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1.  Doppler echocardiographic evaluation of the normal human fetal heart. 
British Heart Journal  1987;57(6):528-533.
Pulsed wave Doppler estimates of blood flow velocity were made across the mitral, tricuspid, aortic, and pulmonary valves in a series of 120 normal fetuses (gestational age 16-36 weeks). In 36 of these the data were obtained in all four sites. The maximum and mean velocities were calculated for each valve and these values were plotted against gestational age. There was little change in these values throughout pregnancy. The orifice dimensions of the valves were measured by cross sectional echocardiography. At all ages the tricuspid orifice was larger than the mitral and the pulmonary orifice was larger than the aortic. The blood flow values for each valve were derived from the product of the mean velocity and the valve orifice dimensions. The output of the right ventricle was usually, but not always, greater than that of the left ventricle. Combined ventricular output increased from approximately 50 ml/min at 18 weeks to 1200 ml/min at term. Despite limitations in the accuracy of the technique these results form a useful basis for the analysis of blood flow in the normal fetus and for the interpretation of abnormal Doppler findings in prenatal life.
PMCID: PMC1277222  PMID: 3620229
2.  A new non-invasive estimation of the stenotic aortic valve area by pulsed Doppler mapping. 
British Heart Journal  1987;57(1):44-50.
A new pulsed Doppler mapping technique has been used to measure the severity of aortic valve stenosis. The Doppler examination was performed at the site of the aortic orifice in the parasternal short axis echocardiographic view and the method was based on the detection of the area of systolic flow through the stenotic orifice. This area was derived by planimetry and the measurements obtained by the Doppler method were compared with the aortic valve area calculated at catheterisation according to the Gorlin formula. The method was applicable in 41 of the 44 patients studied. The Doppler data were consistent with the haemodynamic measurements even in patients with decreased cardiac index. It is concluded that this new application of the flow mapping procedure is reliable and is easily applied to adult patients with a wide range of clinical conditions.
PMCID: PMC1277145  PMID: 3801258
3.  A Novel Approach to Standard Techniques in the Assessment and Quantification of the Interventricular Systolic Relationship 
Blood flow between the right and left ventricles is subject to the continuity equation and systolic ventricular interdependence. Quantification of this relationship might aid in understanding inter-ventricular function. The purpose of this study was to evaluate and quantify ventricular interdependence by directly comparing right and left ventricular systolic function though echocardiographic surrogates of right and left ventricular systolic function such as MAPSE, TAPSE, RV TVI and LV TVI.
This study prospectively evaluated 51 healthy participants (mean age, 41 ± 17 years) by resting echocardiography. In addition to standard measurements, tricuspid annular plane of systolic excursion, (TAPSE), mitral annular plane of systolic excursion (MAPSE), and the peak annulus systolic velocity of the right ventricular (RVs) and left ventricular (LVs) free walls were measured by M-mode and pulsed wave Doppler tissue echocardiography and further evaluated for variance across age, gender, and body surface area.
TAPSE (22.1 ± 2.9 mm) was over 54.5% greater than MAPSE (14.3 ± 2.6 mm) and RVs was 64.4% greater than LVs. The LV to RV systolic relationship measured by MAPSE/TAPSE and LVs/RVs ratios were 0.66 ± 0.14 and 0.76 ± 0.21 respectively. These values were not significantly affected by age, gender or body surface area (BSA).
MAPSE/TAPSE and LVs/RVs ratios appear stable across age, gender, and BSA potentially making them good surrogates of systolic ventricular relationship and interdependence.
PMCID: PMC3280943  PMID: 22185470
ventricular interdependence; ventricular function; TAPSE; MAPSE; tissue Doppler
4.  Comparison of acoustic quantification and Doppler echocardiography in assessment of left ventricular diastolic variables. 
British Heart Journal  1993;70(5):448-456.
OBJECTIVE--To assess the haemodynamic correlations of the waveforms of left ventricular area change obtained by automated boundary detection with newly developed acoustic quantification technology. DESIGN--The timing of events in the cardiac cycle was identified on the wave-form automated boundary detection and was correlated with the corresponding timing derived from pulsed wave Doppler flow velocity traces of the mitral valve and left ventricular outflow tract. The amounts of area change during the rapid filling phase and during atrial contraction were correlated with the time-velocity integrals of early and late diastolic ventricular filling obtained from Doppler tracings of the mitral inflow. SETTING--A university medical school echocardiography laboratory. SUBJECTS--16 healthy volunteers and 19 patients referred for echocardiographic studies. RESULTS--A significant correlation was found between the methods for measurement of the time from the R wave to mitral valve opening (r = 0.72, p < 0.01), isovolumic relaxation time (r = 0.62, p < 0.01), and ejection time (r = 0.54, p < 0.01). The change of total area that occurred during rapid filling and atrial filling phases measured from the acoustic waveform correlated with the time-velocity integrals of the early and late diastolic mitral valve inflow velocity derived from Doppler echocardiography (r = 0.60 and r = 0.80, respectively). CONCLUSION--The waveform of left ventricular area obtained by the automated boundary detection technique identifies the phases of the cardiac cycle and correlates with Doppler values of left ventricular diastolic function. Therefore, this new method of automated boundary detection has potential uses in the assessment of left ventricular diastolic function.
