LESSON 10

MITRAL VALVE STENOSIS

Mitral stenosis can be diagnosed using M-Mode, B-Mode, and LESSON CONTENT
spectral Doppler.
Mitral stenosis

 Diagnosis of mitral stenosis.

One-Dimensional Echocardiography (M-Mode)  Mitral Valve Area by Tracing.
 Mitral Valve Area by PHT.
 Decrease in the rate of diastolic closure of the anterior  Mitral Valve Area (CONTINUITY
leaflet of the mitral valve. EQUATION).
 Unilateral movement of the mitral valve anterior and  Degree of Mitral Stenosis by Mean
posterior leaflets. Pressure Gradient.

Due to the high pressure in the left atrium during diastole, the
valve leaflets remain open and, unlike the norm, do not close
after the left ventricle early rapid filling.
The curve of the mitral valve movement has a п-shaped form
instead of an M-shaped one.

The unilateral movement of the anterior and posterior leaflets of

the mitral valve can be seen due to the fusion of the leaflets.
(Normally, the leaflets move in different directions).

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MITRAL STENOSIS

Left parasternal view, the lond axis of the heart. One dimensional Echocardiography (m-mode). Normal Mitral
Valve. Simulation By Echocardiography Online Simulator MyEchocardiography.com

Left parasternal view, the long axis of the heart. One-dimensional Echocardiography (m-mode). Mitral
Stenosis. Decrease in the rate of diastolic closure of the anterior leaflet of the mitral valve and Unilateral movement of
the mitral valve anterior and posterior leaflets. Simulation By Echocardiography Online
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MITRAL STENOSIS

Two Dimensional Echocardiography (B-Mode) Spectral Doppler (PW, CW)

From the early stages of mitral stenosis, in the diastole
 Increased early transmitral diastolic flow
phase, there is a dome-shaped bulging of the anterior
velocity - caused by the increased pressure
leaflet of the mitral valve (towards the septum), which
gradient between LA and LV.
is caused by an increase in pressure on its unfixed part
 Spectrogram extension - caused by a
(Left parasternal view, the long axis of the heart).
reduction of the fall of the diastolic filling rate.
In the later stages of mitral stenosis, the valve leaflets
thicken and become rigid. Fusion of the leaflets and
restriction of movement are often observed. From the
left parasternal position, the short axis of the heart,
there is a decrease in the area of the mitral orifice,
which takes the form of an ellipsoid or gap. There is an
increase in the size of the left atrium.

Increased pressure in the pulmonary circulation

causes hypertrophy and dilatation of the right heart.
The hepatic veins and inferior vena cava can be
dilated.

Apical 4 Chamber View. PW Doppler. Normal transmitral

Diastolic Flow. Simulation By Echocardiography Online
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Apical 4 chamber view. 2D Echocardiography. Mitral

Stenosis. Thick and rigid mitral valve leaflets. Simulation By
Echocardiography Online
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 Methods of measurement of the Mitral Valve Area
(MVA)

 MVA Tracing
 PISA
 PHT
 Mitral Valve Area (MVA) by Continuity
Equation
 Mean Pressure Gradient (PG mean)

Apical 4 Chamber View. CW Doppler. Mitral stenosis.

Increase in velocity of early transmitral diastolic flow and
spectrogram extension. Simulation By Echocardiography
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MITRAL STENOSIS

MITRAL VALVE AREA BY TRACING

The area of the mitral orifice is measured

planimetrically using two-dimensional
echocardiography from the left parasternal position,
the short axis of the heart at the level of the mitral
valve (at the moment of maximum opening of the
leaflets).

The contour of the orifice is outlined with the cursor

(tracing). The ultrasound device will automatically
calculate the area.

Assessment of mitral stenosis using planimetry can be

divided into the following steps:

• The image must first be acquired from the Left

Parasternal Position at the Level of the Papillary
Muscles.
• Then rotate the transducer until the end of the mitral
leaflets is imaged. In this case, the area of the mitral
orifice is minimal.
• Freeze the image in the early diastole phase.
• Make a tracing of the mitral valve along the internal Left Parasternal View, Short axis at the level of the mitral
borders. valve. Tracing of the Mitral Valve. Simulation By
Echocardiography Online
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 SIMULATION
MITRAL VALVE AREA MEASUREMENT BY
TRACING
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 2 from the list <<Patient>>

 Choose <<Parasternal Short MV>> (Left Parasternal View, Short axis At the Level of Mitral Valve) from the
List <<Positions>> or find the position with 3D Transducer
 Click the button <<Freeze>> to freeze image. Using Slider find the frame of maximum opening of the mitral
valve.
 Click Button <<Calculations>> Click Tab <<MV St >> Click the Radio Button <<MVA>>
 Click the button <<Curve>> trace around inner side of the Mitral Valve.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

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 Left Parasternal View, Short axis at the level of the mitral valve. Tracing of the Mitral Valve. Simulation By
Echocardiography Online Simulator MyEchocardiography.com

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MITRAL STENOSIS

MITRAL VALVE AREA BY PHT (Pressure Half-time)

The time at which the maximum gradient of the trans-

mitral diastolic flow is halved can be used to measure
Mitral Valve Area (MVA). It is the so-called pressure
half-time (T ½) or PHТ (Pressure Half-time).

Empirically, if the Mitral Valve Area (MVA) is 1 cm2,

then the Pressure Half-Time (PHT) is 220 s. From here,
we can find the MVA:

MVA - Mitral Valve Area. PHT - Pressure Half-Time

Apical 4 Chamber View. CW doppler. Transmitral

diastolic flow. Measurement of the Pressure Half-Time
(PHT). Simulation By Echocardiography Online
Simulator MyEchocardiography.com

Assessment of mitral stenosis by the Mitral Valve Area

(MVA):

 Mild > 1.5 cm2

 Moderate 1.0 - 1.5 cm2
 Severe < 1.0 cm2

Apical 4 Chamber View. Sample Volume position for

examining the transmitral diastolic flow. Simulation By
Echocardiography Online
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 SIMULATION
MITRAL VALVE AREA MEASUREMENT BY
PHT
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 2 from the list <<Patient>>

 Choose <<Apical 4 Chamber>> (Apical For Chamber View) from the List <<Positions>> or find the position
with 3D Transducer
 Click the button <<CW>> Place the “Sample Volume” in the Mitral Valve and click.
 Click Button <<Calculations>> Click Tab <<MV St >> Click the Radio Button <<PHT>> and perform Spectral
Doppler Measurements (see Lesson 8)
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

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Apical 4 Chamber View. CW doppler. Transmitral diastolic flow. Measurement of the Pressure Half-Time
(PHT). Simulation By Echocardiography Online Simulator MyEchocardiography.com

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MITRAL STENOSIS

MITRAL VALVE AREA (CONTINUITY EQUATION)

The Continuity Equation can be used to calculate the

area of the mitral valve and estimate the degree of
stenosis:

CSALVOT - Cross-Sectional Area of LVOT. VTIAo - VTI of

the transaortic flow. VTIMV - VTI of the transmitral flow.

To calculate the cross-sectional area of LVOT (CSALVOT), Left Parasternal View, the Long axis of LV. Measurement of
it is necessary to measure the D - diameter of the Left the LVOT diameter. Simulation By Echocardiography
Online Simulator MyEchocardiography.com
Ventricular Outflow Tract (LVOT).

D - LVOT diameter.

