Quantification of Aortic Regurgitation
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1 Quantification of Aortic Regurgitation ASE Review 2018 Boston Susan E Wiegers, MD, FASE, FACC Professor of Medicine And thanks to Dr. Roberto Lang Disclosure None related to this presentation 1
2 Objectives Anatomy Acute vs chronic Etiology Grading severity Qualitative Semiquantitative Quantitative The cusps The aorta including Sinuses of Valsalva Sinotubular junction The aortomitral continuity The membranous septum 2
3 Valve cusps are not planar 3
4 JASE April
5 Abnormal Leaflets LEAFLET CONGENITAL Bicuspid, unicuspid, quadracuspid, VSD ACQUIRED Endocarditis, rheumatic disease, calcification, radiation, anorectic drugs 5
6 Abnormal aorta CONGENITAL ACQUIRED Bicuspid aortic valve, annuloaortic ectasia, CT disease HTN, SLE, Ankylosing spondylitis, dissection, syphilis trauma Acute severe Chronic severe LV not dilated Jet may appear small or not be visible EF likely to be reduced Early MV closure LV dilated and globular Jet visible in all views EF may fall as late finding 6
7 Cause of Acute Severe Aortic Dissection Dissection with disruption of the valve commissures Endocarditis Chest trauma Acute Aortic Regurgitation 69-year-old man admitted for sudden onset of severe shortness of breath with production of pink, frothy sputum 7
8 Acute Aortic Regurgitation Pressure (mmhg) ECG LV PCW FA DOAV Early DCMV Early Diastolic Closure of the Mitral Valve Diastolic Opening of the Aortic Valve Severe Acute Aortic Regurgitation Early DCMV 8
9 Diastolic Opening of the Aortic Valve Meyer T et al., Am J Cardiol 1987;59:
10 AR assessment What is the etiology What are the hemodynamic consequences How severe is the regurgitation 10
11 HTN most common cause of mild AR 11
12 Etiology of Chronic AR is key to surgical plan Grading the Severity of Chronic AR Structural parameters Qualitative Doppler parameters Semi-quantitative Doppler parameters Quantitative Echo-Doppler parameters 12
13 Natural History of Asymptomatic Patients with Severe AI and Normal LV Function Courtesy of Dr Bonow Asymptomatic Severe AR with Normal LV Function Rate of Progression to death, symptoms and LV Dysfunction Courtesy of Dr Bonow Chronic AR generally evolves slowly with a long asymptomatic compensated phase. 13
14 Grading the Severity of Chronic AR Structural parameters Aortic leaflets LV size Grading the Severity of Chronic AR Qualitative Doppler parameters Jet width in LVOT Flow convergence Jet density, CW Jet deceleration rate, CW (PHT,msec) Diastolic flow reversal in descending AO, PW 14
15 Qualitative Doppler parameter Qualitative Doppler parameter 15
16 Qualitative Doppler parameter Qualitative Doppler parameter 16
17 Decel slope vs PHT PHT - msec Mild - > 500 Moderate Severe < 200 Decel slope cm/sec Mild - < 200 Moderate Severe >300 PHT here is 130 msec Peal velocity? Disadvantage of PHT method is that detecting peak velocity is key Easy in Mitral inflow Tougher in AR 17
18 Qualitative Doppler parameter Severe Aortic Regurgitation 18
19 Grading the Severity of Chronic AR Qualitative Parameters Grading the Severity of Chronic AR Semiquantitative parameters VCW (cm) Jet width/lvot width, central jets (%) Jet CSA/LVOT CSA, central jets (%) 19
20 Semi-quantitative parameter 3D Color Doppler Semi-quantitative parameter 20
21 How severe is this AR? How about now? Explanation 21
22 Semi-quantitative parameter Grading the Severity of Chronic AR Semi-Quantitative Parameters 22
23 Grading the Severity of Chronic AR Quantitative parameters RVol (ml/beat) RF EROA (cm 2 ) Quantitative parameter 23
24 V alias cm/s Flow 1 V2 V1 Flow 2 V1 Peak AI velocity (cm/)s Q prox = Q distal A 1 V 1 = A 2 V 2 (2πr 2 ) x Va = EROA x Vjet Flow Convergence Calculation V alias 25.1 cm/s r = 0.86 cm Peak AI velocity= 525 cm/s (2πr 2 ) x V alias = EROA x V AI 6.28 (.86) 2 x 25.1 = EROA x = EROA x /525 =.22 cm 2 =EROA 24
25 Quantitative parameter Regurgitant Volume EROA x VTI AI RVOL= 0.22 x 294 = 65cc EROA =.22 cm 2 VTI = 294 cm 25
26 26
27 Regurgitant Volume Mild <30 cc Mild-moderate cc Regurgitant Volume = 65cc Moderate cc Severe 60 cc Quantitative parameter 27
28 Regurgitant Volume = SV Ao SV MV LA LA Regurgitant Fraction AR regurg. volume (cc) RF % X 100 Ao stroke volume = = 65 (cc) cc X cc RF = % < RF 40 = % >50 28
29 Effective Regurgitant Orifice Area Reg Vol = ERO x REG TVI ERO = REG Vol / Reg TVI Regurgitant volume ERO = = ERO Regurgitant TVI J Am Soc Echocardiogr 2003;16: Grading the Severity of Chronic AR Quantitative Parameters 29
30 30
31 When to Perform CMR or TEE A B C D Forward: 138 ml Reverse: 70 ml RF: 51 % 31
32 Conclusions Establishing the size of the ventricle and aorta of key importance Serial echoes in asymptomatic severe (or suspected severe) AR meet appropriate use criteria for echo Be prepared for discrepant indices Thank you for your attention 32
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