Diastolic Flow Reversal Research Articles

Ultrasound in acute scrotum

The acute scrotum is an urgent clinical condition characterized by the, more or less, sudden appearance of intense pain, generally with inflammatory signs in the scrotum or in its content. The use of ultrasound is extremely useful in clinical practice, because it allows an opportune diagnosis that, in many cases, can save the integrity of the testicle. The advent of new technologies and transducers with greater frequency of transmission, allow us a detailed visualization of the scrotal structures: testicle, appendices and epididymis. Techniques of pre and post-processing of images such as reduction of specular echoes, harmonics, elastography and, of course, Doppler, produce precise information on the structures, with characteristics that allow us to confirm the etiology of the condition presented by the patient. Similarly, these techniques optimize sensitivity and specificity values ​​for various pathologies, reaching values above 95%. The use of linear transducers with a frequency >/= 10 MHz is recommended. It is not advisable to work with 7.5 MHz probes, in light of current technology. There are several causes, intra and extra-testicular, that produce the onset of acute scrotum: trauma, infections, hernias, etc., being the most dangerous, testicular torsion. Testicular torsion can be intravaginal (94%), affecting only the testicle or extravaginal (6%), with torsion of the spermatic cord and ischemia of the testicle and epididymis. Testicular torsion constitutes a true urological emergency. The ultrasound diagnosis must be done as soon as possible, because the recovery of the testicle depends on how early the surgery is done. If the patient is operated before 6 hours after the onset of symptoms, it has a 90-100% chance of recovery, up to 12 hours, 20-50% and after 24 hours, 0-10%. The sonographic signs of acute testicular torsion are: normal or increased size, diffuse hypoechogenicity of the parenchyma, absence of color Doppler signal. As the hours pass, the testicle appears heterogeneous, a mottled pattern with alternating zones of greater and lesser echogenicity. The spectral analysis shows variable results, with increased venous and arterial resistance, even reaching reverse diastolic flow.

Reversal of End Diastolic Flow in Anterior Cerebral Artery in Late-Onset Neonatal Sepsis

Hemodynamics in neonatal sepsis is complex and poorly understood. Circulatory abnormalities are variable from vasodilatation with increased systemic blood flow to vasoconstriction with decreased blood flow, volume depletion or myocardial depression. Cerebral hemodynamics changes in neonatal sepsis. Most studies on cerebral hemodynamics in neonatal sepsis till now have been conducted on early-onset neonatal sepsis, and most of them have shown increased cerebral blood flow with a decreased resistive index (RI) in sepsis. Only a few studies have documented decreased cerebral flow in neonatal sepsis. Here we report a case of late-onset neonatal sepsis with the reversal of end diastolic flow, leading to increased RI associated with the death of the infant.

Ductus arteriosus outcome with focus on the initially patent but hemodynamically insignificant ductus in preterm neonates.

The hemodynamically insignificant (hisPDA) ductus arteriosus often progresses to hemodynamic significance. In this review, we sought risk factors predictive of progression. Early hisPDAs were subdivided into those that closed spontaneously vs. those that progressed to hsPDA. Sixty percent of early hisPDAs subsequently progressed to hsPDAs. In all but one, the ductus never closed, but rather became progressively more significant over time. The echocardiographic parameters best associated with subsequent progression were an increased transductal diameter (1.81 ± 0.77 vs. 1.21 ± 0.44 mm; p < 0.001) and the presence of diastolic flow reversal. ROC curve analysis showed that the best ductal diameter criterion for predicting the progression to hsPDA was >1.4 (sensitivity = 91; specificity = 81). The combined morbidity score was higher in those infants who progressed to hsPDA as compared with those who did not (p = 0.0038). Increased ductal diameter and diastolic flow reversal on the first echocardiogram were best correlated with progression of hisPDA to hsPDA.

