The document discusses mixed valvular heart disease, which involves multiple stenotic or regurgitant lesions on two or more cardiac valves. Mixed valvular heart disease is prevalent but challenging to assess and manage due to heterogeneity in combinations and severity of lesions. Echocardiography plays a key role in evaluation but has limitations, so additional modalities like cardiac catheterization, 3D echocardiography, cardiac MRI, stress echocardiography, and CT may be useful in selected cases.
This document discusses multivalvular heart disease (MVD), which refers to two or more diseased cardiac valves. It defines MVD and provides epidemiological data showing its prevalence. The most common causes of acquired MVD are rheumatic heart disease and degenerative calcific disease. Congenital disorders can also cause MVD. The document examines the pathophysiology and interactions of different valve combinations, such as aortic stenosis with mitral regurgitation. Echocardiography is key for diagnosis but has limitations in MVD, so cardiac catheterization may be needed in some cases.
This document provides information about exercise stress testing, including:
1. Exercise stress testing is a fundamental test used to evaluate cardiovascular disease that is easy to perform, flexible, reliable, and inexpensive.
2. Exercise stress testing can elicit abnormalities not seen at rest, estimate functional capacity and prognosis of coronary artery disease, and evaluate many cardiovascular conditions.
3. Proper patient preparation, test protocol selection, monitoring during the test, and follow up are important to ensure safety and accurate results. Electrocardiogram measurements during the test help identify ischemic changes indicative of cardiovascular disease.
1. Contrast agents enhance ultrasound images by increasing the backscatter of blood allowing visualization of small vessels. They oscillate non-linearly when exposed to ultrasound, emitting harmonic frequencies not seen in tissue.
2. Harmonic imaging exploits non-linear backscatter to identify the contrast agent signal and suppress tissue echoes, enabling visualization of microvascular flow.
3. Care must be taken in injecting contrast agents to avoid destroying bubbles, and infusion may provide a longer enhancement window for some studies compared to a bolus injection.
Treadmill testing principles and protocols are discussed. The document outlines the objectives, indications, contraindications, and preparations for treadmill testing. It describes various treadmill testing protocols including the Bruce, Balke, Naughton, and Cornell protocols. Key points about metabolic equivalents, Borg scale, and complications are provided. Exercise testing is used to detect cardiovascular disease, reproduce symptoms, screen for exercise programs, and monitor therapeutic responses.
Exercise testing is a noninvasive tool to evaluate the cardiovascular system's response to stress from exercise. During exercise, the body's metabolic rate and cardiac output increase substantially, placing high demands on the cardiopulmonary system. This makes exercise an effective way to assess cardiac function and perfusion. Various protocols exist for exercise testing using treadmills, bicycles, or other devices, with different protocols suited for evaluating patients with different cardiovascular conditions or exercise capacities. Careful analysis of electrocardiogram changes during and after exercise can provide information about myocardial ischemia.
The document discusses guidelines for assessing diastolic dysfunction according to the ASE/EACVI 2016 guidelines. It defines diastolic dysfunction and describes the stages from grade I to grade IV. For each grade, it discusses the pathophysiology and key echocardiographic findings including mitral inflow patterns, tissue Doppler measurements, pulmonary vein flow, and left atrial size. The guidelines simplify the assessment of diastolic function into four grades based on parameters of left ventricular relaxation, left atrial pressure, mitral E/A ratio, E/e' ratio, pulmonary vein flow, and left atrial size.
The document provides an overview of transcatheter aortic valve implantation (TAVI), including a brief history of its development, descriptions of the Edwards Sapien valve and delivery systems, approaches for TAVI, and complications. It also discusses patient screening and risk stratification, as well as newer valve devices that are being developed.
This document discusses percutaneous pulmonary valve interventions. It begins by providing background on the history of pulmonary valve interventions, starting with open surgical techniques and moving to percutaneous approaches developed in the 1950s. It then discusses the first successful percutaneous pulmonary valve implantation in 2000. The document provides details on the anatomy of the pulmonary valve, causes of pulmonary valve disease, techniques for percutaneous balloon pulmonary valvuloplasty, indications and contraindications for percutaneous pulmonary valve interventions, and the evolution and indications for transcatheter pulmonary valve implantation.
This document discusses multivalvular heart disease (MVD), which refers to two or more diseased cardiac valves. It defines MVD and provides epidemiological data showing its prevalence. The most common causes of acquired MVD are rheumatic heart disease and degenerative calcific disease. Congenital disorders can also cause MVD. The document examines the pathophysiology and interactions of different valve combinations, such as aortic stenosis with mitral regurgitation. Echocardiography is key for diagnosis but has limitations in MVD, so cardiac catheterization may be needed in some cases.
This document provides information about exercise stress testing, including:
1. Exercise stress testing is a fundamental test used to evaluate cardiovascular disease that is easy to perform, flexible, reliable, and inexpensive.
2. Exercise stress testing can elicit abnormalities not seen at rest, estimate functional capacity and prognosis of coronary artery disease, and evaluate many cardiovascular conditions.
3. Proper patient preparation, test protocol selection, monitoring during the test, and follow up are important to ensure safety and accurate results. Electrocardiogram measurements during the test help identify ischemic changes indicative of cardiovascular disease.
1. Contrast agents enhance ultrasound images by increasing the backscatter of blood allowing visualization of small vessels. They oscillate non-linearly when exposed to ultrasound, emitting harmonic frequencies not seen in tissue.
2. Harmonic imaging exploits non-linear backscatter to identify the contrast agent signal and suppress tissue echoes, enabling visualization of microvascular flow.
3. Care must be taken in injecting contrast agents to avoid destroying bubbles, and infusion may provide a longer enhancement window for some studies compared to a bolus injection.
Treadmill testing principles and protocols are discussed. The document outlines the objectives, indications, contraindications, and preparations for treadmill testing. It describes various treadmill testing protocols including the Bruce, Balke, Naughton, and Cornell protocols. Key points about metabolic equivalents, Borg scale, and complications are provided. Exercise testing is used to detect cardiovascular disease, reproduce symptoms, screen for exercise programs, and monitor therapeutic responses.
