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

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Presentation on theme: "Echo Conference Aortic Regurgitation September, 2007 Christopher Dibble, M.D."— Presentation transcript:

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

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

3 Peripheral Signs of Severe Aortic Regurgitation Quincke’s sign: capillary pulsation Quincke’s sign: capillary pulsation Corrigan’s sign: water hammer pulse Corrigan’s sign: water hammer pulse Bisferiens pulse (AS/AR > AR) Bisferiens pulse (AS/AR > AR) De Musset’s sign: systolic head bobbing De Musset’s sign: systolic head bobbing Mueller’s sign: systolic pulsation of uvula 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: Can be a caused by: Valve Disease Valve Disease Aortic root disease Aortic root disease Percentage of aortic root disease steadily increasing over past few decades Percentage of aortic root disease steadily increasing over past few decades Root disease now accounts for >50% of all AVRs Root disease now accounts for >50% of all AVRs

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

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

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

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

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

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

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

12 AR – M-Mode As the aortic jet cascades across the anterior MV leaflet it can create a high frequency fluttering 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 In acute AR premature closure of the MV can be seen Due to rapidly increasing LV pressure 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 valve and root Detailed evaluation of LV size and function Detailed evaluation of LV size and function Many important causes of AR easily seen on 2D evaluation Many important causes of AR easily seen on 2D evaluation Even when AR is severe, sometimes 2D imaging is suprisingly normal Even when AR is severe, sometimes 2D imaging is suprisingly normal

15 AR – 2D Imaging

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18 AR – Doppler Evaluation Pulsed, continuous wave, and color flow Doppler are highly sensitive for detection of regurgitation and are complementary studies 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 Most regurgitant jets >1.5 m/sec CW lacks spatial resolution CW lacks spatial resolution PW needed to map location and direction of jet PW needed to map location and direction of jet Mitral Inflow Helpful for flow profile; gradient Identifies turbulence in an area; color flow derived from PW data

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

21 AR MS

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23 Presence of mitral stenosis or mechanical mitral valve

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

25 AR – Color flow Doppler Detects even trivial AR Detects even trivial AR 1% of subjects under 40 y.o. 1% of subjects under 40 y.o % of patients greater than 60 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. Measurement of the most narrow portion of jet behind the valve. Mild: <3.0mm Mild: <3.0mm Moderate: mm Moderate: mm Severe: >=6.0mm Severe: >=6.0mm Enriquez-Sarano et al. Aortic Regurgitation. NEJM; 351:

27 Echo assessment: Jet / LVOT height Jet height to LVOT height ratio Jet height to LVOT height ratio Mild: 1-24% Mild: 1-24% Moderate: 25-46% Moderate: 25-46% Moderate-severe: 47-64% Moderate-severe: 47-64% Severe: >=65% Severe: >=65% Limitations: Limitations: Lateral resolution of color Doppler Lateral resolution of color Doppler Sensitive to angulation of ultrasound transducer 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. 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 The density of the jet compared with antegrade aortic flow is a (very simple) qualitative indication of the volume of regurgitation

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

30 AR – CW Doppler Aortic regurgitant fraction can be estimated by ratio of reversed flow VTI / forward flow VTI in the distal aortic arch. 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: ; Antegrade Retrograde

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

32 AR - pressure half-time Limitations: Limitations: Pressure half-time sensitive to chronicity of AR 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. 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 Pressure half-time varies with systemic vascular resistance vasodilators may shorten the pressure half-time even as the aortic regurgitant fraction improves. 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. Compare flow through aortic valve versus mitral or pulmonary valve. Regurgitant volume (fraction): Regurgitant volume (fraction): Mild: <30cc (<30%) Mild: <30cc (<30%) Mild to moderate: 30-44cc (30-39%) Mild to moderate: 30-44cc (30-39%) Moderately severe: 45-59cc (40-49) Moderately severe: 45-59cc (40-49) Severe: >=60cc (>=50%) Severe: >=60cc (>=50%)

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

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

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

38 Summary

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

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

41 AR – Surgical Indications


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