Evaluation of secondary tricuspid regurgitation by intraoperative epicardial pulsed Doppler echocardiography

Since 1985, we have evaluated secondary tricuspid regurgitation associated with acquired mitral valve disease in patients undergoing open mitral surgery by intraoperative epicardial two-dimensional and pulsed Doppler echocardiography. We found intraoperative pulsed Doppler echocardiography to be a sensitive, safe technique allowing surgeons to evaluate the severity of tricuspid regurgitation intraoperatively, even in critically ill patients who cannot afford preoperative cardiac catheterization. To assess the severity of tricuspid regurgitation intraoperatively, the transducer was placed directly on the right atrium. The ultrasound beam was transmitted into the right atrium at right angles to the tricuspid valve orifice to record intraoperative four-chamber two-dimensional echocardiograms, which were used to detect the sites of eight sample volumes, one in the right ventricle and seven in the right atrium, for pulsed Doppler echocardiography. The pulsed Doppler signals were recorded in each sample volume before and after cardiac procedures. The pansystolic abnormal signals lasting from tricuspid valve closure to the subsequent opening and consisting of components moving away from the tricuspid valve were interpreted as tricuspid regurgitant flows. Without operative correction of the tricuspid valve, secondary tricuspid regurgitation can resolve following mitral valve surgery alone. However, to our knowledge, there are no published reports of objective findings of intraoperative changes of secondary tricuspid regurgitation. Here we present the unique intraoperative pulsed Doppler echocardiographic features of tricuspid regurgitation before and after cardiac procedures. A 30-year-old woman with preoperative diagnosis of aortic regurgitation, mitral stenosis and severe tricuspid regurgitation underwent aortic and mitral valve replacement. The intraoperative pulsed Doppler echocardiograms recorded after pericardiotomy and before cannulation of the heart showed tricuspid regurgitant flow signal in all of the seven sample volumes in the right atrium, which was interpreted as severe tricuspid regurgitation. After surgical procedures, no regurgitant flow from the tricuspid orifice to the right atrium was detected in the eight sample volumes. This suggested that preoperative secondary tricuspid regurgitation improves without operative procedures for the tricuspid valve. All intraoperative echocardiographic procedures were performed within 5 min, and no arrhythmias or other complications related to this technique were noted. Epicardial pulsed Doppler echocardiography is helpful in assessing tricuspid valve function of patients undergoing mitral valve surgery bef     

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.     

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.     

Evaluation of aortic insufficiency by Doppler color flow mapping

The color Doppler echocardiographic studies and aortic angiograms of all patients who had these procedures performed within 2 weeks of each other between October 1984 and August 1985 were reviewed to determine whether any parameters of the regurgitant jet visualized by color Doppler study predicted the severity of aortic insufficiency as assessed by angiographic grading. Patients with an aortic valve prosthesis were excluded. Twenty-nine patients had aortic insufficiency and had adequate color Doppler studies for analysis. The mean time between color Doppler examination and angiography was 2.3 days (range 0 to 12). The maximal length and area of the regurgitant jet were poorly predictive of the angiographic grade of aortic insufficiency. The short-axis area of the regurgitant jet from the parasternal short-axis view at the level of the high left ventricular outflow tract relative to the short-axis area of the left ventricular outflow tract at the same location best predicted angiographic grade, correctly classifying 23 of 24 patients. However, the jet could be seen from this view in only 24 of the 29 patients. The height of the regurgitant jet relative to left ventricular outflow tract height measured from the parasternal long-axis view just beneath the aortic valve correctly classified 23 of the 29 patients. Mitral stenosis or valve prosthesis, which was present in 10 patients, did not interfere with the diagnosis or quantitation of aortic insufficiency by these methods.(ABSTRACT TRUNCATED AT 250 WORDS)     

Doppler echocardiography diagnosis and classification of the degree of aortic valve insufficiency in patients with aortic stenoses and mitral valve diseases

