Venous Flow Patterns Research Articles

Cerebral sinus thrombosis with tamoxifen

To the Editor: The case reported by Finelli and Schauer1 raises interesting points about the physiologic patterns of venous flow across the transverse sinuses. In 50 to 80% of cases, there is an asymmetry in flow across the transverse sinuses, with up to 5% of cases displaying agenesis of part or all of one transverse sinus, which should not be confused with sinus thrombosis.2,3⇓ Therefore, an alternative explanation may exist for the large right temporal lesion presented in figure 1A in the original article,1 especially because …

Doppler velocimetry in superior vena cava provides useful information on the right circulatory function in patients with congestive heart failure.

Although flow velocities curves recorded with pulsed-wave Doppler in systemic vein are known to provide functional data on the right circulatory function, little information is available on the relationship between right heart filling dynamics and right ventricular function. Consecutive patients with chronic heart failure due to severe systolic left ventricular dysfunction and in sinus rhythm underwent echocardiography and right heart catheterization. In the initial part of the study, the hemodynamic correlates of different flow velocity patterns recorded into the superior vena cava were evaluated in 120 patients. The accuracy of the prediction of different right heart hemodynamic profiles by means of the different venous flow patterns was then prospectively tested in a subsequent series of 86 patients. The venous flow pattern was closely related to right heart hemodynamics. A normal Doppler pattern identified patients with normal right heart hemodynamics (sensitivity 86%, specificity 78%); a "predominant systolic wave" pattern identified patients with a reduced thermodilution-derived right ventricular ejection fraction (< 30%) and normal or slightly elevated right atrial pressure (< or = 8 mmHg) (sensitivity 69%, specificity 81%); a "predominant diastolic wave" pattern identified patients with a reduced right ventricular ejection fraction (< 3 0%) and elevated right atrial pressure (> 8 mmHg) (sensitivity 52%, specificity 95%). The observed and the predicted hemodynamic profiles turned out to be concordant in 80% of patients. The analysis of the flow velocity pattern into the superior vena cava is a useful tool to estimate the extent of the right circulatory impairment in patients with congestive heart failure.

Body mass index can predict left ventricular diastolic filling in asymptomatic obese children.

To examine the effects of body mass index on left ventricular diastolic function, flow velocity patterns of the pulmonary vein and mitral valve were measured by pulse Doppler echocardiography in 21 asymptomatic obese children and were compared with those of an age-matched control population. The degree of obesity was calculated as (actual body mass index/ideal body mass index -1) x 100. The pulmonary venous flow indexes were peak systolic (S) and diastolic (D) velocities and peak D/S. The mitral inflow indexes were peak velocities of early diastole (E) and atrial contraction (A) and peak E/A. The pulmonary venous flow velocity pattern in obese patients was characterized by unchanged peak S, decreases in peak D (43 +/- 7 vs 51 +/- 8, p < 0.01) and peak D/S (0.98 +/- 0.19 vs 1.29 +/- 0.20, p < 0.01), suggesting the reduction in the early diastolic filling. The peak D/S decreased significantly with an increase in the percentage body mass index (r = -0.84, p < 0.01). In contrast to the pulmonary venous flow pattern (peak D > peak S) as seen in normal controls, all of the obese patients with > 70% over body mass index had abnormal pulmonary venous flow velocity patterns (peak D < peak S). The mitral flow velocity pattern in obese patients was also characterized by a decrease in early diastolic filling. However, these indices did not correlate with an increase in the percentage over body mass index. This study suggests that body mass index predicts the abnormality of left ventricular diastolic filling assessed by pulmonary venous flow patterns.

Assessment of left atrial appendage function and its relationship to pulmonary venous flow pattern by transesophageal echocardiography