PMCID: PMC1025358  PMID: 8260277
5.  Doppler echocardiographic evaluation of valve regurgitation in healthy volunteers. 
British Heart Journal  1993;69(2):109-113.
OBJECTIVE--To study the prevalence and the characteristics of physiological valve regurgitation. DESIGN--Pulsed wave Doppler echocardiography, continuous wave Doppler echocardiography and Doppler colour flow mapping were performed prospectively in healthy volunteers. SETTING--Echocardiography laboratory in a city hospital. PATIENTS--32 consecutive healthy volunteers (age 21-49 years, mean age 29.4). MAIN OUTCOME MEASURES--Identification of regurgitation with colour Doppler flow mapping and measurement of the jet area, jet length, and maximal velocity of the regurgitation. RESULTS--Regurgitation was recorded at the pulmonary (100%), tricuspid (100%), mitral (56%), and aortic valves (6%). The velocity of pulmonary and tricuspid regurgitation was similar to that predicted from the pressure gradient calculated from the Bernoulli equation. The jet area and jet length were generally small. CONCLUSION--Trivial regurgitation from the pulmonary, tricuspid, and mitral valves is common in healthy people. It is important to take such regurgitation into account when valve disease is diagnosed.
PMCID: PMC1024935  PMID: 8435234
6.  Acute Smoking-Induced Alterations in Doppler Echocardiographic Measurements in Chronic Smokers 
Texas Heart Institute Journal  2006;33(2):134-138.
Acute effects of smoking on left ventricular function have been studied previously. However, effects on right ventricular function have not yet been investigated. In this study, we attempted to investigate, through a combination of conventional and tissue Doppler imaging (TDI), the acute effects of smoking on both left and right ventricular function in chronic smokers.
Thirty chronic smokers (with smoking habits of ≥1 pack/day for 7.4 ± 1.3 years) underwent a complete transthoracic echocardiographic examination (2-dimensional, pulsed-wave Doppler transmitral and transtricuspid recordings, and TDI recordings of mitral and tricuspid annular velocities) by 3.5-MHz sector transducer. Pulsed-wave Doppler indices of left and right ventricular diastolic function—such as mitral and tricuspid inflows, peak early (E) and late (A) velocities, and E/A ratios—were obtained by conventional Doppler and TDI. Echocardiographic indices of the left and right ventricles—including isovolumetric relaxation time, isovolumetric contraction time, ejection time, and myocardial performance index of right ventricle—were also measured before and 30 minutes after each subject smoked a cigarette.
Both mitral and tricuspid inflow measurements changed significantly after smoking a cigarette. Among the TDI measurements, mitral lateral annulus and tricuspid lateral annulus (diastolic, but not systolic) velocities changed after smoking a cigarette. Also, the right ventricular myocardial performance index increased immediately after smoking a cigarette.
We found that acute cigarette smoking impaired both left and right ventricular diastolic function in chronic smokers.
PMCID: PMC1524678  PMID: 16878613
Blood flow velocity; diastole/drug effects; echocardiography, Doppler; heart rate/drug effects; heart ventricles/drug effects; hemodynamic processes; myocardial contraction/drug effects; smoking/adverse effects; sympathetic nervous system/drug effects; ventricular function, left/drug effects; ventricular function, right/drug effects
7.  Spurious tricuspid regurgitation 
Thorax  1973;28(4):495-497.
Brown, A. H., and Braimbridge, M. V. (1973).Thorax, 28, 495-497. Spurious tricuspid regurgitation: Three conditions mimicking tricuspid regurgitation diagnosed at operation. The diagnosis of tricuspid incompetence is difficult. Three patients are described in whom the diagnosis of tricuspid regurgitation was made but disproved by the findings at surgery. The first patient had aortic regurgitation, mitral regurgitation from chordal rupture, and constrictive pericarditis; the right atrium was compressed between the pulsating left atrium and the tight pericardium. The chordal rupture caused the mitral murmur to radiate parasternally. The second patient had severe mitral and aortic regurgitation and an interatrial septal defect with transmission of the left-sided `v' waves to the right atrium. The third patient had an iatrogenic Gerbode defect from a previously repaired ostium primum atrial septal defect. Intracardiac phonocardiography failed to distinguish the anatomical situation from tricuspid regurgitation. The best assessment of tricuspid valvular disease is still that of the surgeon at operation.
PMCID: PMC470066  PMID: 4741454
8.  Discrepancies in the measurement of isovolumic relaxation time: a study comparing M mode and Doppler echocardiography. 
British Heart Journal  1990;64(3):214-218.
