Pulmonic regurgitation echocardiography

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Pathophysiology

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Differential diagnosis

Epidemiology and Demographics

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Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2], Aysha Aslam, M.B.B.S[3]

Overview

Echocardiography is the initial test which may be used to assess pulmonary valve morphology,RVOT anatomy, and to identify the presence and quantify the severity of PR. Different modes of echocardiography may be used to improve the accuracy of findings and assess the severity of the disease which include colour flow doppler, flow convergence method, pulsed doppler, spectral doppler and exercise echocardiography.[1][2][3]

Echocardiography

It is the initial imaging diagnostic test to study the pulmonary valve, RVOT anatomy, to identify the presence and quantify the severity of PR. The findings include:[1]

Colour Flow Doppler

The findings suggestive of significant PR include: [5][6][7][8][9]

  • A narrow small central and spindle shaped regurgitant jet is seen in mild PR.
  • In severe PR a wide diastolic jet at the origin which occupies 65% of the the RVOT width is seen on colour doppler imaging. The duration of the jet increases with increasing severity of PR.
  • In severe PR, a rapid equalization of diastolic pressures between the pulmonary artery and RV occurs, resulting in a short-lived regurgitant jet which can mislead in diagnosis of the severity of PR.
  • In patients with chronic significant PR, dilation of the RV can be demonstrated. In patients with physiologic PR and acute PR RV dimensions are normal.

Vena Contracta Width

It is a more accurate method to assess the severity of PR, but it lacks validation studies.[10]

Flow convergence method

It can be assessed in few patients but lacks validation studies.[11][12]

Pulsed Doppler

It is useful to assess the forward and regurgitant flows at the pulmonary annulus and the pulmonary artery, which can be used to calculate the regurgitant volume and regurgitant fraction.[13]

Spectral Doppler

The density of the continous wave signal provides a qualitative measure of regurgitation. [14]

  • Pressure half-time (PHT) of less than 100 ms has a high sensitivity and specificity for identifying hemodynamically significant PR in congenital heart disease.[12]
  • PR Index: It is a ratio expressed between the duration of PR and total diastole which is measured from the end of forward pulmonary flow to the beginning of the next forward pulmonary flow curve. It has shown to have equal sensitivity to determine the severity of PR when compared to CMR.[15]
  • Myocardial performance index: Tei index determined by tissue doppler imaging is a sensitive indicator of RV function in patients with chronic PR.[16]

Exercise Echocardiography

It is used to unmask latent RV dysfunction and is a helpful investigation to assess the RV function in patients who have underwent an intervention for significant PR.

Determination of severity of PR based on the findings on echocardiography:[17]

Parameters Mild Moderate Severe
Pulmonic valve morphology Normal Normal or abnormal Abnormal
Colour flow PR jet width Small, usually 10 mm in length with a narrow origin Intermediate
  • Large, with a wide origin
  • Can be brief in duration due to the equalization right ventricular and pulmonary diastolic pressures
Continous wave signal of PR jet Faint/slow deceleration Dense/variable Dense/steep deceleration, early termination of diastolic flow
Pulmonic vs. Aortic flow by pulse wave Normal or slightly increased Intermediate Greatly increased

M-Mode echocardiography

Right ventricular enlargement is often present with a right ventricular volume overload pattern. Fine diastolic fluttering of the tricuspid valve may be observed. Premature opening of the pulmonic valve (defined as pulmonic valve opening on or before the QRS complex) may be observed as result of severe acute pulmonary regurgitation.

2-D echocardiography

Two-dimensional echocardiography may reveal the anatomic basis for the pulmonary regurgitation including causes such as infective endocarditis and valvular pulmonic stenosis. Dilatation of the right ventricle may be present, as well as a right ventricular volume overload pattern.

PW Doppler echocardiography

Care must be exercised in interpreting pulse wave doppler echocardiography as up to 87% of normal patients may appear to have pulmonary regurgitaion on examination. It is therefore critical to calculate the length and duration of the regurgitant jet to differentiate between true and physiologic insufficiency. In physiologic regurgitation the jet is < 1 cm in length and not holodiastolic in duration. The severity of pulmonary regurgitation should be assessed using mapping techniques.

CW Doppler echocardiography

In this analysis, a comparison is made between the regurgitant doppler spectral display and the pulmonic outflow doppler spectral display. The pulmonary artery end-diastolic pressure is assessed as well.

Color Flow Doppler echocardiography

In this analysis, the length and width of the pulmonary regurgitation is assessed. If there is a pattern of proximal acceleration (flow convergence), this is consistent with 3+ or 4+ pulmonary regurgitation.