To test the capacity of pulsed Doppler echocardiography in the detection and quantification of aortic regurgitation, 64 consecutive patients with aortic and mitral valve disease were examined clinically and by echocardiography before cardiac catheterization. The severity of aortic regurgitation was determined angiographically (I-IV) and compared with the extent of the regurgitant jet in the left ventricle measured by pulsed Doppler echocardiography. In 15 of 64 patients neither angiography nor pulsed Doppler echocardiography showed aortic regurgitation (specificity 100%). Apart from 3 patients with poor echo quality pulsed Doppler echocardiography correctly detected aortic regurgitation in 46 of 49 patients (sensitivity 94%). Clinical examination (63%) and M-mode echocardiography (63%) were significantly less sensitive than Doppler echocardiography (p less than 0.001). The pulsed Doppler echocardiographic degree of aortic regurgitation correlated strongly with angiography (corrected contingency coefficient 0.91). In patients with severe aortic stenosis (systolic gradient greater than 50 mm Hg) aortic regurgitation I was slightly overestimated by pulsed Doppler echocardiography (p less than 0.003). Differentiation of aortic regurgitation III and IV was not possible. Mitral valve disease did not affect quantification of aortic regurgitation (n = 23).     

Prevalence of regurgitant murmurs in patients with valvular regurgitation detected by Doppler echocardiography

STUDY OBJECTIVE: To determine the relation between heart valve regurgitation detected by Doppler echocardiography and audible regurgitant murmurs. DESIGN: Consecutive sample. SETTING: Adult echocardiography laboratory in a tertiary care university hospital. PATIENTS: Sequential sample of 408 patients presenting for clinical echocardiographic studies who had technically satisfactory studies and were available for auscultation. MEASUREMENT AND MAIN RESULTS: Valvular regurgitation occurred in 43% of patients at the mitral valve, 39% of patients at the tricuspid valve, 33% of patients at the aortic valve, and 15% of patients at the pulmonic valve. Corresponding regurgitant murmurs were frequently absent. A murmur corresponding to Doppler-detected regurgitation was detected in 56% of patients with mitral regurgitation, 61% of patients with aortic regurgitation, 28% of patients with tricuspid regurgitation, and 15% of patients with pulmonic regurgitation. There was a highly significant positive correlation of audibility with severity of valve regurgitation for the aortic, tricuspid, and mitral valves. Audibility ranged from 10% to 40% for mild regurgitation to 86% to 100% for severe regurgitation. Murmur audibility was not related to the type of valvular disease present. CONCLUSIONS: Doppler echocardiography is a sensitive method for detecting valve regurgitation. Corresponding regurgitant murmurs are frequently not present. The audibility of regurgitant murmur is highly dependent on the severity of valve regurgitant and has little relation to the type of valve disease present.     

Value and limitations of color Doppler flow mapping in the detection and semiquantification of valvular regurgitation

Summary We compared color Doppler flow mapping data to angiographic data in 294 patients with suspected valvular regurgitation. Thirty-one patients had rheumatic mitral regurgitation and 37 had mitral regurgitation due to mitral valve prolapse by angiography. Ten patients had no angiographic regurgitation (4 rheumatic, 6 prolapse). The remaining patients included 86 with suspected aortic regurgitation and 130 with suspected tricuspid regurgitation. Angiographically 74 had aortic regurgitation and 111 tricuspid regurgitation. The maximum size of regurgitant jets was evaluated in each patient by color flow mapping. The width of the jets was also taken into consideration. In 29 of the 31 with rheumatic regurgitation and 67 of the 74 with aortic regurgitation by angiography, abnormal regurgitant signals were detected by color flow mapping. In both rheumatic mitral regurgitation and aortic regurgitation, color Doppler estimation of the jets correlated well with angiographic grading. The regurgitant jets in these regurgitation were not eccentric. In the 37 with mitral regurgitation in mitral valve prolapse by left ventriculography, abnormal jets were detected in 35 by color flow mapping. However, the regurgitant jets were eccentric and color Doppler estimation of the jets correlated poorly with angiographic grading. In patients with tricuspid regurgitation, color Doppler grading of regurgitation correlated poorly with right ventriculographic grading. A color Doppler underestimation was observed in 48%. In conclusion, color Doppler flow mapping is useful in the noninvasive detection and semiquantification of rheumatic mitral regurgitation and aortic regurgitation having non-eccentric jets, although this technique often underestimates the severity of regurgitation in mitral valve prolapse.     

Noninvasive estimation of pulmonary artery diastolic pressure in patients with tricuspid regurgitation by Doppler echocardiography.

