manual of echocardiography brothers...

Manual of Echocardiography

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Philadelphia | New Delhi | London | Panama

The Health Sciences Publisher

Editors

Navin C Nanda MD DSc (Hon) DSc (Med) (Honoris Causa) FACC FAHA FISCU (D) FSGC FICA FACA

FICP (Hon) FIAE FICMU (Hon) FACIP FCSC (S) FIACS FICC (Hon)

Distinguished Professor of Medicine and Cardiovascular DiseaseDirector, Heart Station/Echocardiography Laboratories

University of Alabama at Birmingham, Birmingham, Alabama, USAPresident, International Society of Cardiovascular Ultrasound

Gültekin Karakuş MD DM

Cardiologist, Acibadem Maslak Hospital Division of Cardiology

Istanbul, Turkey

Aleks Değirmencioğlu MD DM

Assistant Professor of Cardiology Acibadem University School of Medicine

Division of Cardiology Istanbul, Turkey

Manual of Echocardiography

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Jaypee Brothers Medical Publishers (P) LtdHeadquartersJaypee Brothers Medical Publishers (P) Ltd.4838/24, Ansari Road, DaryaganjNew Delhi 110 002, IndiaPhone: +91-11-43574357Fax: +91-11-43574314E-mail: [email protected]

Inquiries for bulk sales may be solicited at: [email protected]

Manual of EchocardiographyFirst Edition: 2016ISBN: 978-93-5152-518-9Printed at:

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Website: www.jaypeebrothers.comWebsite: www.jaypeedigital.com

© 2016, Jaypee Brothers Medical Publishers

The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.All rights reserved. No part of this publication and DVD-ROM may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contra indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.

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Dedicated toMy late parents

Balwant Rai Nanda MD and Mrs Maya Vati Nanda

My wifeKanta Nanda MD

Our childrenNitin Nanda, Anita Nanda Wasan MD and Anil Nanda MD

Their spouses Sanjeev Wasan MD and Seema Tailor Nanda, andour grandchildren Vinay and Rajesh Wasan, and Nayna and Ria Nanda

Navin C Nanda

My parentsNebahat Karakuş MD and Esef Karakuş MD

Gültekin Karakuş

My parentsViyolet Değirmencioğlu and İstepan Değirmencioğlu

My brotherRikardo Değirmencioğlu

My wifeVirna Değirmencioğlu and our son; Stefan

Aleks Değirmencioğlu

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Preface

Echocardiography remains the most useful and most cost-effective non-invasive technique in the assessment of various types of cardiovascular disease. The modality has developed into a valuable tool in the armamen-tarium of both adult and pediatric cardiologists, cardiac surgeons and anes-thesiologists, emergency medicine and critical care specialists and other physicians. Because of the tremendous progress made in cardiovascular ultrasound in recent years, there is a need for a compendium which will give a clear perspective to the physician of the usefulness of various current and newer echocardiographic modalities for optimal patient management. The aim of this book is to fulfil this need and to provide a practical manual which will be useful to all who utilize echocardiography in their day-to-day clinical practice. The manual is expected to serve the needs of both physi-cian and technologist echocardiographers as well as those who are still in training. The contents of this manual have been mainly abstracted from the Comprehensive Textbook of Echocardiography published by the same publisher. Most of the illustrations and movie clips which are included in a DVD provided with this manual have also been taken from the same book. Some of the text has also been copied from the Comprehensive Textbook but a considerable portion has been modified and rewritten. Thus, this manual will also serve as a useful companion to the large Textbook. The manual consists of 13 chapters and an appendix containing some useful tables. To facilitate easy reading and understanding, the contents of all chapters are in the form of questions and answers and these are supplemented in some cases by brief case studies. The first chapter deals with the basics of echocardiography and includes a section on the clinical usefulness of M-mode echocardiography. Pulsed and continuous wave Doppler as well as color Doppler are also covered in this chapter. The second chapter on echocardiographic examination deals with transthoracic, transesophageal and three-dimensional echocardiography. Chapters 3, 4 and 6 delineate all aspects of mitral, aortic, tricuspid and pulmonary valve disease entities as well as pulmonary hypertension. Aortic diseases includ-ing aortic aneurysm, aortic dissection, aortic transection and penetrating aortic ulcer are described in Chapter 5. Normal and abnormal function of prosthetic valves is detailed in Chapter 7. Both systolic and diastolic left ventricular function are comprehensively described in Chapter 8. This chapter also covers tissue Doppler imaging and speckle tracking and velocity vector echocardiography. Chapter 9 deals with various aspects of ischemic heart disease. All commonly used modalities of stress echocardiography as well as complications of myocardial infarction are included in this chapter. Cardiomyopathies are fully discussed in Chapter 10. Dilated, restrictive and

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hypertrophic cardiomyopathy together with its variants are described in detail. Chapter 11 covers pericardial disorders. Pericardial effusion, cardiac tamponade, constriction and differentiation of pericardial effusion from pleural effusion and ascites are described in this chapter. Cardiac masses including thrombus and tumors are detailed in Chapter 12. The last chapter of the manual deals with congenital heart disease. Chamber and great vessel identification, shunt lesions, stenotic disorders, complex lesions and other miscellaneous conditions are described in this chapter. We hope this manual will represent a useful and practical companion to the Comprehensive Textbook of Echocardiography.

Navin C Nanda MD DSc (Hon)

DSc (Med) (Honoris Causa) FACC

FAHA FISCU(D) FSGC FICA FACA

FICP (Hon) FIAE FICMU (Hon)

FACIP FCSC (S) FIACS FICC (Hon)

Gültekin Karakuş MD DM

Aleks Değirmencioğlu MD DM

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Manual of EchocardiographyManual of Echocardiography

Acknowledgments

We are most grateful to all the authors and co-authors who contributed to the Comprehensive Textbook of Echocardiography and from whose monu-mental work this Manual has been abstracted. Their contribution is most appreciated. We are also grateful to Dr Mahmoud Elsayed, Fellow in the Echocardiography Laboratory of the University of Alabama at Birmingham, Birmingham, Alabama, USA for help with the Appendix, Lindy Chapman, erstwhile Administrative Associate who provided excellent editorial and secretarial assistance and James Wetherilt PhD and Lale Susan Türkgeldi MD for their contributions. We wish to express our thanks to the International Society of Cardiovascular Ultrasound for agreeing to have the book under its aegis. We especially appreciate the constant support and encouragement of Mr Jitendar P Vij (Group Chairman) and Mr Ankit Vij (Group President) of Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, India in helping publish this Manual and also their Associates particularly Ms Chetna Malhotra Vohra (Associate Director), Ms Saima Rashid (Project Manager) and Ms Sheetal Arora Kapoor (Developmental Editor) who have been prompt, efficient and most helpful. Last but not least, I appreciate the help, kindness and support of my wife, Kanta.

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1. Basics 1• Artifacts 5• Doppler Echocardiography 8• M-Mode Echocardiography 13

2. Echocardiographic Examination 20• Indications 43• Contraindications and Precautions 43• Esophageal Intubation 43• Transesophageal Echo Examination 44• Ascending AO, SVC, IVC, Atrial Septum and

Right Pulmonary Veins 45• Tricuspid Valve, RAA and Coronary Sinus 47• Transgastric Examination 47• Aortic Valve, PV, and Coronary Arteries 47• Ascending AO and PA 49• Descending AO 50• Aortic Arch 51• Transpharyngeal Examination 52• Focused Examination 53

3. Mitral Valve 59• Mitral Stenosis 59• Mitral Regurgitation 71

4. Aortic Valve 92• Aortic Stenosis 92• Aortic Regurgitation 112

5. Aortic Diseases 128 6. Tricuspid and Pulmonary Valves and

Pulmonary Hypertension 145 7. Prosthetic Valves 166 8. Left Ventricle 182

• Left Ventricular Systolic Function 182• Left Ventricular Diastolic Function 196

9. Ischemic Heart Disease 209 10. Cardiomyopathies 228 11. Pericardial Disorders 269 12. Cardiac Tumors and Masses 289

Contents

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13. Congenital Heart Disease 305• Chamber and Great Vessel Identification 305• Shunt Lesions 311• Stenotic Lesions 335• Complicated Lesions 350• Other Lesions 362

Appendix 367

Index 377

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DVD Contents

CHAPTER 1Additional Movie Clip 1: Reverberations from the mitral valve region.

Two-dimensional transthoracic echocardiography. Lower arrowhead points to rever-berations from the mitral valve region (upper arrowhead). (AO: Aorta; LA: Left atrium; LV: Left ventricle; RV: Right ventricle).

Additional Movie Clip 2: Reverberatory artifact from a pacemaker.

Two-dimensional transthoracic echocardiography. Para-sternal long-axis view. Lower arrowhead shows a linear echo in the left atrium resembling a line or pacemaker but this patient does not have any catheter or pacemaker in the left atrium. This linear echo is a reverberatory artifact from a pacemaker located in the right ventricle (RV, upper arrowhead). (AV: Aortic valve; LA: Left atrium; LV: Left ventricle).

Additional Movie Clip 3: Color artifact mimicking mitral regurgitation.

Two-dimensional transthoracic echocardiography. Arrow points to blue signals in the left atrium mimicking mitral regurgitation. The signals are extremely brief in duration and extend beyond the wall of the left atrium and this feature differen-tiates it from true mitral regurgitation. (LA: Left atrium; LV: Left ventricle; RA, Right atrium; RV: Right ventricle).

Additional Movie Clip 4: Shadowing produced by mitral prosthesis.

Two-dimensional transesophageal echocardiography in a patient with bioprosthetic mitral valve replacement (MVR). Arrow points to prominent shadowing produced by the metallic components of the prosthesis which effectively block passage of the ultrasound beam so that none of the structures behind them are imaged. (LA: Left atrium; LAA: Left atrial appendage; LV: Left ventricle).

Additional Movie Clip 5: Shadowing and reverberations from metallic mitral pros-thesis.

Two-dimensional transthoracic echocardiography. Metallic mitral prosthesis. (A) Arrows point to acoustic shadowing produced by the metallic components of the prosthetic mitral valve (MVR). Reverberations (R) significantly obscure the left atrium because the ultrasound beam encounters the prosthesis first and then the left atrium. (B) Two-dimensional transesophageal echocardiography performed in another patient with a metallic prosthetic valve shows acoustic shadowing (arrows) and reverberations on the ventricular aspect of the prosthetic valve but the left atrium is clear. Thus, both transthoracic and transesophageal modali-ties complement each other in adequately assessing metallic prosthetic valves. (LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 6: Suture from a metallic prosthetic mitral valve and normal prosthetic motion.

Two-dimensional transesophageal echocardiography. Color Doppler examination. Upper arrowhead points to a suture from a metallic prosthetic mitral valve (MV). Arrow shows reverberations from both leaflets of the prosthesis, numbered 1 and 2. MR represents severe paravalvular regurgitation. Both leaflets show intermittent “sticking” in the immediate post-bypass period because the hemodynamics had not normalized. Subsequently, with improved cardiac output, both leaflets showed normal motion. Thus, this finding should not lead to a misdiagnosis of prosthetic dysfunction. (LA: Left atrium; LV: Left ventricle; RA: Right atrium).

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Additional Movie Clip 7: Acoustic shadowing from the metallic components of aortic prosthesis.

Two-dimensional transesophageal echocardio graphy. Upper arrowhead shows a large abscess cavity with septations surrounding the metallic prosthetic aortic valve. Lower arrowhead denotes acoustic shadowing from the metallic compo-nents of the prosthesis. (AVR: Aortic valve replacement; LA: Left atrium; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 8: Reverberations from the descending thoracic aorta.

Two-dimensional transesophageal echocardio graphy. Arrow shows linear reverbera-tions from the descending thoracic aorta (DA).

Additional Movie Clip 9: Artifactual flow signals behind the descending thoracic aorta.

Two-dimensional transesophageal echocardiography. Color Doppler examination. Arrowheads show artifactual flow signals behind the descending thoracic aorta (DA). (PA: Pulmonary artery)

Additional Movie Clip 10: Echogenic artifacts from air bubbles.

Two-dimensional transesophageal echocardio graphy. Small arrowhead points to a line in the left atrium (LA) and the large arrowhead shows air bubbles. Small air bubbles scatter the ultrasound beam producing echogenic artifacts which facili-tate their recognition. (AO: Aorta; LV: Left ventricle; MV: Mitral valve; RV: Right ventricle).

Additional Movie Clip 11: Artifact in descending aorta mimicking dissection.

Two-dimensional transesophageal echocardiography. (A) Long-axis view. Arrow points to a linear echo in the descending aortic (AO) lumen consistent with dissec-tion. (B) Short-axis view. Arrow shows the linear echo extending outside the lumen of the aorta indicating that this is an artifact and not a dissection flap.

Additional Movie Clip 12: Artifacts resulting from the use of cautery during surgery.

Two-dimensional transesophageal echocardiography in the operating room. Color Doppler examination. Arrow shows mitral regurgitation. Arrowhead indicates multiple artifacts resulting from the use of cautery during surgery. So far there is no effective method to eliminate these artifacts. #1 and #2 represent a line in the right ventricle and the “Coumadin ridge,” respectively. #3 and #4 point to accumu-lation of fatty tissue in the base of the atrial septum and tricuspid valve annulus, respectively. Fatty tissue in the tricuspid valve annulus has often been mistaken for a tumor. (LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 13: Effect of instrument gain on the image.

Live/real time, three-dimensional transthoracic echocardiography. Effect of instru-ment gain on the image. Very low gain (A) introduces artifacts making it difficult to visualize some structures while very high gain (B) obscures them. Optimal gain is shown in (C). (LA: Left atrium; LV: Left ventricle; RA: Right C atrium; RV: Right ventricle).

Additional Movie Clip 14: Effect of color gain on color Doppler signals.

Live/real time, three-dimensional transthoracic echocardiography. Effect of color gain on color Doppler signals. Mitral regurgitation signals (arrowhead in A) prac-tically disappear when the color gain is decreased (arrowhead in B). (LA: Left atrium; LV: Left ventricle; RA: Right atrium).

Additional Movie Clip 15: Effect of color gain on color Doppler signals.

Two-dimensional transthoracic echocardiography. Arrow shows a redundant Eusta-chian valve located at the junction of the inferior vena cava (IVC) with the right

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atrium (RA). This can be misdiagnosed as an abnormal structure in RA. (LA: Left atrium; PV: Pulmonary valve; RV: Right ventricle; TV: Tricuspid valve).

Additional Movie Clip 16: Effect of Nyquist limit and color gain on color Doppler signals.

Two-dimensional transesophageal echocardio graphy. Color Doppler examination. In (A), the Nyquist limit has been standar dized between 40 and 50 cm/s and is there-fore kept in this patient at 46 cm/s. However, the color gain has been markedly reduced to 21 units. This has resulted in marked reduction in the area of tricuspid regurgitation (TR) signals (arrowhead) consistent with very mild regurgitation. In (B), the color gain has been increased to 58 units and this has resulted in marked increase in the size of the regurgitant jet (arrowhead). Note also artifactual spil-lage of color Doppler signals outside the cavity of the right ventricle (RV) result-ing from excessive gain. In (C), the color gain has been gradually lowered till the stationary artifactual echoes outside the RV cavity have just disappeared. Thus, both the Nyquist limit and the color gain have been standardized and the jet area (arrowhead) now can be inspected for accurate assessment of TR severity. The regurgitant jet area occupies >35% of the right atrium indicating the presence of severe TR. In (D), the color gain is unchanged at 50 units but the Nyquist limit has been increased to 69 cm/s. Any change in the Nyquist limit also alters the color wall filter and this results in considerable decrease in the jet area. Thus, the severity of regurgitation can be underestimated when the Nyquist limit is increased above the standardized range. In (E), the Nyquist limit has been reduced below the standardized range and is kept at 23 cm/s without change in color gain. This increased the TR jet area and hence a low Nyquist limit can lead to overestimation of regurgitation severity. Similar to increase in color gain (B), a marked reduction in the Nyquist limit may also result in color Doppler signals extending beyond the cardiac chambers (arrowheads). (LA: Left atrium).

