Aortic Regurgitation Flashcards
What is Aortic insufficiency?
Aortic regurgitation
What happens during aortic insufficiency?
Blood moves backwards through the AV from aorta to the left ventricle throughout diastole
What are the 3 groups of mechanisms that can cause AI? 3
- Cuspal abnormalities
- Aortic root dilatation
- Loss of commissures support
Cuspal abnormalities include what? 4
- Congenital abnormalities
- Rheumatic aortic valve disease
- Aortic valve prolapse
- Infective endocarditis
What is Cuspal abnormalities in general?
Any congenital disorder or disease process that affects the AV cusps
What are things we should look for in terms of congenital abnormalities? 2
- Bicuspid AV
- Quadricuspid AV
Wha this Rheumatic AV disease?
Cusp tissue is infiltrated wit fibrous tissue causing them to shorten and retract
What can no longer happen during rheumatic AV disease?
Cups can no longer come together to coapt
Rheumatic AV disease is usually associated with what?
Some degree of Aortic stenosis
How common is aortic valve prolapse?
Rare
What is Aortic valve prolapse defined as?
Cusp leaflet tips displaced below the valve ring during diastole
Aortic valve prolapse maybe due to what? 2
- Myxomatosis degeneration of the valve or due to rheumatic heart disease
- Occur secondary to aortic root dilation or trauma
What is aortic bacterial endocarditis?
Vegetation destroys the AV
What may Aortic bacterial endocarditis may cause?
Perforation of the cusp
What does aortic root dilation prevent?
Normal leaflet coapt action during diastole which leads to AR
What are causes of Aortic dilation? 6
- HTN
- Atherosclerosis
- Connective tissue disorders
- Bicuspid AV
- Sinus of valsalva aneurysm
- Idiopathic dilation
Loss of commissures support may occur with what? 3
- Ventricular septal defects
- Aortic dissections
- Aortic trauma
What are some causes of severe AR? 3
- Trauma
- Infective endocarditis
- Aortic dissection
Acute- severe AI causes an increase in what?
Filling pressures
Mainly LV end diastolic pressure
What is this hole in the AV caused by?
Annular dilation
Why is Acute severe AI mainly in the LVEDP? 2
During diastole we have
1. Normal inflow plus
2. Regurgitation volume leaking back into the LV
During LVEDP Acute means what in terms of acute severe AI?
No time for LV to stretch, therefore LVEDP increases dramatically
What is chronic severe AI pressure?
Filling pressure normal and slightly elevated
In terms of chronic severe AI regurgitation volume causes what?
LV chamber volume to increase over time due to stretching
Chronic severe AI returning eventually leads to what? 2
- Increase in forward volume through AV
- Volume entering LV has increased form the AI (Chamber has dilated to try to accommodate it)
What is Chronic severe overload usually associated with?
Volume overload
Once the LV is dilated in chronic AI what happens? 2
- This leads to near normal filling pressures
- LV MAss will increase (eccentric)
In terms of chronic AI over time the LV may start to do what?
Start to fail at which time the LVEDP will increase
In terms of chronic AI Pressure, overload leads to what?
Volume overload
What are signs and symptoms of AI? 6
- CHF symptoms
- Occasional chest pain with chronic severe AI
- Pulmonary edema with acute AI
- Auscualtion
- ECG (LVH 80%, ventricular arrhythmias)
- Cardiomegaly
Why would someone have occasion chest pain during chronic severe AI?
Increase in LV mass decreases myocardial perfusion causing ischemia
What is a complication of increased LV and LA size and pressure overload for AI? 2
- Leads to pulmonary congestion leading to pulmonary edema, right heart failure, systemic venous congestion and edema
- Edema
What are some medications for AI? 2
- Beta blocker
- ACE inhibitors
What are some lifestyle treatments for AI?
