PV TEE PPT.pptx

PULMONARY VEIN DOPPLER

1. PULMONARY VEIN DOPPLER DR BIVIN WILSON INTERVENTIONAL CARDIOLOGIST GKNM HOSPITAL

2. Overview Anatomy of PV Imaging Physiology of PV and factors affecting it Clinical applications of PV doppler Pitfalls and artifacts Quiz

3. Anatomy of PVF Pulmonary veins are highly complaint structures which allow to maintain a constant LV stroke volume despite beat -beat changes in RV stroke volume There are usually four pulmonary veins including the right and left upper and lower veins. The lower veins run below the inferior border of the right and left bronchi, and the upper veins run anterior to their bronchi. The right pulmonary veins run behind the superior vena cava and right atrium and join the LA adjacent to the atrial septum .

4. Imaging

5. Imaging technique —TEE Mid oesophageal position To obtain the left upper and lower veins, the angle should be set at 110°, and the transducer should be rotated counterclockwise. The left lower veins can be visualized by advancing the probe from the position used for the left upper veins The right pulmonary veins can best be seen at a 45° to 60° angle, and the transducer should be rotated clockwise. In this view, the right upper and lower pulmonary veins appear as a “y” shape. The pulsed-wave Doppler PVF velocity pattern can be recorded by placing the sample volume 1 to 2 cm into the orifice of the pulmonary veins

6. Left Pulmonary veins

7. Right pulmonary veins

8. Physiology of PV and factors affecting

9. Physiology of PVF Pulmonary venous pressure varies according to its proximity to the pulmonary arteries and LA. It resembles the pulmonary artery pressure closer to the pulmonary capillaries and the LA pressure closer to the venoatrial junction . The flow in the pulmonary veins is determined by pressure gradient between PV and LA .

10. Normal PV Flow The normal PVF usually shows a tri- or quadriphasic pattern consisting of a pulmonary venous first systolic wave (S1), pulmonary venous second systolic wave (S2), pulmonary venous early diastolic wave (D), and pulmonary venous atrial reversed flow wave (AR) There is a direct correlation between the mitral inflow E-wave velocity and the D wave velocity

11. PV FLOW S wave – systolic forward flow during LV systolic contraction as at this time LA is relaxing and hence pulmonary veins empty in LA giving rise to forward flow.It may be biphasic with S1 and S2 Waves S1 =Fall in the LA pr during atrial relaxation S2 = Increase in PV forward flow due to ——- 1) continued descent of LV base and decrease in LA pressure 2) Propogation of RV systolic pulse pressure D = diastolic forward flow during early diastole. AR = retrograde flow from LA to pulmonary veins during atrial contraction

12. Physiology of PV doppler correlation with other events

13. Normal values S wave velocity is 30 – 80 cm/sec. D wave velocity is 20 – 70 cm/sec. AR velocity is 10 – 25 cm/sec. Duration of AR (ARdur) is 30-160 msec. Duration of S2 and D Wave are relatively fixed,whereas AR and S1 are variable depending on PR interval,cardiac rhythm

14. Clinical applications of PV doppler

15. Applications of PV waveforms Evaluation of LV diastolic dysfunction Estimation of LV filling pressures To differentiate constrictive pericarditis from restrictive cardiomyopathy Grading mitral regurgitation PV stenosis Atrial septal defect Rhythm disorders & LV dysfunction

16. Abnormal PVF in Diastolic dysfunction Relaxation abnormality Pseudo Normalisation Restrictive Physiology

17. Grade 1 LVDD Slow relaxation—LA LV crossover delay—MV opening delayed. So E wave reduced,prolonged DT PV doppler—-D wave reduces and compensatory increase in S wave. LVEDP and LAP normal

18. Grade 2 LVDD(Pseudonormalization) Modest elevation of LAP compensates for abnormal relaxation Transmitral flow resembles normal filling pattern Look at E/E’ Progressive increase in D wave in PV doppler

19. Grade 3 LVDD Reduction of LV compliance and marked elevation of LAP E wave increases, DT shortens, markedly reduced A wave. So in PV doppler small S wave due to high LAP, D is large, AR prolonged due to elevated LVEDP S/D ratio < 1 is marker of elevated filling pressures in patients with reduced EF, not so in normal LVEF patient as S2 preserved due systolic annular motion.

