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Aortic Regurgitation 2D and Doppler Assessment Dr.Sohail Abrar Khan MBBS,FCPS (Med), FCPS (Card) Diplomate of American certification Board of Echo Assistant.

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Presentation on theme: "Aortic Regurgitation 2D and Doppler Assessment Dr.Sohail Abrar Khan MBBS,FCPS (Med), FCPS (Card) Diplomate of American certification Board of Echo Assistant."— Presentation transcript:

1 Aortic Regurgitation 2D and Doppler Assessment Dr.Sohail Abrar Khan MBBS,FCPS (Med), FCPS (Card) Diplomate of American certification Board of Echo Assistant Professor and Consultant Cardiologist Aga Khan University Hospital Karachi

2 Introduction  Aortic regurgitation is a common and serious health problem  Echo is the most valuable tool in the diagnosis and management of AR  Echo evaluation of AR requires a comprehensive evaluation by an experienced person  Visual and qualitative assessment may be unreliable and misleading

3 Introduction cont…  Patients are often asymptomatic until AR becomes significant  AR murmur usually not heard until AR severity > mild  Detection of AR may be the first clue that aortic root or aortic valve disease is present

4 Role of Echo in Assessment AR  2D and Doppler echocardiography is indispensable in the diagnosis and management of patients with AR  This should be used to assess the severity of AR, the LV response to volume overload (systolic function, ejection fraction [EF] and end-systolic and diastolic dimensions).  Echocardiography may also identify the anatomic cause of AR, which is important for determining the surgical approach

5 Assessment of Regurgitation ERO/RV 2D EchoCFI PW Doppler ERO/R Vol Hemodynamics CW Doppler AR

6 Hemodynamics of AR Chronic AR  Progressive ↑ AR  Heart has time to compensate  ↑ LV volume  ↑ dilatation  ↑ Stroke Volume Acute AR  Rapid onset of AR  Insufficient time for heart to compensate  Leads to ↑ LVEDP  Pulmonary edema  Decreased effective forward Stroke vol

7 Hemodynamics of AR cont… Adapted From: Lilly L. Pathophysiology of Heart Disease Chronic ARAcute AR

8 Aortic Regurgitation 2D Echo  Assess valvular function  Identification of functional anatomy  Assess LV size and function  Evidence of increased LVEDP

9 2D Echo cont… Assessment of LV  Serial reproducible findings  LV chamber enlargement  LV function assessment  Predictors of preserved LV function after AVR  LVESD < 55 mm  LV EF > 50%

10 Years Survival (%) LVS/BSA <25 81±5% 89±3% Conservative Rx for Severe AR Survival vs Indexed LV Systolic Diameter CP Dujardin KS: Circ,99 34±10% 50±9% LVS/BSA  25

11 Aortic Regurgitation 2-D and M-Mode Clues of AR  Diastolic fluttering of anterior MV leaflet  Reverse “doming” of anterior MV leaflet  Diastolic flutter of aortic valve Evidence for increased LVEDP  Presystolic (premature) closure of MV  Presystolic (premature) opening of AV

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13 Aortic Regurgitation Functional Anatomy Valvular  Congenital (bicuspid)  Degenerative  Rheumatic  Endocarditis  Cusp rupture

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17 Functional Anat omy cont… Aortic Root Chronic Dilatation  Marfan syndrome  Senile/hypertensive  Chronic aortitis  Idiopathic Annuloaortic ectasia  Sinus of valsalva aneurysm Acute Disruption  Dissection  Chest trauma  Endocarditis  Post-procedure

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20 Aortic Regurgitation Color Flow Imaging Jet area  LVOT area Jet width  LVOT width Jet area  LVOT area Jet width  LVOT width CP

21 Color Flow Imaging cont… Jet Width/LVOT Width Perry et al. JACC 1987

22 Color Flow Imaging cont… Jet area/LVOT area  AR jet area and LVOT area from parasternal short axis view  Correlates best with angiographic severity of AR  Assess AR at the level of the aortic annulus, just below the AV Oh, Seward,Tajik: The Echo Manual

23 Color Flow Imaging cont… Jet area/LVOT area Grade I< 5% Grade II % Grade III % Grade IV > 60%

24 Vena Contracta  Measure from PLAX (zoom)  Use standard color scale  No baseline shift  Measure width of AR jet at the narrowest point  Measure just below flow convergence  Vena contracta < 6 mm = severe AR  Vena contracta < 3 mm = mild AR

25 Tribouilloy et al: Circulation, mm 6 mm 7 mm VC Width Vena Contracta cont… SnSpSnSpSnSp ERO≥0.3 cm RegVol≥60 ml

26 Vena Contracta Optimize the flow convergence zone

27 Vena Contracta Vena contracta is usually smaller than LVOT jet height Measure width of AR at narrowest point of emitting jet

28 Aortic Regurgitation CW Doppler Assessment  Density of CW signal reflects Reg Vol  Pressure half-time Mild AR > 400 msec Severe AR < 250 msec Oh,Seward, Tajik: The Echo Manual

