Pulsed Doppler echocardiographic detection of right-sided valve regurgitation. Experimental results and clinical significance

The optimal use of cardiac imaging in the quantification of carcinoid heart disease

Carcinoid heart disease is a rare cause of right-sided valvular dysfunction, primarily mediated by serotonin. It is an important complication in patients with carcinoid syndrome and occurs in 20-50% of such patients. Echocardiography is the main technique used for the assessment of carcinoid heart disease, but other imaging modalities are also important, particularly in the quantification of the severity of the disease. We sought to review the role of cardiac imaging in the assessment of carcinoid heart disease.

Pressure half-time predicts hemodynamically significant pulmonary regurgitation in adult patients with repaired tetralogy of fallot

Pulmonary regurgitation (PR) is associated with adverse outcomes late after tetralogy of Fallot repair. Accurate assessment of PR in these patients is, therefore, fundamental to their clinical treatment; however, accurate ultrasound markers of severity are as yet poorly defined. This is a prospective study of 34 adult patients with repaired tetralogy of Fallot. Cardiac magnetic resonance imaging was used to assess the PR fraction and its hemodynamic significance on the right ventricular volumes. Regurgitant fractions >/= 20% were associated with significant increases in right ventricular end-diastolic volumes. Echocardiographic continuous wave Doppler profiles of the PR jet were used to calculate pressure half-time. Pulmonary pressure half-time < 100 milliseconds was found to be a good indicator of hemodynamically significant regurgitation. This measure is highly reproducible and easily accessible.

Increased prevalence of significant tricuspid regurgitation in patients with transvenous pacemakers leads

Transvenous pacemaker leads are associated with an increased prevalence of tricuspid regurgitation. This hemodynamic derangement should be considered as part of the clinical cost and complications of permanent pacemaker implantation.

Tricuspid valve surgery and intraoperative echocardiography: factors affecting survival, clinical outcome, and echocardiographic success

BACKGROUND

The impact of echocardiographic-guided treatment on outcome after tricuspid valve (TV) surgery is not well defined.

OBJECTIVES

The purpose of this study was to determine clinical and echocardiographic factors associated with adverse outcomes after TV surgery and determine the role of intraoperative echo (IOE) in facilitating successful outcomes after TV surgery.

METHODS

Four hundred and one patients (279 females, mean age 60 years) underwent TV surgery and other concomitant cardiac surgery at a single institution and were followed clinically and by echocardiography during a 10-year period.

RESULTS

Decreased survival after TV surgery was associated with: preoperative increased New York Heart Association (NYHA) functional classification (relative risk [RR]=2.02), increased left ventricular dysfunction by echocardiography (RR=1.28), and use of a TV replacement strategy (RR=2.92). Decreased event-free survival after TV surgery was associated with concomitant coronary artery bypass grafting (RR=2.97). Late echocardiographic failure (3 to 4+ tricuspid valve regurgitation [TR]) after TV surgery was associated with increased severity of TR on preoperative echocardiogram (odds ratio [OR]=1.91). Decreased late echocardiographic failure after TV surgery was associated with the use of a TV annuloplasty ring with a repair strategy (OR=0.40). The surgical plan was altered at the time of surgery to insure a successful outcome in 32 (10%) of 335 patients based on IOE findings.

CONCLUSIONS

Adverse outcomes after TV surgery can be predicted by several preoperative clinical and echocardiographic variables. IOE is useful in improving immediate, but not late, outcomes after TV surgery.

Optimal Albunex dosing for enhancement of Doppler tricuspid regurgitation spectra

Intravenous albunex was more effective than agitated saline in enhancing incomplete Doppler echocardiography spectra for tricuspid regurgitation without a significant alteration in the maximal detected velocity. The optimal dose was 1 to 4 ml in most patients, using an initial dose of 1 ml and titrating further dosing on the basis of the initial contrast effect.

Noninvasive evaluation of right ventricle systolic pressure during dynamic exercise by saline-enhanced Doppler echocardiography in progressive systemic sclerosis

Progressive systemic sclerosis (PSS) is characterized in its first phases by vascular damage. Lungs are involved in two thirds of patients with initial progressive destruction of the capillary bed and consequent reduction of the functional reserve, which may lead to hypertension of the pulmonary circulation. For these reasons it is of great interest to have early information about the pressure of the pulmonary circulation, both at rest and during exercise, to follow the progression and the evolution of the illness independently from subjective symptoms. The aim of the study was to evaluate by a noninvasive method, saline-enhanced Doppler echocardiography, the behavior of the right ventricular systolic pressure in patients with PSS, at rest and during exercise, without clear instrumental or clinical signs of pulmonary involvement at rest. Nine patients (7 women and 2 men) with PSS, aged 55.7 +/- 8.7 years, and 9 control subjects were evaluated. All patients had normal pulmonary pressure at rest and negative history for effort dyspnea. Subjects underwent Doppler echocardiographic examination at rest and during exercise. Right ventricular systolic pressure was evaluated by saline-enhanced Doppler technique, at rest and throughout exercise. At rest the right ventricular systolic pressure was normal in all patients and controls. At the end of exercise, in 4 patients, values were still normal (40.7 +/- 2.2 mmHg); in the others pathologic values were recorded (59.8 +/- 3.9 mmHg). In the control group values were always normal (35.6 +/- 4.6 mmHg). In our study the saline-enhanced Doppler echocardiography has been demonstrated to be an important diagnostic tool for the noninvasive evaluation of right ventricular systolic pressure, both at rest and during exercise; it could be useful in monitoring the pulmonary vascular damage in patients with PSS.

Insertion of a pacing lead via the tricuspid valve does not affect cardiac function and tricuspid valve regurgitation in young dogs

A preliminary experimental study in dogs was conducted to evaluate the feasibility of transvenous cardiac pacing in the fetus with complete heart block associated with hydrops. Four young mongrel dogs were anesthetized with intravenous administration of sodium pentobarbital and mechanically ventilated, and a pacing lead was inserted via the tricuspid valve. The right ventricular cardiac output, aortic pressure and central venous pressure were measured, and the tricuspid valve regurgitation was measured semi-quantitatively using echo-Doppler color flow imaging. The relationship between the location of the pacing lead and the tricuspid valve regurgitation and cardiac function was examined. The mean right ventricular cardiac output when the pacing lead was inserted into the superior vena cava (126 +/- 54 mL/min per kg) was not significantly different from that when it was inserted into the right ventricle (110 +/- 43 mL/min per kg). The aortic pressure was 66 +/- 7.7 mmHg and 67 +/- 6.6 mmHg, respectively, and the central venous pressure 5.9 +/- 1.7 mmHg and 5.7 +/- 1.6 mmHg, respectively, under the two conditions (not significantly different). The ratio of demonstrating significant tricuspid valve regurgitation was 4/13 into the superior vena cava and 5/13 into the right ventricle, respectively (not significantly different). The location of the pacing lead did not change the cardiac function or the amount of the tricuspid valve regurgitation in our experimental study. It was therefore concluded that the transvenous cardiac pacing technique has potential application in intrauterine transvenous cardiac pacing in the fetus with complete heart block.

