Aortic Valve

Question 1

What is the El Khoury classification of AR (Type I, II, and III)?

Answer 1

Type I: normal cusp motion with aortic dilation or cusp perforation

Type II: cusp prolapse

Type III: cusp restriction

Mnemonic: NPR
N=normal
P=prolapse
R=restricted

Question 2

What are the Type I subtypes of AR in the El Khoury classification?

Answer 2

Ia: STJ dilation
Ib: sinus dilation and STJ dilation
Ic: isolated annulus dilation
Id: cusp perforation and annulus dilation

Move down from STJ to annulus
A+B involve STJ
C+D involve annulus

Question 3

Normal aortic root diameter

Answer 3

<4.0cm

Question 4

What happens to isovolumic phases in AR?

Answer 4

You lose isovolumic relaxation and contraction (no isovolumic phases)

Question 5

How does the pressure-volume loop change in AR?

Answer 5

LV end-diastolic volume increases
LV end-diastolic pressure is very increased in acute AR
The heart compensates by dilating so LVEDV, LVESV, and SV is very increased in chronic AR to compensate for regurgitant volume that comes back.

Question 6

What are the 5 goals of TEE evaluation of AR?

Answer 6

• Severity
• Mechanism/etiology
• Degree of root dilation
• Effect on the LV
• Whether it is repairable

Question 7

What are 10 ways to evaluate severity of AR with TEE?

Answer 7

• AR jet height/LVOT diameter
• AR jet area/LVOT area
• Vena contracta
• Jet depth*
• Jet slope*
• PHT
• flow reversal in descending Ao
• RV
• RF
• EROA

*Not included in 2017 guidelines

Question 8

Cutoffs for AR jet/LVOT diameter

Answer 8

Mild <25%
Moderate 25-64
Severe >65

Question 9

Cutoffs for AR area/LVOT area

Answer 9

Mild <5%
Severe >60%

Question 10

Cutoffs for AR jet depth

Answer 10

Mild to mid AMVL
Moderate to tip of AMVL
Severe to pap muscle head

Question 11

Cutoff for AR vena contracta (severe)

Answer 11

> 0.6cm

Question 12

Cutoffs for slope of AR jet decay (mod and severe)

Answer 12

Moderate >2m/sec
Severe >3m/sec

Question 13

Cutoffs for AR PHT

Answer 13

Severe <200ms
Mild >500ms

Question 14

What is pressure half time (PHT)?

Answer 14

The time it takes to go from the maximum pressure gradient to 1/2 the maximum pressure gradient.

A larger hole = faster pressure equilibration = shorter PHT

Question 15

What three factors determine prognosis in patients with AR?

Answer 15

• LV dysfunction
• LV dilation
• Asc Ao dilation

Question 16

When should the aortic valve be surgically intervened upon in AR?

Answer 16

• Severe symptomatic AR
• Asymptomatic severe AR in patients with LVESD/BSA >25mm/m2 or LVESD >50mm or LVEDD >65mm
• Asymptomatic severe AR with decreased LVEF (resting LVEF <55%)
• Severe AR undergoing cardiac surgery for other indications

Question 17

What is the cutoff for mild, moderate and severe AS using mean pressure gradient?

Answer 17

Mild = <20
Severe = >40

Question 18

What is the cutoff for mild, moderate and severe AS using the DI?

Answer 18

Mild = >0.5
Severe = <0.25

Question 19

What is the cutoff for mild, moderate and severe AS using AVA?

Answer 19

Normal = 3-4

Mild = >1.5
Severe = <1.0

Question 20

What is the Gorlin Equation?

Answer 20

AVA = CO/peak gradient

AVA = CO/MG^1/2

Question 21

Disorders associated with a bicuspid aortic valve

Answer 21

Aortic aneurysms, aortic coarctation, posterior malalignment VSD, aortic stenosis, Turner syndrome, small left-sided structures.
Note: BAV is autosomal dominant, occurs in ~2% of the population.

Question 22

Echo criteria for severe AS

Answer 22

MG >40
Peak gradient >70
Peak velocity >4
AVA <1
DI <0.25

Question 23

What are the two main valves used for TAVRs?

Answer 23

Sapien family (Edwards) and Evolut family (Medtronic)

Question 24

What is a Gerbode defect?

Answer 24

Flow directly from the LVOT -> the RA

Direct = direct shunt from LVOT to RA (supravalvular, acquired)

Indirect = LVOT -> RV -> TV -> RA (infravalvular, congenital)

Question 25

What is a coronary-cameral fistula?

Answer 25

Coronary artery –> cardiac chamber

• Most frequently from RCA
• Most drain to right-sided chambers

Question 26

What is the equation for the dimensionless index?

Answer 26

VTI_LVOT / VTI_AV

Should be ~1