Exercise testing is a noninvasive tool to evaluate the cardiovascular system's response to stress from exercise. During exercise, the body's metabolic rate and cardiac output increase substantially, placing high demands on the cardiopulmonary system. This makes exercise an effective way to assess cardiac function and perfusion. Various protocols exist for exercise testing using treadmills, bicycles, or other devices, with different protocols suited for evaluating patients with different cardiovascular conditions or exercise capacities. Careful analysis of electrocardiogram changes during and after exercise can provide information about myocardial ischemia.
The document discusses guidelines for assessing diastolic dysfunction according to the ASE/EACVI 2016 guidelines. It defines diastolic dysfunction and describes the stages from grade I to grade IV. For each grade, it discusses the pathophysiology and key echocardiographic findings including mitral inflow patterns, tissue Doppler measurements, pulmonary vein flow, and left atrial size. The guidelines simplify the assessment of diastolic function into four grades based on parameters of left ventricular relaxation, left atrial pressure, mitral E/A ratio, E/e' ratio, pulmonary vein flow, and left atrial size.
The document provides an overview of transcatheter aortic valve implantation (TAVI), including a brief history of its development, descriptions of the Edwards Sapien valve and delivery systems, approaches for TAVI, and complications. It also discusses patient screening and risk stratification, as well as newer valve devices that are being developed.
This document discusses percutaneous pulmonary valve interventions. It begins by providing background on the history of pulmonary valve interventions, starting with open surgical techniques and moving to percutaneous approaches developed in the 1950s. It then discusses the first successful percutaneous pulmonary valve implantation in 2000. The document provides details on the anatomy of the pulmonary valve, causes of pulmonary valve disease, techniques for percutaneous balloon pulmonary valvuloplasty, indications and contraindications for percutaneous pulmonary valve interventions, and the evolution and indications for transcatheter pulmonary valve implantation.
This document discusses balloon aortic valvuloplasty (BAV) as a treatment for aortic stenosis. It can be performed via either a retrograde or antegrade approach. The retrograde approach involves crossing the aortic valve from the femoral artery, while the antegrade approach involves transseptal catheterization from the femoral vein. Key steps for both approaches include rapid ventricular pacing to stabilize the heart during balloon inflation. The goals of BAV are to increase the aortic valve area and reduce pressure gradients. Complications can include hypotension, aortic regurgitation, and embolization of calcium deposits. BAV provides symptomatic relief but is usually not curative, as restenosis may occur.
Doppler echocardiography uses the Doppler effect to analyze the velocity and direction of blood flow. There are several Doppler modalities used in cardiac evaluation including continuous wave Doppler, pulsed wave Doppler, and color flow Doppler. Continuous wave Doppler measures very high velocities, pulsed wave Doppler samples local low velocities, and color flow Doppler visually displays velocities using color scales. The Nyquist limit defines the maximum detectable velocity and avoiding aliasing. Tissue Doppler also evaluates myocardial velocities. The Bernoulli equation relates velocity and pressure gradients which allows Doppler to estimate valve pressures.
This document summarizes the echocardiographic assessment of mitral stenosis (MS). It describes the anatomy of the mitral valve and causes of MS. Methods for assessing MS severity include measuring the pressure gradient, mitral valve area using planimetry and pressure half-time, and pulmonary artery pressure. Suitability for percutaneous transvenous mitral commissurotomy is evaluated. Concomitant valve lesions are also identified. Stress echocardiography may be used when symptoms are equivocal. Transesophageal echocardiography is recommended in some cases.
Echo assessment of lv systolic function and swmaFuad Farooq
This document discusses various techniques for assessing left ventricular systolic function using echocardiography, including:
- Visual assessment of endocardial motion and wall thickening to evaluate global and regional function
- Quantitative measures like fractional shortening, ejection fraction, and volumes
- Tissue Doppler imaging of mitral annular velocities
- Tissue tracking and strain imaging to evaluate timing and extent of myocardial contraction
- Wall motion scoring to characterize regional abnormalities
Trans-esophageal echocardiography (TEE) uses ultrasound to obtain high-quality images of the heart and surrounding structures. It involves inserting a probe with an ultrasound transducer at the tip through the mouth and esophagus. TEE provides clearer images than transthoracic echocardiography as the esophagus is directly behind the heart. A TEE exam involves systematically imaging the heart in various planes as the transducer is advanced and manipulated. Standard views include the mid-esophageal four-chamber, two-chamber, aortic, and RV inflow-outflow views. Real-time 3D TEE can provide en face views of structures.
This document summarizes the evaluation of aortic valve stenosis using echocardiography. It describes the normal aortic valve anatomy and various types of aortic valve stenosis including calcific, bicuspid, rheumatic, and supravalvular or subvalvular stenosis. Doppler echocardiography is used to evaluate aortic valve stenosis severity based on valve area, mean gradient, and peak jet velocity. Stress echocardiography with dobutamine can help distinguish true severe from pseudo-severe low-flow, low-gradient aortic stenosis.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Contrast echocardiography uses microbubble ultrasound contrast agents to improve image quality. These microbubbles remain in the intravascular space and allow for assessment of cardiac structure, function, and perfusion. Second generation contrast agents use an inert gas encapsulated by albumin or phospholipid shells. They interact with ultrasound by reflecting at fundamental frequencies and resonating to produce harmonic frequencies. Continuous infusion provides steady contrast levels needed for perfusion assessment. Contrast echocardiography is a non-invasive technique that improves evaluation of the heart.
Stress echocardiography involves using cardiac ultrasound imaging along with exercise or pharmacological stressors like dobutamine to detect changes in heart wall motion that indicate reduced pumping function during stress. This can help identify blockages in the arteries to the heart. Dobutamine stress echocardiography involves gradually increasing doses of dobutamine, a drug that increases heart rate and contraction. Images are taken at each dose to detect any new wall motion abnormalities that would suggest ischemia. While it is effective for evaluating coronary artery disease, it also carries risks of side effects like arrhythmias that require emergency drugs like esmolol to reverse. Interpreting any new wall motion abnormalities seen under stress is important for diagnosis.
