LECTURE NO-1 – TKV UHAMKA

Simple Congenital
Heart Disease
Echocardiography Examination:
Technical and Practical

Prof. Dr. Hamed Oemar, PhD, Spjp(k), fiha

SUBTYPES ASD
PARA STERNAL LONG-AXIS

ASD NORMAL
M-MODE OF LV

NORMAL
Modification 4-chamber
Clue to diagnose asd-ii

• RV volume overload (dilatation)

• Compression to LV during systolic
• D-sign (of LV)
• IAS defect or echo “gap”
• Color Doppler flow L-to-R shunt
CHAMBER VOLUME CHANGES
CLUE
diastole systole

NORMAL

RV Volume
Overload
D-sign
ASD PRIMUM
 MEASUREMENT

• Pulmonary Artery Pressure (PAP)

• Peak and Mean Pressure
• Tricuspid Regurgitation (TR) Pressure Gradient
• Shunt Flow
• Qp/Qs Ratio
• Pulmonary Vascular resistance
PEAK AND MEAN
PULMONARY ARTERY PRESSURE
 Mean Pulmonary Artery Pressure
FORMULA-1
MEAN PAP (mmHg) = 85 - (AcTMPA)
2
Mean PAP = 80 − (0.5 x ATRVOT)

FORMULA-2
MEAN PAP (mmHg) = 90 - (0.62 x AcTRVOT)
MEAN PULMONARY ARTERY PRESSURE

MEAN PAP =
AcT (ms)
85 - = mmHg
2

= 85 – (1/2 X 59) = 55 mmHg

NORMAL < 25 mmHg

 MEAN PAP
• Mean PAP can be approximated from the systolic
PAP (SPAP) using the following formula:

mPAP = 0.61 x SPAP + 2 mmHg

D. Chemla, V. Castelain, M. Humbert, et al., New formula mean pulmonary artery pressure
systolic pulmonary artery pressure*, Chest 126 (4) (2004) 1313–1317.
PEAK PULMONARY ARTERY PRESSURE

TR VMAX METHOD FOR

MEASURING PASP.

Peak PASP = TR max + 15 mmHg

Peak PASP = 28 + 15 = 43 mmHg

COMMON PITFALLS

• A lesser degree of TR may occur in a compensated RV

(due to elevated ventricular pressure) and this could lead
to underestimation of PASP.
• Severe TR could cause equalisation of right atrial and
ventricular pressures which may cause the TR Doppler
envelope to be cut short, leading to underestimation of
PASP.
Pitfall of TR Gradient - CW
AMPUTATED TR JET (CW)
MEAN PAP (2)

FORMULA:

MEAN PAP
= 4 (PR peak vel)2 + RAP

= 4 (2.16)2. + 15 mmHg =
33.6 mmHg
MEAN PAP

Formula - 3:

mPAP = Mean ΔP + RAP.

PRESSURE GRADIENT FROM TR

PG = 83 mmHg
PAP = 98 mmHg
• As calculated by Doppler echocardiography, TRV/TVIRVOT correlated
well (r 0.929, 95% confidence interval 0.87 to 0.96) with invasive PVR
measurements.
• The Bland-Altman analysis between PVR obtained invasively and that by
echocardiography, using the equation: PVR TRV/TVIRVOT 10 0.16,
showed satisfactory limits of agreement (mean 0 0.41).
• A TRV/TVIRVOT cut-off value of 0.175 had a sensitivity of 77% and a
specificity of 81% to determine PVR 2WU
Measurement of Qp/Qs
 SHUNT RATIO = Qp and Qr

MPA Diameter and TVI, time velocity TVI, time velocity

PW integral LVOT Diameter and PW
integral
Sample Volume of Main PA (cm) Sample Volume
of LVOT (cm)
 MPAdiam /MPATVI
Formula Qp/Qs =
LVOTdiam / LVOTTVI

Left to Right shunt on Color flow mapping and

a large baseline shunt with a Qp:Qs of >2.5 : 1
Pulmonary Vascular Resistance = PVR

• TR velocity = TRV in cm/sec

• TVI = Tricuspid Velocity Integral of Tricuspid Regurgitation
Integral in unit cm

• Ratio = TRV2/TVIRVOT = 0.95 for PVR >6 WU

• Ratio = TRV/TVIRVOT = 0.275 for PVR >6 WU
PVR > 0.175
Equal with >2WU

PVR > 0.275

Equal with >6WU
PULMONARY VASCULAR RESISTANCE = PVR
• PVRecho = TRV/TVIRVOT =
If the ratio from echo >0.175
that is equal to the value of
catheterization for PVR >2 WU

Normal Value PVR < 2.0WU (wood unit)

PATENT FORAMEN OVALE
3DE and Autopsy Images of PFO Tunnel

The RA entrance and the LA exit of PFO Tu

Abdelghani, M., et al. Cardiology 2019;143:6

 Differences Between PFO and CHD
ITEM PFO CHD
Normal Developmental YES NO

Prevalence and Incidence High Low

In Healthy People Common Never

Symptom since Birth NO YES
Noticed since birth or
Unnoticed Noticed
childhood
Presence of Etiology or
No YES
Genetic
Embryonal Remnant YES NO
Congenital Variant YES NO
Abbreviation: PFO = Patent Foramen Ovale; CHD = Congenital Heart Disease
Perbedaan ASD dan PFO
 What do doctors and people
know about PFO?
• PATENT FORAMEN OVALE IS A COMMON ANATOMICAL
INTRACARDIAC VARIANT THAT GOES UNNOTICED AND NOT CONGENITAL HEART
DISEASE
A variant means one that exhibits variation from a type or a norm;
e a disease is a conditioning of the living body or of one of its parts
that impairs normal functioning and its typically manifested by
distinguishing signs and symptoms
(Merriam -Webster Dictionary)
Thank you