Flow dynamics - ECHO

-Dr.V.Govindaraj
DOPPLER ECHOCARDIOGRAPHY
• Doppler imaging is concerned with the direction, velocity, and then pattern of
blood flow through the heart and great vessels.
• The primary targets of the anatomic echocardiographic examination are the
myocardium and valves of the heart. For Doppler imaging, the primary target is
the red blood cells.
Principles of Doppler Ultrasound

• The Doppler principle is based on the work of the Austrian physicist Christian
Doppler, first published in 1842.
• If the source of sound were stationary, then the pitch or frequency of that sound
was constant. If, however, the source of sound moved toward the listener, the
frequency increased and the pitch appeared to rise.
• Conversely, if the sound source was moving away from the listener, the frequency
of the sound decreased relative to the listener and the pitch appeared lower.
• The increase or decrease in frequency due to relative motion between the
transducer and the target is referred to as the Doppler shift.
Factors affecting doppler equation
• Estimation of blood flow velocity is dependent on incident angle between
ultrasound beam and blood flow
• When RBCs parallel-maximum velocity
• When RBCs perpendicular-no doppler shift
• When angle between ultrasound beam and blood flow is less than or equal 20
degree,cosine close to 1 and percent error is less than or equal to 7%
Angle Cosine Percentage error
0 1 0
10 0.98 2
20 0.94 7
30 0.87 13
60 0.5 50
90 0 100

• misalignment of the interrogating beam will lead to underestimation but never

overestimation of true velocity.
Angle correction
• It is possible to correct for angle

• Not recommended as in most cases its possible to align ultrasound beam parallel
by utilising multiple views, serial assessment difficult unless same angle
correction used

• It is assumed that angle between ultrasound beam and direction of blood flow is
parallel
• By adjusting according to the direction of assumed flow, it changes
the angle calculations in the Doppler equation resulting in different
estimates of flow velocity.

• The use of this control does not actually change the direction of the
Doppler beam and its use does not alter the quality of either the
audio output or the spectral recording
Pulsed and Continuous Wave Doppler
 Continuous Wave Doppler

• older and electronically more simple

• continuous generation of ultrasound waves
• continuous ultrasound reception
• two crystal transducer
• Blood flow along entire beam is observed
 Pulsed Wave Doppler

• Ultrasound impulses are sent out in short bursts or pulses

• transducer that alternates transmission and reception of
ultrasound
• ability to provide Doppler shift data selectively from a small
segment along the ultrasound beam- sample volume can be
selected.
• The transducer functions as receiver for a limited time period
• Time corresponds to the interval required for sound to return from specified
area.
• Another burst of sound waves are not transmitted until previous impulses are
received.
• Pulse repetition frequency (PRF)–frequency at which transducer transmits pulses.
• PRF determines sampling rate.
 Aliasing
• The aliasing phenomenon occurs when the velocity exceeds the rate at which the
pulsed wave system can record it properly.
Inability to accurately measure high blood flow velocities- aliasing

“Alias” means false

Nyquist Limit
• The Nyquist limit defines when aliasing will occur using PW Doppler.
• The Nyquist limit specifies that measurements of frequency shifts
(and, thus, velocity) will be appropriately displayed only if the pulse
repetition frequency (PRF) is at least twice the maximum velocity (or
Doppler shift frequency) encountered in the sample volume.
QUANTIFYING BLOOD FLOW
• The rate of flow through an orifice is equal to the product of flow velocity and
cross-sectional area.
• If flow were constant, it would be a simple matter to determine velocity at any
point in time and solve the equation accordingly.
• In the cardiovascular system, however, flow is pulsatile and therefore individual
velocities during the ejection phase must be sampled and then integrated to
measure flow volume.
• This sum of velocities is called the time velocity integral (TVI) and is equal to the
area enclosed by the Doppler velocity profile during one ejection period.
• VTI is obtained by tracing the leading edge of velocity
spectrum.
Pattern of blood flow:
• Flow passing through a normal heart valve or the proximal great vessels tends to
be laminar with a flat profile and is therefore suitable for quantitative analysis.
• physiologic blood flow is never perfectly uniform.
• A distribution of velocities occurs, resulting in a broadening of the Doppler signal.
• The greater the range of velocities is at any point in time, the broader is the
Doppler signal.
SV = TVI * CSA
• A = pr2

