The Noninvasive Evaluation of Hemodynamics in Congenital Heart Disease: Doppler Ultrasound Applications in the Adult and Pediatric Patient with Congenital Heart Disease PDF
Preview The Noninvasive Evaluation of Hemodynamics in Congenital Heart Disease: Doppler Ultrasound Applications in the Adult and Pediatric Patient with Congenital Heart Disease
THENONINVASIVEEVALUATIONOFHEMODYNAMICS INCONGENITALHEARTDISEASE Developments in Cardiovascular Medicine VOLUME 114 Thetitlespublishedinthisseriesarelistedattheendofthisvolume. THE NONINVASIVE EVALUATION OF HEMODYNAMICS IN CONGENITAL HEART DISEASE Doppler UltrasoundApplications in the Adult andPediatric Patient with Congenital Heart Disease Editedby JAMES V. CHAPMAN ScientificResearchCoordinatorinClinicalUltrasound, DepartmentojCardiology, UniversityMedicalCenter,Gent,Belgium and GEORGER. SUTHERLAND DirectorojEchocardiographyLaboratory, DepartmentojCardiology,ThoraxCenter, ErasmusUniversity,Rotterdam,TheNetherlands KLUWER ACADEMIC PUBLISHERS DORDRECHT / BOSTON / LONDON LibraryofCongressCataloging-in-PublicationData The Noninvasive evaluation of hemodynamics in congenital heart disease Doppler ultrasound applications in the adult and pediatric patient with congenital heart disease I [edited by] James V. Chapman. George R. Sutherland. p. em. -- <Developments in cardiovascular medicine; 114) Inc1udes index. 1. Congenital heart disease--Diagnosis--Congresses. 2. Doppler echocardiography--Congresses. 3. Laser Doppler blood flowmetry -Congresses. I. Chapman. J. V. II. Sutherland. George R.• MS. III. Series: Developments in cardiovascular medicine; v. 114. [DNLM: 1. Echocardiography. Doppler. 2. Heart Defects. Congenital--dlagnosis. 3. Hemodynamics. W1 DE997VME v. 114 I WG 220 N813l RC687.N66 1990 616.1'2043--dc20 DNLM!DLC for Library of Congress 90-5172 ISBN-13:978-94-010-6776-8 e-ISBN-13:978-94-009-0647-1 DOl: 10.1007/978-94-009-0647-1 PublishedbyKluwerAcademicPublishers, P.O.Box 17,3300AADordrecht,TheNetherlands. KluwerAcademicPublishersincorporates thepublishingprogrammesof D.Reidel,MartinusNijhoff,DrW.JunkandMTPPress.. SoldanddistributedintheU.S.A.andCanada byKluwerAcademicPublishers, 101 PhilipDrive,Norwell,MA02061,U.S.A. Inallothercountries,soldanddistributed byKluwerAcademicPublishersGroup, P.O.Box322,3300AHDordrecht,TheNetherlands. Printedonacid-freepaper AllRightsReserved ©1990byKluwerAcademicPublishers Softcoverreprintofthehardcover 1stedition 1990 Nopartofthematerialprotectedbythiscopyrightnoticemaybereproducedor utilizedinanyformorbyanymeans,electronicormechanical, includingphotocopying,recordingorbyanyinformationstorageand retrievalsystem,withoutwrittenpermissionfrom thecopyrightowner. Preface The noninvasive evaluation ofhemodynamics in congenital heart disease is an application for which Dopplerultrasound isideally suited. Thepediatric cardiac sonographerhas used 2D and TMimagingforseveralyearstostudythestructuralabnormalitiesassociatedwithvariouslesions. Pulsed Doppler, continuous wave Doppler, and more recently, colorflow mapping techniques havebeenusedtostudythepathophysiology,andtomakequantitativemeasurementsthereof. To thosealready workinginpediatricechocardiography,this bookisintendedtoserveas aguideto theapplicationsofthevariousDopplermodalitiesinspecificabnormalities. Theothergroupfor which this textisintendedare the adultcardiac sonographerswhoseethe occasional patient with congenital heart disease in their echocardiography laboratories. The