Pulmonic regurgitation echocardiography: Difference between revisions
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==Overview== | ==Overview== | ||
[[Echocardiography]] is the initial test that may be used to assess [[pulmonary valve]] morphology, [[RVOT|RVOT anatomy]], and to identify the presence and quantify the severity of [[PR|pulmonary regurgitation]] (PR). Different modes of [[echocardiography]] may be used to improve the accuracy of findings and assess the severity of the [[disease]] which include doppler|color flow [[doppler]], continuous wave [[doppler]], pulsed [[doppler]], spectral [[doppler]] and [[Exercise stress testing#Exercise/Pharmacologic Stress Echocardiography|exercise echocardiography]]. The severity of [[PR]] can be assessed by observing color [[pulmonic valve]] [[morphology]], flow [[PR]] jet size and density, and regurgitant Fraction (RF) via doppler [[echocardiography]]. | |||
[[Echocardiography]] is the initial test that may be used to assess [[pulmonary valve]] morphology, [[RVOT|RVOT anatomy]], and to identify the presence and quantify the severity of [[PR|pulmonary regurgitation]] (PR). Different modes of [[echocardiography]] may be used to improve the accuracy of findings and assess the severity of the disease which include [[ | |||
==Echocardiography== | ==Echocardiography== | ||
It is the initial imaging diagnostic test to study the [[pulmonary valve]], [[RVOT]] anatomy, to identify the presence and quantify the severity of [[PR]]. | It is the initial imaging diagnostic test to study the [[pulmonary valve]], [[RVOT]] anatomy, to identify the presence and quantify the severity of [[PR]].<ref name="pmid24468055">{{cite journal| author=Valente AM, Cook S, Festa P, Ko HH, Krishnamurthy R, Taylor AM et al.| title=Multimodality imaging guidelines for patients with repaired tetralogy of fallot: a report from the AmericanSsociety of Echocardiography: developed in collaboration with the Society for Cardiovascular Magnetic Resonance and the Society for Pediatric Radiology. | journal=J Am Soc Echocardiogr | year= 2014 | volume= 27 | issue= 2 | pages= 111-41 | pmid=24468055 | doi=10.1016/j.echo.2013.11.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24468055 }} </ref> | ||
*Among adults, visualization of the [[pulmonary valve]] is obtained from the [[parasternal]] short-axis view at the level of the [[aortic valve]] or from a [[subcostal]] approach.<ref name="pmid20620859">{{cite journal| author=Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al.| title=Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. | journal=J Am Soc Echocardiogr | year= 2010 | volume= 23 | issue= 7 | pages= 685-713; quiz 786-8 | pmid=20620859 | doi=10.1016/j.echo.2010.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620859 }} </ref><ref name="pmid12835667">{{cite journal| author=Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA et al.| title=Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. | journal=J Am Soc Echocardiogr | year= 2003 | volume= 16 | issue= 7 | pages= 777-802 | pmid=12835667 | doi=10.1016/S0894-7317(03)00335-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12835667 }} </ref> | *Among adults, visualization of the [[pulmonary valve]] is obtained from the [[parasternal]] short-axis view at the level of the [[aortic valve]] or from a [[subcostal]] approach.<ref name="pmid20620859">{{cite journal| author=Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al.| title=Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. | journal=J Am Soc Echocardiogr | year= 2010 | volume= 23 | issue= 7 | pages= 685-713; quiz 786-8 | pmid=20620859 | doi=10.1016/j.echo.2010.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620859 }} </ref><ref name="pmid12835667">{{cite journal| author=Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA et al.| title=Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. | journal=J Am Soc Echocardiogr | year= 2003 | volume= 16 | issue= 7 | pages= 777-802 | pmid=12835667 | doi=10.1016/S0894-7317(03)00335-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12835667 }} </ref> | ||
*[[ | *[[Morphology|Morphological]] anomalies of the [[pulmonary valve]] such as [[bicuspid]] or [[Quadricuspid pulmonary valve|quadricuspid valves]], [[hypoplasia]], [[dysplasia]], absence of [[pulmonary valve]] and motion abnormalities can be detected.<ref name="pmid23733442">{{cite journal| author=Lancellotti P, Tribouilloy C, Hagendorff A, Popescu BA, Edvardsen T, Pierard LA et al.| title=Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. | journal=Eur Heart J Cardiovasc Imaging | year= 2013 | volume= 14 | issue= 7 | pages= 611-44 | pmid=23733442 | doi=10.1093/ehjci/jet105 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23733442 }}</ref> | ||
*[[PR]] is diagnosed | *[[PR]] is [[diagnosed]] by demonstrating a [[diastolic jet]] in the [[RVOT|RV outflow tract]] towards the [[RV]]. | ||
==== Color Flow Doppler ==== | ===Doppler methods=== | ||
===== Color Flow Doppler===== | |||
*Color Doppler flow [[echocardiography]] is the most widely used method utilized to identify [[PR]]. | |||
