VALVULAR

REGURGITATION:

Can We Do Better
than Color Doppler?
HAMED OEMAR
Introduction
 Echocardiography has become the primary non-
invasive imaging different echo modalities [M-
mode, Doppler, 2-DE] method for the evaluation of
valvular regurgitation.
 It provides detailed anatomic and functional
information and mechanism.
 Doppler echocardiography not only detects the
presence of regurgitation, but also permits to
understand mechanisms of regurgitation.
 Mitral
Regurgitation
VALVULAR REGURGITATION:
Which Valve?
IN PRACTICE

 In practice, the evaluation starts with 2D echo,

which can orient readily to a severe regurgitation in
the presence of a major valvular defect or to a
minor leak when the valve anatomy and leaflet
motion are normal.
 Then, a careful assessment of the regurgitant jet by
color etiology, the lesion process, and the type of
dysfunction. Doppler, using multiple views, can
rapidly diagnose minimal regurgitation.
VALVULAR
REGURGITATION

AORTIC REGURGITATION
MITRAL REGURGITATION
TRICUSPID REGURGITATION
PULMONIC REGURGITATION
 VALVULAR REGURGITATION

Volume OVERLOAD
ECHO ROLE IS WHOLE HERE

[kebanjiran volum]

PR AR
VENTRICLE LEFT SIDE
RIGHT SIDE
DILATATION
TR MR

DYSFUNCTION
SYSTOLIC & DIASTOLIC
 ROLE OF ECHO
IN VALVULAR REGURGITATION

Etiology
Ventricular and Atrial Status
Ventricular function (Diast., and Syst.)
Ventricular Pressure
Severity of Disease
Time of operation
Complication
Echo detects following
Abnormalities (Status)

VOLUME OVERLOAD
Ventricle Dilatation (RV and LV)
Atrial Dilatation (RA and LA)
Increased of End-diastolic pressure (LVEDP
or RVEDP)
Wedge Pressure increases
VALVE ASSESSMENT
RECOMMENDATION
RECOMMENDATION-1

Use of a common language for the

valve analysis.
Look of the cause of valvular
regurgitation:
Precise location of involved leaflets,
scallops, the lesion process (e.g. ruptured
chordae),
Describe type of dysfunction (e.g. valve
prolapse)
Assessment Of Ventricular
Size And Function

Valvular regurgitation creates a

volume overload state.
The duration and the severity of the
regurgitation are the main
determinants of the adaptive cardiac
changes in response to volume
overload.
CHECK THE DISEASE’S STAGE

Three major physio-pathological

phases can be described:
(i) acute phase
(ii) chronic compensated phase
(iii) chronic decompensated phase
RECOMMENDATION-2

Quantification of cardiac
chamber size and function ranks
among the most important step in
the evaluation and management
of patients with valvular
regurgitation
General Recommendations
Images are best acquired at end-expiration
(breath-hold) or during quiet respiration.
Avoid valsalva manoeuvre which can
degrade the image quality and alter
cardiac volumes.
At least 2–3 representative cardiac cycles
are analysed in sinus rhythm and 3–5 in
atrial fibrillation
IMPACT OF PRE-OP LV
EJECTION FRACTION
KEY CLINICAL DECISIONS

 Is the mitral regurgitation clinically significant?

 Is the patient symptomatic?
 Is ventricular function affected?
 If regurgitation is severe, but the patient is
asymptomatic – when is the right time for
surgery?
 If regurgitation is not severe – how do we
monitor this in the future?
 Optimal Timing For Surgery
Normal ”EF, dilated LV
Hyperdynamic, dilating LV Poor EF, dilated LV
Atrial Fibrillation, Pulm H/T
Disease Progression

Symptoms

Reversible LV
Dysfunction

Irreversible LV
Dysfunction
Too Early Too Late

Time (Years)
Who Has The Most Regurgitation?
 It’s The Same Patient
Low gain High Low scale High
scale gain
Quantitative Measures Of Valve
Regurgitation

 Vena Contracta Size

– 2d
– 3d
 Regurgitant Orifice Area
– PISA
– Volumetric Flow
 Key Quantitative
Parameters
� Regurgitant Volume
� the volume of blood which
flow backwards through the
leaky valve
� Regurgitation Fraction
� the percentage of the
total stroke volume which
flow backwards
RV = 40 ml
� (Effective) Regurgitant
Orifice Area RF = 40%
� the effective area of the leak
Vena Contracta
by 3-D

Yosefy Am J Card 2009 104:978

 PROXIMAL ISOVELOCITY
SURFACE AREA
– Blood converges towards
orifice.
– Doppler flow imaging reveals
concentric hemispheric
shells, representing
isovelocity surfaces.
– As blood accelerates
towards orifice, velocity
aliasing occurs, and distinct
red-blue interface occurs at
shell boundary.
– The velocity is equal to the Nyquist
limit.
– Adjust the Nyquist limit to
optimise shell size.
– Calculate shell surface area = 2πr2
� Flow rate through any given shell
equals flow rate through orifice
(continuity equation).

