Aortic Valve Flashcards
What is the El Khoury classification of AR (Type I, II, and III)?
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
What are the Type I subtypes of AR in the El Khoury classification?
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
Normal aortic root diameter
<4.0cm
What happens to isovolumic phases in AR?
You lose isovolumic relaxation and contraction (no isovolumic phases)
How does the pressure-volume loop change in AR?
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.
What are the 5 goals of TEE evaluation of AR?
- Severity
- Mechanism/etiology
- Degree of root dilation
- Effect on the LV
- Whether it is repairable
What are 10 ways to evaluate severity of AR with TEE?
- 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
Cutoffs for AR jet/LVOT diameter
Mild <25%
Moderate 25-64
Severe >65
Cutoffs for AR area/LVOT area
Mild <5%
Severe >60%
Cutoffs for AR jet depth
Mild to mid AMVL
Moderate to tip of AMVL
Severe to pap muscle head
Cutoff for AR vena contracta (severe)
> 0.6cm
Cutoffs for slope of AR jet decay (mod and severe)
Moderate >2m/sec
Severe >3m/sec
Cutoffs for AR PHT
Severe <200ms
Mild >500ms
What is pressure half time (PHT)?
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
What three factors determine prognosis in patients with AR?
- LV dysfunction
- LV dilation
- Asc Ao dilation
When should the aortic valve be surgically intervened upon in AR?
- 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
What is the cutoff for mild, moderate and severe AS using mean pressure gradient?
Mild = <20
Severe = >40
What is the cutoff for mild, moderate and severe AS using the DI?
Mild = >0.5
Severe = <0.25
What is the cutoff for mild, moderate and severe AS using AVA?
Normal = 3-4
Mild = >1.5
Severe = <1.0
What is the Gorlin Equation?
AVA = CO/peak gradient
AVA = CO/MG^1/2
Disorders associated with a bicuspid aortic valve
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.
Echo criteria for severe AS
MG >40
Peak gradient >70
Peak velocity >4
AVA <1
DI <0.25
What are the two main valves used for TAVRs?
Sapien family (Edwards) and Evolut family (Medtronic)
What is a Gerbode defect?
Flow directly from the LVOT -> the RA
Direct = direct shunt from LVOT to RA (supravalvular, acquired)
Indirect = LVOT -> RV -> TV -> RA (infravalvular, congenital)
What is a coronary-cameral fistula?
Coronary artery –> cardiac chamber
- Most frequently from RCA
- Most drain to right-sided chambers
What is the equation for the dimensionless index?
VTI_LVOT / VTI_AV
Should be ~1