Cardiac pacing in fetal lambs: intrauterine transvenous cardiac pacing for fetal complete heart block

To evaluate the feasibility of intrauterine transvenous cardiac pacing, the right ventricular output was measured during pacing in six fetal lambs. Under maternal anesthesia, the uterus was opened, and, under local anesthesia, the pacing lead (Medtronic Capsure SP4023) was inserted via the fetal left internal jugular vein. Right ventricular output was estimated using an Aloka SSD-730 ultrasound device, and tricuspid valve regurgitation was evaluated with an Aloka SSD-880 using the transuterine approach. The ultrasonic right ventricular cardiac output was measured under three different conditions: (1) with the tip of the pacing lead in the superior vena cava (control); (2) with the tip of the pacing lead in the right ventricle; and (3) with pacing at 200 beats/min. The right ventricular output decreased when the pacing lead was inserted into the right ventricle, as well as during pacing at 200 beats/min ([1] = 107 +/- 13.2 mL/kg per min; [2] = 73.8 +/- 17.5 mL/kg per min; and [3] = 78.3 +/- 23.6 mL/kg per min). Tricuspid regurgitation did not change under any of the conditions tested. Intrauterine transvenous cardiac pacing was successfully achieved. Insertion of the pacing lead into the right ventricle decreased the ventricular output without increasing tricuspid valve regurgitation.

Use of multiple views in the echocardiographic assessment of pulmonary artery systolic pressure

The purpose of this study was to determine which echocardiographic views most reliably demonstrate the maximum velocity of a tricuspid regurgitant jet in the evaluation of pulmonary artery systolic pressure. Consecutive patients seen in three echocardiographic laboratories during a 3-month period were enrolled. A complete Doppler examination was performed on each patient, including a continuous-wave Doppler evaluation of tricuspid regurgitation in each of seven views. All seven views were used to determine the maximum velocity of tricuspid regurgitation. Of the 1163 studies, 866 (75%) had some tricuspid regurgitation by color-flow Doppler and 614 (53%) had a measurable velocity of tricuspid regurgitation in at least one view. No single echocardiographic view consistently yielded the maximum velocity of tricuspid regurgitation. The apical four-chamber view alone was inadequate. All seven views must be used to be certain that the maximum velocity of tricuspid regurgitation has been obtained.

Echocardiographic evaluation of isolated pulmonary valve disease in adolescents and adults

Congenital pulmonary valve disease is often not discovered until adolescence or adulthood. Transthoracic two-dimensional echocardiography can provide detailed information regarding right ventricular outflow anatomy, although images are often less satisfactory than those obtained in infants and children. The more recent addition of biplanar transesophageal echocardiography has enhanced our ability to image the right ventricular outflow tract, pulmonary valve, and pulmonary artery noninvasively. Pulsed and continuous-wave Doppler estimates of subvalvular and transvalvular gradients have proved to be accurate. Doppler color flow mapping has proved useful in determining the location and direction of stenotic and regurgitant flow. With no accepted standard for comparison, quantification of regurgitation remains problematic. In many cases, echocardiography has replaced catheterization and angiography in the evaluation and long-term follow-up of congenital pulmonary valve disease before and after intervention.

Pulmonary artery diastolic pressure: a simultaneous Doppler echocardiography and catheterization study

Pulmonary hypertension is an important determinant of the clinical presentation of and surgical approach to patients with heart disease. To confirm the utility of continuous wave Doppler echocardiography in assessing the pulmonary artery diastolic pressure in patients with pulmonary regurgitation, 51 patients representing the wide hemodynamic spectrum of pulmonary artery pressure underwent simultaneous determination of pulmonary artery diastolic pressure by continuous wave Doppler echocardiography and cardiac catheterization. Pulmonary artery diastolic pressure was estimated from the Doppler recordings by the end-diastolic pressure gradient obtained by the modified Bernoulli equation plus the estimated right atrial pressure. A correlation was observed (r = 0.935, SEE = 7.4 mmHg) between Doppler and catheterization pulmonary artery diastolic pressure. In addition, comparison between the mean diastolic pressure gradient across the pulmonary valve by Doppler and pulmonary artery diastolic pressure at catheterization yielded a high correlation (r = 0.947, SEE = 5.1 mmHg). These data demonstrate that continuous wave Doppler echocardiography is a useful noninvasive technique for evaluating the pulmonary artery diastolic pressure in patients with pulmonary regurgitation.

Echocardiographic evaluation of pulmonary embolism and its response to therapeutic interventions

Imaging and Doppler echocardiography permits assessment of right ventricular size and systolic function and of pulmonary arterial pressures, and it may facilitate detection of thromboemboli within the heart or pulmonary artery. In patients with acute pulmonary embolism of sufficient severity to appreciably increase right ventricular afterload, the right ventricle becomes dilated and hypokinetic. Tricuspid regurgitation is generally apparent, but in the absence of preexisting pulmonary arterial or left heart pathology, the regurgitant flow velocity suggests only mild to mild-moderate elevation of pulmonary arterial systolic pressure. The absence of a greater degree of pulmonary hypertension reflects the inability of the previously normal, nonhypertrophied right ventricle to generate a mean pulmonary arterial pressure in excess of about 40 mm Hg. The echocardiographic abnormalities resolve during recovery from pulmonary embolism. Currently being investigated is the question of whether right heart abnormalities resolve more rapidly with thrombolytic therapy than with heparin therapy alone.

