AI

Question 2

Causes

Answer 2

o Degenerative lesions
o Vegetative lesions → endocarditis
o Torn/flail cusps
o Congenital leaflet malformations
 Bicuspid valve
 Rheumatic, calcific valve disease

Question 3

Echo: valvular appearance/motion

Answer 3

o Ao valvular lesions
 Absence of lesions ≠ absence of dz
* Nodules/irregularities <2mm could be present
 Degenerative lesions: usually small, smooth and rounded
 Vegetative lesions: large, irregular hyperechoic masses associated w leaflets
* Floppy, can prolapse into LVOT
* If rapid vegetation growth, LVE can be absent

Question 4

Echo M Mode

Answer 4

o Diastolic flutter of AoV and MV→ most common finding
 Entire diastole or only a part of it
 As regurgitant jet strikes MV leaflet
o ↑ EPSS
 Restriction of MV motion by regurgitant jet
 Severity correlated with severity of AI
o Early MV closure: earlier ↑ LVP

Question 5

Echo 2D LV size

Answer 5

o LVE: chronic volume overload
 Degree of LVE depend on AI severity
 Acute AI can have normal LV size
* ↑LV filling pressures

Question 6

Echo 2D LV fct

Answer 6

o Myocardial function
 Greater impact vs MR → higher afterload/wall stress
* No flow into low pressure atrium early during systole (MR)
* Need to deal w all volume into LV
 FS should ↑ and systolic dimension ↓
* If not → suggest myocardial systolic dysfct
* ↓px in Hu when EF% < 50-55%

Question 7

MV motion/lesions

Answer 7

• Mitral valve: reverse doming of anterior leaflet
• Jet lesion on IVS and MV

Question 8

Echo Doppler color flow

Answer 8

severity of AI → correlate to LVE

Question 9

3 ways to evaluate severity of AI on color flow Doppler

Answer 9

Proximal flow convergence into Ao
Vena contracta
Jet direction and size of LVOT

Question 10

Proximal flow convergence into Ao

Answer 10

PISA

Question 11

Vena contracta

Answer 11

• Smallest width of jet through AoV
  o From LAX parasternal views
   Always smaller than jet height since expands in LVOT
  o >7mm → sensitive for severe AI
  o <3mm → sensitive for mild AI
• Regurgitant orifice size can be calculated from vena contracta
  o EROA = pi x (vena contracta/2)2
   >0.3cm2 → severe AI
  o Influenced by systemic BP and size of Ao

Question 12

Jet direction and size of LVOT

Answer 12

• Extent of regurgitant jet into LVOT
  o Mild if dissipates just beyond AoV
  o Moderate if extend to tip of MV leaflets
  o Severe if beyond MV leaflets
• Analyze jet height vs length w color flow → better correlation with jet significance
  o Jet height proximal to AoV compared to LVOT diameter
   R parasternal LAX
   Correlate to quantitative methods
   If ratio of jet height/LVOT
• > 65% = severe
• 47-64% = moderate to severe
• 25-46% = moderate
• <24% = mild
• Inaccurate if eccentric jet

Question 13

Echo Spectral Doppler eval

Answer 13

AI profile shape
Pressure 1/2 time
Regurgitant volume and fraction
Diastolic flow reversal

Question 14

AI profile shape info on severity

Answer 14

AoV closure → rapid ↑ velocity to 3-5m/s → gradual ↓ velocity during diastole →abrupt ↓ velocity in IVCT → baseline at AoV opening
 Will reflect PG across valve → severity and chronicity of AI
 Chronic severe AI: steeper diastolic deceleration slope (vs plateau if mild)
 Acute severe AI: triangular shape + linear deceleration slope
* LV has not adapted to ↑ volume → severe ↑ LV end diastolic

Question 15

Pressure ½ time and slope info on severity

Answer 15

 Depend of rate of pressure equilibration btw LV and Ao
* Large regurgitant orifice → rapid pressure equilibration
o Rapid ↓ in AoP and ↑ in LVP
o Steep slope and short pressure ½ time
* Small regurgitant orifice → slow pressure equilibration
o Plateau shaped profile with long pressure ½ time
 Hu: P ½ >500ms = mild AI, <300ms = severe AI

Question 16

Factors influencing pressure 1/2 time

Answer 16

• Size of regurgitant aperture
• LV compliance
• Ao diastolic P

Question 17

How to calc Regurgitant volume and fraction

Answer 17

 Pulmonary SV – Ao SV
* Should normally be equivalent
* RF = (Total Ao SV – PA SV)/Total SV Ao
 EROA = RV AI x VTI AI

Question 18

How to eval diastolic flow reversal

Answer 18

 TEE
 Analysis of flow in descending Ao
* Significant reversal of flow during diastole
* Normally trivial

Question 19

Definition of severe AI in Hu

Answer 19

• Vena contracta >6mm
• Holodiastolic flow reversal in proximal abdominal Ao
  o PE finding: diastolic murmur in femoral arteries → Duroziez’s sign
• Regurgitant volume > 60ml
• Regurgitant fraction >50%
• EROA <0.3cm2