Pulmonary Venous Flow Determined in Mitral Stenosis

by Doppler Echocardiography

Gad Keren, MD, Avraham Pardes, MD, Hylton I. Miller, MD, Jack Scherez, BsC, and Shlomo Laniado, MD ecent studies have shown that pulmonary venous flow is normally biphasic. Both phasesdepend on R changesin left atria1pressurethat occur during the cardiac cycle.1-3The first phase correspondsto ventricular systole and is dependenton ventricular contraction and on a timed relaxation of the left atrium. The secondphase occurs during diastole and follows the reduction in atria1 pressureduring the rapid transmitral flow and ventricular filling. In mitral stenosis(MS), flow rate acrossthe mitral valve is reduced,asis the rate of left atria1pressure decayand left ventricular pressurerise.4Thesechangesin left atria1 hemodynamics may affect left atria1 filling from the pulmonary veins. Moreover, many patients with MS have atria1 fibrillation. This arrythmia results in a reduced systolic (J) phaseof pulmonary venous flow.ly5 The present study examines the pattern of pulmonary venous flow velocity in patients with MS. Fifteen patients (10 women, 5 men) with MS were included in the study. Their ages ranged from 30 to 64 years. Their mean mitral valve area obtained by echocardiography was 1.4 f 0.8 cm2 (range 0.6 to 2.4). Eleven patients had mild to moderate MS and were all in sinus rhythm and had normal left ventricular dimensions and function. Four patients had severe MS, 2 of whom were in sinus rhythm and 2 were in atrialfibrillation. The mitral valve area of these 4 patients was 0.6, 0.9,0.9 and I .Ocm2, respectively. All 4 underwent cardiac catheterization and mitral valve area assessed inFrom the Department of Cardiology, Tel Aviv Medical Center,6 Weizman Street, Tel Aviv University, Sackler Schoolof Medicine, Tel Aviv, Israel 64239. This study was supported in part by the G. Harold and Leila Y. Mathers Foundation, White Plains, New York. Manuscript received June 30, 1989; revised manuscript received September 22, 1989,and acceptedSeptember 24.


diastols. 246

1. Rormal pattom of pdnonary

venous flow (PVF) vekity.


vasively and noninvasively was well correlated. Thepulmonary venous flow velocity and mitral flow velocity data obtained in these patients were compared to data from normal volunteers previously published.‘T6 All patients were in stable clinical condition. The patients in atrialjibrillation were treated with diuretics, digitalis and anticoagulants. Echocardiography (M-mode and 2-dimensional) and pulsed Doppler echocardiographic studies of mitral and pulmonary venous flow velocity were performed. An Electronics for Medicine/Honeywell Ultraimager was usedfor both imaging and Dopplerflow velocity studies. Mitraljlow velocity and pulmonary venous flow velocity were recorded from the apical I-chamber view. To obtain mitralflow velocity in the pulsed Doppler mode, the sampling volume was positioned between the tips of the mitral leaflets in the left ventricle, whereas to obtain pulmonary venousflow velocity, the transducer had to be rotated, sometimes slightly, so that the orifices of the pulmonary veins into the left atrium were well visualized and the sampling volume was positioned in place. Mitral flow velocity was also obtained with an independent continuous wave Doppler probe using a Vingmed instrument. Echocardiographic and Doppler flow studies were recorded on a black and white hard copy recorder. In patients with sinus rhythm and mild to moderate MS the temporal relation between the phases of mitral flow velocity, pulmonary venous flow velocity and mitral valve motion were analyzed by matching records of similar RR intervals. Five cycles were analyzed for each data point and all the temporal measurements were referenced to the beginning of the QRS complex. A complete description of the analysis method has been provided previously. ty2 In 2 patients with severe MS and sinus

The J phasei occumduringsystoleandtheKphase

I I* i* 1. II I* I I I r * I I is 1I 1I”1. I I t e1I I 6* i; i I I I i I I P611 t


FIGURE 2. Mitral flow vebcity (MIF) and pulmonary venous flow (PVF) velocity in a patient with very mild mitral stenosis (mitral valve LllpB 2.2 cm*). Note that the diastdi phase of pulmonary venous flow is reduced and continuous throughout the end of diastole with retrograde ftow during atrial contraction.

