Transient neonatal tricuspid regurgitation: a Doppler echocardiographic study of three cases

Three patients with normal hearts and no pulmonary abnormality had neonatal tricuspid regurgitation causing cardiorespiratory distress and cyanosis. The signs of tricuspid regurgitation resolved over a few weeks. In the acute phase echocardiography showed gross dilatation of the right atrium and ventricle. The interatrial septum bulged into the left atrium during the whole cardiac cycle. Doppler echocardiography showed clinically significant tricuspid regurgitation, a right to left shunt through the foramen ovale, reduced flow through the pulmonary valve, and in two patients ductal flow into the pulmonary artery. In one patient tricuspid regurgitation was so great that it impeded the opening of the pulmonary valve and produced functional "atresia" of the pulmonary valve. The presence of regurgitant blood flow through the pulmonary valve showed that the "atresia" was functional rather than organic. Doppler echocardiographic study is useful in distinguishing functional neonatal tricuspid regurgitation from structural abnormality of the tricuspid valve.     

Progression of mitral regurgitation: a prospective Doppler echocardiographic study.

OBJECTIVES: This study was performed to define the rates and determinants of progression of organic mitral regurgitation (MR). BACKGROUND: Severe MR has major clinical consequences, but the rates and determinants of progression of the degree of regurgitation are unknown. Quantitative Doppler echocardiographic methods allow the quantitation of regurgitant volume (RVol), regurgitant fraction (RF) and effective regurgitant orifice (ERO) to define progression of MR. METHODS: In a prospective study of MR progression, 74 patients had two quantitative Doppler echocardiographic examinations of MR (with at least two methods) 561 +/- 423 days apart without an intervening event. RESULTS: Progression of MR was observed, with increase in RVol (77 +/- 46 ml vs. 65 +/- 40 ml, p < 0.0001), RF (47 +/- 16% vs. 43% +/- 15%, p < 0.0001), and ERO (50 +/- 35 mm2 vs. 41 +/- 28 mm2, p < 0.0001). Annual rates (95% confidence interval) were, respectively, 7.4 ml/year (5.1, 9.7), 2.9%/year (1.9, 3.9) and 5.9 mm2/year (3.9, 7.8). However, wide individual variation was observed, and regression and progression of RVol >8 ml was found in 11% and 51%, respectively. In multivariate analysis, independent predictors of progression of RVol were progression of the lesions, particularly a new flail leaflet (p = 0.0003), and progression of mitral annulus diameter (p = 0.0001). Regression of MR was associated with marked changes in afterload, particularly decreased blood pressure (p = 0.008). No significant effect of treatment was detected. CONCLUSIONS: Organic MR tends to progress over time with increase in volume overload (RVol) due to increase in ERO. Progression of MR is variable and determined by progression of lesions or mitral annulus size. These data should help plan follow up of patients with organic MR and future intervention trials.     

Reduced atrial contribution to left ventricular filling in patients with severe tricuspid regurgitation after tricuspid valvulectomy: a Doppler echocardiographic study

Patients undergoing valvulectomy for isolated tricuspid valve endocarditis offer the unique opportunity to study the effects of acquired right ventricular volume overload on left ventricular filling in persons free of pulmonary hypertension and preexisting left heart disease. Eleven patients who had undergone total or partial removal of the tricuspid valve were compared with 11 age-matched control subjects; Doppler echocardiographic techniques were used to quantify changes in left ventricular filling and to relate them to changes in left ventricular and left atrial geometry caused by right ventricular and right atrial distension. The late diastolic fractional transmitral flow velocity integral, a measure of the left atrial contribution to left ventricular filling, was significantly decreased in patients undergoing tricuspid valvulectomy compared with control subjects (0.22 +/- 0.11 versus 0.32 +/- 0.09; p less than 0.04). Severe tricuspid regurgitation in these patients resulted in marked right atrial distension, reversal of the normal interatrial septal curvature and compression of the left atrium such that left atrial area was significantly smaller than in control subjects (5.9 +/- 2.2 versus 8.6 +/- 1.2 cm2/m2; p less than 0.005). Acting as a receiving chamber, the left ventricle was maximally compressed by the volume-overloaded right ventricle in late diastole, coincident with the timing of atrial systole, resulting in a significant increase in the left ventricular eccentricity index compared with that in control subjects (1.35 +/- 0.14 versus 1.03 +/- 0.1; p less than 0.001). Thus, right ventricular volume overload due to severe tricuspid regurgitation results in left heart geometric alterations that decrease left atrial preload, impair left ventricular receiving chamber characteristics and reduce the atrial contribution to total left ventricular filling.     

