DK2985_C000 1..28 - AlSharqia Echo Club

462 Transesophageal EchocardiographyTable 19.4 Echocardiographic and Doppler Parameters Used in the Evaluation of Pulmonary Regurgitation Severity: Utility, Advantages,and LimitationsParameter Utility/advantages DisadvantagesRV sizeRV enlargement sensitive for chronic Enlargement seen in other conditionssignificant PRNormal size virtually excludessignificant PRParadoxical septal motion Simple sign of severe PRNot specific for PR(volume overload pattern)Jet length—color flow Simple Poor correlation with severity of PRVena contracta widthSimple quantitative method thatworks well for other valvesMore difficult to perform; requires good images ofpulmonary valve; lacks published validationJet deceleration rate—CWD Simple Steep deceleration not specific for severe PRFlow quantitation—PWD Quantitates regurgitant flowand fractionSubject to significant errors due to difficulties ofmeasurement of pulmonic annulus and a dynamicRVOT; not well validatedNote: CWD, Continuous-wave Doppler; PWD, pulsed-wave Doppler; RV, right ventricle; PR, pulmonary regurgitation; RVOT, right ventricularoutflow tract. [With permission of Zoghbi WA (20).]intraoperative TEE has a controversial ability in predictinglong-term mortality following valve surgery but predicts atleast a reduced event-free survival (2,3).A. Suture Annuloplasty, Complications,Failed RepairThe TV suture annuloplasty by the technique of DeVegais done with a 2.0 propylene suture button stressed withTeflon. A first suture line is started at the anteroseptalcommissure and proceeds clockwise to a point justbeyond the posteroseptal commissure (Fig. 19.20) (38).A second suture line is similarly run 2–3 mm above thefirst one. The sutures are then tied with Teflon over a 27valve sizer in the annulus to prevent valvular stenosis(39). Significant residual TR following repair usuallybecomes clinically evident with symptoms of fatigue andsigns of right-sided heart failure on long-term follow-up.Perioperative TEE may be useful in detecting residualproblems following cardiac surgery. Indeed, right ventriculardimensions and systolic function remain importantpredictors of long-term success as the annuloplastyrepair alone may not correct incomplete tricuspid leafletclosure in the setting of chronic right ventricularTable 19.5Echocardiographic and Doppler Parameters Used in Grading Pulmonary Regurgitation SeverityParameter Mild Moderate SeverePulmonic valve Normal Normal or abnormal AbnormalRV size Normal a Normal or dilated Dilated bJet size by color Doppler c Thin (usually ,10 mm in length)with a narrow originIntermediateUsually large, with a wide origin;may be brief in durationJet density and decelerationrate CWD d Soft; slow deceleration Dense; variabledecelerationDense; steep deceleration earlytermination of diastolic flowPulmonary systolicflow compared tosystemic flow—PWD e Slightly increased Intermediate Greatly increaseda Unless there are other reasons for RV enlargement. Normal 2D measurements from the apical four-chamber view; RV mediolateral end-diastolicdimension ,4.3 cm, RV end-diastolic area ,35.5 cm 2 .b Exception: acute PR.c At a Nyquist limit of 50–60 cm/sec.d Steep deceleration is not specific for severe PR.e Cut-off values for regurgitant volume and fraction are not well validated.Note: CWD, continuous-wave Doppler; PR, pulmonary regurgitation; PWD, pulsed-wave Doppler; RA, right atrium; RF, regurgitant fraction; RV, rightventricle. [With permission of Zoghbi WA (20).]