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Echo Conference Aortic Regurgitation

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1 Echo Conference Aortic Regurgitation
September, 2007 Christopher Dibble, M.D.

2 Aortic Regurgitation: Symptoms
Dyspnea, orthopnea, PND Chest pain. Nocturnal angina >> exertional angina ( diastolic aortic pressure and increased LVEDP thus  coronary artery diastolic flow) With extreme reductions in diastolic pressures (e.g. < 40) may see angina

3 Peripheral Signs of Severe Aortic Regurgitation
Quincke’s sign: capillary pulsation Corrigan’s sign: water hammer pulse Bisferiens pulse (AS/AR > AR) De Musset’s sign: systolic head bobbing Mueller’s sign: systolic pulsation of uvula Durosier’s sign: femoral retrograde bruits Traube’s sign: pistol shot femorals Hill’s sign:BP Lower extremity >BP Upper extremity by > 20 mm Hg - mild AR > 40 mm Hg – mod AR > 60 mm Hg – severe AR

4 Aortic Regurgitation Can be a caused by: Valve Disease
Aortic root disease Percentage of aortic root disease steadily increasing over past few decades Root disease now accounts for >50% of all AVRs

5 AR – Valvular disease Rheumatic disease Calcific AS
Cusps become fibrotic and retract Usually also stenotic MV is involved Calcific AS At least mild AR in 75% of patients

6 AR – Valvular disease II
Infective endocarditis Leaflet perforation Vegetation interferes with coaptation Trauma Bicuspid Valve Can isolated regurgitation or stenosis, or both Complication of catheter based ablation

7 AR – Valvular disease III
Myxomatous degeneration Structural deterioration of bioprosthesis Less common causes: SLE, RA Ankylosing spondylitis Jaccoud arthropathy Takayasu disease Whipple’s disease Anorectic drugs Congential (rare, usually associated with bicuspid valve) Membranous subaortic stenosis

8 Aortic root disease Dilation here is common; especially in AS; does not lead to AR Between aorta proper and the annulus is a tube composed of collagen that forms sinuses of valsalva As little as 2mm of dilation here can cause AR Dilation here is rare

9 Aortic root disease Dilation of the aortic ridge eliminates the normal overlap of the valves

10 AR – Aortic Root Disease
Age related (degenerative) Systemic Hypertension Aortic dissection Cystic medial necrosis either isolated or associated with Marphan syndrome Bicuspid valve

11 AR – Aortic Root Disease II
Syphilitic aortitis Osteogenesis imperfecta Ankylosing spondylitis Relapsing polychondritis Ehlers-Danlos Inflammatory bowel disease

12 AR – M-Mode As the aortic jet cascades across the anterior MV leaflet it can create a high frequency fluttering In acute AR premature closure of the MV can be seen Due to rapidly increasing LV pressure

13 AR - M-mode Fluttering of Anterior Mitral Valve leaflet
Increased duration between E and A peaks Early example of using M-mode to indirectly assess valve disease

14 AR – 2D imaging Detailed evaluation of valve and root
Detailed evaluation of LV size and function Many important causes of AR easily seen on 2D evaluation Even when AR is severe, sometimes 2D imaging is suprisingly normal

15 AR – 2D Imaging



18 AR – Doppler Evaluation
Pulsed, continuous wave, and color flow Doppler are highly sensitive for detection of regurgitation and are complementary studies

19 Use of Doppler to Detect Regurgitant Jets
Most regurgitant jets >1.5 m/sec CW lacks spatial resolution PW needed to map location and direction of jet Mitral Inflow Identifies turbulence in an area; color flow derived from PW data Helpful for flow profile; gradient

20 AR – Pulsed Doppler Early to assess severity of AR used pulsed Doppler to “map” AR sample volume withdrawn towards apex to find length of regurgitant jet Relies on turbulence during diastole on LV outflow side of AV This assumes jet is centrally located and can be tracked towards apex Another possible source of error:

21 AR MS


23 Presence of mitral stenosis or mechanical mitral valve

24 AR – Color Flow Most common technique Sensitivity >95%
False positive negatives; occur in tachycardia with mild AR Frame rate allows only a few diastolic frames to be displayed Can be overcome by using CW which has higher sampling rate Specificity ~100%

25 AR – Color flow Doppler Detects even trivial AR
1% of subjects under 40 y.o. 10-20% of patients greater than 60 y.o

26 Echo assessment: Vena Contracta
Measurement of the most narrow portion of jet behind the valve. Mild: <3.0mm Moderate: mm Severe: >=6.0mm Enriquez-Sarano et al. Aortic Regurgitation. NEJM; 351:

27 Echo assessment: Jet / LVOT height
Jet height to LVOT height ratio Mild: 1-24% Moderate: 25-46% Moderate-severe: 47-64% Severe: >=65% Limitations: Lateral resolution of color Doppler Sensitive to angulation of ultrasound transducer Ekery, DL et al. Aortic Regurgitation: Quantitative Methods by Echocardiography. Echocardiography: ;

28 AR – Continuous wave doppler
Because AR jet is high velocity, CW Doppler necessary to record envelope of jet. The density of the jet compared with antegrade aortic flow is a (very simple) qualitative indication of the volume of regurgitation

29 AR – Continuous wave doppler
Antegrade Density is function of number of blood cells sampled and will generally increase with the regurgitant volume

30 AR – CW Doppler Retrograde Antegrade Aortic regurgitant fraction can be estimated by ratio of reversed flow VTI / forward flow VTI in the distal aortic arch. Ekery, DL et al. Aortic Regurgitation: Quantitative Methods by Echocardiography. Echocardiography: ;

31 AR – Continuous wave doppler
Absolute gradient does not closely reflect amount of AR Severity of AR can be described by the slope or the pressure half time Pressure half time of less than 250 msec is an indicator of severe AR

32 AR - pressure half-time
Limitations: Pressure half-time sensitive to chronicity of AR acute AR leads to much shorter values than chronic AR when ventricle is dilated with increased compliance and can accommodate large regurgitant volumes. Pressure half-time varies with systemic vascular resistance vasodilators may shorten the pressure half-time even as the aortic regurgitant fraction improves.

33 AR- Regurtitant volume

34 AR - Regurgitant Volume or Fraction
Compare flow through aortic valve versus mitral or pulmonary valve. Regurgitant volume (fraction): Mild: <30cc (<30%) Mild to moderate: 30-44cc (30-39%) Moderately severe: 45-59cc (40-49) Severe: >=60cc (>=50%)

35 AR - Regurgitant Volume or Fraction
Limitations: Assumes normal flow through comparison valve. Cannot be used in presence of shunts. Sensitive to small measurement errors.

36 AR - Proximal isovelocity surface area
The PISA method can estimate regurgitant flow rate, and subsequently regurgitant orifice area).

37 AR - Proximal isovelocity surface area
Limitations of PISA Isovelocity contour flattens as it approaches the orifice, underestimating flow. Proximal structures can distort the isovelocity contour. Sensitive to errors in radius measurement 10% error in radius leads to 21% error in flow

38 Summary

39 Severe AR - Surgical Indications
Symptomatic patients (dyspnea or angina) Normal, mildly depressed or moderately depressed LV Surgery. Severely depressed or dilated LV (EF<25% or LVESD>60mm) High surgical risk (~10% operative mortality) but also poor outcomes with medical therapy.

40 Asymptomatic Severe AR - Surgical Indications
Preserved LV Observe with serial echocardiograms. Abnormal LV “Rule of 55”: Surgery if: LVEF <55% (ACC/AHA guidelines <50%) LVESD > 55mm (or > 25 mm/m2). Also surgery if LVEDD >70-75 mm Uncertainty on which combination of criteria most useful.

41 AR – Surgical Indications

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