Assessment of severity of aortic regurgitation by M-mode colour Doppler flow imaging

To assess the value of measuring the aortic regurgitant jet diameter at its origin by M-mode colour Doppler imaging, 82 patients with aortic regurgitation underwent, within 72 h of each other, colour Doppler examination and angiography. After excluding one patient without colour Doppler aortic regurgitation and five with a highly eccentric regurgitant jet, we found a close relationship between the jet diameter at its origin measured by M-mode colour Doppler and the angiographic grade of aortic regurgitation (r = 0.88). A jet diameter greater than or equal to 12 mm identified severe aortic regurgitation (grade III or IV) with a sensitivity of 86.4% and a specificity of 94.4%. In 38 patients, the jet diameter correlated well with the regurgitant fraction measured by a combined haemodynamic-angiographic method (r = 0.88). A jet diameter greater than or equal to 12 mm identified a regurgitant fraction greater than or equal to 40% with a sensitivity of 88.2% and a specificity of 95.2%. This study indicates that the size of the regurgitant jet diameter at its origin measured by M-mode colour Doppler provides a simple and useful measure of the severity of aortic regurgitation. It may allow differentiation between mild or moderate and severe aortic regurgitation and evaluation of regurgitant fraction.     

Quantification of acute aortic regurgitation by color Doppler flow in an experimental animal model

Color Doppler flow studies were performed on ten anesthetized open-chest dogs. Acute aortic regurgitation was created in the dogs by a special valve-spreading catheter. The magnitude of valvular regurgitation was determined by aortic electromagnetic flow recordings of regurgitant fraction. Arbitrarily-designated grades of aortic regurgitation: mild (4%-10%), moderate (11%-30%), and severe ( greater than 30%) were assigned on the basis of electromagnetic flow. We attempted to obtain studies of varying degrees of AR in each animal. Mean regurgitant fraction for the three grades were 6.8 +/- 0.6% (n = 11), 22.0 +/- 2.4% (n = 7), and 40.4 +/- 2.5 (n = 20), respectively (each P less than 0.05). By color Doppler flow assessment, the ratio of regurgitant jet height to the left ventricular dimension at the junction of the left ventricular outflow tract and the aortic annulus (JH/LVOH) was measured in each study. AR was classified by Doppler as grade I (mild), 1%-24%; II (moderate), 25%-64%; and III (severe), greater than or equal to 65% jet height/left ventricular outflow tract height. Color Doppler flow correlated well with flowmeter assessment of regurgitant fraction. Color Doppler flow tests had a calculated sensitivity of 88%, specificity of 83%, and predictive value of 85% for significant (moderate + severe) aortic regurgitation. Our data support the concept that this method of color Doppler flow assessment provides a quantitative noninvasive evaluation of aortic regurgitation.     

Quantitative assessment of aortic regurgitation by magnetic resonance imaging.

Thirty patients with aortic regurgitation and 10 controls were examined using an 0.5 T superconducting magnet with ECG gating. In each case a multislice-multiphase spinecho study in sagittal-coronal double angulated projection (four-chamber equivalent) was performed to assess left and right ventricular volumes, ejection fraction and regurgitation fraction. Additionally, a blood-flow sensitive cine-study (gradient echo, FAME) was performed to visualize direction and area of regurgitant jet. Magnetic resonance imaging (MRI) data were compared with quantitative and qualitative assessment of aortic regurgitation by angiography, Doppler and colour flow mapping. Using the FAME mode MRI, we were able to detect the regurgitant jet as an area of signal loss within the left ventricle in all patients; moderate correlation to jet area was determined by colour flow mapping (R = 0.60, P less than 0.001). Determination of left and right ventricular end-diastolic, end-systolic and stroke volumes by MRI revealed excellent correlation with invasive data (R = 0.94, P = 0.0001). With MRI regurgitant fraction (RF) could be calculated from the difference between right and left ventricular stroke volumes, which showed good correlation with invasively determined RF (R = 0.91, P = 0.001) and with qualitative Sellers' scoring (R = 0.70, P less than 0.001), respectively. Thus MRI provides the basis for noninvasive detection and quantification of aortic regurgitation.     

