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Measures of AS s everity obtained by Doppler-echocardiography Units

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A merican So ciety of Ech o card io g rap h y

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H m n & Ci rcul ari un Ul t rasound Specialists

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Evaiudion of Prosthetic Vllhrn with Echocardiography and Dapplor Uiimmmnd

Adapied from Zughbi WA. Chambers JB, Dumesnrl JG, Foster E, Gottdiener JS. Grayburn PA, Khandheria BK, Levine RA, Marx GFI, Miiief FA, Nakatani S, Ouinones MA, Fiakowski H, Rodriguez LL, Swamrnathan M, WaggonerAD. Weissman NJ, Zabalgoiiia M, Recommendations for Evaluation oi Prosthetic Valves with Echocardiography and Doppler Ultrasound, J Am Soc Echocardxogr 2009 Sept. 22(9) 975-1014 This ASE guideline document was e ndor se d by the Arriencan Coliege ol Cardiology Foundation, Amencan Heart Association, European Association orEchocardiography. a registered branch oi European Society of Cardioiogy, Canadian Socieiy oi Echocardiography, an d J ap an es e Society oi Echocardiography.

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H e m ii c m u i m r w i u i rram u n d s p e f r i m s

Clinical information

Imaging of the valve

Doppler echocardiography of the valve Contour of the jet velocity signal Peak velocity and mean gradient Velocity-time integral (VTI) of the jet Doppler velocity index (DVI) Pressure half-time (PHT) in mitral and tricuspid valves Effective orifice area (EOA) Presence, location, and severity v3;; of regurgitation with previous Comparison of above parameters 55,: Comparison helpful in suspected valvular post-operative study, dysfunction Qwhen available

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specificity for normality or abnormality is seen il the majority ol the parameters listed are normal or abnormal, respectively. WSlightly higher cut-offs are seen in some bioprosthetic valves; these parameters are also abnormal in the presence of signiicant prosthetic mitral regurgitation. /

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-

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Peak velocity through the prosthesis > 3 rn/s, or > 2 mls through a homograft

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3

studies

Impaired RV function or elevated RVsystolic pressure

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H ear t Alt Circulation Ul l rasound Sp eci al i s t s

Guidelines for t h e Echocardiographic Assessment o f t h e Right Heart in Adults

Adapted lr om , Fiudski LG Lai WW. Afilalo J. Hua L Haridscriumaolier MD. Charidrasekarari K. Solomon S D , Louie EK. Schiller NB Guidelines ior the Echocardiograptirc Assessment ol the Right Heart in Adults A Report from the American Society ol Echocardiography J Arri Soc Echocardiogr 2 0 i 0 ; 2 3 ' 6 8 5 -7 1 3 .

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Poster ordering information an d lull text of ASE guideline d o c u m e n ts available at: www.asecho.org/guidelines The information on these pages doe s riot constitute the oiierlrig of medical advice by ASE. and should not be used as the sole basis to make medical practice decisions. illustration e` Copyright 2010 The American Society oi Echocardiography by me dmovie c om Design and

Wwwasecho ‘"9

Guidelines for the Echocaidiographic Assessment o fth e Right Heart in Adults

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Variable

Abnormal

A. RV Basal (RVD1)

> 4.2

cm

RV Mid (RVD2)

>

RV Longitudinal (RVD3)

> 8.6 cm

3.5 cm

B. RVOT PLAX proximal

>

3.3 cm

C, RVOT PSAX distal

>

2.7 cm

D. RV Wall T hicknes s

>

0.5 cm

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Tracing of the right atrium (RA) is performed from the plane of the tricuspid annulus (TA), along the interatrial septum (IAS), superior and antero-lateral walls of the RA. The RA major dimension is measured from the TA center to the superior RA wall, and the RA minor dimension is measured from the anterolateral wall to the IAS, as indicated by the yellow

Inferior vena cava (IVC) view. Measurement of the IVC. The diameter (solid line) is measured perpendicular to the long axis of the IVC at end expiration, just proximal to the junction of the hepatic veins that lie approximately 0.5-3.0 cm proximal to the ostium of the right atrium (RA).