The prevalence of valvular regurgitation in children with structurally normal hearts: a color Doppler echocardiographic study

To determine the prevalence of valvular regurgitation in children (from birth to 14 years old) with structurally normal hearts, the records of 1360 consecutive patients referred for echocardiographic and Doppler examination were analyzed. A total of 461 (33.9%) patients were found to have structurally normal hearts. Flow patterns across the four valves were examined by pulsed, continuous-wave, and color Doppler imaging techniques. Regurgitation was detected in 124 (26.9%). Pulmonic regurgitation was most commonly found and was detected in 101 (21.9%) patients, tricuspid regurgitation in 29 (6.3%), and mitral regurgitation in 11 (2.4%). Aortic regurgitation was not found. Regurgitation of one valve occurred in 106 (23.0%) patients and of two valves in 18 (3.9%) patients. No patient had regurgitation of more than two valves. The prevalence of pulmonic regurgitation increased significantly with age (p less than 0.0001), whereas the prevalence of mitral, tricuspid, and bivalvular regurgitation did not change with age. Valvular regurgitation was trivial or mild in 87% of patients. Thus mild valvular regurgitation is commonly found in children with structurally normal hearts.

Color flow Doppler mapping studies of "physiologic" pulmonary and tricuspid regurgitation: evidence for true regurgitation as opposed to a valve closing volume

Color flow Doppler mapping using either an Aloka 880 or a Toshiba SSH65A system was performed in 39 normal subjects (aged 13 to 45 years) and 43 patients (aged 13 to 82 years) with pathologic tricuspid or pulmonary regurgitation to evaluate the incidence of "physiologic" regurgitation of right heart valves and to determine the differentiating characteristics in the spatial distribution and velocity encoding of "normal" and "pathologic" regurgitant jets. In the normal subjects, tricuspid and pulmonary regurgitation were documented in 32 (83%) and 36 (93%), respectively, and were unrelated to the system being used. Flow acceleration and aliasing were imaged on the right ventricular side of the tricuspid regurgitant orifice and on the pulmonary artery side of the pulmonary valve (in both normal subjects and patients), and indicated flow convergence for true regurgitation through an orifice as opposed to blood being driven retrogradely by the closing valve. Such proximal acceleration was documented in all patients with pathologic tricuspid regurgitation, in 31/32 of the normal subjects with tricuspid regurgitation, and was also observed in 12/15 (80%) of the patients and 4/12 (33%) of normal subjects with pulmonary regurgitation who were examined with the Toshiba system. The dimensions (mean +/- SD) of tricuspid regurgitant jets (length [JL] and area [JA]) were consistently larger in the patients than in the normal subjects [JL: 3.4 +/- 0.9 vs 1.2 +/- 0.5 cm, p less than 0.001; and JA: 5.7 +/- 2.0 vs 1.4 +/- 0.7 cm2, p less than 0.001) as were the pulmonary regurgitation jet dimensions (JL: 1.8 +/- 0.4 vs 0.9 +/- 0.08 cm, p less than 0.001; JA: 1.8 +/- 0.7 vs 0.3 +/- 0.08 cm2, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Contrast echocardiography enhances tricuspid but not mitral regurgitation

Tricuspid regurgitation refers to a systolic leak of blood between the right ventricle and right atrium, across the tricuspid valve. Doppler echocardiographic examination of large numbers of normal individuals has shown that trivial tricuspid regurgitation is extremely common. Measurement of the peak velocity of the regurgitant frequency spectrum on Doppler echocardiography is of considerable clinical importance since it may be used to calculate peak right ventricular and, consequently, peak pulmonary systolic pressure. Doppler recording of the frequency spectrum of a tricuspid regurgitation jet optimally shows a smooth, parabolic, sharply demarcated envelope. In many individuals with trivial tricuspid regurgitation, however, this frequency spectrum is incomplete and its envelope is poorly demarcated. Such inadequate signals do not allow measurement of the spectrum's peak velocity. Like other contrast agents, air-filled microspheres composed of sonicated human serum albumin enhance reflection of Doppler ultrasound and thus have the potential to enhance incomplete tricuspid regurgitation spectra. Furthermore, since sonicated albumin microspheres can cross the pulmonary circulation intact, they have the potential to enhance mitral regurgitation spectra. The purpose of our study was to investigate whether injection of sonicated albumin microspheres enhances incomplete tricuspid and mitral regurgitation frequency spectra to a diagnostic quality. Sonicated albumin microsphere injection enhanced tricuspid regurgitation spectra to optimal quality in 11 of 15 patients (73%). Microsphere injection caused a minor degree of enhancement of the mitral regurgitant spectrum in 1 patient, but did not optimize the spectra in any of 10 patients tested. Saline contrast injection optimally enhanced tricuspid regurgitation spectra in all 8 patients in whom it was used.(ABSTRACT TRUNCATED AT 250 WORDS)

Regurgitant jet size by transesophageal compared with transthoracic Doppler color flow imaging

Combined echocardiography and Doppler color flow mapping from transthoracic imaging windows has become the standard method for the noninvasive assessment of valvular regurgitation. This study compared regurgitant jet areas by Doppler color flow imaging derived from the newer transesophageal approach with measurements obtained from conventional transthoracic apical views. Maximal regurgitant jet area determinations and an overall visual estimate of lesion severity were obtained from 42 patients who underwent color flow examination by both techniques. Seventy-three regurgitant lesions were visualized by transesophageal flow imaging: 34 mitral, 22 aortic, and 17 tricuspid jets. Transthoracic studies in the same patients revealed fewer regurgitant lesions for each valve; 20 mitral, 16 aortic, and 12 tricuspid (p = 0.0009). A comparison of maximal jet areas determined by transesophageal and transthoracic studies showed a good overall correlation (r = 0.85, SEE = 2.8 cm2) and a systematic overestimation by the transesophageal technique (TEE = 0.96 TTX + 2.7). For the subgroup with mitral insufficiency, valve lesions visualized by both techniques were larger by the transesophageal approach (n = 18, 6.0 versus 3.6 cm2, p = 0.008). Semiquantitative visual grading of individual valve lesions by two independent observers revealed a higher grade of regurgitation with more jets classified as mild (38 versus 25), moderate (18 versus 13), and severe (17 versus 10) by esophageal imaging than by transthoracic imaging. Thus, transesophageal color flow mapping techniques yield a higher prevalence of valvular regurgitation than do transthoracic techniques in the same patients. Jet area and the overall estimate of regurgitant lesion severity were also greater by transesophageal color Doppler imaging compared with standard transthoracic imaging.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of mitral regurgitation by biplane transesophageal color Doppler flow mapping

