Echo of the Day
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Echo-of-the-Day Information
The Echo-of-the-Day is a presentation of one to four image or video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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EOTD Information Table
Title: Is it tight or is it leaky?
EOTD#: 293
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes
CME Requirements: Active CME Session and must be a paid, active subscriber to iTEE or eTEE AND have enough CME credits in your bank. AMA CME ONLY.
 
Presentation: A patient presented with the following echo loops:
 
 
Loops:
Discussion Questions:
#1: What is the diagnosis?
 
#2: Which is more severe - stenosis or regurgitation?
 
#3: What are the etiologies of the condition?
 
#4: What is the therapy for the condition?
 
 
 
Explanation/CME Questions
Explanation: The diagnosis is mild pulmonary stenosis and severe pulmonary regurgitation.

The peak PVG is around 36 mmHg. The pulmonary regurgitant CWD is not even pandiastolic which indicates severe pulmonary stenosis. The 2D echo loops shows a restricted pulmonary valve and it appears the remnants of the valve are present - a dyplastic valve is present.

The etiologies of pulmonary valve stenosis is:

  • Congenital (almost all)
    • Valvular
    • Supravalvular (Dome or Ring)
  • Carcinoid
  • Rheumatic Fever
Pulmonary stenosis is graded by the peak pulmonary valvular gradient:
  • Mild:          < 36 mmHg    < 3 m/sec
  • Moderate: 36-64 mmHg    3-4 m/sec
  • Severe:     > 64 mmHg     > 4 m/sec
Treatment consists of balloon valvuloplasty, valvotomy or valve replacement. Balloon valvuloplasty has good short and long term results. In one study the average peak gradient decreased from 85 mmHg to 33 mmHg with a 98% success rate with a 0.5% mortality.  Patients with severe or moderate pulmonary stenosis tended to respond to valvotomy or valvuloplasty.

Pulmonary regurgitation is graded by the appearance of the pulmonary valve, the RV size, the jet size by color Doppler, the jet density of the continuous wave Doppler, the deceleration rate, and the systolic flow compared to the systemic flow.

Parameter
Mild
Moderate
Severe
Pulmonary Valve
Normal
Abnormal/Normal
 Abnormal
 RV Size
 Normal Normal or Dilated
 Dilated
 Jet Size by CFD
 < 10 mm length
Intermediate
Large
 Jet Origin
 Thin
 Intermediate  Wide
 Jet Density
 Soft  Dense  Dense
 Deceleration Rate
 Slow  Variable  Steep
 Qp/Qs  Increased  Intermediate  Markedly Increased

The above indicators of the severity of pulmonary regurgitation are all "soft" indicators. No hard numbers exist. Pieper commented that PR, when severe, would equilibrate quickly with a normal pulmonary artery pressure - there is simply not enough gradient for the PR equilibration to show the true severity of the PR. Therefore, regurgitation fractions > 20% would indicate severe PR (whereas the current PR regurgitation fraction is greater than 20% (by CMR).

Two studies indicated that a PHT < 100 msec to be highly sensitive and specific for severe PR.
A vena contracta may be difficult to identify in many patients with severe PR. A jet width/RVOTd width > 50% was sensitive and specific for identifying severe PR.

The European Association of Echocardiography assess the severity of pulmonary regurgitation similarly to the ASE with soft signs and no hard numbers. There is not enough studies to indicate what the cutoffs would be for mild, moderate or severe PR.

In this patient the peak pulmonary velocity was around 3 m/sec which is a peak gradient of 36 mmHg - mild or just barely moderate pulmonary stenosis. The PR is severe by CFD, RV dilation, and CWD deceleration pattern.

The valve is dysplasic and is not repairable. The leaflets could not even be visualized. The recommendation was to replace the valve.

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