Mitral valve cusp separation on M mode echogram, the mitral valve opening artefact, and the onset of forward transmitral flow recorded by Doppler echocardiography have all been taken to mark the end of isovolumic relaxation, while its onset has been taken either as the aortic closure sound (A2) recorded phonocardiographically or the aortic closure artefact determined by Doppler technique. Possible differences in the measurement of the isovolumic relaxation time were studied when these landmarks were used in 44 healthy people, 14 patients with mitral stenosis, 21 patients with left ventricular hypertrophy, and 24 patients with dilated cardiomyopathy by recording M mode echograms of the mitral valve, and pulsed and continuous wave Doppler spectra of transmitral flow, with simultaneous electrocardiograms and phonocardiograms. A2 was effectively synchronous with the aortic artefact. However, when the onset of Doppler flow was regarded as the end of isovolumic relaxation, the interval was significantly longer than when mitral cusp separation on M mode echograms was used: by 25 (10) ms in healthy individuals, by 25 (15) ms in patients with left ventricular hypertrophy, and by 50 (35) ms in patients with dilated cardiomyopathy. In patients with mitral stenosis the interval was only 5 (5) ms longer. The mitral valve opening artefact consistently followed the onset of flow and corresponded much more closely to the E point on the M mode echogram. This shows that it occurred during the rapid filling period and well beyond isovolumic relaxation by any definition. Thus isovolumic relaxation time measured from A2 to the onset of transmitral flow or the mitral valve opening artefact differs from that derived from A2 to mitral valve cusp separation. These intervals cannot be used interchangeably to measure "isovolumic relaxation time".
PMCID: PMC1024377  PMID: 2144990
9.  Atrioventricular Flow Wave Patterns before and after Birth by Fetal Echocardiography 
Doppler echocardiographic measurements of both valves during intrauterine life can be used to calculate peak early filling velocity (E)/late peak atrial filling velocity (A) ratio as a single index of diastolic performance. The purposes of this study were to estimate the changes in atrioventricular valve flow from gestational age 37-40 weeks to 1 month of postnatal life and to clarify the difference in right and left ventricular diastolic filling patterns.
Atrioventricular flow waves were analyzed in 24 full-term pregnant women by fetal echocardiography. Postnatal follow-up studies were performed at 1 hour, 6 hours, 24 hours, 3 days, 1 week and 1 month. In each time point, pulsed Doppler echocardiography was used to interrogate Doppler waveform of E velocity, A velocity, total area under the curve (time velocity integral) and heart rate.
Mitral E/A ratio significantly increased from 0.7 ± 0.1 before birth to 1.0 ± 0.3 at postnatal 1 hour, 1.0 ± 0.2 at 1 week, and 1.5 ± 1.0 at 1 month. Tricuspid flow E/A ratio was 0.8 ± 0.3 before birth, 0.8 ± 0.1 at 1 hour, 0.8 ± 0.2 at 3 days, 0.9 ± 1.0 at 1 month. Time velocity integral of tricuspid flow was significantly higher than that of mitral flow before birth, but there was no difference after birth.
The dominance of mitral A wave before birth was changed very quickly after birth to the dominance of E wave, but the dominance of tricuspid A wave was maintained at 1 month. Diastolic function and compliance of mitral valve were better than those of the tricuspid valve after birth.
PMCID: PMC3391633  PMID: 22787525
Fetal echocardiography; Atrioventricular valve flow
10.  Left atrial size and function: assessment using echocardiographic automatic boundary detection. 
British Heart Journal  1995;74(6):664-670.
OBJECTIVE--To evaluate the waveforms of left atrial area changes obtained by automated boundary detection with newly developed acoustic quantification technology. DESIGN--All subjects had measurements of left atrial areas taken in the apical four chamber, parasternal long axis, and parasternal short axis views using both conventional echocardiographic methods and automatic boundary detection on two occasions separated by at least a week. On the second visit measurements were also repeated in healthy volunteers after acute intravenous volume loading with 1 litre of saline over 2-5 minutes. SETTING--A university medical school echocardiographic laboratory. SUBJECTS--12 healthy male volunteers and 8 patients with cardiac disease (5 with congestive heart failure, 1 with mitral stenosis, and 2 with hypertensive left ventricular hypertrophy, and dilated left atria). RESULTS--There was close correlation between conventionally derived left atrial areas and those obtained by automatic boundary detection, particularly in the apical four chamber view (r = 0.98). Both inter and intra observer variabilities (coefficient of variation) for left atrial areas measured by automatic boundary detection were good (4.7-14.2% and 8.1-18.6% respectively). The reproducibility (coefficient of variation) for derived indices of left atrial function, however, was much poorer (10.4-104.8% and 12.5-88% respectively). After acute volume loading significant increases in left atrial area were observed at all stages in the cardiac cycle. CONCLUSIONS--These data demonstrate that although the reproducibility of left atrial functional indices is poor, instantaneous left atrial cavity measurements with automatic boundary detection are reproducible. This suggests that automatic boundary detection may assist in serial non-invasive measurement of left atrial size to assess disease states and treatments.
PMCID: PMC484127  PMID: 8541175
11.  Doppler aortic flow velocity measurement in healthy children. 
Journal of Korean Medical Science  2001;16(2):140-144.
