Learn perioperative echocardiography
Concepts, guideline criteria, cases, and deep reads — built for anesthesiologists, intensivists, and internists learning to apply echo in perioperative care.
Perioperative echocardiography is not only about grading valve disease. It helps connect valve severity, mechanism, forward flow, filling pressure, right-sided function, and congestion to perioperative decisions.
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.
Valve learning paths
Pick a valve and follow it through — how to read severity, the mechanism driving it, and how that shapes the intervention and perioperative decision. Each card starts at severity and links onward to mechanism, cases, and deep reads.
Aortic Stenosis
Start with AVA, Vmax, mean gradient, and DVI — then work through discordant and low-flow patterns toward the SAVR-versus-TAVI decision.
MRMitral Regurgitation
Begin with primary versus secondary — they use different thresholds — then follow mechanism into repair, TEER, and GDMT-first decisions.
TRTricuspid Regurgitation
Learn why TR Vmax does not grade severity, then follow mechanism — primary, secondary, atrial functional, device-lead — through right ventricular impact, venous congestion, and perioperative risk framing.
ARAortic Regurgitation
Grade severity from VC, EROA, regurgitant fraction, and diastolic flow reversal — read LV response separately, and recognize the acute findings that change the entire evaluation path.
MSMitral Stenosis
Anchor on MVA, then layer in mean gradient, PHT, pulmonary pressure, rhythm, and symptoms as supporting evidence — including where PHT loses reliability.
Read criteria and summaries
ACC/AHA VHD 2020 — the actual thresholds and how to integrate them.
Aortic stenosis severity criteria
AVA, Vmax, mean gradient, DI — the four parameters and how to reconcile them.
Why AVA and gradient disagree
Discordant AS — a small AVA with a non-severe gradient. What drives the mismatch and how to resolve it.
What low-flow changes in AS
Low-flow, low-gradient severe AS — why a low gradient does not rule out severe disease.
Aortic stenosis intervention indications
When to refer — Class I, IIa, IIb thresholds for symptomatic and asymptomatic AS.
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.
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 anchors MS severity — including the very severe sub-range
MVA ≤ 1.5 cm² supports severe-range MS; MVA < 1.0 cm² is a very severe sub-range within severe, not a separate grade. Gradient provides hemodynamic context, not a co-equal grading criterion.
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.
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.
62-year-old with severe AS: why SAVR stays relevant
Age alone does not decide the approach — why SAVR remains a strong option in a younger surgical candidate.
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.
Ischemic secondary MR when CABG is planned
When CABG is already planned, the question shifts: not whether to operate for MR, but whether to address the mitral valve at the same operation.
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.
Non-severe AR with a short PHT — why the grade does not change
A short pressure half-time can look alarming, but AR is graded from integrated signs — PHT alone does not upgrade severity.
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
Mechanism and decision-making in depth — perioperative hemodynamics and valve-specific reasoning.
Hemodynamics
Aortic Stenosis
Secondary Mitral Regurgitation
COAPT vs MITRA-FR — TEER is about patient selection
Why the trials diverged, and what proportionate vs disproportionate secondary MR means.
GDMT first is not a placeholder
Guideline-directed therapy can reduce secondary MR before any device decision.
Intervention does not fix the ventricle
In secondary MR the valve is downstream of ventricular disease — what intervention can and cannot do.
Aortic Regurgitation
Acute AR: findings you cannot miss
When chronic LV staging does not apply, and hemodynamics drive the pathway.
Holodiastolic flow reversal in AR
What reversal at each site means for severity.
Why PHT is context in the AR tool, not a severity signal
PHT reflects pressure equalization speed — not regurgitant volume. Why this tool treats it as context, not a severity signal.
AR before noncardiac surgery: perioperative risk framing
How severity, LV adaptation, surgical risk, and urgency combine to frame the perioperative evaluation.
Tricuspid Regurgitation
TR mechanism determines the management pathway
Primary, secondary, atrial functional, and device-lead TR each follow a different path.
Why severe TR should not wait for RV and end-organ damage
Symptoms lag behind RV remodeling and venous congestion — earlier evaluation is better.
Severe TR before noncardiac surgery
A perioperative risk modifier — framing the risk rather than an automatic answer.