Novel Stenotic Microchannels to Study Thrombus Formation ...
ECHOCARDIOGRAPHIC ASSESSMENT OF STENOTIC VALVULAR LESIONS
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ECHOCARDIOGRAPHIC ASSESSMENT OF STENOTIC
VALVULAR LESIONSDEEPAK NANDAN
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ANATOMY
Area-2.6-3.5 cm².
Structure 3 cusps,3 commissures supported
by fibrous annulus Arantius nodule 3 sinuses
AORTIC VALVE
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Qualitative diagnosis
Thin and delicate
Plax-opening and closing
Basal short axis view-Y-inverted Mercedes Benz sign
2D-IMAGE
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Maximum jet velocity
◦ BERNOULLI’s equation
◦ Multiple windows
◦ Parallel alignment
◦ Colour doppler
◦ Angle correction
Doppler assessment
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MIPG=4 xV²(maximal jet velocity)m/s
MPG=4x(∑V1²+V2²+…Vn²)/n
MPG=∆P(max)/1.45 +2
MPG=2.4(Vmax)²
Pressure gradients-Instantaneous vMean
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Discrepancies
◦ Tech poor doppler recording
◦ Non parallel interrogation angle
◦ Pressure grad depends on flow rate & valve narrowing –AR/LV dysfunction
Bernoulli's VS invasive
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Continuity equation:-
SV (lvot)= SV (Ao)
SV=CSAxTVI
CSA (lvot) xTVI (lvot)=CSA (Ao) x TVI (Ao)
AVA=CSA x TVI (lvot) / TVI (Ao)
Aortic valve area
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Correlates well with invasive data (GORLINS)
Adv compared to Berrnoulli
co-existing AR
Left ventricular dysfunction
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Rarely are all 3 leaflets imaged perpendicular
Triangular shape- measurement error
Deformities n irregularities- further exacerb
AV- superior-inferior rapid moments
0.25 cm2 margin
AVA-Direct planimetry
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Ao valve area≈Ao flow rate
Dist- true severe valvular stenosis (vs) mild to mod stenosis with LV dysfn
Stepwise infusion of dobutamine(5—30µg/kg/min)
DOBUTAMINE ECHO
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Flexible valves:- AVA ↑ when SV ↑
True stenotis:- AVA↔ when SV ↑
Flexible valves:-Vmax(lvot)/jet ↑
True stenosis:-Vmax(lvot)/jet↔
Safe& clinically useful, limitation- non response to dobutamine
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Stress findings of severe stenosis AVA<1cm² jet velocity>40m/s mean gradient>40mm of Hg
Lack of contractile reserve- failure of LVEF to ↑ by 20% is a poor
prognostic sign
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Maximal aortic cusp separation (MACS) Vertical distance between right CC and non CC
during systole Stenotic AV → decreased MACS
Limitations Single dimension Asymmetrical AV involvement Calcification / thickness ↓ LV systolic function ↓ CO status
M- mode
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AVA MACS
N > 2cm2 N > 15 mm
< 0.75 cm2 < 8 mm
> 1 cm2 > 12 mm
gray area 8 – 12 mm
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Ao valve resistance- flow independent measure of
stenosis severity
Resistance=(∆P/∆Q)mean x1333
Resistance=28√gradient( mean)/AVA
OTHER APPROACHES
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Left ventricular stroke work loss(SWL)
SWL (%) = (100 ×∆ P mean) / (∆P mean + SBP)
Principle-LV expends work during systole to keep the AV open and to eject blood into the aorta
Depends on the stiffness of AVLess dependent on the flow
>25%--- poor outcome
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LVOT overestimated
LVOT TVI recorded too close to valve
Hgh transAo flow rate
mod-sev AR Hgh output state Large body size
LVOT underestimated
LVOT TVI-too far frm val
Small body size Lw transAo flw rate low EF small vent
chamber mod-sev MR mod-sev MS
Discrepencies in AS severity assessmentSevere AS by gradient Severe by area
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Valve anatomy, etiology
Exclude other LVOTO
Stenosis severity – jet velocity
mean pressure gradient
AVA – continuity eq
LV – dimensions/hypertrophy/EF/diastolic fn
Aorta- aortic diameter/ assess COA
AR – quantification if more than mild
MR- mechanism & severity
Pulmonary pressure
APPROACH
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Av ↑in MPG per yr = 0 to 10mm/yr mean 7mm Hg AVA ↓ by 0.1 to ∓ 0.19cm²