We evaluated left atrial appendage function and its relationship to pulmonary venous flow in 53 patients divided into four groups. Group 1 consisted of 10 normal subjects. Group 2 included 15 patients with significant pure mitral stenosis in sinus rhythm. In group 3, there were 13 patients with pure significant mitral stenosis and atrial fibrillation. Group 4 consisted of 15 patients with normal mitral valve and atrial fibrilltion. We found significant decrease in left atrial appendage ejection fraction and maximum emptying flow velocity, velocity time integral of systolic pulmonary venous flow in Groups 2, 3 and 4 in comparison with normal subjects. Systolic pulmonary venous flow velocity was significantly decreased in Groups 3 and 4. There was significant correlation between left atrial appendage ejection fraction and peak emptying flow velocity ( r=0.62, P<0,001). Systolic peak pulmonary venous flow velocity was significantly correlated with left atrial appendage ejection fraction and maximum emptying flow velocity ( r=0.67, P=0,01; r=0.58, P<0,001, respectively). There was also significant correlation between systolic pulmonary venous flow velocity time integral and left atrial appendage ejection fraction ( r=0.66, P=0.001). When normals were excluded from analysis, all the correlations were still significant. We concluded that left atrial appendage is a contractile structure, and that systolic pulmonary venous flow velocity is influenced by left atrial appendage dysfunction. Therefore left atrial appendage function needs to be considered when interpreting Doppler transmitral and systolic pulmonary venous flow patterns.

Detection of changes in diastolic function by pulmonary venous flow analysis in women athletes

Background Left ventricular cavity dimension, wall thickness, relaxation, and filling increase with exercise training and have a role in enhancing physical performance. We probed whether changes in diastole may develop separately from those in cardiac morphometry and still contribute to improve physical performance. Challenging diastole by preload reduction with standing and integrating mitral flow analysis with the pulmonary venous flow analysis were viewed as a means for detecting fine diastolic variations. Methods Patterns of mitral, tricuspid, and pulmonary venous flow were evaluated by echo Doppler imaging in the supine and standing positions in 11 long-distance runner women athletes participating in training programs and having no or very mild cardiac morphologic alterations and were compared with those in 11 healthy women active in daily life not participating in training programs. Maximal exercise tolerance was tested in both groups with a treadmill with use of the standard Bruce protocol. Results Echocardiographic left ventricular mass index and mitral and pulmonary flow patterns in athletes and controls were similar while they were supine. Major (P <.01) percent variations and differences between athletes and controls with standing were smaller decrease in right (–12% ± 5% vs –29% ± 5%) and left ventricular (–3% ± 1% vs –9% ± 2%) dimensions and stroke volume (–7% ± 4% vs –23% ± 4%), smaller lengthening of early mitral deceleration (+7% ± 4% vs +18% ± 5%), and isovolumic relaxation (–3% ± 5% vs +15% ± 7%) times. Athletes showed greater reduction in pulmonary S wave peak velocity (–25% ± 10% vs –12.5% ± 7%) and time velocity integral (Si) (–50% ± 9% vs –21% ± 8%), greater increases in pulmonary venous diastolic (D) wave peak velocity(+20% ± 9% vs +12% ± 10%, meters per second), and time velocity integral (Di) (+81% ± 16% vs +27% ± 14%) and greater decrease of S/D(–30% ± 6% vs –18% ± 5%) and Si/Di (–70% ± 10% vs –33% ± 5%) ratios. At multivariate analysis standing Si/Di was the strongest independent predictor of better exercise tolerance (peak exercise time 1035 ± 88 sec in athletes, 751 ± 20 in controls). Conclusions Pulmonary flow analysis in athletes while standing can detect changes in diastolic function that are dissociated from apparent left ventricular morphologic alterations, are undetected in the supine position, and may, in part, determine exercise performance. (Am Heart J 2001;141:139-47.)

Disturbance of venous flow patterns in patients with transient global amnesia

Transient global amnesia (TGA) is an inability to form new memories. The pathophysiology and cause of TGA have not been defined. We examined the changes of internal jugular venous flow patterns in 21 patients with TGA and 21 age-matched and sex-matched controls using duplex ultrasonography during two Valsalva manoeuvres (blocking venous return through the superior vena cava). During both manoeuvres a retrograde flow component was seen significantly more frequently in the TGA group than in the controls. Ten patients reported Valsalva-like activities preceding TGA. In these patients a retrograde flow component took place more frequently than in those who did not report preceding Valsalva-like activities. Our results lend support to the hypothesis that TGA may be attributable to venous congestion, and consequent venous ischaemia to bilateral diencephalic or hippocampal structures.

Diastolic ventricular interaction in normal and dilated heart during head-up tilting.

