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Chapter 19: Pulmonic Valve

PV assessment and transcatheter pulmonic valve replacement are explored. 3D echocardiographic techniques and catheter guidance are discussed. Imaging examples and procedural videos will be provided.

1

Figures

PV 3D zoom acquisition. (A) 3D zoom acquisition from an ME view should include all 3 PV cusps, and slight portions of the AoV, aorta and LAA. (B) A 3D frustrum is acquired and (C) rotated downward and (D) to the left. An MPA view of the PV is obtained. (E) Slight counterclockwise rotation leads to the recommended PV from an MPA perspective. (F) A 180° rotation allows visualization of the PV through the RV.<em> Abbreviations</em>: 3D, three-dimensional; AC, anterior cusp; AoV, aortic valve; LAA, left atrial appendage; LC, left cusp; ME, mid-esophageal; MPA, main pulmonary artery; PV, pulmonic valve; RC, right cusp; RV, right ventricle. Adapted from Hahn et al. <strong><sup>2</sup></strong>. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 19.7

PV 3D zoom acquisition. (A) 3D zoom acquisition from an ME view should include all 3 PV cusps, and slight portions of the AoV, aorta and LAA. (B) A 3D frustrum is acquired and (C) rotated downward and (D) to the left. An MPA view of the PV is obtained. (E) Slight counterclockwise rotation leads to the recommended PV from an MPA perspective. (F) A 180° rotation allows visualization of the PV through the RV. Abbreviations: 3D, three-dimensional; AC, anterior cusp; AoV, aortic valve; LAA, left atrial appendage; LC, left cusp; ME, mid-esophageal; MPA, main pulmonary artery; PV, pulmonic valve; RC, right cusp; RV, right ventricle. Adapted from Hahn et al. 2.

PV 3D dataset. This is the acquisition sequence using 3D zoom to obtain an en-face view of the PV from a UE Arch SAX view. (A) 3D zoom acquisition centers the PV in the acquisition box including all 3 PV cusps, and slight portions of the AoV, Ao and the LAA (B) A 3D frustrum is acquired and (C) rotated downward and (D) to the left to show the PV from a MPA perspective. (E) Counterclockwise rotation 90° leads to the recommended PV orientation with the AC at 12 o’clock from an MPA perspective. (F) A 180° rotation shows the PV from the RVOT perspective.<em> Abbreviations</em>: 3D, three-dimensional; AC, anterior cusp; Ao, aorta; AoV, aortic valve; LA, left atrium; LAA, left atrial appendage; LC, left cusp; MPA, main pulmonary artery; PV, pulmonic valve; RC, right cusp; RV, right ventricle; RVOT, right ventricular outflow tract; SAX, short-axis; UE, upper esophageal. Adapted from Hahn et al.<strong><sup>2</sup></strong>.

eFigure 19.8

PV 3D dataset. This is the acquisition sequence using 3D zoom to obtain an en-face view of the PV from a UE Arch SAX view. (A) 3D zoom acquisition centers the PV in the acquisition box including all 3 PV cusps, and slight portions of the AoV, Ao and the LAA (B) A 3D frustrum is acquired and (C) rotated downward and (D) to the left to show the PV from a MPA perspective. (E) Counterclockwise rotation 90° leads to the recommended PV orientation with the AC at 12 o’clock from an MPA perspective. (F) A 180° rotation shows the PV from the RVOT perspective. Abbreviations: 3D, three-dimensional; AC, anterior cusp; Ao, aorta; AoV, aortic valve; LA, left atrium; LAA, left atrial appendage; LC, left cusp; MPA, main pulmonary artery; PV, pulmonic valve; RC, right cusp; RV, right ventricle; RVOT, right ventricular outflow tract; SAX, short-axis; UE, upper esophageal. Adapted from Hahn et al.2.

eFigure 19.13

2

Videos

Chapter 19 Fig01A

Chapter 19 Fig01B

Chapter 19 Fig02A

Chapter 19 Fig03A

Chapter 19 Fig04A

Chapter 19 Fig04B

Chapter 19 Fig04D

Chapter 19 Fig05A

Chapter 19 Fig05C

Chapter 19 Fig5D

Chapter 19 Fig06A

Chapter 19 Fig06C

Chapter 19 Fig06E

Chapter 19 Fig06F

Chapter 19 Fig07BCDE

Chapter 19 Fig09A

Chapter 19 Fig09D

Chapter 19 Fig09E

Chapter 19 Fig10A

Chapter 19 Fig10F

Chapter 19 Fig10G

Chapter 19 Fig12A

Chapter 19 Fig12C

Chapter 19 Fig12E

Chapter 19 Fig17A

Chapter 19 Fig17B

Chapter 19 Fig18A

Chapter 19 Fig18B

Chapter 19 Fig18C

Chapter 19 Fig18D

3

Tables

eTable 19.1 TEE views for assessing the RVOT, PV and PA

TEE View

View-Technique

Utility/Disadvantages

ME RV Inflow-Outflow
Angle: 50-70°
(See Figure 4.28)
  • Easily acquired view that allows cusp assessment, RVOT and PV annulus measurements and CFI assessment of turbulence and regurgitation
  • Perpendicular alignment precludes PWD or CWD gradient interrogation