To determine normal values for Doppler parameters of left ventricular function, ascending aortic blood flow velocity was measured by pulsed wave Doppler echocardiography in 63 healthy children with body surface area (BSA) < 1 m(2) (age < 10 yr). Peak velocity was independent of sex, but increased with body size. Mean acceleration was related to peak velocity (r = 0.75, p < 0.0001). Both stroke distance and ejection time had strong negative correlations with heart rate and positive correlations with BSA, suggesting that these parameters should be evaluated in relation to heart rate and body size. Mean intra- and interobserver variability for peak velocity, ejection time, stroke and minute distance ranged from 3 to 7%, whereas variability for acceleration time was 9 to 13%. These data may be used as reference values for the assessment of hemodynamic states in young children with cardiac disease.
PMCID: PMC3054716  PMID: 11306737
12.  Portable spectral Doppler echocardiographic device: overcoming limitations 
Heart  2003;89(9):1014-1018.
Background: There is evidence that new portable echocardiographic devices are useful in evaluating heart anatomy and function, but a lack of Doppler modes has up to now been an important limitation in obtaining haemodynamic data.
Objectives: To report the Doppler capabilities of a new hand held echocardiographic device.
Design: Blinded comparison of two types of echocardiography machine.
Setting: Tertiary care centre.
Patients: 98 consecutive patients were randomly imaged with the hand held device, with a standard platform as reference.
Outcome measures: Pulsed wave transmitral Doppler inflow tract velocities, deceleration time, and continuous wave Doppler measurements of aortic ejection and tricuspid regurgitation peak velocities were recorded.
Results: There was excellent agreement between the hand held device and standard echocardiography for the evaluation of diastolic E and A waves, E/A ratio, and deceleration time with pulsed wave Doppler (intraclass correlation coefficients of 0.97, 0.93, 0.90, and 0.78, respectively). In addition, good agreement was found between continuous wave Doppler measurements of aortic ejection and tricuspid regurgitation velocities (intraclass correlation coefficients of 0.96 and 0.80). However, there was a significant difference between patients with tricuspid regurgitation measured with the hand held device (25.5%) and by standard echocardiography (65.3%), resulting in misdiagnosis of eight patients with pronounced pulmonary hypertension.
Conclusions: New hand held devices with Doppler capabilities overcome previous limitations in evaluating haemodynamic variables. With colour Doppler they are now suitable for the complete evaluation of valvar disease and diastolic function. However, important limitations remain in the evaluation of pulmonary pressures.
PMCID: PMC1767834  PMID: 12923013
echocardiography; Doppler; point of care system
13.  Reliability of quantitative echocardiography in adult sheep and goats 
Echocardiography is a non-invasive method for assessment of the ovine and caprine heart. Complete reference ranges for cardiac dimensions and time indices for both species are not currently available and reliability of these measurements has not been evaluated. The objectives for this study are to report reliability, normal cardiac dimensions and time indices in a large group of adult sheep and goats.
Fifty-one adult sheep and forty adult goats were recruited. Full echocardiographic examinations were performed in the standing unsedated animal. All animals underwent echocardiography four times in a 72-hour period. Echocardiography was performed three times by one author and once by another. Images were stored and measured offline. Technique and measurement repeatability and reproducibility and any differences due to animal or day were evaluated. Reference ranges (mean ± 2 standard deviations) were calculated for both species.
Majority of the images obtained were of good to excellent quality. Image acquisition was straightforward with 5.4% of animals demonstrating a small scanning window. Reliability was excellent for majority of dimensions and time indices. There was less variation in repeatability when compared with reproducibility and differences were greater for technique than for measurements. Dimensions that were less reliable included those for right ventricular diameter and left ventricular free wall. There were many differences in cardiac dimensions between sheep and goats.
This study has demonstrated that specific reference ranges are required for these two species. Repeatability and reproducibility were excellent for the majority of cardiac dimensions and time indices suggesting that this technique is reliable and valuable for examination of clinical cases over time and for longitudinal research studies.
PMCID: PMC3574009  PMID: 23017011
Ovine; Caprine; Cardiac; Heart; Measurements; Ultrasonography
14.  Simultaneous Beat-by-Beat Investigation of the Effects of the Valsalva Maneuver on Left and Right Ventricular Filling and the Possible Mechanism 
PLoS ONE  2013;8(1):e53917.
Although the influence of the Valsalva maneuver on the heart and circulatory system has been investigated, the mechanism of intrathoracic pressure influencing cardiovascular function is unclear. To test our hypothesis that the interaction between the anatomy-determined partially-intrathoracic system and the fully-intrathoracic system might explain those issues and help to disclose the mechanism, we used the Hitachi dual pulse wave Doppler echocardiographic apparatus to investigate simultaneously the beat-by-beat influence of 40-mmHg Valsalva maneuver on left and right cardiac ventricular filling in 30 male adult volunteers. The mitral and tricuspid blood inflow velocity spectra during the Valsalva maneuver were recorded simultaneously. The peak velocity (PV), velocity–time integral (VTI) and inflow volume (IV) of each cycle were measured or calculated. The PV, VTI and IV of the left heart remained unchanged at the first beat after the Valsalva maneuver onset (compared with those at rest, p>0.1) and then decreased gradually to the lowest at the 11±1.2th beat (range, 9th to 12th beat). Simultaneously, the PV, VTI and IV of the right heart decreased significantly (p<0.05) at the first cycle, decreased rapidly to the lowest at the 6±0.8th beat (range, 4th to 7th beat) and then increased gradually to the 9±1.3th beat (range, 8th to 10th beat). These results suggest that the left heart and right heart have different physiological responses to the Valsalva maneuver. These could be explained by our hypothesis, the interaction between the partially-intrathoracic system and the fully-intrathoracic system, which might help to disclose the mechanism of how intrathoracic pressure influences the heart and circulatory system.