Relationship of Patent Ductus Arteriosus Size to Echocardiographic Markers of Shunt Volume

To define the technique of estimating ductal diameter (DD) that best correlates with echocardiographic markers of transductal shunt volume in preterm infants >7 days old with persistent patent ductus arteriosus (PDA). We conducted a retrospective study of 104 neonates born at <30 weeks gestation that had targeted neonatal echocardiography evaluation of PDA performed between 7 and 30 days. We used univariate analysis to determine the association of echocardiographic markers of shunt volume with ductal size definitions: DD, DD indexed to weight, and DD indexed to left pulmonary artery diameter. Two hundred echocardiograms were reviewed from 104 patients with a median gestational age of 25.4 weeks (range, 25-26.3 weeks) and a median birth weight of 810 g (range, 740-920 g). We found a weak correlation of each method of PDA size definition with individual echocardiographic markers of transductal shunt volume, of which nonindexed DD demonstrated the best correlation. The best correlation was found with markers of systemic hypoperfusion, such as diastolic flow reversal in the descending aorta (R2 = 0.24) and celiac artery (R2 = 0.21). Markers of pulmonary overcirculation, such as left ventricular end-diastolic diameter (R2 = 0.19) and left ventricular output (R2 = 0.17), showed fair correlation with nonindexed DD. In preterm infants >7 days old with PDA, nonindexed DD demonstrated weak correlations with individual echocardiographic markers of shunt volume. These data highlight the need for comprehensive echocardiographic evaluation in addition to diameter measurements to provide a better understanding of the hemodynamic consequences of PDA.

Decreased Blood Flow in the Testis: Is it Testicular Torsion?

The absence of blood flow in the testis on ultrasound examination is the gold standard for diagnosis of testicular torsion. This imaging finding is seen in the vast majority of patients with testicular torsion, except in patients with partial torsion. Patients with partial testicular torsion may have reversal of arterial diastolic flow on spectral Doppler, decreased amplitude of the spectral Doppler waveform (parvus tardus wave), or monophasic waveforms. However, it is important to consider that not all absence of blood flow or reversal of diastolic flow in testis represents testicular torsion, as other conditions may have a similar appearance, including rare detection of such a pattern in normal asymptomatic patients. Conditions that commonly mimic testicular torsion include incarcerated inguinal hernias and complications following hernia repair,thrombotic phenomena, vasculitis, complicated epididymo-orchitis, asymptomatic variants, and technical limitations of ultrasonography. It is important for a practicing radiologist to be familiar with such cases to avoid unnecessary surgical interventions.We present a pictorial essay of cases in which the absence of testicular blood flow on color flow Doppler or abnormal waveforms on spectral Doppler are identified, without the presence of testicular torsion.

Abstract P-507: APPLICATION OF TRANSCRANIAL DOPPLER ULTRASOUND IN INTRACRANIAL PRESSURE MONITORING IN CHILDREN

Aims & Objectives: Intracranial hypertension is a common critically illness in PICU, there is no ideal noninvasive assessing method. This study is to explore the clinical value of TCD in estimating ICP by continuous monitoring TCD on children with invasive ICP monitoring. Methods The TCD were prospectively performed when the ICP changes in 31 children who received brain surgery and continuous invasive ICP monitoring in the PICU of Shenzhen Children’s Hospital. The TCD parameters of the middle cerebral artery (MCA) of suffering side, the values of ICP and calculated CPP were recorded at the same time. The data were divided into four groups: group A (ICP<15mmHg), B (15mmHg<ICP≤20mmHg), C (20mmHg<ICP≤25mmHg) and D (ICP>25mmHg). The tendency of TCD parameters changes as ICP increased were analyzed. Results As the ICP increased, Vm and Vd became smaller, and PI and RI bigger. There were significant difference in Vm Vd PI RI (P<0.05 or P<0.01)between group C or D and group A. There was a moderate linear correlation betwee ICP with Vd, PI and RI and a weak linear correlation between CCP with Vd, PI and RI. PI≥1 has a sensitivity of 80.59%, specificity of 66.67% for predicting ICP≥ 20mmHg. When the ICP increased, the spectral atlas of TCD presented dynamic changes. When the ICP was persistent more than 30mmHg, single cusp peak, a nail-like spectrum or diastolic reverse blood flow were observed. Conclusions As ICP increased, the parameters and spectral atlas of TCD presented dynamic changes in children. PI≥ 1 had better predictive value to the increased ICP.