Silent severe tricuspid regurgitation: a study by Doppler echocardiography

Sixty-eight patients with severe tricuspid regurgitation proven by right ventriculography were examined using pulsed and continuous wave Doppler echocardiography and color Doppler flow imaging. Among the 68 patients, there was no tricuspid regurgitant murmur in 16 (24%) in whom laminar regurgitant flow signals were demonstrated by pulsed Doppler echocardiography. The area in which laminar flow was detected ranged from 8 to 46 mm2 (mean 19.5 +/- 9.8 mm2). The peak velocities in patients without regurgitant murmurs as measured by continuous wave Doppler echocardiography ranged from 1.1 to 1.9 m/sec (mean: 1.61 +/- 0.21 m/sec). Laminar regurgitant flow signals were obtained in six; and turbulent regurgitant flow signals in 46 of 52 patients with tricuspid regurgitant murmurs, and their peak velocities ranged from 1.7 to 5.1 m/sec (2.80 +/- 0.78 m/sec). The peak velocities of the regurgitant flow signals in patients without tricuspid regurgitant murmurs were significantly lower than those in patients with regurgitant murmurs (p less than 0.01). In six patients with laminar regurgitant flow signals and regurgitant murmurs, the areas of laminar flow signals ranged from 3 to 12 mm2 (mean 7.0 +/- 3.5 mm2) and were smaller than those of patients without regurgitant murmurs (p less than 0.001). A characteristic candle flame pattern of regurgitant flow signals was observed in all patients without murmurs. Thus, the absence of a tricuspid regurgitant murmur results from laminar regurgitant flow signals of low velocity and this is characterized by a candle flame pattern using color Doppler flow imaging.     

Transient mitral regurgitation following vagal stimulation-induced ventricular arrhythmia in rabbits: a color Doppler echocardiographic study

BACKGROUND AND AIM OF THE STUDY: Cervical vagal stimulation in rabbits frequently causes systolic murmur with bigeminy due to premature ventricular contractions. The bigeminy disappears in a few minutes, but the systolic murmur persists for a few days. Peculiar lesions of the mitral valves, mitral annulus and papillary muscles, and an increase in left atrial weight, frequently develop in a week. In this study, color Doppler echocardiography was used to examine whether the systolic murmur was due to mitral regurgitation. METHODS: Echocardiographic monitoring was carried out in anesthetized rabbits restrained in the supine position. RESULTS: Doppler echocardiography and phonocardiography showed systolic murmur at 6 h, three days, and at one, two, three and four weeks after vagal stimulation. At 6 h after stimulation, phonocardiography showed systolic click and late systolic murmur; Doppler echocardiography showed marked mitral regurgitation. The systolic murmur and mitral regurgitation were attenuated and the papillary muscle was swollen three days after vagal stimulation. Following stimulation, mitral regurgitation disappeared within one week, and papillary muscle swelling improved after three weeks. CONCLUSION: Doppler echocardiography confirmed that systolic murmur caused by vagal stimulation in rabbits was due to mitral regurgitation.     

Aortic regurgitation associated with hypertrophic cardiomyopathy: a colour Doppler echocardiographic study.

The frequency, severity, and cause of aortic regurgitation were assessed by colour Doppler and cross sectional echocardiography in 87 patients (mean SD) age 57 (12) years) with hypertrophic cardiomyopathy, and 48 age matched controls (57 (8) years). Aortic regurgitant murmurs were recorded in only three of 87 patients and in none of the controls. Colour Doppler echocardiography showed an aortic regurgitant signal in 20 (23%) of the patients and three (6%) of the 48 controls. The colour Doppler signals typical of aortic regurgitation were limited to the left ventricular outflow tract. There were no significant differences between patients with hypertrophic cardiomyopathy with and without aortic regurgitation in terms of age (59 years v 56 years), blood pressure (140/84 mm Hg v 136/80 mm Hg), aortic diameter (34 mm v 33 mm), or frequency of calcification of the aortic valve (15% v 10%) and of systolic anterior motion of the mitral valve with mitral-septal contact (25% v 16%). On cross sectional echocardiograms, the degree of septal protrusion into the left ventricular outflow tract during systole was significantly more prominent (15 v 10 mm), and the portion of the basal septum that protruded most deeply into the left ventricular outflow tract was significantly closer to the aortic annulus in patients with aortic regurgitation than in those without it (11 v 14 mm). Mild aortic regurgitation was found in almost a quarter of patients with hypertrophic cardiomyopathy. The regurgitation was related to the morphological abnormality of the left ventricular outflow tract.     

