Evaluation of hepatic venous flow patterns using a pulsed Doppler technique

Evaluation of hepatic venous flow patterns was attempted by pulsed Doppler echocardiography. Subjects were 80 patients including those with dilated cardiomyopathy, old myocardial infarction, angina pectoris, pulmonary hypertension, constrictive pericarditis, tricuspid regurgitation (TR), lone atrial fibrillation, and post-cardiac surgery. Eleven normal subjects served as controls. The mean age was 53.0 +/- 12.4 years. Most of the TR patients had atrial fibrillation. Patients with aortic regurgitation and significant mitral regurgitation were excluded. Afterload stress by angiotensin II infusion was performed in 51 subjects, mainly for those with ischemic heart disease, cardiomyopathy and the normal controls. Hepatic venous flow patterns included double-peaked flow signals toward the right atrium, and the relationship between systolic (S) and diastolic flow velocities (D) was expressed as the velocity ratio [S/(S+D)]. A reversed flow during atrial systole was expressed as an "A wave" and that between the S and D waves, as an "O wave". Systolic flow velocity was less than diastolic flow velocity in cases with atrial fibrillation and the post-surgical cases. The velocity ratio was greater than 0.5 in nearly all patients with normal sinus rhythm, and less than 0.5 in cases with atrial fibrillation and the post-surgical cases. In the former, systolic flow velocity was less than diastolic flow velocity after defibrillation, in spite of restoration of normal sinus rhythm. These findings indicate that systolic flow velocity was influenced by atrial relaxation; diastolic flow velocity, by ventricular diastolic function. The A wave was increased in cases with pulmonary hypertension and A wave velocity in the hepatic vein correlated with systolic pulmonary artery pressure. In cases with tricuspid regurgitation, reversed flows were detected during ventricular systole both in normal sinus rhythm and in atrial fibrillation. After infusions of angiotensin II the velocity ratio increased in cases with dilated cardiomyopathy and in normal controls (p less than 0.01). The hepatic venous flow pattern after infusion in the former was characterized by dominant systolic and diminished diastolic flow velocities with a consequent increase in the velocity ratio toward 1.0, while a change in the ratio was less marked in normal controls. In conclusion, analysis of the hepatic venous flow pattern by pulsed Doppler echocardiography is very useful for evaluating cardiac function. A marked increase in the velocity ratio after angiotensin II infusion suggests decreased cardiac function.     

Different mechanisms for diastolic mitral regurgitation illustrated by three comparative cases

Diastolic mitral regurgitation (DMR) has been reported in patients with AV block, aortic regurgitation, cardiomyopathies, and in patients with long filling periods in atrial tachyarrhythmias. The mechanism for DMR is a reversal in the atrioventricular gradient during diastole. However, because of its relatively low velocity, it may be difficult to diagnose noninvasively. We present three different cases of diastolic MR in 2:1 second-degree AV block, atrial flutter, and dilated cardiomyopathy, with different locations in diastole. Diastolic tricuspid regurgitation commonly accompanies DMR. Careful analysis of echocardiographical images related with online ECG is very important in order to delineate systolic and DMR, and their timing in systole and diastole.     

Constrictive pericarditis versus restrictive cardiomyopathy: the role of Doppler echocardiography in differential diagnosis

Doppler ultrasound recordings of velocities of flow across the mitral and tricuspid valves and in the hepatic veins, and their variation with respiration, were recorded in seven patients with constrictive pericarditis and in six patients with restrictive cardiomyopathy. Deceleration of mitral and tricuspid flow was also evaluated during apnea. Color flow Doppler was performed in order to evaluate mitral and tricuspid regurgitation. Eight healthy adults served as controls. The patients with constrictive pericarditis showed higher peak diastolic velocities of mitral flow, as well as marked increase of velocity of flow at the onset of expiration and decrease at the onset of inspiration. Reciprocal respiratory variation of the velocities were also observed across the tricuspid valve. The patients with restrictive cardiomyopathy showed moderate or severe mitral and tricuspid regurgitation. They also showed shorter deceleration of flow across the mitral and tricuspid valves during apnea. The pattern of flow in the hepatic veins showed reversal during systole with accentuated reversion during inspiration. These results suggest that patient with constrictive pericarditis and restrictive cardiomyopathy can be differentiated by comparing Doppler echocardiographic data, along with changes induced by respiration.     