PMCID: PMC3544743  PMID: 23342040
15.  Ventricular septal defect after myocardial infarction: assessment by cross sectional echocardiography with pulsed wave Doppler scanning. 
British Heart Journal  1987;58(3):214-217.
Eight patients who developed a ventricular septal defect after myocardial infarction were assessed by cross sectional echocardiography and pulsed wave Doppler scanning. Cross sectional echocardiography visualised the defect in four patients and gave an accurate assessment of global and regional left ventricular function in all eight. In all patients pulsed wave Doppler scanning detected turbulent flow at the apex of the right ventricle or adjacent to a wall motion abnormality affecting the interventricular septum. Pulsed wave Doppler detected coexisting mitral regurgitation in one patient and tricuspid regurgitation in another two. In all patients a left to right shunt was confirmed by oximetry and the location of the defect was identified by angiography or at operation or necropsy. Cross sectional echocardiography in combination with pulsed wave Doppler scanning is useful in the rapid bedside evaluation of patients with ventricular septal defect after myocardial infarction.
PMCID: PMC1216439  PMID: 3663420
16.  Reference ranges for cardiac dimensions and blood flow velocity in preterm infants 
Heart  1998;80(3):281-285.
Aim—To establish reference ranges for cardiac dimensions and Doppler measurements in preterm infants.
Methods—79 infants of less than 34 weeks' gestation were examined by echocardiography on days 0, 7, and 28 after birth, to produce a set of reference ranges and to examine changes in these indices over the first month of life. The following dimensions were measured: interventricular septum, left ventricular posterior wall, left interventricular diameter at end systole and diastole, left atrium, and aortic root; Doppler measurements were made of maximum blood flow velocity (Vmax) through the pulmonary, aortic, mitral, and tricuspid valves.
Results—Reference ranges are given. Cardiac dimensions correlated well with gestation and birth weight but Vmax did not. There was a significant increase in measurements over time. The "normal" preterm infant also appeared to often have asymmetrical septal hypertrophy. Antenatal dexamethasone administration did not appear to affect the measurements. 
Conclusions—There is a close correlation with both gestation and birth weight for all physical measurements. Echocardiograms in preterm babies clearly differ from those in older children and adults.

 Keywords: cardiac dimensions;  blood flow velocity;  preterm infant
PMCID: PMC1761096  PMID: 9875089
17.  Mitral valve hypoplasia in children with isolated coarctation of the aorta. 
British Heart Journal  1994;71(4):358-362.
OBJECTIVE--To test the hypothesis that isolated coarctation of the aorta is associated with relative hypoplasia of the mitral valve, even when the valve is morphologically normal. DESIGN--Cross sectional and Doppler echocardiography were used in a prospective, paired, case control study to compare mitral valve dimensions and diastolic transmitral flow characteristics as indices of left heart development. 40 children with isolated coarctation and 40 size matched controls were examined. Within the coarctation group 14 children with apical diastolic murmurs were compared with 14 size matched patients without murmurs. SETTING--A supraregional tertiary referral centre for paediatric cardiology. OUTCOME MEASURES--Mitral valve diameters, measured from the parasternal long axis, short axis, and apical four chamber views; mitral valve cross sectional area measured from the parasternal short axis view; peak early (E) and peak atrial (A) phase diastolic transmitral flow velocities measured by pulsed wave Doppler from the apical four chamber view; derived E/A ratio and pressure half time of decay from peak E. RESULTS--Mitral valve dimensions were significantly smaller in children with coarctation than in controls for long axis diameter (median 1.74 v 1.90cm, p = 0.0001), short axis diameter (2.21 v 2.28 cm, p = 0.027), and cross sectional area (2.37 v 3.15 cm2, p = 0.001). Peak E and A velocities were significantly higher in patients than in controls (0.9 v 0.82 ms-1, p = 0.013 and 0.61 v 0.51 ms-1, p = 0.007). The only difference between children with coarctation plus murmurs and those without murmurs was a marginally longer pressure half time. CONCLUSIONS--Smaller mitral valve dimensions and increased diastolic transmitral flow velocities in children with isolated coarctation compared with normal children suggests that coarctation may be part of a generalised hypoplasia of left heart structures.
PMCID: PMC483686  PMID: 8198886
18.  Feasibility and variability of six methods for the echocardiographic and Doppler determination of cardiac output. 
British Heart Journal  1988;59(3):299-303.