The normal human heart behaves as a single functional unit during preload reduction; adaptations of the left ventricle to head-up tilting is mediated through ventricular interdependence and biventricular-lung interaction. We hypothesized that reduction of venous return in dilated cardiomyopathy is likely to have a great effect on ventricular chamber geometry and filling. The aim of this study was to evaluate the effects of gradual head-up tilting in normal subjects and in patients with dilated cardiomyopathy, addressing special attention to right (RV) and left ventricular (LV) dimensions, geometry, and filling, and to biventricular-lung interaction. Twenty normal subjects and 23 patients with moderate heart failure due to dilated cardiomyopathy were studied with two-dimensional and Doppler echocardiography in supine position and after 20 degrees, 40 degrees, and 60 degrees tilting. Right ventricular and LV dimensions, LV geometry, and tricuspid, mitral, and pulmonary venous flow patterns were recorded at each step of the study. Geometric changes of the LV were evaluated by measurements of volumes and diameters in the apical four-chamber view (which identifies the interventricular septum and lateral wall) and apical two-chamber view (which identifies the inferior and anterior wall of the LV). In the two groups, tilting was associated with reduction of RV area and LV diameter and volumes; percent variations in LV diameter and volumes recorded in four-chamber view were lower at each step of tilting than with those derived from the two-chamber view in controls and in patients. In normal subjects, mitral and tricuspid peak early flow velocities were decreased at any tilting level; peak late velocities were unchanged; peak velocity of systolic forward flow of the pulmonary vein was reduced, diastolic forward flow was unchanged, and the difference in duration between reverse pulmonary flow and forward mitral A wave was reduced. Doppler findings were qualitatively similar in patients, but tilting induced a more marked redistribution of LV filling to late diastole because of a significant increase in atrial contribution. Preload reduction by tilting induces profound effects on left and right dimensions, geometry, and filling in normal and dilated heart; reduction or RV dimensions are associated with changes in LV ventricular geometry (minimal reduction in septal-lateral diameter, marked reduction in anterior-posterior diameter), redistribution of right and left diastolic filling to late diastole, and redistribution of pulmonary venous flow to early diastole. These mechanisms are probably due to a favorable interaction between heart and lungs, which increases compliance within the pericardial space and facilitates redistribution of flow from the lungs. Even a minimal amount of preload reduction causes more marked effects in LV filling patterns in dilated cardiomyopathy than in normal hearts, confirming that ventricular interaction and pericardial constraint are increased when heart volume enlarges.

Effect of age on cerebral venous circulation disturbances in the rat.

Mild cerebral venous circulation disturbances (CVCDs) in aged patients are frequently known to cause unexpectedly severe postoperative complications in neurosurgical practice. The object of the present study was to determine whether there are age-related differences involved in vulnerability to CVCDs. Thirty-eight male Wistar rats were used. A single cortical vein with a 100-microm diameter was occluded photochemically by using rose bengal dye and fiberoptic illumination in young (Group Y, 19 animals aged 10-14 weeks) and aged (Group A, seven animals aged 80-100 weeks) rats. Five young and seven aged animals served as sham-operated controls. Regional cerebral blood flow (rCBF) was determined from local CBF, which was measured at 25 (5 x 5) identical locations, with the occluded vein located central to the scanning field, by using a laser Doppler scanning technique every 15 minutes for 90 minutes after venous occlusion. The cerebral venous flow pattern was examined using fluorescence angiography until 90 minutes after occlusion. Histological specimens were examined 24 hours after occlusion. In Group Y, rCBF did not change significantly after venous occlusion. However, in Group A, rCBF decreased rapidly beginning 15 minutes after occlusion. Significant intergroup differences were observed 30, 60, and 90 minutes after occlusion. Venous flow arrest, which resulted in venous infarct, was observed on angiography 90 minutes after occlusion in two (10.5%) of 19 young and six (85.7%) of seven aged rats. The venous thrombus in Group A rats was significantly larger than that in Group Y rats 90 minutes after occlusion. Venous infarction was seen in all aged rats (100%) and in six young rats (31.6%); the infarct size, expressed as a percentage of the size of the ipsilateral hemisphere, was significantly larger in aged rats than in young rats. This study demonstrated an age-related increase in the rate and size of venous infarct following vein occlusion, suggesting that the greater vulnerability to CVCDs in the aged brain might be attributed to early and extensive hypoperfusion of circumscribed brain areas drained by the occluded vein. The larger thrombus formation in aged animals indicates that a shift in the thrombogenetic/thrombolytic equilibrium is responsible for the observed effect.