CHAPTER 2Movie Clip 2.1: Parasternal long-axis view.

An example of a two-dimensional (B-mode) echocardiogram of the left ventricle (LV) from the parasternal long-axis plane. An indicator is seen to the right of the image sector (arrow), which orients the echocardiographer to the plane of imaging by corresponding with an indicator on the transducer itself. A scale is noted to the right of the image. The image is gated to the patient’s electrocardiogram (ECG). Other cardiac chambers seen in this view include the right ventricle (RV), left atrium (LA), and descending aorta (AO).

Movie Clip 2.4A: Right ventricular inflow view.

Movie Clip 2.4B: Right ventricular inflow view with color.

(A) The anterior and inferior walls of the right ventricle, along with the anterior and posterior tricuspid valve leaflets are seen from the RV inflow view. The inferior vena cava (arrow) is seen along with a prominent Eustachian valve (arrowhead); (B) Color flow Doppler across the tricuspid valve demonstrates a jet that is parallel to the ultrasound beam.

Movie Clip 2.7: Parasternal long-axis view of the right ventricular outflow tract (RVOT).

The anterior segment of the RVOT and its infundibulum are seen along with the pulmonic valve and the bifurcation of the main pulmonary artery (PA). This pulmonary annular dimension is measured here.

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Movie Clip 2.11: Parasternal short-axis view at the level of the aortic valve.

The three cusps of the aortic valve are seen (clockwise from top: right, left, and non-coronary). The interatrial septum provides a useful landmark for identifying the non-coronary cusp. The right coronary cusp can be perpendicular to the tricuspid valve at one commissure, and the pulmonic valve at the other.

Movie Clip 2.12: Parasternal short-axis view at the level of the mitral valve.

The anterior mitral leaflet (AML) is seen closest to the interventricular septum. The posterior mitral leaflet (PML) is seen closest to the inferior wall.

Movie Clip 2.14: Apical four-chamber view.

An apical four-chamber view, showing (clockwise from top left) the RV, LV, LA, and RA. In a normal heart, the RV can be identified by its triangular appear ance, slightly apical position of the tricuspid annulus, the presence of trabeculations, and the more prominent contribution of the left ventricle to the apex. This plane assesses the atrioventricular valves (i.e. mitral and tricuspid), along with the interatrial septum (arrow) and interventricular septum (arrowhead). The pulmonary veins can be seen inserting into the posterior wall of the left atrium (asterisk).

Movie Clips 2.15A: Apical five-chamber view without color.

Movie Clips 2.15B: Apical five-chamber view with color.

(A) Apical five-chamber view with the LVOT (arrow) in plane; (B) Normal color flow Doppler is seen through the LVOT during systole.

Movie Clip 2.16: Apical two-chamber view.

The basal to apical segments of the anterior and inferior walls are seen in the apical two-chamber view.

Movie Clip 2.17: Apical long-axis (three-chamber) view of the left ventricle without color.

Color flow Doppler imaging of the LVOT in the apical three-chamber view showing normal systolic flow.

Movie Clip 2.21A: Subcostal four-chamber view without color.

Movie Clip 2.21B: Subcostal four-chamber view with color.

(A) Short-axis plane at the aortic valve level obtained from the subcostal window. Note the three cusps of the aortic valve. The non-coronary cusp (arrow) is perpendicular to the interatrial septum. The right coronary cusp borders the right ventricle, and the left coronary cusp (arrowhead) is seen perpendicular to the main pulmonary artery; (B) Short-axis plane at the papillary muscle level of the LV obtained from the subcostal window. The right ventricle (RV) is seen adjacent to the left lobe of the liver (asterisk). (IVC: Inferior vena cava; LA: Left atrium; RA: Right atrium; PA: Pulmonary artery).

Movie Clip 2.22A: Subcostal short-axis plane at the aortic valve level.

Movie Clip 2.22B: Subcostal short-axis plane at the LV papillary muscle level.

(A) Inferior vena cava (IVC) and hepatic vein seen in the subcostal window; (B) M-mode of the IVC diameter showing collapse during sudden inspiration (sniff).

Movie Clip 2.27A: Suprasternal notch window without color.

Movie Clip 2.27B: Suprasternal notch window with color.

Continuous-wave Doppler of the aorta performed from the suprasternal notch showing systolic (S) and diastolic (D) flow.

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Movie Clip 2.28A and B: Two-dimensional transthoracic echocardiography. Right parasternal approach (RP). Eustachian valve and the crista terminalis.

The left arrowhead shows the Eustachian valve, and the right arrowhead points to crista terminalis. IVC, inferior vena cava; (LA: Left atrium; RAA: Right atrial appendage; RUPV: Right upper pulmonary vein; SVC: Superior vena cava; TV: Tricuspid valve).

Movie Clip 2.29: Two-dimensional transthoracic echocardiography. Right paraster-nal approach (RP). Ascending aorta, arch of aorta, descending aorta and left main coronary artery.

The arrowhead shows flow signals (blue) in the left main coronary artery between the aorta and the main pulmonary artery (PA); (ACH: Aortic arch; AV: Aortic valve; LA: Left atrium; LPA: Left pulmonary artery).

Movie Clip 2.30A: Five-chamber view.

Two-dimensional transesophageal echocardiog raphy. Five-chamber view. This was obtained at 138° probe rotation. (AO: Aorta; LA: Left atrium; LV: Left ventricle; RV: Right ventricle).

Movie Clip 2.30B: Two-dimensional transesophageal echocar diographic procedure.

The procedure as performed by the physician with the help of a nurse is shown. Vital signs are monitored and the nurse is shown giving sedation to the patient. The suction apparatus is checked and the patient’s oxygen saturation continuously monitored. Insertion of the bite guard and probe by the physician is also shown. The probe was withdrawn after the examination was completed.

Movie Clip 2.30C: Normal two-dimensional transesophageal echocardiographic exa mination.

Various views are shown. (A: Atrial systolic wave; AB: Abdominal aorta; ACH: Aortic arch; AO: Aorta; ASC AO: Ascending aorta; AV: Aortic valve; CS: Coronary sinus; D: Diastolic wave; IVC: Inferior vena cava; LA: Left atrium; LAA: Left atrial appen-dage; LMCA: Left main coronary artery; LVO: Left ventricular outflow tract; LVPV: Left upper pulmonary vein; PA: Main pulmonary artery; RA: Right atrium; RPA: Right pulmonary artery; RUPV: Right upper pulmonary vein; RV: Right ventricle; S: Systolic wave; SVC: Superior vena cava; TH: Thebesian valve).

Movie Clip 2.40: Scanning beam along Y- and Z-axes.

The scanning beam performs azimuth steering along the Y-axis in a phased array manner and produces two-dimensional (2D) sector images. The 2D sector image performs elevation steering along the Z-axis and finally produces a pyramidal three-dimensional (3D) data set.

Courtesy: Philips Medical Systems, Bothell, Washington. Source: Reproduced with permission from Wang et al. Echocardiography. 2003;

20:593–604.

CHAPTER 3Movie Clip 3.1: Double orifice mitral valve.

Two-dimensional transthoracic echocardiography in parasternal short-axis view showing two distinct mitral orifices.

Movie Clip 3.2: Mitral stenosis.

Two-dimensional transthoracic parasternal short-axis view at mitral valve level showing a thickened mitral valve with bicommissural fusion giving a “fish-mouth” appearance.

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Two-dimensional transthoracic parasternal long-axis view showing thickened mitral leaflets with diastolic doming of anterior mitral leaflet (AML) giving the appear-ance of a “hockey stick” (arrow). (AO: Aorta; LA: Left atrium; LV: Left ventricle; RV: Right ventricle).

Movie Clip 3.4: Mitral stenosis. Subvalvular thickening.

Two-dimensional transthoracic echocardiography showing severe subvalvular thick-ening. (AO: Aorta; LA: Left atrium; LV: Left ventricle; RV: Right atrium).

Movie Clip 3.5A and B: Mitral valve orifice area.

Impact of measuring orifice area at different locations: cross-sectional area measured at the chordal level shows an orifice area of 0.484 cm2 (A) whereas in the same patient at the level of commissures, mitral valve area is 2.78 cm2 (B).

Movie Clip 3.6: Mitral valve gradient.

Measurement of mean mitral gradient in atrial fibrillation: mean gradient varies according to the length of the diastole. The mean gradient is 13 mm Hg following the shortest diastole and 9 mm Hg after the longest diastole.

Movie Clip 3.8: Calcific mitral stenosis.

Two-dimensional transthoracic echocardiography showing a heavily calcified mitral valve with bicommissural calcification.

Movie Clip 3.9: Calcific mitral stenosis.

Two-dimensional transthoracic echocardiography showing unicommissural calci-fication of anterolateral commissure. (PMC: Posteromedial com missure).


Live/real time transthoracic three-dimensional echocardiography in parasternal short-axis view at mitral valve level showing a thickened mitral valve with bicom-missural fusion giving a “fish-mouth” appearance. (ALC: Anterolateral commis-sure; PMC: Posteromedial commissure).

Movie Clip 3.11: Rheumatic mitral valve with severe mitral regurgitation.

Two-dimensional transthoracic echocardiography in parasternal long-axis view showing rheumatic mitral valve disease with noncoapting mitral leaflets resulting in severe mitral regurgitation (MR). (LA: Left atrium; LV: Left ventricle).

Movie Clip 3.12: Dilated left ventricle with severe systolic dysfunction and severe mitral regurgitation.

Two-dimensional transthoracic echocardiography in apical four-chamber view show-ing a dilated left ventricle (LV) with the above mentioned findings.

Movie Clip 3.15: Ischemic cardiomyopathy. Sea-gull sign.

Transesophageal apical four-chamber view showing severe mitral regurgitation by color Doppler flow imaging (arrow). Arrowhead shows a kink in the middle of the anterior leaflet mimicking a “seagull.” This “seagull” sign results from tether-ing produced by a strut chord and is considered indicative of ischemic origin of cardio myopathy. (LA: Left atrium; LV: Left ventricle; RV: Right ventricle).

Movie Clip 3.16: Mitral valve prolapse.

Two-dimensional transthoracic echocardiography in a 42 year old patient. Arrow-head points to prolapse of both mitral leaflets. (AO: Aorta; LA: Left atrium; LV: Left ventricle; MV: Mitral valve; RV: Right ventricle; SVC: Superior vena cava).

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Movie Clip 3.17: Mitral valve prolapse.

Two-dimensional transthoracic echocardiography demonstrating myxomatous mitral valves and prolapse of posterior mitral leaflet (PML) with severe mitral regurgita-tion (MR). (RV: Right ventricle; RA: Right atrium; LV:Left ventricle; LA: Left atrium).

Movie Clip 3.18A: Central mitral regurgitation.

Movie Clip 3.18B: Eccentric mitral regurgitation.

Two-dimensional transthoracic echocardiography in apical four-chamber view show-ing severe central mitral regurgitation (A) and wall hugging eccentric mitral regur-gitation (B). If the laminar flow signals moving in the same phasic manner as the turbulent MR jet (to differentiate them from pulmonary venous inflow) are taken into account, MR would not be underestimated and would be considered severe.

Movie Clip 3.22: Severe mitral regurgitation. Vena contracta.

Two-dimensional transthoracic echocardiography in apical four-chamber view show-ing a vena contracta width of 11.3 mm indicative of severe mitral regurgitation (MR).

Movie Clip 3.23: Vena contracta measurement in mitral regurgitation.

Live/real time three-dimensional (3D) color Doppler transtho racic echocardiogra-phic technique for assessment of vena contracta area. 3D color Doppler data set showing mitral regurgitation (MR) cropped from top to the level of the vena c ontracta (arrowhead) and tilted to view it en face. The vena contracta is then plan-imetered by copying onto a videotape. The vena con tracta may also be planimetered using the QLAB. Three-dimensional echo done in another patient shows cropping of the apical four-chamber data set using an oblique plane to align it parallel to the flow-limiting tips of the mitral leaflets. The posterior leaflet is calcified at the tip and shows restricted mobility. En face view shows an oval-shaped stenotic orifice (arrow) with calcification involving only the posterior leaflet. The commissures are free of calcification. This patient also had significant MR on the two-dimensional (2D) study, and hence another apical four-chamber data set was acquired using color Doppler flow imaging. This was cropped to view the MR vena contracta en face (arrow). The blue laminar signals adjacent to the vena contracta represent flow in the left ventricular outflow tract. (LA: Left atrium; LV: Left ventricle).

Source: Reproduced with permission from Khanna D, Vengala S, Miller A, Nanda NC, et al. Quantification of mitral regurgitation by live three-dimensional trans-thoracic echocardiographic measurements of vena contracta area. Echocardio-graphy. 2004;21(8):737–43.

Additional Movie Clip 1: Mitral stenosis.Two-dimensional transthoracic echocardiography shows thickened mitral valve leaf-

lets. (A) Parasternal long-axis view showing a thick and domed mitral valve giving a “hockey stick” appearance (arrow); (B) Two-dimensional transthoracic apical four-chamber view demonstrating similar findings. (AO: Aorta; LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 2: Balloon mitral valvotomy.Two-dimensional transthoracic echocardiography showing post balloon mitral valvo-

tomy (BMV) anterior mitral leaflet tear and severe mitral regurgitation. (AML: Anterior mitral leaflet).

Additional Movie Clip 3: Balloon mitral valvotomy.Live/real time transthoracic three-dimensional echocardiography showing post bal-

loon mitral valvotomy (BMV) anterior mitral leaflet tear. Note the fused bilateral commissures. (AML: Anterior mitral leaflet).

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Additional Movie Clip 4: Mitral stenosis. Subvalvular thickening.Live/real-time transthoracic three-dimensional echocardiography showing severe

subvalvular thickening. (LA: Left atrium; LV: Left ventricle; RV: Right ventricle).Additional Movie Clip 5: (A) Spontaneous contrast in left atrium. (B) Left atrial

appendage clot. (C) Left atrial roof clot.(D) multiple LA clots. (E) LA clot attached to septum. (F) free floating thrombus

All are two-dimensional transthoracic studies. (LA: Left atrium; LAA: Left atrial appendage).

Additional Movie Clip 6: Mitral stenosis with left atrial thrombus.Two-dimensional transthoracic echocardiography showing severe mitral stenosis

with a giant left atrial thrombus. (LA: Left atrium; LV: Left ventricle).Additional Movie Clip 7: Mitral regurgitation secondary to chordal tear.Post balloon mitral valvotomy (BMV) severe mitral regurgitation secondary to chordal

tear. (LA: Left atrium; Left ventricle; RA: Right atrium; RV: Right ventricle).Additional Movie Clip 8: Balloon mitral valvotomy with residual atrial septal defect.Post balloon mitral valvotomy (BMV) two-dimensional transthoracic echocardio-

graphy showing residual atrial septal defect (ASD) with left-to-right shunt. (LA: Left atrium; LV: Left ventricle; RV: Right ventricle; ASD: Atrial septal defect).