OBJECTIVES: The purpose of this study was to determine whether Doppler echocardiographic assessment of right ventricular pressure at the time of pulmonary valve opening could predict pulmonary artery diastolic pressure. BACKGROUND: Doppler echocardiography has been used to estimate right ventricular systolic pressure noninvasively. Because right ventricular and pulmonary artery diastolic pressure are equal at the time of pulmonary valve opening, Doppler echocardiographic estimation of right ventricular pressure at this point might provide an estimate of pulmonary artery diastolic pressure. METHODS: We studied 31 patients who underwent right heart catheterization and had tricuspid regurgitation. Pulmonary flow velocity was recorded by pulsed wave Doppler echocardiography, and tricuspid regurgitant velocity was recorded by continuous wave Doppler echocardiography. The time of pulmonary valve opening was determined as the onset of systolic flow in the pulmonary artery. Tricuspid velocity at the time of pulmonary valve opening was measured by superimposing the interval between the onset of the QRS complex on the ECG and the onset of pulmonary flow on the tricuspid regurgitant envelope. The tricuspid gradient at this instant was calculated from the measured tricuspid velocity using the Bernoulli equation. This gradient was compared to the pulmonary artery diastolic pressure obtained by right heart catheterization. MEASUREMENTS AND RESULTS: The pressure gradient between the right atrium and right ventricle obtained at the time of pulmonary valve opening ranged from 9 to 31 mm Hg (mean, 19+/-5) and correlated closely with invasively measured pulmonary artery diastolic pressure (range, 9 to 36 mm Hg; mean, 21+/-7 mm Hg; r = 0.92; SEE, 1.9 mm Hg). CONCLUSION: Doppler echocardiographic measurement of right ventricular pressure at the time of pulmonary valve opening is a reliable noninvasive method for estimating pulmonary diastolic pressure.     

Can two-dimensional echocardiography and Doppler color flow mapping identify the need for tricuspid valve repair?

Tricuspid regurgitation severity was assessed preoperatively with Doppler color flow mapping and these assessments were compared with surgical findings in 90 patients undergoing mitral or aortic valve replacement, or both. Group I (n = 52) required tricuspid valve annuloplasty because tricuspid regurgitation was judged intraoperatively to be severe; in Group II (n = 38), tricuspid valve annuloplasty was not performed because tricuspid regurgitation was judged intraoperatively not to be severe. With use of the apical four chamber and parasternal short-axis imaging planes, the severity of tricuspid regurgitation by Doppler color flow mapping was assessed by comparing the maximal area of tricuspid regurgitant signals with the right atrial area taken in the same frame in which the maximal tricuspid regurgitant signals were noted. This ratio was found to be greater than or equal to 34% (mean 50.2 +/- 11.8%) in 50 (96%) of 52 patients in Group I and less than 34% (mean 27.5 +/- 6.9%) in 36 (95%) of 38 patients in Group II (p less than 0.001). The maximal diastolic tricuspid anulus diameter measured with the same two-dimensional imaging planes was greater than or equal to mm/m2 body surface area (mean 26.7 +/- 5.2 mm/m2) in 46 patients (88%) in Group I and less than 21 mm/m2 (mean 17.8 +/- 2.5 mm/m2) in 36 patients (95%) in Group II (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Pulsed Doppler in the diagnosis of tricuspid insufficiency

