Echocardiography

Echocardiographic diagnos.c for

valvulopathies
Positive diagnostic
Severity diagnostic
Etiologic diagnostic
Hemodynamics
(LV and RV dimension and function, pulmonary hipertension)
Stenosis evaluation for baloon valvuloplasty
Regurgitation evaluation for valve repair
Leaets: anterior,
posterior
Mitral annulus
Comisures
Chordae
Papilary muscles
posteromedial muscle right coronary artery
anterolateral muscle duble perfusion
MITRAL STENOSIS

ECHOCARDIOGRAPHY = GOLD STANDARD

for diagnostic
Posi%ve diagnos%c
Views: PLAX, PSAX, 4C, 2C,

1. Morphologic aspects:
Mitral leaets (brotic, calcicated)
Papillary muscles, chordae: 4C, 2C
commissures: PSAX
2. Dynamic of the mitral valve - diastolic
doming

Posi%ve diagnos%c 2D
Parasternal long axis view (PLAX)

Normal aspect Mitral stenosis

Posi%ve diagnos%c M mode
PLAX M mode

Normal aspect Mitral stenosis

Posi%ve diagnos%c
Parasternal short axis view (PSAX)

Mitral stenosis
Normal aspect sh mouth
Reduced mitral valve area
Posi%ve diagnos%c
candle light
Posi%ve diagnos%c
Apical 4 chamber view (4C)

Normal aspect Mitral stenosis

Posi%ve diagnos%c
Spectral Doppler: mitral flow

Normal aspect Mitral stenosis

Posi%ve diagnos%c
Spectral Doppler: mitral flow

Sinus rhythm Atrial fibrillation

Severity diagnos%c

1. Planimetry of mitral valve 2D echo -

PSAX
2. Pressure gradient (CWD)
3. PHT method(CWD)

Mitral valve planimetry
 Pressure gradient at mitral orice
Maximum
pressure gradient
(Pmax)
P = 4Vmax2
Medium pressure
gradient
TVI
PHT method
Pressure half time
( PHT )
= the time for maximum
pressure gradient to
drop to half of its
initial value
PHT method
Severity diagnos.c
mild MS moderate MS severe MS

Pmed (mmHg) < 5 6 10 > 10

PHT(ms) 100 150 150 200 > 220

MV Area (cm2) 1,5 2 1 1,5 < 1
E%ology
1. Congenital parachute MV
double mitral orice
supravalvular annulus
Cord triatriatum
2. Rheumatismal (Rheumatic fever)
3. Degenerative
4. Rare causes: atrial tumors (mixoma)
MV vegetations
MV thrombi
MS other signs

LA
thrombi, LA or LAA spontaneous contrast
Other valvulopathies: TS / AoS / AoR
RV dilation
PHT evaluation
TEE
TEE
TEE
 MR Diagnostic: symptomatology + ascultation

Conrmation + severity evaluation

ECHOCARDIOGRAPHY
2D, 3D/4D, M mode, color Doppler, spectral Doppler (PWD, CWD)
TTE + TEE

Gold standard for MR diagnostic

Etiology + severity + complications
+ mitral valve repair posibility
 POSITIVE DIAGNOSTIC

Color Doppler
 POSITIVE DIAGNOSTIC
Pulsa.le Doppler Con.nuous Doppler
 SEVERITY DIAGNOSTIC
Methods
1. Color Doppler / pulsatile Doppler LA
mapping
2. MR jet area
3. MR jet area / LA area
4. vena contracta measurement
5. MR Volume, Regurgitation fraction,
regurgitation orice
6. PISA method (proximal isovelosity area)
+ qualitative parameters
+ hemodynamic measurements
 SEVERITY DIAGNOSTIC
Color Doppler / pulsatile Doppler LA mapping

Grad 1 At the level of mital annulus

Grad 2 First of LA

Grad 3 First 3/4 of LA

Grad 4 At LA posterior wall

SEVERITY DIAGNOSTIC
Color Doppler : MR jet area

TTE: MR area 18,8 cm

 SEVERITY DIAGNOSTIC
vena contracta measurement

vena contracta = the most MR

narrow jet downstream of
regurgitant orifice

BJ Roberts, PA Grayburn. Color flow imaging of the vena contracta in mitral regurgitation: Tehnical considerations. JASE 2003; 9.
Acute MR

Chronic MR
 Acute MR
Patient simptomatology (AMI, IE, traumatism, chordae rupture)

Echo:
Color Doppler no value MR severy underestimation
(pressure rapid equalisation between LV and LA)
MV ail or papillary muscle rupture


- LA normal dimensions
- LV hyperdinamic (FE )
- PHT
 ETIOLOGY

1. Rheumatic MR
2. MV prolapse (mixoumatous)
3. Ischemic MR
4. MR secondary to Infective endocarditis
5. Degenerative MR
6. Congenital MR
7. Tumours
8. Functional (mitral annulus dilation in DCM,
HOCM)
9. Traumatism
Rheuma.c MR
MVP Barlow disease, mixomatos MVP
 Ischemic MR

Mechanisms:
- papillary muscle disfunction (ischemia, necrosis)
- LV shape (inferior aneurism, apical)
- postMI mechanical complications
- acute MR
- chordae / papillary muscle rupture

Guidelines for the Management of Patients with Valvular Heart Disease. European Heart Journal (2007) 28, 234
Ischemic MR
MR caused by chordae rupture
MR caused by chordae rupture
Color Doppler: eccentric MR jet
 Infec.ve endocardi.s MR
Mechanisms:
- large vegetations
- Rupture / leaflet perforation
- MV absess + perforation
- Chordae rupture
Degenera.ve MR
 Func.onal MR
Mechanisms:
- LV dilation mitral annulus
dilation