Abstract 122: Elevated Pulse Wave Velocity is Associated With Regional Aortic Flow Reversal as an Embolic Mechanism in Patients With Cryptogenic Stroke

Introduction: There is recent evidence that diastolic flow reversal in the descending thoracic aorta (DAo) is prevalent in patients with atherosclerosis, enabling a mechanism for cerebral embolism. Specifically, aortic stiffness (assessed by pulse wave velocity, PWV ) is a precursor of plaque formation and reverse aortic flow . The aim of this study was to 1) employ aortic 4D flow MRI for quantification of both PWV and regional flow reversal and 2) evaluate relationships between PWV, reverse flow and age in a cohort of cryptogenic stroke patients with plaques in the DAo and age-matched controls. Methods: Non-contrast free-breathing 4D flow MRI (spatial resolution = 3-3.5 x 2.2-2.6 x 2.6-3 mm 3 , temporal resolution=19.6 ms, venc = 150 cm/s, 1.5T Area, Siemens Germany) was performed in n=10 (age=66±7 [53-80]) patients with cryptogenic stroke and n=12 (age=68±7 [56-78]) controls. Methods were developed for the automatic quantification of global aortic PWV (by cross-correlation) and regional (voxel-wise) reverse flow based on a 3D centerline (Figure 1a-c). Reverse flow during one cardiac cycle was averaged among voxels in user-defined ROIs in the ascending aorta (AAo), aortic arch (AArch) and DAo. Results: Elevated PWV was associated with increased age in all subjects (patients: R 2 =0.52, p=0.02; controls: R 2 =0.58, p=0.004) and increased reverse flow in patients (AAo: R 2 =0.60, p=0.009; AArch: R 2 =0.73, p=0.002; DAo: R 2 =0.44, p=0.04) but not controls (AAo: R 2 =0.04, p=0.52; AArch: R 2 =0.25, p=0.10; DAo: R 2 =0.06, p=0.42) (Figure 1d). Conclusions: Evaluation by 4D flow MRI shows aortic stiffness, as measured by PWV, increases with age and is associated with pronounced reverse aortic flow in cryptogenic stroke patients with DAo plaque compared to controls, providing further evidence retrograde embolism may be a mechanism of stroke in otherwise cryptogenic stroke patients.

Doppler Evaluation of Hepatic Vein Flow

Hepatic vein (HV) flow pattern closely correlates with pressure changes in the right atrium. Normally, there are two forward flow waves – systolic and diastolic. Diastolic wave is slightly smaller than systolic wave. Three reversal waves can be seen – late systolic, mid-diastolic, and third during right atrial contraction. Normally, forward wave velocities increase during inspiration. Reversal waves are slightly more prominent during expiration. Systolic wave is diminished in atrial fibrillation, right ventricular systolic dysfunction, and tricuspid regurgitation. When these pathologies are severe or they coexist, systolic wave may reverse. Diastolic wave is diminished in tricuspid stenosis and impaired relaxation of the right ventricle as seen in right ventricular hypertrophy, right ventricular ischemia, or infarction. Diastolic flow reversal wave becomes prominent in restrictive cardiomyopathy and pericardial constriction. Reversal wave during right atrial contraction is absent in atrial fibrillation. It is diminished or absent when compliance of HVs is decreased due to diseases of liver parenchyma. This reversal wave is prominent in each cardiac cycle in tricuspid stenosis with sinus rhythm and in patients with right ventricular hypertrophy. It is intermittently prominent in the presence of ventricular ectopics and complete atrioventricular block.

Potential Role of Transfontanelle Ultrasound for Infants Undergoing Modified Blalock-Taussig Shunt

Transfontanelle ultrasound is a noninvasive method for assessing cerebral blood flow in neonates and infants. The authors applied this technique as a point-of-care tool, before and after modified Blalock-Taussig shunt procedure, to evaluate cerebral perfusion. Retrospective, observational study. Tertiary care children's hospital. Ten infants undergoing modified Blalock-Taussig shunt procedure. Transfontanelle ultrasound examinations with modified resistive index were analyzed before and after the modified Blalock-Taussig shunt procedure. Two infants died and 2 patients required a revision procedure due to shunt thrombosis. Baseline-modified resistive index and regional cerebral oxygenation were comparable between the right and left hemisphere. However, after the procedure, the modified resistive index decreased at both sides of the internal carotid arteries compared with baseline values (p value right side = 0.012, left side = 0.036) and was greater at the ipsilateral internal carotid arteries with the shunt (p = 0.012, mean difference = 0.07, 95% confidence interval [CI] 0.02-0.12). Four infants with the large patent ductus arteriosus presented diastolic reverse flows at both internal carotid arteries at baseline. However, the diastolic reverse flow disappeared after the procedure. An infant who developed diastolic reverse flow after the procedure, died. Transfontanelle ultrasound is a feasible tool for assessing the pattern of shunt flow and cerebral perfusion before and after the modified Blalock-Taussig shunt procedure. The transfontanelle ultrasound examinations may have potential role in assessing "over-shunting," but it needs more studies.