UE Aortic arch SAX
Angle: 70-90°
(See Figure 4.27)
  • Good alignment to measure pulmonic valve gradients
  • Frequently excellent image of leaflets
  • Technically challenging view, not easily obtainable in all patients
  • Oblique plane of the PV may underestimate annulus diameter

ME Ascending Aorta SAX
Angle: 0-30°
(See Figure 4.15)
  • Only view to measure and CFI assess main and branch PA
  • Can image PV in some patients
  • Left branch PA may not be visible due to interference from left mainstem bronchus

TG RV basal SAX
Angle: 0-20°
(See Figure 4.21)

  • TV is in near field, allowing for cusp assessment and analysis
  • Can measure TR velocity to calculate RVSP
  • Often difficult to visualize PV

TG RV Inflow outflow
Angle: 0-20°
(See Figure 4.20)
  • Favourable alignment for PV velocity and gradient measurements

TG RV inflow
Angle: 90-110°
(See Figure 4.23)
  • TV is in near field, allows for cusp assessment and analysis
  • Often difficult to visualize PV

ME PV SAX
Angle: 130-150°
(Figure 19.3)
  • Alternative SAX view of PV
  • Not possible to obtain in all patients

Abbreviations: CFI, color flow imaging; CWD, continuous wave Doppler; ME, mid-esophageal; PA, pulmonary artery; PV, pulmonic valve; PWD, pulsed-wave Doppler; RV, right ventricular; RVOT, right ventricular outflow tract; RVSP, right ventricular systolic pressure; SAX, short-axis; TEE, transesophageal echocardiography; TG, transgastric; TR, tricuspid regurgitation; UE, upper esophageal. Adapted from Hahn et al. 56

eTable 19.4 Echocardiography parameters for grading PR severity

PR severity classesMildModerateSevere
Structural and qualitative parameters
RV sizeaUsually normalNormal or dilatedUsually dilated
PV morphologyNormalModerate/abnormalAbnormal and may not be visible
CFI PR jet widthbSmall < 10 mm length with narrow originIntermediateLarge with a wide origin May be of brief duration
PWD flow reversal in main PA or branchesAbsentAbsentPresent
CWD signal of PR jetcFaint/slow decelerationDense/variableDense/steep deceleration Early termination of diastolic flow
PWD pulmonic vs aortic flowdNormal or slightly increasedIntermediateGreatly increased
Semi-quantitative parameters
VC width (mm)Not defined
PWD DT of PR (ms)Not defined  < 260
CWD PHT (ms)e< 100
PR jet width/PV annulus ratio (%)f> 65
PR indexg< 0.77
Quantitative Parameters
EROAR (cm²)Not defined
RVol (ml)
RF (%)h< 2020-40> 40
Other modalities
CMR RF (%)< 2020-40> 40
a In the absence of other causes of increased RV size. Unless for other reasons, the RV size is usually normal in patients with mild PR. In acute severe PR, the RV size is often normal. Accepted cut-off values for non-significant right-sided chambers enlargement (measurements obtained from the ME 4C): mild RV dimension ≤ 33 mm, RVEDA ≤ 28 cm², RVESA ≤ 16 cm², RVFAC >32%. b At a Nyquist limit of 50 to 70 cm/s. c Steep deceleration is not specific for severe PR. d Pulmonic systolic VTI compared to LVOT VTI using PWD. The cutoff values for RVol and RF are not well validated. e PHT shortens and is not reliable with increasing RVEDP. f Identifies a CMR-derived PR fraction ≥40%. g PR index: defined as the duration of the CWD PR signal divided by the total duration of diastole, with this cutoff identifying a CMR-derived PR fraction > 25%. h RF data primarily derived from CMR with limited application in echocardiography. Calculate using VTI: RVol = SV RVOT -SV LVOT; RF = RVol/SV RVOT.
Abbreviations: 4C, four-chamber; CFI, color flow imaging; CMR, cardiac magnetic resonance; CWD, continuous wave Doppler; DT, deceleration time; EROAPR, PR effective regurgitant orifice area; LVOT, left ventricular outflow tract; ME, mid-esophageal; PA, pulmonary artery; PHT, pressure half-time; PR, pulmonary regurgitation; PV, pulmonic valve; PWD, pulsed wave Doppler; RF, regurgitant fraction; RV, right ventricle; RVEDA, right ventricular end-diastolic area; RVEDP, right ventricular end-diastolic pressure; RVESA, right ventricular end-systolic area; RVFAC, right ventricular fractional area change; RVol, regurgitant volume; RVOT, right ventricular outflow tract; SV, stroke volume; VC, vena contracta; VTI, velocity integral. Adapted from Zoghbi17 and Lancelotti et al.21