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PTE Masters + A Practical Approach to Transesophageal Echocardiography > Aortic Valve > Flashcards

Aortic Valve Flashcards

1
Q

Label the Aortic Valve Cusps in the Aortic Valve Short Axis

A

Non-Coronary Cusp nearest to the interatrial septum (Does not have a coronary artery)

Left Coronary Cusp is NOT on the Right side

Right coronary cusp near the right heart at the bottom of the screen

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2
Q

What are the 5 views to evaluate the aortic valve?

A

Mid-esophageal Aortic Valve Short Axis

Mid-esophageal Aortic Valve Long Axis

Mid-esophageal 5 chamber view

Deep Transgastric Long Axis

Transgastric Long Axis

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3
Q

How do you determine which coronary cusp is which in the long axis?

A

Right Coronary Cusp = Bottom of the Screen

Left or NON Coronary Cusp = Top of the Screen

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4
Q

What is the measurement seen here?

A

Sinus of Valsalva

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5
Q

What is the blue arrow indicating?

A

Sinotubular Ridge or Sinuotubular Junction

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6
Q

What is seen in red?

A

Aortic Annulus

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7
Q

What is the normal size of the Aortic Root in an adult?

What measurement is termed dilated?

A

Normal = < 40 mm (4.0 cm)

Dilated = >40 mm

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8
Q

Why is the deep transgastric long axis view used to assess the aortic valve? (2 major measurement reasons)

A

Align Doppler parallel to blood flow through aortic valve

1. Measure Cardiac Output

2. AV Area by continuity equation

3. Dimensionless index to assess Aortic Stenosis

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9
Q

Draw a Pressure Volume loop of cardiac cycle labeling:

Systole

Diastole

Opening and closing of Mitral and Aortic Valves

A

Solid Line = Systole

Dotted Line = Diastole

MO and AO = Opening of Left sided valves

MC and AC = Closing of Left sided valves

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10
Q

What are the 3 phases of LV change for aortic insuffiency?

A
  1. Acute
  2. Chronic Compensated
  3. Chronic Uncompensated
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11
Q

List what happens from the compensated AI form to the decompensated AI in terms of:

LV End Diastolic Volume

LV End Systolic Volume

Shortening Fraction

LVEF%

A

Summary:
LVEDD rises (Heart dilates)

LVESD rises (Due to dilation)
Sarcomere Fraction Drops (Falls of Frank Starling Curve)

EF% drops

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12
Q

What is the initial medical/surgical management of AI patients?

A

Serial TTE to look for:

1. LV dysfunction

2. Dilation

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13
Q

When you evaluate for AI, what are the goals of TEE?

A
  1. Severity
  2. Mechanism and Etiology of AI
  3. Degree of Root Dilation
  4. Effect of AI on the LV
  5. Repairable? (If not already in surgery)
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14
Q

What are the 7 ways to quantitatively assess severity of AI?

A
  1. AI jet height / LVOT diameter
  2. AI jet area / LVOT area
  3. Jet Depth
  4. Vena Contracta Size
  5. Slope of AR Jet decay
  6. Pressure Half TIme (PHT) of the jet decay
  7. Holodiastolic flow reversal in the descending Aorta
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15
Q

What TEE view is utilized to assess AI Jet / LVOT diameter to assess quantitatively for AI?

A

Mid Esophageal Aortic Valve Long Axis

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16
Q

AI Jet / LVOT diameter to assess quantitatively for AI:

What determines:

Mild (1-2+) vs. Moderate (2-3+) vs. Severe (3-4+)?

A

Mild (1-2+) = <25%

Moderate (2-3+) = 25-64%

Severe (3-4+) = >65%

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17
Q

What TEE view is utilized to assess AI area / LVOT area?

A

ME AV Short Axis

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18
Q

A.I. area / LVOT area criteria for:
Mild AI?

Moderate AI?

Severe AI?

A

AI area / LVOT area criteria for:
Mild AI = <5%

Moderate AI = 5-59%

Severe AI = >60%

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19
Q

What TEE view using jet depth is best used to quantify A.I. severity?

A

ME Long Axis

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20
Q

How do you quantify Jet Depth in the Mid-Esophageal Long axis view?

Include:

Trivial

Mild

Moderate

Severe

A

Trivial = LVOT

Mild = Mid Anterior Leaflet of Mitral Valve

Moderate = Tip of Anterior Leaflet of Mitral Valve

Severe = Papillary Muscle Head

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21
Q

What are the two TEE views you could assess vena contracta to determine A.I. severity?

A

Mid Esophageal Long Axis

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22
Q

What are the two criteria used to measure the vena contracta to determine A.I. severity?

A

Width = > 6mm

Area = > 7.5 mm2

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23
Q

What TEE views are used to determine slope of the AR Jet Decay?

A

TG Deep Long Axis

TG Long Axis

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24
Q

What are the criteria for determining AI severity using slope of the AR Jet Decay in the TG TEE views?

A

>/= 2 m/s for Moderate A.I.

>/= 3 m/s for Severe A.I.