*A [[diastole|diastolic]] jet in the [[RVOT|right ventricular outflow tract]] (RVOT) directed towards the [[right ventricle]], beginning in line of leaflet coaptation is diagnostic of [[PR]].<ref name="Zoghbi2003">{{cite journal|last1=Zoghbi|first1=W|title=Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography|journal=Journal of the American Society of Echocardiography|volume=16|issue=7|year=2003|pages=777–802|issn=08947317|doi=10.1016/S0894-7317(03)00335-3}}</ref> | |||
*In [[PR]] severity analysis, the jet size, extent and duration are assessed.<ref name="Zoghbi2003">{{cite journal|last1=Zoghbi|first1=W|title=Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography|journal=Journal of the American Society of Echocardiography|volume=16|issue=7|year=2003|pages=777–802|issn=08947317|doi=10.1016/S0894-7317(03)00335-3}}</ref> | |||
*The findings suggestive of significant [[PR]] include: <ref name="pmid1760180">{{cite journal| author=Maciel BC, Simpson IA, Valdes-Cruz LM, Recusani F, Hoit B, Dalton N et al.| title=Color flow Doppler mapping studies of "physiologic" pulmonary and tricuspid regurgitation: evidence for true regurgitation as opposed to a valve closing volume. | journal=J Am Soc Echocardiogr | year= 1991 | volume= 4 | issue= 6 | pages= 589-97 | pmid=1760180 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1760180 }}</ref><ref name="pmid17601802">{{cite journal| author=Maciel BC, Simpson IA, Valdes-Cruz LM, Recusani F, Hoit B, Dalton N et al.| title=Color flow Doppler mapping studies of "physiologic" pulmonary and tricuspid regurgitation: evidence for true regurgitation as opposed to a valve closing volume. | journal=J Am Soc Echocardiogr | year= 1991 | volume= 4 | issue= 6 | pages= 589-97 | pmid=1760180 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1760180 }}</ref><ref name="pmid2810683">{{cite journal| author=Kobayashi J, Nakano S, Matsuda H, Arisawa J, Kawashima Y| title=Quantitative evaluation of pulmonary regurgitation after repair of tetralogy of Fallot using real-time flow imaging system. | journal=Jpn Circ J | year= 1989 | volume= 53 | issue= 7 | pages= 721-7 | pmid=2810683 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2810683 }} </ref><ref name="pmid12062746">{{cite journal| author=Williams RV, Minich LL, Shaddy RE, Pagotto LT, Tani LY| title=Comparison of Doppler echocardiography with angiography for determining the severity of pulmonary regurgitation. | journal=Am J Cardiol | year= 2002 | volume= 89 | issue= 12 | pages= 1438-41 | pmid=12062746 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12062746 }} </ref><ref name="pmid18557879">{{cite journal| author=Puchalski MD, Askovich B, Sower CT, Williams RV, Minich LL, Tani LY| title=Pulmonary regurgitation: determining severity by echocardiography and magnetic resonance imaging. | journal=Congenit Heart Dis | year= 2008 | volume= 3 | issue= 3 | pages= 168-75 | pmid=18557879 | doi=10.1111/j.1747-0803.2008.00184.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18557879 }} </ref> | |||
*#A narrow small central and spindle shaped [[regurgitation|regurgitant jet]] is observed in mild [[PR]]. | |||
*#In severe [[PR]] a wide [[diastole|diastolic]] jet at the origin which occupies 65% of the [[RVOT]] width is seen on [[doppler|color doppler imaging]]. The duration of the jet increases with the increasing severity of [[PR]]. | |||
*#In severe [[PR]], a rapid equalization of diastolic pressures between the [[pulmonary artery]] and [[RV]] occurs, resulting in a short-lived [[regurgitation|regurgitant jet]] which can mislead in the [[diagnosis]] of the severity of [[PR]]. | |||
*#In patients with [[chronic]] significant [[PR]], dilation of the [[RV]] can be demonstrated. In patients with physiologic [[PR]] and acute [[PR]] [[RV]] dimensions are normal. | |||
* '''Vena Contracta Width''': It is a more accurate method to assess the severity of [[PR]], but it lacks validation studies.<ref name="pmid206208592">{{cite journal| author=Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al.| title=Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. | journal=J Am Soc Echocardiogr | year= 2010 | volume= 23 | issue= 7 | pages= 685-713; quiz 786-8 | pmid=20620859 | doi=10.1016/j.echo.2010.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620859 }}</ref> | |||
*'''Flow convergence method''': It can be assessed among few [[patients]] but lacks validation studies.<ref name="pmid76144992">{{cite journal| author=Lei MH, Chen JJ, Ko YL, Cheng JJ, Kuan P, Lien WP| title=Reappraisal of quantitative evaluation of pulmonary regurgitation and estimation of pulmonary artery pressure by continuous wave Doppler echocardiography. | journal=Cardiology | year= 1995 | volume= 86 | issue= 3 | pages= 249-56 | pmid=7614499 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7614499 }}</ref><ref name="pmid14566299">{{cite journal| author=Silversides CK, Veldtman GR, Crossin J, Merchant N, Webb GD, McCrindle BW et al.| title=Pressure half-time predicts hemodynamically significant pulmonary regurgitation in adult patients with repaired tetralogy of fallot. | journal=J Am Soc Echocardiogr | year= 2003 | volume= 16 | issue= 10 | pages= 1057-62 | pmid=14566299 | doi=10.1016/S0894-7317(03)00553-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14566299 }} </ref> | |||