Effect of Atrial Fibrillation on Pulmonary Venous Flow Patterns Assessed by Doppler Transesophageal Echocardiography

To investigate the effect of atrial fibrillation (AF) on pulmonary venous flow (PVF) patterns in a cohort with nonrheumatic AF. A prospective and controlled study undertaken at a tertiary referral medical center. The echocardiographic parameters of left superior PVF as assessed by Doppler transesophageal echocardiography in 40 patients with chronic AF (group 1) were compared to those of 33 volunteers with sinus rhythm (group 2) and well-matched baseline characteristics. : All group 1 patients presented with single systolic forward flow (SFF) patterns. In contrast, single and double SFF patterns were found equally in group 2. With regard to reverse flow (RF), most group 1 patients (33 of 40) had an early systolic RF and none had atrial RF; however, most group 2 subjects (29 of 33) had an atrial RF. Some of the group 1 patients (17%) had a late systolic RF in the absence of significant mitral regurgitation. In group 1, the SFF appeared later and disappeared earlier than in group 2. The mean systolic peak velocity and time-velocity integral (TVI) of the SFF were significantly lower in group 1 compared to group 2. The diastolic peak velocity and TVI were not significantly different between groups. : Our data indicate that AF independently and significantly affects the PVF and leads to characteristic flow patterns different from sinus rhythm. The presence of AF reduces SFF in addition to the absence of atrial RF. These changes in the flow patterns should be taken into account while interpreting the implications of PVF in the presence of AF.

Decision-making in pediatric varicocele surgery: use of color Doppler ultrasound.

Although varicoceles are common in adolescence, the indications for surgery as well as the procedure of choice are controversial. We have evaluated the use of color Doppler ultrasound (CDUS) as an objective tool in the assessment of such patients in a 5-year prospective study for determination of varicocele size, venous flow patterns, testicular volume, and resistance index. A high ligation was performed only when reverse blood flow was demonstrable in the varicocele during a Valsalva maneuver, and a low approach when this finding was absent. Twenty-six boys underwent low ligation and 53 high ligation based on the findings of CDUS. The incidence of recurrence (3.8%) was lower than that encountered by the same surgical team prior to introduction of CDUS (20.5%) (P = 0.004). These results are even more striking when contrasted with published recurrence rates of 12% to 15% (P = 0.015 to 0.003). Thus, CDUS proved to be a useful tool in selecting the proper surgical approach for varicocele in adolescence. The incidence of recurrence was significantly reduced following the introduction of this procedure.

A clinical study on velocity patterns of pulmonary venous flow in canine heartworm disease.

In this study, we evaluated methods of determining the velocity patterns of pulmonary venous flow (PVF) in dogs and then investigated the relationship of the patterns to cardiac functions in heartworm disease (HD) by transthoracic echocardiography (TTE). The results revealed that there was a good correlation between PVF patterns determined by transesophageal echocardiography (TEE) and TTE in animals lying on their left sides. The measurement of S and D wave velocities (PVS and PVD) by TTE was shown to allow clinical determination of the velocity patterns of PVF in dogs. The HD groups showed significant increases in PVS and PVD, and S and D wave time-velocity integrals (S-TVI and D-TVI) of the right cranial lobe PVF, when compared with the normal group, as determined by TTE (P<0.05). In contrast, the HD groups produced significant decreases in PVD and D-TVI of the right caudal lobe PVF compared with the normal group (P<0.05), and a significant increase in the ratio of S-TVI to (S-TVI + D-TVI) (P<0.05). It is, therefore, suggested that measurement of the velocity patterns of the right cranial and caudal lobe PVF could be one method of assessing the stages of obstructive lesions in the pulmonary artery.