To test the role of recently developed biplane transesophageal color Doppler echocardiography in the assessment of severity of mitral regurgitation, we examined 51 patients undergoing cardiac catheterization and left ventriculography. Transesophageal color Doppler flow imaging detected mitral regurgitation in all 32 patients proved to have this lesion. In 10 of 16 patients without mitral regurgitation by angiography, mitral regurgitation signals were detected by transesophageal color Doppler flow imaging. Thus, the sensitivity and specificity of transesophageal color Doppler echocardiography for the detection of mitral regurgitation were 100% and 38%, respectively. There was some correlation between the regurgitant jet area from the longitudinal plane and angiographic grading. An improved angiographic correlation was achieved with the regurgitant jet area from the transverse plane. The best correlation with angiography was obtained when the maximum regurgitant jet area from two planes (the greater of the two measurements, each from a different plane) was considered. There was a significant difference in the maximum regurgitant jet area between none and mild (p less than 0.01), mild and moderate (p less than 0.001), and moderate and severe (p less than 0.01) mitral regurgitation. The maximum regurgitant jet area of less than 1.5 cm2 predicted the angiographic grading as none with a sensitivity and specificity of 88% and 94%, respectively. The maximum regurgitant jet of between 1.5 and 4 cm2 predicted the angiographic grading as mild with a sensitivity and specificity of 82% and 95%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of laminar systolic regurgitant flow in patients with tricuspid regurgitation: a combined pulsed-wave, continuous-wave Doppler and two-dimensional echocardiographic study

To define the significance of laminar systolic tricuspid regurgitant (TR) flow, pulsed-wave and continuous-wave Doppler (PWD, CWD), and two-dimensional and M-mode echocardiography (2-DE, M-mode) were performed in 68 patients with TR, which included five patients with tricuspid valvectomy. The pattern of TR flow (laminar versus turbulent), TR severity (the distance that the regurgitant flow extended into the right atrium [1+ to 4+ as measured by PWD]), the peak flow velocity of TR by CWD, the presence or absence and the amount of systolic tricuspid cusp separation by 2-DE, and the dimension of the right ventricle and the inferior vena cava by M-mode, were assessed. A laminar pattern of TR flow in systole was obtained in 21 patients, five of whom had undergone tricuspid valvectomy. Fourteen of 21 had visible tricuspid cusp separation in systole on 2-DE; of the seven who had no visible tricuspid cusp separation during systole, five had undergone tricuspid valvectomy. All 47 patients with a turbulent pattern of TR flow had no visible systolic tricuspid cusp separation. Severe 4+ TR was present in 14 of 21 (67%) patients with laminar TR flow and in 4 of 47 (9%) patients with turbulent TR flow (p less than 0.001). The peak flow velocity of TR in patients with laminar TR flow (2.0 +/- 0.7 m/sec) was lower (p less than 0.001) than in those with turbulent TR flow (3.1 +/- 0.7 m/sec).(ABSTRACT TRUNCATED AT 250 WORDS)

Value of acceleration flows and regurgitant jet direction by color Doppler flow mapping in the evaluation of mitral valve prolapse

To clarify the role of color Doppler echocardiography in the evaluation of mitral valve prolapse, we studied 49 consecutive patients in whom the sites of mitral valve prolapse were confirmed at the time of operation. The study group consisted of 22 patients with anterior leaflet prolapse, 24 patients with posterior leaflet prolapse, and three patients with multiple scallop prolapse (one patient with both anterior leaflet and middle scallop prolapse, and two patients with both medial and lateral scallop prolapse). Two-dimensional echocardiographic diagnosis of anterior leaflet prolapse was correct in all patients. The diagnosis of posterior leaflet prolapse by two-dimensional echocardiography, however, was mistaken as anterior leaflet prolapse in 16 (13 patients with medial scallop prolapse and three patients with lateral scallop prolapse) of the 24 patients according to current diagnostic criteria for mitral valve prolapse. Eight patients with middle scallop prolapse were diagnosed correctly by two-dimensional echocardiography. Acceleration flows in the left ventricle were observed by color Doppler echocardiography in all 49 patients. The sites of acceleration flows detected by color Doppler echocardiography coincided with those of prolapse confirmed in all at the time of operation. There was a significant correlation between the maximum area of acceleration flow signals and severity of mitral regurgitation estimated by angiography. In the 13 patients with medial scallop prolapse and the three patients with lateral scallop prolapse, a regurgitant jet originated from a bulged portion of the posterior leaflet and was directed toward the opposite left atrial cavity to the bulged portion by short-axis images of color Doppler echocardiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Different effects of prolonged exercise on the right and left ventricles

To examine the functional consequences of the greater increase in right ventricular work with exercise, the effects of prolonged exercise on the right and left heart chambers were compared in 41 athletes before, at the finish (13 min) and after recovery (28 h) from the Hawaii Ironman Triathlon (3.9 km swim, 180.2 km bike ride, 42.2 km run). Two-dimensional and Doppler echocardiograms were analyzed for left and right atrial and ventricular areas at end-diastole and end-systole, right and left ventricular inflow velocities and mitral and tricuspid regurgitation. After exercise, left ventricular and left and right atrial sizes were reduced, whereas right ventricular size increased (diastole: 21.4 to 24.2 cm2; systole: 15.8 to 18.2 cm2; p less than 0.01). The emptying fraction of all chambers was unchanged. Left but not right ventricular inflow showed an increase in peak velocity of rapid filling, whereas both atrial systolic velocities increased (26 to 38 cm/s tricuspid; 38 to 54 cm/s mitral; both p less than 0.01). Overall, the right ventricular early to atrial velocity ratio was reduced after exercise (1.56 to 1.17; p less than 0.05) and the left ventricular pattern was unchanged. The prevalence of tricuspid regurgitation was statistically unchanged (86% to 52%), although that of mitral regurgitation was greatly reduced (76% to 0%). Changes in all variables returned toward prerace values during recovery. Thus, in highly trained athletes, prolonged exercise causes differing responses of the right and left ventricles. These differences may be due to changes in right ventricular function, shape or compliance.