==== | ====Continuous Wave Doppler (CWD)<ref name="Zoghbi2003">{{cite journal|last1=Zoghbi|first1=W|title=Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography|journal=Journal of the American Society of Echocardiography|volume=16|issue=7|year=2003|pages=777–802|issn=08947317|doi=10.1016/S0894-7317(03)00335-3}}</ref>==== | ||
*CW [[doppler]] is usually utilized to determine the [[end-diastolic velocity]] of [[PR]] to estimate [[pulmonary artery]] (PA) [[end-diastolic pressure]]. Although a clinically accepted method utilizing CWD to quantifying [[PR]] has has yet to be rendered. | |||
*The density of the CW signal provides a qualitative measure of [[regurgitation]]. | |||
*Rapid equalization of [[RV|right ventricle]] and [[pulmonary artery]] pressures before the end of [[diastole]] demonstrates severe [[PR]]. It is important to note that similar equilibration may also demonstrate low [[pulmonary artery]] end-diastolic pressure and/or elevated [[RV]] [[diastolic pressure]] (such as [[RV]] [[infarction]]). However, characteristics of jet, pulmonic flow quantification can help differentiate the two. | |||
====Pulse Wave (PW) Doppler (PWD)<ref name="Zoghbi2003">{{cite journal|last1=Zoghbi|first1=W|title=Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography|journal=Journal of the American Society of Echocardiography|volume=16|issue=7|year=2003|pages=777–802|issn=08947317|doi=10.1016/S0894-7317(03)00335-3}}</ref><ref name="pmid4014018">{{cite journal| author=Goldberg SJ, Allen HD| title=Quantitative assessment by Doppler echocardiography of pulmonary or aortic regurgitation. | journal=Am J Cardiol | year= 1985 | volume= 56 | issue= 1 | pages= 131-5 | pmid=4014018 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4014018 }}</ref><ref name="pmid4014018">{{cite journal |vauthors=Goldberg SJ, Allen HD |title=Quantitative assessment by Doppler echocardiography of pulmonary or aortic regurgitation |journal=Am. J. Cardiol. |volume=56 |issue=1 |pages=131–5 |date=July 1985 |pmid=4014018 |doi=10.1016/0002-9149(85)90581-8 |url=}}</ref> ==== | |||
*It is important to calculate the length and duration of the [[regurgitation|regurgitant]] jet to differentiate between true and physiologic [[insufficiency]] as up to 87% of normal patients may appear to have [[PR]] on [[examination]]. A physiologic [[regurgitation]] jet is < 1 cm in length and not holo[[diastolic]] in duration. | |||
*Forward and [[regurgitant]] flows at the [[pulmonary annulus]] and the [[pulmonary artery]] can be utilized to calculate the regurgitant volume and regurgitant fraction. | |||
*The technique can also be utilized to calculate [[stroke volume]] at different annular sites. | |||
*The severity of [[pulmonary regurgitation]] should be assessed using mapping techniques. | |||
*The technique is not valid among [[patients]] with [[pulmonic stenosis]] due to post-[[stenosis|stenotic]] turbulent flow. | |||
====Spectral Doppler==== | ====Spectral Doppler==== | ||
The density of the continous wave signal provides a qualitative measure of [[regurgitation]]. <ref name="pmid7614499">{{cite journal| author=Lei MH, Chen JJ, Ko YL, Cheng JJ, Kuan P, Lien WP| title=Reappraisal of quantitative evaluation of pulmonary regurgitation and estimation of pulmonary artery pressure by continuous wave Doppler echocardiography. | journal=Cardiology | year= 1995 | volume= 86 | issue= 3 | pages= 249-56 | pmid=7614499 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7614499 }}</ref> | The density of the continous wave signal provides a qualitative measure of [[regurgitation]]. <ref name="pmid7614499">{{cite journal| author=Lei MH, Chen JJ, Ko YL, Cheng JJ, Kuan P, Lien WP| title=Reappraisal of quantitative evaluation of pulmonary regurgitation and estimation of pulmonary artery pressure by continuous wave Doppler echocardiography. | journal=Cardiology | year= 1995 | volume= 86 | issue= 3 | pages= 249-56 | pmid=7614499 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7614499 }}</ref> | ||
*Pressure half-time (PHT) of less than 100 ms has a high sensitivity and specificity for identifying hemodynamically significant [[PR]] in [[congenital heart disease]].<ref name="pmid14566299">{{cite journal| author=Silversides CK, Veldtman GR, Crossin J, Merchant N, Webb GD, McCrindle BW et al.| title=Pressure half-time predicts hemodynamically significant pulmonary regurgitation in adult patients with repaired tetralogy of fallot. | journal=J Am Soc Echocardiogr | year= 2003 | volume= 16 | issue= 10 | pages= 1057-62 | pmid=14566299 | doi=10.1016/S0894-7317(03)00553-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14566299 }} </ref> | *Pressure half-time (PHT) of less than 100 ms has a high [[sensitivity]] and [[specificity]] for identifying hemodynamically significant [[PR]] in [[congenital heart disease]].<ref name="pmid14566299">{{cite journal| author=Silversides CK, Veldtman GR, Crossin J, Merchant N, Webb GD, McCrindle BW et al.| title=Pressure half-time predicts hemodynamically significant pulmonary regurgitation in adult patients with repaired tetralogy of fallot. | journal=J Am Soc Echocardiogr | year= 2003 | volume= 16 | issue= 10 | pages= 1057-62 | pmid=14566299 | doi=10.1016/S0894-7317(03)00553-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14566299 }} </ref> | ||
