Echocardiography in the Assessment of Valve Regurgitation– Incremental Role of Three Dimensional Echocardiography

Figures

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  Fig. 1.. Degenerative MR due to Flail posterior mitral valve leaflet. (A) TEE 4 chamber view showing a flail posterior mitral valve resulting in a severe anteriorly directed mitral regurgitation jet. LA, left atrium; LV, left ventricle; AML, anterior mitral leaflet; PML, posterior mitral leaflet. (B) TEE 4 chamber view color Doppler showing anteriorly directed mitral regurgitation with PISA (red arrow). AML, anterior mitral leaflet; AV, aortic valve. (C) Pulsed wave Doppler showing left upper pulmonary vein systolic flow reversal. (D) 3D TEE enface view of the mitral valve from the atrial perspective demonstrating P2 flail scallop with torn chordae. Aortic valve is a 9 o’clock position. AML, anterior mitral leaflet; PML, posterior mitral leaflet.

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  Fig. 2.. Mitral leaflet Cleft. (A) TTE short axis at the mitral valve level showing posterior mitral cleft. (B, C) Isolated cleft within the P2 segment of the posterior leaflet (associated with mitral regurgitation) on 3D TEE and TTE short axis views. AML, anterior mitral leaflet; PML, posterior mitral leaflet.

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  Fig. 3.. Functional Mitral regurgitation. (A) Transesophageal echocardiogram biplane view shows a dilated LV with mitral valve coaptation point displaced into the LV and central MR jet. (B) 3D TEE showing central mitral leaflet malcoaptation (white asterisks). (C) 3D TEE surgical view of the mitral valve showing severe central mitral regurgitation. LA, left atrium; LV, left ventricle; AML, anterior mitral.

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  Fig. 4.. Functional Tricuspid regurgitation. (A) TEE mid esophageal inflow-outflow view shows a dilated RV and tricuspid annulus (white arrows). (B) TEE 4 chamber view color Doppler showing centrally directed severe tricuspid regurgitation with PISA (white arrows). (C) PW Doppler showing systolic hepatic flow reversal, which suggests severe TR (red arrows). RA; right atrium; RV, right ventricle; AO, aorta.

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  Fig. 5.. Tricuspid regurgitation induced by pacemaker lead impingement. (A) 3D transthoracic echo showing and dilated RV, RA and anterior leaflet impingement by the device lead (red arrows). (B) Inspiratory systolic hepatic flow reversal (red arrows), which suggests severe TR. (C) Apical four chamber view showed severe tricuspid regurgitation. RA, right atrium; RV, right ventricle; AV, aortic valve; AL, anterior leaflet; PL, posterior leaflet; SL, septal leaflet; MV, mitral valve.

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  Fig. 6.. Tricuspid regurgitation induced by pacemaker lead valve perforation. (A) Transthoracic 2D 4 chamber view showing pacemaker lead going through the TV leaflet (white arrow) and causing TR. (B) 3D enface view of the TV from the right atrial perspective showing the pacemaker lead going through the margin of the septal leaflet (SL) of the TV (white arrow). (C) 3D color Doppler view of the TV from the atrial perspective showing origin of TR at the site of leaflet perforation. MV, mitral valve; AV, aortic valve; PL, posterior leaflet; AL, anterior leaflet

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  Fig. 7.. Tricuspid regurgitation following endomyocardial biopsy. (A) Flail tricuspid valve leaflet that occurred as a complication of an endomyocardial biopsy. Apical 4 chamber view showed flail septal leaflet (SL, septal leaflet; AL, anterior leaflet). (B) Color-flow Doppler imaging. Eccentric, anteriorly directed jet of tricuspid regurgitation (SL, septal leaflet of tricuspid valve; AL, anterior leaflet of tricuspid valve).