Assessment of left-to-right atrial shunting after percutaneous mitral valvuloplasty by transesophageal color Doppler flow-mapping

To evaluate left-to-right shunts after percutaneous balloon mitral valvuloplasty, we studied 15 consecutive patients by using transesophageal color Doppler flow-imaging system. Transesophageal color Doppler examinations were performed five times in each patient (before valvuloplasty and 1 day, 1 week, 1 month, and 6 months after valvuloplasty). No shunt flow was observed before valvuloplasty. On 1 day after mitral valvuloplasty, transesophageal color Doppler echocardiography demonstrated left-to-right shunts in 13 (87%) of 15 patients. However, a significant oxygen step-up was present in the right heart in only one patient. The mean diameter of the interatrial septal defect detected by transesophageal two-dimensional echocardiography was 1.8 +/- 1.0 mm. The mean velocity of left-to-right shunting flow measured by high-pulse repetition frequency Doppler technique was 0.83 +/- 0.38 m/sec. One week after the procedure, left-to-right shunt flow was detected in 11 (73%) patients. One month after valvuloplasty, left-to-right shunting flow was detected in seven (47%) of 15 patients. There was a significant decrease in the diameter of an interatrial septal defect between 1 day and 1 week (p less than 0.01), between 1 week and 1 month (p less than 0.01), and between 1 month and 6 months (p less than 0.05). Six months after valvuloplasty, left-to-right shunting flow remained in three (20%) patients. By using transthoracic color Doppler echocardiography, we detected left-to-right shunting flow in two patients on 1 day after the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Tricuspid Regurgitation

A complete noninvasive assessment of patients with suspected tricuspid regurgitation should include two-dimensional echocardiography, color flow imaging, and continuous wave Doppler. Two-dimensional echocardiography may be used to demonstrate abnormalities in tricuspid valve morphology as well as changes in right heart size and function due to tricuspid regurgitation. Color flow imaging provides a semiquantitative method for determining the presence and extent of tricuspid regurgitant jet area. When tricuspid regurgitation is present, continuous wave Doppler is used to measure right ventricular (or pulmonary artery) systolic pressure by means of the modified Bernoulli equation of 4 X regurgitant jet velocity2 plus an assumption of the value of right artrial pressure. Contrast-enhancement of tricuspid regurgitant jet signals may be necessary if continuous wave Doppler does not delineate the jet envelope.

Prevalence of multivalvular regurgitation in athletes

To assess the effects of exercise training on the prevalence of valvular regurgitation, 2-dimensional echocardiography and Doppler flow mapping were performed in 45 athletes and 26 sedentary control subjects of similar age and sex. Mitral, tricuspid, aortic and pulmonic regurgitations were sought in all possible views and mitral and tricuspid flow velocities were recorded. Mitral and tricuspid anulus diameters and the maximal areas of regurgitant flow were planimetered. Regurgitation of at least one of the cardiac valves was found in 91% of athletes but in only 38% of control subjects (p less than 0.001). Mitral and tricuspid regurgitation occurred more commonly in athletes than in control subjects (mitral 69 vs 27%; tricuspid 76 vs 15%). The prevalence of aortic and pulmonic regurgitation was similar. Although athletes and sedentary normal subjects differed with respect to heart rate, right and left ventricular filling patterns and tricuspid and mitral anulus diameters, none of these variables was related to the presence or severity of regurgitation. Thus, exercise training is associated with an increased prevalence of mitral and tricuspid regurgitation and altered ventricular inflow patterns. The mechanism of these findings is unclear. Multivalvular regurgitation is common in athletes and does not imply structural valvular abnormalities.

Prevalence of catheter-induced valvular regurgitation as determined by Doppler echocardiography

It has been suggested that cardiac catheters traversing competent heart valves may induce valvular regurgitation. To evaluate this possibility, continuous-wave and pulsed Doppler echocardiographic studies were performed immediately before, during and immediately after removal of various catheters in a total of 47 adult patients without clinical evidence of valvular regurgitation. With the tip of a 7Fr balloon flotation catheter positioned in the pulmonary artery, 9 of 36 patients (25%) had pulmonary regurgitation documented by continuous-wave Doppler. Evidence for regurgitation by pulsed Doppler examination was noted in 4 of these 9, with the regurgitant signal extending a mean of 1.8 cm into the right ventricular outflow tract. Similarly, a tricuspid regurgitant signal was present in 10 of 37 patients (27%) by continuous-wave Doppler and in 6 of these 10 by pulsed Doppler, with a mean regurgitant signal depth of 2.3 cm. Doppler examination also was performed in 7 patients (2 with aortic regurgitation) with a 7Fr pigtail catheter across the aortic valve, and in 4 patients (1 with tricuspid regurgitation) with a 6Fr bipolar pacing catheter across the tricuspid valve. Catheter removal resulted in no change in either the presence or absence of a regurgitant signal, or in the regurgitant signal depth in any of the patients studied. It is concluded that standard cardiac catheters neither induce Doppler-detected valvular regurgitation, nor do they affect the retrograde distance to which an existing regurgitant signal can be mapped.

Pulsed and continuous wave Doppler echocardiographic assessment of valvular regurgitation in normal subjects

To assess the prevalence and flow characteristics of valvular regurgitation detected by Doppler echocardiography in normal subjects, pulsed and continuous wave Doppler studies were performed in 100 adult volunteers without evidence of heart disease. Evidence of valvular regurgitation was present in 73% of subjects. There were 46 subjects with regurgitation of one valve, 24 with regurgitation of two valves and 3 with regurgitation of three valves. Right-sided regurgitation was significantly more common than was left-sided regurgitation (81 versus 22 valves, p less than 0.01). Regurgitant flow was never detected farther than 1 cm from the valve by pulsed Doppler study. Tricuspid regurgitation was detected in 50 subjects and was characterized by a holosystolic velocity signal; a complete spectral envelope was recorded in 32 subjects. The peak velocity of the regurgitant jet for this group was 1.7 to 2.3 m/s (mean 2.0 +/- 0.2). Thirty-one subjects were found to have pulmonary regurgitation with a peak velocity of 1.2 to 1.9 m/s (mean 1.5 +/- 0.2); no subject demonstrated regurgitant flow in early diastole. There were 21 subjects with mitral regurgitation; continuous wave Doppler signals were always of low intensity with a poorly defined spectral envelope and an absence of high velocities. Peak velocities ranged from 1.1 to 4.4 m/s (mean 2.3 +/- 0.9) and in 19 subjects were less than 3.5 m/s. The mean age of subjects with mitral regurgitation was significantly higher than that of subjects without mitral regurgitation (p = 0.01). Aortic regurgitation was detected in only one subject. This study provides further evidence that valvular regurgitation is frequently detected by Doppler echocardiography in normal subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Temporal resolution of mitral regurgitation in patients with mitral valve prolapse: a phonocardiographic and Doppler echocardiographic study