Assessment of colour flow imaging in the grading of valvular regurgitation

To assess the accuracy of colour flow imaging in the gradingof valvular regurgitation, we studied 100 consecutive patientswith angiographic mitral regurgitation (55), aortic regurgitation(35) or both (10). The etiology of valve regurgitation was rheumaticin 42 and non-rheumatic in 58 patients. For comparison, 28 subjectswith no structural cardiac disease were studied. Mitral valveregurgitation was assessed with colour flow imaging by measuringthe maximal regurgitant jet area and the maximal jet area normalizedto left atrial area; aortic valve regurgitation was assessedfrom jet area and jet width normalized to ventricular outflowtract width. The best correlation between colour flow imagingand angiography was obtained with normalized measurements forboth mitral (r = 0.82, P<0.0001) and aortic regurgitation(r = 0.94, P<0.0001). A proportion of patients and controlswithout angiographic regurgitation showed evidence of mild mitral(31% and 32%) and aortic (14% and 11%) regurgitation on colourflow imaging. There was a large overlap in the normalized colourflow measurements between angiographically mild and moderatemitral regurgitation: (43%); the overlap was greater when regurgitationwas rheumatic in origin (45% ) rather than non-rheumatic (10%)(P<0.001). There was also overlap in the normalized colourflow findings in patients with angiographic aortic regurgitation,which was greater in rheumatic vs non-rheumatic disease. Knowledgeof the etiology significantly improved the separation of allangiographic grades of aortic regurgitation using colour flowmeasurements (P = 0.006). These findings confirm the high sensitivityof colour flow imaging in the detection of valvular regurgitationand indicate that its accuracy is higher in patients with non-rheumaticthan rheumatic heart disease.     

Quantification of aortic regurgitation using Doppler imaging

Summary Aortic insufficiency induces the development of a jet within the left ventricular outflow tract. The cross sectional area of this jet at its origin is the major determinant of the severity of the regurgitation. M mode Doppler imaging reportedly allows the measurement of jet diameter. This study was designed to evaluate the quantification of aortic regurgitation using a measurement of the jet diameter by M mode Doppler imaging. The left ventricular outflow tract of 32 patients was imaged using either a multigate pulsed Doppler velocimeter or color flow mapping system (Hewlett Packard). The jet diameter was compared to a 4 grade semiquantification derived from supravalvular aortography. Adequate imaging was obtained in the 32 patients. Four of them had no regurgitation: no diastolic flow image could be found during their Doppler investigation. A clear jet image was obtained in the 28 remaining patients. We found a close relationship between the jet diameter (jd in mm) and the angiographic grade (ag): jd = 2.4 + 6.1 ag, r = 0.88, the most significant differences being found between grade 0 and grade 1, and grade 1 and grade 2. In conclusion, direct M mode measurement of the regurgitant jet of aortic insufficiency at its origin offers an additional approach of the severity of the leak.     

应用血管内多普勒超声评价主动脉瓣返流对冠状动脉血流的影响

目的应用血管内多普勒超声评价主动脉瓣返流对冠状动脉血流的影响。方法选取慢性重度的主动脉瓣返流患者12例,先行冠状动脉造影检查,排除冠心病,再行冠状动脉内多普勒检查,测定前降支中远端的平均峰值流速(APV),舒张收缩流速比值(DSVR),冠状动脉血流储备(CFR)等,并测定左心室舒张末压力(LVEDP),用12例正常数据作对照。结果与正常对照相比,主动脉瓣返流患者 APV 升高[(45.8±19.5)cm/s vs.(23.5±15.4)cm/s,P<0.05];DSVR 降低[(1.4±0.8)vs.(2.6±1.7),P<0.05];CFR 降低[(1.5±1.9)cm/s vs.(3.8±2.1)cm/s,P<0.05];LVEDP 升高[(20.6±10.5)mm Hg(1 mm Hg=0.133 kPa)vs.(8.2±5.6)mm Hg,P<0.05];前降支中段内径无变化[(3.8±1.5)mm us.(3.5±1_4)mm,P>0.05]。结论慢性重度主动脉瓣返流对冠状动脉血流有显著影响,表现为基础状态时 APV 升高,而 DSVR 和 CFR 降低,并使左心室舒张功能减低。CFR减低可能是冠状动脉造影正常的主动脉瓣返流患者心绞痛的主要机制。     

Assessment of chronic tricuspid regurgitation by colour Doppler echocardiography: a comparison with angiography in the catheterization room

