Recent cardiac case (with echo!)

[sevoflurane]

Question for you: when you MPR and crop the 3d color of one of these highly eccentric jets (i.e. the VC is essentially orthogonal from standard central MR), do you think you're able to get a frame where you you can trace an accurate vena contracta area?

You are taking your VC area measurements on the LV side of things, so I think the direction of the jet is a little less important although you want to apply planimetry to the VC en face.
J peterman summed it up quite nicely. If your frame rates are high enough on 2d MPR Pisa you can find it's narrowest point and take a VC area there. Admittedly, I don't do this on every case as it's a little more time consuming in Qlab. I think it's more helpful pre-op when you are trying to add up multiple jets to asses severity.

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[T-burglar]

Good case . Late to the party so I don’t have anything to add in terms of major points. I noticed in some of the original images that the PA looks grossly dilated.

Pulmonary Htn?

 

[vector2]

Good case . Late to the party so I don’t have anything to add in terms of major points. I noticed in some of the original images that the PA looks grossly dilated.

Pulmonary Htn?

Yes, SPAP in 70s by swan after induction. Improvement to 40-50s post-MVR.



e:

Your comment also reminds me that there was a UoUtah TEE video about RV/pHTN that mentioned that there's no really any echo guidelines about normal PA dimensions. The video is a couple years old so I'm not sure if that's still the case, but there's definitely more CT-based data from the pulmonology literature. Looks like 2.9cm or PA:AA ratio >1.0 are the magic numbers for specific identification of PH, but I don't know if a ME/UE Asc Ao SAX measurement of the PA and AA correlates to CT measurement.

Increased pulmonary artery diameter on chest computed tomography can predict borderline pulmonary hypertension

Pulmonary hypertension (PH) often leads to dilatation of the pulmonary artery (PA), which can be measured on chest computed tomography (CT). While the predictive capability of PA dilatation is useful to distinguish PH (mean PA pressure ≥25 mmHg) ...

www.ncbi.nlm.nih.gov

Pulmonary artery diameter to predict pulmonary hypertension in pulmonary sarcoidosis

Pulmonary hypertension (PH) is a known complication of pulmonary sarcoidosis with a prevalence ranging from 5% to 74% [1]. The aetiology of PH in sarcoidosis is not fully understood. Usually, it is attributed to the destruction of the distal capillary bed by lung fibrosis and/or chronic...

erj.ersjournals.com

https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201406-253PP

ee:

Also, anyone studying for echo boards would be wise to know what these are and what they signify

 

[anes121508]

For sure...
Frames/clips per second and direction of flow make a difference on cropping down on an en face 3D color flow jet when you are showing your surgeon the area in question after dropping in your lines. Functional MR jets, perforation jets, isolated a1/p1, combined a1/p1 + a3/p3 jets or whatever jets that are directed towards the probe are pretty easy (and fun) to isolate on 3D CFD. Big coandas by definition hug the wall of the atrium and when big enough the en face 3D CFD of the jet would likely distort your exact location because of cutting the jet tangentially instead of across the jet- frames/volumes/bests per second matter here. If your frames per second doesn’t catch it, then it becomes difficult to isolate.

3d w/o color and 2D with and w/o color adds a ton of info. On 3D CFD you can still take the image, crop and rotate towards the lateral and medial commissures, look behind then valve for a jet hunt... but it may not give you the info you need and 3D/2D CFD is probably faster.

IMO, a plain 3D mitral interrogation w/o color plus some good 2D with and w/o CFD is way more valuable than a 3D CFD alone.

I'm not sure if I ever replied. Appreciate the response.

I think you answered my question, by pointing out the tangential cut of the jet. If I'm interpreting this correctly, you would say that an eccentric wall hugging jet is difficult to pin point the exact origin? Which would be different than present vs not present.