Effect of general anesthesia on the severity of mitral regurgitation by transesophageal echocardiography

The effect of general anesthesia on the severity of mitral regurgitation (MR) was examined in 43 patients with moderate or severe MR who underwent preoperative and intraoperative transesophageal echocardiography. Systolic blood pressure, mean arterial pressure, and left ventricular end-diastolic and end-systolic dimensions were significantly lower during the intraoperative study, reflecting altered loading conditions. The mean color Doppler jet area and mean vena contracta decreased and the mean pulmonary venous flow pattern changed from reversed to blunted, reflecting a significant reduction in the severity of MR. Overall, 22 of the 43 patients (51%) improved at least 1 MR severity grade when assessed under general anesthesia. Thus, intraoperative transesophageal echocardiography may significantly underestimate the severity of MR. A thorough preoperative assessment is preferable when deciding whether to perform mitral valve surgery.

541 Pulmonary venous flow pattern predicts impairment of exercise capacity in hypertrophic cardiomyopathy

541 Pulmonary venous flow pattern predicts impairment of exercise capacity in hypertrophic cardiomyopathy

Correlation between clinical and Doppler echocardiographic findings in patients with moderate and large pericardial effusion: Implications for the diagnosis of cardiac tamponade

Background Clinical data are of unquestionable value for management purposes in cardiac tamponade, whereas the precise value of Doppler echocardiographic findings is not yet fully understood. We aimed to prospectively assess the correlation between clinical and Doppler echocardiographic signs in the diagnosis of cardiac tamponade in a large series of patients with pericardial effusion. Methods During a 2-year period, all patients with moderate and large pericardial effusion were prospectively assessed. The presence of clinical findings suggesting cardiac tamponade, right cardiac chamber collapse on the echocardiogram, and Doppler venous flow pattern were simultaneously evaluated. Results One hundred ten patients were included (49 with moderate and 61 with large effusions). Thirty-eight patients showed clinical features suggestive of cardiac tamponade and 72 did not. In patients with clinical tamponade, 90% had collapse of one or more right cardiac chambers, but 4 (10%) did not have any collapse. Venous flow was analyzable in 63%, suggesting tamponade in 75% of the patients. In patients without clinical tamponade, 34% showed collapse of one or more cardiac chambers. Venous flow pattern was normal in 80%, inconclusive in 11%, and only suggestive of tamponade in 9% of patients. If clinical features of tamponade were considered the diagnostic standard, sensitivity and specificity would be 90% and 65% for the presence of any collapse, 68% and 66% for right atrial collapse, 60% and 90% for right ventricular collapse, and 45% and 92% for simultaneous collapse of both chambers. Sensitivity and specificity of venous flow analysis would be 75% and 91%, respectively. Conclusions There is a good correlation between absence of collapse and absence of tamponade, but the correlation is poor between collapse and tamponade. Abnormal venous flow has a good correlation with clinical features of tamponade, with a higher sensitivity than right ventricular collapse and a much higher specificity than right atrial collapse. (Am Heart J 1999;138:759-64.)

Instantaneous pressure–flow velocity relations of systemic venous return in patients with univentricular circulation

OBJECTIVETo assess the pressure and flow velocity relations and respiratory variability of the systemic venous and hepatic venous return in patients with univentricular circulation.PATIENTS15 selected patients who had undergone cavopulmonary...

The Value of Assessing Pulmonary Venous Flow Velocity for Predicting Severity of Mitral Regurgitation: A Quantitative Assessment Integrating Left Ventricular Function