Mitral stenosis can be evaluated using echocardiography. Key findings include measuring the mitral valve area using planimetry, pressure half-time, and continuity equation methods. Pressure gradients and pulmonary artery systolic pressure can also assess severity. Mild mitral stenosis is defined as a mitral valve area greater than 1.5 cm2, moderate as 1-1.5 cm2, and severe as less than 1 cm2. Stress echocardiography may reveal symptoms in borderline cases by monitoring pressures with exercise.
Echocardiography in ischemic heart diseaseBhargav Kiran
This document discusses the clinical utility of echocardiography in ischemic heart disease. Echocardiography is useful for diagnosing IHD and its complications through detection of wall motion abnormalities. It can assess haemodynamic status, viability, and guide therapy. Key uses include diagnosing acute MI, evaluating chest pain, detecting complications like thrombus, assessing viability for revascularization, and prognosticating post-MI risk through evaluation of ejection fraction and diastolic function. New technologies like 3D echo, myocardial contrast echo, and speckle tracking further improve detection of IHD, perfusion defects, and quantitative assessment of function.
This document summarizes dobutamine stress echocardiography (DSE). Key points include:
- DSE uses the drug dobutamine to simulate exercise and increase heart rate, contractility, and myocardial oxygen demand to detect ischemia.
- It is useful for evaluating ischemia, viability, and valvular dysfunction in patients unable to exercise.
- The document reviews the DSE protocol, interpretation of wall motion abnormalities, indications, side effects, and applications for assessing ischemic heart disease, viability, valvular stenosis like mitral and aortic stenosis, and pulmonary hypertension.
The document provides an overview of echocardiographic assessment of aortic valve stenosis. It describes the normal aortic valve anatomy and imaging windows used to visualize the valve. Common causes of aortic stenosis including bicuspid aortic valve and calcific stenosis are discussed. Methods for Doppler assessment of aortic stenosis including peak velocity, mean gradient, and valve area via the continuity equation are summarized. Limitations of these assessment techniques are also noted.
Tissue Doppler echocardiography allows assessment of myocardial motion using Doppler ultrasound. It uses frequency shifts of ultrasound waves to calculate myocardial velocity, focusing on lower velocities than blood flow Doppler. There are two techniques: pulsed TDE uses a sample volume gate while color-coded TDE uses autocorrelation to display multigated velocity data superimposed on images. TDE is useful for evaluating systolic and diastolic left ventricular function by measuring velocities of the mitral annulus, and can help distinguish conditions like constrictive pericarditis from restrictive cardiomyopathy.
Three sentences:
The document provides details on the anatomy and evaluation of aortic stenosis using echocardiography. It describes the normal aortic valve anatomy and how various types of aortic stenosis like calcific, rheumatic, bicuspid and subvalvular present on echo. Quantitative assessment of aortic stenosis severity is done using Doppler ultrasound to measure the maximum jet velocity and calculate the pressure gradient across the stenotic valve.
TAVR is a minimally invasive procedure to replace a severely stenotic aortic valve. The aortic valve regulates blood flow from the left ventricle to the aorta. Aortic valve stenosis occurs when the valve thickens and narrows, reducing blood flow. TAVR can treat aortic stenosis in patients at high risk for open heart surgery or those whose artificial valves have failed. During TAVR, a catheter is used to guide a replacement valve through the body to the heart, where it is deployed to replace the diseased valve. TAVR allows for quicker recovery and shorter hospital stays than open heart surgery.
The document summarizes key aspects of cardiac catheterization and hemodynamic data collection. It describes the normal cardiac cycle, pressure measurement systems, normal pressure waveforms, methods to measure cardiac output like thermodilution and Fick, how to evaluate valvular stenosis and regurgitation, determine vascular resistance and shunts. Specific details are provided on assessing aortic stenosis, mitral stenosis, right-sided valves and quantifying regurgitant fractions. Oxygen saturation analysis and Fick principles are outlined for shunt determinations.
The main hemodynamic interactions that may impact on the diagnosis of multiple and mixed Multiple and Mixed Valvular Heart Diseases:HOW TO USE IMAGINGThe interplay of multiple valve pathology.The clinical challenge of concomitant aortic and mitral valve stenosis
.
.
This document provides a comprehensive review of mitral valve disease, including both mitral stenosis and mitral regurgitation. It discusses the anatomy of the mitral valve and the disease processes that can affect it. Rheumatic fever is still the leading cause of mitral stenosis worldwide. Mitral regurgitation can be classified as primary, due to lesions of the mitral valve apparatus, or secondary, caused by left ventricular geometric alterations. Optimal treatment requires an understanding of mitral valve anatomy and the specific causes of valve dysfunction in each patient.
This document discusses balloon aortic valvuloplasty (BAV) as a treatment for aortic stenosis. It can be performed via either a retrograde or antegrade approach. The retrograde approach involves crossing the aortic valve from the femoral artery, while the antegrade approach involves transseptal catheterization from the femoral vein. Key steps for both approaches include rapid ventricular pacing to stabilize the heart during balloon inflation. The goals of BAV are to increase the aortic valve area and reduce pressure gradients. Complications can include hypotension, aortic regurgitation, and embolization of calcium deposits. BAV provides symptomatic relief but is usually not curative, as restenosis may occur.
Doppler echocardiography uses the Doppler effect to analyze the velocity and direction of blood flow. There are several Doppler modalities used in cardiac evaluation including continuous wave Doppler, pulsed wave Doppler, and color flow Doppler. Continuous wave Doppler measures very high velocities, pulsed wave Doppler samples local low velocities, and color flow Doppler visually displays velocities using color scales. The Nyquist limit defines the maximum detectable velocity and avoiding aliasing. Tissue Doppler also evaluates myocardial velocities. The Bernoulli equation relates velocity and pressure gradients which allows Doppler to estimate valve pressures.
This document summarizes the echocardiographic assessment of mitral stenosis (MS). It describes the anatomy of the mitral valve and causes of MS. Methods for assessing MS severity include measuring the pressure gradient, mitral valve area using planimetry and pressure half-time, and pulmonary artery pressure. Suitability for percutaneous transvenous mitral commissurotomy is evaluated. Concomitant valve lesions are also identified. Stress echocardiography may be used when symptoms are equivocal. Transesophageal echocardiography is recommended in some cases.
