Pediatric Cardiology

https://doi.org/10.1007/s00246-018-2045-y

ORIGINAL ARTICLE

Utility of Doppler Echocardiography to Estimate the Severity

of Pulmonary Valve Regurgitation Fraction in Patients with Repaired
Tetralogy of Fallot
Neha Bansal1   · Pooja Gupta1 · Aparna Joshi2 · J. Michael Zerin2 · Sanjeev Aggarwal1

Received: 26 July 2018 / Accepted: 9 December 2018

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Background  In patients with repaired Tetralogy of Fallot (rTOF), pulmonary regurgitation (PR) leads to significant morbidity.
Cardiac magnetic resonance imaging (CMR) is the gold standard to assess severity of PR in rTOF patients. We compared
Doppler echocardiography derived indices of PR with CMR to find the best predictive parameter for hemodynamically
significant (hs) PR.
Methods  This is a retrospective analysis of echocardiogram and CMR measurements. Doppler indices obtained included:
PR deceleration slope, pressure half time (PHT) and PR index. Receiver operating characteristic curve analysis was used
to optimize the sensitivity and specificity of selected variables in predicting hsPR. Inter-observer variability of the Doppler
parameters was assessed in a random sample of 25 Doppler spectral recordings.
Results  Our cohort (n = 96) comprised of 52 (54.2%) males. The mean (SD) age at CMR was 22.9 (10.3) years. 83.4%
patients underwent complete repair with transannular patch. 78 (81%) patients had hsPR as defined by CMR PR > 20%.
Doppler parameters with the values of; PR index of < 0.86, PR deceleration slope of > 375 cm/s2 and a PHT < 130 ms,
demonstrated high sensitivity (93%) and high negative predictive values (98–99%). All the Doppler indices demonstrated
minimal inter-observer variability (PHT = 0.9, 95% CI 0.69–0.97; PRi = 0.95, 95%CI 0.83–0.98).
Conclusion  Our data, with its high negative predictive values, show that Doppler derived echocardiography indices have an
ability to rule out hsPR, as measured by CMR. PHT, PR index and deceleration slope correlate with hsPR and can be used
as screening tools for further testing.

Keywords  Tetralogy of Fallot · Pulmonary regurgitation · Cardiac magnetic resonance · Doppler echocardiography

Introduction advances in surgical techniques and postoperative care,

Tetralogy of Fallot (TOF) is the most common cyanotic con-
genital heart defect with a reported incidence of approxi-
mately 1 in 2518 births in the United States [1]. Surgical
repair of TOF involves reconstruction of the right ventricular
outflow tract (RVOT) with or without a transannular patch
and closure of the ventricular septal defect (VSD) [2]. With
* Neha Bansal
nehban@gmail.com
1 are suggested as indications for pulmonary valve replace-
Division of Cardiology, Carman and Ann Adams
Department of Pediatrics, Children’s Hospital of Michigan,
3901 Beaubien Blvd, Detroit, MI 48201‑2119, USA
2
Department of Radiology, Wayne State University School
of Medicine, Detroit, MI, USA
patients with repaired TOF (rTOF) now have excellent long-
term survival outcomes [3, 4]. However, morbidity is still
high and due to free pulmonary regurgitation (PR) from the
transannular patch, progressive RV dilation occurs in this
population. The free PR, well tolerated in early childhood,
is associated with long-term complications in adulthood [5]
such as RV dysfunction [6, 7], ventricular arrhythmias [8],
exercise limitations [9, 10] and sudden cardiac death [11].
Hemodynamically significant PR (hsPR) defined as PR frac-
tion (PRF) > 20%, together with arrhythmias, and other car-
diac symptoms and/or moderate to severe RV enlargement,
ment (PVR) [12, 13]. Thus, accurate assessment of PR in
patients with rTOF is essential for timely interventions.
Cardiac magnetic resonance imaging (CMR) is the cur-
rent gold standard imaging modality to assess the RV end