*PR Index: It is a ratio expressed between the duration of [[PR]] and total [[diastole]] which is measured from the end of forward [[pulmonary flow]] to the beginning of the next forward [[pulmonary flow]] curve. It has shown to have equal sensitivity to determine the severity of [[PR]] when compared to CMR.<ref name="pmid14691436">{{cite journal| author=Li W, Davlouros PA, Kilner PJ, Pennell DJ, Gibson D, Henein MY et al.| title=Doppler-echocardiographic assessment of pulmonary regurgitation in adults with repaired tetralogy of Fallot: comparison with cardiovascular magnetic resonance imaging. | journal=Am Heart J | year= 2004 | volume= 147 | issue= 1 | pages= 165-72 | pmid=14691436 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14691436 }} </ref> | *'''[[PR]] Index''': It is a ratio expressed between the duration of [[PR]] and total [[diastole]] which is measured from the end of forward [[pulmonary flow]] to the beginning of the next forward [[pulmonary flow]] curve. It has shown to have equal sensitivity to determine the severity of [[PR]] when compared to CMR.<ref name="pmid14691436">{{cite journal| author=Li W, Davlouros PA, Kilner PJ, Pennell DJ, Gibson D, Henein MY et al.| title=Doppler-echocardiographic assessment of pulmonary regurgitation in adults with repaired tetralogy of Fallot: comparison with cardiovascular magnetic resonance imaging. | journal=Am Heart J | year= 2004 | volume= 147 | issue= 1 | pages= 165-72 | pmid=14691436 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14691436 }} </ref> | ||
*Myocardial performance index: [[Tei index]] determined by tissue doppler imaging is a sensitive indicator of RV function in patients with chronic PR.<ref name="pmid14648001">{{cite journal| author=Yasuoka K, Harada K, Toyono M, Tamura M, Yamamoto F| title=Tei index determined by tissue Doppler imaging in patients with pulmonary regurgitation after repair of tetralogy of Fallot. | journal=Pediatr Cardiol | year= 2004 | volume= 25 | issue= 2 | pages= 131-6 | pmid=14648001 | doi=10.1007/s00246-003-0514-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14648001 }}</ref> | *'''Myocardial performance index''': [[Tei index]] determined by tissue doppler imaging is a sensitive indicator of RV function in patients with chronic PR.<ref name="pmid14648001">{{cite journal| author=Yasuoka K, Harada K, Toyono M, Tamura M, Yamamoto F| title=Tei index determined by tissue Doppler imaging in patients with pulmonary regurgitation after repair of tetralogy of Fallot. | journal=Pediatr Cardiol | year= 2004 | volume= 25 | issue= 2 | pages= 131-6 | pmid=14648001 | doi=10.1007/s00246-003-0514-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14648001 }}</ref> | ||
==='''[[Exercise stress testing#Exercise/Pharmacologic Stress Echocardiography|Exercise Echocardiography]]''' === | |||
It is used to unmask latent [[RV dysfunction]] and is a helpful investigation to assess the [[RV function]] | It is used to unmask latent [[RV dysfunction]] and is a helpful investigation to assess the [[RV function]] among [[patients]] who have undergone an intervention for significant [[PR]]. | ||
===M-Mode | ===M-Mode Echocardiography=== | ||
[[Right ventricular | [[RV|Right ventricular]] enlargement is often present with a [[RV|right ventricular]] volume overload pattern. The fine [[diastolic]] fluttering of the [[tricuspid valve]] may be observed. Premature opening of the [[pulmonic valve]] (defined as [[pulmonic valve]] opening on or before the [[QRS]] complex) may be observed as a result of severe acute [[pulmonary regurgitation]]. | ||
===2-D | ===2-D Echocardiography=== | ||
*[[Two-dimensional echocardiography]] may reveal the anatomic basis for the [[pulmonary regurgitation]] including causes such as [[infective endocarditis]] and valvular [[pulmonic stenosis]]. Dilatation of the [[right ventricle]] may be present, as well as a [[RV|right ventricular]] volume overload pattern. | *[[Two-dimensional echocardiography]] may reveal the [[anatomy|anatomic]] basis for the [[pulmonary regurgitation]] including causes such as [[infective endocarditis]] and valvular [[pulmonic stenosis]]. Dilatation of the [[right ventricle]] may be present, as well as a [[RV|right ventricular]] volume overload pattern. | ||
*[[TTE|Transthoracic Echocardiography]] (TTE) is recommended as the first-line imaging modality for [[regurgitation|valvular regurgitation]].<ref name="LancellottiTribouilloy2010">{{cite journal|last1=Lancellotti|first1=P.|last2=Tribouilloy|first2=C.|last3=Hagendorff|first3=A.|last4=Moura|first4=L.|last5=Popescu|first5=B. A.|last6=Agricola|first6=E.|last7=Monin|first7=J. L.|last8=Pierard|first8=L. A.|last9=Badano|first9=L.|last10=Zamorano|first10=J. L.|last11=Sicari|first11=R.|last12=Vahanian|first12=A.|last13=Roelandt|first13=J. R. T. C.|title=European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease)|journal=European Journal of Echocardiography|volume=11|issue=3|year=2010|pages=223–244|issn=1525-2167|doi=10.1093/ejechocard/jeq030}}</ref> | *[[TTE|Transthoracic Echocardiography]] (TTE) is recommended as the first-line imaging modality for [[regurgitation|valvular regurgitation]].<ref name="LancellottiTribouilloy2010">{{cite journal|last1=Lancellotti|first1=P.|last2=Tribouilloy|first2=C.|last3=Hagendorff|first3=A.|last4=Moura|first4=L.|last5=Popescu|first5=B. A.|last6=Agricola|first6=E.|last7=Monin|first7=J. L.|last8=Pierard|first8=L. A.|last9=Badano|first9=L.|last10=Zamorano|first10=J. L.|last11=Sicari|first11=R.|last12=Vahanian|first12=A.|last13=Roelandt|first13=J. R. T. C.|title=European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease)|journal=European Journal of Echocardiography|volume=11|issue=3|year=2010|pages=223–244|issn=1525-2167|doi=10.1093/ejechocard/jeq030}}</ref> | ||