Echo assessment of lv systolic function and swmaFuad Farooq
This document discusses various techniques for assessing left ventricular systolic function using echocardiography, including:
- Visual assessment of endocardial motion and wall thickening to evaluate global and regional function
- Quantitative measures like fractional shortening, ejection fraction, and volumes
- Tissue Doppler imaging of mitral annular velocities
- Tissue tracking and strain imaging to evaluate timing and extent of myocardial contraction
- Wall motion scoring to characterize regional abnormalities
Trans-esophageal echocardiography (TEE) uses ultrasound to obtain high-quality images of the heart and surrounding structures. It involves inserting a probe with an ultrasound transducer at the tip through the mouth and esophagus. TEE provides clearer images than transthoracic echocardiography as the esophagus is directly behind the heart. A TEE exam involves systematically imaging the heart in various planes as the transducer is advanced and manipulated. Standard views include the mid-esophageal four-chamber, two-chamber, aortic, and RV inflow-outflow views. Real-time 3D TEE can provide en face views of structures.
This document summarizes the evaluation of aortic valve stenosis using echocardiography. It describes the normal aortic valve anatomy and various types of aortic valve stenosis including calcific, bicuspid, rheumatic, and supravalvular or subvalvular stenosis. Doppler echocardiography is used to evaluate aortic valve stenosis severity based on valve area, mean gradient, and peak jet velocity. Stress echocardiography with dobutamine can help distinguish true severe from pseudo-severe low-flow, low-gradient aortic stenosis.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Contrast echocardiography uses microbubble ultrasound contrast agents to improve image quality. These microbubbles remain in the intravascular space and allow for assessment of cardiac structure, function, and perfusion. Second generation contrast agents use an inert gas encapsulated by albumin or phospholipid shells. They interact with ultrasound by reflecting at fundamental frequencies and resonating to produce harmonic frequencies. Continuous infusion provides steady contrast levels needed for perfusion assessment. Contrast echocardiography is a non-invasive technique that improves evaluation of the heart.
Stress echocardiography involves using cardiac ultrasound imaging along with exercise or pharmacological stressors like dobutamine to detect changes in heart wall motion that indicate reduced pumping function during stress. This can help identify blockages in the arteries to the heart. Dobutamine stress echocardiography involves gradually increasing doses of dobutamine, a drug that increases heart rate and contraction. Images are taken at each dose to detect any new wall motion abnormalities that would suggest ischemia. While it is effective for evaluating coronary artery disease, it also carries risks of side effects like arrhythmias that require emergency drugs like esmolol to reverse. Interpreting any new wall motion abnormalities seen under stress is important for diagnosis.
Mitral stenosis can be evaluated using echocardiography. Key findings include measuring the mitral valve area using planimetry, pressure half-time, and continuity equation methods. Pressure gradients and pulmonary artery systolic pressure can also assess severity. Mild mitral stenosis is defined as a mitral valve area greater than 1.5 cm2, moderate as 1-1.5 cm2, and severe as less than 1 cm2. Stress echocardiography may reveal symptoms in borderline cases by monitoring pressures with exercise.
Echocardiography in ischemic heart diseaseBhargav Kiran
This document discusses the clinical utility of echocardiography in ischemic heart disease. Echocardiography is useful for diagnosing IHD and its complications through detection of wall motion abnormalities. It can assess haemodynamic status, viability, and guide therapy. Key uses include diagnosing acute MI, evaluating chest pain, detecting complications like thrombus, assessing viability for revascularization, and prognosticating post-MI risk through evaluation of ejection fraction and diastolic function. New technologies like 3D echo, myocardial contrast echo, and speckle tracking further improve detection of IHD, perfusion defects, and quantitative assessment of function.
This document summarizes dobutamine stress echocardiography (DSE). Key points include:
- DSE uses the drug dobutamine to simulate exercise and increase heart rate, contractility, and myocardial oxygen demand to detect ischemia.
- It is useful for evaluating ischemia, viability, and valvular dysfunction in patients unable to exercise.
- The document reviews the DSE protocol, interpretation of wall motion abnormalities, indications, side effects, and applications for assessing ischemic heart disease, viability, valvular stenosis like mitral and aortic stenosis, and pulmonary hypertension.
The document provides an overview of echocardiographic assessment of aortic valve stenosis. It describes the normal aortic valve anatomy and imaging windows used to visualize the valve. Common causes of aortic stenosis including bicuspid aortic valve and calcific stenosis are discussed. Methods for Doppler assessment of aortic stenosis including peak velocity, mean gradient, and valve area via the continuity equation are summarized. Limitations of these assessment techniques are also noted.
Tissue Doppler echocardiography allows assessment of myocardial motion using Doppler ultrasound. It uses frequency shifts of ultrasound waves to calculate myocardial velocity, focusing on lower velocities than blood flow Doppler. There are two techniques: pulsed TDE uses a sample volume gate while color-coded TDE uses autocorrelation to display multigated velocity data superimposed on images. TDE is useful for evaluating systolic and diastolic left ventricular function by measuring velocities of the mitral annulus, and can help distinguish conditions like constrictive pericarditis from restrictive cardiomyopathy.
Three sentences:
The document provides details on the anatomy and evaluation of aortic stenosis using echocardiography. It describes the normal aortic valve anatomy and how various types of aortic stenosis like calcific, rheumatic, bicuspid and subvalvular present on echo. Quantitative assessment of aortic stenosis severity is done using Doppler ultrasound to measure the maximum jet velocity and calculate the pressure gradient across the stenotic valve.
TAVR is a minimally invasive procedure to replace a severely stenotic aortic valve. The aortic valve regulates blood flow from the left ventricle to the aorta. Aortic valve stenosis occurs when the valve thickens and narrows, reducing blood flow. TAVR can treat aortic stenosis in patients at high risk for open heart surgery or those whose artificial valves have failed. During TAVR, a catheter is used to guide a replacement valve through the body to the heart, where it is deployed to replace the diseased valve. TAVR allows for quicker recovery and shorter hospital stays than open heart surgery.