To assess the timing and duration of mitral regurgitation in mitral valve prolapse, 20 patients with a mid-systolic click or late systolic murmur, or both (Group 1) and 16 patients with a pansystolic murmur with late systolic accentuation (Group 2) were studied with phonocardiography and echocardiography including various Doppler techniques. The subjects' ages ranged from 15 to 73 years. Mitral valve prolapse with mitral regurgitation was observed in 15 of 20 patients in Group 1 and in all 16 patients in Group 2. M-mode Doppler color echocardiography demonstrated a mitral regurgitant signal throughout systole and isovolumic relaxation in all but 1 of these 31 patients regardless of the pattern of the systolic murmur. The regurgitant signal was recorded after the click in only one patient with mitral valve prolapse in Group 1. Two of the five patients in Group 1 without two-dimensional echocardiographic findings of mitral valve prolapse had the early systolic signal of mitral regurgitation. The timing and duration of the mitral regurgitant signal detected in patients in Group 1 with pulsed or continuous wave Doppler ultrasound varied with the site of the sample volume or beam direction. In the patients in Group 2, however, the signal was demonstrated throughout systole and isovolumic relaxation by both Doppler methods. Compared with M-mode Doppler color echocardiography, therefore, pulsed and continuous wave Doppler methods were less sensitive and thus inadequate to investigate the timing and duration of mitral regurgitation in mitral valve prolapse, especially in patients with a mid-systolic click or a late systolic murmur, or both, who had mild or eccentric mitral regurgitant jets.(ABSTRACT TRUNCATED AT 250 WORDS)

Diastolic atrioventricular valve closure and regurgitation following atrial contraction: their relation to timing of atrial contraction

Some authors have proposed that atrial contraction per se is able to close the atrioventricular (AV) valves. To determine whether tight closure of the AV valves can be accomplished solely by atrial contraction, the existence of diastolic regurgitation following atrial contraction and its relation to the PQ interval were examined in 13 patients with AV block (2 of the first degree, 4 of the second degree, and 7 of the third degree), using pulsed Doppler echocardiography, which allowed noninvasive estimation of valvular regurgitation in the physiological state. Diastolic mitral and tricuspid regurgitations were detected in the left and right atria near the respective AV valves in all 13 patients despite different degrees of AV block, while these valves were observed to be in apparently closed position during regurgitation on the two-dimensional and M-mode echocardiograms. The duration of regurgitant signals was prolonged with an increase in the PQ interval in the electrocardiogram, but it became short again as the P wave approached the preceding rapid filling wave. These results suggest that atrial contraction may initiate the closure of the AV valves but is not capable of closing the valves tightly, and atrial contraction with long PQ interval may contribute little to augmentation of cardiac output in patients with AV block.

The echo Doppler spectrum of valvular abnormalities in the hospitalized octogenarian

Cardiac valves thicken and become more opaque with advancing age. As more individuals live longer and as more treatment modalities such as valvuloplasty evolve, the presence and significance of these valvular abnormalities become important. We retrospectively studied 628 octogenarian patients to try and define further the presence and significance of these abnormalities detected by Doppler echocardiography. A group of 547 patients were suitable for analysis. Age ranged from 80 to 96 years (mean 84.4). The female:male ratio was 1.9:1. Mitral, aortic, and tricuspid regurgitation (MR, AR, and TR) were significant if the jet moved greater than 2 cm from the plane of the valve away or toward the transducer, depending on transducer position. Mitral regurgitation was detected in 331 patients (60.5%) and was significant in 82 patients (15%). Aortic regurgitation was detected in 276 patients (50.5%) and was significant in 70 patients (12.8%). Tricuspid regurgitation was detected in 131 patients (23.9%) and was significant in 30 patients (5.5%). Regurgitant lesions were detected in two valves in 150 patients (27.4%) three valves in 57 patients (10.4%), in all four valves in 17 patients (3.1%). Aortic stenosis was detected in 160 patients (29.3%). The gradient range was 16-156 mmHg (mean 47.8). Significant aortic stenosis was present in 70 patients (12.8%) (gradient greater than 50 mmHg), of whom 54 had isolated pure aortic stenosis and 16 had mixed lesion. In 40% of these patients, significant aortic stenosis was an unexpected finding at two-dimensional echocardiography. Valvular pathology is common in the octogenarian population.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulsed Doppler assessment of tricuspid regurgitation: usefulness of regurgitant signal patterns for estimation of severity

A study on the value of pulsed Doppler in the detection and quantitative assessment of tricuspid regurgitation (TR) has been conducted on 33 consecutive adult patients with valvular heart disease. Only 1 patient had to be excluded owing to a technically inadequate Doppler examination. Data for comparison were obtained from a right heart catheterization performed within a twenty-four-hour interval from the Doppler study. Sensitivity and specificity in the detection of the lesion were 88% and 100%, respectively. A previously undescribed pulsed Doppler method for the estimation of the degree of TR was tested, based on the consideration of two distinctive patterns of the regurgitant Doppler signal: type I: a protosystolic regurgitant signal with progressively fading intensity along systole; and type II: a homogeneously intense pansystolic signal. Correlation between these patterns and the angiographic degrees of TR showed that milder lesions correspond to the type I Doppler pattern, whereas significant regurgitations present a type II pattern, this allowing a clinically useful method of assessment of TR.

Causes of false-negative auscultation of regurgitant lesions: a Doppler echocardiographic study of 294 patients

Few data are available regarding the prevalence and causes of false-negative auscultation (mis-auscultation) of aortic (AR), mitral (MR), or tricuspid regurgitation (TR), and there are no such data that are relevant when the patient's pretest probability of having regurgitation is unknown. The authors therefore studied 294 patients examined by pulsed Doppler echocardiography. On 755 examinations (2.57 examinations per patient), Doppler velocity patterns typical of AR, MR, or TR were found in 63, 96, and 49 patients, respectively. For all three murmurs, mis-auscultation was the rule, rather than the exception, with sensitivities of auscultation ranging from 0 to 37%, depending (but weakly) on the site of the murmur and the years of training of the observer. Specificity of auscultation was high (85% to 100%). The factors associated with the mis-auscultation of AR were poor image quality in the echocardiograms, absence of cardiomegaly, and less experience of the examiner. The probability of missing MR increased in the presence of coronary artery disease (CAD) or if the examiner had less experience. The likelihood of missing TR by auscultation was increased by CAD, obesity, chronic obstructive pulmonary disease, or the absence of cardiomegaly. This study suggests that there is a high prevalence of "silent" murmurs, and that not hearing a regurgitant murmur does not suffice to rule out the presence of regurgitation.