29 Align Doppler parallel to flow Move lateral or try a lower rib space

30 CW Doppler Assessment cont… Mild AR > 400 msec Otto and Pearlman: Textbook of Clinical Echocardiography Pressure Half Time PHT

31 CW Doppler Assessment cont… Severe AR < 250 msec Otto and Pearlman: Textbook of Clinical Echocardiography Pressure Half Time PHT

32 CW Doppler Ass essment cont…  AR PHT may be shortened due to other causes of elevated LVEDP i.e LV systolic and diastolic dysfunction and Mitral Regurgitation  It can be increased due to Mitral Stenosis

33 Aortic Regurgitation PW Doppler Assessment  LV stroke volume  Mitral inflow  Descending thoracic aorta  Abdominal aorta

34 PW Doppler cont… Mitral Inflow  High LA Pressure & LVEDP  Restrictive mitral inflow  Mitral pattern dependent on compliance of ventricle Oh,Seward, Tajik: The Echo Manual

35 PW Doppler cont… Pre-op Post-op Premature Cessation of Mitral Flow in Acute Severe AR

36 CP PW Doppler cont…

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38 Descending Aorta Diastolic flow reversal Retrograde flow TVI Severe AR TVI > 14 cm

39 PW Doppler cont… Abdominal Aorta  Place PW sample volume in abdominal aorta  Diastolic flow reversal consistent with significant aortic regurgitation Otto and Pearlman: Textbook of Clinical Echocardiography

40 Indications for Quantitative Doppler  When regurgitation appears moderate or more by CFI/qualitative assessment  Serial assessment  Assess LV size & function  Assess regurgitation  Assist clinician/surgeon  Clinical management  Timing of surgery

41 Quantitative Doppler Methods Continuity Equation PISA Method CSA TVI

42 Continuity Equation  Stroke volume  Valve area  Shunt lesions  Regurgitant volume  Regurgitant fraction

43 Continuity Equation cont… What goes in (the ventricle) must go out!!

44 Regurgitant Volume  Volume of blood that regurgitates through an incompetent valve with each heart beat

45 CP Continuity Equation Calculation Stroke volume AreaAreaTVITVI A A TVI = X

46 Continuity Method cont… “What goes in must go out”  Measurements required LVOT diameter & TVI MV annulus diameter & TVI  Limitation of continuity method Unable to use with multiple regurgitant lesions > mild and shunt lesions

47 Continuity Method cont… Calculate SV LVOT Measure LVOT diameter Obtain PW Doppler signal in LVOT Trace LVOT TVI  SV LVOT = CSA LVOT x TVI LVOT

48 Continuity Method cont… Calculate SV MV Measure diameter of mitral annulus Obtain PW Doppler signal at level of mitral annulus Trace MV annulus TVI  SV MV = CSA MV x TVI MV

49 SV MV = CSA MV x TVI MV SV LVOT = CSA LVOT x TVI LVOT RV AR = SV LVOT - SV MV Regurgitant Volume and Fraction RF AR = RV AR /SV LVOT

50 Pitfalls of Continuity Method  Learning curve of the operator  Incorrect placement of sample volume  Incorrect annulus measurement  Requires 4 separate measurements Introduces 4 possible errors  Diameters are squared in the equation so any small error will be magnified and spoil the result  Invalid with multivalvular regurgitation or intracardiac shunts

51 PISA P roximal Isovelocity S urface A rea

52 Advantages of PISA Method  Can be used in the presence of other valvular regurgitation or shunts  Can be used in the presence of valve stenosis or prosthetic valves  Uses fewer variables (2 measurements)

53 PISA Method  Shift color baseline in the direction of flow  Alias velocity varies (range of cm)  Note alias velocity Adapted from Oh, et. al.

54 AR Peak Velocity and VTI  Using CW Doppler, obtain optimal regurgitant jet  Use alternate windows to be parallel to flow  Measure peak regurgitant velocity  Trace regurgitant TVI

55 PISA Calculations  Flow (cc/sec) = 6.28 x [r (cm)] 2 x V a (cm/sec)  ERO (cm 2 ) = Flow (cc/sec) V (cm/sec)  RV (cc) = ERO (cm 2 ) x TVI (cm)

56 Effective Regurgitant Orifice  Size of orifice through which regurgitation passes  Also referred to as ROA (regurgitant orifice area)

57 Pitfalls of PISA Method  Learning curve of operator  Assumption of hemispherical flow convergence area  Inability to accurately measure radius  Inability to obtain complete MR jet by CW Doppler

58 Severity of AR Mild Severe Jet/LVOT area 60% Jet/LVOT Width 60% Vena Contracta 6 mm CW Doppler faint dense AR PHT > 400 msec < 250 msec Descending Aorta early holodiastolic diastolic Reversal TVI > 14 cm

59 Summary  Aortic regurgitation is a common and serious health problem  Echo is the most valuable tool in the diagnosis and management of AR  Echo evaluation of AR is complex and often suboptimal  Visual and qualitative assessment is is often misleading  It is now very reliable by the use of quantitative methods  An organized and comprehensive approach by using all the available qualitative and quantitative methods is required for proper assessment of AR

60 Thank You


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