Main diagnostic challenges (and potential solutions) of echocardiography in the assessment of valvular disease severity and subsequent myocardial damage in MVD
| . | Diagnostic challenges in the assessment of myocardial damage . | Diagnostic challenges in the quantification of valvular heart diseases severity . |
|---|---|---|
| Combination of AS and MR | Over-estimation of LV Ejection due to significant MR. GLS (especially when discrepant from LV ejection fraction) might help but no cut-off is validated in this setting. | Mis-interpretation of AS severity by both paradoxical and classical low-flow, low-gradient AS. |
| Increased trans-mitral systolic pressure gradient for which color-flow-mapping parameters becomes less reliable. | ||
| Combination of AS and TR | Severe myocardial damage of the right chambers might be more frequent but difficult to assess. RV–PA coupling and strain imaging of the RV and RA could be used in combination but need further validation. | Mis-interpretation of AS severity due to low LV pre-load related to the TR. (possible low-flow low-gradient AS). |
| Difficult assessment of TR severity due to high load-dependency; anatomical characteristics (annulus dimension and leaflet tethering) could be used instead. | ||
| Combination of MR and AR | Severe LV remodelling due to the significant increase in pre-load (and afterload). GLS may be more sensitive than LV ejection fraction to depict LV dysfunction but no cut-off value is validated in this setting. Assessment of the aortic root and ascendens dimension is also important. | Pressure half-time method and mitral to aortic velocity time integral measurements are not reliable. |
| Doppler volumetric methods using left-sided assessment of net forward flow are invalid. PISA and (3D) Vena contracta methods should be preferred. | ||
| Combination of MR and TR | Over-estimation of both LV and RV function by using ejection fraction. | Under-estimation of the MR severity related to the decrease in pre-load. |
| GLS might help but no cut-off value is validated in this setting, RV–PA coupling and strain imaging of the RV and RA could be used in combination but need further validation. | ||
| Combination of MS and AS | Marked reduction in cardiac output, which is poorly tolerated. | Decrease in pressure gradients across both valves (low-flow low-gradient) and thus, risk of an under-estimation of both valvular heart diseases. |
| Risk for acute severe LV dysfunction related to the acute change in loading condition if the MS is treated alone. | MS pressure half-time method becomes unreliable. | |
| Combination of MS and AR | Presence of severe MS may delay the AR-related LV dilatation (used for timing the intervention). | MS severity should not be evaluated using the continuity equation with the aortic valve flow as reference; pulmonic flow could be eventually used. |
| Pressure half-time across the mitral valve may be shortened, leading to mitral valve area over-estimation. Mitral valve area could be assessed by direct planimetry (3D preferred). |
| . | Diagnostic challenges in the assessment of myocardial damage . | Diagnostic challenges in the quantification of valvular heart diseases severity . |
|---|---|---|
| Combination of AS and MR | Over-estimation of LV Ejection due to significant MR. GLS (especially when discrepant from LV ejection fraction) might help but no cut-off is validated in this setting. | Mis-interpretation of AS severity by both paradoxical and classical low-flow, low-gradient AS. |
| Increased trans-mitral systolic pressure gradient for which color-flow-mapping parameters becomes less reliable. | ||
| Combination of AS and TR | Severe myocardial damage of the right chambers might be more frequent but difficult to assess. RV–PA coupling and strain imaging of the RV and RA could be used in combination but need further validation. | Mis-interpretation of AS severity due to low LV pre-load related to the TR. (possible low-flow low-gradient AS). |
| Difficult assessment of TR severity due to high load-dependency; anatomical characteristics (annulus dimension and leaflet tethering) could be used instead. | ||
| Combination of MR and AR | Severe LV remodelling due to the significant increase in pre-load (and afterload). GLS may be more sensitive than LV ejection fraction to depict LV dysfunction but no cut-off value is validated in this setting. Assessment of the aortic root and ascendens dimension is also important. | Pressure half-time method and mitral to aortic velocity time integral measurements are not reliable. |
| Doppler volumetric methods using left-sided assessment of net forward flow are invalid. PISA and (3D) Vena contracta methods should be preferred. | ||
| Combination of MR and TR | Over-estimation of both LV and RV function by using ejection fraction. | Under-estimation of the MR severity related to the decrease in pre-load. |
| GLS might help but no cut-off value is validated in this setting, RV–PA coupling and strain imaging of the RV and RA could be used in combination but need further validation. | ||
| Combination of MS and AS | Marked reduction in cardiac output, which is poorly tolerated. | Decrease in pressure gradients across both valves (low-flow low-gradient) and thus, risk of an under-estimation of both valvular heart diseases. |
| Risk for acute severe LV dysfunction related to the acute change in loading condition if the MS is treated alone. | MS pressure half-time method becomes unreliable. | |
| Combination of MS and AR | Presence of severe MS may delay the AR-related LV dilatation (used for timing the intervention). | MS severity should not be evaluated using the continuity equation with the aortic valve flow as reference; pulmonic flow could be eventually used. |
| Pressure half-time across the mitral valve may be shortened, leading to mitral valve area over-estimation. Mitral valve area could be assessed by direct planimetry (3D preferred). |