Assessment of mitral stenosis by the Mitral Valve Area

(MVA):

 Mild > 1.5 cm2

 Moderate 1.0 - 1.5 cm2
 Severe < 1.0 cm2

Apical 5 chamber view. CW Doppler. Control Volume in

LVOT. Simulation By Echocardiography Online
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MVA - Mitral Valve Area. PHT - Pressure Half-Time

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Apical 5 chamber view. CW doppler. Measurement of the
VTI LVOT. Simulation By Echocardiography Online
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Apical 4 chamber view. CW doppler. VTI MV

measurement. Simulation By Echocardiography Online
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 SIMULATION
MITRAL VALVE AREA MEASUREMENT BY PHT
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 2 from the list <<Patient>>

 Choose << Parasternal Long >> (Left Parasternal View, Long axis of LV ) from the List <<Positions>> or find the
position with 3D Transducer
 Click the button <<Freeze>> to freeze image.
 Click Button <<Calculations>> Click Tab <<MV st >> Click Radio Button <<D Lvot>> (Calculator MVA by
Continuity equation).
 Click the button <<Line>> Measure linear size of Left Ventricular Outflow Tract (LVOT).
 Click the button <<Enter>>

Left Parasternal View, the Long axis of LV. Measurement of the LVOT diameter. Simulation By Echocardiography Online
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 Apical 5 chamber view. CW Doppler. “Sample Volume” in LVOT. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

 From the List <<Positions>> Choose Apical 5 Chamber or find the same position with 3D Transducer. in the
Tab <<MV st >> Click Radio Button <<VTI Lvot>>
 Click the button <<CW>> to start CW doppler examination. Place the “Sample Volume” in the LVOT (Left
Ventricular Outflow Tractact) and Click.
 Click the button <<Curve>> place points around spectrogram of the LVOT flow. (see Lesson 8)
 Click the button <<Enter>>

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 Apical 5 chamber view. CW doppler. Measurement of the VTI LVOT. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

Apical 4 chamber view. CW doppler. VTI MV measurement. Simulation By Echocardiography Online

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 Choose <<Apical 4 Chamber>> (Apical For Chamber View) from the List <<Positions>> or find the position with 3D
Transducer
 Click the button <<CW>> Place the “Sample Volume” in the Mitral Valve and click.
 Click the Radio Button <<VTI mv>> and perform Spectral Doppler Measurements (see Lesson 8)
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

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MITRAL STENOSIS

DEGREE OF MITRAL STENOSIS BY MEAN PRESSURE

GRADIENT

For mitral stenosis assessment, measuring the pressure

difference between the left atrium and the ventricle (in
the apical four-chamber position) is necessary.
Both maximum and mean pressure gradients can be
measured.
PGmax - Maximum flow gradient, measured at the
maximum point of velocity.
PGmid - (Mean Gradient) - The sum of the gradients
measured every 2 seconds, divided by the number of
measurements.

For PGmax calculation, we need the maximum flow

rate at point E. Using the Bernoulli formula ultrasound
device will calculate the maximum pressure gradient:

V - maximum flow rate.

Apical 4 Chamber View. CW doppler. Transmitral diastolic
flow. Measurement of the Pressure Mean Gradient.
For the mean pressure gradient (PGmid), we need to
Simulation By Echocardiography Online
trace the spectrogram of the transmitral diastolic flow.
Simulator MyEchocardiography.com
The ultrasound device will calculate the mean pressure
gradient.

The mean gradient is the relevant hemodynamic

finding. The maximal gradient is of little interest as it
derives from peak mitral velocity, which is influenced
by left atrial compliance and LV diastolic function.

Assessment of mitral stenosis by the mean pressure

gradient (PGmid)

 Mild < 5 mmHg

 Moderate 5 - 10 mmHg
 Severe > 10 mmHg

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 SIMULATION
DEGREE OF MITRAL STENOSIS BY MEAN
PRESSURE GRADIENT
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 2 from the list <<Patient>>

 Choose <<Apical 4 Chamber>> (Apical For Chamber View) from the List <<Positions>> or find the position with 3D
Transducer
 Click the button <<CW>> Place the “Sample Volume” in the Mitral Valve and click.
 Click Button <<Calculations>> Click Tab <<MV St >> Click the Radio Button <<PG mean>> and perform
Spectral Doppler Measurements (see Lesson 8)
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

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 Apical 4 Chamber View. CW doppler. Transmitral diastolic flow. Measurement of the Pressure Mean
Gradient. Simulation By Echocardiography Online Simulator MyEchocardiography.com

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 LESSON 11
MITRAL REGURGITATION

One and two-dimensional Echocardiography LESSON CONTENT

There are no direct echocardiographic signs of mitral Mitral Regurgitation

regurgitation using 1D and 2D Echocardiography.
 Mitral regurgitation diagnosis.
The only relatively reliable finding can be the Incomplete  Degree of Mitral Regurgitation by
closure of the valve on a one-dimensional echocardiogram, JET AREA or JET AREA/LA AREA
which is rarely seen. RATIO
 Degree of Mitral Regurgitation by
Non-specific symptoms: Increase in the size of the left atrium. LV Flow ConvergenceE Method
Myocardial hypertrophy and dilatation. (PISA)
 Degree of Mitral Regurgitation by
Regurgitation Volume and
Fraction.
Color Doppler  Degree of Mitral Regurgitation by
VENA CONTRACTA WIDTH (VCW)
The most informative method is Color Doppler. Regurgitation
flow is observed in the systolic phase, which returns to the left
atrium (away from the transducer) and is encoded in blue. Its
size and volume depend on the severity of regurgitation.

Slight regurgitation can be identified in 40-60% of healthy

people (physiological regurgitation).

The best positions for evaluation: Apical 4 Chamber, Apical 2

Chamber Views, and the Left Parasternal View, long axis.

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MITRAL REGURGITATION

Left Parasternal View, the long axis. Color Doppler. Mitral regurgitation. One dimensional Echocardiography (m-
mode). Normal Mitral Valve. Simulation By Echocardiography Online Simulator MyEchocardiography.com

Apical 4 Chamber View. CW Doppler. Mitral regurgitation. Simulation By Echocardiography Online

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MITRAL REGURGITATION

Spectral Doppler (PW, CW) JET AREA/LA AREA RATIO

The best positions for evaluation: Apical 4 Chamber Jet has to be measured in Color Doppler mode using
and Apical 2 Chamber Views. To find the regurgitation apical positions (Tracing around the regurgitation jet).
and determine the depth of its penetration, the The Left Atrium area has to be measured in the same
sample volume has to be moved at different echocardiography view.
distances from the mitral valve.
The regurgitation flow is visible on the spectrogram as Grading the severity of chronic mitral regurgitation by
a characteristic spectrum directed downward from jet area/LA area ratio:
the baseline. The flow captures the entire systole (from
the mitral valve's closing to the aortic valve's  Mild - Small, central, narrow, often brief (usually
opening). < 20% of LA area).
 Moderate - Variable.
 Severe - Large central jet (>50% of LA) or
eccentric wall-impinging jet of variable size.
Methods of assessment severity of the mitral
Regurgitation:

 Regurgiration Area
 Reg Area / LA area
 PISA
 Regurgitation volume and fraction (CV
method)
 Vena Contracta

DEGREE OF MITRAL REGURGITATION BY JET AREA OR JET

AREA/LA AREA RATIO

Using the color Doppler, it is possible to assess the

degree of mitral regurgitation by the regurgitation
area and its percentage ratio with the area of the left
atrium.