The document summarizes key aspects of cardiac catheterization and hemodynamic data collection. It describes the normal cardiac cycle, pressure measurement systems, normal pressure waveforms, methods to measure cardiac output like thermodilution and Fick, how to evaluate valvular stenosis and regurgitation, determine vascular resistance and shunts. Specific details are provided on assessing aortic stenosis, mitral stenosis, right-sided valves and quantifying regurgitant fractions. Oxygen saturation analysis and Fick principles are outlined for shunt determinations.
The main hemodynamic interactions that may impact on the diagnosis of multiple and mixed Multiple and Mixed Valvular Heart Diseases:HOW TO USE IMAGINGThe interplay of multiple valve pathology.The clinical challenge of concomitant aortic and mitral valve stenosis
.
.
This document provides a comprehensive review of mitral valve disease, including both mitral stenosis and mitral regurgitation. It discusses the anatomy of the mitral valve and the disease processes that can affect it. Rheumatic fever is still the leading cause of mitral stenosis worldwide. Mitral regurgitation can be classified as primary, due to lesions of the mitral valve apparatus, or secondary, caused by left ventricular geometric alterations. Optimal treatment requires an understanding of mitral valve anatomy and the specific causes of valve dysfunction in each patient.
1. Echocardiography is the standard method for evaluating the severity of aortic stenosis. The primary parameters used are peak transvalvular velocity, mean transvalvular gradient, and valve area calculated by the continuity equation.
2. Echocardiography plays a major role in evaluating mitral stenosis by allowing confirmation of diagnosis, quantification of stenosis severity, and analysis of valve anatomy. Key indices of severity include pressure gradient, mitral valve area measured by planimetry, and pressure half-time.
3. Guidelines are provided for standardized data collection and measurement techniques for assessing aortic and mitral valve stenosis severity, including recommendations for primary and secondary parameters to measure based on clinical use.
echo pada penyakit jantung katup final.pptxBenevolent7
This document discusses the use of echocardiography in assessing valvular stenosis. It defines the stages of valvular heart disease from asymptomatic to symptomatic severe. It provides guidelines for grading the severity of aortic stenosis based on parameters such as jet velocity, mean gradient, and aortic valve area. It also discusses the measurement techniques and parameters used to grade the severity of mitral stenosis, pulmonic stenosis, tricuspid stenosis, and various types of valvular regurgitation. Measurement of specific anatomical features is recommended to assess valve anatomy and function.
This document discusses sonographic evaluation for diagnosing upper extremity deep venous thrombosis (UEDVT). It provides an overview of the risk factors and complications of UEDVT. Color Doppler sonography is outlined as the preferred noninvasive screening technique, with sensitivity of 78-100% and specificity of 82-100% for diagnosing UEDVT. The normal venous anatomy of the upper extremity is described and techniques for performing the sonographic examination are explained. Examples of sonographic appearances of acute and chronic UEDVT are illustrated and described.
Measurement of Aortic area in Echocardiography and DopplerNizam Uddin
This study compared aortic valve area (AVA) measurements from Doppler echocardiography (AVAEcho) and multidetector computed tomography (MDCT) (AVACT) in 269 patients with aortic stenosis. The study aimed to determine if AVACT was superior to AVAEcho in assessing hemodynamic correlations, predicting survival outcomes, and resolving discordant assessments of aortic stenosis severity. The study found that while AVACT measurements of the left ventricular outflow tract were larger than AVAEcho, leading to slightly higher calculated AVA values, AVACT did not improve correlations with transvalvular gradients, concordance between gradient and AVA, or prediction of mortality compared to AVAEcho. Both AVAEcho and AV
STATIC INDICES OF FLUID RESPONSlVENESS' with you.pptxMohammad Abbas
Static measures of fluid responsiveness such as central venous pressure, pulmonary artery occlusion pressure, right ventricular end-diastolic volume, and global end-diastolic volume have limitations in accurately predicting a patient's fluid responsiveness. While some studies found statistically significant differences in these measures between fluid responders and non-responders, the overlap between individual values means no threshold can reliably discriminate the two groups. Due to their poor accuracy, static measures are best used alongside dynamic tests of fluid responsiveness to guide fluid management in critically ill patients.
This document discusses various imaging modalities for assessing the right heart, including echocardiography and cardiac magnetic resonance imaging (CMR). It provides details on:
1) The challenges of using echocardiography to evaluate right ventricular (RV) structure and function due to its complex geometry, though it is commonly used. Quantitative measures like fractional area change and tricuspid annular plane systolic excursion are recommended.
2) CMR is considered the clinical reference technique due to unlimited imaging planes, superior resolution, and ability to perform 3D volumetric rendering, making it ideal for serial exams.
3) Other modalities like multidetector computed tomography and radionuclide techniques play roles
The Progression of Hypertensive Heart Disease.From hypertension to heart failuremagdy elmasry
Staging of Hypertensive Heart Disease.Precipitants and clinical sequelae related to LVH and myocardial fibrosis.Imaging in hypertensive heart disease .Differential diagnosis of LVH.Concentric LVH .Eccentric LVH . Concentric remodeling .linking hypertension and atrial fibrillation
This document discusses the challenges of evaluating multivalve heart disease using echocardiography. It notes that interactions between multiple valve lesions can alter the clinical effects of each individual lesion. It also states that Doppler methods used to assess severity have been validated for single valve disease but not multivalve disease. The key points are that methods less dependent on loading conditions, like direct planimetry of stenotic valves, are preferred for assessment. The presence of multiple valve diseases can impact the diagnosis of individual valve lesions by causing underestimation or overestimation of severity depending on the combination of lesions present.
This document provides an overview of tricuspid and pulmonary valve diseases. It discusses the anatomy of the right atrium, right ventricle, and tricuspid valve. It then covers tricuspid stenosis, including causes, chest X-ray findings, echocardiography findings, and severity assessment. Tricuspid regurgitation is also discussed, including causes, chest X-ray findings, and echocardiography findings. MRI and CT imaging of tricuspid valve disease is briefly mentioned. The document concludes by stating that Ebstein anomaly is a myopathy.