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diastolic (RVEDV) and end systolic volumes (RVESV) as
well as severity of PR in patients with rTOF [12, 14, 15].
CMR is routinely performed early in the second decade of
life to evaluate patients for elective PVR [16]. However,
CMR remains time consuming, sometimes requiring proce-
dural anesthesia and is still not widely accessible. Echocar-
diography is a convenient bedside imaging modality that can
be used with greater ease and convenience in the follow-up
of patients with rTOF. Echocardiographic continuous and
pulse wave Doppler of the RVOT have been utilized in some
small previous studies as follow-up measures for patients
with rTOF [17–19]. Doppler parameters such as pulmonary
pressure half time (PHT), pulmonary regurgitation index
(PRi) and diastolic to systolic time-velocity integral ratio
(DSTVI) have been separately evaluated in this popula-
tion with conflicting results [17, 18, 20]. The performance
of multiple Doppler echocardiographic parameters in the
assessment of severity of PR in comparison with gold stand-
ard MRI during follow-up of rTOF has not been rigorously
evaluated. The purpose of our study was to compare the vari-
ous Doppler echocardiography derived indices of PR with
the CMR derived PR in patients with rTOF [17]. We also
evaluated the utility of Doppler echocardiographic param-
eters for predicting hsPR.
Methods
Patient Population
This was a retrospective study of patients with rTOF cared
for at a single tertiary care center. Patients with rTOF who
underwent an echocardiogram and CMR within 3 months
of each other between January 2009 and April 2017 were
included. The Institutional Review Board at Wayne State
University and Detroit Medical Center approved the study.
Patients with incomplete data, artifact on CMR compromis-
ing PR fraction analysis, interim interventions or changes in
clinical status between the two imaging studies, poor echo-
cardiographic windows and more than mild tricuspid regur-
gitation were excluded from the study. Patients with pros-
thetic mitral or aortic valves, significant residual shunts, or
any additional congenital heart lesions were also excluded.
Data collected included demographic details such as patient
age, sex, race, clinical characteristics such as underlying
anatomy, details of the surgical repair, and the results of the
CMR as well as echocardiograms.
CMR Protocol
CMR was performed using 1.5 T scanners (GE Medical Sys-
tems). A stack of short axis cine images was obtained using
breath-hold Steady State Free Precision (SSFP) method. The
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Pediatric Cardiology
images were analyzed offline to obtain RVEDV and RVESV.
The endocardial borders were manually drawn on all RV
short-axis images by means of the previously validated soft-
ware (Mass, MEDIS, The Netherlands). The RVEDV and
RVESV normalized for the body surface area (ml/m2), were
then calculated and the RV ejection fraction was derived.
The cine phase velocity pulse sequence was used to measure
the PRF. RVEDV indexed (RVEDVi) to body surface area
more than or equal to 150 ml/m2 was taken as significant
RV dilation [13]. Similar to previously published data, we
considered PRF > 20% as hemodynamically significant [17].
Echocardiographic Measurements
All echocardiograms were performed using Philips IE33 and
stored in DICOM for offline analysis. All measurements at
the pulmonary valve were made in a standard parasternal
short-axis view and for the aortic valve, the apical five-
chamber view was used. A single experienced cardiologist
(S.A) blinded to the CMR data performed echocardiographic
measurements. An average of two measurements for each
variable was taken for analysis. Doppler indices obtained
were peak PR velocity, deceleration slope, total diastolic
time, PR duration, velocity–time integral (VTI) to assess the
pulmonary and aortic forward flow (systolic VTI) as well as
regurgitation flow (diastolic VTI) (Fig. 1).
The regurgitant velocity profile demonstrates the pressure
gradient between the main pulmonary artery and the RV
during diastole [21]. An indicator of the severity of the PR is
how quickly the pressure equalizes between the main pulmo-
nary artery and the RV during diastole. The higher the pres-
sure difference, the higher the velocity profile and shorter
the regurgitation time. Thus, in case of mild PR, the pres-
sure equalizes slowly and the regurgitant flow may occupy
almost all of the diastolic duration. Another measure used