Assessment of severity

PW and Color flow Doppler

  • Physiologic : < 1 cm in length and not holodiastolic in duration
  • Borderline : 1 to 2 cm in length and holodiastolic in duration
  • Clinically significant : > 2 cm in length with a peak velocity > 1. 5 m/sec and holodiastolic in duration

CW Doppler Spectral Strength of Regurgitant Jet

  • Grade 1+ : Spectral tracing stains sufficiently for detection, but not enough for clear delineation
  • Grade 2+ : Complete spectral tracing can just be seen
  • Grade 3+ : Distinct darkening of spectral tracing is visible but density is less than antegrade flow
  • Grade 4+ : Dark-stained spectral tracing

References

  1. 1.0 1.1 Valente AM, Cook S, Festa P, Ko HH, Krishnamurthy R, Taylor AM; et al. (2014). "Multimodality imaging guidelines for patients with repaired tetralogy of fallot: a report from the AmericanSsociety of Echocardiography: developed in collaboration with the Society for Cardiovascular Magnetic Resonance and the Society for Pediatric Radiology". J Am Soc Echocardiogr. 27 (2): 111–41. doi:10.1016/j.echo.2013.11.009. PMID 24468055.
  2. 2.0 2.1 Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K; et al. (2010). "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography". J Am Soc Echocardiogr. 23 (7): 685–713, quiz 786-8. doi:10.1016/j.echo.2010.05.010. PMID 20620859.
  3. 3.0 3.1 Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA; et al. (2003). "Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography". J Am Soc Echocardiogr. 16 (7): 777–802. doi:10.1016/S0894-7317(03)00335-3. PMID 12835667.
  4. Lancellotti P, Tribouilloy C, Hagendorff A, Popescu BA, Edvardsen T, Pierard LA; et al. (2013). "Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging". Eur Heart J Cardiovasc Imaging. 14 (7): 611–44. doi:10.1093/ehjci/jet105. PMID 23733442.
  5. Maciel BC, Simpson IA, Valdes-Cruz LM, Recusani F, Hoit B, Dalton N; et al. (1991). "Color flow Doppler mapping studies of "physiologic" pulmonary and tricuspid regurgitation: evidence for true regurgitation as opposed to a valve closing volume". J Am Soc Echocardiogr. 4 (6): 589–97. PMID 1760180.
  6. Maciel BC, Simpson IA, Valdes-Cruz LM, Recusani F, Hoit B, Dalton N; et al. (1991). "Color flow Doppler mapping studies of "physiologic" pulmonary and tricuspid regurgitation: evidence for true regurgitation as opposed to a valve closing volume". J Am Soc Echocardiogr. 4 (6): 589–97. PMID 1760180.
  7. Kobayashi J, Nakano S, Matsuda H, Arisawa J, Kawashima Y (1989). "Quantitative evaluation of pulmonary regurgitation after repair of tetralogy of Fallot using real-time flow imaging system". Jpn Circ J. 53 (7): 721–7. PMID 2810683.
  8. Williams RV, Minich LL, Shaddy RE, Pagotto LT, Tani LY (2002). "Comparison of Doppler echocardiography with angiography for determining the severity of pulmonary regurgitation". Am J Cardiol. 89 (12): 1438–41. PMID 12062746.
  9. Puchalski MD, Askovich B, Sower CT, Williams RV, Minich LL, Tani LY (2008). "Pulmonary regurgitation: determining severity by echocardiography and magnetic resonance imaging". Congenit Heart Dis. 3 (3): 168–75. doi:10.1111/j.1747-0803.2008.00184.x. PMID 18557879.
  10. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K; et al. (2010). "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography". J Am Soc Echocardiogr. 23 (7): 685–713, quiz 786-8. doi:10.1016/j.echo.2010.05.010. PMID 20620859.
  11. Lei MH, Chen JJ, Ko YL, Cheng JJ, Kuan P, Lien WP (1995). "Reappraisal of quantitative evaluation of pulmonary regurgitation and estimation of pulmonary artery pressure by continuous wave Doppler echocardiography". Cardiology. 86 (3): 249–56. PMID 7614499.
  12. 12.0 12.1 Silversides CK, Veldtman GR, Crossin J, Merchant N, Webb GD, McCrindle BW; et al. (2003). "Pressure half-time predicts hemodynamically significant pulmonary regurgitation in adult patients with repaired tetralogy of fallot". J Am Soc Echocardiogr. 16 (10): 1057–62. doi:10.1016/S0894-7317(03)00553-4. PMID 14566299.
  13. Goldberg SJ, Allen HD (1985). "Quantitative assessment by Doppler echocardiography of pulmonary or aortic regurgitation". Am J Cardiol. 56 (1): 131–5. PMID 4014018.
  14. Lei MH, Chen JJ, Ko YL, Cheng JJ, Kuan P, Lien WP (1995). "Reappraisal of quantitative evaluation of pulmonary regurgitation and estimation of pulmonary artery pressure by continuous wave Doppler echocardiography". Cardiology. 86 (3): 249–56. PMID 7614499.
  15. Li W, Davlouros PA, Kilner PJ, Pennell DJ, Gibson D, Henein MY; et al. (2004). "Doppler-echocardiographic assessment of pulmonary regurgitation in adults with repaired tetralogy of Fallot: comparison with cardiovascular magnetic resonance imaging". Am Heart J. 147 (1): 165–72. PMID 14691436.
  16. Yasuoka K, Harada K, Toyono M, Tamura M, Yamamoto F (2004). "Tei index determined by tissue Doppler imaging in patients with pulmonary regurgitation after repair of tetralogy of Fallot". Pediatr Cardiol. 25 (2): 131–6. doi:10.1007/s00246-003-0514-3. PMID 14648001.
  17. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K; et al. (2010). "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography". J Am Soc Echocardiogr. 23 (7): 685–713, quiz 786-8. doi:10.1016/j.echo.2010.05.010. PMID 20620859.




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