Pulmonary hypertension predicts mortality and morbidity in patients with dilated cardiomyopathy.

OBJECTIVE: To ascertain whether pulmonary hypertension, as assessed noninvasively by continuous-wave Doppler of tricuspid regurgitation, can be an important independent factor in the prognosis of patients with ischemic or idiopathic dilated cardiomyopathy. DESIGN: Cohort study of consecutive patients with dilated cardiomyopathy in whom follow-up was obtained on all survivors for 28 months. SETTING: Outpatient cardiology private practice office in a tertiary care center. PATIENTS: Consecutive sample of 108 patients who presented for a scheduled office visit during a 15-month period. MEASUREMENTS: M-mode, two-dimensional, and Doppler echocardiographic examinations were done on all patients at entry into the study and on survivors 1 year later. All examinations included extensive pulsed- and continuous-wave Doppler evaluation for tricuspid regurgitation. MAIN OUTCOME MEASURES: Overall mortality, mortality due to myocardial failure, and hospitalization for congestive heart failure. RESULTS: Twenty-eight patients had a high velocity of tricuspid regurgitation (greater than 2.5 m/s), and 80 patients had a low velocity (less than or equal to 2.5 m/s). After 28 months of follow-up, the mortality rate was 57% in patients with a high velocity compared with 17% in patients with a low velocity (difference of 40%, 95% CI, 20% to 60%). Hospitalization for congestive heart failure occurred in 75% and 26% of patients, respectively (difference of 49%, CI, 30% to 68%). Eighty-nine percent of patients with a high velocity either died or were hospitalized compared with only 32% of patients with a low velocity (difference of 57%, CI, 42% to 72%). The peak velocity of tricuspid regurgitation was the only prognostic variable selected using stepwise logistic regression models for the three outcome events. CONCLUSION: Noninvasive assessment of pulmonary hypertension using continuous-wave Doppler of tricuspid regurgitation can predict morbidity and mortality in patients with ischemic or idiopathic dilated cardiomyopathy.     

Diagnosis of constrictive pericarditis by pulsed Doppler echocardiography of the hepatic vein

The diagnostic value of hepatic venous flow patterns was evaluated for constrictive pericarditis by pulsed Doppler. A characteristic flow pattern was assumed to be associated with the well-known atrial pressure curve. Thirteen patients with constrictive pericarditis were compared to 13 control subjects and to 25 patients with right ventricular pressure overload including 13 patients with tricuspid regurgitation. The characteristic finding in constrictive pericarditis was a W-wave pattern of flow velocities in the dilated hepatic veins, with abrupt reversal of flow late in systole and diastole before the A wave (100% specificity, 68% sensitivity). This depends, however, on the absence of tricuspid regurgitation (for its systolic component) or fast sinus rhythm (for its diastolic component). Additional diagnostic markers were systolic deceleration time of forward flow (40 to 130 ms) and systolic integral of flow velocities (4.3 to -4.0 cm) (sensitivity and specificity greater than or equal to 92%). In the presence of tricuspid regurgitation, diastolic deceleration time less than 150 ms and diastolic integral of flow velocities less than 6 cm were useful diagnostic signs. If combined, these criteria had 100% sensitivity and specificity for the diagnosis. Thus, pulsed Doppler assessment of flow velocities in the hepatic vein facilitates the diagnosis of constrictive pericarditis in clinical routine, using an auxiliary site with unlimited diagnostic access to the characteristic flow velocity pattern, which reflects right atrial pressure curve and filling abnormalities.     