Colour Doppler echocardiographic (CDE) assessment of tricuspidregurgitation (TR) has been limited by the lack of an acceptedmodel against which it can be compared. Angiography is saidto be inadequate because catheter placement across the tricuspidvalve could induce artifactual TR. Thirty-five consecutive patients with left-sided valvulopathyand recent heart failure were studied. Angiography was validatedby CDE, which demonstrated that catheter placement across thetricuspid valve did not increase the size of the regurgitantjet in the first 30 cases. All the patients were studied withCDE immediately before performing the angiography in order tocompare the findings of both techniques. From all the CDE parameters measured among the angiographicgroups, the jet area overlapped the least (p-0.024). The diametersof the right cardiac chambers were larger in angiographicallysevere cases (P=<0.003 to 0.041), and a scale of severitythat combined jet area and right atrium area showed an excellentcorrelation with angiography (r=0.924; P<0.001). Furthermore,maximal instant systolic gradients between the right cavities,estimated by catheterization, were lower in severe cases (P=0.038).Assessment of these gradients by continuous Doppler can enhancerecognition of severe TR. The analysis of jet area, right atrium area and regurgitantgradient by CDE can provide excellent assessment of TR.     

Sensitivity and specificity of pulsed Doppler echocardiography in detection of aortic and mitral regurgitation

In order to assess the value of pulsed Doppler echocardiographyin detection of valvular regurgitation, 63 patients were evaluatedfor aortic and/or mitral regurgitation using pulsed Dopplerechocardiography and selective cineangiography. The Dopplerstudy was considered as positive when a turbulent flow was detectedbelow the aortic valve for aortic insufficiency and behind themitral valve for mitral insufficiency on a graphic display (timeinterval histogram) when technically adequate andor on an audiosignal.These results were compared with standard angiographic evaluationof the regurgitation: pulsed Doppler echocardiography had 94%sensitivity and the specificity rate was very high (87.5%) evenfor mild regurgitation. Thus, Doppler technique is highly specificand sensitive in detection of aortic and mitral regurgitationwhen both audiosignal and time interval histogram are simultaneouslyperformed.     

What is the ideal orientation of a mitral disc prosthesis? An in vivo haemodynamic study based on colour flow imaging and continuous wave Doppler

Doppler colour flow imaging demonstrates normal laminar flowto enter the left ventricle in diastole through the mitral inflowtract located posteriorly in the left ventricle. Laminar flowthen passes around the left ventricular apex to the anteriorlylocated outflow tract. As this is the normal physiologic flowpattern, it would seem appropriate that in the surgical implantationof a mitral tilting disc prosthesis the greater orifice shouldbe directed posteriorly to mimic the normal native valve flowpattern. To determine whether variable positioning of the greater orificehad any significant haemodynamic conse–quences, intracavitaryblood flow patterns were studied in 30 patients with mitralBjörk-Shiley prostheses variously orientated in the mitralorifice. The orientation of the greater orifice (OGO) of theprosthesis was determined by fluoroscopy and the pattern ofthe left ventricular inflow from Doppler colour flow imaging.Twelve patients had their OGO and inflow directed towards theinflow tract (orientation I): nine patients had their OGO andinflow directed anteriorly towards the outflow tract (orientationII) and nine patients had their prosthesis with OGO and inflowin an intermediate position (orientation III). The mean prostheticdiastolic gradient, calculated using continuous wave Doppler,averaged 2.8 mmHg (±0.5mmHg) for the 25-mm prosthesisin orientation I, but 6.0 mmHg (±0.7mmHg) for the samesize prosthesis in orientation II and 5.8 mmHg (±0.9mmHg) with a 25-mm prosthesis in orientation III. Similarly,for prostheses of 27 mm and 29–31 mm the lowest mean diastolicgradient was found in orientation I (2.7 mmHg ± 0.8 and2.8 mmHg ± 0.5, respectively). However, the differencein mean gradient between orientations I, II (5.6 mmHg±0.2and 3.6 mmHg) and III (5.1 mmHg ±0.7 and 3.8 mmHg ±0.4)was less pronounced for the larger prostheses. From these results,it was concluded that the best haemodynamic result is obtainedby a mitral disc prosthesis when its greater orifice is orientatedposteriorly. This would appear to be especially important forthe smaller disc prosthesis.     