JET AREA

Jet has to be measured in Color Doppler mode using

apical positions (Tracing around the regurgitation jet). Apical 4 chamber View. Mitral regurgitation.
Grading the severity of chronic mitral regurgitation by Regurgitation jet area measurement. Simulation By
jet area: Echocardiography Online
 Mild - Small, central, narrow, often brief (usually Simulator MyEchocardiography.com
< 4 cm2).
 Moderate - Variable.
 Severe - Large central jet (usually > 10 cm2) or
eccentric wall-impinging jet of variable size

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MITRAL REGURGITATION

Apical 4 chamber View. Mitral regurgitation. LA area

measurement. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

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 SIMULATION
DEGREE OF MITRAL REGURGITATION BY
JET AREA OR JET AREA/LA AREA RATIO
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 8 from the list <<Patient>>

 Choose <<Apical 4 chamber>> from the List <<Positions>> or find the position with 3D Transducer
 Using Slider find the frame of maximum regurgitation size.

JET AREA

 find the calculator <<Regurgitation Area>> Click Radio Button <<Area>>

 Click the button <<Curve>> place points around regurgitation jet.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

JET AREA / LA AREA

 After the above step, find the calculator << Area reg / Area LA>> Click Radio Button << Area LA>>
 Click the button <<Curve>> place points around inner side of the Left Atrium.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

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Apical 4 chamber View. Mitral regurgitation. Regurgitation jet area measurement. Simulation By Echocardiography
Online Simulator MyEchocardiography.com

Apical 4 chamber View. Mitral regurgitation. LA area measurement. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

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MITRAL REGURGITATION

DEGREE OF MITRAL REGURGITATION BY FLOW Measurement can be divided into the next stages:
CONVERGENCE METHOD (PISA)
 Align insonation beam with the flow, usually in
apical views; zoomed view
The radius of the proximal zone (PISA - Proximal  Lower the color Doppler baseline in the
Isovelosity surface Area) is a parameter characterizing direction of the jet.
the severity of regurgitation, determined by color  Look for the hemispheric shape to guide the
Doppler. PISA is part of the color spectrum on the best low Nyquist limit
ventricular side of the mitral valve.  Look for the need for angle correction if the flow
convergence zone is nonplanar
The formation of the flow of regurgitation begins before  Measure PISA radius at roughly the same time as
entering the left atrium. The more regurgitation, the the CW jet peak velocity
more area PISA occupies in the left ventricle. To
measure the radius of the proximal zone, the
regurgitation flow velocity must exceed the Nyquist Degree of Mitral Regurgitation by EROA (cm2)
limit and turn red. We need to increase the image size
and decrease the Nyquist limit to do this.  Mild < 0.20
 Mild-Moderate 0.20 - 0.29
PISA is made up of several layers. Each of them  Moderate-severe 0.30 - 0.39
corresponds to a specific flow rate. The volumetric  Severe > 0.40
regurgitation rate can be calculated based on the
assumption that all of the regurgitation flow will be on
the other side of the valve and based on the principle
of mass invariance.

r - the radius of the proximal zone of the flow of

regurgitation. Vr - Minimum speed when the Doppler
spectrum is distorted (exceeds the Nyquist limit).

The area of the regurgitation orifice is calculated by

the following formula:

Apical 4 Chamber view. Color Doppler. Degree of Mitral

Regurgitation by Proximal Isovelocity Surface Area (PISA).
Simulation By Echocardiography Online
Vmax - Maximum regurgitation flow rate. V r- Nyquist limit. Simulator MyEchocardiography.com

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MITRAL REGURGITATION

Apical 4 Chamber view, CW Doppler. Mitral Regurgitation

Vmax (maximum velocity) Assessment. Simulation By
Echocardiography Online
Simulator MyEchocardiography.com

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 SIMULATION
DEGREE OF MITRAL REGURGITATION BY
FLOW CONVERGENCE METHOD (PISA)
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 8 from the list <<Patient>>

 Choose <<Apical 4 chamber>> from the List <<Positions>> or find the position with 3D Transducer
 Click the button <<Color>>
 Click the button <<Freeze>> to freeze image. Click the Button << -||- >> and increase zoom level. Using
Slider find the best frame for PISA measurement. The Nyquist Limit is set to 2.5.
 Click Button <<Calculations>> Click Tab <<MV Reg>> Click Radio Button <<r>> (Calculator EROA by PISA).
 Click the button <<Line>> measure radius of the PISA.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

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Apical 4 Chamber view. Color Doppler. Degree of Mitral Regurgitation by Proximal Isovelocity Surface Area (PISA).
Zoomed image. Simulation By Echocardiography Online Simulator MyEchocardiography.com

Apical 4 Chamber view, CW Doppler. Mitral Regurgitation Vmax (maximum velocity) Assessment. Simulation By
Echocardiography Online Simulator MyEchocardiography.com

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MITRAL REGURGITATION

DEGREE OF MITRAL REGURGITATION BY REGURGITATION The following formula determines the regurgitation
VOLUME AND FRACTION fraction (RF%):

The volume of mitral regurgitation is the difference

between the transmitral flow and the flow in the
outflow tract of the left ventricle.

Assessment of mitral regurgitation by the regurgitation

RV - regurgitation volume. SVmv - transmitral stroke fraction (RF%):
Volume. SVLVOT - LVOT Stroke Volume.
 Mild < 30
 Mild-Moderate 30 - 39
To calculate the transmitral Stroke Volume (SV),  Moderate-severe 40 - 49
measuring the mitral annulus's D-diameter and VTI of  Severe > 50
the transmitral flow is necessary.

D - diameter of the mitral annulus. VTIMV - VTI of the

transmitral flow.

To calculate the stroke volume through the outflow

tract of the left ventricle, it is necessary to measure the
D-diameter of the LVOT and the VTI of the flow in the
outflow tract of the left ventricle (LVOT).

D - diameter of the LVOT. VTILVOT - VTI of the LVOT flow

 LVOT diameter measured at the annulus in systole

and pulsed Doppler from apical views at the same
site
 Mitral annulus measured at mid diastole; pulsed
Doppler at the annulus level in diastole
 Total LV SV can be measured by the pulsed
Doppler technique at the mitral annulus or by the
difference between LV end-diastolic and end-
Left Parasternal View. The long axis of LV. Measurement of
systolic volumes. the Left Ventricular Outflow Tract (LVOT) diameter.
 LV volumes are best measured in 3D. Contrast may Simulation By Echocardiography Online
be needed to trace endocardial borders better. If Simulator MyEchocardiography.com
3D is not feasible, use the 2D method of disks.

Assessment of mitral regurgitation by the regurgitation

volume:

 Mild < 30
 Mild-Moderate 30 - 44
 Moderate-severe 45 - 59
 Severe > 60

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MITRAL REGURGITATION

Apical 5 chamber view. CW Doppler. VTI LVOT

Apical 4 chamber view. Measurement of the Mitral measurement. Simulation By Echocardiography Online
Annulus Diameter. Simulation By Echocardiography Simulator MyEchocardiography.com
Online Simulator MyEchocardiography.com

Apical 4 chamber view. PW Doppler. VTI mv

measurement. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 234

 SIMULATION
DEGREE OF MITRAL REGURGITATION BY
REGURGITATION VOLUME AND FRACTION
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 From the List <<Patients>> Choose Patient 4 (User can Choose other patients with mitral regurgitation as well).
 From the List <<Positions>> Choose Parasternal Long (Left Parasternal View, Long axis of LV). or find the same
position with 3D Transducer.
 Click the button <<Freeze>> to freeze image.
 Click Button <<Calculations>> Click Tab <<MV Reg>> Click Radio Button <<D Lvot>>
 Click the button <<Line>> Measure linear size of Left Ventricular Outflow Tract (LVOT). See Linear measurements.
 Click the button <<Enter>>

Left Parasternal View. The long axis of LV. Measurement of the Left Ventricular Outflow Tract (LVOT) diameter.
Simulation By Echocardiography Online Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 235