An Unusual Cause of Left Ventricular Volume Overload after Aortic Valve Repla...escardio
A 67-year-old female presented with syncope and was found to have left ventricular volume overload. Transthoracic echocardiography revealed a patent ductus arteriosus causing a left-to-right shunt, elevating pulmonary pressures and resulting in functional mitral and tricuspid regurgitation. While the PDA may have been an incidental finding, it was thought to be the primary cause of left ventricular volume overload. The patient was referred for percutaneous closure of the PDA to treat her symptoms.
This document provides an overview of congenital obstructive lesions that may be seen in adults, including:
1) Congenital obstructive lesions increase ventricular afterload and can cause ventricular hypertrophy, reduced compliance, and higher filling pressures. Symptoms are generally related to the severity of obstruction.
2) Common obstructive lesions include subvalvar, valvar, and supravalvar pulmonary stenosis. Severe obstructions can cause right ventricular dysfunction, arrhythmias, and sudden cardiac death.
3) Indications for intervention include symptoms, elevated right ventricular pressures, and reduced systolic function. Balloon valvuloplasty is now preferred over surgery for valvar pulmonary stenosis. Surgical options
MDCT Evaluation of Varices in Portal HypertensionVishwanath R S
MDCT is useful for identifying portosystemic collateral vessels in patients with portal hypertension. It can accurately demonstrate the majority of collateral channels. Dynamic CT with contrast allows visualization of varices in the esophagus, stomach, rectum, and other locations. Precise mapping of collateral vessels is important before surgical or interventional procedures to avoid blood loss. MDCT plays an invaluable role in managing portal hypertension.
"Navigating Cortical Cerebral Venous Thrombosis (CVT) Management with Dr. Ganesh"
🌟 Hello, everyone! Dr. Ganesh here, and today, we're delving into a critical topic in neurology: the management of Cortical Cerebral Venous Thrombosis (CVT). Whether you're a healthcare professional, a patient, or simply interested in understanding the complexities of cerebrovascular health, this discussion is crafted to provide valuable insights.
The passage of the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA) was meant to be the dawn of a new day in healthcare to help rectify these disparities. For graduate medical education trainees transitioning from practicing in sheltered residency and fellowship environments into independent practice, understanding these new healthcare delivery models will be vital to providing high-quality care to patients.
Primary mitral valve regurgitation is the second most frequent valve disease in the Western world. Definite treatment is surgical with few controlled studies to rely on. In general mild and mild/moderate regurgitation is well tolerated for years, but severe regurgitation often necessitates valve surgery. It is equally important to rule out severe mitral valve regurgitation, since unnecessary surgery can be avoided, but also rule in severe regurgitation because surgery too late often may be associated with an unfavourable outcome due to poor left ventricular function going unnoticed as a result of the mitral valve regurgitation related low impedance to left ventricular output.
Mitral regurgitation (MR) is a common form of valvular heart disease that is associated with significant morbidity and
mortality. Treatment decisions are completely dependent on accurate diagnosis of both mechanism and severity of MR,
which can be challenging and is often done incorrectly. Transthoracic echocardiography is the most commonly used
imaging test for MR; transesophageal echocardiography is often needed to better define morphology and MR severity,
and is essential for guiding transcatheter therapies for MR. Multidetector computed tomography has become the standard to assess whether transcatheter valve replacement is an option because of its ability to assess valve sizing, access,
and potential left ventricular outflow tract obstruction. Finally, cine cardiac magnetic resonance has been recommended
by recent guidelines to quantify MR severity when the distinction between moderate and severe MR is indeterminate by
echocardiography. This paper focuses on the main questions to be answered by imaging techniques and illustrates some
common tips, tricks, and pitfalls in the assessment of MR.
This document discusses peripheral pulmonary artery stenosis, including its description, associated conditions, classification, clinical features, diagnosis using imaging modalities like echocardiography and angiography, and treatment options like balloon angioplasty. Peripheral pulmonary artery stenosis can involve the main pulmonary artery or its branches and is present in 2-3% of congenital heart disease cases. Diagnosis relies on cardiac catheterization and angiography to determine severity and anatomy. Balloon angioplasty is an option for treating moderate or severe stenosis when surgery is difficult.
Hemodynamics of valvular disorders as measured by cardiac catheterization - U...franciscomaan
This document provides an overview of how cardiac catheterization can be used to evaluate valvular heart disorders by measuring hemodynamics and pressures. Key findings include:
- Aortic stenosis causes a pressure gradient between the left ventricle and aorta due to obstruction of blood flow. Catheterization can precisely measure this gradient.
- Aortic regurgitation results in backward blood flow from the aorta to left ventricle during diastole due to inadequate valve closure. The regurgitant fraction can be calculated.
- Abnormal pressures may be seen in the left ventricle, left atrium, and aorta depending on the specific valvular disorder and degree of dysfunction.
Similar to Evaluation of Mixed Valvular Heart Disease on Echo (20)
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
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Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
2. Introduction
Multiple valvular heart disease (VHD) -
combination of stenotic or regurgitant lesions
occurring on ≥2 cardiac valves
Mixed VHD - combination of stenotic and
regurgitant lesions on the same valve.
Highly prevalent but limited data in the literature
and current guidelines to support and guide
clinical decision-making.
explained by the heterogeneity of these conditions
in terms of combinations, pathogenesis, severity,
surgical risk, reparability, and suitability for
transcatheter therapies
3. Prevalence
In the Euro Heart Survey, multiple VHD, as defined by at
least 2 moderate VHDs, was observed in 20% of the patients
with native VHD and in 17% of those undergoing
intervention.
In the American Society of Thoracic Surgeons Database
including 290 000 patients who underwent surgery between
2003 and 2007, 11% had double valve procedures
(replacement or repair), most often aortic and mitral,2 and
triple valve surgery has been performed in 1% of cases.
Swedish nationwide study - multiple VHD accounted for
11% of patients.
The most frequent associations were aortic stenosis (AS)
plus aortic regurgitation (AR), AS plus mitral regurgitation
(MR) and AR plus MR.
4. Mechanism
Often acquired.
In the Euro Heart Survey, rheumatic fever was the predominant
pathogenesis (51%), but degenerative VHD was also highly prevalent
(41%).
