Color Doppler twinkling artifact of calcified cardiac valves in vitro: a not well known phenomenon in echocardiography.

The color Doppler twinkling artifact manifests as a rapidly changing mixture of red and blue colors behind strongly reflective structures. The twinkling artifact occurs behind diseased cardiac valves, although the phenomenon is not well described. This study sought to determine the presence of the color Doppler twinkling artifact in calcified cardiac valves in vitro using soft tissue radiography for reference. Seventeen specimens of diseased cardiac valves from patients undergoing valve replacement surgery were studied. The overall sensitivity and specificity for the detection of calcifications using the presence of the twinkling artifact were 66.7% and 81.8%, respectively. If valves with only microcalcifications or smooth calcifications were eliminated from the analysis, all (100%) of the three valves with irregular macrocalcifications exhibited the twinkling artifact. It is important to recognize this artifact because it may lead to misdiagnosis of vascular flow in echocardiography.