Additional Movie Clip 9: Mitral valve prolapse.Two-dimensional transthoracic echocardiography. Mitral valve prolapse of the A2

segment associated with aortic valve prolapse and sinus of Valsalva aneurysm. (A and B) Parasternal long-axis views. (A) Lower arrow points to prominent ante-rior mitral leaflet prolapse, upper arrow to aortic valve prolapse, and arrowhead to a localized aneurysmal dilatation of a sinus of Valsalva. (B) Color Doppler exami-nation shows severe mitral regurgitation (MR) and mild to moderate aortic regur-gitation (AR). (C) Short-axis view at the level of the mitral valve (MV). Arrowhead points to marked redundancy of the middle segment of the anterior leaflet consis-tent with prominent A2 prolapse. Some redundancy of the middle scallop (P2) of the posterior leaflet is also seen. These are best visualized in mid-diastole. (D and E) Apical four-chamber views. Arrow in D points to anterior mitral leaflet prolapse. E shows a large flow acceleration area (PISA) consistent with very significant MR. (F) Live/real-time three-dimensional transthoracic echocardiography showing prominent A2 prolapse (arrow). (AO: Aorta; LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 10: Flail mitral valve leaflet.Two-dimensional transthoracic echocardiography. Parasternal long-axis (A and

B) and apical four-chamber (C and D) views. Arrows in A and C point to a flail posterior mitral leaflet which does not coapt with the anterior leaflet in systole resulting in severe mitral regurgitation (shown in B). The anterior leaflet also shows prolapse. The turbulent portion of MR jet in B is eccentric, narrow, and directed anteriorly and would be erroneously diagnosed as mild MR if the laminar flow signals (red) which move with the turbulent jet are not taken into account. D shows a large flow acceleration (PISA). (AO: Aorta; LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 11: Flail posterior mitral valve leaflet associated with aortic root aneurysm.

Two-dimensional transthoracic echocardiography. Parasternal long-axis (A) and apical four-chamber (B and C) views show a flail posterior leaflet (arrow) with systolic noncoaptation seen in B. Severe mitral regurgitation (MR) with swirling flow is seen in C. (AO: Aorta; LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

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Additional Movie Clip 12: Mitral valve prolapse.Live/real time three-dimensional transthoracic echocardiography of myxo matous mitral

valve with severe prolapse of posterior mitral leaflet (PML).Additional Movie Clip 13: Mitral valve prolapse with chordae rupture.Live/real time three-dimensional transesophageal echocardiographic assessment

of ruptured chordae tendinae. (A) Arrowhead shows a ruptured chord of severely prolapsing A2 segment of anterior mitral leaflet (AML). (B) Color Doppler imaging. Numbers 1 and 2 point to two jets of severe MR. Arrowhead points to the ruptured chord. (MV: Mitral valve).

Additional Movie Clip 14: Severe mitral regurgitation in ischemic cardiomyopathy.Two-dimensional transthoracic echocardiography in parasternal long-axis view

showing severe mitral regurgitation. Note the thin and akinetic basal and mid posterior segments. (AO: Aorta; LA: Left atrium; LV: Left ventricle).

Additional Movie Clip 15: Mitral annular calcification resulting in mitral regurgitation.Two-dimen sional transthoracic echocardiography. Arrow points to mitral annular

calcification seen in parasternal long-axis (A) and apical four-chamber (B and C) views. Turbulent flow is also noted moving from the mitral valve (MV) into the left ventricle (LV) indicative of high velocities but there was no significant mitral stenosis. (D) Parasternal short-axis view in another patient showing crescent-shaped annular calcification. (AO: Aorta; LA: Left atrium; RA: Right atrium; RV: Right ventricle.

Additional Movie Clip 16: Mitral valve vegetations.Two-dimensional transthoracic echocardio graphy. Infective endocarditis resulting

in vegetations over the anterior mitral leaflet (AML) causing mitral regurgitation (MR).

Additional Movie Clip 17: Mitral valve abscess and rupture into left atrium.Two-dimensional transthoracic echocardiography demonstrating infective endocar-

ditis with mitral valve abscess and rupture into the left atrium resulting in severe mitral regurgitation (MR).

Additional Movie Clip 18: Mitral valve perforation due to endocarditis.Two-dimensional transesophageal echocardio graphy showing two perforations in

anterior mitral leaflet (AML) secondary to infective endocarditis resulting in severe mitral regurgitation (MR).

Additional Movie Clip 19: Mitral prosthesis. Paravalvular regurgitation.Two-dimensional transesophageal echocardiography in a patient with mitral valve

replacement showing a paravalvular defect (arrow) with severe mitral regurgita-tion (MR).

CHAPTER 4Movie Clip 4.5: Quadricuspid aortic valve.

Mid-transesophageal short-axis view of a quadricuspid aortic valve; Note incomplete valve closure in diastole. Four cusps can be seen is systole. (AV: Aortic valve; LA: Left atrium; LV: Left ventricle; RVOT: Right ventricular outflow tract).

Movie Clip 4.6A to C: Aortic valve stenosis.

Live/real time three-dimensional trans thoracic echocardiography. (A to C) Careful cropping of the parasternal long-axis data set at the flow-limiting tips of the aortic valve (AV) leaflets demonstrate a bicuspid morphology and severe stenosis. (LA: Left atrium; LV: Left ventricle).

Source: Reproduced with permission from Nanda NC, Hsiung MC, Miller AP, Hage FG. Live/Real Time 3D Echocardiography. Oxford, UK: Wiley-Blackwell; 2010.

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Movie Clip 4.19A to C: Mild, moderate and severe aortic regurgitation.

Color flow Doppler in the parasternal long-axis view demonstrating mild, moderate, and severe AR. The vena contracta is indicated by arrows. Note the increasing vena contraca width with worsening AR severity. (AO: Aorta; AR: Aortic regurgitation; LA: Left atrium; LV: Left ventricle; RV: Right ventricle).

Movie Clip 4.23A and B: Aortic regurgitation resulting from aortic valve endocarditis.

Mid-transesophageal long-axis view of the aortic valve in a patient with aortic root abscess, vegetation, and perforation of aortic valve cusps; (A) 2D image demon-strating echo density on the ventricular aspect of the aortic valve consistent with vegetation and thickening of the aortic root with echo-free spaces consistent with root abscess. (B) Color Doppler shows severe AR with evidence of color flow traversing through a cusp indicating perforation. (AO: Aortic; AO: Aorta; AR: Aortic regurgitation; AV: Aortic valve; LA: Left atrium; LVOT: Left ventricular outflow tract; RV: Right ventricle).

Movie Clip 4.24A to C: Aortic regurgitation resulting from obstructive subaortic mem-brane.

Mid-transesophageal long-axis views of the aortic valve demonstrating a mobile subvalvular membrane and a discrete nonmobile subvalvular membrane. Color flow Doppler demonstrating AR in diastole; Color flow Doppler in systole demon-strating stenotic accelerated blood flow arising from the membrane. (AO: Aorta; AR: Aortic regurgitation; LA: Left atrium; LVOT: Left ventricular outflow tract; RV: Right ventricle).

Additional Movie Clip 1: Bicuspid aortic valve with perforation and vegetation.

3D TEE of a bicuspid aortic valve with true perforation (arrow) of the left coronary cusp. Note mobile vegetation (arrowhead) at the base of the right coronary leaflet.

Additional Movie Clip 2: Bicuspid aortic valve.

2D TEE image of a bicuspid aortic valve. (Abbreviations as in pre vious movie clip).

Additional Movie Clip 3: Degenerative fibrocalcific aortic valve disease.

Images from a patient with degenerative fibrocalcific aortic valve disease, Parasternal long (A) and short-axis (B) view demonstrating restricted aortic valve opening in systole and AR in diastole. (AO: Aorta; AR: Aortic regurgitation; AS: Aortic steno sis; AV: Aortic valve; LA: Left atrium; LV: Left ventricle; RV: Right ventricle).

Additional Movie Clip 4 and 5: Ascending aortic dissection causing aortic regurgi-tation

Transthoracic and transesophageal echo examples of ascending aortic dissection causing aortic regurgitation.

CHAPTER 5Movie Clip 5.2A: Ascending aortic aneurysm.

Movie Clip 5.2B: Ascending aortic aneurysm with aortic regurgitation.

TEE imaging of the proximal aorta and root at 133° (A) shows that, despite a normal thickness, trileaflet aortic valve, there is central malcoaptation (arrow) due to disruption of upper commissural support from proximal aneurysm. This results in a central jet (B, arrow) of mild-to-moderate aortic insufficiency (B). (TEE: Transesophageal echo).

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Movie Clip 5.5A and B: Aortic dissection.

(A) In this Type B dissection, the intimal tear of entry is clearly seen on these TEE views of the proximal descending aorta. The dissection flap (arrow) has an echo-free zone, which represents the tear. On color Doppler imaging (B), flow from the smaller true lumen (TL) can be seen into the false lumen (FL).

Movie Clip 5.9A and B: Aortic dissection.

(A) Proximal extension of the dissection flap in Type A dissection can result in damage to the superstructure of the aortic valve. In this case, there is loss of commissural support of the commissure between noncoronary and left coronary cusps (arrow), leading to moderate aortic regurgitation (in B) despite a normal valvular morpho-logy. In cases such as this, surgical repair/resuspension of the native aortic valve is possible.

Additional Movie Clip 1: Ascending aortic dissection.A baseline echocardiogram showing aortic dissection in a patient hospita lized for

chest pain (parasternal long [A] and short-axis [B] view). The stress echocardio-gram was cancelled and patient underwent a computed tomography of the chest which was consistent with ascending aortic dissection (Type A). The patient underwent subsequent surgery for repair of the aortic dissection.

Additional Movie Clip 2: Aortic dissection.Two-dimensional transesophageal echocardiography. Aortic dissection. Short-axis

view of the aorta (AO) shows a dissection flap (F), aortic valve leaflets (L) and an artifact (A). The close proximity of the F to the origin of the left main coronary artery (LMCA) is also visualized. Arrow points to a communication between the perfus-ing (PL) and non-perfusing (NPE) lumens in the descending thoracic aorta (D) using color Doppler flow mapping. Further examination showed the presence of an additional communication (numbered #1 and #2).

Additional Movie Clip 3: Aortic dissection.Two-dimensional transesophageal echocardiography. Aortic dissection. Short-axis

view. F shows the dissection flap in the aortic root (AO) in close proximity to the origin of the left main coronary artery (LMCA). Dissection flaps (F, arrowhead) are also noted in the aortic arch (ACH). More intense flow signals are visualized in the perfusing lumen (PL) as compared to the nonperfusing lumen (NPL) and this serves to differentiate them. Arrow points to a communi cation between the two lumens detected by color Doppler flow examination.

CHAPTER 6Movie Clip 6.1A to B: Tricuspid valve stenosis.

(A) Tricuspid valve stenosis in a 65-year-old female with rheumatic heart disease. Apical four-chamber view. Arrow points to diastolic doming of the tricuspid valve (TV) consistent with stenosis. Mitral valve (MV) is also thickened and stenotic (B) Shows turbulent stenotic jets originating from TV (left arrow) and MV (right arrow). Also, note the eccentric tricuspid regurgitation (TR) jet.

Movie Clip 6.4: Tricuspid regurgitation.

Two-dimensional transthoracic echocardio graphy. Right ventricular two-chamber views. Severe tricuspid valve regurgitation (TR) is noted in this patient with poor right ventricular (RV) function. The tricuspid valve leaflets do not coapt (arrow) in systole and are displaced into the RV. (RA: Right atrium).

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Additional Movie Clip 1: Tricuspid regurgitation.Two-dimensional transthoracic echocardiography. (A and B) Apical four-chamber

views demonstrating a dilated tricuspid valve (TV) annulus measuring > 40 mm. Arrow points to marked noncoaptation of anterior (A) and septal (S) leaflets of TV. Note the marked enlargement of the right atrium (RA); (B) Shows severe tricuspid regurgitation (TR). The severity of TR can be underestimated if one does not take into account laminar flow signals moving in the same cardiac phase with the turbu-lent flow signals. Also note that the Nyquist limit is kept high at 56 cm/s which could also lead to underestimation of TR. It should be between 40 and 50 cm/s for optimal evaluation of regurgitation severity.

Additional Movie Clip 2: Tricuspid regurgitation before annuloplasty.Two-dimensional transesophageal echocardiography. Severe tricuspid regurgitation

(TR) is noted before surgery.Additional Movie Clip 3: Tricuspid regurgitation after annuloplasty.Two-dimen sional transeso phageal echocardiography. After surgery the TR is mild.

Arrowhead in B points to a catheter in right atrium (RA). Additional Movie Clip 4: Tricuspid valve fibroelastomaThe patient was a 71-year-old female who presented with a soft systolic murmur.

(A to C) Two-dimensional (A to C) and live/real time three-dimensional (D) tran-sthoracic echocardiography. Right ventri cular inflow (A and B) and short-axis (C) views show a small, irregular mass with crenated margins attached to the tricus-pid valve (TV) consistent with a fibroelastoma. It measured 1.2 × 1.1 cm with an area of 0.513 cm2; (D) Live/real time three-dimensional transthoracic echocardio-graphy. Arrow points to an irregular mass with fronds attached with a stalk to the septal leaflet (S) of the TV. (AO: Aorta; LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 5: Tricuspid valve vegetation.Two-dimensional transthoracic echocardio graphy. Apical four-chamber (A), short-

axis (B), modified five-chamber (C) and zoomed right ventricular two-chamber (E) views. Arrow points to a huge vegetation on the septal (S) leaflet of the tricus-pid valve measuring 2.13 × 3.69 cm with an area of 5.52 cm2. The anterior (A) and posterior (P) leaflets are also involved to some extent. The posterior leaflet (P) is identified in the modified five-chamber view. Movie clips A (parts 1 and 2), B and C. Movie clip B shows no involvement of the pulmonary valve (PV). Movie clip G shows a prominent inferior vena cava with only minimal collapse during respira-tion due to severe eccentric TR (Movie clip F). (AO: Aorta; LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 6: Tricuspid papillary muscle and chordae rupture.The patient was a 32-year-old male who was involved in a motorcycle accident. Two-

dimensional transthoracic echocardiography. The arrow points to the ruptured anterior papillary muscle, which has prolapsed into the right atrium.

Additional Movie Clip 7: Tricuspid valve prolapse.Tricuspid valve prolapse. (A) Two-dimensional transthoracic (A) and transesopha-

geal (B and C) echocardiography. (A) Apical four-chamber view shows prolapse (right arrow) of the anterior leaflet of the tricuspid valve (TV). Prominent prolapse (left arrow) of the mitral valve (MV) is also present; (B and C) Five-chamber (B) and four-chamber (C) views showing redundancy of all the three leaflets (A: Anterior, P: Posterior, S: Septal) of the TV as well as the chordae (arrows). (AO: Aorta; LA: Left atrium; LV: Left ventricle; RA: Right atrium, RV: Right ventricle).

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Additional Movie Clip 8: Mild pulmonary valve regurgitationTwo-dimensional transthoracic echocardiography. Aortic (AO) short-axis view in a

patient with systemic lupus erythematosus. The pulmonary regurgitation (PR) jet is thin and occupies only 10–15% of the proximal width of the right ventricular outflow tract immediately at its origin from the pulmonary valve. This denotes mild PR. (L: Left pulmonary artery; MPA: Main pulmonary artery; RPA: Right pulmo-nary artery).