Other acquired pathogeneses
(less frequent):
1. Infective endocarditis,
2. radiation therapy,
3. drug-induced VHD,
4. inflammatory diseases.
5. Associations
The most frequent associations were aortic stenosis (AS) plus aortic
regurgitation (AR), AS plus mitral regurgitation (MR) and AR plus MR.
Shift from Rheumatic Degenerative = in in industrialized countries
reflecting aging and the overall decreased incidence of rheumatic fever
AS + MS
Degenerative mitral annulus and leaflet calcifications often coexist with AS
in the elderly patients and may cause MS.
This multiple VHD entity is often associated with worse prognosis and
poses specific therapeutic challenges because balloon commissurotomy or
surgical mitral valve replacement is often not an option in these patients.
6. Associations
MR/TR + Other.
Secondary MR and tricuspid regurgitation (TR) may develop in patients
with aortic VHD and in patients with right ventricular volume or
pressure overload because of left-sided or pulmonary VHD.
Because of the high prevalence of coronary artery disease with
previous myocardial infarction in patients with degenerative VHD,
associated ischemic MR is not uncommon.
PR + Other
is unusual, and acquired pathogeneses include endocarditis, carcinoid
disease, and, rarely, left-sided VHD-related pulmonary hypertension
Congenital pathogeneses
far less frequent. In industrialized countries, it is mainly Bicuspid valve
+ other VHD.
7. Pathophysiology
The main hemodynamic interactions that may impact on the diagnosis of
multiple and mixed VHDs are
(1) low-flow, low-gradient stenosis is frequent;
(2) mixed valve disease may be associated with increased anterograde flow and
gradient;
(3) the continuity equation is inapplicable when transvalvular flows are unequal;
(4) any severe valvular lesion may induce or increase upstream secondary MR or
TR;
(5) pressure half-time–derived methods may be invalid in the presence of
altered left ventricular (LV) compliance/relaxation in the presence of mixed
VHD.
8. Echocardiographic assessment
Combination of
Valve Lesions
AS AR MS MR
AS
C: AR pressure half-
time method
unreliable
C: MS pressure half-
time method
unreliable
C: increased mitral
regurgitant volume
S: peak aortic jet
velocity and Doppler
mean gradient
reflect severity of
both AR and AS
C: low-flow, low-
gradient MS can
occur
C: Increased area of
MR jet using color-
flow mapping. Mitral
effective regurgitant
orifice less affected
than MR volume and
color-flow mapping
parameters
S: 3D
echocardiography to
measure mitral valve
anatomic area and
confirm MS severity
S: CMR may be used
to quantify MR
volume and fraction
and corroborate MR
severity
9. Echocardiographic assessment
Combination of
Valve Lesions
AS AR MS MR
AR
C: simplified Bernoulli equation
for gradient determination might
not be applicable if LV outflow
tract velocity is elevated
C: aortic regurgitant jet
can be mistaken for MS
jet
C: Doppler volumetric
method using left-
sided assessment of
net forward flow invalid
C: Gorlin formula using
thermodilution/Fick method is
invalid
C: continuity equation is
unreliable to calculate
mitral valve area if aortic
valve is used as the
reference flow
C: mitral-to-aortic
velocity time integral
ratio unreliable
S: Continuity equation is
applicable to assess AVA
C: MS pressure half-time
method unreliable
S: the PISA method
remains accurate for
the assessment of MR
C: most echo parameters only
reflect the severity of only one
component of the disease: AS
(AVA) or AR (regurgitant orifice
area or volume)
S: 3D echocardiography
to measure mitral valve
anatomic area and
confirm MS severity
S: peak aortic jet velocity and
Doppler mean gradient reflect
severity of both AS and AR
S: consider using
pulmonic flow as the
reference for the
continuity equation
10. Echocardiographic assessment
Combination of
Valve Lesions
AS AR MS MR
MS
C: low-flow, low-
gradient AS is
common
C: MS can blunt the
increase in pulse
pressure and the LV
dilation associated
with AR
C: mitral-to-aortic
velocity time
integral ratio
unreliable
S: DSE or aortic
valve calcium
scoring by MDCT
can be used to
confirm AS severity
S: Doppler mitral
gradient reflects
severity of both MS
and MR
11. Echocardiographic assessment
Combination of
Valve Lesions
AS AR MS MR
MR
C: mitral regurgitant jet
should not be mistaken
for the AS jet
C: Doppler volumetric
method using left-sided
assessment of net
forward flow invalid
C: continuity
equation unreliable
C: low-flow, low-
gradient AS is common
C: pressure half-time
method can be
unreliable
C: pressure half-time
method may not be
reliable
S: DSE or aortic valve
calcium scoring by
MDCT can be used to
confirm AS severity
S: CMR may be used to
quantify AR and MR
volumes and fractions
and corroborate both
AR and MR severity
C: Gorlin formula
using thermodilution
invalid
S: Doppler mitral
gradient reflects
severity of both MS
and MR
12. Cardiac Catheterization
Cardiac catheterization is recommended where imaging is
inconclusive or discordant.
It remains commonly performed in patients with multiple
VHD (B Lung, Eur Heart J, 2003). 👀
Cardiac Output caveats:
Accurate CO is essential for the Gorlin formula
But is inaccurate in patients with severe TR and very low CO
states (common in multiple VHD patients)
Also, right heart flow does not equal the transvalvular flow in
patients with mixed aortic and mixed mitral VHD, thus, the
Gorlin formula is inherently inaccurate and should not be
used in this setting.
13. 3D and Stress Echocardiography #echoFirst
Three-dimensional echocardiography can be ideal:
1. To obtain more accurate assessment of aortic valve area
Allows direct measurement of LV outflow tract area (the which is usually not circular).
2. To measure mitral valve area in rheumatic MS.
Stress echocardiography may be used:
1. To distinguish true severe from pseudosevere AS
2. Symptoms disproportionate to resting hemodynamics – may provide a
mechanistic explanation e.g. increase in transvalvular gradient or PA pressure
3. Resting hemodynamics are disproportionate to symptoms – may unmask
symptoms, an abnormal blood pressure response to exercise, ST-segment
abnormalities, or exercise-induced arrhythmias.