20. Estimation of LV filling pressures The difference between the PVF-AR wave duration and the mitral inflow atrial-wave duration has been reported to correlate with an increase in LV pressure during atrial contraction and LV end-diastolic pressure The PVF-AR wave duration exceeding mitral inflow A-wave duration by 30 ms is reported to provide high sensitivity (82%) and specificity (92%) for the detection of LV end-diastolic pressure >20 mm Hg Rule out short PR

21. PV doppler in assessing LVEDP

22. Restrictive Cardiomyopathy In restrictive cardiomyopathy, PVF shows Blunting of the S2 velocity Increase in D wave and increased AR wave Decreased S2/D ratio throughout the respiratory cycle .

23. Constrictive pericarditis The respiratory variation of the Doppler flow velocities has been reported in the differentiation between constriction and restriction . In contrast, marked respiratory change in PVF was observed in constrictive pericarditis . The S2 and D velocities increased, especially the D velocity, during expiration, and decreased during inspiration. This is explained by incomplete transmission of the inspiratory fall of intrathoracic pressure to the LA . Respiratory variation of D velocity >40% correctly classified 86% of patients with constrictive pericarditis .

24. Constrictive pericarditis

25. Limitations 12% lack respiratory variation—very shallow breathing,marked LA pressure and combined constrictive -restrictive process Significant variation without CP—-PE, rv INFARCTION,OBESITY,COPD WITH INCREASED RESPIRATORY EFFORTS

26. Mitral regurgitation To estimate the severity of MR : As the degree of MR increases, the S2 velocity decreases, thus causing systolic blunting and then late systolic flow reversal and, finally, pan-systolic reversal occurs, while the D velocity increases . A qualitative grading system for MR was proposed using PVF. Normal systolic flow was seen in patients with 1+ or 2+ MR, whereas blunted and reversed systolic flows were detected in patients with 3+ and 4+ MR, respectively. The sensitivity and specificity of reversed systolic flow for severe MR were reported as 90% to 100% by Castello et al. and 82% and 100%, respectively, by Kamp et al.

27. Mitral regurgitation

28. Limitations False negative results: Increased LA compliance False positive: Jet directions and jet areas may also influence the effect of MR on PVF patterns . So both PVF patterns must be evaluated when assessing the severity of MR because the left PVF usually shows blunted systolic flow, and the right PVF shows reversed systolic flow—depending on jet direction .

29. Mitral stenosis The characteristics of the PVF pattern in patients with mitral stenosis and normal sinus rhythm are lower S2, D, and AR velocities . The pressure half time of the D wave is longer and correlated with that in the mitral inflow E-wave because of the gradual decay of the AV pressure gradient We observed the blunted PVF pattern in 61% of the patients with mitral stenosis .

30. PV doppler in MS

31. AF & LV Dysfunction The AR and S1 waves are generated by active LA contraction and relaxation, respectively , because of the loss in effective LA function, both of them disappear in patients with AF In AF, the onset of the S2 wave is delayed, and the S2 velocity and systolic fraction are reduced with increased D velocity . The S2 velocity is especially lower in patients with LV dysfunction than in those with lone AF.

32. Radiofrequency ablation A new use of monitoring PVF is the detection of pulmonary vein stenosis after radiofrequency catheter ablation for AF. The focal origin of AF mainly inside of the pulmonary veins, and catheter ablation has been demonstrated to interrupt chronic incessant AF. However, the progressive veno-occlusive syndrome as a consequence of PV stenosis is reported Using TEE, the site of stenosis in all four pulmonary veins could be observed two-dimensionally and the severity estimated by the increased PVF velocities .

33. PV stenosis

34. Atrial septal defect Uncoupling of PV flow and left heart filling. Loss of distinct systolic and diastolic waves Single continuous wave

35. Pitfalls —Doppler recording

36. Pitfalls—-SVC flow

37. Pitfalls —DA flow

38. Summary TEE is superior to TTE for PV doppler. Always correlate PV doppler with Mitral inflow, never interpret it independently. Always time it with ECG tracing. Before interpreting PV doppler keep in mind the age,rhythm, PR interval,HR and LV function of the patient. Beware of pitfalls and artifacts

39. QUIZ TIME

40. Find the age

41. Find the age

42. Q. Grade LVDD

43. Q. Diagnosis

44. Q.Diagnosis

45. Q.Discuss DD

46. Q.Discuss DD

47. Discuss DD

48. THANK YOU