquired stenosis of the pulmonary valve is very uncommon. Quantitative assessment of pulmonary stenosis severity is based mainly on the transpulmonary pressure gradient. The estimation of the systolic pressure gradient is derived from the transpulmonary velocity flow curve usingthe simplified Bernoulli equation ΔP = 4 (V) ². This estimation is reliable, as shown by the good correlation with invasive measurement using cardiac catheterization. Continuous-wave Doppler is used to assess the severity when even mild stenosis is present. It is important to line up the Doppler sample volume parallel to the flow with the aid of colour flow mapping where appropriate. In adults, this is usually most readily performed from a parasternal short-axis view.

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Input: Peak velocity (m/s)

Output: Peak Gradient (mmHg)

Valvular regurgitationAortic regurgitation: Jet diameter/LVOT diameter ratio %

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Imaging of the regurgitant jet is used in all patients with AR because of its simplicity and real time availability.The parasternal views are preferred over apical views because of better axial resolution. The recommended measurements are those of maximal proximal jet width obtained from the long-axis views and its ratio to the LV outflow tract diameter. Similarly, the cross-sectional area of the jet from the parasternal short-axis view and its ratio to the LV outflow tract area can also be used. The criteria to define severe AR are ratios of ≥ 65% for jet width and ≥ 60% for jet area. Is possible to use the CSA instead width for both Jet and LVOT.

Input: Jet Width (red)LVOT Width (yellow)

Output: Jet width/LVOT Width ratio (%)

Valvular regurgitation

Aortic regurgitation: VC (Vena contracta)

The Vena contracta is the narrowest portion of the regurgitant jet downstream from the regurgitant orifice. It is sligtly smaller than the anatomic regurgitant orifice due to boundary effect. For AR, imaging of the VC is obtained from the PLAX view. To properly identify the VC the three components of the regurgitant jet should be visualized (flow convergence zone, vena contracta, jet turbulence). A narrow colour sector scan coupled with the zoom mode is recommended to improve measurement accuracy. It provides thus an estimation of the size of the EROA (Estimated regurgitant orifice area) and is smaller that the regurgitant jet width in the LVOT. Using a Nyquist limit of 50-60 cm/s, a vena contracta width of < 3mm correlates with mild AR, whereas a width > 6mm indicates severe AR. When feasible the measurement of VC width is recommended to quantify AR severity. Intermediate VC values (3-6 mm) needs confirmation by a more quantitative method.

Input: AR VC width – Aortic regurgitation Vena Contracta width (cm)

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Valvular regurgitationAortic regurgitation: PISA (Proximal Isovolumetric Surface Area)

The assessment of the flow convergence zone has been less extensively performed in AR than in MR. The colour flow velocity scale is shifted towards the direction of the jet (downwards or upwards in the left parasternal view depending on the jet orientation and upwards in the apical view).1- Color Doppler settings must be correctly adjusted for the PISA method. The Nyquist-limit should be placed around 50-60 cm/s. 2- Afterwards, base line should be shifted in the direction of the regurgitation jet, until a well-defined hemisphere appears. 3- To calculate VTI of regurgitation jet, CW-Doppler profile area should be delineated. 4- By measuring PISA radius it is important to hit correctly the limit ot the hemisphere. Small errors can produce important variations. When feasible, the PISA method is highly recommended to assess the severity of AR. It can be used in both central and eccentric jets. The window recommended is PLAX view for flow convergence.

Input: PISA Radius AR VTI

Output: AR EROA (Effective Regurgitant Orifice Area) cm ²AR R Vol (regurgitant volume) mL/beat

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Valvular regurgitationAortic regurgitation: Jet deceleration rate (PHT)

The rate of deceleration of the diastolic regurgitant jet and the derived pressure half-time reflect the rate of equalization of aortic and LV diastolic pressures. With increasing severity of AR, aortic diastolic pressure decreases more rapidly. Pressure half-time is easily measured if the peak diastolic velocity is appropriately recorded. A pressure half-time 500 ms is usually compatible with mild AR whereas a value 200 ms is considered consistent with severe AR. CW Doppler of the AR jet should be routinely recorded but only utilized if a complete signal is obtained. The PHT is influenced by chamber compliance and pressure, for this reason it serves only as a complementary finding for AR severity assessment.