Additional Movie Clip 9: Severe pulmonary regurgitation.Two-dimensional transthoracic echocardiography. Apical 4-chamber view shows a

dilated right ventricle (RV), reduced coaptation of the tricuspid valve in systole, severe tricuspid regurgitation (TR) and a normal pulmonary artery systolic pres-sure using continuous wave Doppler derived TR velocity. The aortic short-axis view shows the pulmonary regurgitation (PR) jet occupying the full proximal width of the right ventricular (RV) outflow tract immediately adjacent to the pulmo-nary valve (PV) indicative of torrential PR. The left atrial (LA) appendage imaged beneath the PV appears clear. (LV: Left ventricle; RA: Right atrium).

Additional Movie Clip 10: Severe pulmonary regurgitation.Two-dimensional transthoracic echocardiography. Aortic short-axis view. The pulmo-

nary regurgitation (PR) jet is wide at its origin occupying approximately 75% of the width of the right ventricular (RV) outflow tract on the ventricular aspect of the pulmonary valve. This indicates severe PR. Also, the jet extends all the way to the tricuspid valve and into the right atrium (RA) in diastole (blue signals). Extension of the PR jet into the RA occurs when the diastolic pressure in the RV increases above the RA pressure as a result of severe PR and this leads to backflow into the RA in diastole through a partially closed tricuspid valve. This is also a reliable sign of severe PR. Any PR jet extending into the RV within 1 cm of the tricuspid valve is considered severe. This type of PR jet is easily missed and the severity of PR underestimated because of loss of turbulence and high velocity as a result of impingement of the PR jet against the RV wall. The flow signals thus change from high velocity mosaic colored signals to low velocity laminar signals, mostly blue.They are identified as representing PR because of their continuity with the turbulent jet and similar phasic motion in diastole. (LA: Left atrium).

CHAPTER 7Movie Clip 7.5A to C: Paravalvular mitral prosthetic regurgitation.

(A) Two-dimensional transesophageal echocardiogram shows lateral paravalvular (P) mitral regurgitation (MR) in this patient with porcine mitral valve replacement (MVR); (B and C) Live/ real time three-dimensional transesophageal echocardio-gram. En face views. The paravalvular (P) defect is localized at the 10 to 11 o’clock position (B). Color Doppler examination (C) confirms the site of the defect. (PV: Pulmonary valve).

Source: Reproduced with permission from Ref. 6 in chapter 7.Additional Movie Clip 1: Normally functioning porcine tricuspid valve prosthesis.Two-dimensional transthoracic echocardiography. (A and B) Right ventricular two-

chamber views show normal motion of prosthetic leaflets which are only mildly thickened. The right atrium (RA) is markedly enlarged. Arrowhead in A points to a pacemaker in the right ventricle (RV). Color Doppler (B) study shows absence of any significant regurgitation but several artifacts from metallic components of the prosthesis are noted in the RA. (TVR: Tricuspid valve replacement).

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Additional Movie Clip 2: Prosthetic valve thrombosis.Transesophageal echocardiography. Arrow head shows a thrombus protruding into

left atrium and obstructing the metallic mitral prosthesis (MVR) in a 42-year-old female patient. Color Doppler directed conti nuous wave Doppler examina-tion shows a very small orifice area (MVA) measur ing 0.19 cm2 by the pressure half-time method. This is indicative of severe obstruction. (LA: Left atrium; LV: Left ventricle, MVA: Mitral valve area, MVR: Mitral valve replacement; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 3: Prosthetic valve thrombosis.Transesophageal echocardiography. A 36-year-old female patient. One leaflet (#1) of

the metallic mitral valve prosthesis is fixed in the open position and the other one (#2) shows restricted motion. Arrowhead shows a portion of the thrombus. Conti-nuous wave Doppler examination shows a very flat diastolic slope indicative of severe obstruction. The metallic prosthetic valve was replaced with a tissue valve. The postoperative (post-op) study shows thin normally moving leaflets. (LA: Left atrium; LV: Left ventricle; MVR: Mitral valve replacement; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 4: Stuck bioprosthetic mitral valve leaflet.Intraoperative transesophageal echocardiography. A 75-year-old male underwent

mitral valve replacement for severe mitral regurgitation secondary to calcification and myxoid valvular changes. In the post bypass period a portion of the papil-lary muscle with an attached chord (arrow) trapped within the prosthetic leaflets (#1 and #2) is seen. In diastole, leaflet #1 opens well but leaflet #2 remains stuck in the closed position. Color Doppler examination shows significant mitral regurgitation (MR). After resection of the obstructing chord and papillary muscle both leaflets showed normal motion with trivial mitral regurgitation. Asterisks represent the struts of bioprosthetic valve. (LA: Left atrium; LV: Left ventricle). Source: Reproduced with permission from: Singh A, Nanda NC and Kirklin J. Intra-operative Transesophageal Echocardiographic Diagnosis of a Stuck Bioprosthetic Mitral Valve Leaflet. Echocardiography 2007;24(4):436-438.

Additional Movie Clip 5: Acute mechanical mitral prosthetic valve obstruction.Two-dimensional (A to D) and live/real time three-dimensional (E to H) transeso-

phageal echo cardio graphy. (A) Four chamber view. Diastolic frame. One leaflet (#2) is in the fully open position while the other (#1) shows only partial opening. Initially, following valve replacement both prosthetic leaflets move well but sub-sequently one leaflet numbered 1 shows only partial opening in systole. The other leaflet numbered 2 moves well; (B) Color Doppler study shows severe mitral regur-gitation; (C and D) Status post resection of papillary muscle head. Four chamber view. Both leaflets (# 1 and 2) are shown in the fully open position in diastole (C). D shows trivial mitral regurgitation (arrowheads); (E and F). Taken before mitral valve (MV) replacement. Arrowheads point to thickened chordae and papil-lary muscles within the left ventricle (LV). Arrow in F denotes mitral valve (MV); (G and H) Arrowhead in G and arrow in H show the papillary muscle obstructing one leaflet (#1) of the prosthetic valve; (I) Specimen of resected papillary muscle head. (AO: Aorta, LA: Left atrium; LV: Left ventricle; R: Reverberations from the prosthetic mitral valve; RV: Right ventricle).

Source: Reproduced with permission from Pattabiraman V, Nanda NC, Iqbal F, et. al. Incremental Value of Three- Dimensional over Two-Dimensional Transeso-phageal Echocardiography in the Assessment of Acute Dysfunction of Mechanical Mitral Valve Prosthesis. Echocardiography 2010;27:885-887.

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Additional Movie Clip 6: Mitral prosthetic dehiscence.Transthoracic echocardiography; (A) Arrow points to dehiscence of a metallic mitral

prosthetic valve which also shows hypermobility (“rocking motion”) in this region. The lateral aspect of the prosthesis is normally attached with no hypermobility. Arrowhead shows a remnant of a chord which was resected during valve replace-ment; (B) Color Doppler examination shows significant mitral regurgitation (MR). (LA: Left atrium; LV: Left ventricle; MVR: Mitral valve replacement; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 7: Paravalvular mitral regurgitation.The patient was a pregnant female. Transesophageal echocardiography. Medially

located eccentric and turbulent paravalvular mitral regurgitation (MR) in a patient with metallic mitral and aortic prosthetic valves. The arrowhead points to a fibri-nized suture. Systolic backflow in the left upper pulmonary vein (PV) is noted by color Doppler and pulsed wave Doppler interrogation and is a good indicator of severe MR. It is important to keep the Doppler sample volume in the pulmonary vein within 1 cm of its entrance since the MR jet may not extend further upstream into the pulmonary vein and can be missed if the sample volume is placed more distal-ly. Because the eccentric MR jet strikes the left atrial wall immediately after its exit from the prosthesis, a portion of it loses its high velocity from the impact (Coanda effect) and presents as low velo city laminar red and blue flow signals. These signals which move in the same phase as the turbulent jet should also be taken into account when assessing the MR jet area to avoid underestimation of severity. R and S represent reverberations and shadowing from the prosthesis. (LA: Left atrium; LV: Left ventricle; MVR: Mitral valve replacement; PA: Pulmonary artery; SV: Doppler sample volume).

Additional Movie Clip 8: Prosthetic vegetation.Transesophageal echocardiography. Arrow points to a vegetation located medially on

the atrial aspect of a metallic mitral prosthesis in a pregnant female patient with endocarditis. No paravalvular regurgitation is noted and both leaflets of the pros-thetic valve move well with normal washing jets (MR). The vegetation measures 1.58 cm in length and its large size distinguishes it from relatively benign strands and fibrinized sutures which are also generally located at the suture line. (AO: Aorta; LA: Left atrium; LV: Left ventricle; MVR: Mitral valve replacement).

Additional Movie Clip 9: Prosthetic obstruction.Transesophageal echocardiography. Arrow points to a large echo density on the aortic

aspect of metallic aortic prosthesis consis tent with thrombus. Arrowhead shows associated significant aortic regurgitation. (AO: Aorta, LA: Left atrium; LV: Left ventricle).

Additional Movie Clip 10: Patient aortic prosthetic mismatch.Transthoracic echocardiography. The leaflets of the tissue prosthetic valve move well

but the orifice area assessed carefully at the tip measures 0.95–1.0 cm2 suggestive of significant stenosis. Peak and mean pressure gradients measured by Doppler are also high at 49 and 32 mm Hg, respectively. This is most likely related to a small size prosthetic aortic valve. (AVR: Aortic valve replacement; LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 11: Paravalvular aortic regurgitation.Transesophageal echocardiography. (A) 69-year-old male patient with a metallic

aortic prosthesis. Arrow points to posteriorly located severe paravalvular regurgi-tation; (B) Posteriorly located paravalvular regurgitation (arrowhead) in another

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patient. Arrow points to a small hematoma; (C) Paravalvular regurgitation (arrow-head) in another 68-year-old male with Starr Edward’s aortic prosthesis. #1, #2 and #3 represent three struts of the prosthesis viewed in short-axis. (AO: Aorta; AVR: Aortic valve replacement; LA: Left atrium; LV: Left ventricle; PA: pulmonary artery, RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 12: Transcutaneous aortic valve replacement.Transthoracic echocardio graphy. 70-year-old male. Parasternal long-axis (A and B)

and apical 5 chamber views (C) show thin prosthetic valve (AVR) leaflets with good motion. Arrowhead shows mild to moderate paravalvular aortic regurgitation. (AO: Aorta, LA: Left atrium; LV: Left ventricle, RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 13: Mitral prosthetic valve dysfunction.Two-dimensional transesophageal echocardiography (intraoperative). Leaflet #2 of

the mitral prosthesis (MVR) is stuck in the closed position. The other leaflet (#1) moves well. No thrombus is evident on the atrial aspect. The ventricular aspect of the prosthesis cannot be adequately evaluated because of reverberations and shadowing effect from the metallic components of the prosthesis. During surgery, a large thrombus (arrow) was removed from the prosthesis with normal return of motion of the previously stuck leaflet (#2) and no significant mitral regurgitation (MR).

Additional Movie Clip 14: Thrombus following mitral valve replacement.Two-dimensional transesophageal echocardiography (intraoperative). Four chamber

view. The arrow points to a clot in the left atrium (LA) detected immediately following tissue mitral valve replacement (MVR). The clot was subsequently removed by the surgeon. (LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle TVR: Tricuspid valve repair).

Additional Movie Clip 15: Mitral prosthesis valvular regurgitation.Two-dimensional transesophageal echocardiography (intraoperative). Severe mitral

prosthetic valve (MVR) regurgitation (MR) is markedly reduced following surgery. (LA: Left atrium; LV: Left ventricle).

Additional Movie Clip 16: Paravalvular mitral prosthetic regurgitation.Two-dimensional transesophageal echocardiography (intraope rative). 1 and 2 repre-

sent the two leaflets of a metallic mitral prosthesis (MVR). Color Doppler study shows severe paraval vular (P) mitral regurgitation (MR) located laterally near the left atrial appendage. Following surgical repair, the paravalvular MR has disap-peared. (LA: Left atrium; LV: Left ventricle).

Additional Movie Clip 17: Paravalvular mitral prosthetic regurgitation.Two-dimensional transesophageal echocardiography. The paravalvular (P) leak is

located laterally near the left atrial (LA) appendage in this patient with a tissue prosthetic valve (MVR). It was best visualized at 64° probe rotation.

Additional Movie Clip 18: Degenerated tissue mitral prosthesis with cusp prolapse.Two-dimensional transesophageal echocardiography. The arrow in the 4-chamber

view shows cusp prolapse without rupture of a thickened, degenerated tissue mitral prosthesis (MVR). Color Doppler examination shows significant valvular mitral regurgitation (MR). M-mode examination also shows cusp prolapse and MR. Pulsed Doppler interrogation of the right upper pulmonary vein (LUPV) demon-strates systolic backflow (arrowhead) indicative of severe MR. (LA: Left atrium; LV: Left ventricle; RA: Right atrium).

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Additional Movie Clip 19: Degenerated tissue mitral prosthesis with cusp rupture.Two-dimensional transesophageal echocardiography. Arrow points to rupture and

prolapse of two cusps of a thickened and degenerated tissue mitral prosthesis (MVR). Both 4 and 2 chamber views were utilized to detect these findings. Arrow in M-mode also points to ruptured cusps. (LA: Left atrium; LV: Left ventricle; RA: Right atrium; TV: Tricuspid valve).

Additional Movie Clip 20: Prosthetic aortic valve abscess.Two-dimensional transesophageal echocardiography. Arrowhead points to septa-

tions in the abscess (A) cavity posterior to aortic valve replacement (AVR) imaged using a modified short-axis view. Color Doppler examination clearly shows a com-munication between the prosthesis and the abscess cavity in addition to signifi-cant aortic regurgitation. (LA: Left atrium; LV: Left ventricle; RA: Right atrium).

Additional Movie Clip 21: Ventricular septal defect following aortic valve replacement.Two-dimensional transesophageal echocardiography (intraoperative). Same patient

as above. Arrow points to a small iatrogenic ventricular septal defect which deve-loped following surgery. (Abbreviations as above).

Additional Movie Clip 22: Homograft aortic valve prosthesis degeneration.Two-dimensional transesophageal echocardiography. Short- and long-axis views.

Marked thickening from degeneration is visualized involving a homograft aortic valve replacement (AVR). Arrow points to severe aortic regurgitation (AR). Following initial repair (1st bypass) the AR is still significant but reduces to mild after further repair (2nd bypass). (LA: Left atrium; LV: Left ventricle; RV: Right ventricle).

Additional Movie Clip 23: Normal tricuspid valve prosthesis.Two-dimensional transesophageal echocardiography. Longitudinal plane examina-

tion at 87°. A tissue prosthetic valve (TVR) is visualized in the tricuspid position. (LA: Left atrium; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 24: Flail mitral annuloplasty ring.Transesophageal echocardiography. (A) 51-year-old male patient. Arrowhead points

to the flail ring which was found attached by only one suture to the mitral annu-lus. Severe mitral regurgitation (MR) is noted; (B) Arrowhead points to a dehisced mitral ring in another male patient. Severe MR is also noted. This patient under-went tissue mitral valve replacement which shows normally functioning leaflets post operatively (post-op). (LA: Left atrium, LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 25: Left ventricular outflow tract obstruction following mitral annuloplasty.

Transesophageal echocardiography. (A) The patient had a thickened, myxomatous mitral valve (MV) with a flail posterior leaflet and severe mitral regurgitation (MR). The anterior mitral leaflet and aortic valve (arrowhead) also showed prolapse. Following annuloplasty the patient developed systolic anterior movements of the mitral valve (arrow) with left ventricular outflow obstruction. This is thought to result from redundant anterior leaflet tissue and the obstruction often disappears if the size of the leaflet is reduced; (B) Intraoperative transesophageal echocar-diogram. Another patient demonstrating prominent systolic anterior movements (lower arrowhead) of the mitral valve and left ventricular outflow tract obstruction following annuloplasty (upper arrowheads). (AO: Aorta; LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle.