*If [[TTE]] is non-diagnostic, the [[TEE|Transesophageal Echocardiography]] (TEE) is advocated.<ref name="LancellottiTribouilloy2010">{{cite journal|last1=Lancellotti|first1=P.|last2=Tribouilloy|first2=C.|last3=Hagendorff|first3=A.|last4=Moura|first4=L.|last5=Popescu|first5=B. A.|last6=Agricola|first6=E.|last7=Monin|first7=J. L.|last8=Pierard|first8=L. A.|last9=Badano|first9=L.|last10=Zamorano|first10=J. L.|last11=Sicari|first11=R.|last12=Vahanian|first12=A.|last13=Roelandt|first13=J. R. T. C.|title=European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease)|journal=European Journal of Echocardiography|volume=11|issue=3|year=2010|pages=223–244|issn=1525-2167|doi=10.1093/ejechocard/jeq030}}</ref> | *If [[TTE]] is non-diagnostic, the [[TEE|Transesophageal Echocardiography]] (TEE) is advocated.<ref name="LancellottiTribouilloy2010">{{cite journal|last1=Lancellotti|first1=P.|last2=Tribouilloy|first2=C.|last3=Hagendorff|first3=A.|last4=Moura|first4=L.|last5=Popescu|first5=B. A.|last6=Agricola|first6=E.|last7=Monin|first7=J. L.|last8=Pierard|first8=L. A.|last9=Badano|first9=L.|last10=Zamorano|first10=J. L.|last11=Sicari|first11=R.|last12=Vahanian|first12=A.|last13=Roelandt|first13=J. R. T. C.|title=European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease)|journal=European Journal of Echocardiography|volume=11|issue=3|year=2010|pages=223–244|issn=1525-2167|doi=10.1093/ejechocard/jeq030}}</ref> | ||
*[[TEE]] is not indicated if [[TTE]] is available in good quality except in [[operating room]] while the [[valve]] surgery is being performed.<ref name="LancellottiTribouilloy2010">{{cite journal|last1=Lancellotti|first1=P.|last2=Tribouilloy|first2=C.|last3=Hagendorff|first3=A.|last4=Moura|first4=L.|last5=Popescu|first5=B. A.|last6=Agricola|first6=E.|last7=Monin|first7=J. L.|last8=Pierard|first8=L. A.|last9=Badano|first9=L.|last10=Zamorano|first10=J. L.|last11=Sicari|first11=R.|last12=Vahanian|first12=A.|last13=Roelandt|first13=J. R. T. C.|title=European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease)|journal=European Journal of Echocardiography|volume=11|issue=3|year=2010|pages=223–244|issn=1525-2167|doi=10.1093/ejechocard/jeq030}}</ref> | *[[TEE]] is not indicated if [[TTE]] is available in good quality except in [[operating room]] while the [[valve]] surgery is being performed.<ref name="LancellottiTribouilloy2010">{{cite journal|last1=Lancellotti|first1=P.|last2=Tribouilloy|first2=C.|last3=Hagendorff|first3=A.|last4=Moura|first4=L.|last5=Popescu|first5=B. A.|last6=Agricola|first6=E.|last7=Monin|first7=J. L.|last8=Pierard|first8=L. A.|last9=Badano|first9=L.|last10=Zamorano|first10=J. L.|last11=Sicari|first11=R.|last12=Vahanian|first12=A.|last13=Roelandt|first13=J. R. T. C.|title=European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease)|journal=European Journal of Echocardiography|volume=11|issue=3|year=2010|pages=223–244|issn=1525-2167|doi=10.1093/ejechocard/jeq030}}</ref> | ||
*The severity of cardiac involvement is the main predictor of clinical outcomes among [[patients]] with [[carcinoid syndrome|carcinoid heart disease]]. [[PR]] is demonstrated as thickened and retracted [[pulmonary valve]]. Among [[patients]] with carcinoid heart disease, [[right atrial]] and [[right ventricular]] enlargement is present in up to 90% of cases.<ref name="pmid15367531">{{cite journal |vauthors=Fox DJ, Khattar RS |title=Carcinoid heart disease: presentation, diagnosis, and management |journal=Heart |volume=90 |issue=10 |pages=1224–8 |date=October 2004 |pmid=15367531 |pmc=1768473 |doi=10.1136/hrt.2004.040329 |url=}}</ref> | |||
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==Assessment of severity== | ==Assessment of severity== | ||
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=== | ===PWD and Color flow Doppler<ref name="Zoghbi2003">{{cite journal|last1=Zoghbi|first1=W|title=American Society of Echocardiography: recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography A report from the American Society of Echocardiography's Nomenclature and Standards Committee and The Task Force on Valvular Regurgitation, developed in conjunction with the American College of Cardiology Echocardiography Committee, The Cardiac Imaging Committee, Council on Clinical Cardiology, The American Heart Association, and the European Society of Cardiology Working Group on Echocardiography, represented by:|journal=European Journal of Echocardiography|volume=4|issue=4|year=2003|pages=237–261|issn=15252167|doi=10.1016/j.euje.2003.07.001}}</ref>=== | ||
* '''Physiologic :''' < 1 cm in length and not holodiastolic in duration | * '''Physiologic :''' < 1 cm in length and not holodiastolic in duration | ||
* '''Borderline :''' 1 to 2 cm in length and holodiastolic in duration | * '''Borderline :''' 1 to 2 cm in length and holodiastolic in duration | ||