Input: AR PHT - Aortic reg Pressure half-time (ms)

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Output: EROAR Vol.RF (Regurgitant Fraction ) %

Aortic regurgitation: Flow quantitation - PW

Valvular regurgitation

Quantitation of flow with pulsed Doppler for the assessment of AR is based on comparison of measurement of aortic stroke volume at the LVOT with mitral or pulmonic stroke volume. Total stroke volume (aortic stroke volume) can also be derived from quantitative 2D measurements of LV end-diastolic and end-systolic volumes. EROA can be calculated from the regurgitant stroke volume and the regurgitant jet velocity time integral by CW Doppler. As with the PISA method, a regurgitant volume ≥60 ml and EROA ≥0.30 cm2 are consistent with severe AR. The quantitative Doppler method cannot be used if there is more than mild mitral regurgitation, unless the pulmonic site is used for systemic flow calculation. In general, a RF > 50 % indicates severe AR. Volumetric measurements with PW are Time consuming, and requires multiple measurements, so the source of errors are higher.

Input: LVOT PW profile (A5C)LVOT diameter (PLAX)Mitral inflow profile PW (A4C)Mitral annulus diameter (max opening MV (A4C)

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Valvular regurgitationAortic regurgitation: Aortic diastolic flow reversal PW

It is normal to observe a brief diastolic flow reversal in the aorta. The flow reversal is best recorded in the upper descending aorta at the aortic isthmus level using a suprasternal view, or in the lower descending aorta using a longitudinal subcostal view. With increasing aortic regurgitation both the duration and the velocity of the reversal increase. Therefore, a holodiastolic reversal is usually a sign of at least moderate aortic regurgitation. A prominent holodiastolic reversal with a diastolic time integral similar to the systolic time integral is a reliable qualitative sign of severe AR. However, reduced compliance of the aorta seen with advancing age may also prolong the normal diastolic reversal in the absence of significant AR. In general, an end-diastolic flow velocity > 20 cm/s is indicative of severe AR.

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Input: End-diastolic velocity (cm/s)

Valvular regurgitationMitral regurgitation: Vena Contracta (VC)

The vena contracta should be imaged in high-resolution, zoom views for the largest obtainable proximal jet size for measurements. The examiner must search in multiple planes perpendicular to the commissural line (such as the parasternal long-axis view), whenever possible. The width of the neck or narrowest portion of the jet is then measured. The regurgitant orifice in MR may not be circular, and is often elongated along the mitral coaptation line. The two-chamber view, which is oriented parallel to the line of leaflet coaptation, The width of the vena contracta in long-axis views and its cross-sectional area in short-axis views can be standardized from theparasternal view.s A vena contracta 0.3 cmusually denotes mild MR where as the cut-off forsevere MR has ranged between 0.6 to 0.8 cm.Input:

MR VC width (cm)

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Valvular regurgitationMitral regurgitation: PISA

Most of the experience with the PISA method for quantitation of regurgitation is with MR. Qualitatively, the presence of PISA on a routine examination (at Nyquist limit of 50-60 cm/s) should alert to the presence of significant MR. Several clinical studies have validated PISA measurements of regurgitant flow rate and EROA. This methodology is more accurate for central regurgitant jets than eccentric jets, and for a circular orifice than a noncircular orifice. Flow convergence should be optimized from the apical view, usually the fourchamber view, using a zoom mode. For determination of EROA, it is essential that the CW Doppler signal be well aligned with the regurgitant jet. Poor alignment with an eccentric jet will lead to an underestimation of velocity and an overestimation of the EROA. Generally, an EROA 0.4 cm2 is consistent with severe MR, 0.20-0.39 cm² moderate, and 0.20 cm² mild MR.

Input: PISA Radius MR VTI

Output: MR EROA (Effective Regurgitant Orifice Area) cm²MR R Vol (regurgitant volume) mL/beat

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In most patients, maximum MR velocity is 4 to 6 m/s due to the high systolic pressure gradient between the LV and LA.The velocity itself does not provide useful informationabout the severity of MR. However, the contourof the velocity profile and its density are useful. Atruncated, triangular jet contour with early peakingof the maximal velocity indicates elevated LA pressure or a prominent regurgitant pressure wave in the LA. The density of the CW Doppler signal is a qualitative index of MR severity. A dense signal thatapproaches the density of antegrade flow suggestssignificant MR, whereas a faint signal, with or withoutan incomplete envelope represents mild or traceMR. Using CW Doppler, the tricuspid regurgitation jetshould be interrogated in order to estimate pulmonary artery systolic pressure. The presence of pulmonary hypertension provides another indirect clue as to MR severity and compensation to the volume overload.