Evaluation of mitral regurgitation by Doppler echocardiography

The diagnosis and assessment of mitral regurgitation has been one of the main challenges for cardiac ultrasound. Imaging techniques (M-mode and two-dimensional echocardiography) provide direct morphologic and etiologic information of the evaluation of patients with suspected mitral regurgitation. The advent of cardiac Doppler increased tremendously the ability to evaluate mitral regurgitation noninvasively. Continuous-wave and pulsed Doppler have been found to be sensitive and specific in the detection of mitral regurgitation. The introduction of color flow Doppler simplified enormously the assessment of patients with suspected mitral regurgitation. The maximal regurgitant area and maximal regurgitant area corrected for left atrial size have become the most commonly used parameters to evaluate mitral regurgitation by color flow Doppler in the clinical setting. However, the color regurgitant jet area is highly dependent on anatomical, hemodynamic, and equipment factors. A new method, based on the proximal isovelocity surface area, is being evaluated and appears to be relatively independent of equipment factors. Transesophageal echocardiography has been shown to be exquisitely sensitive in the detection of mitral regurgitation. Quantitation of mitral regurgitation by transesophageal echocardiography is currently based on the maximal regurgitant area and this parameter appears to correlate closely with the angiographic degree of mitral regurgitation. Pulmonary venous flow analysis had been used in conjunction with color flow mapping for the evaluation of mitral regurgitation by transesophageal echocardiography. The presence of reversed systolic flow has been shown to be sensitive and specific for the diagnosis of severe mitral regurgitation. Patients with clinically difficult surface studies, flail mitral valve leaflets, and prosthetic mitral valve are best evaluated by the transesophageal approach with interrogation of pulmonary venous flow.     

Quantitative assessment of aortic regurgitation by colour flow Doppler in an open chest canine model

Colour flow Doppler maps the extent of the flow velocity disturbance of aortic regurgitation onto the two dimensional echocardiographic image of the left ventricular cavity. The spatial extent of this flow velocity disturbance expressed as a percentage of end diastolic left ventricular cavity area (CD%) was compared to regurgitant fraction (RF), measured volumetrically, in nine open chest dogs with varying degrees of surgically created aortic regurgitation (RF 0-85%). Right heart bypass controlled venous return to the left atrium and hence net left ventricular output, while total left ventricular output was measured with an aortic electromagnetic flow probe under various loading conditions, achieving mean diastolic transvalvular pressure gradients of 23-114 mm Hg, net left ventricular outputs of 750-3000 ml.min-1 and diastolic filling periods of 162-320 ms. A linear correlation between CD% and RF (r = 0.89) was demonstrated over this wide range of loading conditions. At a given transvalvular diastolic pressure gradient [68(SD9) mm Hg] CD% was linearly proportional to regurgitant aortic orifice area (r = 0.87). Thus CD% is proportional to the volumetric severity of aortic regurgitation under a wide range of haemodynamic conditions and varies appropriately with regurgitant aortic orifice area when diastolic transvalvular pressure gradient is held constant. The application of these principles to the non-invasive quantitation of valvular regurgitation by colour Doppler appears feasible.     

Velocity distributions in the left ventricular outflow tract and the aortic anulus measured with Doppler colour flow mapping in normal subjects

This study was designed to investigate the velocity distributionsin the left ventricular outflow tract and aortic anulus. In18 out of 22 healthy male individuals, instantaneous cross-sectionalflow velocity profiles were constructed at different levelsof the left ventricular outflow tract and aortic anulus by timeinterpolation of digital velocity data from sequentially delayedDoppler colour flow maps. The results showed that: (1) the velocity distributions in theleft ventricular outflow tract and the aortic anulus were skewedwith the highest velocities along the anterior and septal partsof the flow channel; (2) based on the time-velocity integralprofiles in the aortic anulus, which were also skewed with thehighest integrals along the anterior and septal parts, the maximaltime-velocity intergrals were higher than the mean cross-sectionaltime-velocity integrals by approximately 30% in the four chamberview and 40% in the long axis view. However, the time-velocityintegrals at the middle point of the diameter correlated significantlywith the mean cross-sectional time-velocity integrals in thefour chamber view (10.3±0.8 vs 9.9±0.9 cm; r=0.95)and in the long axis view (12.5±0.9 vs 11.8±0.8cm; r=0.95). Therefore, it can be concluded that: (1) the velocity distributionsin the left ventricular outflow tract and the aortic anulusare skewed; (2) if the aortic anulus is used for cardiac outputmeasurement by pulsed Doppler echocardiography in normal subjects,the middle point of its diameter is the best sampling site.     

Usefulness of colour tissue Doppler imaging in assessing aortic elastic properties in Type 1 diabetic patients.