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Abnormal

RA Major Dimension

>5.3 cm

RA Minor Dimension

>4.4 cm

RA End-Syslolic Area

>18 cm?

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TCO = Time from *closure to opening of tricuspid valve ET = Ejection time ICT = lsovolumetric contraction time IRT = Isovolumetric relaxation time ED = End-diastole ES = End-systole RVMPI = Right ventricular myocardial performance index

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Abnormal

Variable

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<1_6 cm

B_ Pulsed Doppler peak velocity at the annulus (S')

<10 cm/s

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He/zr1& Ci rcul al i on Ultrasound Sp eci al i s t s

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E c h o c a r d io g r a p h y

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Putnam Right Atrial on

Estimation of RApressure Variable IVC diameter

the basis of IVC diameter and collapse

Normal Intennediate 5-10 (0-5 (3) mmHg) ( (8) mmHg) $2.1

cm

S 2.1

>50%

Collapse with sniff

High (15 mmHg)

cm >2.1 cm

<50%

> 2_1 Cm

>50%

<

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Secondary indices of elevated RA

predominance in HV " Ranges are provided for low and intermediate categories; however, for simplicity, a mid-range value of 3 mmHg for “normal” and 8 mmHg for “intermediate” are suggested. Intermediate (8 mmHg) RApressures may be downgraded to normal (3 mmHg) if no secondary indices of elevated RA pressure are present, upgraded to high ifminimal collapse with sniff (<35%) and secondary indioes of elevated RApressure are present, or left as 8 mmHg if uncertain. lVC = Inferior vena cava; RA=Right atrium; HV= Hepatic veins

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Guidelines lor the Echocardiographic Assessment of the Right Heart in Adults

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Valve structure and motion Mechanical or Bioprosthetic Structural parameters

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Abnormal iv

Abnormal ~v

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Doppler Parameters (Qualitative or Semi-

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Intermediate Intermediate

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30 59 ml/beat 30 50%

Large, (2 65%) Dense Steep

(<200) Greatly increased Prominent,

holodiastolic

3 60 ml/beat 3 50%

WAbnomiel mecnenloel valves; eg, immobile oocluder (valvular regurgitation), denisoenoe or rocking (paravslvular regurgitation); Abnormal biological valves: eg. Leatlet thickening or pmlapee (vat/utar), dehisoenoe or rocking (pafavalvular regurgitation)

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applicable to oentraljets and is less accurate in eccentric jets; Nyquist limit ot 50-60 cmls lrmuenosd § by LVcompliance GtApplies to chronic, late postoperative ARIn the absence of other etlologles CW= continuous wave Doppler; LV= tell ventricle; LVO =left ventricular outflow tract; PHT = pressure halt-lime; PW= pulsed weve Doppler.

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Normal Normal or dilated Abnormal Y Usually normal

Prosthetic valve ra Doppler Parameters

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Mild

`

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;

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Usually dilated

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incomplete or faint

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Usually parabolic SY°‘°**° M

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< 0.3 < 30 < 30 < 0.20

RyVol(ml/beat)

_A

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EROA (cmz)

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Early peaking triangular

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Intermediate

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Am e r ic a n S ociety of


ma n a ci rcuzfm an ultra sound s p m a l z m

f/ f W ff/

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hmmthlllnnwlllnns Values Normal Doppler Echocardiograploy Mitral alves for Selected Prosthetic Valve

Sin

23 sji-m
Curbomodics Bileafiei

cnrwmar- sauna Stented biopmsfhesis

Clrpomior- Edwards

partcardlal Stented Bioplusthesis

Nlncock I or not lpsslfl sd

Stenled blopmsihesis Mldtronic- Hall Ti/ring dim:

Ihdtronk: lntlm Porclm Slsnted biopruslhssis

Omniclrbon /?§~;'?{"»:'I=>,‘[

Tilting disc

`/?f<"i§~"`<"3fi

'f

;,,.,,~;/,

SI Judn llldical Bileallot

//'Q'

/

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Starr- Edwards Caged ball

25 27

29 31 23 25 27

29 31 33 27 29 31 33 27 29 31 33 27 29 31 33 27

M un gradient (mmHg) 5.0 5.57 2 2.3 4.53 2 2.2 4.26 2 1.6 4.9 2 1.6

31

33 35 23 25 27

29 31 33 23 25 27 29 31 26

1.9

Pr assun lull-time (ms)

Effective orlflco : r u (cm*)

2.92 0.8 2. 92 0.75 2 .3 2 0.4 2,821.14

1 .8 2 0 .3

1.72 0_4 1 6 2 0 .3

17 2 0.3

3.6 2 0.6

1 .9 2 0 .1 1 .3 2 0 .1

3.46 2 1.03 3,39 2 0.97

1.61 20. 3 1. 52203

12627 9328 89220 88217

3.32 2 0.87

1 .6 1 2 0 2 9

92224

4.B 2 2 .5

1. 5202

93212

8.0 2 2.0 4.7 2 2.0 4.4 2 2.0

1 .7 2 0 .3

98228

1. 752027 1.5-120.15

92219

6.0 2 3.0

3.6 5.25 2 2.36 4, 05 2 0.83 1.0 5.0 2 2.0 2.46 2 0.79 4.86 2 1.69 3.87 2 2.0

3.5 2 0.51 4.2 2 1.44 4.0 2 1.3 3.2 2 1 , 7 7 8.0 6.05 2 1.81

4.89 2

2.05

4.93 2 2 16 4.18 2 1 .4 4,0 2 2 0

4.0 2.5 2 1.0 5.0 2 1.82 4.15 2 1.8 4.46 2 2.22 10 0 7.0 2 2.75 6.99 at 2.5 5.08 2 2.5

5.0

92214 93212 100

1.6 1.67 2 0.3

110215

1.53 2 0,1 0.0

90211 80

1.3 20. 5

1.4 1 .5 7 2 0 1 1. 452012

29

31 29

P u k voloclty (mls)

115220

1. 5202

95217

1. 6202

90212 78 69215 77217

1,920.2

1. 62012 1,620.26

1 .4 2 0 2 4

1. 3205 1.77 2 0.24 1.63 2 0.36 1.56 2 0.27 1.3 2 0 23

102215

105233 120240 134231

160

1.5 13421. 12 1.61 20.29 1. 572029 15920. 33

75210

1 7 2 0 .3 1 7 2 0 .3

125225 110225

7524 85210 74213

1.0 1.35 2 0.17 1.67 2 0.17 1.75 2 0.24 2.03 2 0.32 1.4 1.9 2 0.57 1 65 2 0.4 1.98 2 0.4 2.6

P399 4016

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Echocardiographic and Doppler Parameters Used in Grading Severity of Prosthetic Tricuspid Valve Regurgitation Parameters

Mild Usually normal

r

t t

Severe

Moderate Abnormal or valve dehisoence

Qggizggglgr

Jet area by color Doppler - <5 central jets only (cm2) Not defined VC Width Q

5 10

MO

Jet density and contour by CW Doppler

Dense, variable

Valve structure

(Cm)

Incomplete or faint, parabolic Normal or Doppler systolic hepatic flow bmmed Normal* RA/RV/IVC

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but

contour

>

Valve \

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0.7

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1UI''C

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H I

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Markedly dilated

' If no other reason ior dilatation Q For a valvular TRjet, extrapolated from native TR; unknown cuvofls for paravalvular TR, RA= right atrium; RV= right ventricle; IVC = inferior vena cava; VC = vena contracts,

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