'Color Doppler stripes' make it difficult to diagnose the severity of valvular heart diseases: a report of two cases

Abstract

Background: Echocardiography remains the reference-standard imaging technique for assessing valvular heart disease (VHD), but artifacts like the 'color Doppler stripe' can complicate diagnosis. This artifact is not widely recognized and can mimic severe VHD, leading to potential misdiagnoses. We present two cases where color Doppler stripes mimicked severe VHD, highlighting the need for awareness and accurate interpretation in echocardiographic assessments.

Case presentations: Case 1: An 85-year-old patient was referred for mitral valve surgery due to suspected severe mitral regurgitation (MR). Upon evaluation, transthoracic echocardiography (TTE) showed mitral valve prolapse (P3) and a high-echoic, vibrating structure attached to the mitral valve, indicative of chordal rupture. Color Doppler echocardiography revealed strong systolic signals in the left atrium, mimicking severe MR. Transesophageal echocardiography (TEE) also detected the vibrating structure and color Doppler stripes in the left atrium, left ventricle, and outside the cardiac chambers. The PISA method on TEE indicated moderate MR and left ventriculography showed Sellers grade II MR. The artifact was identified as color Doppler stripes caused by the vibrating high-echoic structure from the ruptured chorda. Case 2: A 64-year-old patient with severe aortic stenosis, end-stage kidney disease requiring hemodialysis, and a history of coronary bypass grafting presented for routine follow-up. B-mode echocardiography showed a severely calcified tricuspid aortic valve with a vibrating calcified nodule and restricted opening, corresponding to severe aortic stenosis. During systole, color Doppler signals were observed around the aortic, pulmonary, and tricuspid valves, mimicking significant pulmonary stenosis and tricuspid regurgitation. However, pulmonary stenosis was ruled out as the pulmonary valve opening was normal. Mild tricuspid regurgitation was confirmed in the apical view.

Conclusions: These cases highlight the diagnostic challenges posed by color Doppler stripes. Recognizing and understanding this artifact are crucial for the accurate diagnosis and management of VHD, ensuring appropriate treatment and patient outcomes.

Keywords: Artifact; Color Doppler stripe; Valvular heart disease.

Fig. 1

Transthoracic echocardiography in case 1. B-mode in parasternal long axis view. The arrow shows high echoic structure attached to the mitral valve [mitral valve prolapse (P3)]. M-mode in parasternal long axis view. The arrow shows vibration structure (shaggy eco). Color Doppler in parasternal long axis view. Yellow allows are showed color Doppler stripes. Color Doppler in apical 4-chamber view. Yellow arrows are showed color Doppler stripes. Ao: aorta, LA: left atrium, LV: left ventricle, RA: right atrium, RV: right ventricle

Fig. 2

Transesophageal echocardiography in case 1. B-mode in long axis view. The arrow shows high echoic structure attached to the mitral valve [mitral valve prolapse (P3)]. Color Doppler transesophageal echocardiography. Color Doppler stripes are visible on the annular side within the LA and LV, as well as in the RA and RV. (yellow arrows). M-mode in long axis view. The arrow shows vibration structure (shaggy eco). Color M-mode in long axis view. The arrow shows that color Doppler stripes appear just below the shaggy echo, whether inside or outside of the LV. Ao: aorta, LA: left atrium, LV: left ventricle, RA: right atrium, RV: right ventricle

Fig. 3

Transesophageal echocardiography showing moderate MR in case 1. Color Doppler transesophageal echocardiography (0 degree). Color Doppler transesophageal echocardiography (60 degree). LA: left atrium, LV: left ventricle

Fig. 4

Left ventriculography showing Sellers grade II MR in case 1. right anterior oblique projection (RAO). left anterior oblique projection (LAO)

Fig. 5

Transthoracic echocardiography in case 2. B-mode in parasternal short axis view. Severely calcified tricuspid aortic valve with a small, vibrating, calcified nodule, and severely restricted opening. Continuous wave at the aortic valve. A peak velocity at the aortic valve of 4.4 m/s without a fast Fourier transformation (FFT) stripe. Color Doppler in parasternal short axis view. Color doppler stripes appear around the aortic (yellow arrows), pulmonary (yellow arrows), and tricuspid (red arrows) valves. Color Doppler in apical 4 chamber view showing mild tricuspid regurgitation. AoV: aortic valve, PA: pulmonary valve, RA: right atrium, RV: right ventricle