Quantification of Aortic Valve Regurgitation by Pulsed Doppler Examination of the Left Subclavian Artery Velocity Contour: A Validation Study with Cardiovascular Magnetic Resonance Imaging

Reflux of the aortic regurgitation (AR) causes an increased diastolic reverse flow in the aorta and its branching vessels. We aimed to evaluate the feasibility and accuracy of Doppler measurements in the left subclavian artery (LSA) for quantification of AR in a cardiovascular magnetic resonance imaging (CMR) validation study. Systolic and diastolic flow profiles of the LSA (subclavicular approach) were evaluated prospectively by use of pulsed wave Doppler in 59 patients (55.5±15years; 44 men), 47 with a wide spectrum of AR and 12 as control group. Using CMR phase-contrast sequences (performed 1cm above the aortic valve), the AR was divided into three groups: mild, regurgitant fraction (RF)<20% (n=17); moderate, RF 20%-40% (n=10); and severe, RF>40% (n=20). The LSA Doppler-derived RF was calculated as the ratio between diastolic and systolic velocity-time integrals (VTI). Quality LSA Doppler signal could be obtained in all cases. Patients with CMR severe AR had higher values of LSA Doppler-derived RF (51%±9% vs 36%±11% vs 16%±8%; P<.0001). LSA Doppler showed a good correlation with CMR, with a sensitivity of 95%, specificity of 89%, and diagnostic accuracy for severe AR of 91.5%. Finally, Bland-Altman plots showed agreement in the group with moderate to severe AR (mean bias=-2.2%±8%, 95% CI, -17.7 to 13.3; P=.145) but differed in mild AR. Measurements of the RF for quantification of AR using LSA Doppler are comparable to those of CMR, highlighting the potential role of LSA Doppler as an adjunctive technique to assess the severity of AR.

Effusive-Constrictive Pericarditis After Pericardiocentesis: Incidence, Associated Findings, and Natural History

ObjectivesThis study sought to investigate the incidence, associated findings, and natural history of effusive-constrictive pericarditis (ECP) after pericardiocentesis. BackgroundECP is characterized by the coexistence of tense pericardial effusion and constriction of the heart by the visceral pericardium. Echocardiography is currently the main diagnostic tool in the assessment of pericardial disease, but limited data have been published on the incidence and prognosis of ECP diagnosed by echo-Doppler. MethodsA total of 205 consecutive patients undergoing pericardiocentesis at Mayo Clinic, Rochester, Minnesota, were divided into 2 groups (ECP and non-ECP) based on the presence or absence of post-centesis echocardiographic findings of constrictive pericarditis. Clinical, laboratory, and imaging characteristics were compared. ResultsECP was subsequently diagnosed in 33 patients (16%) after pericardiocentesis. Overt clinical cardiac tamponade was present in 52% of ECP patients and 36% of non-ECP patients (p = 0.08). Post-procedure hemopericardium was more frequent in the ECP group (33% vs. 13%; p = 0.003), and a higher percentage of neutrophils and lower percentage of monocytes were noted on pericardial fluid analysis in those patients. Clinical and laboratory findings were otherwise similar. Baseline early diastolic mitral septal annular velocity was significantly higher in the ECP group. Before pericardiocentesis, respiratory variation of mitral inflow velocity, expiratory diastolic flow reversal of hepatic vein, and respirophasic septal shift were significantly more frequent in the ECP group. Fibrinous or loculated effusions were also more frequently observed in the ECP group. Four deaths occurred in the ECP group; all 4 patients had known malignancies. During median follow-up of 3.8 years (interquartile range: 0.5 to 8.3 years), only 2 patients required pericardiectomy for persistent constrictive features and symptoms. ConclusionsIn a large cohort of unselected patients undergoing pericardiocentesis, 16% were found to have ECP. Pre-centesis echocardiographic findings might identify such patients. Long-term prognosis in those patients remains good, and pericardiectomy was rarely required.

Splenic Vein Thrombosis Following Pancreas Transplantation: Identification of Factors That Support Conservative Management.

