Quantitation of Aortic Regurgitation ASCeXAM / ReASCE Review Course
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1 Quantitation of Aortic Regurgitation 2017 ASCeXAM / ReASCE Review Course David Adams, ACS, RCS, RDCS, FASE Duke University Medical Center May 1, 2017 Disclosures None 1
2 Exam based on: Zoghbi et al. JASE (2003) 16: Not This Zoghbi et al. JASE (2017) April Edition 2
3 However AR parameters haven t changed! Better graphics / Algorithm s Zoghbi et al. JASE (2017) April Edition Chronic AR Zoghbi et al. JASE (2017) April Edition 3
4 AR Severity Zoghbi et al. JASE (2017) April Edition Rwanda Case #1 15yo M at 37kg FC IIb SOB with exertion since Can play but tires easily. Curr no SOB at night, but does cough 4
5 5
6 6
7 Severe AR! 7
8 AR Etiology Ao Valve Ao Root Acute vs chronic AR Etiology Ao Valve Congenital (BAV, Sub Ao membrane) Degenerative Endocarditis Traumatic Rheumatic Prolapse Radiation 8
9 Sub Valvular Membrane AR Etiology Ao Root Dilated Connective tissue dz (Marfan, Ehlers Danlos) Systemic HTN Vasculitis Ao Dissection Sinus of Valsalva Aneurysm 9
10 AR Etiology Zoghbi et al. JASE (2017) April Edition AR Pathophysiology Acute Chronic 10
11 AR Acute Endocarditis Ao Dissection 11
12 Sinus of Valsalva Aneurysm BAV AR Chronic 12
13 Systemic HTN AR Quantitation Qualitative eyeball Quantitative volumetric calculations 13
14 AR Qualitative AV anatomy Ao root anatomy LV size & shape Echo in AR MV fluttering MV pre-closure ( LVEDP) Before onset of QRS LV dilation & check fx TEE for dissections Serial echo's / chronic 14
15 Diastolic Fluttering MV Preclosure 15
16 AR Severity CF Doppler AR jet width Jet eccentricity AR by Jet Size 16
17 Problems with jet size Zoghbi et al. JASE (2017) April Edition AR Quantitation Qualitative eyeball Quantitative (Semi) volumetric calculations 17
18 AR Severity Table Zoghbi et al. JASE (2017) April Edition AR Severity Doppler CW slope / PHT 18
19 Doppler Limitations Poor alignment of Doppler beam to flow FIX: use multiple windows/views Arrhythmias FIX: in Afib average 3-5 consecutive beats AR Severity Doppler Bonita Anderson Echocardiography (2017) 3 rd Edition 19
20 Ao P ½ time Mild = 500 msec Mod. = msec Sev. = 200 msec Ao P ½ time 20
21 What is the LVEDP? LVEDP = dias BP end dias gradient LVEDP = 50 mmhg 16 LVEDP = 34 mmhg AR Severity Doppler CW slope / PHT Jet density 21
22 HINT Mild AR has an incomplete spectrum. Incomplete Spectrum 22
23 Not in the jet In the jet Jet Density Zoghbi et al. JASE (2017) April Edition 23
24 AR Severity Doppler CW slope / PHT Jet density DescAo flow reversal Desc Ao Technique Suprasternal Central position Level of RPA (usually below the L Subclavian artery) 24
25 Diastolic flow reversal Diastolic flow reversal Zoghbi et al. JASE (2017) April Edition 25
26 AR Quantitative AR jet width / LVOT JW / LVOT (ratio) Zoghbi et al. JASE (2017) April Edition 26
27 JW / LVOT (ratio) Mild = < 25% Mod. = 25-64% Sev. = 65% AR Quantitative AR jet width / LVOT Vena contracta width Mild = 0.3 cm Mod. = cm Sev. = 0.6 cm 27
28 AR Quantitative AR jet width / LVOT Vena contracta width Zoghbi et al. JASE (2017) April Edition AR Quantitative AR jet width / LVOT Vena contracta width Rvol (ml/beat) RF (%) EROA (cm 2 ) 28
29 AR Quantitative Zoghbi et al. JASE (2017) April Edition AR RVol Zoghbi et al. JASE (2017) April Edition 29
30 EROA in AR AR Quantitative Zoghbi et al. JASE (2017) April Edition 30
31 AVR Recommendations Nishimura et al. CIRC (2014) AVR Recommendations Nishimura et al. CIRC (2014) 31
32 AVR Recommendations Nishimura et al. CIRC (2014) Know This!! Zoghbi et al. JASE (2017) April Edition 32
33 AR Conclusions Assess pt symptoms Serial echo assessment LV size & fx Identify mechanism of AR Use multiple quantitative parameters Integrate!! 33
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