Presentation is loading. Please wait.

Presentation is loading. Please wait.

Aortic Regurgitation 2D and Doppler Assessment

Similar presentations

Presentation on theme: "Aortic Regurgitation 2D and Doppler Assessment"— 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
2D Echo CFI AR Hemodynamics ERO/R Vol ERO/RV CW Doppler PW Doppler

6 Hemodynamics of AR Acute AR Chronic AR Rapid onset of 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…
Acute AR Chronic AR Adapted From: Lilly L. Pathophysiology of Heart Disease

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 Conservative Rx for Severe AR Survival vs Indexed LV Systolic Diameter
Years Survival (%) LVS/BSA <25 81±5% 89±3% 34±10% 50±9% LVS/BSA ³25 Dujardin KS: Circ,99 CP

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


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




17 Functional Anatomy 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



20 Aortic Regurgitation Color Flow Imaging
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 Vena Contracta cont… VC Width 5 mm 6 mm 7 mm Sn Sp 100 73 95 90 84 96
ERO≥0.3 cm 2 100 73 95 90 84 RegVol≥60 ml 96 81 94 65 Tribouilloy et al: Circulation, 2000

26 Vena Contracta Optimize the flow convergence zone

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

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…
Pressure Half Time PHT Mild AR > 400 msec Otto and Pearlman: Textbook of Clinical Echocardiography

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

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

36 PW Doppler cont… CP


38 PW Doppler cont… 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 Continuity Equation Calculation
TVI A = X Stroke volume Area TVI CP Raster: tif 45

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 SVLVOT Measure LVOT diameter Obtain PW Doppler signal in LVOT Trace LVOT TVI SVLVOT = CSALVOT x TVILVOT

48 Continuity Method cont…
Calculate SVMV Measure diameter of mitral annulus Obtain PW Doppler signal at level of mitral annulus Trace MV annulus TVI SVMV = CSAMV x TVIMV


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 Proximal Isovelocity Surface Area

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 Va (cm/sec)
ERO (cm2) = Flow (cc/sec) V (cm/sec) RV (cc) = ERO (cm2) 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 <2 5% > 60%
Jet/LVOT Width < 25% > 60% Vena Contracta < 3 mm > 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

Download ppt "Aortic Regurgitation 2D and Doppler Assessment"

Similar presentations

Ads by Google