The feasibility and the intrinsic variability of six different methods of echocardiographic and Doppler flow determination of cardiac output were analysed in 34 healthy volunteers. Four were excluded because of poor quality echocardiograms. The mean (range) age of the remaining 30 (12 women, 18 men) was 21 years (13-36 years). Cardiac output was calculated by six methods as a product of echocardiographically determined cross sectional area of the aorta (apical and suprasternal views), pulmonary trunk, tricuspid annulus, and mitral annulus (circular and corrected for diastolic variations), and the flow velocity integral measured by Doppler. Cardiac output ranged from 2.79 to 6.56 1/min (4.45 (1.29) 1/min) (mean (SD)). The feasibility of the methods ranged from 87% (26 patients) for the aorta from the suprasternal notch to 100% (30 patients) for the mitral orifice corrected for diastolic variations and for the tricuspid valve. The corresponding results for all 34 individuals were 76% and 88% respectively. Three way analysis of variance was performed in the 23 healthy volunteers in whom all six methods were feasible. Interobserver and intraobserver interpretative variabilities were 6.8% and 5.9% respectively. The intrinsic variability of each single measurement of cardiac output, independently of the observer and the method used, was 25%. Provided the image was suitable for analysis echocardiographic and Doppler flow determination of cardiac output was feasible in most healthy volunteers. But there was significant intrinsic variability for each of different methods. A single value of cardiac output in an individual should be interpreted with caution.
PMCID: PMC1216463  PMID: 3355721
19.  Pericardial effusion after cardiac surgery: incidence, site, size, and haemodynamic consequences. 
British Heart Journal  1994;72(4):327-331.
OBJECTIVE--To evaluate the incidence, characteristics, and haemodynamic consequences of pericardial effusion after cardiac surgery. DESIGN--Clinical, echocardiographic, and Doppler evaluations before and 8 days after cardiac surgery; with echocardiographic and Doppler follow up of patients with moderate or large pericardial effusion after operation. SETTING--Patients undergoing cardiac surgery at a tertiary centre. PATIENTS--803 consecutive patients who had coronary artery bypass grafting (430), valve replacement (330), and other types of surgery (43). 23 were excluded because of early reoperation. MAIN OUTCOME MEASURES--Size and site of pericardial effusion evaluated by cross sectional echocardiography and signs of cardiac tamponade detected by ultrasound (right atrial and ventricular diastolic collapse, left ventricular diastolic collapse, distension of the inferior vena cava), and Doppler echocardiography (inspiratory decrease of aortic and mitral flow velocities). RESULTS--Pericardial effusion was detected in 498 (64%) of 780 patients and was more often associated with coronary artery bypass grafting than with valve replacement or other types of surgery; it was small in 68.4%, moderate in 29.8%, and large in 1.6%. Loculated effusions (57.8%) were more frequent than diffuse ones (42.2%). The size and site of effusion were related to the type of surgery. None of the small pericardial effusions increased in size; the amount of fluid decreased within a month in most patients with moderate effusion and in a few (7 patients) developed into a large effusion and cardiac tamponade. 15 individuals (1.9%) had cardiac tamponade; this event was significantly more common after valve replacement (12 patients) than after coronary artery bypass grafting (2 patients) or other types of surgery (1 patient after pulmonary embolectomy). In patients with cardiac tamponade aortic and mitral flow velocities invariably decreased during inspiration; the echocardiographic signs were less reliable. CONCLUSIONS--Pericardial effusion after cardiac surgery is common and its size and site are related to the type of surgery. Cardiac tamponade is rare and is more common in patients receiving oral anticoagulants. Echo-Doppler imaging is useful for the evaluation of pericardial fluid accumulations after cardiac surgery. It can identify effusions that herald cardiac tamponade.
PMCID: PMC1025541  PMID: 7833189
20.  Sustained cardiac diastolic changes elicited by ultrafiltration in patients with moderate congestive heart failure: pathophysiological correlates. 
British Heart Journal  1993;70(2):135-140.
OBJECTIVE--To investigate the pathophysiological (cardiac function and physical performance) significance of clinically silent interstitial lung water accumulation in patients with moderate heart failure; to use isolated ultrafiltration as a means of extravascular fluid reabsorption. DESIGN--Echocardiographic, Doppler, chest x-ray evaluations, and cardiopulmonary tests at baseline, soon after ultrafiltration (veno venous extracorporeal circuit), and four days, one month, and three months later. SETTING--University institute of cardiology. SUBJECTS--24 patients with heart failure due to idiopathic dilated cardiomyopathy or ischaemic myocardial disease with sinus rhythm and ejection fraction less than 35%. Twelve were randomised to ultrafiltration and 12 were taken as controls. MAIN OUTCOME MEASURES--Left ventricular systolic function (from ultrasonography); Doppler evaluation of mitral, tricuspid, and aortic flow and echo-Doppler determination of cardiac output; radiological score of extravascular lung water; right and left ventricular filling pressures; oxygen consumption at peak exercise and exercise tolerance time in cardiopulmonary tests. RESULTS--Soon after ultrafiltration (1976 (760) ml of fluid removed) the following was observed: a reduction in radiological score of extravascular lung water (from 15(1) to 9(1)) and of right (from 7.1 (2.3) to 2.3 (1.7) mm Hg) and left (from 17.6 (8.8) to 9.5 (6.4) mm Hg) ventricular filling pressures; an increase in oxygen consumption at peak exercise (from 15.8 (3.3) to 17.6 (2) ml/min/kg) and of tolerance time (from 444 (138) to 508 (134) s); a slight decrease in atrial and ventricular dimensions; no changes in the systolic function of the left ventricle; a reduction of the early to late filling ratio in both ventricles (mitral valve from 2 (2) to 1.1 (1.1)); (tricuspid valve from 1.3 (1.3) to 0.69 (0.18)) and an increase in the deceleration time of mitral and tricuspid flow, reflecting a redistribution of filling to late diastole. Variations in the ventricular filling pattern, lung water content, and functional performance persisted for three months in all cases. None of these changes was detected in the control group. CONCLUSIONS--Reduction of interstitial lung water was probably the mechanism whereby ultrafiltration modified the pattern of filling of the two ventricles and improved functional performance.
