Quantifying Aortic Regurgitation
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1 Quantifying Aortic Regurgitation Linda D. Gillam, MD, MPH Morristown Medical Center Dorothy and Lloyd Huck Chair Cardiovascular Medicine Atlantic Health System No Disclosures 1
2 Valve Dysfunction Functional Disturbance Anatomic Change Disease 2
3 3
4 Color Jet Dimensions Vena Contracta Spectral Doppler Approaches Density Pressure half time Flow reversal (descending and/or abdominal aorta) Quantitative Doppler PISA 4
5 Length Color Jet Characteristics Color Jet Characteristics Indexed Width vs. LVOT diameter <25% = mild 25-45% = mild to moderate 46-64% = moderate to severe 65% = severe 5
6 6
7 7
8 Color Jet Characteristics Indexed CSA vs. LVOT CSA <5% = mild 5-20% = mild to moderate 21-59% = moderate to severe 60% = severe 8
9 Pros 1) Easy 2) Easy 3) Easy 4) Cons Setting dependent Jet dimension Directly related to gain, transmit power Inversely related to Nyquist limit (Wall constraints) May not be constant flow rate BP dependent Reference to LVOT dimension may be inappropriate The color jet volume is not the same as the regurgitant volume 9
10 Vena Contracta the point in a fluid stream where the diameter (and cross-sectional area) of a fluid stream moving through a narrowing is the least, and fluid velocity is at its maximum. the maximum contraction takes place at a section slightly downstream of the orifice, where the jet is more or less horizontal 10
11 Why does this happen? Fluid streamlines cannot abruptly change direction. In the case of a sudden change in orifice diameter, the streamlines are unable to closely follow the sharp angle into the orifice Instead, the converging streamlines follow a smooth path, which results in the narrowing of the jet. 11
12 Vena Contracta < 0.3 = mild = moderate >0.6 = severe Semi-quantitative assessment of aortic regurgitation severity using the vena contracta (VC) width. Patrizio Lancellotti et al. Eur J Echocardiogr 2010;11: Published on behalf of the European Society of Cardiology. All rights reserved. The Author For permissions please journals.permissions@oxfordjournals.org. 12
13 Problems Imprecision of the measurement Spatial resolution Spatial variation (noncircular) Assumes sphericity Temporal variability Multiple jets?? Large gray zone Spectral Doppler Density problematic with eccentric jets 13
14 Pressure Half Time > 500 = mild = moderate <200 = severe 586 ms 185 ms J Am Soc Echocardiogr 1998;11:332-7.) 14
15 Fig. 3 Journal of the American Society of Echocardiography , DOI: ( /S (98) ) Copyright 1998 American Society of EchocardiogryaphyTerms and Conditions AR Halftime vs RF Contrasting Effect of ROA and SVR Halftime Slope [msec] [m/s/s] AROA SVR SVR SVR AROA Regurgitant Fraction Griffin et al Am Heart J 1991;122: , Eur Heart J 1994; 15: With thanks to Jim Thomas 15
16 PHT not very helpful Flow Reversal 16
17 17
18 18
19 19
20 Noise Default wall filters Limitations Impact of vascular compliance on accuracy still unknown 20
21 Quantitative Doppler Regurgitant volume <30 = mild = mild to moderate = moderate to severe 60 = severe Regurgitant fraction <30 = mild = mild to moderate = moderate to severe 50 = severe 21
22 RV = Stroke Volume Forward Flow Pros Only way we have to get at regurgitant fraction Measures the same thing as MRI Echo methods of measuring forward flow are robust Handles multiple jets 22
23 Limitations Limited validation Using mitral inflow as reference makes lots of assumptions Using pulmonic flow as reference is difficult Concomitant aortic stenosis may create problems PISA 23
24 Proximal Convergence Method Flow thru any isovelocity shell is equal to instantaneous orifice flow Quantitative assessment of aortic regurgitation (AR) severity using the proximal isovelocity surface area (PISA) method. Patrizio Lancellotti et al. Eur J Echocardiogr 2010;11: Published on behalf of the European Society of Cardiology. All rights reserved. The Author For permissions please journals.permissions@oxfordjournals.org. 24
25 Regurgitant volume (cc) <30 = mild = mild to moderate = moderate to severe 60 = severe EROA (cm 2 ) <0.10= mild = mild to moderate = moderate to severe.30 = severe Limitations Spatial resolution Geometric assumptions Limited validation Other echo methods (quantitative Doppler, 2D) 25
26 Can 3D help with quantitation? Maybe 26
27 27
28 Am J Cardiol 2013;112:560e566 28
29 3D still research tool Summary Use an integrated approach Every method has pitfalls 29
30 Thank you! 30
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