Unilateral neck pulsations in a patient with a permanent pacemaker

An asymptomatic patient with a permanent pacemaker presented with unilateral accentuated neck pulsations. Evaluation revealed tricuspid insufficiency, a massively dilated right internal jugular vein, and obstruction of the left internal jugular vein. There was no evidence of aneurysm, vascular tumor, or fistula. The most likely explanation for this constellation of findings is tricuspid regurgitation occurring in the setting of unilateral internal jugular vein occlusion. Such a combination should be considered in the differential diagnosis of asymmetrical neck pulsations in a patient with a transvenous pacemaker.     

Flow patterns of mitral regurgitation due to different etiologies: analysis by color-coded Doppler echocardiography

We have used cross-sectional real time color-coded Doppler echocardiography to characterize the patterns of the regurgitant jet seen in mitral valvar disease of different etiologies. We studied 118 patients with mitral regurgitation due to rheumatic valve disease (n = 26), hypertrophic obstructive cardiomyopathy (n = 22), dilated cardiomyopathy (n = 35) and prolapse of the leaflets of the mitral valve (n = 35). We analyzed the origin, spatial distribution, extent and duration of the regurgitant jet. A semiquantitative grading system was used to evaluate the extent of the jet by measuring its maximal area and the duration of regurgitant flow. Typical flow patterns could be observed in hypertrophic obstructive cardiomyopathy, (in which the crescent shaped jet was elongated in midsystole and directed posteriorly) in dilated cardiomyopathy (in which oval shaped jets were observed throughout systole) and in prolapse of the leaflets (in which early or late systolic regurgitant jets occurred with an eccentric "drop-like" pattern, being directed posteriorly in patients with a prolapse of the aortic leaflet and anteriorly in those with a prolapse of the mural leaflet of the valve). A large variety of patterns was found in rheumatic disease due to the individual deformation of the leaflets. A comparison of the measured area of the jet revealed no significant differences between regurgitation caused by rheumatic valve disease and dilated cardiomyopathy. The regurgitation in 80% of these patients was of moderate to severe degree. In contrast, regurgitation due to prolapse of the leaflets or hypertrophic obstructive cardiomyopathy appeared to be of mild to moderate degree in 90% of cases.     

Cross sectional echocardiographic feature in carcinoid heart disease. A mechanism for tricuspid regurgitation in this syndrome

In a patient with severe tricuspid regurgitation and mild pulmonary stenosis due to carcinoid heart disease cross sectional echocardiography showed nodular thickening and coaptation of the tricuspid leaflets at the beginning of systole. The leaflets were, however, seen to be increasingly pulled apart as right ventricular systole proceeded. This finding, which is probably due to traction on the leaflets by the thickened chordae tendineae, is therefore a mechanism of valvular incompetence, perhaps accounting for the particularly severe tricuspid regurgitation seen in carcinoid heart disease.     

Cross sectional echocardiographic feature in carcinoid heart disease. A mechanism for tricuspid regurgitation in this syndrome.

In a patient with severe tricuspid regurgitation and mild pulmonary stenosis due to carcinoid heart disease cross sectional echocardiography showed nodular thickening and coaptation of the tricuspid leaflets at the beginning of systole. The leaflets were, however, seen to be increasingly pulled apart as right ventricular systole proceeded. This finding, which is probably due to traction on the leaflets by the thickened chordae tendineae, is therefore a mechanism of valvular incompetence, perhaps accounting for the particularly severe tricuspid regurgitation seen in carcinoid heart disease.     

Tricuspid regurgitation occurring in the early‐diastolic phase in a case of heart failure: Insights from echocardiographic and invasive hemodynamic findings

Although the presence and physiological significance of late‐diastolic tricuspid regurgitation (TR) have been reported, those in TR occurring in early diastole have not been well known. We herein first presented a case of heart failure due to dilated cardiomyopathy showing functional TR occurring in the early‐diastolic phase in whom the mechanism for its genesis could be precisely assessed from echocardiographic findings and intra‐cardiac pressure recordings.     

Jugular venous ''a'' wave in dilated cardiomyopathy: sign of abbreviated right ventricular filling time.