PVF 60

FlGURE 3. puhronary venous Row velocity in a patient with significant mitral stenosis (1.1 cm*). Notice the reduced flow velocity &atng the diastogc K phase. Notice the regurgitant flow (RF) during atrial contraction. Abbreviations as in Fire 2.




I Pulmonary Venous Flow and Mitral Flow Velocity Measurements

RR (4

Q-BJ (ms)

Q-J (ms)

Q-K (ms)

Q-KE (ms)

J (cm/s)

K (cm/s)

PVF 855 f190 NV* NV+

115 f 26

263 f 43

619 f 104

818 f 160

49 f 15 45 f 10 48f8

30 f 14 53f15 49fll

in Mild to Moderate Mitral Stenosis (n = 11) RR Cm9


844 f 199

Q-D 0-m)

Q-E 6-M

Q-A @W

Q-C Cms)

E (cm/s)

A (cm/s)

459 f 69

523 f 75

860 f 181

935 f190

152 h 18

146 f 27




A = peak velocity of atrial contribution; E = peak velocity of rapid filkng wave; J = peak veloaty of first phase of PVF; K = htghest velocity of diastolic phase of PVF; MVF = m!tral flow velocity; PVF = pulmonary venous flow velocity; Q-A = peak atnal contribution; Q - BJ = duration from the beginning of the Q wave on the electrocardiogram to the onset of the J phase of pulmonary venous flow; Q-C = cessation of mitral flow; Q-D = onset of mitral flow; Q-E = peak of rapid filling wave; Q-J = peak of J phase; Q-K = peak of K phase: Q-KE = end of K phase. l NV = normal values for J and K.’ t Normal values.2

rhythm who underwent cardiac catheterization, the echo Doppler studies were performed immediately before the hemodynamic study. Dopplerflow velocity tracings were matched to hemodynamics data by superimposing Figures 4 and 5 with reference to the R wave of the electrocardiogram.

FIGURE 4. superimporea i@~re pf @nonary VIMWS flow veammitral Bow, loft vonhwkir prouure (LVP) and z=L Bmwe&e preuure (PWP)inapatientwitk -dtdsho=s.NotketkatthemsmandpemkpuhopreuveMngsystoleisbwerthan nuycclpiluywaclge ckaingtbstoke. RlnonrywnoUrrfbWiSd@kbdonlyill systole (J). The smal time delay in M-=Y eapikry wadgo lxossworaeordngslwukibo~kutodtotkodlaractbwidii oftholkidfiliedcath&rtrsystem. MIAF = ttow at themitralamhs.OtherabbrdationsashFiire2. 248


As previously described in normal subjects and as shown in Figure 1 and Table I, pulmonary venous flow velocity is biphasic with a peak velocity of the systolic J phase equal to or smaller than the peak velocity of the K phase. This pattern changes in MS. In 11 patients with mild to moderate MS and normal left ventricular dimensions and function, the ftrst phase of pulmonary venousjlow (J) peaked early during ventricular systole and reached a peak velocity of 49 f 15 cm/s. The diastolic (K) phase ofjlow was continuous throughout the end of diastole, with a reduced peak flow velocity (30 f 14 cm/s, Figures 2 and 3). There was no statistically significant correlation between mitral valve area and peak velocity of the J or K phase. The peak of the diastolic K phase of pulmonary venous flow in patients with mild to moderate MS (Table Z) occurred signifycantly later than the peak of the rapid ventricularfilling phase (E wave) of mitral flow (619 f 104 us 523 f 75 ms, p

Pulmonary venous flow determined by Doppler echocardiography in mitral stenosis.

Pulmonary Venous Flow Determined in Mitral Stenosis by Doppler Echocardiography Gad Keren, MD, Avraham Pardes, MD, Hylton I. Miller, MD, Jack Schere...
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