AIMS: Diabetes mellitus (DM) is associated with macrovascular disease and impaired aortic function. We hypothesized that the change in aortic elastic properties could be investigated with colour tissue Doppler imaging (CTDI) in Type 1 diabetic patients and that these findings could be related to the aortic stiffness index. METHODS: We examined by echocardiography 66 patients with Type 1 DM (mean age 35 +/- 10 years, mean duration of disease 20 +/- 9 years) without a history of arterial hypertension or coronary artery disease (negative thallium-201 stress test) and 66 age- and sex-matched normal subjects. Arterial pressure was measured before echocardiography was performed. Internal aortic systolic and diastolic diameters by M-mode echocardiography and aortic systolic upper wall tissue velocity (Sao, cm/s) by CTDI were measured 3 cm above the aortic valve. Aortic distensibility and aortic stiffness index were calculated using accepted formulae. RESULTS: Aortic stiffness, distensibility and Sao velocity differed significantly between the studied groups. In the diabetic group, duration of diabetes correlated with aortic stiffness (r = 0.53, P < 0.001), distensibility (r = -0.61, P < 0.001) and Sao velocity (r = -0.48, P < 0.001). There was a negative correlation between aortic stiffness and Sao velocity (r = -0.49, P < 0.001). Multiple stepwise linear regression analysis in the diabetic group revealed that aortic S velocity (beta = 0.30, P = 0.005) and duration of diabetes (beta = -0.49, P = 0.001) were the main predictors of aortic distensibility (overall R(2) = 0.48). CONCLUSIONS: Aortic elastic properties can be directly assessed by measuring the movements in the upper aortic wall. Reduced aortic S velocity is associated with increased aortic stiffness in Type 1 diabetic patients.     

彩色多普勒血流会聚法测定主动脉瓣反流量的可行性探讨

目的探讨彩色多普勒血流会聚(FC)法测定主动脉瓣反流量的可行性。方法近端血流会聚角呈水平型的单纯性主动脉瓣反流患者27例,分别用FC法和心导管技术测定主动脉瓣反流量。结果FC法和心导管测定的主动脉瓣每搏反流量分别为(60±27)cm3和(58±25)cm3(P>0.05),两者存在良好相关性(r=0.91,P<0.01)。结论对于近端血流会聚角为水平型的主动脉瓣反流患者,FC法能准确测定其主动脉瓣反流量。     

Comparison of the proximal flow convergence method and the jet area method for the assessment of the severity of tricuspid regurgitation

Aims To compare the value of the proximal flow convergence methodand the jet area method for the determination of the severityof tricuspid regurgitation. Methods and Results The proximal isovelocity surface area radius and the jet area/lengthwere measured in 71 consecutive patients with angiographicallygraded (grade 0/I–III) tricuspid regurgitation. Rank correlationcoef-ficients with the angiographic grade were 0·71 (P<0·001)for the proximal isovelocity surface area radius (aliasing borderof 28cm.s^–1), 0·66 (P<0·001) for thejet area, and 0·63 (P<0·001) for the jet length.The proximal isovelocity surface area radius was significantlycorrelated with the jet area/length (correlation coefficients0·82/0·77, P<0·001). Correct differentiationbetween mild to moderate (grade I–II) and severe (gradeIII) tricuspid regurgitation was achieved in 62 of 71 patients(87%) by means of the proximal isovelocity surface area radius,in 61 of 71 (86%) by the jet area, and in 62 of 71 (87%) bythe jet length. Grade III tricuspid regurgitation was not identifiedin five of 21 patients (24%) by means of the proximal isovelocitysurface area radius, in six of 21 (29%) by the jet area, andin seven of 21 (33%) by the jet length. Conclusion The flow convergence method and the jet area method are of similarvalue for the determination of the severity of tricuspid regurgitation.Both methods differentiated mild to moderate from severe tricuspidregurgitation in most patients. However, underestimation ofsevere tricuspid regurgitation in 20–30% of the casesrepresents a serious limitation of both methods.     