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Additional Movie Clip 26: Development of thrombus post mitral annuloplasty.Transesophageal echocardiography. Arrowhead shows a mobile poorly defined mass

on the annulo plasty ring consistent with thrombus formation. Severe valvular regurgitation (MR) is also present. (AO: Aorta; LA: Left atrium; LV: Left ventricle).

CHAPTER 8Movie Clip 8.4: Radial strain.Shows radial thickening of the myocardium during systole. In the end-diastolic frame

on the left, the myocardial thickness is 1.6 cm and increases to 2.3 cm in end systole as depicted on the right; hence, the radial strain will be +43.7% (Movie clip cour-tesy of Toshiba Medical Systems Europe BV).

Movie Clip 8.5: Longitudinal strain.Shows shortening of ventricular length during systole. The figure on the left denotes

end diastole and the one on the right depicts end systole. Note the downward descent of the mitral annulus toward the apex in systole. There is a reduction in length by 2 cm, which is a 25% decrease. As there is a decrease in the longitudinal length, it will be denoted by a negative (–) sign; hence the longitudinal strain will be –25% (Movie clip courtesy of Siemens Ultrasound).

Movie Clip 8.6: Circumferential strain.This refers to the change in the circumference of each segment as denoted by the

dotted yellow line. There is a 25% reduction in the circumferential length in end-systole from the baseline end-diastole; hence the circumferential strain will be –25% (Movie clip courtesy of Toshiba Medical Systems Europe BV).

Movie Clip 8.7 Parts 1 to 3: Velocity vector imaging.Apical four-chamber view. The direction of the arrows indicates the direction of the

movement of the left ventri cular myocardium, and the length of the arrows indi-cates the velocity of such movement. This is also shown in (Part 1). (Part 2) and (Part 3) show velocity vectors obtained separately from the left ventricular endo-cardium and epicardium.

Source: Part 1, reproduced from Buckberg G, Hoffman JI, Nanda NC, et al. Ventri-cular torsion and untwisting: further insights into mechanics and timing interde-pendence: a viewpoint. Echocardio graphy. 2011;28:782–804, with permission from Wiley-Blackwell. (Parts 2 and 3), courtesy of Siemens Ultrasound].

CHAPTER 9Movie Clip 9.1: Proximal coronary arteries.Typical image of proximal coronary arteries in parasternal short-axis view. (AO: Aorta,

LCA: Left coronary artery; RCA: Right coronary artery; RV: Right ventricle).Movie Clip 9.3: Proximal left coronary artery. Biplane transesophageal imaging.Normal left main coronary artery with bifurcation visualized in transesophageal

echocardiography (TEE). (AO: Aorta; LA: Left atrium; RVOT: Right ventricle outflow tract).

Movie Clips 9.4A and B: Ischemic cardiomyopathy.Two-dimensional transthoracic echocardiography. Parasternal long-axis (A) and

apical four-chamber (B) views. All the chambers are markedly dilated with extremely poor function of both ventricles. The septum is thin and echogenic, consistent with scarring and fibrosis indicating ischemic heart disease. Arrowhead points to a pacemaker wire. (AO: Aorta; LA: Left atrium; LV: Left ventricle; MV: Mitral valve; RA: Right atrium; RV: Right ventricle).

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Movie Clip 9.9: Ventricular septal rupture post myocardial infarction.

Example of a postmyocardial infarction ventricular septal rupture (asterisk); 2D image (A) and 3D image (B). The arrow in the 3D image views the rupture en face. Abbre-viations as in previous figures.

Movie Clip 9.10: LV papillary muscle rupture.

Examples of papillary muscle rupture (arrows).

Movie Clip 9.12: Post exercise myocardial ischemia.

This treadmill exercise echocardiogram dem onstrates ischemia. The resting study is normal while the post-exercise images reveal anteroapical wall motion abnor-malities. The distribution is consistent with obstructive coro nary artery disease involving left anterior descending artery

Movie Clip 9.13: Post exercise LV dilatation.

This video demonstrates an abnormal left ventricular volume response to stress. The resting study is normal. Post-exercise, there is evidence of anteroseptal, apical, and lateral ischemia, resulting in left ventricular dila tation or transient ischemic dilata-tion (TID). Cardiac catherization was consistent with severe multivessel coronary artery disease.

Additional Movie Clip 1: Ischemic cardiomyopathy. Sea-gull sign.Transesophageal apical four-chamber view showing severe mitral regurgitation by

color Doppler flow imaging (arrow). Arrowhead shows a kink in the middle of the anterior leaflet mimicking a “seagull.” This “seagull” sign results from tether-ing produced by a strut chord and is considered indicative of ischemic origin of cardiomyopathy. (LA: Left atrium; LV: Left ventricle; RV: Right ventricle).

Additional Movie Clip 2: Left ventricle aneurysm.(A) Two dimen sional transthoracic echocardio graphy. Apical four cham ber view

shows a large aneurysm (AN) involving approxi mately 50% of the distal left ventricle (LV). Spontaneous contrast (arrow) is noted in the aneurysm but there is no obvious thrombus. (B and C). Live/real time three-dimen sional transthoracic echocardio-graphy. Arrow points to dyski nesis of the distal ventricular septum. Short-axis view (C) shows thrombus (arrowhead) lining the aneurysm wall; (D)Transgastric echo-cardiography in another patient shows a large LV aneurysm (AN). (LA: Left atrium, LV: Left ventri cle, RA: Right atrium, RV: Right ventricle).

Additional Movie Clip 3: Left ventricular wall motion abnormalities and clot.Live/real time three-dimensional transthoracic echocardiography. The arrowhead

points to a large clot in the left ventricular apex. It shows thinning out of the distal portion of the ventricular septum which is markedly hypoki netic. Sectioning of the clot shows areas of lysis.

Additional Movie Clip 4: Right ventricular myocardial infarction.Ischemic heart disease. Trans thoracic echocardiography. (A) Par asternal long-axis

view shows hypokinesis of the proximal left ventricular posterior wall and akinesis of the right ven tricular (RV) free wall; (B) Apical four chamber view shows a dilated RV with hypokinesis of the free wall. (AO: Aorta, LA: Left atrium, LV: Left ventricle, RA: Right atrium, RV: Right ventricle).

Additional Movie Clip 5: Ventricular septal rupture following acute myocardial infarction.

Tran sesophageal echocardiography. Transgastric color Doppler examination. Arrow points to a large rupture in the middle portion of the ventricular sep tum. (LV: Left ventricle, RV: Right ventricle).

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Additional Movie Clip 6: Ventricular septal rupture with pseudoaneurysm following myocardial infarction.

Transthoracic echocardi ography. Arrow points to the tract from left ventricle (LV) to pseudoaneurysm (PAN) and subsequently communication (arrowhead) with right ventricle (RV). (LA: Left atrium, RA: Right atrium).

Additional Movie Clip 7: Cardiac rupture following myocardial infarction.Transesophageal echocardiography. Four-chamber view. Yellow arrow shows a huge

rupture in the free wall of left ventricle (LV) resulting in pseudoaneurysm (PAN) forma tion. Color Doppler examination demonstrates flow signals (arrowhead) moving to-and-fro from LV to PAN. Three-di mensional reconstruction shows distortion of mitral annulus (green arrow) produced by PAN which most likely signifi cantly contri buted to severe mitral regurgitation (MR) noted in this patient. (AO: Aorta, LA: Left atrium, RA: Right atrium, RV: Right ventricle).

CHAPTER 10Movie Clip 10.2A and B part 1-2: Hypertrophic cardiomyopathy with mid-left ventri-

cular obstruction and apical aneurysm.

Two-dimensional transthoracic echocardiography. Arrows point to what appear to be two thrombi in the apical aneurysm (AN). Use of an echo contrast agent outlines the AN and a thrombus (arrows). Arrowhead shows the narrow channel. Color M-mode and continuous wave Doppler exami nation. Shows flow signals moving into the AN in late diastole (arrow), then into the left ventricular cavity (LV) with high velocity (hollow arrow) in early systole. Thereafter, the velocity markedly decreases in mid and late systole (hollow arrowhead). Finally, high velocity signals are seen moving from the AN into the LV during diastole (arrowhead).

Movie Clip 10.3A to C: Dilated cardiomyopathy.

Two-dimensional transthoracic echo cardiography. Parasternal long-axis (A), parasternal short-axis (B), and apical four-chamber (C) views showing marked global left ventricle (LV) hypokinesis. Arrow points to a catheter in the right heart. The echo-genic tricuspid valve (TV) annulus probably represents fatty infiltration. (Ao: Aorta; DA: Descending thoracic aorta; IVS: Interventricular septum; LA: Left atrium; MV: Mitral valve; PW: Posterior wall; RV: Right ventricle).

Movie Clip 10.4A and B, E to H: Ischemic cardiomyopathy.

This was a 38-year-old female patient. Two-dimensional transthoracic echocardio-graphy. (A and B) Parasternal long-axis views demonstrating a huge left ventricle (LV) measuring 90 mm and severe mitral regurgitation (arrow).

(E to G) Apical views. (E) The coaptation point of the mitral leaflets is displaced into the LV and directed eccentrically toward the LV free wall, suggesting ischemic origin of cardiomyopathy; (F) Shows dyskinesis (arrow) of the distal LV inferior wall and septum; (G) Severe mitral regurgitation (arrow) resulting from reduced coaptation of the displaced mitral leaflets. Movie clip H shows hypokinesis (arrow) of the distal right ventricular (RV) free wall. (AO: Aorta; LA: Left atrium; G RA: Right atrium)

Movie Clip 10.5A and B: Amyloidosis.

Two-dimensional transthoracic echocardio graphy. Parasternal long-axis (A) and apical four-chamber (B) views in a 86-year-old female patient with amyloidosis. All chamber walls are echogenic and markedly hypokinetic due to the infiltrative process. The ventricular walls appear thickened because of amyloid deposition, not hypertrophy. (AO: Aorta; LA: Left atrium; LV: Left ventricle; MV: Mitral valve; RA: Right atrium; RV: Right ventricle; TV: Tricuspid valve)

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Movie Clip 10.6: Fabry’s disease.

Two-dimensional transthoracic echocardiography. Arrow shows an echolucency within the myocardium of the ventricular septum, which has been reported in patients with this entity. This finding reflects glycosphingoli pids compartmentalization in which the subendocardial layer is spared resulting in an echolucent area. Note that left ventricle (LV) function is poor. Arrowhead points to an intracardiac defibril-lator lead. (LA: Left atrium; RA: Right atrium; RV: Right ventricle).

Movie Clip 10.7A to E: Loeffler endocarditis.

Two-dimensional transthoracic echocardiography. Baseline. (A and B) Modified four-chamber view. (A) Arrowhead shows marked thickening of the tricuspid valve (TV). The arrow points to a large mass in the right ventricular (RV) apex. A small pericardial effusion (PE) is also noted; (B) Color Doppler examination. Arrow-head shows moderate to severe TV regurgitation; (C and D) Aortic (AO) short-axis view; (C) Shows marked thickening of the pulmonary valve (PV); (D) Color Dopple guided continuous wave Doppler interrogation shows a peak gradient of 48.50 mm Hg consistent with moderate PV stenosis (arrow). After therapy; (E) Modified four-chamber view. Shows complete normalization of TV and RV apex. Arrow-head points to moderator band. PE is absent. (LA: Left atrium; LV: Left ventricle; PA: Pulmonary artery; RA: Right atrium).

Source: Reproduced with permission from Garg A, Nanda NC, Sungur A, et al. Transthoracic echocardiographic detection of pulmonary valve involvement in Loeffler’s endocarditis. Echocardiography (2013, in press).

Movie Clip 10.10: Sarcoidosis.

Two-dimensional transthoracic echocardiography. Para sternal long-axis view. Both the ventricular septum (VS) and posterior wall (PW) are echogenic, consistent with myocardial fibrosis. (AO: Aorta; LA: Left atrium; MV: Mitral valve; RV: Right ventricle).

Movie Clip 10.11: Arrhythmogenic right ventricular dysplasia.

Two-dimensional trans thoracic echocardiography. Apical four-chamber view shows diminished right ventricular (RV) function as well as presence of small, localized berry-like aneurysms involving the RV free wall (arrows) typical of this entity. The left ventricle (LV) function is normal. (LA: Left atrium; MV: Mitral valve; RA: Right atrium).

Movie Clip 10.13A and B: Takotsubo cardiomyopathy.

Apical four-chamber view. Velocity vector imaging. The individual arrows point to the direction of endocardial motion, while the lengths are proportional to velocity. (A) Compared to baseline, the velocity of motion has significantly increased in the left ventricle (LV) mid segments, while the apex is still hypokinetic during follow up; (B) No change is noted by visual inspection in the left atrial (LA) wall motion during follow-up as compared to baseline. This patient belonged to a series of five patients with Takotsubo cardiomyopathy, in whom the left atrium also appeared to be involved by velocity vector imaging with a statis tical tendency toward improve-ment during follow-up. (RA: Right atrium; RV: Right ventricle).

Movie Clip 10.14: Peripartum cardiomyopathy.

Morphological assessment of left ventricular thrombus by live/real time three-dimen-sional transthoracic echocardio graphy. Thrombus attached to left ventricle (LV) apex. Transverse plane (TP, horizontal plane or short-axis) section at the attach-ment point of the thrombus (arrowhead) shows it to be highly echogenic. TP and

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longitudinal plane (LP, vertical plane or long-axis) sections through the thrombus (arrowhead) showing the echogenic attachment (arrow) and a large echolucency within the thrombus consistent with lysis. TP and both TP and LP sections at mid-thrombus level showing clot lysis. TP section at thrombus tip level showing a solid rim. LP section through thrombus showing clot lysis. Frontal plane (FP) section through the thrombus viewed en-face. The data set has been tilted and rotated to show the position of the FP. Oblique sections through the thrombus. There are residual fibrin strands within the lytic area of the thrombus.

Source: Reproduced with permission from Sinha A, et al. Morphological assess-ment of left ventricular thrombus by live three-dimensional transthoracic echocar-diography. Echocardiography. 2004;21:649–55.

Movie Clip 10.15A to C: Carcinoid disease.

Two-dimensional transthoracic echocardiography. (A) Apical four-chamber view shows systolic noncoaptation of thickened anterior (1) and septal (2) leaflets of tricuspid valve (TV); (B) Color Doppler examination shows severe tricuspid regurgitation (arrowhead) resulting from systolic noncoaptation of TV leaflets. Tricuspid regurgitation (TR) jet practically fills the right atrium (RA); (C) Aortic (AO) short-axis view shows severe pulmonary regurgitation (PR) with the PR jet extending all the way to the TV level. (LA: Left atrium; LV: Left ventricle; PA: Pulmonary artery; RV: Right ventricle).

Source: Reproduced with permission from Dumaswala B, Bicer EI, Nanda NC et al: Echocardiography 2012;29:751-756.

Movie Clip 10.16: Adriamycin induced cardiomyopathy.