Although alteration in pulmonary venous flow has been reported to relate to mitral regurgitant severity, it is also known to vary with left ventricular (LV) systolic and diastolic dysfunction. There are few data relating pulmonary venous flow to quantitative indexes of mitral regurgitation (MR). The object of this study was to assess quantitatively the accuracy of pulmonary venous flow for predicting MR severity by using transesophageal echocardiographic measurement in patients with variable LV dysfunction. This study consisted of 73 patients undergoing heart surgery with mild to severe MR. Regurgitant orifice area (ROA), regurgitant stroke volume (RSV), and regurgitant fraction (RF) were obtained by quantitative transesophageal echocardiography and proximal isovelocity surface area. Both left and right upper pulmonary venous flow velocities were recorded and their patterns classified by the ratio of systolic to diastolic velocity: normal (≥1), blunted (<1), and systolic reversal (<0). Twenty-three percent of patients had discordant patterns between the left and right veins. When the most abnormal patterns either in the left or right vein were used for analysis, the ratio of peak systolic to diastolic flow velocity was negatively correlated with ROA ( r = –0.74, P < .001), RSV ( r = –0.70, P < .001), and RF ( r = –0.66, P < .001) calculated by the Doppler thermodilution method; values were r = –0.70, r = –0.67, and r = –0.57, respectively (all P < .001), for indexes calculated by the proximal isovelocity surface area method. The sensitivity, specificity, and predictive values of the reversed pulmonary venous flow pattern for detecting a large ROA (>0.3 cm 2) were 69%, 98%, and 97%, respectively. The sensitivity, specificity, and predictive values of the normal pulmonary venous flow pattern for detecting a small ROA (<0.3 cm 2) were 60%, 96%, and 94%, respectively. However, the blunted pattern had low sensitivity (22%), specificity (61%), and predictive values (30%) for detecting ROA of greater than 0.3 cm 2 with significant overlap with the reversed and normal patterns. Among patients with the blunted pattern, the correlation between the systolic to diastolic velocity ratio was worse in those with LV dysfunction (ejection fraction <50%, r = 0.23, P > .05) than in those with normal LV function ( r = –0.57, P < .05). Stepwise linear regression analysis showed that the peak systolic to diastolic velocity ratio was independently correlated with RF ( P < .001) and effective stroke volume ( P < .01), with a multiple correlation coefficient of 0.71 ( P < .001). In conclusion, reversed pulmonary venous flow in systole is a highly specific and reliable marker of moderately severe or severe MR with an ROA greater than 0.3 cm 2, whereas the normal pattern accurately predicts mild to moderate MR. Blunted pulmonary venous flow can be seen in all grades of MR with low predictive value for severity of MR, especially in the presence of LV dysfunction. The blunted pulmonary venous flow pattern must therefore be interpreted cautiously in clinical practice as a marker for severity of MR. (J Am Soc Echocardiogr 1999;12:736-43.)

Prognostic value of diastolic filling parameters derived using a novel image processing technique in patients ≥70 years of age with congestive heart failure

Conventional echocardiographic characterization of diastolic function requires manual analysis of Doppler E- and A-wave amplitudes, deceleration times, isovolumic relaxation times, and pulmonary venous flow patterns. Mathematic modeling of the suction pump activity of the heart permits characterization of diastolic function through model-based image processing, which relies solely on transmitral Doppler images. This automated method uniquely specifies the entire E-wave contour using 3 parameters (x o, k, and c) that determine E-wave amplitude, width, and rate of decay. Moreover, the index β = c 2 − 4k, reflecting the balance between chamber viscosity and stiffness/recoil, represents a novel parameter for characterizing diastolic function. We analyzed Doppler E waves from 39 patients (mean age 79 years, 61% women, mean ejection fraction 47%) using the model-based image processing technique. A value of β <−900 was selected as indicative of severe diastolic dysfunction. Of 17 subjects with β <−900, 8 (47%) were no longer alive at 1 year. Of 22 subjects with β >−900, all were alive (p = 0.001). The index β, dichotomized at <−900, had a predictive accuracy of 0.769 (30 of 39), a negative predictive value of 1.0 (22 of 22 alive), and a positive predictive value of 0.471 (8 of 17 deceased) for 1-year vital status. Of 14 subjects with deceleration time ≤160 ms, 5 (36%) were deceased at 1 year, whereas for deceleration time >160 ms, 22 of 25 patients were alive (p = NS). Of 16 subjects with ejection fraction <45%, 6 (38%) were deceased at 1 year. Of 23 subjects with ejection fraction >45%, 21 were alive at 1 year (p = 0.074). On multivariate analysis, β dichotomized at −900 was the strongest independent predictor of 1-year mortality. We conclude that evaluation of diastolic function using model-based image processing provides valuable prognostic information in elderly patients with heart failure.