OBJECTIVE--To study the mechanisms underlying the high venous pressure often seen in patients with dilated cardiomyopathy. DESIGN--Retrospective and prospective examination of the pattern of flow in the superior vena cava, cardiac echo-Doppler studies, and recordings of the jugular venous pulse. SETTING--A tertiary referral cardiac centre. PATIENTS PARTICIPANTS--23 patients with dilated cardiomyopathy, all with functional mitral and tricuspid regurgitation. RESULTS--Two patterns of venous pulse were seen: a dominant 'a' wave and 'x' descent, with systolic flow in the superior vena cava (group 1, n = 11), and a dominant 'v' wave with 'y' descent and diastolic flow in the superior vena cava (group 2, n = 12). A comparison of group 1 and group 2 showed: age (mean (SD] 58 (12) v 61 (6) years, left ventricular end diastolic dimension 7.0 (0.7) cm in both groups, right ventricular short axis 3.3 (0.6) v 3.6 (0.5) cm and long axis 7.3 (0.5) v 7.1 (0.7) cm, and duration of tricuspid regurgitation 350 (65) v 370 (50) ms. The RR interval (550 (100) v 680 (80) ms) and right ventricular filling time (150 (30) v 290 (50) ms) were significantly shorter in group 1. In all patients in group 2 right ventricular filling time was more than 200 ms with separate E and A waves on the tricuspid Doppler echocardiogram, while in all group 1 patients it was less than 200 ms with a single summation peak. In nine patients in group 1, the right ventricular filling time was limited by prolonged tricuspid regurgitation and in the remaining two by prolonged isovolumic relaxation time (215 (80) ms), so that it was consistently significantly less than that of the left ventricle. CONCLUSION--In patients with dilated cardiomyopathy, right ventricular filling time may be so short that it limits stroke volume. Such patients can be recognised by a dominant 'a' wave on the jugular venous pulse. Patients in whom the right ventricular filling time was longer showed a dominant 'v' wave. Both groups can present as "congestive heart failure".     

Jugular venous 'a' wave in dilated cardiomyopathy: sign of abbreviated right ventricular filling time

OBJECTIVE--To study the mechanisms underlying the high venous pressure often seen in patients with dilated cardiomyopathy. DESIGN--Retrospective and prospective examination of the pattern of flow in the superior vena cava, cardiac echo-Doppler studies, and recordings of the jugular venous pulse. SETTING--A tertiary referral cardiac centre. PATIENTS PARTICIPANTS--23 patients with dilated cardiomyopathy, all with functional mitral and tricuspid regurgitation. RESULTS--Two patterns of venous pulse were seen: a dominant 'a' wave and 'x' descent, with systolic flow in the superior vena cava (group 1, n = 11), and a dominant 'v' wave with 'y' descent and diastolic flow in the superior vena cava (group 2, n = 12). A comparison of group 1 and group 2 showed: age (mean (SD] 58 (12) v 61 (6) years, left ventricular end diastolic dimension 7.0 (0.7) cm in both groups, right ventricular short axis 3.3 (0.6) v 3.6 (0.5) cm and long axis 7.3 (0.5) v 7.1 (0.7) cm, and duration of tricuspid regurgitation 350 (65) v 370 (50) ms. The RR interval (550 (100) v 680 (80) ms) and right ventricular filling time (150 (30) v 290 (50) ms) were significantly shorter in group 1. In all patients in group 2 right ventricular filling time was more than 200 ms with separate E and A waves on the tricuspid Doppler echocardiogram, while in all group 1 patients it was less than 200 ms with a single summation peak. In nine patients in group 1, the right ventricular filling time was limited by prolonged tricuspid regurgitation and in the remaining two by prolonged isovolumic relaxation time (215 (80) ms), so that it was consistently significantly less than that of the left ventricle. CONCLUSION--In patients with dilated cardiomyopathy, right ventricular filling time may be so short that it limits stroke volume. Such patients can be recognised by a dominant 'a' wave on the jugular venous pulse. Patients in whom the right ventricular filling time was longer showed a dominant 'v' wave. Both groups can present as "congestive heart failure".     