Valvular regurgitationMitral regurgitation: Continuous wave doppler

Input: MR VTI

Output: MR Peak velocity (m/s)

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Valvular regurgitationMitral regurgitation: Mitral to Aortic TVI ratio

In the absence on mitral stenosis, the increase in transmitral flow that occurs with increasing MR severity can be detected as higher flow velocities during early sistolic filling (increased E velocity). In the absence of mitral stenosis, peak E velocity > 1.5 m/s suggest severe MR. Conversely, a dominant A wave (Atrial contraction) basically excludes severe MR. The PW doppler mitral to aortic TVI ratio is also used as an easily measured index for the quantification of the isolated pure organic MR. Mitral inflow doppler tracings are obtaines at the mitral leaflet tips and aortic flow at the annulus level in the apical four-chamber view. A TVI ratio > 1.4 strongly suggest severe MR whereas a TVI ratio < 1 is in favor of mild MR.Both the pulsed Doppler mitral to aortic TVI ratio and the systolic pulmonary flow reversal are specific for severe MR. They represent the strongest additional parameters for evaluating MR severity.

Input: Mitral VTIAortic VTI

Output: Mitral to Aortic VTI ratio

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Valvular regurgitationMitral regurgitation: Pulmonary venous flow

Pulsed Doppler evaluation of pulmonary venous flow pattern is another aid for grading the severity of MR. In normal individuals, a positive systolic wave (S) followed by a smaller diastolic wave (D) is classically seen in the absence of diastolic dysfunction. With increasing severity of MR, there is a decrease of the S wave velocity. In severe MR, the S wave becomes frankly reversed if the jet is directed into the sampled vein. As unilateral pulmonary flow reversal can occur at the site of eccentric MR jets, sampling through all pulmonary veins is recommended, especially during transoesophageal echocardiography. Although, evaluation of right upper pulmonary flow can often be obtained using TTE, evaluation is best using TEE with the pulse Doppler sample placed about 1 cm deep into the pulmonary vein.Both the pulsed Doppler mitral to aortic TVI ratio and the systolic pulmonary flow reversal are specific for severe MR. They represent the strongest additional parameters for evaluating MR severity.

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Pulmonary venous flow is a qualitative parameter, no measurements have to be done.

Output: MR EROAMR R Vol.MR RF (Regurgitant Fraction ) %

Valvular regurgitation

Input: LVOT PW profile (A5C)LVOT diameter (PLAX)Mitral inflow profile PW (A4C)Mitral annulus diameter (max opening MV (A4C)

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Mitral regurgitation: Flow quantitation - PW

Pulsed Doppler tracings at the mitral leaflet tips are commonly used to evaluate LV diastolic function. Patients with severe MR often demonstrate a mitral inflow pattern with a dominant early filling (increased E velocity) due to increased diastolic flow across the mitral valve, with or without an increase in left atrial pressure. In severe mitral regurgitation without stenosis, the mitral E velocity is higher than the velocity during atrial contraction (A velocity), and usually greater than 1.2 m/sec. For these reasons, a mitral inflow pattern with an A- wave dominance virtually excludes severe MR. Volumetric measurements with PW are Time consuming and not recommended as first level method to quantify MR severity.

Valvular regurgitationTricuspid regurgitation: Vena contracta (VC)

The vena contracta of the TR is typically imaged in the apical four-chamber view using the same settings as for MR. Averaging measurements over at least two to three beats is recommended. A vena contracta ≥7 mm is in favour of severe TR although a diameter <6 mm is a strong argument in favour of mild or moderate TR. Intermediate values are not accurate at distinguishing moderate from mild TR. As for MR, the regurgitant orifice geometry is complex and not necessarily circular. When feasible, the measurement of the vena contracta is recommended to quantify TR.

