Case Reviews: Hemodynamic Calculations in Valvular Regurgitation

Transcription

1 Case Reviews: Hemodynamic Calculations in Valvular Regurgitation

2 Case 5 History: 69-year-old man with orthotopic heart transplant 15 years ago. Inferior MI several years ago. Recurrent CHF. Currently dyspneic with minimal exertion. Exam: S1 and S2 normal. S3 present. Grand 2/6 holosystolic murmur. Measurements: PISA radius Alias velocity MR CW velocity MR CW TVI 1.1 cm 44 cm/sec 5.53 m/sec 1.31 m Calculate the following: 1. MR flow rate 2. MR ERO 3. MR RV

3 Case 5 Answers 1. MR flow rate Flow rate = (2Π) x (r) 2 x (Alias velocity) = (6.28) x (1.1 cm) 2 x (44cm/sec) = 338 cc/sec 2. ERO ERO = (Flow Rate) (MR CW velocity) = (338 cc/sec) (556 cm/sec) = 0.6 cm 2 3. RV RV = (ERO) x (MR CW TVI) = (0.6 cm 2 ) x (131 cm) = 79 cc

4 Case 6 History: 57-year-old woman with mitral valve prolapse. Mitral regurgitation characterized as at least moderate by recent echo. She has no cardiac symptoms. Measurements: BSA 1.89 m 2 PISA radius 1.5 cm Alias velocity 49 cm/sec MV annulus diameter 3.5 cm MD annulus TVI 19 cm LVOT diameter 2.3 cm LVOT TVI 24 cm MR CW velocity 520 cm/sec MR CW TVI 175 cm A. Should you use the PISA method to quantitate her MR? B. Use the continuity method to calculate 1) Regurgitant volume 2) LVOT stroke volume index 3) Effective regurgitant orifice area

5 Case 6 Answers A. The PISA hemisphere is distorted by the lateral wall of her left ventricle, so using the PISA method here will significantly over represent the amount of mitral regurgitation. So do not use PISA method for this case (out of interest, if you did use PISA calculations you would obtain MR flow rate 692 cc/sec, ERO 1.3 cm 2, and RV 228 cc). B. Continuity method 1) Regurgitant volume = (MV stroke volume) (Aortic stroke volume) a) Mitral SV = (MV area) x (MV TVI) = (0.785) x (3.5 cm) 2 x (19 cm) = 183 cc b) Aortic SV = (LVOT area) x (LVOT TVI) = (0.785) x (2.3 cm) 2 x (24 cm) = 100 cc c) Regurgitant volume = (183 cc) (100 cc) = 83 cc 2) Stroke Volume Index = (LVOT SV) (BSA) = (100 cc) (1.89 m 2 ) = 53 cc/m 2 Normal = cc/m 2 3) Effective Regurgitant Orifice Area = (Regurgitant Volume) (MR CW TVI) = (83 cc) (175 cm) = 0.47 cm 2

6 Case 7 History: This 36-year-old man developed strep viridans endocarditis which caused aortic regurgitation. After the infection was eradicated he began to note dyspnea and mild chest tightness with exertion. The following echo/doppler data were obtained: Heart rate 63/min BSA 2.22 m 2 LVOT d 2.9 cm LVOT TVI 34 cm MV annulus d 3.2 cm MV annulus TVI 14 cm Aortic regurgitation TVI 202 cm Calculate the following: Cardiac Output Cardiac Index Regurgitant Volume Regurgitant Fraction Effective Regurgitant Orifice Area

7 Case 7 Answers 1. Before calculating the cardiac output and index you have to recognize that he has significant aortic regurgitation. Therefore you cannot use the LVOT diameter and TVI to calculate forward output -- since the LVOT stroke volume contains not only the forward output, but also the regurgitant volume. He has no significant mitral regurgitation, so the mitral annulus data can be used for cardiac output and index: Mitral Stroke Volume = (3.2) 2 x (0.785) x (14) = 113 cc Cardiac Output = (113) x (63) = 7.1 L/min 2. Cardiac Index = (7.1) (2.22) = 3.2 L/min/m 2 3. Regurgitant Volume = (LVOT SV) (MV annulus SV) LVOT SV = (2.9) 2 x (0.785) x (34) = 224 cc RV = (224) (113) = 111 cc 4. Regurgitant Fraction = (RV) (LVOT SV) = = 50% 5. Effective Regurgitant Orifice Area = (RV) (Regurgitation TVI) = (111) (202) = 0.55 cm2

8 Case 8 History: 55-year-old man with systolic murmur for 9 years. Bi-leaflet MV prolapse with significant regurgitation on previous echoes. Exercises at altitude of 8,500 ft. No symptoms. Measurements: PISA radius Alias velocity MR CV velocity MR CW TVI 1.0 cm 49 cm/sec 5.27 m/sec 1.31 m Calculate the following: 1. MR ERO 2. MR RV

9 Case 8 Answers 1. MR ERO Flow Rate = (2 Π) x (r 2 ) x (alias velocity) = (6.28) x (1 cm) 2 x (49 cm/sec) = 308 cc/sec ERO = Flow Rate CW velocity = (308 cc/sec) (527 cm/sec) = 0.58 cm 2 2. MR RV RV = (ERO) x (CW TVI) = (0.58 cm 2 ) x (131 cm) = 76 cc

10 Case 9 History: 55-year-old man with staph sepsis 26 years ago. Known AR and MR. Recent DOE. There are 2 MR jets, by color Doppler. Measurements: Mitral Aortic PISA 1 r Alias velocity PISA 2 r Alias velocity MR velocity MR TVI PISA r Alias velocity AR velocity AR TVI 0.6 cm 37 cm/sec 1.0 cm 37 cm/sec 563 cm/sec 171 cm 0.8 cm 46 cm/sec 503 cm/sec 221 cm Calculate the following: 1. MR flow rate 2. MR ERO 3. MR RV 4. AR ERO 5. AR RV

11 Case 9 Answers The overall ERO and regurgitant volume for the MR can be calculated as the sum of ERO1 and ERO2 and the sum of RV1 and RV2. The same CW velocity and TVI are used for both jets. Therefore, you can simply sum the flow rates for the 2 jets, and then use the CW data. 1. MR flow rate = flow rate 1 + flow rate 2 flow rate 1 = (PISA1 r) 2 x (6.28) x (alias velocity) = (0.6 cm) 2 x (6.28) x (37 cm/sec) = 84 cc/sec flow rate 2 = (PISA2 r) 2 x (6.28) x (alias velocity) = (1.0 cm) 2 x (6.28) x (37 cm/sec) = 232 cc/sec MR flow rate = (84) + (232) = 316 cc/sec 2. MR ERO = (flow rate) (MR velocity) = (316 cc/sec) (563 cm/sec) = 0.56 cm 2 3. MR RV = (ERO) x (MR TVI) = (0.56 cm 2 ) x (171 cm) = 96 cc 4. AR ERO = (AR flow rate) (AR velocity) = (PISA r) 2 x (6.28) x (alias velocity) (AR velocity) = (0.8 cm) 2 x (6.28) x (46 cm/sec) (503 cm/sec) = (185 cc/sec) (503 cm/sec) = 0.37 cm 2 5. AR Regurgitant Volume = (ERO) x (AR TVI) = (0.37 cm 2 ) x (221 cm) = 82 cc