• A = 0.785 × D2

• Stroke volume = 0.785 × D2 ×

TVI
• The importance of accurately measuring the outflow tract diameter is illustrated
in the following example.
• Assume that the “true” diameter is 2 cm and the TVI is 20 cm. This would yield a
stroke volume of 63 mL.
• Underestimation of the diameter by just 10% would have the following effect on
stroke volume calculation:
• Stroke volume = 0.785 × (1.8 cm)2 × 20 = 51 mL
• Thus, a 2-mm (or 10%) underestimation in diameter would lead to a 19%
underestimation (51 mL instead of 63 mL) in stroke volume.
CLINICAL APPLICATION OF BLOOD FLOW
MEASUREMENT
• In the absence of regurgitation, stroke volume across all four valves should be
equal.
• In the presence of aortic regurgitation, for example, the difference between aortic
flow and mitral flow represents the aortic regurgitant volume:
MEASURING PRESSURE GRADIENTS

• One of the most important applications of the Doppler method is to measure

transvalvular pressure gradients.
• This approach is based on Newton’s law of conservation of energy, which states
that the total amount of energy within closed system must remain constant.
• Thus, as applied to blood flow measurements, the flow velocity through a valve
must increase as the valve area decreases.
• ΔP = 1>2 ρ(v22 − v12) + ρ∫(dv/dt) × ds + R(μ)
• ΔP = 4(v22 − v12)
• ΔP = 4v2
• where v is the maximal velocity of the stenotic jet.
• The technique has had its greatest
application in measuring the severity
of valve stenosis.
• It used to estimate intracardiac
pressures in patients with valvular
regurgitation or intracardiac shunts,
such as ventricular septal defects.
Limitations :
• Most errors are technical in nature and result in underestimation of the true
pressure gradient.
• The most common example occurs when the ultrasound beam cannot be properly
aligned relative to the direction of blood flow.
• The signal-to-noise ratio will affect whether the entire Doppler envelope is
recorded for analysis. If part of the envelope is “missing” because of an
incomplete signal, the peak velocity will be missed and underestimation will
occur.
• Proper gain setting, optimal beam alignment, are all necessary to accurately
measure pressure gradients.
• The application of echo contrast agents to boost the signal of the jet is another
practical way to avoid underestimation.
• Doppler-derived pressure gradients
are compared with cardiac
catheterization data.
• When discrepancies occur, a
plausible explanation is often
apparent.
• Doppler measures peak
instantaneous gradient.
• Catheterization data are most often
reported as peak-to-peak, which is
usually less.
PRESSURE RECOVERY
PHENOMENON
• Complex hemodymanic concept- pressure of fluid decreases as
velocity increases.
• Once flow passes through a narrowing pressure drops and increases
towards original value
• Rate and magnitude of pressure recovery is variable
• Maximum velocity and lowest pressure is at narrowest orifice.
• Immediately distal to orifice, pressure increases (recovers)and velocity
decreases.
• Doppler gradients are measured at narrowest orifice, while catheter
gradients are recorded downstream to prosthetic valve where the
pressure has already recovered.
• Hence, Doppler derived pressure gradients are more compared to
catheter derived pressure gradients.
APPLICATIONS OF THE BERNOULLI EQUATION
• To determine the mean gradient,
the instantaneous gradients are
measured at multiple points
throughout the flow and their sum
is divided by the duration of flow.

• The shape or contour of the

Doppler signal also contains
relevant information.
• This pattern is typical of
dynamic obstruction as
occurs with hypertrophic
cardiomyopathy.

• In contrast, valvular stenosis

is characterized by rapid
acceleration of blood flow
in early systole with an
earlier peak velocity.
 RVSP IN VSD:

• The acceleration of blood through a

ventricular septal defect in systole is
a reflection of the instantaneous
pressure difference between the two
ventricles
RVSP IN TR:
• The tricuspid regurgitation jet is a reflection of the peak pressure difference between the right
ventricle and the right atrium in systole.
• If that gradient can be measured using the Bernoulli equation, right ventricular systolic pressure
can be estimated, provided right atrial systolic pressure is known.
By observing the degree of dilation and the respiratory variability in inferior vena cava
caliber, right atrial pressure can be estimated with reasonable accuracy.
 pulmonary artery diastolic pressure.

• In pulmonary regurgitation, we can meaure

enddiastolic pulmonary regurgitant jet
velocity.
• It gives pressure gradient between the
pulmonary artery and the right ventricle at
the end of diastole.
• Combining this pressure gradient with right
ventricular diastolic pressure or right atrial
pressure provides a measurement of
pulmonary artery diastolic pressure.
• Specifically, by adding the enddiastolic
pressure gradient (from the pulmonary
regurgitation velocity) to the right atrial
pressure, pulmonary artery diastolic pressure
can be estimated.
left ventricular end-diastolic pressure - aortic regurgitation.