Input: TR VC width (cm)

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Valvular regurgitationTricuspid regurgitation: Flow convergence (PISA)

Although providing quantitative assessment, clinical practice reveals that the flow convergence method is rarely applied in TR. This approach has been validated in small studies. The apical four-chamber view and the parasternal long and short axis views are classically recommended for optimal visualization of the PISA. The area of interest is optimized by lowering imaging depth and the Nyquist limit to ∼15–40 cm/s. The radius of the PISA is measured at mid-systole using the first aliasing. Qualitatively, a TR PISA radius >9 mm at a Nyquist limit of 28 cm/s alerts to the presence of significant TR whereas a radius <5 mm suggests mild TR. An EROA ≥ 40 mm2 or a R Vol of ≥45 mL indicates severe TR. When feasible, the PISA method is reasonable to quantify the TR severity. An EROA ≥ 40 mm2 or a R Vol ≥ 45 mL indicates severe TR.

Input: TR PISA Radius TR VTI

Output: TR EROA (Effective Regurgitant Orifice Area) cm²TR R Vol (regurgitant volume) mL/beat

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②Valvular regurgitationTricuspid regurgitation: CW jet velocity

Recording of TR jet velocity provides a useful method for noninvasive measurement of RV or pulmonary artery systolic pressure. It is important to note that TR jet velocity, similar to velocity of other regurgitant lesions, is not related to the volume of regurgitant flow. In fact, massive TR is often associated with a low jet velocity ( 2m/s), as there is near equalization of RV and right atrial pressures, conversely, mild regurgitation may have a very high jet velocity, when pulmonary hypertension is present.Similar to MR, the features of the TR jet by CW Doppler that help in evaluating severity of regurgitation, are the signal intensity and the contour of thevelocity curve.

Input: TR flow profile

Valvular regurgitationTricuspid regurgitation: Anterograde velocity of tricuspid inflow

A small degree of tricuspid regurgitation (TR) is present in about 70% of normal individuals. Pathologic regurgitation is often due to right ventricular (RV) and tricuspid annular dilation secondary topulmonary hypertension or RV dysfunction. Primary causes of TR include endocarditis, carcinoid heartdisease, Ebstein’s anomaly, and rheumatic disease.Similar to MR, the severity of TR will affect the early tricuspid diastolic filling (E velocity). In the absence of tricuspid stenosis, the peak E velocity increases in proportion to the degree of TR. Tricuspid inflow Doppler tracings are obtained at the tricuspid leaflet tips. A peak E velocity ≥1 m/s suggests severe TR

Input: E wave velocity

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Valvular regurgitationPulmonary regurgitation: Jet width - CFM

Minor degrees of pulmonary regurgitation (PR) have been reported in 40-78% of patients with morphologically normal pulmonary valves and no other evidence of structural heart disease Pathologicregurgitation is infrequent, and should be diagnosed mainly in the presence of significant structural abnormalities of the right heart. Color Doppler flow mappingis the most widely used method to identify PR. A diastolic jet in the RV outflow tract, beginning at the line of leaflet coaptation and directed toward theright ventricle is diagnostic of PR. Although this measurement suffers from a high inter-observer variability, a jet width that occupies >65% of the RV outflow tract width measured in the same frame is in favour of severe PR.

Input: Color Jet width (white)RVOT width (yellow)

Output:Jet to RVOT width ratio (%)

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Valvular regurgitationPulmonary regurgitation: Vena contracta (VC)

Although the vena contracta width is probably a more accurate method than the jet width to evaluate PR severity by colour Doppler, it lacks validation studies. As for other regurgitations, the same limitations are applicable. The shape of the vena contracta is complex in most cases.

Input: PR VC width (cm)

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Valvular regurgitationPulmonary regurgitation: Jet density and deceleration rate

CW Doppler is frequently used to measure the end-diastolic velocity of PR and thus estimate pulmonary artery end-diastolic pressure. However, there is no clinically accepted method of quantifying pulmonary regurgitation using CW Doppler. Similar to AR, the density of the CW signal provides a qualitative measure of regurgitation. A rapid deceleration rate, while consistent with more severe regurgitation, is influenced by several factors including RV diastolic properties and filling pressures.A pressure half-time < 200 ms is consistent with severe PR.

