Aortic Regurgitation - Iowa ACC Chapter - Home

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Aortic RegurgitationVAANI PANSE GARG, MDA S S I S T A N T P R O F E S S O R O F M E D I C I N E

A S S O C I A T E P R O G R A M D I R E C T O R C A R D I O L O G Y F E L L O W S H I P

M O U N T S I N A I M O R N I N G S I D E – N E W Y O R K , N Y

I O W A A C C E C H O B O A R D R E V I E W S E R I E S 2 0 2 1

Normals

Aortic valve leaflets are uniform in thickness except for a slightly more fibrous region at the anatomic midpoint of each cusp or nodules of Arantius

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Aortic Valve

PIAZZA ET AL. CIRCULATION: CARDIOVASCULAR INTERVENTIONS. 2008;1:74–81

Normal aortic valve area (AVA) 3-4 cm2 ;Normal opening usually 2 cm

Normal Aortic Valve M-Mode

RCC

NCC

IVCT

IVRT

Parallelogram in shape

Midline closure

RCC = right coronary cusp

NCC = non-coronary cusp

IVCT = isovolumetric contraction time

IVRT = isovolumetric relaxation time

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Aortic Valve: Transthoracic

ASE 2018 GUIDELINE ADULT COMPREHENSIVE TTE

Aortic Valve: Transesophageal

ASE GUIDELINE COMPREHENSIVE TEE 2013HTTP://PIE.MED.UTORONTO.CA/TEE/INDEX.HTM

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Questions

Question 1

KLEIN, A. CLINICAL ECHOCARDIOGRAPHY REVIEW, 2017

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Question 2


Question 3


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Question 4


Aortic Regurgitation

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Aortic Regurgitation: Classification

FAA = functional aortic annulusSTJ = sinotubular junction SCA = subcommisural annuloplasy

BOODWHANI ET AL J OF THORACIC AND CARDIAC SURGERY 2009; ZOGHBI ET AL. JASE 2017.

Aortic Regurgitation: Jet Width/LVOT Diameter

ZOGHBI ET AL. JASE 2017;OTTO ET AL. AHA/ACC UPDATE 2020.

Mild Jet width <25% of LVOT diameter

Moderate Jet width within 25-64%

Severe Jet width >65% LVOT diameter = jet more than 2/3 in comparison to LVOT

*Nyquist limit at 50-60 cm/s

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Aortic Regurgitation: Jet AreaMild Cross sectional area <5%

Moderate In between

Severe Cross sectional area >60%

= basically more than 2/3



Aortic Regurgitation: Vena Contracta


Mild Vena contracta < 0.3 cm

Moderate Vena contracta 0.3 – 0.6 cm

Severe Vena contracta > 0.6 cm

*Vena contracta measured in the parasternal long axis due to best axial resolution (depth resolution)


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Aortic Regurgitation: Proximal Flow Convergence


Coming later…

M-Mode: Severe Aortic Regurgitation

Early opening of aortic valve C

C

Early closure of mitral valve

Normal mitral valve

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Aortic Regurgitation:Pulse Wave Diastolic

reversal in descending

aorta

Aortic Regurgitation:Continuous Wave

ZOGHBI ET AL. JASE 2017.

Mild Pressure half time (PHT)

>500 ms

Moderate In between 200-500

Severe Pressure half time (PHT)

<200 ms

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Severity of Chronic Aortic Regurgitation

ZOGHBI ET AL. JASE 2017.OTTO ET AL. AHA/ACC UPDATE 2020.


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Aortic Regurgitation

GOLDBARG & HALPERIN, NATURE CLINICAL PRACTICE CARDIOVASCULAR MEDICINE, MAY 2008.

Key PointsChronic Aortic Regurgitation

Severity graded using a combination of structural, qualitative Doppler, and semiquantitative parameters

Jet often visible in all views

Assess left ventricular size and volume Globular and dilated

Ejection fraction may fall as late finding

Normal chamber volumes are unusual with chronic severe aortic regurgitation

Acute Severe Aortic Regurgitation

Diagnostically more challenging Color Doppler with short duration

Tachycardia

Low aortic regurgitation velocity

Eccentric jet

Left ventricle not dilated

Ejection fraction likely reduced

M-Mode findings for aortic and mitral valves

Low threshold for transesophagealechocardiogram (TEE)

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Specific Diseases


RCC

NCC

LCC

Transthoracic

RCC

NCC

LCC

Transesophageal

Bicuspid Aortic Valve

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Bicuspid Aortic ValveMale predominance 2:1