Clinical implications of pulmonary regurgitation in healthy individuals: detection by cross sectional pulsed Doppler echocardiography

Pulsed Doppler echocardiography in healthy individuals often shows a disturbance of diastolic flow in the right ventricular outflow tract just below the pulmonary valve that suggests regurgitation. This disturbance of diastolic flow was studied in 50 healthy individuals and 40 patients with cardiopulmonary disease, some of whom had a pulmonary regurgitant murmur. Diastolic flow was disturbed in 39 of the 50 healthy individuals. In 32, cross sectional echocardiography gave a satisfactory image of the pulmonary valve. The characteristic Doppler signals usually lasted throughout diastole, were directed toward the right ventricular cavity, and gradually waned towards end diastole; they formed a spindle shaped area of abnormal signals that extended to within 10 mm of the coaptation of the pulmonary valve towards the right ventricular cavity and the pressure difference estimated from the signals by the modified Bernoulli equation seemed to be proportional to the normal retrograde transpulmonary pressure difference. In all 40 patients with cardiopulmonary disease, signals indicating pulmonary regurgitation were found whether or not a regurgitant murmur was present. When it was present, however, the spindle was longer than 20 mm and in patients with pulmonary hypertension the velocity of abnormal diastolic flow was higher than in healthy individuals. The Doppler signals registering disturbed flow in the healthy individuals resembled the signals caused by pulmonary regurgitation in the patients in terms of location, orientation, and configuration. These results show that healthy individuals usually have trivial pulmonary regurgitation. In practice the distance that the flow disturbance extends from the valve and estimated pressure difference across the valve are probably the most important variables for assessing the clinical significance of pulmonary valve regurgitation.

Echocardiographic recognition of pulmonary arterial disease and determination of its cause

Echocardiography provided the initial diagnosis of significant pulmonary hypertension, unrelated to left heart pathologic conditions, in 10 patients: four with acute pulmonary embolism; five with chronic pulmonary hypertension, primary in three patients and secondary to tumor emboli in the other two patients; and one with Eisenmenger's syndrome due to previously unsuspected atrial septal defects. Referral diagnoses were pericardial disease in five patients (including three with suspected tamponade), and right ventricular infarction versus pericarditis, atrial septal defect, dyspnea, inferoposterior infarction (by electrocardiography), and Ebstein's malformation in one patient each. The echocardiographic diagnoses were confirmed by lung scan (ventilation/perfusion mismatches were interpreted as high probability for pulmonary emboli in all four patients considered to have acute pulmonary emboli by echocardiographic study), pulmonary angiography (one patient), cardiac catheterization (four patients), and autopsy (three patients). No patient had evident aortic or mitral valvular, myocardial, or other left heart pathologic condition. In acute pulmonary embolism, mean right ventricular diameter was increased at 4.2 cm (range 3.2 to 6 cm) and right ventricular wall thickness was normal (mean 4.5 mm, range 3 to 5 mm). Moderate or marked right ventricular hypokinesis was noted in two patients each. Doppler examination, performed in three patients, revealed tricuspid regurgitation in all, with an increased flow velocity suggestive of mild to moderate systolic pulmonary hypertension (right ventricular minus right atrial pressures of 28 to 36 mm Hg). Patients with chronic pulmonary hypertension also had right ventricular dilatation (mean 4.4 cm diameter, range 3 to 5.4 cm) and hypokinesis (marked in four and moderate in one patient), but wall thickness was increased in all (mean of 9 mm, range 6 to 14 mm) and the flow velocities in the tricuspid regurgitant jets, detected by Doppler in all patients, suggested higher right ventricular minus right atrial pressures of 44 to 104 mm Hg (mean 64 mm Hg). The single patient with Eisenmenger's syndrome had right ventricular dilatation (3.2 cm), hypertrophy (10 mm), and hypokinesis (mild). Only the patient with Eisenmenger's syndrome had Doppler or contrast echocardiographic evidence for an intracardiac or extracardiac shunt. In the absence of left heart pathologic conditions, right ventricular dilatation and hypokinesis strongly suggest pulmonary arterial or primary right ventricular disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Continuous measurement of intracardiac and pulmonary blood flow velocities with transesophageal pulsed Doppler echocardiography: technique and initial clinical experience

Pulsed Doppler techniques have become well established adjuncts to conventional echocardiography in the noninvasive diagnosis of various cardiac malfunctions. Disadvantages of the transthoracic approach, such as inaccessibility and instability of the probe position, limit the continuous application of pulsed Doppler echocardiography during surgery. This study presents a new technique using the transesophageal approach that combines pulsed Doppler measurements with two-dimensional echocardiographic imaging (TDE). The first intraoperative experience with this new enhancement to two-dimensional transesophageal echocardiography (TEE) showed that this relatively noninvasive technique is a safe method allowing constant monitoring of cardiac and pulmonary blood flow velocities. The simultaneous high-resolution two-dimensional imaging facilitates spatial orientation and placement of the sample volume, as well as continued control of the sampling location. The typical flow velocity patterns in standard TEE views are described. The mitral valve and pulmonary artery offer particularly favorable conditions for continuous high-quality TDE measurements. It is concluded that the new technique may further increase the value of TEE to clinicians in the perioperative period.

Age-related valvular regurgitation: a study by pulsed Doppler echocardiography

To assess the prevalence of valvular regurgitation in the aged, we studied 176 apparently healthy volunteers with no history or physical evidence of cardiac abnormality. Their ages ranged from 40 to 90 (66 +/- 14, mean +/- SD) years. We examined these subjects by pulsed Doppler echocardiography combined with two-dimensional echocardiography to determine the prevalence of valvular regurgitation. Regurgitation began to appear in subjects in their fifties, increasing in prevalence with advancing age (r = .81, p less than .001), and was documented in all over age 80. Similarly, regurgitation involving more than one valve appeared in those 60 years and older, and was very common (89%) in subjects in their eighties. With each type of valvular regurgitation, the prevalence of each type of regurgitation increased with aging, but this tendency was most prominent for aortic regurgitation. We conclude that (1) single or multivalvular regurgitation as detected by pulsed Doppler echocardiography is very common in the aged and may be considered a normal finding in the absence of other evidence of heart disease, and (2) the high prevalence of regurgitation in the aged must be taken into account when Doppler examinations are being performed.