 From the List <<Positions>> Choose Apical 4 Chamber or find the same position with 3D Transducer.
 Click the button <<Freeze>> to freeze image.
 Click Button <<Calculations>> Click Tab <<MV Reg>> Click Radio Button <<D mv>>
 Click the button <<Line>> Measure Mitral Anullus Diameter. See Linear measurements.
 Click the button <<Enter>>

Apical 4 chamber view. Measurement of the Mitral Annulus Diameter. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

 In the Tab <<MV Reg>> Click Radio Button <<VTI mv>>

 Click the button <<PW>> to start Pulse Wave Doppler examination. Place Control Volume Between Mitral Valve
Leaflets and Click.
 Click the button <<Curve>> place points around spectrogram of trans-mitral diastolic flow.
 Click the button <<Enter>>

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 236

 Apical 4 chamber view. PW Doppler. VTI mv measurement. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

Apical 5 chamber view. CW Doppler. VTI LVOT measurement. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 237

 https://youtu.be/4qF88qt3K7M

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 238

MITRAL REGURGITATION

DEGREE OF MITRAL REGURGITATION BY VENA

CONTRACTA WIDTH (VCW)

Vena Contracta - this is the width of the flow at the site

of its formation, the so-called neck of the regurgitation,
the narrowest point of the flow, at the ends of the
leaflets of the closed mitral valve.

Vena Contracta Width (VCW) can be used to assess

the severity of regurgitation:

Vena Contracta Width (VCW) can be used to assess

the severity of regurgitation:

 Mild - Vena Contracta < 0.3 cm.

 Moderate - Intermediate.
 Severe - Vena Contracta > 0.7 cm (>0.8 for
biplane. For average between apical two and
four-chamber views).

Left Parasternal View, the Long axis of LV, Mitral

Vena Contracta can also be used to determine the regurgitation. VCW measurement. Simulation By
effective area of the regurgitation orifice (EROA): Echocardiography Online
Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 239

 SIMULATION
DEGREE OF MITRAL REGURGITATION BY
VENA CONTRACTA WIDTH (VCW)
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 4 from the list <<Patient>>

 Choose <<Apical 4 chamber>> from the List <<Positions>> or find the position with 3D Transducer
 Click the button <<Color>> to run Color Doppler.
 Click the button <<Freeze>> to freeze image. Using Slider find the frame of maximum regurgitation size.
 Click Button <<Calculations>> Click Tab <<MV Reg >> Click Radio Button <<VCW>>
 Click the button <<Line>> Measure linear size of VCW.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 240

Left Parasternal View, the Long axis of LV, Mitral regurgitation. VCW measurement. Simulation By Echocardiography
Online Simulator MyEchocardiography.com

https://youtu.be/JJvpEp66OsI

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 241

 LESSON 12
AORTIC STENOSIS

One-dimensional Echocardiography LESSON CONTENT

The examination must be done in the left parasternal position, Mitral Regurgitation
on the long axis of the heart.
 Aortic stenosis diagnosis.
One-dimensional echocardiography will reveal changes in the  Degree of the Aortic Stenosis by
structure and motion of the valve leaflets. There is a decrease in Pic Velosity of the Stenotic Flow
the amplitude of the systolic opening of the leaflets and their  Degree of the Aortic Stenosis by
movement in one direction. It is worth noting that the hardening Mean Pressure Gradient
and thickening of the aortic valve also give us a similar picture  Degree of the Aortic Stenosis by
even in the absence of hemodynamically significant stenosis, so Aortic Valve Area (AVA)
a one-dimensional echocardiogram cannot be focused only
on.

Two dimensional Echocardiography

A two-dimensional echocardiographic study should be

performed on the short and long axis.

The number of leaflets, the amplitude of their movement

(opening), thickness, and the presence of calcification should
be evaluated.

A two-dimensional echocardiogram will reveal a decrease in

the opening amplitude of the leaflets.
In the case of hemodynamically significant stenosis, such
indirect signs as the post-stenotic expansion of the aorta,
increase in the thickness and mass of the left ventricular wall,
and increase in the size of the left atrium can be presented.

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 242

AORTIC STENOSIS

Left Parasternal View.The long axis. M-Mode. Aortic Stenosis. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

Apical 5 Chamber View. B-Mode. Aortic Stenosis. Simulation By Echocardiography Online

Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 243

AORTIC STENOSIS

Apical 5 Chamber View. CW Doppler. Measurement of the Pic Velosity of the systolic flow and Mean pressure
gradient. Aortic Stenosis. Simulation By Echocardiography Online Simulator MyEchocardiography.com

Spectral Doppler (PW, CW) DEGREE OF AORTIC STENOSIS BY PIC VELOCITY OF THE
STENOTIC FLOW
Continuous-wave and pulsed-wave spectral Doppler
will reveal increased flow velocity beyond the aortic Flow velocity beyond the narrowed aortic valve is
valve. Increased transaortic flow velocity is one of studied on spectral Doppler in CW mode. The best
the most sensitive tests for aortic stenosis. position for the evaluation is the Apical 5 Chamber
view. The flow should be as much parallel to the
In spectral Doppler examination, the maximum flow ultrasound beam as possible.
velocity through the stenotic aortic valve is usually
obtained from the apical five-chamber position. The In the case of severe stenosis, the shape of the flow is
ultrasound beam should be directed parallel to the more rounded. Mild stenosis is characterized by a
stenotic flow. peak at the beginning of systole; the flow is more
triangular on the spectrogram. A late peak is
The pressure gradient (pressure difference) between characteristic of subaortic dynamic stenosis
the left ventricle and the aorta is calculated using
continuous wave Doppler. Assessment of Aortic Stenosis by Pic Velocity:

 Mild - 2.6-2.9 m/c

 Moderate 3.0-4.0 m/s
Methods of assessment severity of the Aortic  Severe > 4 m/s
Stenosis:

 Pic Velocity
 Mean Pressure Gradient (PG mean)
 AVA by Continuity Equation

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 244

MITRAL REGURGITATION
DEGREE OF AORTIC STENOSIS BY MEAN PRESSURE
GRADIENT

The transaortic pressure gradient can assess the

severity of aortic stenosis, the pressure gradient
between the aorta and the left ventricle during D - diameter of the base of the aorta. VTILVOT - integral
systole. of the linear velocity of the flow in the LV outflow tract.
VTIAO - integral of the linear velocity of the flow in the
Aorta.
The mean systolic pressure gradient is more
consistent with cardiac catheterization data than the
peak pressure gradient.

The mean gradient is calculated by averaging the

pressure gradient over the entire ejection period.
Calculators are embedded in echocardiographs;
the operator will only trace the spectrogram.

Assessment of Aortic Stenosis by Mean Pressure

Gradient:

 Mild < 20 mmHg

 Moderate 20-40 mmHg
 Severe > 40 mmHg

DEGREE OF AORTIC STENOSIS BY AORTIC VALVE AREA

(AVA)

The best indicator of the severity of aortic stenosis is

the area of the aortic valve opening. It is calculated
from the flow continuity equation. The flow in the
output tract of the left ventricle is studied in pulseless
wave mode, in the aorta in continuous wave mode Left Parasternal View. The long axis. Measurement of
The calculation is based on the flow continuity the D - diameter of the base of the aorta. Simulation By
equation, according to which the stroke volume of Echocardiography Online
the flow in the left ventricular outflow tract is equal to Simulator MyEchocardiography.com
the stroke volume of the transaortic flow:

AVA - Aortic valve orifice area. CSALVOT - left

ventricular outflow tract area.