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Input: PR PHT

Output:Deceleration rate (ms)

Cardiac shunts

Qp/Qs can be estimated by using 2D echo and spectral doppler measurements in patients who have intra- or extra- cardiac shunts, e.g. atrial or ventricular septal defects.This formula only works in cases where there is pure left to right shunting.

Qp = RVOT VTI x π x (RVOT / 2)²

Qs = LVOT VTI x π x (LVOT / 2)²

Qp/Qs ratio = Qp/Qs

Qp/Qs: Pulmonary-systemic flow ratio

Input: LVOT (mm)LVOT VTI (cm)RVOT (mm)RVOT VTI (cm)

Output:Qp/Qs

Prosthetic valvesProsthetic aortic valves: doppler investigation (formulas previously described)

Doppler echocardiography of the valve

- Peak velocity gradient- Mean gradient-Contour of the jet velocity, AT (acceleration time)-DVI (doppler velocity index) *-EOA (Effective orifice area)- Presence, location, and severity of regurgitation

Pertinent cardiac chambers - LV size, function, and Hypertrophy

* DVI = VLVO / VPrAV . DVI is the Ratio of respective VTIs, and can be approximated as the ratio of the respective peak velocities. (simplified continuity equation)

DVI = Doppler Velocity IndexVLVO = Subvalvular (LVOT) velocity VPRAV = Max velocity across the valve

Prosthetic valves

Doppler echocardiography of the valve

- Peak early velocity- Mean gradient- Heart rate at the time of Doppler- Pressure half-time-DVI*: (Doppler velocity index)-EOA (Effective oriffice area)- Presence, location, and severityof regurgitation†

Other pertinent echocardiographic and doppler parameters

- LV size and function- RV size and function- Estimation of pulmonary artery pressure

* DVI = VPrMV / VLVO DVI is the Ratio of respective VTIs, and can be approximated as the ratio of the respective peak velocities. (simplified continuity equation)

Prosthetic mitral valves: doppler investigation (formulas previously described)

VPRMV = Max velocity across the prosthetic mitral valve

Prosthetic valves

Doppler echocardiography of the valve

- Peak velocity/peak gradient- Mean gradient- DVI * - EOA*- Presence, location, and severity of regurgitation

Related cardiac chambers - RV size, function, and hypertrophy- RV systolic pressure

* Theoretically possible to measure. Few data exist.

Prosthetic pulmonary valves: doppler investigation (formulas previously described)

Prosthetic valves

Doppler echocardiography of the valve

- Peak early velocity- Mean gradient- Heart rate at time of Doppler assessment- Pressure half-time- VTIPRTV / VTILVO * - EOA- Presence, location, and severity of TR

Related cardiac chambers, inferior vena cava and hepatic veins

- RV size and function- Right atrial size- Size of inferior vena cava and response to inspiration- Hepatic vein flow pattern

Prosthetic tricuspid valves: doppler investigation (formulas previously described)

* Feasible measurements of valve function, similar to mitral prostheses,but no large series to date.

VTIPRTV: Velocity Time Integral Prosthetic Tricuspid ValveVTILVO: Velocity Time Integral LVOT

AT = Acceleration timeEF = Ejection fractionET = Ejection timeFAC = Fractional area changeIVA = Isovolumic accelerationIVC = Inferior vena cavaIVCT = Isovolumic contraction timeIVRT = Isovolumic relaxation timeMPI = Myocardial performance indexMRI = Magnetic resonance imagingLV = Left ventriclePA = Pulmonary arteryPADP = Pulmonary artery diastolic pressurePH = Pulmonary hypertensionPLAX = Parasternal long-axisPSAX = Parasternal short-axisPVR = Pulmonary vascular resistanceRA = Right atriumRIMP = Right ventricular index of myocardial performance (MPI RV)RV = Right ventricleRVH = Right ventricular hypertrophyRVOT = Right ventricular outflow tractRVSP = Right ventricular systolic pressureSD = Standard deviationSPAP = Systolic pulmonary artery pressureTAM = Tricuspid annular motionTAPSE = Tricuspid annular plane systolic excursion3D = Three-dimensionalTR = Tricuspid regurgitation2D = Two-dimensional

Other abreviations