Prophylaxis for graft portal/splenic venous thrombosis following pancreas transplant varies between institutions. Similarly, treatment of venous thrombosis ranges from early re-exploration to conservative management with anticoagulation. We wished to determine the prevalence of graft splenic vein (SV) thrombosis, as well as the clinical significance of non-occlusive thrombus observed on routine imaging. Records of 112 pancreas transplant recipients over a 5-year period at a single center were reviewed. Venous thrombosis was defined as absence of flow or presence of thrombus identified in any part of the graft SV on ultrasound. Thirty patients (27%) had some degree of thrombus or absence of flow in the SV on postoperative ultrasound. There were 5 graft losses in this group. Four were due to venous thrombosis, and occurred within 20 days of transplant. All patients with non-occlusive partial SV thrombus but normal arterial signal on Doppler ultrasound were successfully treated with IV heparin followed by warfarin for 3-6 months, and remained insulin independent. Findings of arterial signal abnormalities, such as absence or reversal of diastolic flow within the graft, require urgent operative intervention since this finding can be associated with more extensive thrombus that may lead to graft loss.

Abdominal Near-Infrared Spectroscopy Detects Low Mesenteric Perfusion Early in Preterm Infants with Hemodynamic Significant Ductus Arteriosus

Background: The therapeutic decision to close patent ductus arteriosus in preterm infants entails great uncertainty. Near-infrared spectroscopy is a noninvasive bedside technique used to monitor mixed regional oxygen saturation. We hypothesized that near-infrared spectroscopy could identify preterm infants at risk of mesenteric hypoperfusion associated with hemodynamically significant ductus arteriosus. Methods: This is a prospective observational study including consecutively admitted preterm infants with a gestational age <32 weeks. Mesenteric regional oxygenation was blindly monitored using an INVOS 5100 device. The presence of a hemodynamically significant patent ductus arteriosus was routinely confirmed by echocardiography/Doppler. Statistical analysis including Bland-Altman plots was performed to assess near-infrared spectroscopy intraobserver repeatability. Results: A total of 72 preterm infants were enrolled. The daily mean regional oxygen saturation for preterm infants was determined both in mesenteric and cerebral regions and plotted against time. We identified a differential temporary baseline. Hemodynamic significant ductus arteriosus was associated with lower blood pressures and lower regional splanchnic oxygenation. There was a significant relationship between reversal diastolic flow in the descending aorta and the regional oxygen saturation, which remained significant after controlling for ductal size and nil per os. Conclusions: The simultaneous monitoring of splanchnic near-infrared spectroscopy and echocardiography could identify low mesenteric perfusion in the presence of hemodynamic ductus arteriosus.

Abnormal umbilical artery Doppler velocimetry and placental histopathological correlation in fetal growth restriction

Background . Doppler velocimetry (DV) is widely used to assess the vascular formation of the placenta in fetal growth restriction (FGR) and to estimate the haemodynamic condition of the growth-restricted fetus. Umbilical artery (UA) flow is essentially placental, rather than fetal. Hence, DV provides information about the fetal side of the placenta and, alongside placental histopathology, it could possibly help to decipher aetiopathogenesis in FGR cases. Objective . To correlate UA DV findings occurring in FGR with placental findings. Methods. The study was prospective and conducted in a low-income setting. A total of 130 non-anomalous singleton FGR pregnancies (≥24 weeks) were included in the study. All pregnancies were confirmed to be small for gestational age (SGA) after the birth of the neonate. The placental lesions and neonatal outcomes were correlated with DV findings before delivery: 65 cases with normal DV results constituted group 1, and group 2 had 65 cases with abnormal DV results such as reduced flow, absent UA end diastolic flow or reversal of UA end diastolic flow. Results . Group 2 had significantly lower mean (standard deviation) birth weights of 1.59 (0.4) kg v. 1.87 (0.23) kg for group 1 ( p <0.001). Considerably higher NICU mortality was seen in group 2 (30.5%) compared with group 1 (6.7%) ( p <0.001). The group 2 placentas weighed less, had a higher number of maternal underperfusion (MUP) lesions, higher levels of calcification. Among lesions of MUP, 4 lesions i.e. villous infarction ( p <0.001), villous agglutination ( p <0.001), syncytial knots ( p =0.003) and intervillous fibrin deposition ( p =0.001) were present in significantly higher numbers in the abnormal Doppler group compared with the normal Doppler group. Abnormal Doppler had a sensitivity of 80% and specificity of 92.3% for abnormal placental pathology (placental lesions ≥3). Conclusions. There was a significantly higher number of MUP lesions and neonatal morbidity in SGA patients with abnormal DV findings

The value of diastolic flow reversal in the descending thoracic aorta as a determinant of invasively measured aortic pulse pressure.

