Quantitative assessment of aortic regurgitation by combined two-dimensional, continuous-wave and colour flow Doppler measurements.

The width of the regurgitant jet at the aortic valve plane, i.e. the core flow diameter, the ratio of the jet width to the left ventricular outflow diameter, the regurgitant volume and regurgitant fraction were determined using two-dimensional, continuous wave and colour flow Doppler echocardiography. The relationship between the non-invasive measurements and semiquantitative angiographic grading of the regurgitant flow (1 + to 4+) was examined in a primary group of 20 patients with chronic aortic regurgitation. Cut-off points for the non-invasive measurements were selected so as to separate patients with mild or moderate regurgitation (1+ or 2+) from patients with moderately severe or severe regurgitation (3+ or 4+). These cut-off points were prospectively applied in a new group of 35 patients with aortic regurgitation to predict the angiographic grading. Jet width correctly predicted the angiographic grading in 86% of cases, the ratio of the jet width to the outflow diameter in 83% of cases, the regurgitant volume in 86% of cases and the regurgitant fraction in 91% of cases. We conclude that the severity of aortic regurgitation as determined by angiographic grading can be estimated with reasonable accuracy by non-invasive techniques based on colour flow imaging.     

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.     

Assessment of aortic regurgitation severity by magnetic resonance imaging of the thoracic aorta

A new method of assessing the severity of aortic regurgitationseverity by magnetic resonance imaging has been developed. Twogroups were studied: 20 controls (age=58 ± 19 years)without valvular aortic disease, and 24 patients (age=62 ±13 years) with chronic aortic insufficiency evaluated by magneticresonance and aortic root cineangiography within 1 week of eachother. A magnetic resonance sequence (TR=35 mslTE=12 mslflipangle=20°/magnet=1.5 T) was acquired in a plane containingthe thoracic aorta. A transverse saturation band 30 mm widewas positioned 30–40 mm above the aortic valve. Aorticinsufficiency was graded, the importance of end-diastolic retrogrademovement in the saturation band in the descending aorta wasnoted. Magnetic resonance was also compared to Doppler echocardiographyin 20 patients. In the controls, we found that retrograde blood flow was absent(18/20) or mild (2/20). In contrast, the presence of markedretrograde movement in a saturation band across the thoracicaorta was always associated with severe aortic regurgitation(angiographic grade III or IV). This rapid method (imaging time less than 20 min) can be appliedin most patients with aortic regurgitation and is likely tobe helpful when echocardiography is not possible or gives inconclusiveresults.     

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 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.     

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.     

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.     

Relationship of aortic regurgitant velocity slope and pressure half-time to severity of aortic regurgitation under changing haemodynamic conditions

The slope and pressure half-time of the aortic regurgitant velocityspectrum have been used as non-invasive markers of regurgitantseverity. Recent in vitro and theoretical work, however, hassuggested a confounding effect of systemic vascular resistanceand left ventricular compliance on these parameters. To studythis situation in vivo, we have investigated the determinantsof the aortic regurgitant velocity profile in an animal modelof aortic regurgitation in which the regurgitation was inducedsurgically and in which the afterload was varied pharmacologically.Specifically, we examined the relationship of slope and pressurehalf-time of the aortic regurgitant velocity profile to theseverity of aortic regurgitation under varying conditions ofafterload using multilinear analysis. Slope varied directlywith regurgitant orifice area and inversely with systemic vascularresistance and both left ventricular and aortic compliance (allP<0.001). Pressure half-time related to these variables inthe opposite direction. When the regurgitant orifice was variablein size, slope related directly (P<0.001) and half-time inverselyto the severity of the aortic regurgitation (the clinicallyexpected response). In contrast, when the regurgitant orificearea was constant, slope varied inversely (P<0.001) and half-timevaried directly (P<0.07) with the severity of the aorticregurgitation. Following nitroprusside infusion, slope tendedto increase (P=0.08) and pressure half-time tended to shorten(P=0.08) despite a significant reduction in the regurgitantfraction (P=0.009). Similarly, following dopamine infusion,a significant increase in regurgitant fraction (P=0.01) wasassociated with a slight fall in aortic regurgitation slopeand a lengthening of the half-time. The conventionally anticipated alterations in aortic regurgitationvelocity slope and pressure half-time predict the change inthe severity of aortic regurgitation when this is varied bychange in the size of regurgitant orifice but are unreliablewhen this is altered by pharmacological manipulation of theafterload.     

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.     

Striking effect of left ventricular high filling pressure with mitral regurgitation on mitral annular velocity during early diastole. A study using colour M-mode tissue Doppler imaging.