Noninvasive assessment by Doppler and M-mode echocardiography of hemodynamic responses to temporary pacing and to ventriculoatrial conduction

A new, dual-chamber temporary pacing lead was introduced via the subclavian vein in 20 patients who needed a temporary pacemaker. Stroke volume (SV) was measured continuously by combining M-mode and noninvasive Doppler echocardiography during spontaneous rhythm (SR), AV sequential pacing at a positive AV interval (DP), ventricular pacing (VP) and AV sequential pacing at a negative AV interval (VA pacing). The valvular functions were determined by Doppler echocardiography. Left ventricular dimensions and function, and left atrial size were measured by M-mode echocardiography. In the nine patients with no valvular heart disease and with no ventriculoatrial (VA) conduction (group I) the CO increased 83 +/- 11% during DP and 42 +/- 9% during VP as compared to during SR when the heart rate (HR) was increased from 34 +/- 3 to 72 +/- 1 beats/min. The CO was 29 +/- 3% higher during DP than that during VP. In the seven patients with valvular heart disease and with no VA conduction (group II), the increment in CO compared to that during SR was 53 +/- 12% during DP and 31 +/- 11% during VP; the CO was 17 +/- 4% higher during DP than that during VP. In the four patients with spontaneous VA conduction (group III), the CO during DP was 35 +/- 10% greater than that during VP, which did not result in an increase in the CO compared to that during SR in spite of an increase in HR from 52 +/- 8 to 74 +/- 2 beats/min. The study demonstrated that DP is the preferred temporary pacing mode and also that VA conduction during VP resulted in a mean decrease of 20% in CO compared to that during VP without VA conduction. The hemodynamic benefit from DP compared to SR seems to decrease when the left ventricular end-diastolic dimension increases. Furthermore, patients with large left ventricular end-systolic dimensions seem to have a lower increase in stroke index during DP as compared to that during VP than patients with smaller end-systolic dimensions.

Tricuspid regurgitation in newborn infants with respiratory distress: echo-Doppler study

The purpose of this investigation was to use Doppler echocardiography to evaluate respiratory problems significant enough to warrant supplemental oxygenation in newborn infants. Of 17 infants (mean gestational age 37.5 weeks, mean birth weight 3070 g) 14 (82%) had detectable tricuspid regurgitation. By modified Bernoulli equation, all infants had right ventricular pressure greater than 60% of systemic pressure, and nine of 14 had estimated right ventricular pressure at or near systemic pressures. In eight infants for whom sequential evaluations could be obtained, right ventricular pressure as a percentage of systemic pressure gradually decreased, and corresponded to decreasing needs for supplemental oxygenation. Tricuspid regurgitation could no longer be detected between 3 and 16 days after the first study, and was associated with decreased right ventricular pressures (less than 50% systemic) and weaning from supplemental oxygenation. We conclude that in the near-term infant with early respiratory difficulties, tricuspid regurgitation is common and is associated with increased right ventricular pressure.

A time-related study by Doppler and M-mode echocardiography of hemodynamics, heart size, and AV valvular function during activity-sensing rate-responsive ventricular pacing

Noninvasive Doppler and M-mode echocardiography were used to: measure stroke volume (SV), left atrial (LA) size, left ventricular end-diastolic (EDD), end-systolic dimensions (ESD), left ventricular fractional shortening (FS), and for determination of mitral and tricuspid insufficiency (MI and TI) before starting and after 1, 3, and 6 months of rate-responsive ventricular pacing (RRP). The study group consisted of 13 patients (mean age, 75 years) who could be expected to benefit from an increase in cardiac output mediated by an increment of heart rate during exercise. In VVI + activity mode (RRP), the pacemaker was programmed to a basic heart rate of 60 and a maximum heart rate of 125 bpm. The SV at rest was 71 +/- 5 before RRP, and fell to 57 +/- 4 after 3 months (p less than 0.05) and to 53 +/- 4 ml/beat after 6 months of RRP (p less than .01). The LA size and ESD were unchanged during follow-up. The EDD decreased from 6.2 +/- 0.3 to 5.4 +/- 0.2 (p less than 0.002) during the first 6 months of RRP. The FS was reduced from 33 +/- 4 to 27 +/- 3% (p less than 0.02) during the first 6 months of RRP. Four of 6 patients treated previously with a VVI pacemaker (mean duration, 9 years) had MI + TI, and 3 of the 7 patients not paced previously had MI before RRP. In the last group, 1 new patient developed MI, 1 new patient developed MI + TI, and 2 patients who had MI also developed TI within 6 months of pacing. Thus, of 13 patients, 9 (69%) had either MI or MI + TI.

Comparison of three Doppler ultrasound methods in the prediction of pulmonary artery pressure

Pulmonary artery pressure was noninvasively estimated by three Doppler echocardiographic methods in 50 consecutive patients undergoing cardiac catheterization. First, a systolic transtricuspid gradient was calculated from Doppler-detected tricuspid regurgitation; clinical jugular venous pressure or a fixed value of 14 mm Hg was added to yield systolic pulmonary artery pressure. Second, acceleration time from pulmonary flow analysis was used in a regression equation to derive mean pulmonary artery pressure. Third, right ventricular isovolumic relaxation time was calculated from Doppler-determined pulmonary valve closure and tricuspid valve opening; systolic pulmonary artery pressure was then derived from a nomogram. In 48 patients (96%) at least one of the methods could be employed. A tricuspid pressure gradient, obtained in 36 patients (72%), provided reliable prediction of systolic pulmonary artery pressure. The prediction was superior when 14 mm Hg rather than estimated jugular venous pressure was used to account for right atrial pressure. In 44 patients (88%), pulmonary flow was analyzed. Prediction of mean pulmonary artery pressure was unsatisfactory (r = 0.65) but improved (r = 0.85) when only patients with a heart rate between 60 and 100 beats/min were considered. The effect of correcting pulmonary flow indexes for heart rate was examined by correlating different flow indexes before and after correction for heart rate. There was a good correlation between corrected acceleration time and either systolic (r = -0.85) or mean (r = -0.83) pulmonary artery pressure. Because of a high incidence of arrhythmia, right ventricular relaxation time could be determined in only 11 patients (22%). Noninvasive prediction of pulmonary artery pressure is feasible in most patients.(ABSTRACT TRUNCATED AT 250 WORDS)