Main diagnostic challenges (and potential solutions) of echocardiography in the assessment of valvular disease severity and subsequent myocardial damage in MVD
| . | Diagnostic challenges in the assessment of myocardial damage . | Diagnostic challenges in the quantification of valvular heart diseases severity . |
|---|---|---|
| Combination of AS and MR | Over-estimation of LV Ejection due to significant MR. GLS (especially when discrepant from LV ejection fraction) might help but no cut-off is validated in this setting. | Mis-interpretation of AS severity by both paradoxical and classical low-flow, low-gradient AS. |
| Increased trans-mitral systolic pressure gradient for which color-flow-mapping parameters becomes less reliable. | ||
| Combination of AS and TR | Severe myocardial damage of the right chambers might be more frequent but difficult to assess. RV–PA coupling and strain imaging of the RV and RA could be used in combination but need further validation. | Mis-interpretation of AS severity due to low LV pre-load related to the TR. (possible low-flow low-gradient AS). |
| Difficult assessment of TR severity due to high load-dependency; anatomical characteristics (annulus dimension and leaflet tethering) could be used instead. | ||
| Combination of MR and AR | Severe LV remodelling due to the significant increase in pre-load (and afterload). GLS may be more sensitive than LV ejection fraction to depict LV dysfunction but no cut-off value is validated in this setting. Assessment of the aortic root and ascendens dimension is also important. | Pressure half-time method and mitral to aortic velocity time integral measurements are not reliable. |
| Doppler volumetric methods using left-sided assessment of net forward flow are invalid. PISA and (3D) Vena contracta methods should be preferred. | ||
| Combination of MR and TR | Over-estimation of both LV and RV function by using ejection fraction. | Under-estimation of the MR severity related to the decrease in pre-load. |
| GLS might help but no cut-off value is validated in this setting, RV–PA coupling and strain imaging of the RV and RA could be used in combination but need further validation. | ||
| Combination of MS and AS | Marked reduction in cardiac output, which is poorly tolerated. | Decrease in pressure gradients across both valves (low-flow low-gradient) and thus, risk of an under-estimation of both valvular heart diseases. |
| Risk for acute severe LV dysfunction related to the acute change in loading condition if the MS is treated alone. | MS pressure half-time method becomes unreliable. | |
| Combination of MS and AR | Presence of severe MS may delay the AR-related LV dilatation (used for timing the intervention). | MS severity should not be evaluated using the continuity equation with the aortic valve flow as reference; pulmonic flow could be eventually used. |
| Pressure half-time across the mitral valve may be shortened, leading to mitral valve area over-estimation. Mitral valve area could be assessed by direct planimetry (3D preferred). |
| . | Diagnostic challenges in the assessment of myocardial damage . | Diagnostic challenges in the quantification of valvular heart diseases severity . |
|---|---|---|
| Combination of AS and MR | Over-estimation of LV Ejection due to significant MR. GLS (especially when discrepant from LV ejection fraction) might help but no cut-off is validated in this setting. | Mis-interpretation of AS severity by both paradoxical and classical low-flow, low-gradient AS. |
| Increased trans-mitral systolic pressure gradient for which color-flow-mapping parameters becomes less reliable. | ||
| Combination of AS and TR | Severe myocardial damage of the right chambers might be more frequent but difficult to assess. RV–PA coupling and strain imaging of the RV and RA could be used in combination but need further validation. | Mis-interpretation of AS severity due to low LV pre-load related to the TR. (possible low-flow low-gradient AS). |
| Difficult assessment of TR severity due to high load-dependency; anatomical characteristics (annulus dimension and leaflet tethering) could be used instead. | ||
| Combination of MR and AR | Severe LV remodelling due to the significant increase in pre-load (and afterload). GLS may be more sensitive than LV ejection fraction to depict LV dysfunction but no cut-off value is validated in this setting. Assessment of the aortic root and ascendens dimension is also important. | Pressure half-time method and mitral to aortic velocity time integral measurements are not reliable. |
| Doppler volumetric methods using left-sided assessment of net forward flow are invalid. PISA and (3D) Vena contracta methods should be preferred. | ||
| Combination of MR and TR | Over-estimation of both LV and RV function by using ejection fraction. | Under-estimation of the MR severity related to the decrease in pre-load. |
| GLS might help but no cut-off value is validated in this setting, RV–PA coupling and strain imaging of the RV and RA could be used in combination but need further validation. | ||
| Combination of MS and AS | Marked reduction in cardiac output, which is poorly tolerated. | Decrease in pressure gradients across both valves (low-flow low-gradient) and thus, risk of an under-estimation of both valvular heart diseases. |
| Risk for acute severe LV dysfunction related to the acute change in loading condition if the MS is treated alone. | MS pressure half-time method becomes unreliable. | |
| Combination of MS and AR | Presence of severe MS may delay the AR-related LV dilatation (used for timing the intervention). | MS severity should not be evaluated using the continuity equation with the aortic valve flow as reference; pulmonic flow could be eventually used. |
| Pressure half-time across the mitral valve may be shortened, leading to mitral valve area over-estimation. Mitral valve area could be assessed by direct planimetry (3D preferred). |
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