AIMS: To evaluate the effect of considerably high left ventricular filling pressure with mitral regurgitation on mitral annular velocity during early diastole. SUBJECTS: Two hundred and forty-three patients who underwent cardiac catheterization for evaluation of chest pain. METHODS: Mitral annular velocity during early diastole was measured by colour M-mode tissue Doppler imaging. Patients were divided into the following three groups according to the cardiac catheterization data. Group A (n=147): patients having left ventricular relaxation time constant tau<46 ms and left ventricular end-systolic volume index <38 ml m(-2); group B (n=88): patients having tau>or=46 ms and/or end-systolic volume index >or=38 ml m(-2); group C (n=8): patients having mean pulmonary capillary wedge pressure >or=16 mmHg in addition to tau>or=46 ms and end-systolic volume index >or=38 ml m(-2). RESULTS: Mitral annular velocity during early diastole was significantly less in group B (4.8+/-1.4 cm s(-1)) than in group A (7.7+/-1.9 cm s(-1)). However, there was no significant difference between groups A and C (8.3+/-0.8 cm s(-1)). A transmitral E/A >1.0 was observed in 12/147 patients of group A, 10/88 of group B, and 8/8 of group C. The incidence of >or=Sellers' grade II mitral regurgitation was higher in group C than the others. CONCLUSIONS: A paradoxically faster mitral annular velocity during early diastole is found in patients having left ventricular dysfunction with moderate to severe mitral regurgitation and considerably high left ventricular filling pressure. Attention should be paid to an interpretation of mitral annular velocity during early diastole regarding left ventricular early diastolic performance in patients having mitral regurgitation with an E/A >1.0 in their transmitral flow.     

Systolic aortic regurgitation.

Aortic regurgitation is normally a diastolic phenomenon. Echocardiographic images of systolic aortic regurgitation in a patient with atrial fibrillation and heart failure are presented, and haemodynamic interpretation is provided.     

Color M-mode regurgitant flow propagation velocity: a new echocardiographic method for grading of mitral regurgitation

PURPOSE: The aim of this study was to evaluate the reliability of mitral regurgitation color M-mode regurgitant flow propagation velocity (RFPV) in grading mitral regurgitation (MR). METHODS: We prospectively examined 52 consecutive patients with grades of MR mild in 10 patients, moderate in 19 patients, and severe in 23 patients with quantitative pulse Doppler echocardiography. MR was evaluated by vena contracta diameter (VCD), regurgitant jet area (RJA), and RFPV. These qualitative and quantitative methods were compared with the pulsed Doppler quantitative flow measurements and concordance of these three methods was determined. RESULTS: The mean RFPV for mild, moderate, and severe MR were 26.4 +/- 7 cm/sec, 43.3 +/- 7 cm/sec, and 60.3 +/- 7.3 respectively (P < 0.001). RFPV is highly sensitive and moderately specific in differentiating mild and severe MR from other subgroups. Sensitivity and specificity were 92.1%-64.3% for mild and 100%-68.5% for severe MR, respectively. Significant correlation was observed between pulse Doppler quantitative grades, RFPV, VC, and RJA (P < 0.0001, r = 0.87; P < 0.0001, r = -0.84; P < 0.0001, r = 0.76, respectively). CONCLUSION: This results show that RFPV is a reliable and simple semiquantitative new method that can be used for determining severity of MR.     

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.     

多普勒组织显像技术在生理性肺动脉瓣反流研究中的应用

目的探讨多普勒组织显像（DTI）技术在生理性肺动脉瓣反流中的应用价值。方法采用DTI技术检测150例正常小儿三尖瓣、肺动脉瓣反流发生情况、反流速度以及肺动脉瓣根部运动速度;并根据反流速度估测肺动脉压。结果三尖瓣、肺动脉瓣生理性反流发生率为31．3％、18．0％,反流速度95％上限为243．3、143．1cm/s。肺动脉收缩压、舒张压95％上限为29．68、8．19mmHg。有肺动脉瓣反流的小儿其肺动脉瓣根部运动速度显著慢于无肺动脉瓣反流者。结论DTI技术判断生理性肺动脉瓣反流简便、易行;肺动脉瓣反流可能与肺动脉瓣关闭较慢有关。     

升主动脉瘤合并主动脉瓣关闭不全的外科治疗

目的：回顾性总结自１９９１年１２月至１９９９年５月期间,３３例升主动脉瘤伴主动脉瓣关闭不全外科治疗的经验。方法：３３例升主动脉瘤中,１例为真性动脉瘤。３２例为夹层动脉瘤。夹层动脉瘤按ＤｅＢａｋｅｙ分型法,Ｉ型８例,ＩＩ型２４例,均伴主动脉关闭不全,均行Ｂｅｎｔａｌｌ手术,１０例合并二、三尖瓣关闭不全,做二、三尖瓣整形手术。１例合并冠心病,做内乳动脉与前降支搭桥术,结果：手术死亡率为６．０％（２／３３）,２例分别死于感染性心内膜为和吻合不可控制性渗血,２例有严重脑部并发症,随访时间１～５５个月,远期死亡２例,均系错迷窒息死亡,其余２９例心功能明显改善,眩动脉瘤无复发。结论：（１）升主动脉瘤合并主动脉瓣关闭不全行Ｂｅｎｔａｌｌ手术,采用良好的心肌保护方法,注意吻合技术防止出血,可以取得良好的手术效果。（２）对Ｄ     

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.     

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.     

Quadricuspid aortic valve: a rare etiology of aortic regurgitation.

Quadricuspid aortic valve is a rare cause of aortic insufficiency. We report two unusual cases of this valvular pathology associated with a dilatation of the aortic root. The mechanism leading to this valve incompetence is incompletely understood and is discussed in regard to these cases.