* '''Clinically significant :''' > 2 cm in length with a peak velocity > 1. 5 m/sec and holodiastolic in duration | * '''Clinically significant :''' > 2 cm in length with a peak velocity > 1. 5 m/sec and holodiastolic in duration | ||
=== | ===CWD Doppler Spectral Strength of Regurgitant Jet<ref name="Zoghbi2003">{{cite journal|last1=Zoghbi|first1=W|title=American Society of Echocardiography: recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography A report from the American Society of Echocardiography's Nomenclature and Standards Committee and The Task Force on Valvular Regurgitation, developed in conjunction with the American College of Cardiology Echocardiography Committee, The Cardiac Imaging Committee, Council on Clinical Cardiology, The American Heart Association, and the European Society of Cardiology Working Group on Echocardiography, represented by:|journal=European Journal of Echocardiography|volume=4|issue=4|year=2003|pages=237–261|issn=15252167|doi=10.1016/j.euje.2003.07.001}}</ref>=== | ||
* '''Grade 1+ :''' Spectral tracing stains sufficiently for detection, but not enough for clear delineation | * '''Grade 1+ :''' Spectral tracing stains sufficiently for detection, but not enough for clear delineation | ||
* '''Grade 2+ :''' Complete spectral tracing can just be seen | * '''Grade 2+ :''' Complete spectral tracing can just be seen | ||
Latest revision as of 14:53, 8 August 2020
|
Pulmonic regurgitation Microchapters |
|
Diagnosis |
|---|
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2], Aysha Anwar, M.B.B.S[3], Javaria Anwer M.D.[4]
Overview
Echocardiography is the initial test that may be used to assess pulmonary valve morphology, RVOT anatomy, and to identify the presence and quantify the severity of pulmonary regurgitation (PR). Different modes of echocardiography may be used to improve the accuracy of findings and assess the severity of the disease which include doppler|color flow doppler, continuous wave doppler, pulsed doppler, spectral doppler and exercise echocardiography. The severity of PR can be assessed by observing color pulmonic valve morphology, flow PR jet size and density, and regurgitant Fraction (RF) via doppler echocardiography.
Echocardiography
It is the initial imaging diagnostic test to study the pulmonary valve, RVOT anatomy, to identify the presence and quantify the severity of PR.[1]
- Among adults, visualization of the pulmonary valve is obtained from the parasternal short-axis view at the level of the aortic valve or from a subcostal approach.[2][3]
- Morphological anomalies of the pulmonary valve such as bicuspid or quadricuspid valves, hypoplasia, dysplasia, absence of pulmonary valve and motion abnormalities can be detected.[4]
- PR is diagnosed by demonstrating a diastolic jet in the RV outflow tract towards the RV.
Doppler methods
Color Flow Doppler
- Color Doppler flow echocardiography is the most widely used method utilized to identify PR.
- A diastolic jet in the right ventricular outflow tract (RVOT) directed towards the right ventricle, beginning in line of leaflet coaptation is diagnostic of PR.[5]
- In PR severity analysis, the jet size, extent and duration are assessed.[5]
- The findings suggestive of significant PR include: [6][7][8][9][10]
- A narrow small central and spindle shaped regurgitant jet is observed in mild PR.
- In severe PR a wide diastolic jet at the origin which occupies 65% of the RVOT width is seen on color doppler imaging. The duration of the jet increases with the increasing severity of PR.
- In severe PR, a rapid equalization of diastolic pressures between the pulmonary artery and RV occurs, resulting in a short-lived regurgitant jet which can mislead in the diagnosis of the severity of PR.
- In patients with chronic significant PR, dilation of the RV can be demonstrated. In patients with physiologic PR and acute PR RV dimensions are normal.
- Vena Contracta Width: It is a more accurate method to assess the severity of PR, but it lacks validation studies.[11]
- Flow convergence method: It can be assessed among few patients but lacks validation studies.[12][13]
Continuous Wave Doppler (CWD)[5]
- CW doppler is usually utilized to determine the end-diastolic velocity of PR to estimate pulmonary artery (PA) end-diastolic pressure. Although a clinically accepted method utilizing CWD to quantifying PR has has yet to be rendered.
- The density of the CW signal provides a qualitative measure of regurgitation.
- Rapid equalization of right ventricle and pulmonary artery pressures before the end of diastole demonstrates severe PR. It is important to note that similar equilibration may also demonstrate low pulmonary artery end-diastolic pressure and/or elevated RV diastolic pressure (such as RV infarction). However, characteristics of jet, pulmonic flow quantification can help differentiate the two.
Pulse Wave (PW) Doppler (PWD)[5][14][14]
- It is important to calculate the length and duration of the regurgitant jet to differentiate between true and physiologic insufficiency as up to 87% of normal patients may appear to have PR on examination. A physiologic regurgitation jet is < 1 cm in length and not holodiastolic in duration.