14. MDCT #yesCCT
Multidetector computed tomography calcium score:
For low-flow, low-gradient AS and preserved LV ejection fraction.
High calcium scores = increased likelihood of severe AS
15. Cardiac MR #whyCMR
In patients with discrepant results
Useful for:
1. Regurgitant fraction
Do not rely solely on ventricular volumes for regurgitant fraction as it assumes that
only one valve is affected
Use phase contrast mapping instead.
2. Ventricular volumes and EF
16.
17.
18. Case 1 – AS & AR
Transthoracic echocardiographic images in a symptomatic
(New York Heart Association class II and III) man with a
body surface area of 1.85 m2. A, Parasternal long-axis
color Doppler view showing a moderate aortic
regurgitation. The vena contracta width is 5.8 mm. B and
C, Left ventricular outflow tract diameter is 26.5 mm, and
VTI is 25 cm with a calculated stroke volume of 138 mL.
The aortic flow velocity time integral by continuous wave
Doppler valve effective orifice area by continuity equation
is 1.34 cm2 (indexed, 0.72 cm2/m2). Hence, the
echocardiographic findings suggest the concomitance of
a moderate aortic regurgitation with a moderate aortic
stenosis.
In this case, it is challenging to establish whether or not
aortic valve intervention is indicated. Neither the aortic
regurgitation nor the aortic stenosis is severe and
mandate intervention according to the guidelines.
However, (D) shows a peak velocity of 4.5 m/s and a mean
gradient of 44 mm Hg. These parameters provide an
assessment of the severity of the overall aortic valve
disease, that is, regurgitation plus stenosis.
The patient was thus referred to aortic valve replacement.
19. Case 2 –
AR & MS
Fifty-six-year-old woman with concomitant rheumatic mitral and aortic valve disease. A, Transthoracic
echocardiographic color Doppler apical 4-chamber view during diastole showing aortic regurgitation jet
(yellow arrow) and accelerated transmitral flow velocities consistent with mitral stenosis (white arrow). B,
Continuous wave Doppler signal and tracing across the mitral valve, with an 8-mm Hg mean diastolic
pressure gradient, a 1.5 cm2 mitral valve area using the pressure half-time method.
20. Case 2 –
AR & MS
C, Aortic valve CW = mean gradient 16mmHg, AVA 1.5cm2. The ERO for AR was 0.20 cm2 by PISA (not
shown). D, Three-dimensional (3D) view of the mitral valve orifice, with a 1.1-cm2 mitral valve area using 3D
reconstruction of the mitral valve orifice (E).
This case highlights the overestimation of MVA using PHT method. Furthermore, the continuity equation for
MVA cannot be used due to AR. 3D echo and planimetry are ideal.
In summary, this patient had concomitant severe mitral stenosis, moderate aortic regurgitation, and mild-
to-moderate aortic stenosis.
21. Case 3 – ASMR 😂
Eighty-year-old symptomatic man with concomitant aortic stenosis, aortic regurgitation, and mitral
regurgitation. A, Transthoracic echocardiographic parasternal long-axis view in midsystole. Left ventricular
(LV) ejection fraction is 65%. The aortic valve is calcified, and there is a P2 mitral valve prolapse with a dilated
left atrium (LA). B, Moderate mitral regurgitation with eccentric jet (orange arrow). C, Mild aortic regurgitation
(orange arrow).
22. Case 3 – AS & MR
D, AV is severely calcified. LVOT diameter is 24.9 mm and Annulus diameter 24.4 mm. E, LVOT flow velocity by
pulsed wave Doppler. The LVOT velocity time integral is 11 cm, and the calculated SV in the LVOT is 54 mL.
The SVI is thus 30 mL/m2 (body surface area, 1.8 m2), consistent with a low-flow state. F, Continuous-wave
Doppler of the aortic valve flow. The aortic mean gradient is 28 mm Hg, and the aortic valve area by
continuity equation is 0.75 cm2.
There is thus a discordant echocardiographic grading, with the concomitance of a small valve area and a low
gradient.
23. Case 3 – AS & MR
G, Parasternal short-axis view in midsystole showing a calcified aortic valve with restricted opening. H,
Noncontrast multidetector computed tomography showing severe valve calcification (aortic valve calcium
score, 2395 AU).
Thus, considered to have true severe AS. Underwent TAVR with a SAPIEN 3 valve. I, MR (orange arrow) at 30 d
post-valve replacement. The severity of MR was similar compared with baseline.
24. Case 3 – AS & MR
The stroke volume increased to 60 mL but remained in the low-flow range (33 mL/m2). The aortic valve area
was 1.97 cm2, and the mean gradient decreased to 7 mm Hg. Symptoms improved from NYHA III I/II 1 mo
after intervention.
In summary, this is a case of a patient with severe AS with paradoxical (preserved LV ejection fraction) low-
flow, low-gradient pattern. The low-flow state was, at least partly due to MR. Severe AS was confirmed by
MDCT.
25. Case 4 – AS & MR
This 85-y-old patient
presenting severe aortic
stenosis and
degenerative mitral
regurgitation because of
prolapsed A2 segment
underwent transcatheter
aortic valve replacement
as initial procedure.
Severe MR persisted after
aortic valve replacement,
as shown by the long-axis
transesophageal view (A),
and the patient remained
symptomatic. A MitraClip
procedure was thus
performed (B), with only
minimal residual MR (C).
26. Management
Summary of the AHA/ACC and ESC/EACTS Guidelines:
Left sided VR for severe VHD is indicated when undergoing other cardiac
surgery (Class I)
Right sided VR for severe VHD is indicated at the time of operation for left-
sided VHD (Class I)
Mitral valve surgery is reasonable for patients with chronic severe secondary MR
(stages C and D) who are undergoing AVR. (Class IIa)
Left sided VR for moderate VHD is reasonable when undergoing other cardiac
surgery (Class IIa)
Tricuspid repair may be beneficial for moderate TR at the time of operation for
left-sided VHD if there is: tricuspid annular dilatation, right heart failure,
pulmonary HTN (Class IIa)