Echo Case: Diagnose Dyspnea From the Doppler

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Ronald H Wharton, MD: Hello and thank you for tuning in. This is Ronald Wharton. I am an attending cardiologist at Montefiore Medical Center of the Albert Einstein College of Medicine in Bronx, New York, and I call this "Diagnose Dyspnea from the Doppler" and, yes, I do like alliterations. I thought this was a very interesting case, especially because of the morphology of the Doppler.

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I am going to start with two Dopplers before I give the history. This is the continuous-wave Doppler through the pulmonic valve. Take a look at it for a second.

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Here is the continuous-wave Doppler through the aortic valve and the apical five-chamber view. Take a look at that for a second. Do you notice that in both of the Dopplers the pulmonic-insufficiency (PI) and aortic-insufficiency (AI) jets have very steep descents with a lot of early filling happening in early diastole, suggesting the very rapid rise in the diastolic pressure of both the RV and the LV. You have seen a lot of AI and a lot of PI jets before, I am sure, all of you. These look a little different from most of them, I think.

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Here is the history. The patient was a 68-year-old woman presenting with dyspnea and edema. She has an elevated [B-type natriuretic peptide] BNP level. Her creatinine clearance is normal. I am telling you that so that is not a confounder with the BNP level being elevated and I am showing you cardiographic images. Obviously, there is something in the history that I am purposely omitting, for now.

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And here you can see the parasternal long axis. What are we seeing here? There is thickening of the aortic valve, thickening of the mitral valve. Both valves are opening normally.

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In the next slide you can see that there is, perhaps, moderate aortic insufficiency and moderate mitral regurgitation, as well. There is a small pericardial effusion. There are probably pleural effusions, as well, that are not really showing well on this image.

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This is a color Doppler of the tricuspid regurgitation jet in the RV in-flow view. You can see it is a very dense jet, suggesting severe tricuspid regurgitation (TR).

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In the next slide you can see that, in fact, it is severe TR because the density of the regurgitant jet is almost out of the antegrade flow.

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Now we go in an apical four-chamber view, which is a little off axis. You can see there is a large left pleural effusion. You will also notice that there is a small pericardial effusion as well. Again, note some calcification of the mitral chordae and thickening of the mitral valve. The overall biventricular systolic function is normal.

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You can see, here, is a pulse-wave Doppler through the mitral valve. The E and A waves are fused because of the tachycardia. The heart rate here is 110 bpm. There is a little variation from beat to beat in the overall velocity of the fused E and A waves.

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Here is a continuous-wave Doppler of the mitral regurgitation jet that you saw. You can see that there is a lot of variation in the velocity of the MR jet. Looking at that on the tricuspid side it is common to see variation in TR jets from beat to beat, even when the RR interval is regular, because velocities on the right side of the heart are inherently more susceptible to changes that parallel the respiratory cycle, but one doesn't usually see that quite as pronounced on the left side of the heart. Looking at the density of mitral regurgitant jet I think calling it moderate is fair.

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So what have we seen? We have two ventricles that have very steep rises in diastolic pressure because the AI and the PI jets plateau very quickly, which is unusual. There is a pericardial effusion. You may have also noticed that the pericardium looked a little thick. What do you think the mitral Dopplers, specifically the mitral annular Dopplers, look like? I will give you a second to think about it before I show them to you.

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Well, here they are. This next slide shows you the septal velocity at the mitral annulus. Notice that the velocity is measured to be 9.1 cm/s-yes, E and A are fused or, in this case, E' and A' are fused, but they are fused the same way throughout the cycle, so even if we call this a fused E' and A', we are getting 9.1 cm/s, and since the R intervals are regular we compare that with the velocities obtained from the lateral annulus.

The lateral-annulus velocity is about 7.7 cm/s. Wait a minute. Isn't the lateral velocity supposed to be higher than the septal velocity?

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The fact that the septal velocities are higher than the lateral velocities is unusual. Don't forget the lateral wall has a longer path to travel than the septal wall in the longitudinal expansion of the heart during diastoles, so this is an unusual finding.

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Here is the mitral-inflow posterior Doppler at a very slow sweep speed, so we get a lot of beats, and you will notice the respirometer. During expiration the mitral-inflow velocity approaches 2 m/s. During inspiration it may go as low as a little less than 1 m/s, probably in the vicinity of about 0.9 m/s, but certainly more than a 25% variation in the velocity through the mitral valve with the respiratory cycle, with the higher velocities occurring during expiration.

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In the next slide is something that you don't really see that often, largely because most labs don't take the time to do this, unless you are in an academic center. You will notice that in expiration the N diastolic-flow reversals in the hepatic vein are very pronounced. This is all coming to one unifying diagnosis.

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What I intentionally omitted from this patient's history is a remote history of chest radiation. I forget exactly which malignancy she was treated for, but that really doesn't matter. These are all manifestations of chronic constrictive pericarditis, and the findings of the valvular heart disease, the pericardial thickening, the ventricular interdependence, and also the hepatic vein Doppler, which, by the way, for those of you who are taking echo boards, it may come up (that is not inside information, just in my experience it always seems to) are all classic findings of chronic constrictive pericarditis. I thought the initial Dopplers of the aortic insufficiency and pulmonic insufficiency, in which the flow comes very fast and furious early and then tapers off, demonstrating a rapid rise in the ventricular pressures, were worth sharing with the echo community out there.

So thank you for tuning in. This is Ron Wharton from Bronx, New York and Montefiore Medical Center for theheart.org on Medscape Cardiology, and I hope you enjoyed this.