Regurgitant Lesions. Bicol Hospital, Legazpi City, Philippines July Gregg S. Pressman MD, FACC, FASE Einstein Medical Center Philadelphia, USA
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1 Regurgitant Lesions Bicol Hospital, Legazpi City, Philippines July 2016 Gregg S. Pressman MD, FACC, FASE Einstein Medical Center Philadelphia, USA
2 Aortic Insufficiency Valve anatomy and function LVOT and annulus, valve leaflets and commissures, aortic root (Sinuses of Valsalva), and ascending aorta Ventricular size and function EAE Recommendations 2010
3 Aortic Insufficiency Carpentier Classification Normal leaflet motion Excessive leaflet motion Restricted leaflet motion EAE Recommendations 2010
4 Aortic Insufficiency Important Etiologies: Leaflet disease (rheumatic, prolapse, VSD, fenestrations, endocarditis, rheumatologic, calcific) Bicuspid AV Dilated aorta (hypertension, Marfan, bicuspid AV, annuloaortic ectasia, collagen vascular disease, syphilis) Dissection EAE Recommendations 2010
5 Aortic Insufficiency Echo Allows Evaluation of: AV/root anatomy LV size and systolic function Quantitation of AI Supportive findings when severe AI suspected
6 Aortic Insufficiency Echo is Essential in Decision Making No adequate medical Rx for AI Therefore, severe AI requires valve replacement
7 Aortic Insufficiency AHA/ACC 2014 Valve Guidelines
8 Aortic Insufficiency Functional Classification Type I: aortic root (annulus, sinuses, sinotubular junction) with normal cusps Type II: prolapse or free edge fenestration eccentric AI Type III: poor cusp tissue quality (retraction, calcification, endocarditis) EAE Recommendations 2010
9 Aortic Insufficiency PISA Method: Similar drawbacks as VC method Assumes a hemispheric PISA EAE Recommendations 2010
10 Aortic Insufficiency Volumetric Method: Multiple sources of error Time consuming EAE Recommendations 2010
11 Aortic Insufficiency Echo Markers of Severe AI: Vena contracta width > 6 mm Important to zoom image Can be difficult to define Prone to measurement error EAE Recommendations 2010
12 Aortic Insufficiency Other Doppler Findings: Holodiastolic reversal in the descending aorta > 20 cm/s Pressure ½ time < 200 ms Increased forward TVI EAE Recommendations 2010
13 Aortic Insufficiency
14 Aortic Insufficiency
15 Aortic Insufficiency
16 Aortic Insufficiency
17 Aortic Insufficiency
18 Echo provides info on: Valve Anatomy Mechanism of Regurgitation (primary or secondary) Etiology Allows Quantitation of MR Repairability
19 Normal MV function involves complex interaction between: MV leaflets Subvalvular apparatus (chordae, pap muscles) Mitral annular geometry and motion LV size and function
20 EAE Recommendations 2010
21 EAE Recommendations 2010
22 Valve analysis should integrate etiology and type of dysfunction Distinction between primary and secondary MR is mandatory EAE Recommendations 2010
23 Primary MR ( organic ) = leaflet disease Barlow, FE deficiency, rheumatic, endocarditis, Marfan, Ehler s-danlos, MAC Secondary MR ( functional ) = LV disease Ischemic & Non-Ischemic Cardiomyopathy
24 Primary MR 2014 AHA/ACC Valvular Heart Disease Guideline
25 Wherever possible quantitation is important Most often done using PISA For primary MR severe defined by: ERO 0.40 cm 2, Regurg vol 60 ml, EF > 60%, LVESD 40 mm (stage C2) 2014 AHA/ACC Valvular Heart Disease Guideline
26 In absence of MS, E vel > 1.5 m/s suggests severe MR MV VTI (pulsed)/lvot VTI > 1.4 suggests severe MR Vena contracta 7 mm suggests severe MR Systolic reversal of flow in pulmonary vein(s) also suggests severe MR EAE Recommendations 2010
27 MVP defined on long-axis views: Movement of coaptation line beyond annulus, or leaflet displacement >2 mm beyond annular line Can involve an isolated segment (FE deficiency) or multiple segments (Barlow) best defined on 3D imaging
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29
30
31 For secondary MR severe defined by: ERO 0.20 cm2, Regurg vol 30 ml Treatment less well defined EAE Recommendations AHA/ACC Valvular Heart Disease Guideline
32 Secondary MR 2014 AHA/ACC Valvular Heart Disease Guideline
33 Functional usually involves papillary muscle displacement and valve tenting Prominent bend in AML and loss of line of coaptation Annular dilation can play a role but usually less important EAE Recommendations 2010
34 Can be due to LV/pap muscle dysfunction post MI (usually inferior) Circulation. 2005;112:
35
36 Carpentier A, Adams DH, Filsoufi F. Carpentier s Reconstructive Valve Surgery Saunders Elsevier JACC 64:1867
37 EHJ Cardiovascular Imaging 16:290
38
39 The End
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