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25
Q

Using Pressure Half time, what is the criteria of using AI jet decay?

A

Mild = >500 ms

Moderate = 200-500 ms

Severe = <200 ms

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26
Q

What would determine severe AI for:

Effective Regurgitant Orifice Area

A

Effective Regurgitant Orifice Area = > 0.3 cm2

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27
Q

What would determine severe AI for:

Regurgitant Fraction

A

Regurgitant Fraction = > 50%

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28
Q

What would determine severe AI in terms of:

Regurgitant Volume?

A

Regurgitant Volume = > 60 mL/beat

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29
Q

What are the 2 ways to measure A.I. using AI jet / LVOT diameter?

A
  1. ME AV Long Axis direct measurements
  2. M-Mode of ME AV Long Axis
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30
Q

What is the pathophysiology of Pressure Half Time when evaluating Aortic Insufficiency?

A

High PHT = Trivial / Mild AI

Low PHT = Severe AI

PHT is the time is takes to go from max pressure gradient to 1/2 max pressure gradient

Pathophysiology: The larger the hole, the faster the equilibriation between two chambers (LV and Aorta) and the less time it takes for PHT to occur

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31
Q

Why is pressure half time not the best measurerment of Aortic Insufficiency?

A
  1. Diastolic Function
  2. Compliance of the Heart
  3. Relaxation of the hearrt
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32
Q

How do you logistically obtain a pressure half time measurement for Aortic Insufficiency?

A
  1. Deep Transgastric Long Axis view
  2. Continuous Wave Doppler on the Aortic Valve
  3. Look at Diastolic Regurgitant Flow
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33
Q

How do you logistically obtain the slope of the AR jet decay?

A
  1. TG Deep Long Axis View
  2. CWD spectal profile through Aortic Valve
  3. Rate the slope
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34
Q

Explain the slope and how it correlates to the degree of A.I. when using slope of AI jet decay of TG Long axis view using CWD.

A

Steeper the slope = Worse the A.I = Faster the chambers equilibriate (Aorta vs. LV)

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35
Q

What is seen in this image?

A

Holodiastolic Flow reversal in the Descending Thoracic Aorta

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36
Q

What are the 3 factors that influence prognosis of a patient with aortic insufficiency?

A
  1. LV Dysfunction
  2. LV Dilation
  3. Dilation of the Ascending Aorta
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37
Q

What are the characteristitics of high risk patients with Aortic Insufficiency?

A
  1. Symptomatic Patients
  2. LVEF <55%
  3. End Systolic Diameter normalized to body surface area > 25 mm/m2
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38
Q

What is the normal measurement of the sinus of valsalva?

A

25 - 31 mm

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39
Q

What is the threshold value of dilation of the sinus of valsalva?

A

No consensus

>50-55 mm then replace the valve regardless of the level of Aortic Insufficiency

40
Q

What is the low risk group of AI?

A

Pertains to Patients with Marfans Disease

Ao ratio of < 1.3 (Sinus of Valsalva diameter actual / Predicted)

  • Predicted is determined by age of the patient

Annual Rate of Change of <5%

41
Q

When you have a patient with Aortic Insufficiency, when should you replace the valve?

A
  1. Symptomative Severe AR

OR
1. Asymptomatic

  • Dilated Heart

- Decreased EF

- Dilated Aortic Root

42
Q

What is the only indication for Sinotubular Junction Annuloplasty?

A

Ic Type 1 A.I.

(Normal cusp motion with FAA dilatition or cusp perforation)

43
Q

Aortic insufficiency is a “x” problem

Aortic Stenosis is a “y” problem

A

X = Volume overload

Y = Pressure overload

44
Q

Show a PV loop of Aortic Stenosis

A
45
Q

Aortic Stenosis Grading:

Mild

Peak Velocity (M/Sec)

A

2.6 - 2.9 m/s

46
Q

Aortic Stenosis Grading:

Moderate

Peak Velocity (M/Sec)

A

3 - 3.9 m/sec

47
Q

Aortic Stenosis Grading:

Severe

Peak Velocity (M/Sec)

A

>4.0 m/sec

48
Q

Aortic Stenosis Grading:

Mild

Mean Peak Gradient (mmHg)

A

15 - 29 mmHg

49
Q

Aortic Stenosis Grading:

Moderate

Mean Peak Gradient (mmHg)

A

20 - 40 mmHg

50
Q

Aortic Stenosis Grading:

Severe

Mean Peak Gradient (mmHg)

A

>50 mmHg

51
Q

Aortic Stenosis Grading:

Mild

Max Peak Gradient (mmHg)

A

20 mmHg

52
Q

Aortic Stenosis Grading:

Moderate

Max Peak Gradient (mmHg)

A

40 - 69 mmHg

53
Q

Aortic Stenosis Grading:

Severe

Max Peak Gradient (mmHg)

A

> 70 mmHg

54
Q

Aortic Stenosis Grading:

Mild

Dimensionless INdex (TVILVOT / TVIAV ratio)

A

> 0.5

55
Q

Aortic Stenosis Grading:

Moderate

Dimensionless INdex (TVILVOT / TVIAV ratio)

A

0.25 - 0.5

56
Q

Aortic Stenosis Grading:

Severe

Dimensionless INdex (TVILVOT / TVIAV ratio)

A

< 0.25

57
Q

Aortic Stenosis Grading:

Normal

Aortic Valve Area (AVA) cm2

A

3 - 4 cm2

58
Q

Aortic Stenosis Grading:

Mild

Aortic Valve Area (AVA) cm2

A

1.6 - 2.9 cm2

59
Q

Aortic Stenosis Grading:

Moderate

Aortic Valve Area (AVA) cm2

A

1 - 1.5 cm2

60
Q

Aortic Stenosis Grading:

Severe

Aortic Valve Area (AVA) cm2

A

< 1.0 cm2

61
Q

Aortic Stenosis Grading:

Mild

Aortic Valve Area (AVA) cm2 / BSA (m2)

A

>0.85

62
Q

Aortic Stenosis Grading:

Moderate

Aortic Valve Area (AVA) cm2 / BSA (m2)

A

0.6 - 0.85

63
Q

Aortic Stenosis Grading:

Severe

Aortic Valve Area (AVA) cm2 / BSA (m2)

A

< 0.6

64
Q

What pressure gradient is the best gradient to measure when evaluating Aortic Stenosis?

A

Mean Gradient

65
Q

If you have a low pressure gradient, is aortic stenosis still possible?

What would you use to determine?

A

AS still possible if low SV

Use = Continuity Equation

66
Q

What equation do you use if you have small AVA, but not have aortic stenosis?

A

Modified Gorlin Equation

AVA = CO / (Mean Gradient)1/2

AVA = CO / Peak Grad

Rearranged - Peak Grade = CO / AVA

67
Q

What view do you use to determine Dimensionless Index?

A

Deep TG Long Axis

68
Q

Derive the Dimensionless Index from the Continuity Equation.

A

Q1 = Q2

Q AV = Q LVOT

AreaAV * TVIAV = ALVOT * TVILVOT

AreaAV = [ALVOT * TVILVOT] / TVIAV

69
Q

Continuity equation:

What do we substitute for TVI?

A

Vpeak

70
Q

Continuity equation:

What do we substitute for Area LVOT?

A

Pie (π) r2

71
Q

Rate the severity of Aortic Insufficiency.

LVOT diameter = 2.3 cm

Jet diameter = 1.0 cm

A

Moderate:

In this equation, we have 1/2.3 = 43%

Remember, Moderate (2-3+) = 25-64%

72
Q

List 4 advantages of using a dimnesionless index to determine degree of aortic stenosis.

A
  1. Not affected by cardiac left sided regurgitant disease
  2. Not affected by decreases in LV Stroke volume
  3. Independent of Patient’s size
  4. Avoids errors due to inaccurate measurements of LVOT radius
73
Q

What is the most common type of VSD?

A

Membranous VSD

74
Q

What is structure 1?

A

RV

75
Q

What is structure 2?

A

Pulmonic Valve

76
Q

What is structure 3?

A

Right Coronary Cusp

77
Q

What is structure 4?

A

Left Coronary Cusp

78
Q

What is structure 5?

A

Non-Coronary Cusp

79
Q

What is structure 6?

A

Main Pulmonary Artery

80
Q

What is structure 7?

A

Left Pulmonary Artery

81
Q

What is structure 8?

A

Right Pulmonary Artery

82
Q

What is structure 9?

A

Left Atrium

83
Q

What is structure 10?

A

Right Atrium

84
Q

What is structure 11?

A

Interatrial Septum

85
Q

What is structure 12?

A

Tricuspid Valve

86
Q

Label 1-3

What view is this?

A

1 = LVOT

2 = Aortic Valve

3 = Aorta

View = Epicardial View

87
Q

Label 1-3

What view is this?

A

1 = Left Atrium

2 = Aortic Valve

3 = LV

View = Parasternal Long Axis view

88
Q

The non-coronary cusp is always adjacent to what structure?

A

Interatrial Septum

89
Q

Label 1 - 3

A

1 = RV

2 = LV
3 = Aortic Valve
90
Q

What is the relationship of the right, left, and non-coronary cusps in relation to the mitral valve? (This is the aortic mitral curtain)

Draw this

A
91
Q

Label 1-3 in the surgeon view of the mitral valve

A 
1 = LCC
2 = RCC
3 = NCC
92
Q

Label 1-3

A

1 = LCC

2 = Flail P2 Scallop

3 = Interatrial Septum

93
Q

Epicardial View

Label 1-3

A 
1 = RCC
2 = NCC
3 = LCC
94
Q

Label 6-9

A

6 = LV

7 = RV

8 = AV

9 = LA

95
Q

Label 6-9

A

6 = Anterior Mitral Valve Leaflet

7 = Posterior Mitral Valve Leaftlet

8 = AV

9 = LA

PTE Masters + A Practical Approach to Transesophageal Echocardiography (55 decks)

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