� – FR = aliasing velocity x 6.28

x r2 (PISA).

� Flow rate = ERO x velocityjet

� Velocityjet obtained by CW.
� ERO – effective regurg orifice area

� ERO = Flow rate ÷ velocityjet

� Regurg. vol. = ERO x TVIMR

REGURGITANT ORIFICE
Regurgitant Volume
 LIMITATIONS OF PISA METHOD

 Irregular orifice shape – may be helped by

3-D
 Flattening of the contours near the orifice.
 Loss of hemispheric shape.
 Constraint of flow by proximal structures.
 Affects ability to form hemisphere.
 Uncertainty in localising regurgitant orifice.
 An issue as you square the area in the PISA formula.
 Variability in regurgitant orifice through
cardiac cycle.
 Multiple jets
Sources of Error with PISA
Contour Flattening Near the Orifice
Contour velocity: va
Orifice velocity: v0
Conventional PISA
Q = 2r2va

Flow underestimated by va/v0

Ensure the hemisphere is
large enough to minimize this
Sources of Error with PISA
Proximal Flow Constraint by Surrounding Structures

Flail Leaflet Wall Constraint

Sources of Error with PISA
Variable Orifice Size

Lancellotti, EHJ-CVI 2013 14:611

 Measurement of Mitral ROA
Simplified PISA Formula
40 Assume LV-LA  p
is 100 mmHg

LA Set aliasing velocity to

40 cm/sec

40
Then ROA = r2/2

MV
r = 8 mm

LV

ROA = 82/2 = 32 mm2

ROA by Simplified PISA Method: r2/2

r2/2
R=1.0cm
ROA=0.5cm2

Pu, Prior et al., JASE 2001 14:180

 What Is Our Reference
Method?

Echo Studies
 – Volumetric Flow
MRI Studies
 – Volumetric Flow
 Quantitative Assessment of MR
- Volumetric Flow
 Measure SV in 2 regions,
one of which includes the
regurgitant volume.
 Difference b/n these two SVs
is the regurgitant volume
through the valve.
 Area of the LVOT x VTI
 Mitral annular area x VTI
 Or

– LV stroke volume
Mitral annulus – LVEDV-LVESV (3-d or
Simpson’s biplane)

LVOT - Beware of AR Regurg. flow rate (ml/s), fraction

(%), orifice area.
 Improving Accuracy & Usability
Volumetric flow not often used
– Time-consuming

Lancellotti, EHJ-CVI 2013 14:611

Simultaneous MV and LVOT flow
- Real Time Colour Flow Doppler

Thavendiranathan, JASE 2012 25:1

Simultaneous MV and
LVOT flow

Thavendiranathan, JASE 2012 25:1

Factor That Affect
Regurgitant Jet Size

Instrumentation
Doppler frequency, Nyquist limit, and Gain
Eccentricity leading to jet distortion
Hemodynamics – driving pressure
Chamber compliance
Vena Contrata Width
Systolic Flow reversal in PV in LA
 Mitral Regurgitation
• LV Dilatation
• Wall motion
hyperkinetic at
early stage
• LA dilatation
MR: Image of LAX
Mild MR
Moderate MR
Be Careful !!!!
MR due to MV Prolapse
Valve restriction due to
Calcification
 Aortic
Regurgitation
 Aortic Reg.
• LV Volume overload
• LV Dilatation
• Diastolic
Dysfunction
• Systolic Dysfunction
(in severe cases)
VALVULAR REGURGITATION
1. Valve regurgitation volume loads the ventricles
2. Chronic volume loading may lead to ventricular
dysfunction

3. Irreversible ventricular dysfunction

may precede the development of
symptoms
You may miss the boat if you wait for symptoms
ACUTE AR CHRONIC AR
o Dissection o AV calcification
o Endocarditis o Malformation
o Annulus
Dilatation
AR
First Step
Aortic Regurgitation
(severe)
Ascending -Arcus Aorta-
Descending Ao
Aortic Arc
Flow
Reversal
Severe AR

PHT = 123 msec

 Pulmonic
Regurgitation
 Pulmonary
Regurgitation

• RV volume
Overload
• PA dilatation
• Followed by PH
(hypertension)
• RVH in the long run
RV Dilatation
PR with RV dilatation and
hypertrophy
Tissue Doppler Imaging
 Tricuspid
Regurgitation
Tricuspid Reg.
TR in RV Volume overload
Tricuspid Regurgitation
Thank You