Learn perioperative echocardiography
Concepts, guideline criteria, cases, and deep reads — built for anesthesiologists, intensivists, and internists learning to apply echo in perioperative care.
Featured learning themes
Aortic Stenosis
Severity grading across four parameters — and how to integrate when they disagree.
MRMitral Regurgitation
Primary and secondary MR use different thresholds because they represent different diseases.
TRTricuspid Regurgitation
Severity criteria, TR Vmax explained, mechanism matters — and why each pathway leads somewhere different.
ARAortic Regurgitation
AR severity, LV response, acute red flags, PHT, holodiastolic reversal, and perioperative framing.
MSMitral Stenosis
MVA-centered severity assessment, PHT method accuracy, gradient context, and perioperative hemodynamic risk.
Learn the concepts
What does E/e' mean?
Filling pressure estimation — what the ratio measures and where it breaks down perioperatively.
SVV, PPV, and CVP — three different questions
Fluid responsiveness and venous congestion are separate problems. SVV/PPV answers one; E/e' and LAVI answer the other.
Why preserved EF does not guarantee forward flow
EF can look normal while cardiac output and LVOT VTI are reduced.
TEE is not TTE
Window differences, structural limitations, and what the ascending aorta blind spot means intraoperatively.
Read criteria and summaries
ACC/AHA VHD 2020 — the actual thresholds and how to integrate them.
Primary MR severity criteria
The six severe-range signals and how they combine into a severity grade.
Primary vs secondary MR
Why the two pathways use different thresholds and cannot share the same intervention criteria.
Secondary MR — ventricular disease, not a valve-first problem
EROA 0.20 cm² is a prognostic signal, not the severe threshold. How the same numbers carry different clinical meaning.
TR severity criteria at a glance
The parameters that grade TR severity and why TR Vmax is not one of them — at a glance.
Why TR Vmax does not equal TR severity
TR Vmax reflects pressure gradient, not regurgitant volume. In severe TR, pressure equalization lowers TR Vmax.
Why hepatic vein systolic reversal matters
Systolic reversal extends TR's hemodynamic impact beyond the right atrium into the systemic venous circulation.
TR mechanisms: why each drives a different pathway
Primary structural, secondary RV-induced, device lead, and atrial functional TR each require a different management approach.
Device lead-associated TR: why the team matters
Lead presence does not prove causality. Device and valve team evaluation is always needed — not a single-discipline recommendation.
Why severe TR should not wait for RV and end-organ damage
Symptoms often lag behind RV remodeling and systemic venous congestion. Earlier evaluation is better than waiting.
Left-sided valve surgery and TR: evaluate explicitly
Coexisting TR in left-sided valve surgery requires deliberate evaluation — but concomitant repair is not automatic.
Severe TR before noncardiac surgery: risk framing
Severe TR is a perioperative risk modifier. Framing the risk and optimizing what can be optimized — not automatic cancellation.
AR severity criteria
AR severity is integrated from multiple echo signs: VC, EROA, regurgitant volume, regurgitant fraction, and holodiastolic flow reversal. LV response changes intervention timing but does not define severity.
LV response in chronic AR
Chronic AR triggers LV eccentric hypertrophy. LV dimensions and LVEF determine when the compensation phase ends and intervention evaluation begins.
MVA ≤ 1.5 cm² supports severe-range MS
MVA is the primary severity anchor — gradient provides hemodynamic context, not a co-equal grading criterion.
MVA < 1.0 cm² is a very severe sub-range, not a separate grade
The ACC/AHA framework does not define a fourth grade — very severe MVA sits within the severe category.
Mean gradient is heart-rate and flow dependent
Gradient alone does not define severity. Low gradient with severe-range MVA is context-dependent, not a downgrade trigger.
PHT-derived MVA is context dependent
Coexistent AR, AF, post-commissurotomy, tachycardia, and LV diastolic dysfunction each reduce PHT accuracy.
Rheumatic, MAC-related, and prosthetic/post-repair MS require different interpretation paths
Etiology changes anatomy, calcification pattern, and which options are available for specialist evaluation.
Think through a case
One patient, one key lesson — start here when the numbers feel abstract.
TTE cases
EF is normal — so why is blood pressure so hard to maintain?
E/e' is elevated — should I give more fluid intraoperatively?
Severe MR is reported — how do I assess effective cardiac output?
TEE cases
LV pump failure after CPB separation
Is this preload, contractility, or SAM? Compare with pre-CPB LV size and function.
RCA territory ischemia after CPB separation
Distinguish fixed RCA obstruction from air embolism. Integrate ST changes, CVP rise, and RV findings.
Aortic dissection just after CPB initiation
Know what TEE can see well and what it cannot. Arch and descending are in range; ascending is not.
Valve cases
LFLG-AS: confirm severity before choosing TAVI or SAVR
Paradoxical low-flow, low-gradient — why severity confirmation matters before any approach decision.
81-year-old with symptomatic severe AS: why TAVI rises to the top
Age, frailty, and access anatomy — how multiple factors converge toward TAVI.
Flail posterior leaflet — severe primary MR
Clear structural mechanism with multiple severe-range signals — how the decision to refer is made.
High-risk elderly primary MR — is TEER an option?
Anatomy assessment for TEER eligibility — what the criteria actually mean in practice.
Moderate-looking MR in advanced HFrEF — why context matters
Numbers that look moderate but carry severe prognostic weight in the right clinical context.
Severe secondary MR despite optimized GDMT — when TEER enters the discussion
Post-optimization: COAPT criteria and what anatomy eligibility means in practice.
Atrial functional TR — when is intervention appropriate?
AF-induced annular dilation with preserved RV function — when to escalate vs. optimize.
Severe TR with hepatic vein systolic reversal before elective surgery
Hepatic vein systolic reversal connects echo severity with systemic venous congestion and perioperative risk.
Left-sided valve surgery with moderate/severe TR
When left-sided valve surgery is planned, TR should be explicitly evaluated — but concomitant repair should not be assumed.
Device lead-associated TR
Device lead-associated TR requires device and valve team evaluation — not automatic lead extraction.
Massive TR with RV dysfunction and end-organ damage
Symptoms are 'mild' but objective findings say otherwise — the timing question.
Acute AR with normal LV — why normal size does not mean tolerated
Acute AR with preserved LV dimensions — hemodynamic instability, not LV size, drives the acute evaluation pathway.
Severe AR with LVESD >50 mm — LV dilation changes the path
Preserved LVEF but LVESD above threshold — why LV end-systolic dimension triggers a separate evaluation path.
Stable severe AR before elective noncardiac surgery
Asymptomatic severe AR with no LV thresholds reached — how the NCS context shapes the perioperative evaluation frame.
Non-severe AR with bicuspid valve and 50 mm aortic root
Non-severe AR plus aortic root finding — the root flag is an overlay and does not change the AR evaluation class.
Severe MS with absent mean gradient — why missing gradient does not change the grade
MVA 1.2 cm² by planimetry with no gradient measured. The tool grades on MVA — gradient absence is context, not a penalizing signal.
PHT-derived MVA in atrial fibrillation — when confidence drops
MVA 1.4 cm² by PHT in AF: R-R variability reduces PHT reliability and shifts the grade to likely_severe_ms.
Discordant MS before hip replacement — very severe MVA with unexpectedly low gradient
MVA 0.8 cm² by planimetry, gradient 7 mmHg, sinus rhythm, no documented low-flow. Hemodynamic clarification before elective surgery.
Deep reads