PMCID: PMC1025273  PMID: 8038023
21.  Acute effects of cigarette smoking on the cardiac diastolic functions 
Smoking is an independent risk factor for coronary heart diseases and it increases all causes of cardiovascular morbidity and mortality.
Aim of the work
To assess the acute effect of cigarette smoking on ventricular diastolic functions (LV and RV) in healthy, young, and slim smokers.
Thirty volunteers who had recently commenced smoking (less than one year) and who smoked 1–2 cigarettes per day, underwent ECG, 2D and M-mode echocardiography, standard Doppler echocardiography, pulsed TDI (tissue Doppler imaging) on septal and lateral side of mitral annulus and lateral tricuspid annulus. Vp values were measured. The investigator asked them to hold smoking for at least two days after which echocardiographic examination was conducted before smoking one cigarette and the second examination conducted immediately after smoking one cigarette containing at least 0.4 mg of nicotine.
Doppler findings over the mitral valve showed the E wave was significantly reduced from 82.7 ± 10.4 to 74.6 ± 10.4 after smoking; the A wave increased; the E/A ratio was reduced from 1.5 ± 0.3 to 1.2 ± 0.2; the E′ septal significantly decreased (15.3 ± 2.4 vs. 11.2 ± 1.1) after smoking, and the E/E′ ratio increased from 5.5 ± 1.1 to 6.7 ± 1.1. Doppler findings over the tricuspid valve showed the E wave was reduced from 60.6 ± 9.7 to 52.7 ± 9.6; the A wave increased from 42.2 ± 6.5 to 50.1 ± 6.6; and the E/A ratio decreased (1.45 ± 0.25 vs. 1.06 ± 0.19). The E′ significantly decreased from 14.1 ± 1.8 to 10.9 ± 2.4, while the A′ increased (10.2 ± 2.4 vs. 12.7 ± 3.6) after smoking; and the IVRT of the RV was significantly prolonged from 62.9 ± 7.5 to 68.7 ± 7.9 after smoking. The Vp was markedly reduced from 67.8 ± 8 to 55.2 ± 3.5 after smoking. These findings reflected on the LV filling pressure (LVFvp) which increased from 9.8 ± 1.4 to 10.5 ± 1.3 after smoking. All changes were statistically significant at P < 0.001.
Our study reveals that cigarette smoking can result in significant acute alteration in the diastolic functions of both ventricles.
PMCID: PMC3809467  PMID: 24174857
Cigarette; Smoking; RV dysfunction; LV dysfunction; Acute effect
22.  A new automated system to identify a consistent sampling position to make tissue Doppler and transmitral Doppler measurements of E, E′ and E/E′☆☆☆ 
International Journal of Cardiology  2012;155(3):394-399.
Transmitral pulse wave (PW) Doppler and annular tissue Doppler velocity measurements provide valuable diagnostic and prognostic information. However, they depend on an echocardiographer manually selecting positions to make the measurements. This is time-consuming and open to variability, especially by less experienced operators. We present a new, automated method to select consistent Doppler velocity sites to measure blood flow and muscle function.
Our automated algorithm combines speckle tracking and colour flow mapping to locate the septal and lateral mitral valve annuli (to measure peak early diastolic velocity, E′) and the mitral valve inflow (to measure peak inflow velocity, E). We also automate peak velocity measurements from resulting PW Doppler traces. The algorithm-selected locations and time taken to identify them were compared against a panel of echo specialists — the current “gold standard”.
The algorithm identified positions to measure Doppler velocities within 3.6 ± 2.2 mm (mitral inflow), 3.2 ± 1.8 mm (septal annulus) and 3.8 ± 1.5 mm (lateral annulus) of the consensus of 3 specialists. This was less than the average 4 mm fidelity with which the specialists could themselves identify the points. The automated algorithm could potentially reduce the time taken to make these measurements by 60 ± 15%.
Our automated algorithm identified sampling positions for measurement of mitral flow, septal and lateral tissue velocities as reliably as specialists. It provides a rapid, easy method for new specialists and potentially non-specialists to make automated measurements of key cardiac physiological indices. This could help support decision-making, without introducing delay and extend availability of echocardiography to more patients.
PMCID: PMC3314963  PMID: 21093935
Echocardiography; Doppler; Pulsed; Heart failure; Systolic; Heart failure; Diastolic; Automated
23.  Evaluation of mitral and tricuspid valve velocities in 45 fetuses 
The study was done to assess the tricuspid and mitral valve velocities in 45 fetuses between 18 and 28 weeks and to compare these findings with reported values from literature.