for quantitative assessment of PR severity is the slope of the
deceleration velocity of the regurgitant jet. As the PR gradi-
ent increases, the pressure both in the main PA and proximal
to the pulmonary valve equilibrates faster, with a steeper
slope on the PR spectral Doppler tracing [19]. A derived
measure of the slope is the pressure half time (PHT), the
time (in milliseconds) taken to reach half of the transvalvular
pressure gradient, thus identifying the rate of deceleration.
The PHT was determined using the continuous wave Dop-
pler tracing of the PR jet as described previously [17]. The
ratio between the regurgitant (diastolic) velocity–time inte-
gral to the antegrade (systolic) velocity–time integral, across
the main pulmonary artery called diastolic to systolic VTI
(DSTVI), as described previously was also calculated [18].
PR duration was measured from its onset in early diastole
to the end of the regurgitant Doppler signal. The total dias-
tolic time was measured from the end of forward pulmonary
flow (coinciding with the onset of the retrograde PR flow)
Pediatric Cardiology
Fig. 1  Continuous wave Doppler in the main pulmonary artery in a
patient with repaired Tetralogy of Fallot with pulmonary regurgita-
tion. a Doppler tracing of a patient with mild regurgitation with a
gentler slope. b Doppler tracing of a patient with severe regurgitation
with a steeper slope
to the beginning of the next forward pulmonary flow curve
[20]. PR index (PRi), calculated as the ratio of the PR time
to the total diastolic time, was measured from continuous
pulse-wave spectral Doppler signals in the main pulmonary
artery [19, 20]. We also derived a new echocardiographic
parameter to define PR fraction called PR fraction measured
via VTI (PRFVTI) as a ratio of the difference in the pulmo-
nary valve systolic VTI and aortic valve systolic VTI to the
pulmonary valve systolic VTI (pulmonary VTI − aortic VTI/
pulmonary VTI). The rationale for this parameter was that
the difference in RV and LV cardiac output should be equal
to the PR amount in the absence of aortic regurgitation.
Statistical Analysis
Statistical analysis was performed using SPSS software
(Version 20, SPSS, Chicago, IL). Data were presented as
mean (SD) and number (%) for continuous and categorical
variables as appropriate. Categorical variables were com-
pared using the Chi square or Fisher exact tests and the Stu-
dent t test or Mann Whitney-U tests were used to compare
continuous characteristics between patients with PRF ≤ 20%
and PRF > 20% on CMR (hsPR). Receiver operating char-
acteristic (ROC) curve analysis was used to optimize the
sensitivity and specificity of selected variables in predict-
ing hsPR. Positive and negative predictive values were also
determined. Statistical significance was set at a p value of
< 0.05. A second reader (N.B.), blinded to clinical data as
well as the measurements by the first author, performed
repeat echo measurements in a random sample of 25 Dop-
pler spectral recordings. Similar to the first reader, each
measurement was performed in duplicate and the average
of both authors’ measurements were taken to perform the
inter-observer variability by using the intraclass correlation
coefficient (ICC).
Results
A total of 148 charts were reviewed and 96 patients were
included in the study. We excluded 44 patients whose CMR
and echocardiograms were performed more than 3 months
apart and eight patients who had incomplete Doppler data on
echocardiogram. None of our patients had additional lesions,
which could cause RV dilation such as tricuspid regurgita-
tion, atrial level shunts or residual hemodynamically sig-
nificant VSD. Baseline characteristics of all patients are
presented in Table 1. The mean age at the time of echocardi-
ogram was 22.9 ± 10.3 years [median 20.5 years IQR (15.8,
26.6), range 6–51 years], 52 (54.2%) patients were male and
60.4% were Caucasian. TOF was the primary diagnosis in
88.5% of our patients. Transannular patch was performed
as the primary surgical repair in 80 (83.4%) patients. In our
cohort, 17 (18%) patients had pulmonary valve replaced
prior to the CMR and echocardiograms. The mean ± SD
indexed RVEDV and RVESV was 152.04 ± 46.7 ml/m2 and
89.6 ± 35.1 ml/m2 respectively.
Our cohort was divided into two groups (Table 2): those
without PR (PRF ≤ 20%) (n = 16) and those with hsPR
(PRF > 20% on CMR) (n = 78). The demographic profile
including age, weight, gender distribution of the two groups
did not differ significantly. There was a statistically signifi-