Jet vel < 3m/s – rate of symptom onset needing MVR is 8 % /yr
3-4m/s – 17%/yr
>4m/s – 40% /yr
NATURAL HISTORY
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MITRAL STENOSIS
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Mitral annulus
The leaflets
Chordae tendinae-papillary muscle
Underlying ventricular wall
Mitral valve-anatomy
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Annulus
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Leaflets
Anterior- three scallops
Posterior- three scallops
Scallop 1-lateral most
Scallop 3-medial most
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LEAFLETS & SCALLOPS
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Antero lateral PM- chordae to AL half of both leaflets
Dual blood supply
Postero medial PM- chordae to PM half both leaflets
RCA blood supply
Chordae and papillary muscles
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2d echo-features Maximal excursion of leaflet tips Tubular channel
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Commissural fusion⇒doming/bowing
Chordal thickening ⇒ abnormal motion
Progressive fibrosis⇒stiffening ⇒calcification
RHEUMATIC MS
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Doming of the mitral valve (hockey stick AML)
Funnel shaped opening of mitral valves
Focal thickening and beading of leaflets
calcification
Mitral stenosis 2D
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early diastolic doming motion of the AML, restriction of tip motion. Pliable, little fibrosis, calcification, or thickening. Dilated LA
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2D-Planimetry
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2D short axis imaging of diastolic orifice -planimetry
Smallest orifice at the leaflet tips
Inner edge of the black/white interface traced
Correlates well with hemodynamic assessment
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1. Funnel-shaped
Actual limiting orifice at the tip
2. Instrumentation setting
‘’blooming” of the echoes due to increased gain
Technical factors
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M-mode assessment
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Increased echogenicity of leaflets
Decreased E-F slope >80mm/s⇒MVA =4-6cm² <15mm/s⇒MVA <1.3cm²
Paradoxical anterior motion of PML
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Doppler assessment
Trans mitral pressure gradient single most imp factor in determining the
severity & relation to symptoms & functional status
Depends on
Volume statusHeart rate
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Early trans mitral flow volume Cardiac output High output states Mitral reguritation
Mean pressure gradient Average MVA Cardiac output
Peak pressure gradient
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Pressure half time
Measure of rate of decay of mitral valve gradient
Time in ms at which initial instant pr gradient declines to one half
Time interval from V max to the point where velocity has fallen to Vmax/√2
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PHT=½ Peak=V½
V½=Vmax/√2
V½=V max/1.414
V½=Vmax x .707
MVA=220/PHT
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Limitation
Post BMV- accuracy ↓
Aortic regurgitation- over estimates MVA
Severe LVH- ↓LV compliance
Prosthetic mitral valve- not validated
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Independent of
Cardiac output Mitral regurgitation
PHT
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Pressure half time=29% of Deceleration time
MVA=220 ÷ (0.29 × DT)
MVA=759 ÷ DT
Deceleration time
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Left atrial dilation
Atrial fibrillation
Spontaneous echo contrast
LA thrombus
Secondary pulm htn-TR
Secondary features of MS
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Echo approach to MS Valve morphology Exclude other causes of clinical
presentation MS severity Mean transmitral pr gradient 2D valve area PHT valve area Assos MR LA enlargement Pulmonary art pressure Co-existing TR severity TEE for LA clot
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Individuals with score≤8 –excellent for BMV
Those with score≧12-less satisfactory results
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THANK YOU