Ronald H Wharton, MD

Disclosures

August 27, 2015

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Ronald H Wharton, MD: Hello, and greetings from Bronx, New York. This is Dr Ronald Wharton at Montefiore Medical Center. I thought I would show you an interesting Doppler and see if you could figure out where this Doppler came from.

On this slide you see a continuous-wave Doppler signal with both a dense systolic and almost as dense a diastolic signal. I thought we would look at the 2D images and see if you could figure out how this signal arrived on the echo.

Here is a parasternal long-axis view. You'll notice that there is a bioprosthetic mitral valve. Left ventricular systolic function and right ventricular systolic function look okay. The aortic valve appears to be opening normally. The mitral leaflets appear to be opening normally.

If you look at the next slide with color, there seems to be laminar flow through the aortic valve. It doesn't seem to have any significant aortic regurgitation, none at all really, and a typical flow pattern through the mitral bioprosthesis. Again, there is no mitral regurgitation (MR) seen in this image.

If you look at the next slide with the short axis of the aortic-valve level, you can see flow in and out of the pulmonic valve with a small amount of pulmonic insufficiency. The leaflets appear to be moving normally. The leaflets are thin and easily mobile.

In the next slide we have a slightly off-axis view of the apical four-chamber view. The left atrium is somewhat dilated. That's not surprising considering that there's a mitral bioprosthesis. The tricuspid valve leaflets look normal.

Now I'm showing you color flow in and out of the tricuspid valve. There doesn't seem to be anything alarming here, either. So you've now seen 2D and color Doppler of all four valves.

Here again in the next slide you can see an apical long-axis view with the left ventricle and the right ventricular outflow tract (RVOT) on the right side.

So, how do we explain the Doppler? When you look at any Doppler signal, what are we looking at? We're looking at the velocities, the density, the timing, the contour, and obviously any signal that's on the other side as well.

We have a dense systolic flow that seems to be throughout the entire systolic cycle that's peaking at 3m/s, and then there's a pan-diastolic flow with a peak velocity of 2 m/s. Remember that velocities of flow have to correlate with typical pressures that you would expect inside the cardiac chambers.

What could this be? You could get pulmonic stenosis (PS) with a systolic velocity of 3 m/s. You can get some pulmonic regurgitation (PR) with a velocity like the one we have here of 2 m/s, but there's a problem. If there were PS and PR, we would see it on the color Doppler. There was really no turbulence to the pulmonic valve. The pulmonic valve opens up nicely. Additionally, pulmonic stenosis would be going away from the transducer and pulmonic insufficiency would be going toward the transducer. That's not happening here. That doesn't make sense. Then of course, as I said, the pulmonic valve looks normal on the 2D imaging.

So, what else could this be? Well, it can't be aortic. The velocities aren't compatible with any aortic pathology. One could also say that's true for mitral and tricuspid valves as well. We looked at the valves. The valves looked fine. The bioprosthetic mitral valve looked normal. The aortic valve looked normal. You can't explain the Doppler profiles on any of those valves either via 2D imaging or via the velocity profiles that we see.

Take a look at the 2D images one more time. This is the parasternal long axis with color now just slightly moved away from the mitral valve, a little toward the center of the screen. This defect, where you can see the color going in and out, was actually apparent on the 2D images all along. I just didn't bother to point it out because I was concentrating on the valves. Take a look at that. There seems to be flow in and out of that defect.

In fact, if you go to the next slide, which is a color shot of the apical long axis from earlier, you can see to-and-fro systolic and diastolic flow coming in and coming out.

Here are the same Doppler images you had before except now I've shown the 2D guided image above (initially I had blocked it out). You can see where this is in fact coming from. It's not coming from a valve at all. There is an inferolateral pseudoaneurysm.

How did this happen? Well, sometimes when you operate on the mitral valve you can ligate the left circumflex artery, and patients can have these for years and be completely unaware of it, completely asymptomatic. This can sometimes be detected on a routine transthoracic echocardiogram. Fortunately, in this patient the dam never burst, as it were, because if you see a pseudoaneurysm one has to worry about the potential for acute pericardial tamponade, which doesn't usually bode well for patients.

The, take-home lesson? Not all Doppler signals are from valves. I just thought you'd find this as enjoyable and as educational as I did. I've seen pseudoaneurysms before but never one quite this large, where the flow velocities were this high. My understanding is the patient is doing quite well. I hope you enjoyed this. Again, this is Ronald Wharton from Montefiore Medical Center, Bronx, New York for theheart.org on Medscape Cardiology. Thanks for tuning in.

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