1-2% of general population

Most common is RCC-LCC fusion RCC and NCC fusion 32%

Anterior/Posterior 14%

Eccentric closure line on M-Mode

Diagnose in SYSTOLE

TTE 92% sensitivity; 96% specificity for detection

50% have associated aortopathy

Coarctation If bicuspid, 5% have coarctation

If coarctation, 50% have bicuspid

RCC

NC

LC

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Quadricuspid Aortic Valve

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Quadricuspid Aortic ValveNo gender preference

Associated with aortic regurgitation

Associated with anomalous coronary arteries (10%)

Rare

Ventricular Septal Defect

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Endocarditis with Valve Destruction

Subaortic MembraneDiscrete fibrous membrane (90%)Muscular narrowing of LVOT (10%)Most common associated lesion are PDA, VSD, coarctationof the aorta, pulmonary valve stenosis

M-Mode Abrupt, very early posterior

motion of right aortic cusp Early systolic premature closure of

aortic valve Fluttering of the aortic leaflets post

“dip” due to aortic regurgitation

Treatment is surgical resection Symptomatic with

peak LVOT gradient 50 mmHg or more

Peak LVOT gradient < 50 mmHg with heart failure or ischemia

Asymptomatic with mild aortic regurgitation and peak gradient 50 mmHg or more

2018 AHA/ACC GUIDELINE MANAGEMENT ADULTS CONGENITAL HEART DISEASE

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Connective Tissue Disorder (Marfan’s)

Marked aortic root dilation

Aortic Dissection

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Quantitative Analysis & Equations

PrinciplesContinuity = conservation of mass Continuity for aortic valve

Area = volume / distance Aortic valve area

Stroke volume = LVOT area x stroke distance

Transaortic distance (velocity time integral (VTI))

Bernoulli = conservation of energy Simplified ∆P = 4V2

Account for V2 if LVOT velocity > 2 m/s

4(V22 – V1

2)

Flow Convergence = as blood approaches a regurgitant orifice, its velocity increases forming concentric, roughly hemispheric shells of increasing velocity and decreasing surface area

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Flow Convergence MethodEffective Regurgitant Orifice Area (EROA) Area cm2 = (flow cm/s) / (peak velocity cm/s)

Proximal Isovelocity Surface Area (PISA) radius in cm


2πr2 = 6.28r2

(6.28r2)(nyquist) / peak AR velocity

Equals EROA

Flow Convergence & PISA Example

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Stroke Volume (SV) Method


Volume through mitral valve is representative of “full” amount

Volume through LVOT will include regurgitant volume

SVmitral + Rvol = SVlvot

Rvol = SVlvot – SVmitral

SV = πr2 x stroke distance

πr2 = π(d/2)2 = π(d2/4) = 0.785 d2

Via PISA method

AR volume is regurgitant volume, then divided by outflow stroke volume

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Left Ventricular End Diastolic PressurePressure originating chamberaorta = 4v2 + Pressure receiving chamberleft ventricle

ΔP = 4 V2

ΔP = DBP – LVEDP

DBP – LVEDP = 4 (ARend-diastolic peak velocity)2

LVEDP = DBP - 4 (ARend-diastolic peak velocity)2

If BP is 130/40:4 m/s

1.5 m/s4(AR velocity)2 = DBP – LVEDPLVEDP = DBP - 4(AR velocity)2

LVEDP = 40 - 4(1.5)2

LVEDP = 40 – 9LVEDP = 31 mmHg

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Aortic Valve Interventions

NISHIMURA 2014; OTTO ET AL 2020

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Mechanical Aortic Valve

MitralAortic

Bioprosthetic Aortic Valve

Systole

DiastoleLeft Main Artery

IMAGE ADAPTED FROM PIAZZA ET AL, BMJ 2012

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Back to the Questions

Question 1Teaching points

The non-coronary cusp is adjacent to the interatrial

septum.

The right coronary cusp is the most anterior cusp

(farthest from the transducer on TEE)

Teaching points

Papillary fibroelastomas are benign tumors

Seen on aortic valve

Small, well-delineated, pedunculated masses

Small <20 mm

Half have stalks

Highly mobile

High embolic risk

RCC

NCC

LCC

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Question 2

Teaching points

Subaortic stenosis is treated surgically

Most common associated lesion are PDA, pulmonary

valve stenosis, coarctation of the aorta, VSD

Question 3

Teaching points

Watch units!!!

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Question 4

Thank You and

Good Luck!

Aortic Regurgitation - Iowa ACC Chapter - Home

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