Cardiac sarcoidosis with primary involvement of the tricuspid valve

Sarcoid granulomas usually involve the myocardium with rare focal extensions into the pericardium and endocardium with resultant conduction defects, ventricular arrhythmias, and ventricular systolic and diastolic dysfunction. Primary involvement of valvular leaflets resulting in valvular regurgitation or stenosis is not known. We present a case of a wastewater consultant who developed tricuspid regurgitation and symptomatic atrioventricular block secondary to infiltration of tricuspid leaflets and conduction system from sarcoid granulomas. The patient later developed severe dilated cardiomyopathy as a result of extensive cardiac sarcoidosis necessitating cardiac transplantation. Valvular regurgitation should be included as one of the presenting manifestations of cardiac sarcoidosis.     

"A-wave" liver

The finding and timing of hepatic pulsations can provide important information regarding the status of right heart structures and function. We report a 54-year-old woman with idiopathic dilated cardiomyopathy, who had prominent hepatic presystolic pulsations ("A-wave" liver). The clinical findings and the venous and hepatic pulse recordings are presented and discussed in terms of clinical pathophysiology and significance.     

Echographic early systolic partial closure (notching) of the aortic valve in congestive cardiomyopathy

We investigated the prevalence and significance of aortic valve early systolic partial closure (notching) in congestive cardiomyopathy by reviewing clinical and M-mode echocardiographic findings in 33 patients. We also compared their echocardiographic aortic root and valve findings to those in 17 aortic regurgitation patients and 24 normal subjects. Thirteen cardiomyopathy patients (39%) exhibited aortic valve partial closure--similar to the prevalence in the aortic regurgitation (41%) and normal (33%) groups. However, patients with dilated cardiomyopathy and aortic valve notching exhibited a higher mean percentage of partial closure (18% +/- 10) than those with notching in either the aortic regurgitation (8% +/- 9) or normal (5% +/- 2) group. There was no significant difference in age, body surface area, left ventricular dimension, systolic function, or presence of mitral regurgitation between cardiomyopathy patients with and without aortic valve notching, but the former had slightly greater aortic root dimensions and maximal aortic leaflet separation. Although the reason for this difference is unknown, a wider aortic root may result in low-pressure areas bordering the aortic flow stream during early systole, which may favor partial aortic valve closure.     

Clinical correlates and mortality of hemodynamically significant tricuspid regurgitation

BACKGROUND AND AIM OF STUDY: Limited data exist regarding the etiologies and prognostic significance of severe tricuspid regurgitation (TR) in the modern medical era. This retrospective chart review examines the causes of, and mortality associated with, hemodynamically significant TR. METHODS: The database of the echocardiography laboratory at a major academic medical center was searched from August 2000 to October 2001, identifying 91 patients (1.2%) with transthoracic echocardiograms demonstrating moderate-severe or severe TR. A total of 77 available charts was reviewed retrospectively for medical history, examination and electrocardiogram findings. The underlying cause of each patient's TR was determined by compiling data from the chart and echocardiogram. All deaths were recorded from the date of echocardiography until September 2002. RESULTS: A cause for TR was determined in 96% of patients. Functional TR due to right ventricular pressure or volume overload was found in 85.5% of patients, while 14.5% had primary TR due to organic abnormalities of the tricuspid valve leaflets. Conditions associated with significant TR included pulmonary hypertension (46%), ischemic cardiomyopathy (25%), non-ischemic dilated cardiomyopathy (8%), Ebstein's anomaly (4%), rheumatic heart disease (4%), endocarditis (4%), tricuspid valve prolapse (2%), and severe mitral valve disease (2%). Of 37 patients (44.6%) who died, 17 (21%) did so within one month of the echocardiogram. CONCLUSION: Among patients presenting to a tertiary medical center, hemodynamically significant TR was more commonly functional than due to organic tricuspid valve disease. The most frequently associated diseases included pulmonary hypertension and cardiomyopathy. Significant TR may be a marker of increased mortality risk as it reflects the severity of underlying disease. Further studies in this area are warranted.     