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 245

Apical 5 Chamber View. PW Doppler. Measurement of Apical 5 Chamber View. CW Doppler. Measurement of
the VTI LVOT. Simulation By Echocardiography Online the VTI Ao. Simulation By Echocardiography Online
Simulator MyEchocardiography.com Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 246

 SIMULATION
AORTIC SENOSIS BY PIC VELOCITY AND
MEAN PRESSURE GRADIENT
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 18 from the list <<Patient>>

 Choose <<Apical 5 Chamber>> from the List <<Positions>> or find the position with 3D Transducer
 Click the button <<CW>> plase the Sample Volume in the Aorta and click.

Pic Velosity

 Click the Button <<Calculations>> Click Tab <<Ao st >> Click Radio Button <<Pic Velocity>>
 Click the button <<Curve>> and place the points around spectrogram of the Ao flow.
 Click the button <<Enter>>

Mean pressure gradient

 Click Radio Button <<PG mid>>

 Click the button <<Curve>> and place the points around spectrogram of the Ao flow.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 247

Apical 5 Chamber View. CW Doppler. Measurement of the Pic Velosity of the systolic flow and Mean pressure
gradient. Aortic Stenosis. Simulation By Echocardiography Online Simulator MyEchocardiography.com

https://youtu.be/62hJZSbS1xg

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 248

 SIMULATION
AORTIC VALVE AREA (AVA)
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 18 from the list <<Patient>>

 Choose <<Parasternal Long>> from the List <<Positions>> or find the position with 3D Transducer
 Click the Button <<Calculations>> Click Tab <<Ao st >> Click Radio Button <<D Lvot>> (Calculator AVA by
Continuity Equation)
 Click the button <<Line>> and measure Left ventricular outflow tract Diameter.
 Click the button <<Enter>>
 Click the Radio Button <<VTI Lvot>> (Calculator AVA by Continuity Equation)
 Choose <<Apical 5 Chamber>> from the List <<Positions>> or find the position with 3D Transducer
 Click the button <<PW>> plase the Sample Volume in the Left Ventricular outflow tract and click.
 Click the button <<Curve>> and place the points around spectrogram of the LVOT flow.
 Click the button <<Enter>>
 Click the Radio Button <<VTI Ao>> (Calculator AVA by Continuity Equation)
 Click the button <<CW>> plase the Sample Volume in the Aorta and click.
 Click the button <<Curve>> and place the points around spectrogram of the Ao flow.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 249

Left Parasternal View. The long axis. Mitral Stenosis. Measurement of the D - diameter of the base of the aorta.
Simulation By Echocardiography Online Simulator MyEchocardiography.com

Apical 5 chamber View. Mitral Stenosis. Position of the Sample Volume for the LVOT flow. Simulation By
Echocardiography Online Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 250

 Apical 5 Chamber View. Mitral Stenosis . PW Doppler. Measurement of the VTI LVOT. Simulation By
Echocardiography Online Simulator MyEchocardiography.com

Apical 5 chamber View. Mitral Stenosis. Position of the Sample Volume for the Ao flow. Simulation By
Echocardiography Online Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 251

Apical 5 Chamber View. Mitral Stenosis . CW Doppler. Measurement of the VTI Ao. Simulation By Echocardiography
Online Simulator MyEchocardiography.com

https://youtu.be/iZWkre-e720

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 252

 LESSON 13
AORTIC REGURGITATION

One and two-dimensional Echocardiography LESSON CONTENT

The only relatively reliable specific finding can be Diastolic Aortic Regurgitation
vibration of the anterior leaflet of the mitral valve is caused by a
reversed turbulent outflow of blood from the aorta into the left  Aortic regurgitation diagnosis.
ventricle (one-dimensional echocardiography).  Degree of Aortic Regurgitation by
Non-specific symptom: LV Myocardial hypertrophy and The Jet Deceleration Rate (PHT)
dilatation  Degree of Aortic Regurgitation by
JET WIDTH / LVOT DIAMETER
 Degree of Aortic Regurgitation by
Color Doppler JET AREA/LVOT AREA
 Degree of Aortic Regurgitation by
The most informative method is color, Doppler. The best positions VENA CONTRACTA WIDTH (VCW)
for evaluation are the Apical 5-chamber view and the Left  Degree of Aortic Regurgitation by
Parasternal View, the Long axis of the heart. Regurgitation flow is Regurgitation Volume and
observed in the diastolic phase and returns to the left ventricle. Fraction
If examining from Apical 5 Chamber View, The flow is directed
towards the transducer accordingly encoded in red.

When examining from a parasternal approach the long axis of

the heart, the regurgitation flow can be directed towards or
away from the transducer. It depends on the orientation of the
outflow tract to the ultrasound beam. If the LV outflow tract is in
front of the transducer, then the regurgitation flow is directed
away from the transducer and accordingly coded in blue.
When positioned at the back, the flow is directed toward the
transducer and coded in red.

Regurgitation size and volume depend on the severity of

regurgitation.

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 253

AORTIC REGURGITATION

Left Parasternal View, the long axis. Color Doppler. Aortic regurgitation. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

CW Doppler. Aortic regurgitation. Simulation By Echocardiography Online Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 254

AORTIC REGURGITATION

Spectral Doppler (PW, CW) Degree of the Aortic regurgitation by PHT:

The best positions for evaluation: Apical 5 Chamber  Mild - PHT < 500 msec
View, and to find the regurgitation and determine the  Moderate - PHT 500-200 msec
depth of its penetration, the sample volume is placed  Severe - PHT < 200 msec
in the outflow tract of the left ventricle at the level of
the junction of the aortic valve leaflets. After, it has to
be moved at different distances from the Aortic valve
(in LV).

The regurgitation flow is clearly visible on the

spectrogram (both in PW and CW mode) as a
characteristic spectrum above the baseline. The flow
captures the entire diastole (from the aortic valve's
closing to the mitral valve's opening).

Methods of assessment severity of the Aortic

Regurgitation:

 PHT
 Regurgitation jet width / LVOT diameter
 Regurgitation jet area / CSA LVOT
 Vena Contracta
 Regurgitation volume and fraction (SV
method)

Apical 5 Chamber View. CW Doppler Control Volume in

the LVOT (Left ventricular outflow tract). Simulation By
Echocardiography Online
Simulator MyEchocardiography.com
DEGREE OF AORTIC REGURGITATION BY THE JET
DECELERATION RATE (PHT)

This method is based on determining the pressure

gradient half-time (PHT) between the left ventricle
and the aorta.
 Align the insonation beam with the flow
 Usually best from apical windows
 In eccentric jets, it may be best from the
parasternal window, helped by the color
Doppler

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 255

AORTIC REGURGITATION

Apical 5 Chamber View. CW Doppler. Degree of Aortic

Regurgitation by PHT Simulation By Echocardiography
Online Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 256

 SIMULATION
DEGREE OF AORTIC REGURGITATION BY
THE JET DECELERATION RATE (PHT)
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 4 from the list <<Patient>>

 Choose <<Apical 5 chamber>> from the List <<Positions>> or find the position with 3D Transducer
 Click Button <<Calculations>> Click Tab <<Ao Reg>> Click Radio Button <<PHT>> (Calculator PHT).
 Click the button <<CW>> to move to Continuous Wave Spectral Doppler (CW).
 Place Control Volume in LVOT (Left ventricular outflow tract) and click.
 Measure PHT (See the Lesson 8).
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 257

Apical 5 Chamber View. CW Doppler Control Volume in the LVOT (Left ventricular outflow tract). Simulation By
Echocardiography Online Simulator MyEchocardiography.com

Apical 5 Chamber View. CW Doppler. Degree of Aortic Regurgitation by PHT. Simulation By Echocardiography
Online Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 258

 https://www.youtube.com/watch?v=-pGFfgI4mOs

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 259

AORTIC REGURGITATION

AORTIC REGURGITATION ASSESSMENT BY

JET WIDTH / LVOT DIAMETER

The severity of aortic regurgitation can be assessed

using the width of the regurgitation jet (on color
Doppler) and its percentage to the diameter of the
outflow tract of the left ventricle.
In the left parasternal position, the long axis of the
heart, the width of the regurgitation flow is measured (1
cm distal to the aortic valve), and its percentage to
the diameter of the outflow tract of the left ventricle is
found.