Physiologic multivalvular regurgitation during pregnancy: a longitudinal Doppler echocardiographic study

Valvular function, assessed by Doppler technique, has not been extensively investigated during normal pregnancy. To prospectively study this feature, 18 normal pregnant women were followed during their pregnancies and puerperium, with serial clinical and pulsed-continuous Doppler echocardiographic examinations. In four gestational periods and the puerperium, we analysed: (a) ventricular and atrial dimensions, as well as valve annular diameters; (b) prevalence and characteristics of trivial valvular regurgitations. During pregnancy, slight but significant increases of the four cardiac chamber dimensions and valve annular diameters were observed, except for the aortic ring. The prevalence of physiologic valvular regurgitation in early pregnancy (mitral, 0%; tricuspid, 38.9%; pulmonary, 22.2%; aortic, 0%), was similar to a control group of 18 healthy non-pregnant women. As pregnancy evolved, there was a progressive and significant increase of multivalvular regurgitation, maximal at full-term (mitral, 27.8%; tricuspid, 94.4%; pulmonary, 94.4%, P < 0.05 vs. early pregnancy). Aortic regurgitation was not detected in any stage of pregnancy. In the puerperium, mitral regurgitation resolved, but tricuspid and pulmonary regurgitation were still significantly prevalent (83.3% and 66.7%, respectively, P < 0.05 vs. early pregnancy). It is concluded that physiologic multivalvular regurgitation is frequent in pregnancy, mainly involving right-sided valves in late gestational periods, occasionally persisting in the early puerperium. Chamber enlargement, valve annular dilatation, and increased prevalence of trivial valve regurgitation are time-related events during normal pregnancy, resulting from a reversible cardiac remodeling process induced by physiologic volume overload. These aspects should be considered for a correct interpretation of Doppler echocardiographic findings in pregnant women with suspected heart disease.     

Transvenous pacemaker leads do not worsen tricuspid regurgitation: a prospective echocardiographic study

Limited prospective data are available regarding the influence of pacemaker leads on tricuspid valve function. To examine the true incidence of these complications, 35 patients were prospectively examined by two-dimensional and Doppler echocardiography before and after implantation of either a permanent pacemaker or an automatic implantable cardioverter-defibrillator. Of the 35 patients imaged preoperatively, the amount of tricuspid regurgitation (TR) was judged as normal or trivial in 15 (43%), mild in 10 (29%), moderate in 8 (23%), and severe in 2 (6%). Following electrode implantation, TR was noted to be normal or trivial in 13 (38%), mild in 15 (48%), moderate in 6 (17%) and severe in 1 (3%). We conclude that implantation of permanent right ventricular electrodes is not usually associated with an acute worsening of tricuspid regurgitation in most patients.     

Relationship between regurgitant flow dynamics and cardiac physical in tricuspid regurgitation: a phono-, mechano- and Doppler echocardiographic study

To evaluate the relationships between regurgitant flow dynamics of tricuspid regurgitation (TR) and cardiac physical signs, and to clarify the role of atrial function on central venous flow, we investigated physical signs by cardiac auscultation and palpation of the liver. In addition, phonocardiography, jugular venous and hepatic pulse tracings and Doppler echocardiographic recordings were performed. The subjects, 109 patients with Doppler-detected TR, were categorized as an SR group of 42 with sinus rhythm, an Af group of 63 with atrial fibrillation and four with sinus arrest. Thirty-five patients underwent open heart surgery before six months or more. Results were as follows: 1. In the Af group, the maximum systolic flow velocity data in the superior vena cava (SVC) and hepatic vein (HV) correlated well with the maximum tricuspid regurgitant signal area on the color Doppler echocardiogram, and systolic backward flow from the heart was more evident in the HV than in the SVC. In the SR group, however, no correlation was observed between the maximum systolic flow velocity and the TR signal area, and systolic backward flow was not evident even in cases with severe TR. 2. After open heart surgery, systolic flow velocities in the SVC and HV were significantly decreased in the SR group compared to the Af group. 3. There was close correlation between the presence of hepatomegaly and systolic backward flow towards the liver. Hepatomegaly was more marked in the Af group than in the SR group. 4. Jugular venous and hepatic pulse data correlated well with the flow velocity data in the SVC and HV and with the TR signal area. 5. Intensity of the tricuspid regurgitant murmur as estimated by the Levine's classification correlated relatively well with the systolic pressure gradient between the right ventricle and right atrium as calculated by the modified Bernoulli equation, but did not correlate with the TR signal area. From these results, we conclude that the intensity of the tricuspid regurgitant murmur and the jugular venous or hepatic pulse patterns are useful for evaluating tricuspid regurgitant dynamics, when they are applied clinically with precise recognition of their significance and limitations, and that sinus rhythm or atrial fibrillation is also an important factor.     