cant difference in the RV dilation between the two groups
(p < 0.05). On evaluation of the Doppler indices, decelera-
tion slope, PHT, peak PR velocity, PRi and PR duration dif-
fered significantly between patients with and without hsPR
(p < 0.05).
We created  ROC curves for the significant Doppler
parameters of PHT, PRi and deceleration slope. PHT and
deceleration slope had areas under the curve (AUC) of 0.97,
while PRi had an AUC of 0.77 (Table 3). PHT, at a cutoff
value of 130 ms, had the highest negative predictive value
(NPV) of 98.6% for identification of hsPR. PRi at a cutoff
of 0.87 had a NPV of 98.2% where as the deceleration slope
at a cutoff of 375 cm/s2 had a NPV of 98.7%.
A linear regression analysis, conducted to examine the
significance of Doppler indices with the PR as a continuous
variable, demonstrated that PHT, PRi and deceleration slope
correlated well with PR as measured by CMR (p < 0.05)
(Fig. 2). However, DSVTI was not found to correlate statisti-
cally significantly with the PR fraction.
Using the intraclass coefficient correlation (ICC), all
the Doppler indices were reproducible with minimal inter-
observer variability (p = 0.001) (Table 4).
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Table 1  Demographic, clinical, Demographic characteristics (N = 96)
echocardiographic and CMR
characteristics of the cohort of Age (years)
patients with Tetralogy of Fallot
Height (cm)
Weight (kg)
BSA ­(m2)
Male gender
Race
 • Caucasian
 • African American
 • Others
Primary cardiac diagnosis
 • TOF
 • PA, VSD
 • TOF with AV canal
 • TOF with absent pulmonary valve
Surgical repair
 • Trans-annular Patch
 • Valve sparing surgery
 • Conduit
BT shunt prior to complete repair
Pulmonary valve replacement prior to enrollment
CMR findings
 iRVEDV (ml/m2)
 iRVESV (ml/m2)
 RV EF (%)
 Pulmonary regurgitation fraction (%)
Echocardiographic measures
 Pressure half time (ms)
 Pulmonary Regurgitation Index
 Deceleration slope (cm/s2)
BSA body surface area, TOF Tetralogy of Fallot, PA pulmonary atresia, VSD ventricular septal defect, BT
blalock taussig, iRVEDV indexed right ventricular end diastolic volume, iRVESV indexed right ventricular
end systolic volume, AV atrio-ventricular
Discussion
Our study examines the utility of echocardiographic spec-
tral Doppler indices in the identification of hsPR on CMR
in patients with rTOF. CMR is currently the gold standard
in the measurement of ventricular volumes and PR sever-
ity in patients with rTOF [15, 19]. However, it is not uni-
versally available, time consuming and requires significant
expertise for accurate interpretation. Some patients might be
claustrophobic and may require sedation/anesthesia. Dop-
pler echocardiography is a widely used, easily available,
non-invasive technique for diagnosis and quantification of
valvular regurgitation. The visualization and quantification
of PR jet across the main pulmonary artery can be easily
performed via continuous or pulse wave Doppler. There-
fore, we explored the utility of multiple simple and accurate
Doppler indices for the identification of hsPR. We found
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Pediatric Cardiology
Mean ± SD (median; IQR) or n (%)
22.9 ± 10.3 (20.5; 15.8–26.6)
163.7 ± 14.2 (165; 157–173.5)
65.2 ± 21.9 (64.1; 50–80)
1.69 ± 0.32 (1.72; 1.5–1.9)
52 (54.2)
58 (60.4)
32 (33.3)
6 (6.3)
85 (88.5)
4 (4.2)
4 (4.2)
3 (3.1)
80 (83.4)
9 (9.4)
5 (5.2)
22 (22.9)
17 (17.7)
152.04 ± 46.7
89.6 ± 35.1
41.59 ± 8.2
37.4 ± 15.3
133.6 ± 88 (111.5; 86.3–136.5)
0.82 ± 0.18 (0.83; 0.69–1)
514.4 ± 196 (528.7; 410–645.3)
that three Doppler indices, PHT, PRi and deceleration slope,
had excellent sensitivities and negative predictive values in
identifying hsPR.
Similar to previous studies, we found that PRF > 20%
on CMR was associated with significantly dilated RV [17].
Therefore, we used PRF > 20% on CMR as a surrogate
marker of significantly dilated RV to assess the validity of
the Doppler indices for screening purposes.
We found a cut off of 375 cm/s 2 for the deceleration
slope as a reliable marker for hsPR with the best negative
predictive value and specificity. Similar to deceleration
slope, PHT measurements depend significantly on the
dynamic transvalvular pressure gradients and not the total
volume of the regurgitant flow [19]. PHT < 100 millisec-
onds in a small study of 34 adult patients with repaired
TOF was shown to identify hsPR [17]. Our cutoff value of
130 ms had superior (93% vs. 76%) sensitivity but lower
Pediatric Cardiology