Degree of the Aortic regurgitation by Jet width/LVOT

diameter:

 Mild < 25 %
 Mild-Moderate 25-45 %
 Moderate-Severe 46-64 %
 Severe > 65 %

Left Parasternal View, Long axis of LV, Color Doppler.

Measurement of the LVOT diameter. Simulation By
Echocardiography Online
Simulator MyEchocardiography.com

Left Parasternal View, the Long axis of LV, Color Doppler.

Measurement of the regurgitation jet width. Simulation By
Echocardiography Online
Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 260

 SIMULATION
AORTIC REGURGITATION ASSESSMENT BY
JET WIDTH / LVOT DIAMETER
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 5 from the list <<Patient>>

 From the List <<Positions>> Choose Parasternal Long (Left Parasternal View, Long axis of LV) or find the same
position with 3D Transducer.
 Click the button <<Color>>
 Click the button <<Freeze>> to freeze image. Click the Button << -||- >> and increase zoom level. Using Slider
find the best frame of Aortic regurgitation jet.
 Click Button <<Calculations>> Click Tab <<Ao Reg>> Click Radio Button <<D reg >> (Calculator D reg / D Lvot).
 Click the button <<Line>> measure regurgitation jet diameter in LVOT.
 Click the button <<Enter>>
 Click the button <<Line>> measure Diameter of LVOT (Left Ventricular Outflow Tract).
 Click the button <<Enter>>.
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 261

Left Parasternal View, the Long axis of LV, Color Doppler. Measurement of the regurgitation jet width. Simulation By
Echocardiography Online Simulator MyEchocardiography.com

Left Parasternal View, Long axis of LV, Color Doppler. Measurement of the LVOT diameter. Simulation By
Echocardiography Online Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 262

 https://youtu.be/fry349s4YaI

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 263

AORTIC REGURGITATION

AORTIC REGURGITATION ASSESSMENT BY JET AREA/LVOT

AREA

The percentage of the cross-sectional area of the

regurgitation flow (CSA) to the area of the outflow tract
of the left ventricle (CSA LVOT) can be used to
evaluate the degree of the aortic regurgitation (In
practice, these parameters are often visually assessed).
In the left parasternal position, the short axis of the
heart at the level of the Ao valve, the cross-sectional
area of the regurgitation flow is measured
planimetrically (tracing).
The formula calculates the area of the outflow tract of
the left ventricle:

DLVOT - Diameter of the Left Ventricular Outflow tract

(LVOT).

Degree of the Aortic regurgitation by Jet area/LVOT

Left Parasternal View, the Long axis of LV, Measurement of
area:
the Left Ventricular Outflow Tract (LVOT) Diameter. Using
this parameter, the Echocardiography calculator will
 Mild < 5 % measure LVOT Area. Simulation By Echocardiography
 Mild-Moderate 5 - 20 % Online Simulator MyEchocardiography.com
 Moderate-Severe 21-59 %
 Severe > 60 %

Left Parasternal View, the short axis at the level of Ao

valve. Color Doppler. Measurement of the regurgitation
jet area. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 264

 SIMULATION
AORTIC REGURGITATION ASSESSMENT BY
JET AREA/LVOT AREA
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 5 from the list <<Patient>>

 From the List <<Positions>> Choose Parasternal Short Ao (Left Parasternal View, Short axis of Ao) or find the same
position with 3D Transducer.
 Click the button <<Color>>
 Click the button <<Freeze>> to freeze image. Using Slider find the best frame of aotic regurgitation jet.
 Click Button <<Calculations>> Click Tab <<Ao Reg>> Click Radio Button <<Area reg >> (Calculator Area reg /
CSA Lvot).
 Click the button <<Curve>> measure regurgitation jet area by tracing around it.
 Click the button <<Enter>>
 Click the button <<Line>> measure Diameter of LVOT (Left Ventricular Outflow Tract).
 Click the button <<Enter>>.
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 265

Left Parasternal View, the short axis at the level of Ao valve. Color Doppler. Measurement of the regurgitation jet area.
Simulation By Echocardiography Online Simulator MyEchocardiography.com

Left Parasternal View, Long axis of LV, Color Doppler. Measurement of the LVOT diameter. Simulation By
Echocardiography Online Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 266

AORTIC REGURGITATION

DEGREE OF AORTIC REGURGITATION BY VENA

CONTRACTA WIDTH (VCW)

Vena contracta - this is the width of the flow at the site of

its formation, the so-called neck of the regurgitation, the
narrowest point of the flow, at the ends of the leaflets of
the valve.
Vena contracta is best visualized and measured in a
zoomed, parasternal long-axis view. Since it is the
narrowest area of the jet, it is smaller than the jet width in
the LVOT. It can be measured in most patients with good
echocardiographic images.

Vena Contracta Width (VCW) can be used to assess the

severity of regurgitation:

 Mild - Vena Contracta < 0.3 cm.

 Moderate - 0.3-0.6 cm.
 Severe - Vena Contracta > 0.6 cm.

Left Parasternal View, the Long axis of LV, color Doppler,

Aortic regurgitation. VCW measurement. Simulation By
Echocardiography Online
Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 267

 SIMULATION
DEGREE OF AORTIC REGURGITATION BY
VENA CONTRACTA WIDTH (VCW)
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 5 from the list <<Patient>>

 From the List <<Positions>> Choose Parasternal Long (Left Parasternal View, Long axis of LV) or find the same
position with 3D Transducer.
 Click the button <<Color>>
 Click the button <<Freeze>> to freeze image. Click the Button << -||- >> and increase zoom level. Using
Slider find the best frame of Aortic regurgitation jet.
 Click Button <<Calculations>>, Click Tab <<Ao Reg>> Click Radio Button <<VCW >> (Calculator Vena
Contracta).
 Click the button <<Line>> measure Vena Contracta Width.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 268

Left Parasternal View, Long axis of LV, Color Doppler. Vena Contracta Width. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

https://youtu.be/KQ1jFS12zv8

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 269

AORTIC REGURGITATION

DEGREE OF AORTIC REGURGITATION BY Regurgitation fraction (RF%) is determined by the

REGURGITATION VOLUME AND FRACTION following formula:

The volume of Aortic regurgitation is the difference

between the flow in the outflow tract of the left
ventricle and the transmitral flow:

Assessment of Aortic regurgitation by the regurgitation

RV - regurgitation volume. SVmv - transmitral stroke fraction (RF%):
Volume. SVLVOT - LVOT Stroke Volume.
 Mild < 30
To calculate the transmitral Stroke Volume (SV), it is
 Mild-Moderate 30 - 39
necessary to measure the mitral annulus's D-diameter
 Moderate-severe 40 - 49
and the transmitral flow's VTI.
 Severe > 50

D - diameter of the mitral annulus. VTIMV - VTI of the

transmitral flow.

To calculate the stroke volume through the outflow

tract of the left ventricle, it is necessary to measure the
D-diameter of the LVOT and the VTI of the flow in the
outflow tract of the left ventricle (LVOT).

D - diameter of the LVOT. VTILVOT - VTI of the LVOT flow.

