1. ADULT ECHOCARDIOGRAPHY Lesson Nine Valvular Heart Disease
Harry H. Holdorf PhD, MPA, RDMS, RVT, LRT, N.P.

2. Aortic Regurgitation
Etiology
Primary cusp disease (stenosis, endocarditis, ankylosing spondylitis)
Dilated aortic annulus and root (Marfan, aortitis, HTN, aneurysm)
Los of commissural support (trauma, aortic dissection, membranous VSD)
Prosthetic valve dysfunction

3. Aortic dissection & Flap in descending AO

4. Which anomaly goes with aortic dissection?
NOTES:
Which anomaly goes with aortic dissection?
Marfan Syndrome
If you have a uniformly dilated aortic root, which term best describes this?
Fusiform

5. Sinus of Valsalva Aneurysm

6. Pathophysiology
Left ventricular volume overload leads to LV dilatation
Decreased ejection fraction with long standing regurgitation
Increased risk of endocarditis
Physical Signs
Bounding (bifid (bisferious) atrial pulse
High-pitched diastolic “blowing” murmur left sternal border (LSB)
Symptoms of CHF, DOE, angina, and or syncope.
Wide pulse pressure (big difference between systolic and diastolic numbers during BP readings.

7. Know diastolic “blow” (the classic aortic regurgitation murmur)
NOTES
Which is the most common chamber for a sinus of Valsalva aneurysm to rupture into?
Right atrium
What kind of murmur would you hear in a patient with a rupture of a sinus of Valsalva aneurysm?
Continuous
Know diastolic “blow” (the classic aortic regurgitation murmur)

8. Ao Regurg
Echo
M-mode may show diastolic fluttering of the mitral valve leaflets (mostly anterior) or interventricular septum
Mitral valve “pre-closure” with severe acute AR
Diastolic fluttering or lack of closure of he aortic leaflets
Decreased excursion of the anterior MV leaflet
LV dilatation with increased LV mass

9. Aortic valve or root abnormalities may be present
Pre-systolic opening of the aortic leaflets
LV contractility may be hyper or hypo-dynamic (acute vs. chronic)
TEE best for diagnosing aortic dissections
Chronic AR patients should have serial echoes to follow changes in diastolic and systolic size.

10. M-mode of Diastolic MV Fluttering NOTE: know diastolic mitral valve fluttering from aortic regurgitation by M-mode

11. M-mode of Premature MV closure
NOTE: What causes MV pre-closure?
An elevated LVEDP
The line in the QRS: MV pre-closure should be in the middle.

12. Normal MV closure is in the middle to the end of the QRS complex

13. Doppler
Diastolic turbulence in the LVOT
Diastolic flow reversal in the descending Ao (Mod to Sev AR)
Obtain the end diastolic gradient from CW Doppler to estimate the LVEDP (diastolic BP – end diastolic gradient
Map the regurgitant area with pulsed or color flow Doppler
Try to determine the regurgitant area in LAX and SAX to estimate severity

14. NOTE: Know Color Doppler M-Mode of aortic insufficiency
JH/LVOT (ratio)
Mild = <25%
Mod = 25-65%
Sev = >65%
JH (Jet height)
Ao P ½ time
Mild = > 500 msec
Mod = msec
Sev = <200 msec

15. Images showing Ao P ½ time

16. B is more severe because Ao & LV pressures are equal at end diastole.
LVEDP = diastolic BP – end diastolic gradient
Ex. Patient w/ BP of 120/50 and end diastolic velocity of 2 m/sec
LVEDP = (converting the 2 m/sec using 4V2
= 34 mmHg

17. AI diastolic flow reversal –Descending Ao

18. NOTE:
Know descending aorta diastolic flow reversal (also called retrograde)
Antegrade = normal flow direction
Retrograde = flow in opposite direction
NOTE: Mild aortic regurgitation has an incomplete spectral trace

19. Mild Ao regurgitation incomplete spectral trace

20. Pulmonary Regurgitation
NOTE: Flick your bick
Candle flame is normal regurgitation
Etiology
Primary valve disease (stenosis, endocarditis)
Pulmonary hypertension
Carcinoid heart disease
Trivial/mild regurgitation is common.

21. PATHOPHYSIOLOGY RV volume overload may lead to RV dilatation.
Severe regurgitation may cause right heart failure
Evan moderate regurgitation will be well tolerated for years
Increased risk for endocarditis
Physical signs
Low-pitched diastolic murmur (LSB) may increase with inspiration
With pulmonary hypertension a high-pitched blowing diastolic murmur (Graham-Steele) may be heard (LSB)

22. ECHO
RV dilatation with displacement of LV septum posteriorly.
Tricuspid valve fluttering is rare
Doppler
Diastolic turbulence in the RVOT
Map the regurgitant area with pulsed or color flow Doppler
Severe PI spectral trace is NOT holodiastolic

23. Severe PI

24. Calculating PA End Diastolic Pressure
NOTE:
How would you calculate pulmonary artery end diastolic pressure?
Pulmonic insufficiency velocity
Know how to calculate PAEDP when given a Right Atrial Pressure (RAP) of 10 mmHg and from the PI spectral trace an End Diastolic velocity (EDV) of 1.5 m/sec.

25. PAEDP
RAP + EDP (end diastolic pressure) converted from the DEV
10 +4 (1.5) sq.
10 +4 (2.25)
10 +9 = 19 mmHg

26. Tricuspid Regurgitation
Etiology
Primary valve abnormalities (rheumatic, prolapse, endocarditis, carcinoid)
Elevated pulmonary pressure
Annular dilatation/calcification
Congenital valve abnormalities (Ebstein’s)
Prosthetic valve dysfunction
Trivial/mild TR is common

27. Pathophysiology
Right atrial volume overload lends to right atrial dilatation
Increased risk for endocarditis
Physical signs
Holosystolic murmur which increases with inspiration may be present
Jugular venous distension
Symptoms of right heart failure
Echo
Valvular abnormalities may be seen
Right atrial dilatation
RV dilatation with displacement of LV septum posteriorly
Dilatation of IVC
Contrast: systolic appearance of bubbles in IVC

28. TR vs. Tamponade by Saline Contrast (M-mode)
NOTE:
Systolic flow reversal of bubbles in the IVC-TR of tamponade?

29. TR or Tamponade

30. Dilated RV & IVC

31. Carcinoid Heart Disease-Fixed leaflets

32. NOTE:
What is the most common valvular abnormality associated with carcinoid syndrome?
Tricuspid regurgitation
END PAGE 88

33. Next: Prosthetic Valves
End lesson Nine
Next: Prosthetic Valves