Table 2  Comparison between Demographic and echo parameters PR ≤ 20% PR > 20% p value

patients with PR ≤ 20% and Mean ± SD or n (%) (N = 16) (N = 78)
hemodynamically significant
PR > 20% Age (years) 22.3 ± 10.3 23.2 ± 10.2 0.75
Height (cm) 164.08 ± 18.9 164.04 ± 12.6 0.99
Weight (kg) 71.1 ± 24.95 64.5 ± 21 0.28
Male gender 10 (62.5) 40 (51.3) 0.41
Trans-annular patch 8 (50) 69 (88.5) 0.001*
Previous BT shunt 5 (31) 17 (22) 0.61
CMR findings
 iRVEDV (ml/m2) 119.1 ± 32.5 161.1 ± 44.3 0.0001*
 iRVESV (ml/m2) 70.4 ± 27 94.6 ± 35.2 0.005*
 RV EF (%) 41.5 ± 10 41.5 ± 7.9 0.99
 iLVEDV (ml/m2) 85.4 ± 19.5 75.2 ± 20.6 0.99
 iLVESV (ml/m2) 36.4 ± 13.9 33.96 ± 12.7 0.49
 LV EF (%) 58 ± 9.6 55.1 ± 9.6 0.28
 Heart rate (bpm) 64.9 ± 9.6 70.0 ± 11.5 0.09
Echocardiographic findings
 Deceleration slope (cm/s2) 216.3 ± 115.8 573.7 ± 150.97 0.0001*
 Peak pulmonary regurgitation velocity (mm/s) 157.2 ± 65.5 198.7 ± 35.6 0.001*
 Pressure half time (ms) 235.4 ± 64.4 113.44 ± 78.5 0.0001*
 Pulmonary diastolic duration (ms) 59.6 ± 14.7 53.5 ± 13.02 0.15
 Pulmonary regurgitation duration (ms) 55.8 ± 17.7 41.2 ± 8.2 0.007*
 Pulmonary regurgitation index 0.94 ± 0.17 0.79 ± 0.18 0.009*
 Pulmonary systolic VTI (cm) 44.5 ± 15.3 43.7 ± 14.2 0.85
 Pulmonary diastolic VTI (cm) 51.5 ± 21.8 44.3 ± 12.96 0.25
 Aortic systolic VTI (cm) 22.3 ± 4.7 21.96 ± 3.99 0.82
 DSVTI 1.19 ± 0.46 1.07 ± 0.28 0.33
 PRFVTI 0.54 ± 0.17 0.55 ± 0.18 0.93