Although the diastolic flow reversal of the descending aorta has been recognized in patients with aortic regurgitation, its generation without this condition is still unknown. This study was performed to investigate whether flow patterns of the descending thoracic aorta, as measured by echocardiography, can represent invasively measured aortic pulse pressure (APP). A total of 100 patients (age, 62.3±11.0years; men, 62.0%) undergoing invasive coronary angiography (ICA) was analyzed. APP was measured at ascending thoracic aorta using pigtail catheter before ICA. Flow in the descending thoracic aorta was assessed using pulse wave Doppler echocardiography, and R/F ratio was defined as reverse peak velocity (R)/forward peak velocity (F). Eighty patients (80.0%) had obstructive coronary artery disease (CAD) (≥50% stenosis of one or more epicardial coronary arteries) in ICA. APP and R/F ratio were significantly higher in patients with obstructive CAD than those without (P<.05 for each). Both R/F ratio (β=0.379, P<.001) and APP (β=0.255, P<.001) were positively correlated with age. In simple linear regression analysis, there was a significant positive correlation between R/F ratio and APP (β=0.266, P<.001). This correlation remained significant even after controlling for potential confounders including age, gender, E/e', and left atrial volume index in multiple linear regression analysis (β=0.193, P=.036). R/F ratio may be independently associated with APP in patients undergoing ICA.

Cross-Sectional Associations of Flow Reversal, Vascular Function, and Arterial Stiffness in the Framingham Heart Study.

Experimental studies link oscillatory flow accompanied by flow reversal to impaired endothelial cell function. The relation of flow reversal with vascular function and arterial stiffness remains incompletely defined. We measured brachial diastolic flow patterns along with vasodilator function in addition to tonometry-based central and peripheral arterial stiffness in 5708 participants (age 47±13 years, 53% women) in the Framingham Heart Study Offspring and Third Generation cohorts. Brachial artery diastolic flow reversal was present in 35% of the participants. In multivariable regression models, the presence of flow reversal was associated with lower flow-mediated dilation (3.9±0.2 versus 5.0±0.2%; P<0.0001) and reactive hyperemic flow velocity (50±0.99 versus 57±0.93 cm/s; P<0.0001). The presence of flow reversal (compared with absence) was associated with higher central aortic stiffness (carotid-femoral pulse wave velocity 9.3±0.1 versus 8.9±0.1 m/s), lower muscular artery stiffness (carotid-radial pulse wave velocity 9.6±0.1 versus 9.8±0.1 m/s), and higher forearm vascular resistance (5.32±0.03 versus 4.66±0.02 log dyne/s/cm5; P<0.0001). The relations of diastolic flow velocity with flow-mediated dilation, aortic stiffness, and forearm vascular resistance were nonlinear, with a steeper decline in vascular function associated with increasing magnitude of flow reversal. In our large, community-based sample, brachial artery flow reversal was common and associated with impaired vasodilator function and higher aortic stiffness. Our findings are consistent with the concept that flow reversal may contribute to vascular dysfunction.

A granular approach to improve reproducibility of the echocardiographic assessment of paravalvular regurgitation after TAVI.

Paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI) is challenging to quantitate. Transthoracic echocardiography (TTE) is the main tool used for the assessment of PVL but is modestly reproducible. We sought to develop a reproducible echocardiographic approach to assess PVL in the post-TAVI setting. Four observers independently analyzed eleven parameters of PVL severity in 50 pre-discharge TTE studies performed after TAVI. The parameters included color-Doppler parameters [jet circumferential extent (CE) and planimetered vena contracta area in the short-axis view and jet breadth and qualitative features in the long-axis views], continuous-wave Doppler parameters [jet velocity time integral (VTI) and pressure half time (PHT)], quantitative Doppler parameters (regurgitation volume and fraction and effective regurgitant orifice area), aortic diastolic flow reversal and valve stent eccentricity. Intraclass correlation coefficient (ICC) and coefficient of variation (CV) for numerical parameters and kappa coefficient (κ) for categorical parameters were calculated for inter- and intra-observer comparisons. Inter-observer ICC was highest and CV lowest for CE (0.88 and 0.36), jet origin breadth (0.82 and 0.39), jet qualitative features in long-axis views (0.87 and 0.26), jet VTI (0.87 and 0.04) and PHT (0.73 and 0.10). Similar results were found in intra-observer comparisons. A 2-step granular approach combining the most reproducible parameters was used to grade PVL by the four observers. Inter-observer agreement was achieved in 86 % of cases (κ = 0.79). Combining color Doppler and continuous wave Doppler parameters in a granular algorithm yields excellent reproducibility of PVL assessment by TTE.Electronic supplementary materialThe online version of this article (doi:10.1007/s10554-016-0947-4) contains supplementary material, which is available to authorized users.