incidenceofcongenitalheartdiseaseis notdecreasing. As more patients survivetochild bearing age,theadultcardiologistseesmoreandmorereferralsfrom thepediatriccardiologistto followup the parent withcorrectedcongenital heartdisease, and in many smallerinstitutions, toexamine theiroffspringas well. Forthisgroup, thebookisintendedtoserveasareferencewhichgivesa basicdescriptionofthepathology,therelevantparameterstoobserve,andaguide totheDoppler applicationsusedtomaketheseobservations. While there are afew books availableon the subjectofechocardiography in congenital heart disease, they do not usually go into much detail on noninvasive assessment of the pathophysiology.Itisourhopethatthis textfillsthatgap. Theeditors May, 1990 Contributors JamesV.ChapmanBSc,RDCS ScientificResearchCoordinator inClinicalUltrasound DepartmentofCardiology,UniversityMedicalCenterGent, Belgium AlanG.FraserMB,ChB,MRCP DepartmentofCardiology,ThoraxCenter,Rotterdam,TheNetherlands BeatFriedliMD ProfessorofPediatricCardiology DepartmentofPediatricCardiology,UniversityMedicalCenter,UniversityofGeneva,Switzerland HowardM.McAlpineMB,ChB,MRCP DepartmentofCardiology,ThoraxCenter,Rotterdam,TheNetherlands IngridOberhaensliMD DirectorofEchocardiographyLaboratory DepartmentofPediatricCardiology,UniversityMedicalCenter,UniversityofGeneva,Switzerland NaryswamySreeramMD DepartmentofCardiology,ThoraxCenter,Rotterdam,TheNetherlands OliverF.W.StiimperMD DepartmentofCardiology,ThoraxCenter,Rotterdam,TheNetherlands GeorgeR.SutherlandMD,ChB,FRCP DirectorofEchocardiographyLaboratory, DepartmentofCardiology,ThoraxCenter,Rotterdam,TheNetherlands Acknowledgments Iwouldliketothankseveralpeoplewho havehelpedme bothdirectlyandindirectlyin the writing ofthis text. Throughout the technical chapters I have borrowed extensively from the explanations ofBj~mAngelsen Dr. Techn. and Kjell Kristoffersen Dr. Techn., and thank them for helping me understand difficult technical issues. I would like to acknowledge AlbertoMeguiraM.Sc. andPhillipBrun M.D. from CHU Creteil. Muchof my chapter on blood flow measurements was based on their works in our earlier collaboration "Basic Conceptsin CardiacDoppler". Iwould like to extendmy thariks to David1.SahnM.D., UCSanDiego,whointroducedmetopediatricechocardiographyand initiatedmyinterestin this application,andto DavidT. LinkerM.D., whoas anengineer, adult,andpediatriccardiologist,offeredaninterestingperspectiveonthemultidisciplinary field in which we work. My thanks to Lenny van Kooten for secretarial assistance, and finally, Iwouldlike todedicate my workonthis bookto my wifeSandraand sonJamie forthehoursofneglectimposedupon themduringits writingandlayout. J.Chapman/Gent4/90. Ishouldliketothankthefollowing colleagueswhosehelpandtutionhasbeeninvaluable during the past ten years. I was fortunate to be introduced to both two-dimensional echocardiographyandfluteplayingbyDr.Gert-JanvanMilduringmy stayinUtrecht. Dr. Stewart Hunter in Newcastle convinced me that echocardiographers need not be bad golfers. During my stay in Trondheim, Prof. Liv Hatle not only taught me much about cardiac utrasound, butalso tried to convince me thatcross-country skiing was a viable substitutefor downhill skiing. I would like to thank ProfessorJos Roelandt, whose help and encouragement during the past three years in Thoraxcentrum has been greatly appreciatedandwhohastaughtmemuchaboutwinesfromPomerol,secondhandBMW's and the needto wax your skis beforearace. Ihope