Two-dimensional transeso phageal echocardiography. Parasternal long- and short-axis views. Left ventricle (LV) is markedly enlarged and severely hypokinetic. The right ventricle (RV) is also very hypokinetic. Arrow points to a catheter in the right heart. (LA: Left atrium; RA: Right atrium)

Additional Movie Clip 1: Tachycardia induced cardiomyopathyTwo-dimensional transthoracic echo cardio graphy. (A) Parasternal long-axis view. The

left ventricle (LV) is dilated with poor function. The heart rate was 133/min; (B) Apical four-chamber view. The patient was placed on a β-blocker, which resulted in heart rate reduction and improvement in LV function. (AO: Aorta; DA: Descend-ing aorta; LA: Left atrium; MV: Mitral valve; RA: Right atrium; RV: Right ventricle).

CHAPTER 11Additional Movie Clip 1: Large pericardial effusion. “Swinging heart”.

Oscillatory motion of the apex is seen within a large pericardial effusion from the parasternal long-axis view. Note this phasic motion of the heart is responsible for “electrical alternans” on ECG.

Additional Movie Clip 2: Cardiac tamponade.

Diastolic collapse of the right ventricular free wall in a patient with cardiac tampo-nade. Parasternal long-axis view. During late diastole there is inversion of the mid-right ventricular free wall.

Additional Movie Clip 3: Constrictive pericarditis.

Septal shudder of the interventricular septum is demonstrated in a patient with cons-trictive pericarditis. Note the thickened and echo-bright posterior pericardium.

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Additional Movie Clip 4: Pericardial cyst.Live/real time three-dimensional transthoracic echocardiography in a 36-year-old

male. (A) The arrowhead points to a pericardial cyst confirmed by a CT scan of the chest (see 4A). (B) Cropping of the three-dimensional data set demonstrates multiple band-like tissue (arrowhead) within the cyst (see 4B). 4C and D represent two-dimensional images which do not show multiple bands criss-crossing the cyst (arrowhead). (L: Liver).

Additional Movie Clip 5: Pericardial and left pleural effusion. Parasternal long-axis view. The arrow points to a small pericardial effusion. AO: Aorta;

LA: Left atrium; LV: Left ven tricle; PLE: Pleural effusion; RVOT: Right ventricular outflow tract.

Additional Movie Clip 6: Pleural effusion. Examination from left back. The arrow points to collapsed lung tissue. DA: Descend-

ing thoracic aorta; RV: Right ventricle.Additional Movie Clip 7: Pleural effusion. Examination from left back. Arrow points to collapsed lung tissue; PLE: Pleural

effusion; S: Spleen.Additional Movie Clip 8: Pleural effusion. Examination from right back in the same patient as Movie 7. Shows no echo free space

and hence absence of right pleural effusion. Only lung interface is demonstrated.Additional Movie Clip 9: Ascites together with pericardial and pleural effusion. Subcostal examination. Arrowhead points to ascites. Arrow shows fibrinous material

in the pericardial effusion. D: Diaphragm; FL: Falciform ligament; L: Liver; PLE: Pleural effusion; RA: Right atrium.

CHAPTER 12Movie Clip 12.1: Mitral valve vegetation.

Small vegetation (arrow) on the atrial aspect of the mitral valve is visualized in transesophageal four chamber view. (RA: Right atrium).

Movie Clip 12.2: Aortic valve vegetation.

Arrowhead points to a vegetation on the ventricular aspect of the aortic valve and arrow points to a posteriorly located aortic root abscess visualized from the transesophageal approach.

Movie Clip 12.5: Lambl’s excrescence on the aortic valve.

Two-dimensional transesophageal echocardiography. Arrowhead points to a Lambl’s excrescence on an aortic (AO) valve cusp. (LA: Left atrium; LV: Left ventricle; RV: Right ventricle).

Movie Clip 12.6: Aortic valve fibroelastoma.

Transesophageal echo movie clip showing a papillary fibroelastoma attached to the aortic valve.

Source: Dr Hashmat Ashraf, Chief of Cardiac Surgery, Buffalo General Medical Center, Buffalo, NY.

Movie Clip 12.7: Mitral annular calcification.

Real time two-dimensional transesophageal echocardiography. The arrowhead denotes posterior mitral annular calcification. Note shadowing and reverberations beneath the calcification. (LA: Left atrium; LV: Left ventricle).

Source: Reproduced with permission from Assudani J, Singh B, Samar A, et al. Echocar diography. 2010;27:1147–50.

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Movie Clip 12.8A to C: Left atrial myxoma.

Two-dimensional (A) and live/real time three-dimensional (3D; B and C) transeso-phageal echocardiography. (A) Arrow points to a myxoma in the left atrium with a broad attachment on the atrial septum. The dense areas represent calcification, while the echolucent areas indicate the presence of hemorrhages. (B and C) The attachment of the tumor is much better delineated by the 3D technique. (IAS: Interatrial septum; LA: Left atrium; RA: Right atrium).

Source: Reproduced with permission from Nanda NC et al. Incremental value of three-dimensional echocardiography over transesophageal multiplane two- dimensional echocardiography in qualitative and quantitative assessment of cardiac masses and defects. Echocardiography. 1995;12:619–28.

Movie Clip 12.9: Left atrial clot.

Two-dimensional transesophageal echocardiography showing spontaneous echo-contrast (arrowhead) and a clot (arrow) attached to the roof of the left atrium (LA). (LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Movie Clip 12.10: Left atrial hemangioma.

Left atrial hemangioma. Live/real time three-dimensional transthoracic echocardio-graphy. Arrowheads point to two of the large number of closely packed echolucen-cies in the tumor mass with sparse solid tissue. (LA: Left atrium; LV: Left ventricle; MV: Mitral valve; RA: Right atrium; RV: Right ventricle).

Source: Reproduced with permission from Mehmood F, Nanda NC, Vengala S, et al. Live three-dimensional transthoracic echocardiographic assessment of left atrial tumors. Echocardiography. 2005;22(2):137–43.

Movie Clip 12.11: Left atrial appendage lobe mimicking a mass lesion.

Transesophageal echocardiography. The arrowhead points to what appears to be a mass in or adjacent to LAA. Keeping the mass-like lesion in the middle of the moni tor screen and rotating the transducer from 0° to 180° shows that the mass-like effect is produced by a lobe of the LAA. (AO: Aorta; LA: Left atrium; LAA: Left atrial appendage; LV: Left ventricle; M: Mass; MV: Mitral valve; PA: Pulmonary artery; PE: Fluid in the transverse sinus of pericardium).

Source: Reproduced with permission from Giove GC, Singla I, Mishra J, Nanda NC. Transesophageal echocardiographic finding of left atrial appendage lobe mimick-ing a mass lesion. Echocardiography. 2011;28:684–5.

Additional Movie Clip 1: Tricuspid valve myxoma.

Transesophageal echocardiogram of a patient with a tricuspid valve myxoma. (LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 2: Left atrial myxoma

Transesophageal echocardiogram of a patient with a large left atrial septal myxoma (LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 3: Right atrial myxoma.

Four-chamber views demonstrating a large right atrial myxoma attached to the atrial wall by a stalk and prolapsing through the tricuspid valve into the right ventricle. (RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 4: Right ventricular myxoma.

Two-dimensional (A) and live/real time three-dimensional (B and C) transesopha-geal echocardiography of right ventricular myxoma. (A) The tumor (T) is visualized

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in the right ventricular (RV) outflow tract beneath the aortic valve (AV). (B) Arrow-heads show large echolucencies consistent with hemorrhages in the tumor (T). Arrow points to a linear area of calcification. (C) The dotted line shows the echo-genic area of attachment of the tumor viewed en face. It measured 1.47 × 1.44 cm, area 1.04 cm2. The aortic (AO) wall adjacent to the tumor attachment area is also echogenic. The three-dimensional data set was cropped from the bottom to the tumor attachment just beneath the AV. Then, the data set was rotated to fully deli neate en face the echogenic area of tumor attachment.

Additional Movie Clip 5: Left atrial myxoma.

Two-dimensional transesophageal echocardiography. A huge myxoma is seen occu-pying almost the whole of the left atrium (LA) with a broad attachment to the atrial septum. Highly reflectile component of the tumor represents calcification. The portion of the tumor protruding into the left ventricle (LV) in diastole is very mobile and because of this, it has a greater potential to embolize as compared to the remaining tumor. (RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 6: Mitral valve chordal fibroelastoma.

(A) Magnified two-dimensional (2D) echocardiogram apical four-chamber view and (B) two-dimensional transesophageal echocardiogram (2D TEE) showing a papil-lary fibroelastoma attached to the chordal apparatus of the mitral valve. (LA: Left atrium; LV: Left ventricle; RV: Right ventricle).

Additional Movie Clip 7: Aortic valve fibroelastoma.

Two-dimensional transesophageal echocardio graphy. The mass has prominent, short, discrete projections on the surface, resembling a sea urchin or fronds of a curtain, and an echogenic central area from colla gen deposition. These findings are typical of a fibroelastoma. (AO: Aorta; LA: Left atrium; LAA: Left atrial appendage; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 8: Tricuspid valve fibroelastoma.

Two-dimensional transthoracic echocardio graphy. Right ventricular inflow (A) and parasternal short-axis (B) views show an echo density with small, multiple spicule-like structures typical of a fibroelastoma (arrowhead). (AV: Aortic valve; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 9: Mitral valve vegetation.

Large vegetation (arrow) seen on the mitral valve in the transthoracic parasternal long axis view. (AO: Aorta; LA: Left atrium; LV: Left ventricle; MV: Mitral valve, RV: Right ventricle).

Additional Movie Clip 10: Aortic valve vegetation.

Arrow points to a large vegetation involving the aortic valve visualized by transeso-phageal echocardiography.

Additional Movie Clip 11: Aortic valve vegetation.

Arrowhead points to a vegetation on the ventricular aspect of the aortic valve and arrow points to a posteriorly located aortic root abscess visualized from the transesophageal approach.

Additional Movie Clip 12: Tricuspid valve vegetation.

Arrow denotes a huge lizard-like vegetation involving the tricuspid valve and pace-maker lead in this modified transthoracic parasternal approach. Large vegetations of this size are generally due to fungus infection. Blood cultures were negative in this patient but vegetations were confirmed at a subsequent autopsy.

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Additional Movie Clip 13: Pulmonary valve vegetation.

Transthoracic parasternal short-axis view at the level of the aortic root demonstrates large vegetations (arrows) involving the left and anterior cusps of the pulmonary valve. The echolucencies within the vegetations are suggestive of abscess forma-tion. (PA: Pulmonary artery).

CHAPTER 13Additional Movie Clip 1: Ebstein’s anomaly.

Two-dimensional transthoracic echocardiography. Apparent apical displacement of the attachment of septal leaflet (S) of the tricus pid valve (TV) as compared to the mitral valve (MV) is seen in apical four-chamber view (A). This displacement is related to tethering of the septal leaflet to the interventricular septum resulting in a bubble-like appearance. The septal leaflet in this patient and in almost all other patients with Ebstein’s anomaly actually originates normally from the atrioven-tricular junction; (B) Severe tricus pid regurgitation (TR); (C) Posterior (P) leaflet of the TV can be seen in right ventricular two-chamber view; (D) Left ventricular short-axis view at the level of mitral valve demonstrates all the three leaflets of the tricuspid valve. (A: Anterior tricuspid leaflet).

Additional Movie Clip 2: Pulmonary valve stenosis.

(A) Two-dimensional transthoracic echocardiography. A 26-year-old male. Aortic (AO) short-axis view demonstrates a thickened pulmonary valve (PV) with systolic doming and a peak gradient by color Doppler guided continuous wave Doppler of 84 mm Hg consistent with severe stenosis. Trivial pulmonary regurgitation is present. M-mode echo of the PV is normal in this patient. However, with severe stenosis, the PV may open during atrial systole and occasionally even earlier in diastole when the RV diastolic pressure exceeds the pulmonary artery (PA) dias-tolic pressure which is low in severe stenosis. This finding, when present, is best demon strated by M-mode, seen in another patient with very severe pulmonary valve stenosis; (B) In this patient, the pulmonary valve (PV) image on the left shows “full” opening following atrial systole during the expiratory phase (Exp) of respira-tion (Resp). The tracing on the right is obtained during inspiration and shows the valve in a fully opened position in mid-diastole before the onset of the P wave. (PCG: Phonocardiogram; ECG: Electrocardiogram).

Additional Movie Clip 3: Ventricular septal aneurysm.

Two-dimensional transthoracic echocardiography. Apical four-chamber view. Color Doppler examination. (A) The upper arrowhead shows the ventricular septal aneurysm (actually an extension of the septal TV leaflet), and the lower arrowhead points to flow signals moving into the right ventricle (RV) through a small defect in the aneurysm; (B) The upper arrow points to a Doppler cursor line passing through the defect, and the lower arrow shows a high peak velocity of 4.01 m/s obtained using continuous wave Doppler. This high velocity also suggests the absence of significant pulmonary hypertension. The arrowhead points to the aneurysm. In Movie clip 3B, the upper arrowhead points to the aneurysm and the lower to the septal leaflet of the tricuspid valve. (LA: Left atrium; LV: Left ventricle; MV: Mitral valve; RA: Right atrium).

Additional Movie Clip 4: Secundum atrial septal defect.

Two-dimensional transthoracic echocardiography. Right parasternal approach (RP). Color Doppler examination. The arrowhead shows flow signals moving from the left atrium (LA) into the right atrium (RA) through a secundum atrial septal defect

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located close to the opening of the superior vena cava (SVC). The parallel orienta-tion of the shunt signals with the Doppler beam resulting from horizontal viewing of the atrial septum in this examination plane facilitates not only the detection of the defect high up in the atrial septum but also an accurate measurement of the shunt velocities and shunt volume.

Additional Movie Clip 5: Patent foramen ovale.

Bicaval view on 2D TEE in the same patient shows a hyper-mobile interatrial septum. Following injection of saline-air contrast there is passage of contrast from the right atrium into the left atrium through a patent foramen ovale.

Additional Movie Clip 6: Fossa ovalis atrial septal defect.

Apical four-chamber view showing fossa ovalis atrial septal defect (arrowhead) with left to right shunt on color flow mapping. (LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 7: Sinus venosus superior vena cava type atrial septal defect.

(A) 2D transeso phageal echocardiography showing superior vena cava straddling the atrial septal defect (arrow). (B) Color flow mapping of the same. (LA: Left atrium, RA = Right atrium).

Additional Movie Clip 8: Sinus venosus inferior vena cava type atrial septal defect.

Atrial septal defect (arrowhead) is profiled on a two-dimensional apical four-chamber view in upper most part of interatrial septum. (LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 9: Sinus venosus inferior vena cava type atrial septal defect.

Transesophageal echocardiography with color flow mapping showing inferior vena cava (IVC) straddling the atrial septal defect (arrow). LA: Left atrium; RA: Right atrium).

Additional Movie Clip 10: Ostium primum atrial septal defect.

(A) Shows the ostium primum defect. Two-dimensional transthoracic 4-chamber view with (B) color flow mapping of the same shows ostium primum atrial septal defect (arrowhead) with mild mitral regurgitation, tricuspid regurgitation and small shunt from left ventricle (LV) to right atrium (RA). (LA: Left atrium; RV: Right ventricle).

Additional Movie Clip 11: Perimembranous ventricular septal defect.

Parasternal long-axis view showing perimembranous ventricular septal defect restric-ted by right coronary cusp prolapse. (AO: Aorta; LA: Left atrium; LV: Left ventricle).

Additional Movie Clip 12: Doubly committed ventricular septal defect.

Parasternal short-axis view with color flow mapping shows a large doubly committed ventricular septal defect (VSD) with laminar left to right shunt (arrowhead). The VSD is roofed by aortic and pulmonary valves (PV). (LA: Left atrium; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 13: Apical muscular ventricular septal defect.