• By measuring the end-diastolic velocity of

the aortic regurgitation jet, left ventricular
end-diastolic pressure can be determined by
subtracting the gradient from the aortic
diastolic pressure.

• The problem with this calculation is that

end-diastolic aortic pressure is difficul to
estimate noninvasively.
 dP/dt

• Use of mitral regurgitation to

estimate the rate of left ventricular
pressure increase during early
systole, also known as dP/dt.
• By measuring the slope of the
mitralregurgitation acceleration
velocity, dP/dt can be determined.
This is done by measuring the time
interval between 1 m/s and 3 m/s on
the mitralregurgitation jet
Pressure half time
• Time required for peak pressure gradient to be reduced to one half.
• If peak pressure is 14 mmhg.
• PHT: time for pressure to become 7 mmhg.
• P= 4(V)2
• In doppler , we measure velocity.
• Hence PHT is time required for peak velocity to become:

• Peak velocity / v^2 i.e v/1.4 = 0.7 * velocity

 MS and PHT
• PHT is measure of severity.
• As stenosis worsens , PHT increases.
• Mitral valve area = 220/PHT.

• Advantages:
• Better measure of severity.
• Less dependent on heart rate, flow compared to gradient.
• Useful in atrial fibrillation as RR varaiton changes
gradient.

• Limitations:

• Altered diastolic compliance like LVH alters the flow

velocity and hence PHT
PHT in AR
• The steeper the slope of AR flow
profile is and the shorter the PHT.
• As aortic regurgitation worsens left
ventricular pressure increases more
quickly, aortic pressure decreases
more quickly and pressure half time
shortens.
THE CONTINUITY EQUATION

• The continuity equation is based on Newton’s second law of thermodynamics,

involving the conservation of mass.
• This principle states that the volumetric flow rate through the cardiovascular
system is constant, assuming that the blood is noncompressible and the conduit is
inelastic.
• The advantages of the continuity equation are that it is unaffected by valvular regurgitation.
• It provides quantitative assessment of severity even in the presence of left ventricular dysfunction
(when gradient alone may lead to underestimation of severity).
32
0.8 cm2

74
0.8 cm2
15
1.3cm2
32
1.3 cm2
• It is apparent that the same gradient can reflect widely different valve areas,
depending on the flow rate through the valve.
• Clearly, in the setting of changing flow states, gradient alone cannot convey
adequate diagnostic information about stenosis severity.
PROXIMAL ISOVELOCITY SURFACE AREA

• As blood converges toward an orifice,

Doppler flow imaging reveals concentric
shells or hemispheres, which represent
isovelocity surfaces.
• As the blood accelerates toward the orifice,
velocity aliasing occurs and a distinct red–
blue interface occurs at the boundary of the
shells.
• By adjusting, the size of the shell can be
maximized to allow its surface area to be
measured according to the formula:
• Surface area = 2πr2.
• Flow rate = 6.28 × r2 × Aliasing velocity
• Flow rate = ERO × Velocityjet
• RV = ERO × TVIMR
Limitations of PISA method
Errors in measurement of radius
Valve area is proportional to square of radius-even small errors are magnified.

Errors in measurement of angle

Measurement is done offline using a protractor

Angle measured in one dimension may not be true representation of valve leaflet
geometry.
• Assumptions about the hemispheric shape of the isovelocity shells may be
oversimplified, may, in fact, be nonhemispheric.
• The PISA calculation also assumes that mitral regurgitation occurs throughout systole
at a constant flow rate.
• Doppler shows that most of the regurgitation occurs in the latter half of systole.
Without correcting for this, PISA would overestimate regurgitant volume.
MYOCARDIAL PERFORMANCE INDEX

• It is an expression of global ventricular performance.

• It is a simple index that includes both systolic and diastolic parameters and can be
applied to either the left or the right ventricle.
• Systolic dysfunction - prolongation of IVCT , a shortening of the ET.
• Diastolic dysfunction - lengthening of the IVRT.
• Thus, both systolic and diastolic dysfunction will result in an increase in the MPI.
• The reported normal range for the MPI is 0.39 ± 0.05.
• Values greater than 0.50 are considered abnormal.
• The MPI can also be used to assess right ventricular function.
• For the right side of the heart, the normal MPI is 0.28 ± 0.04.
• An increased right ventricular MPI is a sensitive and specific marker of pulmonary hypertension .
• Thus, the MPI may be of value in patients in whom tricuspid regurgitation is either not present or
cannot be quantified to assess for pulmonary hypertension.
Thank you!!!