Forty-eight patients underwent M-Mode, 2D and pulsed Doppler echocardiography with systematic apical and subcostal examination of the mitral and tricuspid orifices to determine the value of pulsed Doppler echo in the detection of tricuspid regurgitation. The fourty-eight patients, aged 12 to 69 years, were divided into 2 groups: Group I: 27 patients referred for cardiac catheterisation usually with a view to surgery. The majority of patients had rheumatic valvular, congenital heart disease or cardiomyopathies. All of these patients had phonocardiography, right and left heart catheterisation, right ventricular angiography and measurement od cardiac output. Group II: 21 control patients with no auscultatory, radiological or electrocardiographic changes. This group was studied to determine the specificity of pulsed Doppler examination of the tricuspid valve and the patients only underwent echocardiography. Selective right ventricular angiography was selected as the reference. The sensitivity, specificity and predictive value of pulsed Doppler echocardiography in the positive diagnosis of tricuspid regurgitation were determined. Its value in quantifying tricuspid regurgitation was also analysed. The sensitivity of pulsed Doppler was 93 p. 100 in this series: all but one case of angiographically proven tricuspid regurgitation were detected by the finding of unequivocal systolic turbulence in the right atrium. The specificity of pulsed Doppler was 91 p. 100. The positive predictive value of systolic turbulence in the right atrium was 81 p. 100. The only reliable criteria for quantifying the regurgitation were the intensity of the acoustic signal and the spatial extension of intraatrial turbulent flow: all patients with turbulent flow propagating as far as the superior wall of the right atrium or the inferior vena cava had angiographically severe tricuspid regurgitation. A comparison with other paraclinical methods of detecting tricuspid regurgitation showed that pulsed Doppler echocardiography is the most sensitive tool at the clinician's disposal for diagnosing this lesion: the sensitivity of auscultation and phonocardiography was 50 p. 100, jugular pulse tracings 54 p. 100, right heart catheterisation 50 p. 100, and pulsed Doppler echocardiography 93 p. 100. Pulsed Doppler echocardiography may even be superior to angiography which has, until now, been the method of reference for diagnosing tricuspid regurgitation.     

The importance of tricuspid valve structure and function in the surgical treatment of rheumatic mitral and aortic disease.

A significant proportion of individuals with rheumatic disease have tricuspid valve involvement which may be clinically important and alter the medical or surgical approach to treatment. Therefore 50 patients with rheumatic left-sided valvular lesions who were referred for operative treatment were studied. Thirty patients had angiographically significant tricuspid regurgitation (group I) and 20 had a competent tricuspid valve (group II). Pre-operative cardiac assessment included Doppler echocardiography and contrast ventriculography. Patients with tricuspid regurgitation more commonly had mitral valve disease or combined mitral and aortic valve lesions, (P less than 0.001) and were more likely to have atrial fibrillation than those without tricuspid regurgitation (P less than 0.001). Pulmonary arterial systolic and mean right atrial pressures were higher in group I (both P less than 0.01). A close relationship was found between the angiographic and Doppler assessment of the degree of tricuspid regurgitation (P less than 0.01). Doppler-derived measurement of the right ventricular-right atrial systolic pressure difference correlated well with the systolic trans-tricuspid pressure difference measured at cardiac catheterization (y = 0.7x + 22, r = 0.67, P less than 0.001) and the pulmonary arterial systolic pressure (y = 0.8x + 27, r = 0.71, P less than 0.001). Rheumatic involvement of the tricuspid valve identified by pre-operative echocardiography was confirmed in five patients at surgery. Of the 13 patients with functional tricuspid regurgitation at operation, only two had been diagnosed as having organic disease by echocardiography. Furthermore, in all 18 cases where Doppler suggested grade 3 or 4+ tricuspid regurgitation, surgical repair or replacement of the valve was performed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of aortic valve insufficiency using color Doppler echocardiography

Colour flow mapping Doppler echocardiography is a new, noninvasive method for studying the direction and velocity of blood flow within the cardiac chambers. In order to estimate the sensitivity and specificity of this method in the evaluation of aortic regurgitation, 44 patients were examined consecutively. In 24 patients, aortic valve incompetence was proven by angiography; in 20 patients aortography revealed no regurgitation. Quantification of the severity of aortic insufficiency was performed by grading the amount of colour of the regurgitant flow (grade I-IV) and comparing it with the angiographic data. In 43 out of 44 patients diagnostic images could be obtained with colour flow mapping Doppler echocardiography. With this method aortic insufficiency was detected in all cases (sensitivity 100%). The specificity was 97% (one false positive diagnosis). For quantification of the severity of regurgitation agreement with the angiographic findings was obtained in 18 out of 24 cases. In the remaining 6 patients the difference was one grade. Conclusion: Colour flow mapping Doppler echocardiography is an important advance in the noninvasive preoperative diagnostics of aortic incompetence.     