my advice to himon Speysidemalts was as good. G.R. Sutherland / Rotterdam 4/90. Table of Contents PREFACE v I THETECHNICALASPECTSOFDOPPLERULTRASOUND J.V. CHAPMAN Introduction 2 ReviewofthePhysicalPrinciplesofUltrasound 3 PrinciplesofDopplerUltrasound 7 PulsedDoppler 11 TheSampleVolume 12 Aliasing 13 RangeAmbiguity 15 ContinuousWaveDoppler 16 TheColorTMMode 19 BidimensionalColorFlowMapping(CFM)Mode 20 LowVelocityRejectintheColorFlowMappingMode 24 MethodsofImplementingaColorFlowMappingSystem 24 FrameRateinaColorFlowMappingSystem 29 Summary 33 II CLINICALLYRELEVANTTOPICSINSIGNALANALYSIS J.V. CHAPMAN FrequencyAnalysis 36 QuadratureDemodulation 36 TheFourierTransform 37 TheSpectralDisplay 40 Filtering 43 SpectralBroadening 43 SignalAnalysisinColorFlowImaging 44 TheMeanFrequencyandVariance 47 ColorFlowMapping DisplayAlgorithms 49 MethodsofQuantifyingColorFlowSignals 51 III BLOODFLOWMEASUREMENTBYDOPPLERULTRASOUND J.V. CHAPMAN Introduction 55 LaminarBloodFlow 55 TheFlowProfile 58 TurbulentFlow 60 VolumetricFlowMeasurements 60 TheClinicalMeasurementofBloodFlow 64 TheAorticSite 64 ThePulmonicSite 65 TheMitralSite 65 MeasurementoftheQp/QsRatio 66 IV THENORMALEXAMINATIONTECHNIQUE J.V. CHAPMAN Introduction 71 TheCharacterizationofBloodRowbyDopplerUltrasound 71 TheNormalDopplerExamination 74 TheAcousticWindowsandTransducerPositions 75 EvaluationofLeftVentricularOutflowandTransaorticBloodRow 75 EvaluationofPulmonaryArteryBloodFlow 80 EvaluationofMitralBloodFlow 82 EvaluationofTricuspidBloodFlow 84 EvaluationofPulmonaryVeinousFlow 85 EvaluationoftheSuperiorandInferiorVenaCavalFlow 85 EvaluationofBloodFlowintheHepaticVeins 85 MeasurementofNormalBloodFlows 86 RegurgitationinNormalValves 86 V OBSTRUCTIVELESIONSINCONGENITALHEARTDISEASE J.V.CHAPMAN,1.OBERHAENSLI,B.FRIEDLI Introduction 90 DeterminationofthePressureGradient 90 LimitationsoftheModifiedBernoulliEquation 93 EstimationoftheValveArea 99 ValvularAorticStenosis 101 SubvalvularAorticStenosis 103 CoarctationoftheAorta 106 ObstructiveCardiomyopathy 113 Pulmonic S~enosis 116 InfundibularPulmonicStenosis 125 PulmonaryBranchNarrowing 128 MitralStenosis 132 Valvuloplasty 137 Summary 148 x VI REGURGITANTLESIONSINCONGENITALHEARTDISEASE J.V. CHAPMAN Introduction 152 AorticInsufficiency 152 BidimensionalandTMImaginginAorticRegurgitation 153 PulsedDopplerTechniquesinAorticInsufficiency 154 ContinuousWaveApplicationsinAorticInsufficiency 159 ColorFlowMappinginAorticInsufficiency 161 TheMulti-modalityApproach 165 MitralInsufficiency 165 PulsedDopplerinMitralInsufficiency 166 ContinuousWaveApplicationsinMitralRegurgitation 170 ColorFlowMappinginMitralRegurgitation 170 PulmonaryRegurgitation 172 PulsedDopplerApplicationsinPulmonicValveRegurgitation 172 ColorFlowMappinginPulmonicValveRegurgitation 173 TricuspidRegurgitation 175 PulsedDopplerApplications 175 ColorFlowMappingApplications 177 VII ESTIMATIONOFPULMONARYARTERYPRESSURE J.V. CHAPMAN TheMeasurementofPulmonaryArteryPressure 187 ThePulmonaryArteryAccelerationTime 187 TheBernoulliEquationinDeterminationofRightVentricularPressure 190 TricuspidRegurgitation 191 PulmonaryRegurgitation 195 VentricularSeptalDefect 196 PatentDuctusArteriosus 197 Conclusion 197 VlII ATRIALSEPTALDEFECTS A.G. FRASER Introduction 201 NormalDevelopmentoftheAtrialSeptum 201 PatentForamenOvale 203 TypesofAtrialSeptalDefects 205 SecundumDefects 206 SinusVenosusDefects 211 CoronarySinusDefects 212 xi
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