I think the point you make about FPS when looking for a jet is important given the temporal nature of the jet throughout systole. Although, I think this impacts quantifying more so than locating. Assuming you do everything you can to optimize the image and focus on the area of interest, how often would your FPS be so low that you would completely miss the jet? I think it'd be a function of the duration of the jet vs FPS. Not totally sure the threshold.

I also really like your point about cropping and rotating towards the commissures. En Face is definitely not the best view to pick up certain pathology.

As much as I think the full volume 3d color and rotating it around is cool for the surgeon, I really like using the MPR to identify location and quantify jets. I like to set myself up on the plane of the annulus and then drag my plane across the commissure of the valve from medial to lateral and evaluate. Anyone doing this?

 

[anes121508]

Thank you Vector for sharing your case. Super interesting and super fun. Glad things turned out ok.

I had a case a few days ago that reminded me of this thread. These are just pix off of my phone so sorry for the marginal quality. We also have an iE33 that is pretty old at this point (just now starting to trickle in epiq’s into our fleet).


Large p2 flail/several ruptured cords, huge coanda.

3d and 2D CFD together made it pretty easy to make the call. No real need for 3d CFD and pretty fast to acquire the info while you are hustling to get your case moving.

Spent a few seconds reviewing the images with my cardiac surgeon before he scrubbed in and then I decided to try and hunt down the jet in 3d CFD.

Here you can see what I was talking about earlier with regards to large coandas and 3d CFD. The en face coanda view made it hard to isolate exactly where the jet originated from (although I already knew where it was). Rotating the image out of en face so you are looking down the medial or lateral commissures one frame at a time while cropping down on the jet does help locate its origin. Honestly though, in this case, I find the 3d plus 2d CFD more meaningful than 3d CFD alone.

Did the repair and came off without any PVL or other issues. Easy Cheese.









Hopefully these images/clips upload. Might have to follow a link to see them. Not sure.

Anyways, great case. Hope some of you other rockstars bring some more cases like the one Vector presented.

Sorry, too quick to reply and slow to read your recent post. I guess me doing it with the MPR plane on a 2d view generated from my full volume is the same concept as what you are doing. I like the MPR adjustments in 2D because I feel that alignment of my medial to lateral axis and the anterior posterior axis in plane with the annulus sets me up to make it obvious where I'm slicing through. I do find that as I scan through the valve in my AP axis from medial to lateral across the commissure, I'll find a jet, but since the jet isn't directed right at the probe, I'll have to adjust planes off axis to really bring out the entire VC. Which, is precisely (I think), the same concept you discussed before about tangential nature in the 3D full volume with color and making an eccentric jet difficult to evaluate.

 

[anes121508]

Question for you: when you MPR and crop the 3d color of one of these highly eccentric jets (i.e. the VC is essentially orthogonal from standard central MR), do you think you're able to get a frame where you you can trace an accurate vena contracta area?

Great point. I have to tweak and change the angle of the MPR lines once I find the jet just to bring it out. Furthermore, if I go to the next frame, the jet has moved and I again have to realign myself. I guess then, I'd have to question how accurate color flow doppler represents the EROA of a jet going 90 degrees from the beam.

 

[anes121508]

Yes. Using MPR on the Philips platform, by convention I’ll put the 5C view in the upper right hand quadrant (red plane) with the midcommissural orthogonal view in the upper left hand corner (green plane). Scan through your systolic frames to find the frame with the largest PISA radius (late systole for degenerative, early or late systole for functional). Move the blue plane in both of those images Perpendicular to the PISA radius such that it cuts through the mitral tissue edges, and then measure the 3D vena contracta area in the blue plane. Never measure anything directly on a 3D image because you’re introducing error due to parallax, only make measurements on the MPR 2D cuts where you’ve chosen exactly what slice you’re measuring from the 3D dataset.

Im so glad you brought up the concept of parallax. I nearly brought it up in my previous post when sevo mentioned that locating the eccentric jet can be tough because of the tangential cut. Im not 100% positive, but I think this is the same concept.