Example of Physician Quality Assurance Meetings for Non Invasive Cardiology.

1. Non Invasive Cardiology
Quality Assurance Summit
“3rd Quarter 2010”

2. Summit Agenda
• Evaluation of Mitral Regurgitation:
“American Society of Echocardiography Guidelines”
• Quality Assurance Case Review
• Interesting Case Study Review
• “Technical Tips for Today’s Sonographers”
• Open Discussion for Miscellaneous Topics
• Adjournment

3. Recommendations for the Evaluation of the Severity of:
“Native Valvular Regurgitation”
With 2D Echocardiography and Doppler Mapping

4. “General Principles”
i. Clinical Evaluation for Severity
ii. Echocardiography Assessment:
• Evaluate Severity
• Assess Etiology
• Cardiac Chamber Remodeling
iii. Doppler Mapping: Method of Choice

5. Role of 2D Echocardiography
and Doppler Mapping
• Evaluation of Valvular Structure
• Impact of Volume Overload on Chambers
• Cardiac Remolding: Not Specific for the degree of
Regurgitation
• With significant Regurgitation perform serial 2D
Echocardiograms with Doppler Mapping as the
method of choice for Follow Up Evaluations
• Idea of these Evaluations is the timing of Surgery
(Critical)
“Transesophageal Echocardiography may be used when Clinically necessary…….”

6. Doppler Method for the
Evaluation of Regurgitation
Modalities:
• Color Doppler
• Pulse Wave
• Continuous Wave

7. Color Doppler Evaluation
• Origin of the Regurgitant Jet
• Width: Vena Contracta
• Spatial Orientation of Regurgitant Jet
Orifice
• Flow convergence into the Regurgitant
Orifice
• Better than assessing the traditional Jet
Area alone…….

8. Color Doppler Evaluation
Size of Regurgitant Jet Area of Regurgitant Jet
• Color Flow Mapping • Rapid Screening:
• Temporal Resolution Eccentric Jets
• Instrument Settings • Semi Quantitative
(Gain, Output) Impinging Jets
• Nyquist Limit • Underestimated Jets
• Sample Volume Size • Sole Reliance: Misleading
• Depth of the Sector

9. Technical Aspects
• Pulse Repetition Frequency: The jet area is
inversely related to the PRF……
• Color Gain: Eliminate random Color
Speckling from non – moving regions
• Aliasing Velocity: 50 to 60 cm/second
• Importance of measuring the Patient’s
Blood Pressure: Contributes to the driving
force across the Valves……

10. Vena Contracta
• Narrowest portion of • Measure Cross
the Jet at or just Sectional Area (EROA)
downstream from the • Affected by changing
Orifice Hemodynamics and
• High Velocity Cardiac Cycles
• Laminar Flow • Considerably less
• Slightly smaller than sensitive to technical
the anatomical factors such as PRF
Regurgitant Orifice

11. Technical Aspects
• It is often necessary to • Narrow the Color Flow
angulate the Doppler Sector
Transducer out of • Use the least Depth to
normal Echo Planes maximize Lateral and
• Optimize: Downstream Temporal Spatial
expansion is Resolution
distinguished……. • Small Errors in
• Preferable Zoom Mode Measurements, larger
Percentile Errors……

12. PROXIMAL ISOVELOCITY SURFACE AREA
“PISA or Flow Convergence”

13. Hemodynamic Principle
As Regurgitant Flow approaches:
• Increased Velocity
• Concentric Hemispheric Shell
• Decreased Surface Area
• EROA = (6.28 r² x Aliasing Velocity) MR Velocity
• MR Velocity is obtained with CW and measuring the
Peak Velocity
• EROA Measurement is slightly larger than other
Method……..

14. Technical Aspects
• Shift Baseline towards direction of Flow
• Decrease Nyquist Limit
• This technique is more accurate for
Central Jets………

15. Pulse Wave Doppler Flow Method
• Stroke Volume: Product of the Cross Sectional Area
(CSA) and Velocity Time Interval (VTI)
• Regurgitant Volume: SV of the Regurgitant Valve, SV
of the Competent Valve
• Regurgitant Fraction =
SV Regurgitant Valve – SV Competent Valve
Stoke Volume – Regurgitation
• EROA = Regurgitant Volume
VTI Regurgitant Jet

16. Technical Aspects
• Proper Annular Measurement
• Use the Velocity Trace Method, to calculate
both a Maximum and Mean Velocity…….
• Select the most “defined and brightest”
Spectral Doppler Waveform
• Position the Sample Volume with minimal
angulation at the level of the Annulus

17. Technical Aspects

18. Technical Aspects

19. Technical Aspects

20. Technical Aspects

21. Technical Aspects

22. Technical Aspects

23. ASE Criteria & Characteristics of:
Severe Mitral Regurgitation

24. Role of 2D Echocardiography
• Anatomy of Mitral Valve Apparatus
• Functional or Primary
• Underlying Left Ventricular Function,
Wall Motion Abnormality……..
• Left Atrial and Left Ventricular Size

25. Quality Assurance and Interesting
Study Case Review

26. Technical Tips for
“Today's’ Sonographer”

27. Technical Tips for
“Today’s Sonographer”

28. Technical Tips for
“Today’s Sonographers”

29. Technical Tips for
“Today’s Sonographers”

30. “Open Discussion Session”
Adjournment
Thank You for your Participation……..