Assessment of aortic regurgitation by transesophageal echocardiography: correlation with angiographic determination

Transthoracic echocardiographic studies have shown that color Doppler mapping of the aortic regurgitation (AR) jet correlated well with the severity of regurgitation as assessed by contrast aortography. The present study was performed to assess whether these parameters could be similarly applied to measurements determined by transesophageal echocardiography (TEE). In order to determine and validate criteria for the assessment of AR severity, 39 clinically stable patients with a TEE color Doppler study and contrast aortography within a 2-week period were identified. The ratio of the jet area (JA) to left ventricular diastolic area (LVDA) had the best correlation to AR severity as determined by contrast aortography (r = 0.89). Jet length, JA, the ratio of jet width to the width of the left ventricular outflow tract and jet width had r values of 0.88, 0.88, 0.83, and 0.84, respectively. The best sensitivity and specificity for the assessment of AR by TEE were obtained as follows: JA/LVDA ratio of 0%-7% predicts 0-1 + AR; 8%-20% 2-3 + AR, and greater than 20% 4 + AR. Of the three patients miscategorized, none was misgraded by more than one angiographic grade of AR. Jets that measure more than 6 cm in length or have an area of greater than 10 cm 2 have a 100% sensitivity and specificity for diagnosing 4 + AR. In the present study the ratio of JA to LVDA area correlates best with AR severity as determined by angiography.     

Dynamic three-dimensional color flow Doppler: an improved technique for the assessment of mitral regurgitation

BACKGROUND: Prior studies have reconstructed mitral regurgitant flow in three dimensions displaying gray scale renditions of the jets, which were difficult to differentiate from surrounding cardiac structures. Recently, a color-coded display of three-dimensional (3D) regurgitant flow has been developed. However, this display was unable to integrate cardiac anatomy, thereby losing spatial information, which made it difficult to determine the jet origin and its spatial trajectory. To overcome this limitation, an improved method of 3D color reconstruction of regurgitant jets obtained from color flow Doppler using a transesophageal approach was developed to allow the combined display of both color flow and gray scale information. OBJECTIVES: To demonstrate the feasibility of 3D reconstruction of regurgitant mitral flow jets using an improved method of color encoding digital data acquired by transesophageal echocardiography (TEE). METHODS: We studied 46 patients undergoing a clinically indicated TEE study. All subjects had mitral regurgitation detected on a previous transthoracic study. Atrial fibrillation or poor image quality were not used as exclusion criteria. The 3D study was performed using a commercial ultrasound imaging system with a TEE probe (Sonos 5500, Agilent Technologies). A rotational mode of acquisition was used to collect two-dimensional (2D) color flow images at 3-degree intervals over 180 degrees. Images were processed off line using the Echo-View Software (TomTec Imaging Systems). Volume-rendered 3D color flow jets were displayed along with gray scale information of the adjacent cardiac structures. RESULTS: Mitral regurgitant flow, displayed in left atrial and two longitudinal orientations, was successfully reconstructed in all patients. The time for acquisition, post-processing, and rendering ranged between 10 and 15 minutes. There were 28 centrally directed jets and 15 eccentric lesions. Eight patients in the study had periprosthetic mitral regurgitant flow. CONCLUSIONS: Three-dimensional imaging of mitral regurgitant jets is feasible in the majority of patients. This improved technique provides additional information to that obtained from the 2D examination. Particularly, in patients with paravalvular leaks 3D color flow Doppler provides information on the origin and the extent of the dehiscence, as well as insight into the jet direction. In addition, in patients with eccentric mitral regurgitation, this new modality overcomes the inherent limitations of 2D echo Doppler by depicting the full extent of the jet trajectory.     

Systolic aortic regurgitation in rheumatic carditis: Mechanistic insight by Doppler echocardiography

BackgroundAortic regurgitation (AR) usually occurs in diastole in presence of an incompetent aortic valve. Systolic AR is a rare phenomenon occurring in patients with reduced left ventricular systolic pressure and atrial fibrillation or premature ventricular contractions. Its occurrence is a Doppler peculiarity and adds to the hemodynamic burden.AimRheumatic carditis is often characterised by acute or subacute severe mitral regurgitation (MR) due to flail anterior mitral leaflet and elongated chords. In patients with acute or subacute MR, developed left ventricular systolic pressure may fall in mid and late systole due to reduced afterload and end-systolic volume and may be lower than the aortic systolic pressure, causing flow reversal in aorta and systolic AR.Material and methods17 patients with acute rheumatic fever were studied in the echocardiography lab during the period 2005–2015. Five patients had severe MR of which two had no AR and hence were excluded from the study. Three young male patients (age 8–24 years) who met modified Jones’ criteria for rheumatic fever with mitral and aortic valve involvement were studied for the presence of systolic AR.ResultsIn presence of acute or subacute severe MR, flail anterior mitral valve and heart failure, all three showed both diastolic and late systolic AR by continuous-wave and color Doppler echocardiography.ConclusionSystolic AR is a unique hemodynamic phenomenon in patients with acute rheumatic carditis involving both mitral and aortic valves and occurs in presence of severe MR.