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  Fig. 8.. Aortic regurgitation and left coronary cusp perforation. (A) TTE color Doppler parasternal short axis view demonstrating left coronary cusp perforation (white arrows), resulting in aortic regurgitation. (B) TTE color Doppler short axis view showing origin of aortic regurgitation through the left coronary cusp perforation (white arrow). (C) TEE color Doppler short axis view showing a better delineation of the origin of aortic regurgitation jet through the left coronary cusp perforation (white arrow). (D) TEE long axis view demonstrating the perforated coronary cusp on 2D (white arrow) with aortic regurgitation jet originating through the perforation (white arrow) and not through the aortic leaflet coaptation. (E) 3-dimensional (3D) TEE short axis view of the aortic valve showed a clear definition of the left coronary cusp perforation (white arrow). (F) 3-D TEE color Doppler short axis view showing aortic regurgitation jet originating through the left coronary cusp (black arrowhead). Direct planimetry of color Doppler aortic regurgitant orifice can be performed online or via offline post processing of 3D data sets without geometrical assumptions of PISA method or continuity equation.

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  Fig. 9.. Aortic valve regurgitation induced by dilated annulus. (A) Transthoracic echocardiogram parasternal long axis view showing markedly dilated aortic sinuses (red arrow). (B) Imaging at a higher parasternal window shows aneurysmal aortic sinuses (red arrow) and normal ascending aorta above sinotubular junction. (C) Three chamber view with continuous-wave (CW) Doppler showing dense AI Doppler envelope with a steep deceleration slope (red arrows) suggesting severe AI. (D) CW Doppler recording at the proximal descending thoracic aorta demonstrating pandiastolic flow reversal (red arrows), another feature of severe AI. (E) Color Doppler parasternal long axis view showing AI color jet occupying two third of the LV outflow tract with a wide vena contracta at origin from the aortic valve leaflets (>0.6cm) – two other features of severe AI. (F) Color Doppler apical 3 chamber view showing measurement of AI flow convergence radius (black arrows) to calculate effective regurgitant orifice area by proximal isovolumic flow acceleration method.

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  Fig. 10.. Endocarditis induced aortic cusp tear and aortic regurgitation (AR) demonstrated by TEE: (A) TEE transgastric (TG) view showing dense CW Doppler signal of AR with a steep slope, (B) Mid esophagel (ME) long axis view showing torn and flail aortic valve cusp, (C), same view showing severe AR on color Doppler, (D) ME short axis view showing a tricuspid aortic valve, (E) TEE TG view showing dilated LV and severe AR on color Doppler and (F) torn AV leaflet on 2D. (G) transthoracic parasternal long axis view showing a dilated LV and poorly defined AR on color Doppler, (H) transthoracic AV short axis view with an ill-defined view showing possible of the torn left coronary cusp (white arrow).

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  Fig. 11.. Pulmonic valve regurgitation. (A) TTE basal short axis view showing color Doppler of pulmonic valve (in the long axis view) and aortic valve in the short axis view. There is severe pulmonic regurgitation as shown by a wide diastolic jet in the RVOT occupying >60% of RVOT (white arrow). This jet was very short only visible in 2 frames. AV, aortic valve; RVOT, right ventricular outflow tract. (B) Corresponding CW Doppler showing dense PR signal with rapid deceleration of PR velocity to baseline (white arrows) so that the PR signal terminates before the onset of the next cardiac cycle.

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  Fig. 12.. Pulmonic valve regurgitation and stenosis. Transthoracic echocardiographic images in a patient with carcinoid syndrome involving the pulmonic valve. Short axis biplane color Doppler views at the cardiac base showing severe pulmonic insufficiency (black asterisks - (A) and turbulent forward flow in systole due to pulmonic stenosis in (B). Three dimensional transthoracic views showing diffusely thickened and restricted pulmonic valve leaflets in systole (white arrow - (C)) and incomplete closure of the thickened pulmonic valve leaflets in diastole (white arrow - (D)) causing severe pulmonic regurgitation.