2D echocardiography with color compare. Parasternal long-axis view with a poste-rior tilt shows a large apical muscular ventricular septal defect (VSD, arrow) with laminar left to right shunt. (LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 14: Atrial septal aneurysm with prolapse into the right ventricle and secundum atrial septal defect.

Two-dimensional transesophageal echocardiography. Adult female patient. Lower esophageal views. The arrow points to a very large atrial septal aneurysm prolap sing

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into the right ventricle (RV). A small pericardial effusion is also seen. Color Doppler examination in the 4-chamber view shows a large secundum defect (arrow) with left to right shunting. (LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 15: Two secundum atrial septal defects in the same patient.

Two-dimensional transesophageal echocardiography. A 50-year-old female. Longi-tudinal plane color Doppler examination at around 90 degrees clearly shows the presence of 2 secundum atrial septal defects (numbered #1 and #2). A small rim is seen separating the defects from the superior vena cava (SVC) excluding a sinus venosus defect. (AO: Aorta; LA: Left atrium; RA: Right atrium).

Additional Movie Clip 16: Perimembranous ventricular septal defect.

Two-dimensional transesophageal echocardiography. Arrow shows the defect with prominent left ventricle (LV) to right ventricle (RV) shunt. The defect was noted in the short-axis view adjacent to the origin of the septal leaflet of the tricuspid valve indicating its perimembranous origin. (AO: Aorta; LA: Left atrium).

Additional Movie Clip 17: Apical ventricular septal defect.

Two-dimensional transthoracic echocardiography. The arrow shows an apically located trabecular ventricular septal defect which was initially missed because the apex was not adequately interrogated by color Doppler. A high velocity of almost 4 meters/sec obtained from nonparallel alignment of the ultrasonic beam to defect flow direction indicates absence of pulmonary hypertension in this adult patient. A small ventricular septal aneurysm at the apex (arrow in the latter part of the movie) is also noted. (LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 18: Gerbode defect.

Two-dimensional transthoracic echocardiography. Adult patient. Arrow in the para-sternal long-axis view shows prominent color Doppler flow signals moving from the left (LV) to the right ventricle (RV) consistent with a ventricular septal defect. Arrow in the short-axis view at the level of the left ventricular outflow tract shows a 6 mm defect in the ventricular septum proximal to the attachment of the septal leaflet of the tricuspid valve (TV). Color Doppler study shows two jets, one moving through the septal TV leaflet into the RV and the other directly into the right atrium (RA). These findings are indicative of a Gerbode defect. High velocity (> 5m/sec), systolic flow signals obtained by color Doppler guided continuous wave Doppler through the defect suggest a high pressure gradient between the two ventricles indicative of absence of pulmonary hypertension. (AO: Aorta; LA: Left atrium).

Additional Movie Clip 19: Patent ductus arteriosus.

Two-dimensional transthoracic echocardiography. Supra sternal examination in an adult. Flow signals (arrow) are visualized moving from the descending thoracic aorta (DAO) into an enlarged pulmonary artery (PA). (PDA: Patent ductus arte-riorsus).

Additional Movie Clip 20: Complete atrioventricular septal defect.

Two-dimensional transthoracic echocardiography. An adult patient with left (LV) and right ventricular (RV) systolic dysfunction referred for consideration of cardiac transplantation. The yellow arrow points to a large atrial component of the defect and the blue arrow to the ventricular portion. Significant tricuspid (#1) and mitral (#3) regurgitation as well as shunting into the right atrium (RA, #2) from the LV through the atrial defect are well demonstrated.

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Additional Movie Clip 21: Ebstein’s anomaly.

Two-dimensional transthoracic echocardiography. Adult patient. Apical 4-chamber views. (A) A long anterior tricuspid valve leaflet (A) and marked apparent displacement of the septal leaflet (S) are noted; (B) Color Doppler examination shows severe tricuspid regurgitation (TR). (LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Additional Movie Clip 22: Bicuspid aortic valve and bicuspid aortic valve stenosis.

Two-dimensional transesophageal echocardiography. Several patients with bicuspid aortic valves are shown. The technique for accurate measurement of valve orifice area at the flow limiting tip of the stenotic valve is also explained and illustrated. (Arrow: Bicuspid aortic valve).

Additional Movie Clip 23: Discrete membranous subaortic stenosis.

Two-dimensional transesophageal echocardiography. 28-year old male. Arrow points to a prominent discrete membrane in the subaortic area. Its attachment to both the anterior mitral leaflet and the ventricular septum are well seen. Color Dop-pler examination shows systolic turbulence in the left ventricular (LV) ouflow tract as well as severe aortic regurgitation (AR). (AO: Aorta; LA: Left atrium; RV: Right ventricle).

Additional Movie Clip 24: Tetralogy of Fallot.

Two-dimensional transesophageal echocardiography. 59-year-old female. Long-axis view at around 150°. Arrow points to a ventricular septal defect. The aorta (AO) is prominent and over-rides the ventricular septum. Very significant aortic regurgi-tation (AR) is noted. Arrow shows mid-cavity narrowing of the right ventricle (RV) produced by prominent muscle bundles. (LA: Left atrium; LV: Left ventricle; PA: Pulmonary artery; PV: Pulmonary valve; TV: Tricuspid valve).

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Abbreviations

2D : Two-dimensional 3D : Three-dimensional AF : Atrial fibrillation AML : Anterior mitral valve leaflet AO : Aorta/aortic AR : Aortic regurgitation AS : Aortic stenosis AV : Aortic valve CA : Coronary artery CAD : Coronary artery disease CS : Coronary sinus DA : Descending aorta DCM : Dilated cardiomyopathy DD : Diastolic dysfunction DTGA : Dextro-transposition of the great arteries EF : Ejection fraction EOA : Effective orifice area HCM : Hypertrophic cardiomyopathy IVC : Inferior vena cava L, Li : Liver LA : Left atrium LTGA : Levo-transposition of the great arteries LV : Left ventricle LVH : Left ventricular hypertrophy LVO : Left ventricular outflow tract ML : Mitral valve leaflet MR : Mitral regurgitation MS : Mitral valve stenosis MV : Mitral valve MVOA : Mitral valve orifice area MVP : Mitral valve prolapse OA : Orifice area PA : Pulmonary artery PDA : Patent ductus arteriosus PH : Pulmonary hypertension PHT : Pressure half time PISA : Proximal isovelocity surface area PMBV : Percutaneous mitral balloon valvuloplasty PML : Posterior mitral valve leaflet

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PR : Pulmonary regurgitation PS : Pulmonaty stenosis PV : Pulmonary valve RA : Right atrium RCM : Restrictive cardiomyopathy Reg Vol : Regurgitation (regurgitant) volume RV : Right ventricle RVO/RVOT : Right ventricular outflow tract SAM : Systolic anterior movement of the mitral valve STE : Speckle tracking echocardiography SVC : Superior vena cava TAPSE : Tricuspid annulus planar systolic excursion TDI : Tissue Doppler imaging TEE : Transesophageal echocardiography TGA : Transposition of the great arteries TOF : Tetralogy of Fallot TR : Tricuspid regurgitation TTE : Transthoracic echocardiography TV : Tricuspid valve VC : Vena contracta VS/IVS : Ventricular septum VSD : Ventricular septal defect VTI : Velocity time integral WMA : Wall motion abnormality

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Prosthetic Valves 7Chapter

1. What clinical data are needed to evaluate prosthetic valves by echo? Position, type and size of the prosthetic valve, date of implantation, indi-

cation for implantation, heart rate, blood pressure, body surface area, history of fever, embolic events, shortness of breath, hemodynamic data from prior echo, and compliance with warfarin or aspirin as indicated.

2. What are the main reasons for obstruction of a prosthetic valve? Thrombosis and pannus formation. Most prosthetic valves are inher-

ently stenotic and therefore demonstrate higher than expected gradients even when the leaflet motion appears normal and there is no thrombus or pannus. This is particularly true for metallic prostheses where other factors also play a part in generating high gradients. These are described below. It is therefore crucial to do an echo/Doppler study shortly after surgery to establish baseline gradients and if much higher gradients are found during follow up in the absence of significant changes in load-ing conditions including development of moderate/severe regurgitation, prosthetic obstruction/stenosis can be suspected. This could then lead to a more thorough assessment for thrombus and pannus as well as examination of individual leaflet motion (Figs. 7.1A to I).

AFig. 7.1A

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Figs. 7.1B to D

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Figs. 7.1E to G

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Figs. 7.1A to I: St Jude mitral prosthesis: thrombus. Transesophageal echo examination. Localized echo densities consistent with thrombus (T) are noted on the St Jude prosthesis (P, MP) in two different patients. In both patients, thrombus prevented the opening of one of the leaflets (arrow in D) of the prosthesis (A to E). Continuous wave Doppler shows a flat velocity profile in early diastole (arrows) as well as a high peak velocity of 152 cm/sec consistent with obstruction. (G and H; one patient) and (I; another patient) show two other patients with thrombosed (TH, T) St Jude mitral prostheses. Thrombi are less dense than the metallic components of the prosthesis and are different from prosthetic reverberations that are anteriorly directed, more prominent and larger linear echoes. In addition, reverberations are not seen on the atrial aspect of the prosthesis during transesophageal echo examination. (AO: Aorta; LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle; RVO: Right ventricular outflow tract).Source: Reproduced with permission from Nanda NC and Domanski MJ. Atlas of Transesophageal Echocardiography, Ist edition, Baltimore, Maryland, USA: Williams and Wilkins; 1998. Fig. 5.2 AI.

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3. What are the distinguishing features of pannus from thrombus? Pannus represents in-growth of fibrous tissue at the interface between

prosthetic material and native tissue. Pannus is more dense because of fibrosis and less mobile than a thrombus and does not usually project outside the prosthesis. On the other hand, a thrombus may be less echogenic, could be mobile, and may protrude outside the sewing ring. Using three-dimensional transthoracic echocardiography (3D TTE), a thrombus may show echolucent areas from partial clot lysis even if the patient has not been on anticoagulant therapy. This finding is absent in a pannus. However, it may not always be easy to differentiate the two and both may co-exist. Both are more common with metallic prosthe-ses than tissue valves. The combination of findings of a soft density on the prosthesis and a subtherapeutic INR has been found to have posi-tive and negative predictive values of 87% and 89%, respectively, for a thrombus.

4. When does prosthesis patient mismatch occur? Prosthesis patient mismatch occurs when the effective orifice area (EOA)

of the prosthesis is too small in relation to the patient’s body surface area resulting in abnormally high postoperative trans-prosthetic gradi-ents. It should be emphasized that the indexed EOA, and not the size or geometric specifications of the prosthesis, is consistently related to postoperative gradients and/or adverse clinical outcomes. Prosthesis patient mismatch is considered to be hemodynamically insignificant for aortic prostheses if the indexed EOA is > 0.85 cm2/m2, moderate if between 0.65 and 0.85 cm2/m2, and severe if < 0.65 cm2/m2. This may hold true in many clinical scenarios but the rationale for this is weak for metallic aortic prosthetic valves since the aortic EOA calculated by echo using the continuity equation correlates very poorly with the actual pros-thetic valve area obtained from manufacturers. The discrepancy is even greater when the left ventricular outflow tract (LVOT) is ≤ 20 mm in size. This discrepancy is partly related to the pressure recovery phenomenon (already discussed in the chapter on the aortic valve) and partly to the localized high gradients detected by Doppler in the region of the pros-thesis that may not reflect the true gradient across the prosthesis. This makes it occasionally very difficult to distinguish the normally high gradients across some metallic prostheses (especially if they are small in size, ≤21 mm, in which case the gradients are even higher) from actual prosthesis patient mismatch because in both cases the leaflets will show normal mobility. One recommendation is to ask the surgeon to always enlarge a small aorta in order to avoid inserting a small prosthetic valve. This may help prevent mismatch. Mismatch becomes clinically impor-tant only when the patient becomes symptomatic.

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In patients with prosthetic obstruction/stenosis, in addition to high gradients, the leaflets will show restricted mobility. It is very important to examine all the individual leaflets of the prosthetic valve for mobility and if this cannot be done by two-dimensional (2D) TTE, then 3D TTE should be used. It may also become necessary in some patients to perform both 2D transesophageal echocardiogram (TEE) and 3D TEE to assess the motion of all prosthetic valve leaflets. Fluoroscopy is also very helpful in evaluating leaflet motion and is an important component of non-invasive workup of a patient with suspected prosthetic dysfunction.

5. How is prosthetic vegetation differentiated from a thrombus? Both are difficult to differentiate echocardiographically. Clinical findings

of infective endocarditis such as fever, a new murmur, are helpful in making the diagnosis of a vegetation while a subtherapeutic INR points to a thrombus (Fig. 7.2).

Fig. 7.2: Bioprosthetic mitral valve with large masses suggestive of vegetations on valve leaflets. (LA: Left atrium; LV: Left ventricle; RV: Right ventricle).

6. Which of the following functionally normal aortic mechanical valves is expected to have lower gradients than others?a. 23 mm bileaflet St Judeb. 23 mm Starr-Edwardsc. 25 mm tilting diskThe correct answer is c.

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All prosthetic valves are to some extent inherently stenotic; hence, a large normally functioning prosthesis would be expected to have a lower gradient compared to a smaller one. Metallic prostheses tend to have significantly higher gradients than tissue prosthetic valves where the metallic component is confined only to the ring and struts. Porcine valves may be thicker than other tissue valves and consequently the gra-dients may be higher.

7. Which index should be used in an aortic prosthetic valve with high gradient that may be possibly caused by high flow rate?

Similar to native aortic valve (AV) stenosis, a dimensionless velocity index (ratio of velocity proximal to the prosthetic valve to the velocity through the valve) may differentiate true prosthetic obstruction or stenosis from a high gradient caused by volume overload and high flow rate due to a concomitant pathology not related to the prosthetic valve. Increased flow rate results in high velocities in both the LVOT and the prosthetic valve and hence the index remains in the normal range that is 0.35−0.50 for a prosthetic AV. In a normal native AV, the dimension-less index ranges from 0.7 to 0.9. Use of this dimensionless index can decrease the incidence of false-positive results for stenosis, especially in cases of high flow rates. A dimensionless index of <0.2 is indicative of prosthetic AV stenosis.

8. What are the most common reasons for stenosis of aortic and mitral prosthetic valves?

Pannus formation occurs more commonly in aortic prosthesis because of the normally much higher velocity of blood flow through it as com-pared to mitral prosthesis where the velocity of flow is much lower that favors thrombus formation rather than a pannus build up. The high velocity and turbulence of flow through an aortic prosthetic valve is believed to elicit an endothelial reaction that results in the develop-ment of pannus. Both pannus and thrombus as well as a vegetation can result in prosthesis obstruction/stenosis with the echocardiogram showing restricted mobility of one or more leaflets and high mean and peak gradients. Restriction or complete immobility of a prosthetic leaflet may also occur from impingement produced by a plug inserted during percutaneous repair of paravalvular mitral regurgitation (MR) or AR. A large mitral prosthesis or its components protruding into the LVOT specially if it is narrow, may produce LVOT obstruction with high gradients. This may particularly occur in the setting of associated hypo-volemia in which case administration of fluids is beneficial since this would result in a decrease of pressure gradients. Occasionally, small linear echoes are visualized in the region of the sewing ring of a prosthesis, most commonly a mitral prosthetic valve. These are generally considered benign and are thought to represent fibrosed sutures especially if they are cut long during surgery.

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9. A normally functioning mechanical AV prosthesis and a mildly sten-otic native AV, having the same maximal velocities, frequently exhibit dissimilar mean transaortic gradients. What is the reason for this?