Echo:
- Mitral ring dilation
- LV dilation
- Central MR jet
Func.onal MR - DCM
Aor.c valve anatomy

3 leaflets; 3 comisures
Ao annulus
Valsalva Sinuses
Sinotubular junction
Ascending Ao
2D
Views: PLAX, PSAX,
5C, 3C

morphologic aspect /
mobility:

l brosis

l calcication
Posi%ve diagnos%c
PLAX, PSAX aortic valve aspect
Posi%ve diagnos%c M mode

PLAX:
l Closing: a line in the
middle of Ao
l Opening: patrulater
Posi%ve diagnos%c Color Doppler
Posi%ve diagnos%c Con%nous Doppler
apical 5C, 3C, right parasternal, suprasternal
Severity diagnos%c

M mode AoV opening

2D planimetry (TEE)
Continuous Doppler: Medium gradient
Severity diagnos%c
M mode AoV opening

Severity diagnos%c
planimetry
Severity diagnos%c
Continuous Doppler
Pmax, Pmed
Severity diagnos%c
Severe AS:

lVmax > 4,5 m / sec.

lPmax > 80 mmHg
lP med 50 mm Hg
lAVA 0,75cm2(1cm2) (< 0,6cm2/m2 sc)
E%ology
Rheumatic AS
Degenerative AS
Congenital AS
Valvular AS

Subvalvular AS

Supravalvular AS
Congenital AS



TEE
Subvalvular / Supravalvular AS
POSITIV DIAGNOSIS Color Doppler

Views:
PLAX, PSAX,
apical 5C, 3C


POSITIV DIAGNOSIS Con.nuous Doppler

Views:
apical 5C, 3C
SEVERITY DIAGNOSIS

LVOT Mapping

AR Grade RA jet

Grade 1 Just under aortic valve

Grade 2 In LVOT

Grade 3 After mitral leaflets

Grade 4 At mitral papillary muscles

 DIFFERENTIAL DIAGNOSIS
Acute AR # Chronic severe AR

Echo Acute AR Chronic severe AR

LA N

LVEDV N
EF /N
LV output /N
Acute AR

CORELATION BETWEEN ECHO

AND PATIENT
SIMPTOMATOLOGY
ETIOLOGY
1. Rheumatic AR
2. Degenerative AR
3. Infective endocarditis AR
4. AR in systemic inamatory diseases (LES, spondilitita anchilopoetica,
silis, boala Takayasu)
5. Congenital AR (bicuspid AV)
6. Posttraumatic AR
7. AV prolapse
8. AR secondary to aortic dilation (ectasia)
9. AR secondary to Ao dissection
10. .....
AR in infec.ve endocardi.s
AR in infec.ve endocardi.s
Dicult evalua.on

Acustic artefacts:
reverberations

Back shadow

Large variety of prostheses

No standardization

TTE + TEE
MECHANICAL PROSTHESES
Caged ball; tilting-disc bi-leaet
MECHANICAL PROSTHESES
Advantages:

- Long life
MECHANICAL PROSTHESES
Disadvantages:

- Permanent anticoagulation therapy
BIOLOGICAL PROSTHESES
 Classica.on

Autograft
Autolog (autogen)
Homograft (alograft)
Heterograft (xenograft)
Ross operation: Pulmonary valve aortic position

Porcine valve
Valve from bovine pericardium, etc.
 HeterograS
(xenograS)
Porcine valve

- Hancock I i II
- Carpentier-Edwards
- Intact

Stentless porcine valve

- Toronto SPV
- Freestyle
Valve from bovine pericardium
- Carpentier-Edwards
- Ionescu-Shiley
BIOLOGICAL PROSTHESES

Advantages:

No anticoagulant therapy

Central ow better hemodynamics

BIOLOGICAL PROSTHESES

Disadvantages:
Deterioration rate short life
(reoperation)
Mitral biologic prosthesis
Bi-leaet Ao prosthesis +
Bi-leaet mitral prosthesis
Prostheses disfunc.on
I. Mechanical prostheses:
1. Mismatch
2. Thrombosis of the prosthesis
3. Paravalvular leaks
4. others

II. Biological prostheses:
degenerescence stenosis / regurgitation
Thrombosis of a bi-leaet mitral prosthesis
Aor%c regurgita%on
(paravalvular leak?)
DIAGNOSIS ROLE OF ECHOCARDIOGRAPHY
DIAGNOSIS ROLE OF ECHOCARDIOGRAPHY

! ECHO interpretation

Vegetations presence # positiv diagnosis of IE

No echo chriteria for positiv diagnosis # negativ diagnosis

Vegeta%ons
structure (echogenicity) dierent from the that
of endocardium
TTE (transthoracic echocardiography) > 2 - 3 mm
Sesil / pediculated
Visible signal on entire or on a part of cardiac
cycle
subvalvular mitral apparatus

vegeta%ons
localisation
vegeta%ons
Aortic valve
vegeta%ons
Aortic valve
vegeta%ons
Mitral valve
vegeta%ons
Mitral valve
 vegeta%ons
Tricuspid valve
Abscess
Diagnosis on TEE (transesophageal
echocardiography)
Wall thickening > 10 mm, cavity echo free (no
signal) (black hole)
perforation can appear comunication
Aor%c ring abscess
Aor%c ring abscess