iRVEDV indexed right ventricular end diastolic volume, iRVESV indexed right ventricular end systolic vol-
ume, VTI velocity time integral, DSVTI diastolic-systolic velocity time integral, PRFVTI pulmonary regur-
gitation fraction measured via VTI. Asterix (*) indicate statistically significant values

Table 3  Sensitivity, specificity, negative and positive predictive values of select Doppler indices at optimal cut off values derived from ROC
curves
Parameter and cut-off value ROC area under Sensitivity % (95% CI) Specificity % (95% CI) Positive predictive Negative predic-
the curve (95% CI) value % (95% CI) tive value % (95%
CI)

PHT 130 ms 0.97 (0.94–1.00) 93.3 (68.1–99.8) 87.5 (78.2–93.8) 58.3 (43.6–71.7) 98.6 (91.3–99.8)
PRi 0.87 0.77 (0.64–0.89) 92.9 (66.1–99.8) 68.4 (56.9–78.4) 34.2 (26.7–42.6) 98.2 (89.0–99.7)
Deceleration slope 375 cm/s2 0.97 (0.94–1.00) 93.3 (68.1–99.8) 94.9 (87.4–98.6) 77.8 (57.2–90.2) 98.7 (91.8–99.8)

CI confidence interval, PHT pressure half time, PRi Pulmonary Regurgitation Index

specificity (87 vs. 94%) as a marker of hsPR compared to
the previous cutoff of 100 ms. One explanation for differ-
ence in results may be due to difference in patient popula-
tion. In contrast to the previously mentioned study, which
exclusively included adult population, our cohort included
younger children as well. A higher cut off value for PHT
may be more inclusive at the expense of specificity but
will ensure that we will not miss any patients who may
need further imaging.
The PRi is a ratio of the duration of pulmonary regurgita-
tion to the total diastolic time across the pulmonary valve
and decreases with increasing severity of regurgitation [20].
This finding was corroborated in our study, as we found a
significantly shorter regurgitation time (p = 0.007) and thus,
a significantly smaller PRi (p = 0.009) in patients with hsPR.
Further analysis showed that a PRi < 0.86 demonstrated the
highest sensitivity and specificity for detecting hsPR. Li and
colleagues published their data in adults using a PRi cut off

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 Pediatric Cardiology

Fig. 2  Linear regression analysis, showing pressure half time (a), diastolic to systolic velocity time integral (DSVTI) does not correlate
Pulmonary Regurgitation Index (b) and deceleration slope (c) cor- with PR fraction as measured by cardiac magnetic resonance imaging
relating well with pulmonary regurgitation (PR) fraction. Ratio of (d)

Table 4  Intraclass correlation Intraclass cor- 95% confidence interval f value p value

coefficient of select Doppler relation
indices Lower bound Upper bound

PHT 0.913 0.695 0.970 15.636 0.001

PRi 0.951 0.830 0.983 27.091 0.001
Deceleration slope 0.896 0.733 0.959 10.503 0.001
DSVTI 0.848 0.618 0.940 6.421 0.001

PHT pressure half time, PRi Pulmonary Regurgitation Index, DSVTI diastolic-systolic velocity time inte-
gral

below 0.77 for identifying patients with PRF > 24.5% [20].
Our PRi cut off value of 0.86 has a negative predictive value
of 98% and thus likely reducing the number of false positives
as detected by this test.
A recent study by Mercer-Rosa et al. described a moder-
ate correlation (R = 0.60; p < 0.0001) of DSVTI with PRF
by CMR [18], which was further validated in a longitudi-
nal study (r = 0.62, p = 0.0001) by Bhat et al. [22]. Higher
values of DSVTI correlated with higher PRF. In our study,
we did not find a significant difference in DSVTI nor our
newly defined echocardiographic parameter PRFVTI (PRF
via VTI) between the two groups: with and without hsPR. It
is possible that we were unable to illustrate this difference
due to a small sample size. Another explanation could be
that we did not distinguish between moderate and severe PR.
Some other echocardiographic methods used in previous
studies to identify significant PR by color Doppler are: (A)
presence of diastolic flow reversal in the branch pulmonary
arteries, (B) width of the vena contracta of the PR jet com-
pared to the pulmonary valve annulus diameter or RVOT
size and (C) the PR index by M-mode echocardiography
(PRIME) [23]. We decided not to perform some of these