Dynamics of mitral regurgitation during nitroglycerin therapy: a Doppler echocardiographic study

Seven patients with decompensated chronic heart failure and functional mitral regurgitation were studied before and during administration of nitroglycerin at a mean dose of 42 micrograms/min (range 20 to 90 micrograms/min). Forward aortic flow obtained by pulsed Doppler increased significantly from 35 +/- 8 to 45 +/- 9 ml/beat (p less than 0.001) and correlated well with the cardiac output measured by thermodilution technique (r = 0.8). Whereas regurgitant mitral volume calculated from the difference between echocardiographic total stroke volume and forward aortic flow decreased significantly from 19 +/- 9 to 3 +/- 3 ml/beat (p less than 0.001), peak velocity of mitral regurgitant flow increased from 4.1 +/- 0.9 to 4.4 +/- 1.0 m/sec (p less than 0.05). The decrease in effective mitral regurgitation area derived from a modified Gorlin formula average 80%. Accordingly, in patients with decompensated chronic heart failure and functional mitral regurgitation, nitroglycerin decreases mitral regurgitant area substantially, and thus almost abolishes mitral regurgitation despite an increase in systolic pressure gradient between left ventricle and atrium. Moreover, the increase in forward flow can be entirely accounted for by the reduction in mitral regurgitant flow.     

Aortic regurgitation associated with hypertrophic cardiomyopathy: a colour Doppler echocardiographic study

The frequency, severity, and cause of aortic regurgitation were assessed by colour Doppler and cross sectional echocardiography in 87 patients (mean SD) age 57 (12) years) with hypertrophic cardiomyopathy, and 48 age matched controls (57 (8) years). Aortic regurgitant murmurs were recorded in only three of 87 patients and in none of the controls. Colour Doppler echocardiography showed an aortic regurgitant signal in 20 (23%) of the patients and three (6%) of the 48 controls. The colour Doppler signals typical of aortic regurgitation were limited to the left ventricular outflow tract. There were no significant differences between patients with hypertrophic cardiomyopathy with and without aortic regurgitation in terms of age (59 years v 56 years), blood pressure (140/84 mm Hg v 136/80 mm Hg), aortic diameter (34 mm v 33 mm), or frequency of calcification of the aortic valve (15% v 10%) and of systolic anterior motion of the mitral valve with mitral-septal contact (25% v 16%). On cross sectional echocardiograms, the degree of septal protrusion into the left ventricular outflow tract during systole was significantly more prominent (15 v 10 mm), and the portion of the basal septum that protruded most deeply into the left ventricular outflow tract was significantly closer to the aortic annulus in patients with aortic regurgitation than in those without it (11 v 14 mm). Mild aortic regurgitation was found in almost a quarter of patients with hypertrophic cardiomyopathy. The regurgitation was related to the morphological abnormality of the left ventricular outflow tract.     

Intra- and paraprosthetic valve regurgitation. A color Doppler echocardiographic study

We prospectively followed a cohort of 64 patients bearing an aortic or mitral prosthetic valve (mean follow-up 5.2 +/- 3.2 months) in order to evaluate if color-coded two-dimensional Doppler echocardiography (CFD) could provide some major advantages with respect to pulsed (PW) and continuous wave (CW) Doppler in the diagnostic accuracy of detection of intra-, and paraprosthetic leaks. During follow-up 4 cases of pathologic prosthetic regurgitation ensued and were all correctly and easily identified by CFD while one of them was missed both by PW and CW Doppler. Based on our results we conclude that CFD is the best noninvasive tool actually available for the correct identification of prosthetic valvular regurgitation because it can provide useful accessory information difficult to obtain with other echocardiographic techniques.     

Doppler echocardiographic evaluation of mitral regurgitation

Evaluation of the severity and hemodynamic significance of mitral regurgitation remains an important and difficult problem. Cardiac ultrasound has emerged as the procedure of choice for the initial evaluation of mitral incompetence, as a result of its ability to confirm the diagnosis and provide a semiquantitative estimate of the severity of incompetence, determine its etiology, and assess the hemodynamic impact of the incompetence on ventricular function. This article reviews established as well as investigational methods of evaluating mitral incompetence by echocardiography and explores established and potential clinical applications of this evolving technology.     

Doppler echocardiographic evaluation of aortic regurgitation

Aortic regurgitation is diverse in presentation, perhaps pursuing a long indolent course or presenting as a catastrophic acute illness. Aortic regurgitation of any degree may be difficult to detect clinically, but echocardiographic Doppler studies afford a sensitive means of detecting and quantifying the lesion noninvasively. Pulsed-wave, continuous-wave, and color-flow Doppler modalities are complementary in the evaluation of aortic regurgitation, and all should be utilized in individual patients when surgery is contemplated. M-mode echocardiography and two-dimensional echocardiography have endured as excellent noninvasive means for evaluating the adequacy of ventricular hypertrophy in response to the insufficiency lesion. Recent interest in wall stress analysis may allow an index of ventricular performance that lends quantitative support for decisions to intervene surgically. Newer surgical options such as aortic valve homografts and pulmonary autografts may make surgery more attractive for patients considered for aortic valve replacement.