Contemporary Outcomes and Factors Associated With Mortality After a Fetal or Neonatal Diagnosis of Ebstein Anomaly and Tricuspid Valve Disease

BackgroundEbstein anomaly (EA) and tricuspid valve dysplasia (TVD) are rare anomalies and data on outcomes after a fetal or neonatal EA/TVD diagnosis are conflicting. MethodsTo examine the outcome and identify markers predictive of mortality, we reviewed our single-centre experience from 2000-2014. Variables were analyzed separately for cases diagnosed in utero without pregnancy termination and for all live-born patients. ResultsOf 47 fetal cases, 8 (17%) died in utero and 10 (21%) as neonates. Independent predictors associated with fetal demise included severe tricuspid regurgitation with a Doppler gradient < 40 mm Hg (odds ratio, 1.22 per mm Hg deduction; P = 0.003) and pulmonary regurgitation (odds ratio, 11.4; P = 0.03) at the baseline examination. A novel prognostic score (range, 0-10) combining the severity of 5 echocardiographic findings was independently associated with overall mortality (hazard ratio [HR], 1.39 per point increase; P = 0.01). Survival rates of 66 live births at 1 month, 1 year, and 5 years were 86%, 82%, and 80% respectively, and 75%, 60%, and 55% remained free from surgery at the same points in time. Factors associated with postnatal death in multivariate analysis included a younger gestational age at birth (HR per week, 1.59; P < 0.001), tricuspid annulus diameter (HR per z-score increase, 1.76; P = 0.004), and no pulmonary forward flow (HR, 4.63; P = 0.03). ConclusionsOur experience with fetal and neonatal EA/TVD shows better survival rates than previously reported. Mortality after a fetal diagnosis was significantly associated with hemodynamic changes indicative of a circular shunt, including pulmonary and tricuspid regurgitation severe enough to cause diastolic umbilical arterial flow reversal.

Diagnostic Difficulties in a Patient with Reverse Diastolic Intrarenal Doppler Flow Caused by Tacrolimus Nephrotoxicity: A Case Report

Diagnostic Difficulties in a Patient with Reverse Diastolic Intrarenal Doppler Flow Caused by Tacrolimus Nephrotoxicity: A Case Report

Haemodynamic analysis of femoral artery bifurcation models under different physiological flow waveforms

Thrombus in a femoral artery may form under stagnant flow conditions which vary depending on the local arterial waveform. Four different physiological flow waveforms – poor (blunt) monophasic, sharp monophasic, biphasic and triphasic – can exist in the femoral artery as a result of different levels of peripheral arterial disease progression. This study aims to examine the effect of different physiological waveforms on femoral artery haemodynamics. In this regard, a fluid–structure interaction analysis was carried out in idealised models of bifurcated common femoral artery. The results showed that recirculation zones occur in almost all flow waveforms; however, the sites at where these vortices are initiated, the size and structure of vortices are highly dependent on the type of flow waveform being used. It was shown that the reverse diastolic flow in biphasic and triphasic waveforms leads to the occurrence of a retrograde flow which aids in ‘washout’ of the disturbed flow regions. This may limit the likelihood of thrombus formation, indicating the antithrombotic role of retrograde flow in femoral arteries. Furthermore, our data revealed that the flow particles experience considerably higher residence time under blunt and sharp monophasic waveforms than under biphasic and triphasic waveforms. This confirms that the risk of atherothrombotic plaque initiation and development in femoral arteries is higher under blunt and sharp monophasic waveforms than under biphasic and triphasic flow waveforms.