- Forward and regurgitant flows at the pulmonary annulus and the pulmonary artery can be utilized to calculate the regurgitant volume and regurgitant fraction.
- The technique can also be utilized to calculate stroke volume at different annular sites.
- The severity of pulmonary regurgitation should be assessed using mapping techniques.
- The technique is not valid among patients with pulmonic stenosis due to post-stenotic turbulent flow.
Spectral Doppler
The density of the continous wave signal provides a qualitative measure of regurgitation. [15]
- Pressure half-time (PHT) of less than 100 ms has a high sensitivity and specificity for identifying hemodynamically significant PR in congenital heart disease.[13]
- PR Index: It is a ratio expressed between the duration of PR and total diastole which is measured from the end of forward pulmonary flow to the beginning of the next forward pulmonary flow curve. It has shown to have equal sensitivity to determine the severity of PR when compared to CMR.[16]
- Myocardial performance index: Tei index determined by tissue doppler imaging is a sensitive indicator of RV function in patients with chronic PR.[17]
Exercise Echocardiography
It is used to unmask latent RV dysfunction and is a helpful investigation to assess the RV function among patients who have undergone an intervention for significant PR.
M-Mode Echocardiography
Right ventricular enlargement is often present with a right ventricular volume overload pattern. The fine diastolic fluttering of the tricuspid valve may be observed. Premature opening of the pulmonic valve (defined as pulmonic valve opening on or before the QRS complex) may be observed as a result of severe acute pulmonary regurgitation.
2-D Echocardiography
- Two-dimensional echocardiography may reveal the anatomic basis for the pulmonary regurgitation including causes such as infective endocarditis and valvular pulmonic stenosis. Dilatation of the right ventricle may be present, as well as a right ventricular volume overload pattern.
- Transthoracic Echocardiography (TTE) is recommended as the first-line imaging modality for valvular regurgitation.[18]
- If TTE is non-diagnostic, the Transesophageal Echocardiography (TEE) is advocated.[18]
- TEE is not indicated if TTE is available in good quality except in operating room while the valve surgery is being performed.[18]
- The severity of cardiac involvement is the main predictor of clinical outcomes among patients with carcinoid heart disease. PR is demonstrated as thickened and retracted pulmonary valve. Among patients with carcinoid heart disease, right atrial and right ventricular enlargement is present in up to 90% of cases.[19]
{{#ev:youtube|https://www.youtube.com/watch?v=OjHEHnMAHJE}} {{#ev:youtube|https://www.youtube.com/watch?v=RWVQuJcYYf4}}
Assessment of severity
Determination of severity of PR based on the findings on echocardiography and Doppler:[20][21]
According to the American Society of Echocardiography (ACE) the severity of PR can be graded based upon the following parameters:
| Parameters | Mild | Moderate | Severe |
|---|---|---|---|
| Pulmonic valve morphology | Normal | Normal or abnormal | Abnormal/ may not be visible |
| Color flow PR jet size and density |
|
|
|
| Regurgitant Fraction (RF) | <20% | 20-40% | >40% |
| Pulmonic vs. systemic flow by pulse wave | Slightly increased | Intermediate | Greatly increased |
PWD and Color flow Doppler[5]
- Physiologic : < 1 cm in length and not holodiastolic in duration
- Borderline : 1 to 2 cm in length and holodiastolic in duration
- Clinically significant : > 2 cm in length with a peak velocity > 1. 5 m/sec and holodiastolic in duration
CWD Doppler Spectral Strength of Regurgitant Jet[5]
- Grade 1+ : Spectral tracing stains sufficiently for detection, but not enough for clear delineation
- Grade 2+ : Complete spectral tracing can just be seen
- Grade 3+ : Distinct darkening of spectral tracing is visible but density is less than antegrade flow
- Grade 4+ : Dark-stained spectral tracing
References
- ↑ Valente AM, Cook S, Festa P, Ko HH, Krishnamurthy R, Taylor AM; et al. (2014). "Multimodality imaging guidelines for patients with repaired tetralogy of fallot: a report from the AmericanSsociety of Echocardiography: developed in collaboration with the Society for Cardiovascular Magnetic Resonance and the Society for Pediatric Radiology". J Am Soc Echocardiogr. 27 (2): 111–41. doi:10.1016/j.echo.2013.11.009. PMID 24468055.
- ↑ Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K; et al. (2010). "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography". J Am Soc Echocardiogr. 23 (7): 685–713, quiz 786-8. doi:10.1016/j.echo.2010.05.010. PMID 20620859.
- ↑ Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA; et al. (2003). "Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography". J Am Soc Echocardiogr. 16 (7): 777–802. doi:10.1016/S0894-7317(03)00335-3. PMID 12835667.
- ↑ Lancellotti P, Tribouilloy C, Hagendorff A, Popescu BA, Edvardsen T, Pierard LA; et al. (2013). "Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging". Eur Heart J Cardiovasc Imaging. 14 (7): 611–44. doi:10.1093/ehjci/jet105. PMID 23733442.
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Zoghbi, W (2003). "Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography". Journal of the American Society of Echocardiography. 16 (7): 777–802. doi:10.1016/S0894-7317(03)00335-3. ISSN 0894-7317.