 LVOT diameter is measured at the annulus in

systole; PW Doppler from apical views at the
same site.
 Mitral annulus measured at mid diastole; PW
Doppler at the annulus level in diastole.
 Total LV SV can also be measured by the
difference between LV end-diastolic volume
and end-systolic volume.
 LV volumes are best measured by 3D. Contrast Left Parasternal View. The long axis of LV. Measurement
may be needed to better trace endocardial of the Left Ventricular Outflow Tract (LVOT) diameter.
borders. If 3D not feasible, use 2D method of Simulation By Echocardiography Online
disks. Simulator MyEchocardiography.com

Assessment of Aortic regurgitation by the regurgitation

volume:

 Mild < 30 ml
 Mild-Moderate 30 – 44 ml
 Moderate-severe 45 – 59 ml
 Severe > 60 ml

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 270

AORTIC REGURGITATION

Apical 4 chamber view. Measurement of the Mitral

Apical 5 chamber view. CW Doppler. VTI LVOT
Annulus Diameter. Simulation By Echocardiography
measurement. Simulation By Echocardiography Online
Online Simulator MyEchocardiography.com
Simulator MyEchocardiography.com

Apical 4 chamber view. PW Doppler. VTI mv

measurement. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 271

 SIMULATION
DEGREE OF AORTIC REGURGITATION BY
REGURGITATION VOLUME AND FRACTION
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 4 from the list <<Patient>>

 From the List <<Positions>> Choose Parasternal Long (Left Parasternal View, Long axis of LV) or find the same
position with 3D Transducer.
 Click the button <<Freeze>> to freeze image.
 Click Button <<Calculations>> Click Tab <<Ao Reg>> Click Radio Button <<D Lvot>>
 Click the button <<Line>> Measure linear size of Left Ventricular Outflow Tract (LVOT).
 Click the button <<Enter>>

Left Parasternal View. The long axis of LV. Measurement of the Left Ventricular Outflow Tract (LVOT) diameter.
Simulation By Echocardiography Online Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 272

 From the List <<Positions>> Choose Apical 4 Chamber or find the same position with 3D Transducer.
 Click the button <<Freeze>> to freeze image.
 in the Tab <<Ao Reg>> Click Radio Button <<D mv>>
 Click the button <<Line>> Measure Mitral Anullus Diameter.
 Click the button <<Enter>>

Apical 4 chamber view. Measurement of the Mitral Annulus Diameter. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

 In the Tab <<Ao Reg>> Click Radio Button <<VTI mv>>

 Click the button <<PW>> to start Pulse Wave doppler examination. Place Control Volume Beetwen Mitral
Valve Leaflets and Click.
 Click the button <<Curve>> place points around spectrogram of transmitral diastolic flow.
 Click the button <<Enter>>

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 273

 Apical 4 chamber view. PW Doppler. VTI mv measurement. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

 From the List <<Positions>> Choose Apical 5 Chamber or find the same position with 3D Transducer.
 In the Tab <<Ao Reg>> Click Radio Button <<VTI Lvot >>
 Click the button <<CW>> to start Continous Wave doppler examination. Place Control Volume in LVOT
and Click.
 Click the button <<Curve>> place points around spectrogram of LVOT Systolic Flow. See Spectral Doppler
Measurements.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

https://youtu.be/gtjxzbqugak

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 274

 LESSON 14
TRICUSPID STENOSIS

Tricuspid stenosis is the rarest acquired heart valve disease. Its LESSON CONTENT
cause can be rheumatism (in such cases, as a rule, we also
have mitral valve damage). It may also develop in carcinoid Tricuspid Stenosis
syndrome and endocarditis.
 Tricuspid stenosis diagnosis.
Two-dimensional Echocardiography  DEGREE OF TRICUSPID STENOSIS BY
MEAN PRESSURE GRADIENT (PG
Two-dimensional echocardiography can observe calcinosis of mean)
the tricuspid valve leaflets, deformation, reduction of opening  Degree of the Tricuspid Stenosis
amplitude, and dilatation of the right atrium and inferior vena by PHT:
cava. The presence of tumors and vegetation (in the case of  Degree of the Tricuspid Stenosis
endocarditis) can be detected. by VTI:

Spectral Doppler (PW, CW)

Spectral Doppler will reveal an increased flow rate. Still, it is

worth noting that the tricuspid flow rate changes with respiratory
phases, so it is necessary to average the data obtained in
different respiratory cycle phases.

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 275

TRICUSPID STENOSIS

Methods of assessment severity of the Tricuspid Degree of the Tricuspid Stenosis by PHT:
Stenosis:
 < 190 m/s mmHg – No Significant stenosis.
 > 190 m/s mmHg – Significant stenosis.
 Mean Pressure gradient
 PHT
 VTI

Degree of the Tricuspid Stenosis by VTI:

 < 60 cm – No Significant stenosis.
 > 60 cm – Significant stenosis.

DEGREE OF TRICUSPID STENOSIS BY MEAN PRESSURE

GRADIENT (PG mean)

 < 5 mmHg – No Significant stenosis.

 > 5 mmHg – Significant stenosis.

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 276

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 277
 LESSON 15
TRICUSPID REGURGITATION

Tricuspid valve insufficiency often develops secondary to right LESSON CONTENT

ventricular decompensation due to pulmonary hypertension.
Organic damage to the valve is usually rare (endocarditis, Tricuspid Regurgitation
carcinoid syndrome, Ebstein's anomaly, rheumatism). Notably,
minor tricuspid regurgitation occurs in 70% of the healthy  Tricuspid regurgitation diagnosis.
population.  Degree Of Tricuspid Regurgitation
By Regurgitation Area (cm2)
 Degree Of Tricuspid Regurgitation
Color Doppler By Pisa Radius (cm)
 Degree Of Tricuspid Regurgitation
Direct and reliable signs can be detected only by Doppler. By Hepatic Vein Flow Reversal
During color Doppler examination, we can easily see the  Degree Of Tricuspid Regurgitation
regurgitation flow. It is coded in blue and directed towards the By Density Of Regurgitation Jet
right atrium during the systole.

Spectral Doppler (PW, CW)

When examined by PW or CW Doppler, the regurgitation flow is

directed opposite to the transducer and is located above the
baseline. The flow in the hepatic veins is studied by pulsed wave
Doppler, severe tricuspid regurgitation is characterized by
systolic flow reversal on the spectrogram.

Spectral Doppler study of tricuspid regurgitation is also used to

assess pulmonary artery pressure (systolic pressure).

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 278

TRICUSPID REGURGITATION

Apical Four-chamber view. Color Doppler. Tricuspid regurgitation. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

Apical Four-chamber view. PW Doppler. Tricuspid regurgitation. Simulation By Echocardiography Online

Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 279

TRICUSPID REGURGITATION

Methods of assessment severity of the Tricuspid

Regurgitation (ASE):

 Regurgitation area
 PISA
 Hepatic vein flow reversal
 Density of regurgitant jet

DEGREE OF TRICUSPID REGURGITATION BY

REGURGITATION AREA (cm2)

 < 5 - mild regurgitation.

 5 -10 - moderate regurgitation.
 > 10 - severe regurgitation.

Apical Four-chamber view. Degree of Tricuspid

Regurgitation by PISA. Simulation By
Echocardiography Online
Simulator MyEchocardiography.com

DEGREE OF TRICUSPID REGURGITATION BY

HEPATIC VEIN FLOW REVERSAL

 Systolic dominance - mild regurgitation.

 Systolic blunting - moderate regurgitation.
 Systolic flow reversal - severe regurgitation.