Assessment of valvular heart disease by Doppler echocardiography

Doppler echocardiography provides direct hemodynamic data that are often complementary to those demonstrated by M-mode and two-dimensional echocardiographic imaging. This relatively new noninvasive technique has a number of important uses in patients with valvular heart disease. In both adults and children, Doppler measures of peak flow velocity through a stenotic valve allow accurate prediction of the pressure gradient across the valve, and the technique has particular promise for screening patients with suspected aortic or pulmonic stenosis. In patients with mitral stenosis but parasternal short-axis images of limited quality, Doppler velocity measures can provide novel data about the pressure gradient and mitral orifice area. Doppler techniques can also provide direct evidence for or against the presence of valvular regurgitation, and several approaches allow clinically useful estimation of the extent of aortic, mitral, or tricuspid regurgitation. In patients with known disease of one cardiac valve, Doppler is accurate for evaluating the integrity of a second valve. Finally, Doppler techniques have great promise for defining the nature, and perhaps the severity, of suspected prosthetic valve malfunction. Hence, we believe that Doppler echocardiography should become a routine part of the noninvasive evaluation of patients with known or suspected valvular heart disease.     

Quantification of aortic regurgitation using continuous and pulsed wave Doppler echocardiography

In a prospective blind study, continuous and pulsed wave Doppler echocardiography were used to predict the severity of angiographically assessed aortic regurgitation in 36 patients. High quality continuous wave spectral recordings of the regurgitant jet were obtained in 32 patients but four patients with mild aortic regurgitation had dropout of high velocity signals precluding accurate assessment. The deceleration slope of the peak to end-diastolic velocity measured by continuous wave Doppler, and pulsed wave Doppler mapping of the regurgitant jet in the left ventricle were compared with angiographic severity. The deceleration slope was significantly steeper in patients with severe rather than mild or moderate aortic regurgitation (3.65 +/- 1.04 vs. 1.89 +/- 0.42 vs. 1.52 +/- 0.59 m sec-2). A decay slope of greater than 3 m sec-2 was observed only in patients with 3+ or 4+ aortic regurgitation and a decay slope less than 1.2 m sec-2 was seen only in mild 1+ aortic regurgitation but there was considerable overlap between groups, making it difficult in individual cases to assess severity on the basis of the continuous wave deceleration slope. The pulsed wave Doppler technique was more time consuming, added little to the continuous wave Doppler assessment and underestimated severe regurgitation in almost 50% of cases. Hence, there are significant problems using either Doppler technique in quantitatively assessing aortic regurgitation.     

Pulsed doppler echocardiographic detection of right-sided valve regurgitation: Experimental results and clinical significance

Pulsed Doppler echocardiography may allow noninvasive detection of tricuspid insufficiency as disturbed or turbulent systolic flow in the right atrium and pulmonary insufficiency as turbulent diastolic flow in the right ventricular outflow tract. Accordingly, six open chest mongrel dogs were examined with Doppler echocardiography before and after surgical creation of tricuspid and pulmonary insufficiency. The Doppler technique detected the appropriate lesion in all instances, with a specificity of 100 percent.In 121 patients (20 without heart disease, 101 with heart disease of various causes), pulsed Doppler echocardiography was used to detect right-sided valve regurgitation. Results were compared with right-sided pressure measurements and M mode echocardiographic findings in all, and with right ventricular angiography in 21 patients. Pulsed Doppler study detected tricuspid insufficiency in 61 of 100 patients, 12 (20 percent) of whom had clinical evidence of this lesion. Angiographic evidence of tricuspid regurgitation was present in 18 patients, 17 of whom had positive Doppler findings (sensitivity 94 percent), and absent in 3, all with negative Doppler findings. Pulmonary insufficiency was found on pulsed Doppler study in 47 of 91 patients, 3 of whom (all after pulmonary valvotomy) had clinical evidence of this lesion. Increased right ventricular systolic pressure (greater than 35 mm Hg) was noted more often in patients with (55 of 61 or 90 percent) than in those without (22 of 59 or 37 percent) tricuspid insufficiency (p <0.01). Pulmonary arterial mean pressure was elevated (22 mm Hg or less) more often in patients with (38 of 43 or 88 percent) than in those without (24 of 64 or 38 percent) pulmonary insufficiency (p <0.01).Thus, pulsed Doppler echocardiography appears to be an accurate noninvasive technique for detection of right-sided valve regurgitation. The absence of diagnostic physical findings in many of the patients indicates that the hemodynamic severity of the Doppler-detected valve insufficiency was probably insignificant. However, because of its high incidence rate (87 percent) and association with pulmonary hypertension (87 percent), pulsed Doppler detection of tricuspid or pulmonary insufficiency, or both (in the absence of pulmonary stenosis) was found superior to M mode echocardiographic measurements (right ventricular size, pulmonary valve motion) in the prediction of pulmonary hypertension.     