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Pediatric Cardiology
measurements, as the diastolic flow reversal is a subjective
measure, there are no standardized measures of the PR vena
contracta and technical limitation to measuring vena con-
tracta jet in cases of free PR. The M-mode at the pulmonary
artery level is not a part of our routine echocardiography
protocol and hence precluded the measurement of PRIME
retrospectively.
In our current study, we found three easily measure-
able and reliable Doppler indices for diagnosing signifi-
cant PR. All three have very high negative predictive value
with the following cutoff values: PRi < 0.86, deceleration
slope > 375 cm/s2 and PHT < 130 ms. We believe that these
echocardiographic parameters can be used routinely as a sur-
rogate of PRF on CMR in patients with rTOF. With their
high negative predictive values, these echo-based parameters
would allow quick and easy identification of patients with
rTOF who should be sent for a more involved and time con-
suming test such as CMR.
We recognize that these Doppler parameters cannot be
used independently in making decisions for surgical inter-
ventions in patients with rTOF but can act as an effective
screening tool particularly for younger patients who may
require sedation/anesthesia, may have contraindications for
CMR and patients with borderline RV dilation. CMR has
been shown to be superior to echo for accurate assessment
of ventricular volume and function, and RV volumes are
routinely used as indications for PVR. Important limitations
of the echocardiography include difficulties in visualizing
certain parts of the right heart because of restricted acoustic
windows and challenges in quantitative assessment of RV
size, function and valve regurgitation. Thus, echocardiog-
raphy is suboptimal for assessing RV volume and function.
Our study results certainly do not exclude the need for cross-
sectional imaging (CMR or CT), which are critical to man-
agement of patients with repaired TOF. As no single modal-
ity is perfect to evaluate the hemodynamic consequences
of TOF repair, a multimodality approach is recommended.
The utilization of Doppler indices may help delay the first
CMR study or even reduce the need for frequent CMR that
may be more practical and lead to judicious utilization of a
rare resource.
Our study had inherent limitations of a retrospective
study including incomplete data and poor image quality, and
eight such patients were excluded from the study. Our sam-
ple size was relatively small and the possibility of a selection
bias in this cohort cannot be excluded. Our sample cohort is
heterogeneous with some patients requiring prior BT shunt
and 17% with pulmonary valve replacement. While we
believe that this population adds to our knowledge, it’s not
a homogenous sample and may be considered a limitation
of our study. Doppler measurements can potentially overes-
timate severity of PR in patients with raised RV end-dias-
tolic pressure and we did not correlate echocardiographic
findings with the cardiac catheterization hemodynamic data.
Even though we only included those patients who had the
echocardiogram and the CMR within 3 months of each other
and charts were reviewed to confirm no significant interval
clinical changes, there is a small chance there were minor
hemodynamic differences between the two imaging studies
in terms of PR severity. In addition, the utilization of anes-
thesia for the CMR can alter the hemodynamincs. Further
longitudinal prospective studies are warranted in this popu-
lation for validation of these markers.
Conclusion
Our data, with its high negative predictive values, shows
that Doppler derived echocardiography indices have an abil-
ity to rule out hsPR, as measured by CMR. PHT < 130 ms,
PRi < 0.86 and deceleration slope > 375 cm/s2, correlate well
with hsPR as measured by CMR and provide the clinician
with a readily accessible and highly reproducible echocar-
diographic tool to follow patients with rTOF. With their high
negative predictive value, these echocardiographic indices
can be used as adjunct for further testing while avoiding such
testing in low risk patients.
Compliance with Ethical Standards 
Conflict of interest  All the authors have no conflicts of interest.
Informed Consent  This is a retrospective study and the need for
Informed consent was waived by the Institutional Review Board.
Research Involving Human and Animal Participants  This article does
not contain any studies with human participants performed by any of
the authors.
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