In a normally functioning mechanical AV prosthesis, the continuous wave (CW) Doppler envelope for forward flow is generally triangular (V shaped), but in stenotic as well as both stenotic and non-stenotic native AVs it is rounded (U shaped). In the prosthetic valve, the velo-city of forward flow reaches its maximum point and returns to the zero line earlier than with the native valve. This results in a lower velocity time integral and a lower mean gradient in a normal prosthetic AV as compared to mild native valve stenosis even though the peak velocities may be similar in both cases. Alteration of the triangular CW Doppler envelope to a rounded shape often occurs when the prosthesis develops stenosis (Fig. 7.3).

Fig 7.3: Normal flow through St Jude aortic valve using continuous wave (CW) Doppler. Note a low velocity with early peaking (arrow).

10. Pathological regurgitation is generally valvular in bioprosthetic valves, while it is paravalvular in mechanical valves. Is it true or false?

It is true. Bioprosthetic valves may thicken and degenerate over time resulting in varying degrees of valvular regurgitation. One or more cusps may also rupture because of degeneration resulting in a flail prosthesis with very severe regurgitation. These findings are easily observed on 2D echo and more comprehensively on 3D echo. Infective endocarditis may

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mimic degeneration on the echocardiogram and differentiation may be difficult unless clinical and laboratory features of endocarditis are pre-sent. Paravalvular regurgitation in a mechanical prosthesis results from sutures not holding on to a degenerated/calcified annulus or infective endocarditis destroying a portion of the annulus. Paravalvular regurgita-tion is less common in bioprosthetic valves than mechanical prostheses, but it may occur because of loosening of sutures or the sutures cutting through and not holding on to a fibrotic/calcified annulus. Infective endocarditis may also occasionally result in paravalvular regurgitation in a bioprosthetic valve. Significant valvular regurgitation is uncommon in mechanical prostheses but may occur if the prosthetic leaflets are stuck in the open or semi-open position by a thrombus or an element of the subvalvular apparatus protrudes into the prosthesis. The latter can be diagnosed immediately after prosthetic valve replacement, while the former tends to occur in a chronic setting. Unlike tissue prosthetic valves, metallic prostheses are designed in a manner that mild valvular regurgitation jets, up to three in number, are present in practically all of them. These so-called “washing jets” may help prevent thrombus forma-tion. These jets tend to be thin and generally are low velocity with less turbulence and aliasing but in case of mitral prosthetic valves may also be long and reach the back wall of the left atrium (LA). Pathological valvular regurgitation jets, however, are wider and demonstrate more turbulence.

Valvular regurgitation originates within the confines of a prosthetic valve, while a paravalvular leak is observed outside the prosthetic elements and thus easily differentiated by echo. A problem may arise when the regurgitant jet is noted at the very edge of the prosthesis making it diffi-cult to decide whether it is valvular or paravalvular by 2D echo. In these cases, it is useful to look at the site of flow acceleration, if one is present and that may help make the decision. Flow acceleration or convergence points to the site of the defect and its presence outside or within the confines of the prosthesis is useful in identifying paravalvular or valvular regurgitation. When several sutures are dehisced, the prosthesis may show an abnormal rocking movement on the echocardiogram that is a reliable indicator of severe paravalvular regurgitation. Color Doppler in some of these cases is misleading since the regurgitation jet may not appear large because of the dispersion produced by the rocking move-ment of the prosthesis. In general, the same criteria used for assessment of native valve regurgitation are also utilized for semiquantitation of pros-thetic valve regurgitation. Other echocardiographic signs may also point to severe valvular or paravalvular regurgitation. Enlargement of the LV,

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increase in pulmonary artery systolic pressure or increase in the gradient across a prosthetic valve with preserved motion compared to baseline echo may also point to the development of severe regurgitation in the absence of other causes. In this regard, it is important to emphasize the importance of performing a thorough baseline echo after prosthetic valve implantation and before the patient is discharged from the hospital for comparison with follow up studies. Trivial or mild paravalvular regurgitation may be noted immediately after both mitral valve (MV) and AV replacement. This may be due to leakage occurring between individual sutures and tends to disappear over time as the sutures heal undergoing fibrosis and closing the inter-suture spaces.

In general, assessment of prosthetic valves is usually more difficult than native valves and one may need to utilize all available echo modalities to confidently diagnose dysfunction.

11. How do 2D TTE and 2D TEE complement each other in the assess-ment of prosthetic dysfunction? What is the role of 3D echo?

During 2D TTE examination of a metallic mitral prosthesis using the apical four-chamber view, the LA aspect of the prosthesis is not well visualized for thrombus or regurgitation because of the development of artifactual reverberations and shadowing in the LA produced by the ultrasonic beam striking the metallic components of the prosthesis on the ventricular side. Thus, although the ventricular side of the prosthe-sis can be examined very well by 2D TTE, findings on the atrial aspect can be missed. Examination in the parasternal long-axis view with suit-able transducer angulation to avoid the reverberations and shadowing may be helpful. With 2D TEE, however, reverberations and shadowing clutter the ventricular side of the prosthesis and the LV cavity because the ultrasonic beam first encounters the atrial aspect of the prosthesis. Thus, the atrial aspect of the prosthesis and the LA are well visualized but not the ventricular side. Hence, both 2D TTE and 2D TEE serve to complement each other in the assessment of a mitral prosthesis. Two-dimensional TEE has the additional advantage of providing excellent quality images because of the proximity of the esophagus to the LA and the prosthetic valve and the ability to utilize a much higher frequency transducer. The metal in the sewing ring and stents of a bioprosthetic valve also produce reverberations but these are much less of a problem as the leaflets themselves are tissue-based. Similar to mitral prostheses, tricuspid prosthetic valves may also be best assessed using both TTE and TEE.

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detection of aortic regurgitation or thrombus on the ventricular side of the prosthesis when utilizing 2D TEE. This problem does not occur with 2D TTE. However, the overall image quality of 2D TEE is superior to 2D TTE. Hence, both 2D TTE and 2D TEE complement each other in the assessment of aortic prosthetic valves also. Prosthetic valves in the pulmonary position are best evaluated by 2D TTE/Doppler for restricted motion due to a thrombus, vegetations or degeneration, and high gradi-ents indicative of stenosis. Two-dimensional TEE is helpful in patients with poor transthoracic acoustic windows and as a supplement to 2D TTE in selected cases.

Three-dimensional echo often supplements 2D echo in the evaluation of prosthetic valves. The entire prosthetic valve and the surrounding struc-tures are captured in the 3D dataset facilitating a more systematic and comprehensive examination as compared to 2D echo. In addition, the prosthesis can be viewed en face by both 3D TTE and 3D TEE to loca lize the exact site and extent of both valvular and paravalvular regurgitation and also other pathologies such as a thrombus or vegetation. Because the quality of 3D echo is lower than 2D echo, it is important to acquire the best quality 2D images for 3D examination, especially when utilizing the transthoracic approach. Three-dimensional echo assessment of vena contracta of paravalvular regurgitation is useful in quantitatively asses-sing its severity during percutaneous MV and AV repair (Figs 7.4A, B and 7.5A to C and 7.5A to C).

Fig. 7.4A

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Figs. 7.4A and B: Twodimensional transthoracic echocardiography. Metallic mitral prosthesis. (A) Arrows point to acoustic shadowing produced by the metallic components of the prosthetic mitral valve (MVR). Reverberations (R) significantly obscure the left atrium because the ultrasound beam encounters the prosthesis first and then the left atrium. (B) Twodimensional transesophageal echocardiography performed in another patient with a metallic prosthetic valve shows acoustic shadowing (arrows) and reverberations on the ventricular aspect of the prosthetic valve but the left atrium is clear. Thus, both transthoracic and transesophageal modalities complement each other in adequately assessing metallic prosthetic valves. (LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle).

Fig. 7.5A

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Figs. 7.5A to C: Paravalvular mitral prosthetic regurgitation. (A) Twodimensional transesophageal echocardiogram shows lateral paravalvular (P) mitral regurgitation (MR) in this patient with porcine mitral valve replacement (MVR); (B and C) Live/real time threedimensional transesophageal echocardiogram. En face views. The paravalvular (P) defect is localized at the 10 to 11 o’clock position (B). Color Doppler examination (C) confirms the site of the defect. (AO: Aorta; LA: Left atrium; LAA: Left atrial appendage; LV: Left ventricle; PV: Pulmonary valve).Source: Reproduced with permission from Ref. 6.

12. How can we summarize the incremental value of 3D echo over 2D echo in the assessment of prosthetic valves?1. Motion of individual leaflets of the prosthetic valve can be well

visualized. 2. More comprehensive evaluation of the presence or absence of thrombi,

pannus, vegetations, or abscesses, their exact location, and size. Not only their length and breadth, but also their azimuthal dimension, area, and volume can be assessed.

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3. Superior evaluation of degeneration and cusp rupture in patients with tissue prosthetic valves.

4. Superior assessment of other complications related to endocarditis including fistulas and valve perforations.

5. Superior visualization of the location and size of prosthetic valve dehiscence including abnormal “rocking” motion and paravalvular leak using the surgical clock method. This orients 3D images similar to surgical views facilitating communication with the surgeon who looks at the heart that is devoid of blood and hence may have diffi-culty in assessing the site and extent of suture dehiscence.

6. Accurate quantification of valvular and paravalvular regurgitation using the vena contracta method.

13. A dyspneic patient with a bileaflet mitral mechanical valve had an INR value of 1.4. Two-dimensional TEE revealed high transmitral gradients, increased pressure half-time (PHT) and restricted motion of one leaflet, but no visible thrombus. What might be the possible diagnosis?

The diagnosis might still be thrombus even if there was no visible thrombus on 2D TEE examination. Therefore, it would be important to perform a 3D TTE and, if necessary, 3D TEE also for a more thorough and systematic examination for thrombus that could be missed by 2D TEE since it provides only thin slice-like cuts of the prosthetic valve. Three-dimensional echo may even detect small thrombi that have been known to adhere to the hinges of mechanical valves restricting their motion.

14. A 50-year-old male with a metallic prosthetic MV implanted 8 years previously presented to the outpatient clinic complaining of occa-sionally not hearing his prosthetic valve sounds for the past 4 weeks. His electrocardiogram showed normal sinus rhythm with no ecto-pics. How would you evaluate this patient?

First of all, it is important to listen to this patient using a stethoscope for several minutes if necessary to make sure there is no intermittent “stick-ing” or complete cessation of movement of the prosthetic valve that could result from a thrombus completely blocking its motion from time to time. This would be a surgical emergency since the thrombus could at any time completely and permanently prevent the prosthesis from opening result-ing in cessation of mitral inflow and patient death. The next step would be to do fluoroscopy and/or 2D TTE to evaluate prosthesis motion and in this case it would be important to observe motion for a long time since “sticking” may initially occur only occasionally. Two-dimensional-directed M-mode is also important since it may show a delay (which could be vari-able) in the opening movement of the prosthesis more consistently than complete cessation of motion. Two-dimensional/three-dimensional TTE or intraoperative 2D TEE and 3D TEE may show the thrombus obstructing the prosthetic valve (Figs. 7.6A and B).

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Figs. 7.6A and B: (A) Mmode and phonocardiogram in mitral prosthesis dysfunction. The first beat shows normal prosthetic ball motion. With the onset of diastole, both anterior (AP) and posterior (PP) parts of the poppet execute a large opening movement and the anterior poppet echo coapts with the cage echo (CE). This coincides with a large amplitude opening click (O) recorded on the phonocardiogram (PCG). At the beginning of systole, both portions of the poppet show a large posterior movement, coinciding with a prominent closing click (C) on the PCG. During the remainder of systole, the poppet does not have any intrinsic motion, but a gradual anterior movement paralleling that of the cage is recorded, reflecting mitral annular motion produced by left ventricular contraction. In the second beat, there is complete failure of the poppet to open, and no opening or closing clicks are recorded on the PCG. The record shows the poppet moving parallel with the cage echo, reflecting diastolic annular motion: there is no intrinsic poppet motion. Resumption of normal poppet motion is seen in the third beat. The fourth and fifth beats document a delay in the opening of the poppet, more marked in the fourth beat. A corresponding delay in the onset of the opening click is observed on the PCG. The patient underwent emergent surgery and was found to have fibrous tissue and thrombus that was obstructing prosthetic valve motion. The valve was replaced and the patient did well. (B) Shows the excised SmeloffCutter prosthetic valve with thrombus and fibrous tissue on the atrial (left panel) and ventricular (right panel) aspects. X = expected time of poppet opening, X’ = expected time of poppet closure, CW = chest wall, S1 = first heart sound, S2 = second heart sound, ECG = electrocardiogram. The arrow denotes the systolic murmur. Source: Reproduced with permission from Veenendaal M and Nanda NC. Am J Med. 1980;69:45862.

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15. A 30-year-old female underwent MV and tricuspid valve (TV) annu-loplasty with placement of rings 5 years ago. She has come to you for follow-up. What echo findings would you specifically look for?

Color Doppler examination would be important to evaluate the severity of any residual MR and tricuspid regurgitation. Annuloplasty rings are placed to narrow the MV and TV annuli and therefore a PHT study using CW Doppler needs to be performed to check for any significant mitral stenosis or tricuspid stenosis. Dehiscence of a ring with para-ring regur-gitation may also occur due to degenerative changes in the native ann-ulus or infection and these can be evaluated by 2D TTE/color Doppler. A flail mitral ring attached to the annulus by only a single suture and a thrombus attached to a ring have also been observed by us.

BIBLIOGRAPHY 1. Goldberg L, Bortz P, Mekel J. Echocardiographic evaluation of bileaflet mechan-

ical prosthetic valves. Cardiovasc J S Afr. 2001 Aug-Sep;12(4):215-22. Review. 2. Mahjoub H, Pibarot P, Dumesnil JG. Echocardiographic evaluation of prosthetic

heart valves. Curr Cardiol Rep. 2015 Jun;17(6):602. doi: 10.1007/s11886-015-0602-z.

3. Nanda NC, Abd-El Rahman SM, Khatri G, et al. Incremental value of three-dimensional echocardiography over transesophageal multiplane two-dimen-sional echocardiography in qualitative and quantitative assessment of cardiac masses and defects. Echocardiography. 2005;12:619–28.

4. Rosenhek R, Binder T, Maurer G, et al. Normal values for Doppler echocar-diographic assessment of heart valve prostheses. J Am Soc Echocardiogr. 2003 Nov;16(11):1116-27. Review.

5. Singh P, Inamdar V, Hage FG, et al. Usefulness of live/real time three-dimen-sional transthoracic echocardiography in evaluation of prosthetic valve func-tion. Echocardiography. 2009;26(10):1236–49.

6. Singh P, Manda J, Hsiung MC, et al. Live/real time three-dimensional transeso-phageal echocardiographic evaluation of mitral and aortic valve prosthetic paravalvular regurgitation. Echocardiography. 2009;26(8):980–7.

7. Tanis W, Habets J, van den Brink RB, et al. Differentiation of thrombus from pannus as the cause of acquired mechanical prosthetic heart valve obstruc-tion by non-invasive imaging: a review of the literature. Eur Heart J Cardiovasc Imaging. 2014 Feb;15(2):119-29. doi: 10.1093/ehjci/jet127. Epub 2013 Aug 2. Review.

8. Tsang W, Weinert L, Kronzon I, et al. Three-dimensional echocardiography in the assessment of prosthetic valves. Rev Esp Cardiol. 2011;64(1):1–7.Jayp

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