Venous Doppler in the sonographic surveillance of fetuses with supraventricular tachycardia

Objective: In animals and adult humans sustained supraventricular tachycardia leads to myocardial remodelling and dysfunction, persisting even after drug-induced cardioversion to sinus rhythm. This study was undertaken, to evaluate cardiac function in the human fetus by noninvasive determination of the degree of AV valve incompetence and venous blood flow, in order to enhance understanding of the pathophysiology of fetal supraventricular tachycardia. Furthermore, we wanted to determine the usefulness of these methods in the surveillance of these fetuses before and after drug-induced cardioversion. Study design: Eleven fetuses with supraventricular tachycardia between 24 and 35 weeks of gestation were studied. AV valve regurgitation and venous Doppler waveforms of the inferior vena cava and ductus venosus were evaluated before and after conversion to sinus rhythm. Results: Three different groups of fetuses could be distinguished. The first group consisted of four fetuses with neither signs of hydrops nor AV valve incompetence. Venous indices normalized within one to four days (median 2.5 days) after conversion to sinus rhythm. The second group contained two fetuses with hydrops, but without AV valve incompetence. Their venous indices normalized at the day of conversion and 3 days later, respectively (median 1.5 days). The last group of five fetuses consisted of four fetuses with hydrops and AV valve regurgitation during supraventricular tachycardia. In one fetus with hydrops and supraventricular tachycardia the fetal heart rate was continuously decreased to a level of 160–190 beats/min under drug treatment, but no conversion to sinus rhythm occurred. The venous indices of these fetuses normalized within 12–42 days (median 27 days) after conversion Conclusion: Our data suggest that in sustained fetal supraventricular tachycardia alterations of myocardial function similar to tachycardia-induced ‘cardiomyopathy’ occur. The severity of tachycardia-induced changes of cardiac function is reflected by the degree and persistence of AV valve incompetence, as well as by alterations of the venous blood flow pattern. Under clinical conditions, the latter can readily and well reproducibly be demonstrated by calculating the venous blood flow indices of the inferior vena cava and ductus venosus.

The mitral regurgitation index: an echocardiographic guide to severity

OBJECTIVESThe purpose of this study was to develop a semiquantitative index of mitral regurgitation severity suitable for use in daily clinical practice and research.BACKGROUNDThere is no simple method for quantification of mitral regurgitation (MR). The MR Index is a semiquantitative guide to MR severity. The MR Index is a composite of six echocardiographic variables: color Doppler regurgitant jet penetration and proximal isovelocity surface area, continuous wave Doppler characteristics of the regurgitant jet and tricuspid regurgitant jet-derived pulmonary artery pressure, pulse wave Doppler pulmonary venous flow pattern and two-dimensional echocardiographic estimation of left atrial size.METHODSConsecutive patients (n = 103) with varying grades of MR, seen in the Adult Echocardiography Laboratory at UCSF, were analyzed retrospectively. All patients were evaluated for the six variables, each variable being scored on a four point scale from 0 to 3. The reference standards for MR were qualitative echocardiographic evaluation by an expert and quantitation of regurgitant fraction using two-dimensional and Doppler echocardiography. A subgroup of patients with low ejection fraction (EF <50%) were also analyzed.RESULTSThe MR Index increased in proportion to MR severity with a significant difference among the three grades in both normal and low EF groups (F = 130 and F = 42, respectively, p < 0.0001). The MR Index correlated with regurgitant fraction (r = 0.76, p < 0.0001). An MR Index ≥2.2 identified 26/29 patients with severe MR (sensitivity = 90%, specificity = 88%, PPV = 79%). No patient with severe MR had an MR Index <1.8 and no patient with mild MR had an MR Index >1.7.CONCLUSIONSThe MR Index is a simple semiquantitative estimate of MR severity, which seems to be useful in evaluating MR in patients with a low EF.

Fetal Compromise Assessed byDoppler Ultraso und of Venous Flow in Pregnancy-Induced Hypertension

The purpose of this study was to determine the change of venous flow patterns in the inferior vena cava of fetuses in pregnancy-induced hypertension (PIH). We studied 80 normal pregnant women and 46 pregnant women with PIH and their fetuses. We determined the pulsatility index (PI) for arterial vessels, the ratio of peak flow velocities in early diastole and late diastole (E/A) in atrioventricular valves, and the preload index for the inferior vena cava. Twelve of the 46 PIH women showed an umbilical artery PI higher than the 95th percentile in normal pregnant women. Five of them demonstrated a decreased middle cerebral artery PI. Three of the 5 had an increased mitral E/A. Two of them had a decreased tricuspid E/A, an increased preload index, and a poor prognosis. An increased preload index suggests severe compromise in fetuses with a redistribution of arterial and intracardiac blood flow.