- ↑ Maciel BC, Simpson IA, Valdes-Cruz LM, Recusani F, Hoit B, Dalton N; et al. (1991). "Color flow Doppler mapping studies of "physiologic" pulmonary and tricuspid regurgitation: evidence for true regurgitation as opposed to a valve closing volume". J Am Soc Echocardiogr. 4 (6): 589–97. PMID 1760180.
- ↑ Maciel BC, Simpson IA, Valdes-Cruz LM, Recusani F, Hoit B, Dalton N; et al. (1991). "Color flow Doppler mapping studies of "physiologic" pulmonary and tricuspid regurgitation: evidence for true regurgitation as opposed to a valve closing volume". J Am Soc Echocardiogr. 4 (6): 589–97. PMID 1760180.
- ↑ Kobayashi J, Nakano S, Matsuda H, Arisawa J, Kawashima Y (1989). "Quantitative evaluation of pulmonary regurgitation after repair of tetralogy of Fallot using real-time flow imaging system". Jpn Circ J. 53 (7): 721–7. PMID 2810683.
- ↑ Williams RV, Minich LL, Shaddy RE, Pagotto LT, Tani LY (2002). "Comparison of Doppler echocardiography with angiography for determining the severity of pulmonary regurgitation". Am J Cardiol. 89 (12): 1438–41. PMID 12062746.
- ↑ Puchalski MD, Askovich B, Sower CT, Williams RV, Minich LL, Tani LY (2008). "Pulmonary regurgitation: determining severity by echocardiography and magnetic resonance imaging". Congenit Heart Dis. 3 (3): 168–75. doi:10.1111/j.1747-0803.2008.00184.x. PMID 18557879.
- ↑ Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K; et al. (2010). "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography". J Am Soc Echocardiogr. 23 (7): 685–713, quiz 786-8. doi:10.1016/j.echo.2010.05.010. PMID 20620859.
- ↑ Lei MH, Chen JJ, Ko YL, Cheng JJ, Kuan P, Lien WP (1995). "Reappraisal of quantitative evaluation of pulmonary regurgitation and estimation of pulmonary artery pressure by continuous wave Doppler echocardiography". Cardiology. 86 (3): 249–56. PMID 7614499.
- ↑ 13.0 13.1 Silversides CK, Veldtman GR, Crossin J, Merchant N, Webb GD, McCrindle BW; et al. (2003). "Pressure half-time predicts hemodynamically significant pulmonary regurgitation in adult patients with repaired tetralogy of fallot". J Am Soc Echocardiogr. 16 (10): 1057–62. doi:10.1016/S0894-7317(03)00553-4. PMID 14566299.
- ↑ 14.0 14.1 Goldberg SJ, Allen HD (1985). "Quantitative assessment by Doppler echocardiography of pulmonary or aortic regurgitation". Am J Cardiol. 56 (1): 131–5. PMID 4014018.
- ↑ Lei MH, Chen JJ, Ko YL, Cheng JJ, Kuan P, Lien WP (1995). "Reappraisal of quantitative evaluation of pulmonary regurgitation and estimation of pulmonary artery pressure by continuous wave Doppler echocardiography". Cardiology. 86 (3): 249–56. PMID 7614499.
- ↑ Li W, Davlouros PA, Kilner PJ, Pennell DJ, Gibson D, Henein MY; et al. (2004). "Doppler-echocardiographic assessment of pulmonary regurgitation in adults with repaired tetralogy of Fallot: comparison with cardiovascular magnetic resonance imaging". Am Heart J. 147 (1): 165–72. PMID 14691436.
- ↑ Yasuoka K, Harada K, Toyono M, Tamura M, Yamamoto F (2004). "Tei index determined by tissue Doppler imaging in patients with pulmonary regurgitation after repair of tetralogy of Fallot". Pediatr Cardiol. 25 (2): 131–6. doi:10.1007/s00246-003-0514-3. PMID 14648001.
- ↑ 18.0 18.1 18.2 Lancellotti, P.; Tribouilloy, C.; Hagendorff, A.; Moura, L.; Popescu, B. A.; Agricola, E.; Monin, J. L.; Pierard, L. A.; Badano, L.; Zamorano, J. L.; Sicari, R.; Vahanian, A.; Roelandt, J. R. T. C. (2010). "European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease)". European Journal of Echocardiography. 11 (3): 223–244. doi:10.1093/ejechocard/jeq030. ISSN 1525-2167.
- ↑ Fox DJ, Khattar RS (October 2004). "Carcinoid heart disease: presentation, diagnosis, and management". Heart. 90 (10): 1224–8. doi:10.1136/hrt.2004.040329. PMC 1768473. PMID 15367531.
- ↑ Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K; et al. (2010). "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography". J Am Soc Echocardiogr. 23 (7): 685–713, quiz 786-8. doi:10.1016/j.echo.2010.05.010. PMID 20620859.
- ↑ Zoghbi, William A.; Adams, David; Bonow, Robert O.; Enriquez-Sarano, Maurice; Foster, Elyse; Grayburn, Paul A.; Hahn, Rebecca T.; Han, Yuchi; Hung, Judy; Lang, Roberto M.; Little, Stephen H.; Shah, Dipan J.; Shernan, Stanton; Thavendiranathan, Paaladinesh; Thomas, James D.; Weissman, Neil J. (2017). "Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation". Journal of the American Society of Echocardiography. 30 (4): 303–371. doi:10.1016/j.echo.2017.01.007. ISSN 0894-7317.