Echocardiogram (ECHO)

Abstract: Echocardiogram (ECHO) is an essential tool for diagnosis, evaluation, and management of valvular heart disease (VHD). There is an increasing population with valvular heart disease with the advent of advanced medical therapies. The burden of problem is still secondary to rheumatic and degenerative heart disease. In year 2014, the American Heart Association released new guidelines for the management of VHD. They recommend classifying VHD to stages of progression similar to Heart Failure (Table 1). This helps in streamlining the decision making process for patients with VHD. In a patient with VHD it is important to answer these questions in order to make objective decision on whether to intervene or not:
1) Are the symptoms due to VHD?
It is recommended in patients who have high surgical risk, but meet the indications for Aortic valve replacement (AVR) and have an expected post TAVR survival of >12 months. It is contraindicated in patients with bicuspid/unicuspid/noncalcified aortic valve, acute myocardial infarction (MI), significant coronary artery disease (CAD), an LVEF 25 mm, severe aortic regurgitation or mitral regurgitation, a transient ischemic attack within 6 months, severe renal insufficiency or if the 30-day surgical morbidity and mortality is ≥50% (3, 7, 8).
Balloon valvuloplasty is used in hemodynamically unstable patients as a bridge to SAVR or TAVR in selected patients with severe symptomatic calcific AS or as a palliative measure when surgical risk is high due to comorbidities. It is also indicated in patients with symptomatic severe AS requiring urgent major non-cardiac surgery. There is a 10-20% risk of major complication during valvuloplasty. The hemodynamic and clinical benefit is only transient along with poor long-term outcome (3, 4).
Physiological PR is more common and accounts for 40-78% of patients who have minor degrees of PR without structural abnormalities. Pathological PR may be congenital or acquired. Congenital anomalies account for majority of cases and include bicuspid or quadricuspid valves, leaflet hypoplasia, atretic and myxomatous valve prolapse. Acquired causes include pulmonary hypertension, carcinoid tumors, infective endocarditis, rheumatic heart disease, Marfan’s syndrome and post repair of congenital heart disease or pulmonary stenosis (25).
Role of echocardiography in evaluation of Pulmonary Regurgitation
a. 2DE helps in the evaluation of the number, mobility and the structure of the cusps. It also helps to determine right ventricular size and function.
b. CW/PW Doppler helps to differentiate pathological and physiological PR jets. Pathological PR jet is wider, holodiastolic and longer in duration as compared to the physiological PR jet which is small, central, protodiastolic or mid-diastolic and shorter in duration.
c. 3DE can be used for an accurate assessment of the vena contracta and hence severity of PR.
d. Exercise echo is used only in selected cases of congenital heart disease. It helps to assess RV function under stress and unmasks any latent RV dysfunction (3, 4,