Avoidance of heavy physical exertion
What are some surgical treatments for AI? 3
- Indicated for significant, chronic AI
- AV repair
- AV replacement
What are three ways to treat AI? 3
- Medication
- Lifestyle
- Surgical
What is the role of echo if AI? 4
- Determine etiology
- Assess LV size and function
- Measure aortic dimensions
- Estimate severity of AI
How do we determine a quadricuspid AV? 2
- Made in PSAX
- Look for an X or +
How common is a quad AV?
Rare bicuspid is more common
How do we determine bicuspid AV? 2
- Eccentric closure line in PLAX
- Small mass (vegetation) on the AV in the PLAX zoom
both pathologies lead to AI
What does bicuspid AV Jets look like?
Usually eccentric (off to one side)
With a Bicuspid AV the asc AO may be what
Dilated
In terms of a bicuspid AV, AV severity presents how?
Progressive
How does bicuspid AV AI affects younger and older patients? 3
- Younger patients have mild AI
- As the patient gets older it gets worse as the root dilates
- Leads to chronic, severe AI
Infective endocarditis is a common cause of what?
Acute severer AI
What is seen with infective endocarditis?
Hyper mobile mass on the underside of the AV (LV side)
What does infective endocarditis cause?
AI by infection destroying one or more of the cusps
What is aortic root dilation in terms of AI?
Any disease that dilates the aortic root will not allow the cusps to close tightly leading to AI
What is aortic dissection with AI?
A dissection in the proximal portion of the aorta will cause some AI
What is the VSD in terms of AI 2
- Membranous VSD are located just on the LV side of the AV
- This can affect the support structure of the aortic rood leading to AI
Label the image
Label the image
What colour doppler assessments will we do for AI? 3
- Jet height ratio
- Jet area ratio
- Vena contracta width
What are spectral doppler assessments we do? 6
- AI jet intensity
- Flow reversals
- AI P 1/2 t
- Regurgitation volume (RV)
- Regurgitation fraction (RF)
- Effective regurgitation orifice area (EROA)
What structures do we assess for AI? 3
- LV size
- Wall thickness
- LV function
How do we measure Jet height? (Which windows do we use?) 2
- Measure in PLAX
- Measure in LVOT
What is Jet height/ LVOT ratio numbers?
Mild <25% (1/4)
Severe > 65% (2/3)
Do we use the jet height/ LVOT ratio on eccentric AI?
No
Should we zoom for jet height measurements?
Yes
What is the eyeball method values?
How do we measure vena contracta width?
Measure at the narrowest point using zoome
What does Vena contracta width look like? What are the values?
In terms of AI jet intensity, density (brightness) of the AI jet is proportional to what?
Number of RBCs moving in unison
The brighter the AI signal, the more RBCs are travelling where?
Backward through the AV in diastole
What is the difference between bright signal and faint signal for AI? 2
- Bright = more significant
- Faint = trivial or mild AI
What kind of regurgitation doe each of these images have?
Mild on the left and significant on the right
How do we find flow reversal in the descending AO? (What window)
Form the SSN window
When looking for flow reversal in the Desc aort what do we look for in the SSN window? 2
- Look for retrograde flow in Desc Ao
- PW Desc AO
If we see flow reveral in the ABD Ao, this indicates what?
Severe AI and should be holo-diastolic
How do we get AI pressure 1/2 time? 4
- Use CW
- Align to the AI jet direction
- Measure the deceleration rate
- Usually best from apical window
In terms of a AI pressure half time, what does a steep slope and a gentle slope mean? 2
- Steep = severe
- Gentle = mild
What are some values to remember in terms of AI pressure half time?
What is the continuity equation?
What is something we need to remember for the continuity equation?
The SV of regurgitating valve will be higher than the SV on a non-regurgitation (normal) valve
What is AI reg volume numbers for mild and severe? 2
- Mild <30ml
- Severe >60ml
What is regurgitation fraction?
Percentage of blood leaking back across valve
What is the formula for regurgitation fraction?
What are the regurg fraction values for mild and severe?
What does EROA stand for and what is the formula for it? 2
- Effective regurgitation orifice area
- EROA = RVol/VTI ai jet
How do we do a quantitative AI assessment?
PISA
Do we do quantitative AI assessments in Alberta?
No