The study was conducted on 45 women referred to the clinic for sonography examination. They were between 18 and 28 weeks gestation. They had no past history of any medical disorder, no history of drug exposure, and no family history of congenital heart disease. They had undergone 1st trimester screening and the NT was reported as normal. The fetuses were otherwise normal with respect to sonographic findings. Fetal echocardiography was done using 2D and color Doppler. Standard views of the heart were obtained and were confirmed to be satisfactory and normal. When these conditions were satisfied, the patients were included in the study. The mitral and tricuspid velocities were assessed with Pulsed Wave Doppler. Peak “A” wave velocities across both valves were measured. From the data, mean velocity, minimum and maximum values and 95% confidence limits were calculated.
The mitral valve peak “A” wave velocity observations were, mean mitral valve velocity = 45.67 cm/sec, maximum mitral valve velocity = 75.81 cm/sec, minimum mitral valve velocity = 31.00 cm/sec, standard deviation = 10.20, maximum 95% confidence limit = 66.08 cm/sec and minimum 95% confidence limit = 25.27 cm/sec. The tricuspid valve peak “A” wave velocity observation were Mean Tricuspid velocity = 46.61 cm/sec, Max velocity = 76.39 cm/sec, Min velocity = 33.97 cm/sec, sd = 8.44, higher 95% confidence limit = 63.50 and lower 95% confidence limit 29.72 cm/sec.
The results showed that the velocities obtained in the Indian population were similar to those obtained in the western literature.
PMCID: PMC3394525
mitral velocity; tricuspid velocity
24.  New applications of intracardiac echocardiography: assessment of coronary blood flow by colour and pulsed Doppler imaging in dogs 
Heart  2002;88(3):283-288.
Objective: To explore the application of a new 10 French intracardiac echocardiography (ICE) catheter with phased array and Doppler capable transducer for the assessment of epicardial and intramyocardial coronary blood flow.
Methods: The coronary arteries were detected by cross sectional imaging in seven closed chest dogs, and coronary blood flow visualised by colour Doppler. Blood flow velocities were recorded by pulsed Doppler at baseline for reproducibility of repeated measurements, and during hyperaemia for coronary flow reserve measurements. Comparisons were made with Doppler guide wire data obtained simultaneously. Intramyocardial coronary artery blood flow was assessed by colour flow mapping, and the blood flow velocities recorded using pulsed Doppler at baseline and during hyperaemia.
Results: Seven left main, six left anterior descending, seven left circumflex, and five right coronary arteries were visualised in the seven animals by cross sectional or colour Doppler imaging. Repeated measurements of coronary flow velocity showed a good correlation (mean diastolic velocity, r = 0.93, n = 22, p < 0.0001; peak diastolic velocity, r = 0.96, n = 22, p < 0.0001, respectively). Intraobserver/interobserver variability was satisfactorily low. Coronary flow reserve from ICE correlated highly with the value obtained from the Doppler guide wire (r = 0.90, n = 26, p < 0.0001). Intramyocardial coronary blood flow was identified in all seven dogs, and flow velocities were recorded at baseline and during hyperaemia in four animals.
Conclusions: This new ICE catheter provides high quality diagnostic resolution. It is useful for coronary blood flow assessment.
PMCID: PMC1767320  PMID: 12181224
intracardiac echocardiography; Doppler echocardiography; coronary circulation
25.  Augmentation index and aortic stiffness in bicuspid aortic valve patients with non-dilated proximal aortas 
We compared aortic stiffness, aortic impedance and pressure from wave reflections in the setting of bicuspid aortic valve (BAV) to the tricuspid aortic valve (TAV) in the absence of proximal aortic dilation. We hypothesized BAV is associated with abnormal arterial stiffness.
Ten BAV subjects (47 ± 4 years, 6 male) and 13 TAV subjects (46 ± 4 years, 10 male) without significant aortic valve disease were prospectively recruited. Characteristic impedance (Zc) was derived from echocardiographic images and pulse wave Doppler of the left ventricular outflow tract. Applanation tonometry was performed to obtain pulse wave velocity (PWV) at several sites as measures of arterial stiffness and augmentation index (AIx) as a measure of wave reflection.
There were no significant differences between BAV and TAV subjects with regard to heart rate or blood pressure. Zc was similar between BAV and TAV subjects (p=0.25) as was carotid-femoral pulse wave velocity (cf-PWV) and carotid-radial PWV (cr-PWV) between BAV and TAV subjects (p=0.99). Carotid AIx was significantly higher in BAV patients compared with TAV patients (14.3 ± 4.18% versus -3.02 ± 3.96%, p=0.007).
Aortic stiffness and impedance is similar between subjects with BAV and TAV with normal aortic dimensions. The significantly higher carotid AIx in BAV, a proxy of increased pressure from wave reflections, may reflect abnormal vascular function distal to the aorta.
PMCID: PMC3602003  PMID: 23496804
Bicuspid aortic valve; Arterial stiffness; Augmentation index; Pulse wave velocity

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