What are the best diagnostic tools to quantify aortic regurgitation?
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1 What are the best diagnostic tools to quantify aortic regurgitation? Agnès Pasquet, MD, PhD Pôle de Recherche Cardiovasculaire Institut de Recherche Expérimentale et Clinique Université catholique de Louvain
2 Faculty disclosure Agnes Pasquet I have no financial relationships to disclose.
3 Case :53 Yo man Know ascending aorta dilatation Had the feeling that he is more exhausted at the end of the day Clinical examination: Diastolic aortic murmur 3/6, BP: 130/80 mmhg
4
5 Questions? Aortic root is not yet an indication for surgery Does this patient have severe aortic regurgitation? Assessment of Ao regurgitation severity?
6 Assessment of aortic regurgitation Echocardiography remains the corner stone!
7 Assessment of aortic regurgitation: echo tools? Colour flow area Vena contracta PISA method Continuity equation Pressure half time
8 Assessment of AR: Colour flow mapping Apical or Parasternal long axis, ( better axial resolution) Optimize colour /gain scale Easy to use IV jet extending beyond the papillary muscle III jet extending to the papillary muscle II jet extending to the tip of the anterior leaflet I jet confined to LVOT Spatial orientation of the jet Screening for AR
9 Assessment of AR: Colour flow mapping Inaccurate for excentric jets! Influenced by technical and haemodynamical factors! The colour flow area of the regurgitant jet is not recommended to quantify the severity of AR. Should only be used for a visual assessment of AR. A more quantitative approach is required when more than a small central AR jet is observed. 9
10 Assessment of AR: vena contracta The veina contracta is the narrowest portion of the jet dowstrean from the regurgitant orifice PS long axis (Zoom) Identify the 3 component Easy to perform!
11 Assessment of AR: vena contracta Small value? 6 mm Mild Moderate Severe VC (mm) < 3 intermediaire > 6 Vena contracta width is recommended to quantify AR. Intermediate VC values (3 6 mm): confirmation by a quantitative method. Could be obtained and used in eccentric jet. Multiple jets: the respective values of VC width are not additive.
12 Assessment of AR: flow convergence PISA As a blood flow converges towards a regurgitant orifice, it forms concentric isovelocity shells of decreasing surface and increasing velocity. Q= 2 R 2 Va Va=aliasing velocity EROA= Q/peak orifice velocity R Vol (ml) = EROA (cm2) /TVI (cm)
13 Assessment of AR: flow convergence PISA Pisa ao: from apical view or for excentric jet from ps view measurement 13
14 Assessment of AR: flow convergence PISA Flow convergence method (PISA) RV: 65 ml, ERO:32 mm2 Mild Moderate Severe EROA (mm 2 ) < >30 RV (ml) < > 60 ml PISA method is highly recommended to quantify the severity of AR. It can be used in both central and eccentric jets. In eccentric AR jets, use the parasternal long-axis view An EROA 30 mm2 or an R Vol 60 ml indicates severe AR.
15 Assessment of AR: continuity equation Qs 140 cc RV = Qv - Qs Time consuming Qv 100 cc Mitral flow/pulmonary Flow Several errors! RV No valvular regurgitation RF > 50%: severe AR
16 Assessment of AR: continuity equation Q pulm / Q Ao Quantitative: estimate lesion severity (ERO) and volume overload (R Vol) Valid in multiple jets Time-consuming Requires multiple measurements: source of errors 16 Not applicable in the case of significant MR (use the pulmonic site)
17 Pressure mmhg Pressure mmhg Assessment of AR: CW pressure half time CW : Pressure half time Moderate Severe 17
18 Assessment of AR: CW pressure half time PHT: 188 msec Mild Moderate Severe PHT (msec) >500 intermediate <200 The assessment of the pressure half-time requires good Doppler beam alignment. A careful probe angulation is often needed. Influenced by chamber compliance and chamber pressures, it serves only as a complementary finding for the assessment of AR severity. 18
19 Assessment of AR: Flow reverse descending Ao Mild Moderate Severe Flow reversal brief protodiastolic intermediate holodiastolic (>20 cm/s The measurement of the diastolic flow reversal in the descending aorta is recommended, when assessable. It should be considered as the strongest additional parameter for evaluating the severity of AR
20 Assessment of AR: consequence LV dilatation LV volumes 2D, 3D LV diameters, volumes, and ejection fraction should always be evaluated and reported.
21 Assessment of AR: valve and root morphology Tricuspid valve Unicuspid valve Bicuspid valve Quadricuspid valve Source: 21
22 Assessment of AR: valve and root morphology I Enlargement of the aortic root ( annulus, sinus with normal cusp II Cusp flail: complete eversion of a cusp Partial prolapse: distal part of the cusp prolapsing Whole cusp prolapse: free edge ofthe cusp overiding the place of the annulus III Poor cusp quality, thickened valve, with reduce motion
23 Assessment of AR: in summary Source:: Lancellotti et al, Eur J echo 2010;:
24 Assessment of AR: Problems? Conflicting value Or some measurement are not feasible Patient had poor image quality You need some confirmation of the severity and repercussion?
25 Assessment of AR: in summary: TOE Same method as for TTE except diastolic flow reverse in the aorta Aortic root assessment LV function and volumes? ( more difficult)
26 Assessment of aortic regurgitation : MRI Allows volumes measurement Quantification of AR using phase contrast technique Tissue characterization
27 Assessment of aortic regurgitation : MRI LV and volumes
28 Assessment of aortic regurgitation : MRI Aortic valve
29 Assessment of aortic regurgitation : MRI Visual Imaging of jet turbulence no AR. Mild-Moderate AR. Severe AR. Imprecise for quantification with SSFP pulse sequences Useful for direction of jet.
30 Assessment of aortic regurgitation : MRI Q Fw Q Rw Phase contrast technique for flow quantification Quantitative measurement of aortic flow 1000 Systole: forward volume Diastole: backward volume Flux (ml/s) Q Fw = 143 ml Q Reg = 79ml RF= 55% Time (ms)
31 Assessment of aortic regurgitation : MRI Flow reversal in descending aorta Bolen, Radiology 2011
32 Assessment of aortic regurgitation : MRI Tissue Characterization : fibrosis?
33 ACC/AHA guidelines on valve disease 2014 ESC guidelines on valves disease Guidelines : Bicuspid AV
34 Assessment of aortic regurgitation : MRI assessment of the aorta
35 Conclusion: The colour flow area of the regurgitant jet is not recommended to quantify the severity of valvular regurgitation. Both the vena contracta measurement and the PISA method are the recommended approaches to evaluate the severity of regurgitation when feasible. Adjunctive parameters should be used to confirm the results MRI could help for quantification of LV volume and severity of aortic regurgitation
36 Conclusion: Quantified degree of regurgitation and the clinical context must be integrated. All the measurements need to be consistent!
37 Thank you for your attention
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