[Echo] Mitral stenosis

Mitral stenosis - severity

Recommendations for classification of mitral stenosis severity

	Mild	Moderate	Severe
Specific findings
Valve area (cm2)	less than 1.o	1.0-1.5	more than 1.5
Supportive findings
Mean gradient (mmHg)a	less than 5	5-10	more than 10
Pulmonary artery pressure (mmHg)	less than 30	30-50	more than 50
At heart rates between 60 and 80 bpm and in sinus rhythm.

測量MS Seveity的三大指標：

(1) Pressure gradient 

       - diastolic pressure gradient

       - "mean" mitral gradient

       - transmitral velocity flow curve (CW  is preferred)

(2) MVA Planimetry

      - direct tracing of the mitral orifice, including opened commissures

      - parasternal short-axis view

(3) Pressure half-time

     -  T1/2 單位:  milliseconds (ms)

     -  MVA = 220 / T1/2

Wilkins score:

Cormier score:

      

Pulmonary embolism

Case: 

CC: Chronic dyspnea for 2yrs

PE: Widely split S2、accentuated P2、borderline JVE

ECG: SR, tall R in V1, S1Q3T3

Echocardiogram: McConnell's Sign

( Akinesia of the mid-free wall but normal motion of the apex. A 77% sensitivity and a 94% specificity for the diagnosis of acute pulmonary embolism in the setting of right ventricular dysfunction)

Another echocardiographic finding of PE: 60/60 sign

(The “60/60” sign is defined 

as an acceleration time ≦ 60 milliseconds in the presence of a

tricuspid regurgitation pressure gradient of < 60 mmHg.

The sensitivity, specificity, PPV, and negative predictive value of the

60/60 sign in the diagnosis of acute PE was reported to be 25%,

94%, 90%, and 38% respectively.)

Typical PE finding of PE: widely split S2、accentuated P2、RV heave、parasternal S4、high JVP

Q: acute PE和chronic PE的差別?

[ECHO] TEE: 20 standard view

Virtual TEE: Standard Views, Cardiac ... 

ECHO_Aortic stenosis

EAE/ASE guideline-Echocardiographic Assessment of Valve Stenosis

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[Heart ECHO]Right ventricle systolic pressure

https://www.stanford.edu/group/ccm_echocardio/cgi-bin/mediawiki/index.php/Right_ventricle_systolic_pressure#.C2.A0Calculation_of_right_ventricle_systolic_pressure_.28RVSP.29


Right ventricle systolic pressure
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Contents [hide]
1 Calculation of right ventricle systolic pressure (RVSP)
1.1 Measurement of the pressure gradient between right ventricle (RV) and right atrium (RA)
1.2 Estimation of right atrium (RA) pressure
2 Example
3 Reference


Calculation of right ventricle systolic pressure (RVSP)
The right ventricle systolic pressure can be non-invasively measured by echocardiography.

It is obtained by the addition of the pressure gradient between the right ventricle and the right atrium, to the pressure in the right atrium.



Measurement of the pressure gradient between right ventricle (RV) and right atrium (RA)
The RV-RA pressure gradient is measured using the maximum velocity of the tricuspid regurgitation jet.

The maximum velocity measured as the peak regurgitation (systolic) is converted to pressure with Bernouilli law:

P = 4 V2

The maximum velocity of the tricuspid regurgitation can be measured from the parasternal short axis view or from the apical 4 chamber view. It is crucial to get a good envelope of the regurgitant jet, which means that the measurement is accurate.





Estimation of right atrium (RA) pressure
In patients with central venous lines, the RA pressure is easily measured: it is the central venous pressure (CVP).

In spontaneously breathing patients, the RA pressure is estimated from the measurement of the IVC size and collapsibility index:

(maximum diameter - minimum diameter) / maximum diameter.


Example
Apical 4 chamber view, color Doppler on tricuspid valve. Visualization of trace tricuspid regurgitation





Apical 4 chamber view, CW-Doppler aligned on tricuspid regurgitation. Measurement of maximum velocity: 228 cm/sec, translated into maximum pressure gradient between RV and RA: 21mmHg.






Subcostal view, Mmode on IVC. Measurement of maximum and minimum diameter.

--> Collapsibility index = (25.4-23.7)/23.7 = 7 %

--> RA pressure estimated at 20mmHg

Result: RVSP = 21 + 20 = 41 mmHg

Reference
Evaluation of size and dynamics of the inferior vena cava as an index of right-sided cardiac function. Moreno F.L., Hagan A.D., Holmen J.R., Pryor T.A., Strickland R.D., Castle C.H. Am J Cardiol (1984) 53 : pp 579-585