© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12773

Echocardiography

DOPPLER HEMODYNAMICS

Spectral Doppler of the Hepatic Veins in Tricuspid Valve Disease Bahaa M. Fadel, M.D.,* Khaled Almulla, M.D.,* Aysha Husain, M.D.,* Ziad Dahdouh, M.D.,* Giovanni Di Salvo, M.D.,* and Dania Mohty, M.D., Ph.D.† *King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; and †CHU Limoges, Limoges, France

Spectral Doppler recording of the hepatic veins (HV) provides a semiquantitative assessment of tricuspid regurgitation (TR) severity. It complements findings on two-dimensional echocardiography and color Doppler imaging and helps to discriminate between hemodynamically significant and nonsignificant degree of regurgitation. In this manuscript, we discuss the usefulness of the HV Doppler for the diagnosis of tricuspid valve (TV) disease and provide examples of the various spectral Doppler patterns that assist in the quantification of TR. (Echocardiography 2015;32:856–859) Key words: echocardiography, tricuspid regurgitation, tricuspid valve stenosis, Doppler echocardiography

Discussion: Tricuspid Regurgitation: The most common use for spectral Doppler imaging of the hepatic vein (HV) in the echocardiography laboratory relates to the assessment of the severity of tricuspid regurgitation (TR). The latter is a relatively common valvular lesion that carries a negative impact on survival.1 The echocardiographic criteria for assessment of TR severity are less well defined than those for left-sided valvular regurgitation. Current recommendations emphasize the combination of qualitative and quantitative parameters of severity.2 Qualitative parameters include the evaluation of tricuspid valve (TV) anatomy, right ventricular (RV) size, and the density and contour of the continuouswave Doppler signal of TR. The quantitative parameters of severity including the vena contracta, color jet area, and flow convergence of TR are more difficult to reproduce and less well validated than for mitral regurgitation.2,3 In combination with the above parameters, pulse-wave Doppler interrogation of the HV has emerged as a valuable marker of the severity of TR.4,5 Furthermore, findings on the HV Doppler are the only independent echocardiographic predictors of clinical TR.3 Mild TR does not lead to any changes in the HV Doppler (Fig. 1).4,5 Conversely, severe TR is Address for correspondence and reprint requests: Bahaa M. Fadel, M.D., King Faisal Specialist Hospital & Research Center, Heart Center, PO Box: 3354, MBC # 16, Riyadh 11211, Saudi Arabia. Fax: 966-114427482; E-mail: [email protected]

856

almost always associated with abnormalities on the HV Doppler.3–8 Thus, a normal HV Doppler strongly argues against the presence of hemodynamically significant TR (Fig. 1). Progressive worsening of TR leads to a gradual decrease in the peak systolic (S) velocity and systolic filling fraction of the HV flow. In general moderate TR causes blunting of the S-wave resulting in a more prominent diastolic (D) velocity and an S < D pattern (Fig. 2).4,8,9 As a general rule, the more severe the TR is, the more prominent is the “v” wave in the right atrial (RA) and the lower is the systolic velocity

Figure 1. Mild tricuspid regurgitation. Pulse-wave Doppler recording of the hepatic vein (HV) demonstrates a normal flow-pattern with 4 phasic components. The forward systolic (S) velocity is larger than the diastolic (D) velocity. Two reversal waves are noted in late systole (V-wave) and late diastole (A-wave). In the absence of other right heart pathologies, mild tricuspid regurgitation (TR) does not alter the HV flow profile.

Hepatic Vein Doppler in Tricuspid Disease

in the HV.4,5 When severe TR is present, a complete reversal of the S-wave is often evident on every cardiac cycle. Thus instead of the forward S-wave, the HV Doppler demonstrates a retrograde or systolic reversal (SR) wave that typically peaks in late systole (Figs. 3, 4, and 5).3–8 Hemodynamically the

Figure 5. Severe tricuspid regurgitation (TR) and atrial fibrillation on transesophageal echocardiography (TEE). Pulsewave Doppler interrogation of the hepatic vein (HV) complements other parameters for the quantification of TR during TEE studies. The Doppler profile shows prominent holosystolic flow reversal (SR). In contrast to transthoracic imaging, the SR is noted below the baseline due to the direction of flow within the HV on TEE. Figure 2. Moderate tricuspid regurgitation. The hepatic vein (HV) Doppler shows an abnormally blunted systolic (S) wave, a large diastolic (D) wave, and an S/D ratio

Spectral Doppler of the hepatic veins in tricuspid valve disease.

Spectral Doppler recording of the hepatic veins (HV) provides a semiquantitative assessment of tricuspid regurgitation (TR) severity. It complements f...
370KB Sizes 0 Downloads 6 Views