The effects of valvular regurgitation on thermodilution ejection fraction measurements.

Through the use of thermodilution principles and rapid response thermistors, it is now possible to measure right ventricular ejection fractions serially in patients. However, to our knowledge, the extent to which tricuspid regurgitation affects the accuracy of thermodilution ejection fraction measurements has not been quantified. The purpose of this study was to compare actual and thermodilution ejection fraction measurements in an in vitro model of tricuspid regurgitation over a wide range of ejection fractions. Stepwise perforation of the inlet valve resulted in regurgitant fractions ranging from 4 to 40 percent. At each increment of inlet valve regurgitation, triplicate sets of thermodilution (EFthermo) ejection fraction measurements were obtained and compared with actual ejection fractions (EFactual). The mean difference between EFactual and EFthermo significantly increased with 8 percent regurgitation and significantly increased with greater increments of inlet valve regurgitation. EFthermo consistently underestimated EFactual over the entire range of regurgitant values. Linear regression analysis revealed a significant correlation between EFactual and EFthermo for all degrees of regurgitation; however, the correlation coefficient significantly declined from control valves with 13 percent regurgitation and declined further with 33 percent regurgitation. Qualitative classification of the inlet valve regurgitation into mild, moderate, and severe regurgitation was performed using pulsed Doppler echocardiography. Mild inlet valve regurgitation resulted in a significantly increased difference between EFactual and EFthermo from control values. A significant increase in the difference between EFactual and EFthermo was observed with both moderate and severe regurgitation. In summary, thermodilution underestimated actual ejection fraction in a direct linear relationship to the degree of inlet valve regurgitation. Thus, in the presence of tricuspid regurgitation, this method may still be useful in serially measuring changes in right ventricular ejection fraction.     

Doppler mapping of postoperative left atrioventricular valve regurgitation

Left atrioventricular valve regurgitation often occurs as a postoperative hemodynamic complication from repair of an atrioventricular septal defect. In this study, cross-sectional two-dimensional Doppler flow mapping of the left atrium was used to quantify postoperative regurgitant flow in 29 patients. Its severity and location was related to the shape of the three leaflets of the left component of the atrioventricular valve, especially to the size of the mural leaflet. To identify which leaflet configuration was likely to cause regurgitation, the position of the leaflets was obtained from the parasternal short-axis view and the angular size of the mural leaflet expressed in degrees of an arc. Doppler mapping was performed in the apical four-chamber and the parasternal long-axis views, dividing the left atrium in nine squares in each. Regurgitation was defined as a jetlike systolic downstroke of the Doppler frequency shift in early systole. The angular size of the mural leaflet varied from 38 to 144 degrees (mean 86 +/- 36 SD). Massive regurgitation (six to nine sites) was encountered in seven patients, five with a mural leaflet size of over 110 degrees, one with mural leaflet size between 70 and 110 degrees, and one with a mural leaflet size of under 70 degrees. No or minimal regurgitation was encountered in 10 patients, three having a mural leaflet size of 70 to 110 degrees and seven with a mural leaflet size of less than 70 degrees. These data suggest that massive regurgitation is encountered in patients with large mural leaflets, whereas patients with smaller mural leaflets tend to have no or mild regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effective aortic regurgitant orifice area: description of a method based on the conservation of mass