Doppler echocardiography in pericardial disease

In conclusion, an understanding of the physiology of cardiac tamponade and pericardial constriction allows accurate interpretation of the changes in SVC and transatrioventricular valve Doppler flow velocities that characterize each abnormality. Meticulous attention to detail in obtaining the studies is essential for accurate diagnosis, because relative changes in flow velocities during respiration may be obscured or misinterpreted if poor-quality data are obtained. In our laboratory, SVC Doppler studies have proved to be the most technically feasible in patients with cardiac tamponade, but transvalvular studies provide important complementary data and are critical in constrictive pericarditis. Hepatic vein Doppler offers an alternative approach to the analysis of systemic venous return, particularly in stable patients with dilated hepatic veins. These studies must always be interpreted with attention to possible confounding variables such as previous pericardiotomy, significant tricuspid regurgitation, severe chronic lung disease, or restrictive cardiomyopathy. As physiologic rather than anatomic indicators, they are a valuable addition to echocardiography in assessing the hemodynamic significance of pericardial abnormalities.     

Severe tricuspid regurgitation due to ventricular pacing lead - a case report

We present a case of severe symptomatic tricuspid valve regurgitation due to shifting of the septal leaflet of the valve toward the interventricular septum by a permanent ventricular pacemaker lead, making coaptation of the tricuspid leflats in systole impossible.     

Doppler echocardiography in dilated and restrictive cardiomyopathies

Dilated cardiomyopathy is characterized by systolic dysfunction and cardiac enlargement of unknown origin. Various Doppler modalities are useful to detect and quantitate atrioventricular regurgitation, which is common and contributes to clinical symptoms. Pulsed Doppler assessment of mitral and tricuspid inflow velocities shows a spectrum of findings indicative of abnormal diastolic function and hemodynamic status. When mitral regurgitation is more than moderate and heart failure is severe, the ratio between early inflow E wave to atrial inflow A wave peak velocities is increased. Mitral deceleration time may be short. When mitral regurgitation is trivial and left atrial pressure is not increased, abnormal relaxation may be detected as a low E:A ratio. Mitral deceleration time and isovolumic relaxation time are prolonged. In restrictive cardiomyopathy, there is an abrupt limitation in early ventricular filling due to abnormal compliance of endocardial or endomyocardial origin. Mitral and tricuspid inflow velocities show normal to increased early peak velocity, rapid deceleration time, low peak atrial velocity, and an increased E:A ratio. Differentiation between restriction and constriction might be possible by the demonstration in pericardial constriction of inspiratory decreases in mitral early inflow peak velocities and in prolongation of isovolumic relaxation time, with reciprocal changes on tricuspid inflow velocity profiles. In constriction, these respiratory variations are caused by the ventricular limitation to accommodate changes in venous return due to the pericardial shell. Doppler abnormalities and two-dimensional echocardiographic assessment of ventricular and atrial size and ejection fraction provide the practicing physician with valuable diagnostic information.     

Echocardiographic findings after tricuspid valvectomy

Resection of the tricuspid valve without prosthetic replacement has successfully been performed in patients with tricuspid valvular endocarditis. Using M-mode, two-dimensional, and Doppler echocardiograms, we studied four patients who underwent tricuspid valvectomy. All patients had previous history of intravenous drug abuse and staphylococcal endocarditis with tricuspid valvular involvement. In all patients, M-mode and two-dimensional echocardiograms showed that the tricuspid valve was absent. The right ventricle was dilated, and the interventricular septum had paradoxical motion in each patient. In each patient the right atrium was dilated, and with each ventricular systole, it expanded and its short axis increased by 20 to 33 percent. This caused shift of the interatrial septum toward the left atrium, with compression of its cavity. Doppler echocardiographic studies showed retrograde flow during systole in the right atrium, inferior vena cava, and hepatic vein. Echocardiographic findings in patients with tricuspid valvectomy correlate with the pathophysiologic findings of this condition.