Doppler Delights: Spectral Stripes and Systolic Surge

On evaluation of a 55-year-old male patient with a history of ischemic heart disease, we noticed hypokinesia involving the entire anterior wall and the basal-mid posterior wall. Modified Simpson’s method revealed severe left ventricular (LV) systolic dysfunction with an ejection fraction of 30%. The global LV longitudinal strain was also reduced (−10%). Other parameters showed mitral E/A = 2, E deceleration time = 110 ms, and medial E/e’ =20, suggesting Grade III LV diastolic dysfunction. Our patient had moderate aortic regurgitation (the regurgitation jet vena contracta measured 4 mm and the pressure halftime was 400 ms), as well as mild mitral regurgitation. Spectral Doppler assessment of the valvular function demonstrated the following interesting findings. Tiger stripes are high-amplitude signals with a multiple-band-like configuration, seen in Doppler spectral analysis. These striations assume the shape of the waveform’s apex. Earlier studies have demonstrated this finding in patients with cusp tears of bioprosthetic heart valves, attributing it to the fluttering of the disrupted cusps, which leads to the shedding of vortices.[1] Later, it was reported with various other conditions with intracardiac oscillatory structures such as flail porcine prosthetic mitral leaflet, rheumatic carditis, native valvular regurgitation, calcified leaflet, surgical ring, Lambl’s excrescences, and in acute coronary syndrome.[2,3] In our patient, the continuous wave Doppler (CWD) analysis of the transaortic flow revealed tiger stripes, probably occurring due to the high-frequency vibrations generated by the calcified tricuspid native aortic valve leaflets [Figure 1a and b].Figure 1: (a) Apical 5-chamber view showing aortic regurgitation, (b) Continuous wave Doppler across the native aortic valve demonstrating the tiger stripes and the systolic aortic regurgitation (blue arrow), (c) Color M-mode across the aortic valve demonstrating systolic aortic regurgitation (arrow)Systolic aortic regurgitation occurs due to the inability of the left ventricle to overcome the aortic pressures during systole. It is identified in patients with arrhythmia (atrial fibrillation and premature ventricular contraction), cardiopulmonary bypass, and palliative surgical correction of complex congenital heart disease (Damus–Kaye–Stansel procedure for double outlet right ventricle).[4,5] Systolic aortic regurgitation in our patient is demonstrated by both CWD and color M-mode [Figure 1b and c] during a premature ventricular contraction. We report the rare co-occurrence of these interesting Doppler findings in the same patient, due to frequent premature ventricular contractions in the setting of severe LV systolic and diastolic dysfunction, as well as a calcified aortic valve. Authors’ contributions FP: Literature search, manuscript preparation. SKR: Design. SK: Manuscript editing, manuscript review. RGN: Concept, definition of intellectual content, data acquisition. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.