DEGREE OF TRICUSPID REGURGITATION BY

Apical Four-chamber view. Degree of Tricuspid DENSITY OF REGURGITATION JET
Regurgitation by Regurgitation Area (cm2). Simulation By
Echocardiography Online  Faint/partial/parabolic - mild regurgitation.
Simulator MyEchocardiography.com  Dense, parabolic or triangular- moderate
regurgitation.
DEGREE OF TRICUSPID REGURGITATION BY PISA radius  Dense, often triangular - severe
(CM) regurgitation.

 < 0.5 - mild regurgitation.

 0.5 -0.6 - moderate regurgitation.
 > 0.6 - severe regurgitation.

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 280

 SIMULATION
DEGREE OF TRICUSPID REGURGITATION BY
REGURGITATION AREA
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 11 from the list <<Patient>> (or other patient with TR)
 Choose <<Apical 4 chamber>> from the List <<Positions>> or find the position with 3D Transducer
 Click the Button <<Color>>
 Click the Button <<Freeze>> and Using Slider find The frame where the size of the regurgitation flow is
maximum.
 Click the Button <<Calculations>> Click Tab <<TV Reg>> Click Radio Button << Reg Area>> (Regurgitation
Area).
 Click the button <<Curve>> and trace around regurgitation Jet.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 281

 Apical Four-chamber view. Degree of Tricuspid Regurgitation by Regurgitation Area (cm2). Simulation By
Echocardiography Online Simulator MyEchocardiography.com

https://youtu.be/TSeBHdjS4iw

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 282

 SIMULATION
DEGREE OF TRICUSPID REGURGITATION BY
PISA
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 11 from the list <<Patient>> (or other patient with TR)

 Choose <<Apical 4 chamber>> from the List <<Positions>> or find the position with 3D Transducer
 Click the Button <<Color>>
 Click the button <<Freeze>> to freeze image. Click the Button << -||- >> and increase zoom level. Using
Slider find the best frame for PISA measurement. The Nyquist Limit is set to 2.5.
 Click Button <<Calculations>> Click Tab <<TV Reg>> Click Radio Button <<PISA>>
 Click the button <<Line>> measure radius of the PISA.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 283

Apical Four-chamber view. Degree of Tricuspid Regurgitation by PISA. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

https://youtu.be/M-7p5mNj0QE

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 284

 LESSON 16
PULMONRY ARTERY STENOSIS

Pulmonary artery orifice stenosis is one of the most common LESSON CONTENT
congenital malformations. More often, it is isolated, but
sometimes it is accompanied by acquired infravalvular stenosis Pulmonary Valve Stenosis
(supravalvular stenosis can be the result of hypertrophy of the
infundibular part of the ventricular septum), congenital  Pulmonary Valve stenosis
infravalvular stenosis, pulmonary artery branch stenosis, and diagnosis.
atrial septal defects.  Degree of the pulmonary Valve
stenosis by stenotic flow velocity:
A stenotic pulmonary valve can be tricuspid, bicuspid,  Degree of the Pulmonary Valve
unicuspid, or dysplastic. Pulmonary artery stenosis is included in Stenosis by systolic pressure
the combination of the tetrad of Fallot. Acquired pulmonary gradient (PG max):
stenosis is rare.

Two-dimensional Echocardiography

Two-dimensional echocardiography reveals the leaflets' systolic

rounding, thickening, and movement in one direction.
Sometimes post-stenotic expansion of the pulmonary trunk,
reduction of its systolic pulsation, and hypertrophy of the right
ventricle.

Spectral Doppler (PW, CW)

Spectral Doppler will reveal an increased flow rate.

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 285

TRICUSPID STENOSIS

Methods of assessment severity of the Pulmonary DEGREE OF THE PULMONARY VALVE STENOSIS BY
Valve Stenosis: SYSTOLIC PRESSURE GRADIENT (PG MAX):

 Flow Velocity  Mild < 36 mmHg

 systolic pressure gradient (PG max)  Moderate 36 – 64 m/s
 Severe > 64 m/s

DEGREE OF THE PULMONARY VALVE STENOSIS BY

STENOTIC FLOW VELOCITY:

 Mild < 3 m/s

 Moderate 3 – 4 m/s
 Severe > 4 m/s

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 286

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 287
 LESSON 17
PULMONARY REGURGITATION

Small functional regurgitation of the pulmonary valve occurs in LESSON CONTENT

approximately 78% of the healthy population. It is not heard by
auscultation, but it is detected by Doppler examination and Pulmonary regurgitation
allows us to determine the end-diastolic pressure in the
pulmonary artery.  Pulmonary regurgitation diagnosis.
 Degree Of Tricuspid Regurgitation
By Regurgitation Jet Size (mm)
Color Doppler  Degree Of Tpulmonary
Regurgitation By Density Of
Color Doppler examination reveals diastolic flow in the right Regurgitation Jet (cw)
ventricle. When examining with the color Doppler, in the
parasternal position, on the heart's short axis, the regurgitation
flow is coded in red color.

Spectral Doppler (PW, CW)

Pulmonary regurgitation can be detected using Spectral

Doppler examination by placing a control volume under the
valve leaflets in the right ventricular outflow tract (parasternal
position, short axis).

The regurgitation flow is directed to the transducer side and

therefore registers above the baseline on the spectrogram.

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 288

PULMONARY REGURGITATION

Left Parasternal View. Sort axis at the level of Aorta. Color Doppler. Pulmonary regurgitation. Simulation By
Echocardiography Online Simulator MyEchocardiography.com

Left Parasternal View. Sort axis at the level of Aorta. Color Doppler. Pulmonary regurgitation. Simulation By
Echocardiography Online Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 289

PULMONARY REGURGITATION

Methods of assessment severity of the Pulmonary DEGREE OF TPULMONARY REGURGITATION BY

Regurgitation (ASE): DENSITY OF REGURGITATION JET (CW)

 Regurgitation jet size  Soft - mild regurgitation.

 Density of regurgitation jet  Dense - moderate regurgitation.
 Dense; early termination of diastolic
 Flow - severe regurgitation.

DEGREE OF PULMONARY REGURGITATION BY

REGURGITATION JET SIZE (mm)

 < 10 - mild regurgitation.

 > 10 - severe regurgitation.

Left Parasternal View. Sort axis at the level of Aorta.

Degree of Pulmonary Regurgitation by Regurgitation jet
size. Simulation By Echocardiography Online
Simulator MyEchocardiography.com

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 290

 SIMULATION
DEGREE OF PULMONARY REGURGITATION
BY REGURGITATION JET SIZE
Echocardiography Online Simulator
MyEchocardiography.com

 Go to the link https://simulation.myechocardiography.com/

 Run Echocardiography Online Simulator using the On/Off Button

 Choose the patient 8 from the list <<Patient>> (or other patient with PR)
 Choose <<Parasternal Short Ao>> from the List <<Positions>> or find the position with 3D Transducer
 Click the Button <<Color>>
 Click the Button <<Freeze>> and Using Slider find The frame where the size of the regurgitation flow is
maximum.
 Click the Button <<Calculations>> Click Tab <<PA Reg>> Click Radio Button << Jet Size>> (Regurgitation Jet
Size).
 Click the button <<Line>> and measure the Jet size.
 Click the button <<Enter>>
 Click the button << R >> to see the results.
 To change the patient, click the On/Off Button

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 291

Left Parasternal View. Sort axis at the level of Aorta. Degree of Pulmonary Regurgitation by Regurgitation jet size.
Simulation By Echocardiography Online Simulator MyEchocardiography.com

https://youtu.be/dJMCHQ54HV4

WWW.MYECHOCARDIOGRAPHY.COM AUTHOR: Z. GURTSKAIA MD. PHD 292