The natural history of aortic regurgitation is incompletely understood in part because of the lack of a simple method to estimate the defect size. A method of determining the effective regurgitant orifice area that combines Doppler catheter and Doppler echocardiographic techniques and is based on the principle of conservation of mass (the continuity equation) is described. To validate the application of the Doppler catheter system for measuring regurgitant supravalvular diastolic flow, an in vitro model of retrograde aortic flow was used. These studies indicated that measurements of supravalvular retrograde velocity with the Doppler catheter accurately reflect retrograde diastolic velocity when the aorta is less than 4.8 cm in diameter. Twenty-three patients undergoing cardiac catheterization were studied; 20 of these patients had aortic regurgitation. Retrograde supravalvular diastolic velocity was determined from a Doppler catheter positioned above the aortic valve. The effective regurgitant orifice area was calculated with use of the Doppler catheter-derived regurgitant volume and mean transvalvular diastolic velocity as determined by either catheterization or continuous wave Doppler echocardiography. The catheterization-derived regurgitant orifice area increased with the angiographic grade of as follows: 1+ (0.04 to 0.10 cm2), 2+ (0.15 to 0.49 cm2), 3+ (0.29 to 1.11 cm2) and 4+ (1.24 to 1.33 cm2). By combining Doppler catheter, echocardiographic and cardiac catheterization techniques, the effective aortic regurgitant orifice area may be estimated; this hydrodynamic area correlates with grading by supravalvular aortography. Calculation of this area provides a quantitative alternative to aortography for estimating the severity of aortic regurgitation but should be used with caution in patients with a markedly dilated aorta.     

Detection and evaluation of tricuspid regurgitation using a real-time, two-dimensional, color-coded, Doppler flow imaging system: comparison with contrast two-dimensional echocardiography and right ventriculography

To detect and evaluate regurgitant flow in tricuspid regurgitation (TR) with a newly developed, realtime, 2-dimensional (2-D), color-coded, Doppler flow imaging system (Doppler 2-D echo), 27 patients (18 with suspected TR and 9 normal subjects) were examined and the findings were compared with those obtained using contrast 2-D echocardiography (contrast 2-D echo) and right ventriculography. In 16 of 18 patients with suspected TR, Doppler 2-D echo easily visualized the color-coded regurgitant flow in the right atrium and estimated the severity of TR from the distance of the visible TR jet. On the basis of the QRS synchronized appearance of contrast in the inferior vena cava by the subxiphoid approach or of the negative contrast effect above the tricuspid valve just after the contrast entered the right ventricle with its subsequent back-and-forth movements across the tricuspid valve, Doppler 2-D echo was more sensitive and specific in detecting TR (100% and 100%) than contrast 2-D echo (75% and 82% in the subxiphoid view, 56% and 100% in the 4-chamber view) when the fast Fourier transformation frequency analysis was used as the standard of TR, and it was more sensitive in detecting TR (85%) than contrast 2-D echo (69% in the subxiphoid approach, 46% in the 4-chamber view) when right ventriculography was used as the standard of TR. Additionally, the severity of TR as shown by Doppler 2-D echo correlated fairly well with that shown by right ventriculography. Thus, Doppler 2-D echo is clinically useful for detecting and evaluating TR.     

Aortic valve prolapse with aortic regurgitation assessed by Doppler color-flow echocardiography.

The incidence of and the Doppler color-flow echocardiographic characteristics of aortic valve prolapse with nonrheumatic aortic regurgitation were examined. Aortic valve prolapse was observed in 21 of 243 patients (15 men and 6 women) with aortic regurgitation as detected by Doppler color-flow echocardiography (rheumatic, 112; nonrheumatic, 131) in 1247 consecutive patients. Patients with aortic valve prolapse included three patients with essential hypertension and one with annuloaortic ectasia. The remaining 17 patients (7% of those with aortic regurgitation) had no other associated cardiovascular disease (idiopathic aortic valve prolapse). Prolapse of the mitral or the tricuspid valve or both was associated with aortic valve prolapse in seven patients. Aortic regurgitation jet was markedly deviated from the axis of left ventricular outflow tract toward the anterior mitral leaflet or the interventricular septum in 17 of 21 (81%) patients with aortic valve prolapse, whereas 28 of 110 (25%) patients with nonrheumatic aortic regurgitation without prolapse and 17 of 112 (15%) patients with rheumatic aortic regurgitation without prolapse showed the deviation of regurgitant jet (p < 0.001). In conclusion, idiopathic aortic valve prolapse is one of the significant causes of aortic regurgitation, and a marked deviation of regurgitant jet is a characteristic Doppler color-flow echocardiographic finding of aortic regurgitation that results from aortic valve prolapse.