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AR Flashcards

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USMLE® Step 1 flashcards
1
Q

What is the VC severity scale in AR diagnosis?

A
  • Mild = < 0.3cm
  • Moderate = 0.3 - 0.6cm
  • Severe = > 0.6cm
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2
Q

Describe the severity scale in diagnosis of AR:

  • jet width and cross-sectional area
A
  • Mild = < 25%
  • Moderate = 25-65%
  • Severe = > 65%
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3
Q

What are the best views and velocity scale settings for diagnosis of AR?

A
  • parasternal long axis (2D) or long axis - 120 (TEE)
  • Nyquist limit 50-60cm/s
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4
Q

What are the steps/parameters to evaluate AR severity?

A
  • Specific signs
    • Jet width/LVOT width
    • Vena contracta
    • Diastolic flow reversal in descending aorta
  • Quantitative parameters
    • Regurgitant volumes
    • Regurgitant fraction
    • EROA
  • Supportive signs
    • Pressure-half time
    • LV dimensions (LVEDD, EF)
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5
Q

In addition to severity of AR what other parameters should be assessed/obtained in the evaluation?

A
  • AS severity
    • AVA (using continuity equation)
    • Mean pressure gradient
    • Peak transvalvular velocity
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6
Q

Describe the severity scale in diagnosis of AR:

  • diastolic flow reversal
A
  • Mild = no or brief early diastolic flow reversal in the descending aorta
    • obtained from suprasternal view
  • Severe = holodiastolic flow reversal in descending thoracic/abdominal aorta
    • obtained in suprasternal or subcostal view
    • > 25 cm/s consistent with severe AR
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7
Q
A
  • Severe AR
    • holodiastolic flow reversal obtained from TTE PW doppler at the suprasternal notch
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8
Q

Define AR pressure half-time?

A

measure of how quickly the aortoventricular pressure gradient equalizes during diastole

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9
Q
A
  • Moderate AR
    • CW doppler assessing pressure-half time of the regurgitant jet
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10
Q

What are two factors that may influence PHT in AR?

A
  • Systemic vascular resistance
  • Ventricular compliance
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11
Q

Describe the severity scale in diagnosis of AR:

  • Pressure-half time
A
  • Mild = > 500msec
  • Moderate = 200-500msec
  • Severe = < 200 msec
    • or a decay slope of > 3 m/sec2

**Obtained using CW doppler

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12
Q

What are the quantitative measures of AR severity?

A
  • Regurgitant volume
  • Regurgitant fraction
  • EROA
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13
Q

Describe the severity scale in diagnosis of AR:

  • Regurgitant volume
A
  • Mild = < 30 mL/beat
  • Moderate = 30 - 44 mL/beat
  • Moderately severe = 45 - 59 mL/beat
  • Severe = > 60 mL/beat
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14
Q

Describe the severity scale in diagnosis of AR:

  • Regurgitant fraction
A
  • Mild = < 30%
  • Moderate = 30 - 39%
  • Moderately Severe = 40 - 49%
  • Severe = > 50%
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15
Q

Describe the severity scale in diagnosis of AR:

  • EROA
A
  • Mild = < 0.10 cm2
  • Moderate = 0.10 - 0.19 cm2
  • Moderately Severe = 0.2 - 0.29 cm2
  • Severe = > 0.30 cm2
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16
Q

What is the recommended monitoring in patients with:

  • Mild MR
  • normal LV systolic function
  • near normal LV end-diastolic dimension
A
  • Clinical exam yearly
  • Echo every 2-3 years
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17
Q

What is the recommended monitoring in patients with:

  • Severe MR
  • normal LV systolic function
  • evidence of LV dilatation (LV end-diastolic dimension > 60mm)
A
  • Clinical exam - 6 months
  • Echo - 6-12 months
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18
Q

What is the recommended monitoring in patients with:

  • Severe MR
  • normal LV systolic function
  • advanced LV dilatation (LVEDD > 70mm, LVESD > 50mm)
A
  • Clinical exam - < 6months
  • Echo - < 6 months
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19
Q

What are the indications for aortic valve replacement in:

  • Severe AR
  • Asymptomatic
A
  • LV systolic dysfunction (EF < 50%)
  • Severe LV enlargement (regardless of LV function)
    • LVEDD > 75mm
    • LVESD > 55mm
20
Q

What is the normal diameter: aortic annulus (BSA index)

A
  • 20 - 31 mm (13 +/- 1 mm/m2)
  • Upper limit normal:
    • men = 32 mm
    • women = 27 mm
21
Q

What is the normal diameter: aortic root/sinus of valsalva (BSA index)

A
  • 29 - 45 mm (19 +/- 1 mm/m2)
  • Upper limit of normal:
    • men = 40 mm
    • women = 36 mm
22
Q

What is the normal diameter: sinotubular junction (BSA index)

A
  • 22 - 36 mm (15 +/- 1 mm/m2)
  • Upper limit of normal:
    • men = 36 mm
    • women = 32 mm
23
Q

What is the normal diameter: proximal ascending aorta (BSA index)

A
  • 22 - 36 mm (15 +/- 1 mm/m2)
  • Upper limit of normal:
    • men = 38 mm
    • women = 35 mm
24
Q
A
  • Prolapse of the distal right coronary cusp
  • TEE with scalloped appearance
25
Q

Describe the algorithm to distinguish mild or severe AR

A
  1. Is the color Doppler width < 25% of the LVOT width?
    • YES = Mild AI, if CW Doppler is also faint
    • No (o not central jet), continue to 2
  2. What is the VC?
    • < 3 mm = mild AI
    • > 6mm = SEVERE AI
    • 3-6mm (or not obtainable), continue to 3
  3. Is there abdominal aortic flow reversal with PW?
    • YES = SEVERE AI
    • NO, continue to 4
  4. PW quantification?
    • RV > 60% or RF > 50% = SEVERE AI
    • NO (or unobtainable): consider other imaging modality or invasive evaluation.
26
Q

What finding on imeediate post-procedure intraoperative TEE would be the most strongly associated with the risk of recurrence of severe AR after AV repair?

A

distance of the cusp coaptation to the aortic annulus

27
Q

What are the levels of severity in the jet width/LVOT ratio or JWR (jet/width ratio) for evaluation of AR?

A
  • Mild
    • < 25%
  • Moderate:
    • 25-44% (Grade II)
    • 45-64% (Grade III)
  • Severe
    • > 65%
28
Q

What is the downside of the JWR in evaluation of AR?

A
  • Eccentric AR may be underestimated by this method
  • Should not be used with eccentric or multiple jets as it can overestimate severity with rapidly expanding jets
29
Q
A
  • Diastolic flow reversal in the abdominal aorta and descending thoracic aorta
  • Supportive signs of severe AR
30
Q

In what scenario may a patient have a PHT >200ms and still have chronic, severe AR?

A
  • PHT typically shortens with increasing severity of AR
  • However, as LV remodels and LV diastolic pressure decreases over time, a subject with severe chronic AR can have a PHT > 200ms
31
Q

What are two M-mode findings of AR (mainly acute)?

A
  • fluttering of the anterior mitral valve leaflet during diastole due to aortic regurgitant jet hitting the anterior leaflet
  • premature closure of the MV due to increased LV diastolic pressure
32
Q
A
33
Q

What are common differences between acute and chronic AR?

A
  • LV usually not dilated
  • Murmur and color jets not impressive
  • Vena contracta more reliable
  • Diagnosis on high clinical suspicion, context
34
Q

What is the general pathophysiologic mechanism of AR?

A

Volume and pressure overload

    • almost never too late to operate
      *
35
Q

What is the EF cutoff for symptomatic patients with AR and low EF?

A

Almost no cutoff

  • even EF < 25% may benefit
  • prognosis without surgery very poor
36
Q

What is the LVESD

A
37
Q

What is the formula for Jet width ratio (%)?

A

Jet Width Ratio (%) = ((AR Jet Width (cm)/(LVOT Diameter (cm)) x 100

38
Q

What is the formul for Jet Area/LVOT Area Ratio?

What are the cutoffs?

A
  • Jet Area Ratio (%) = ((AR Jet Area (cm2 )/(LVOT Area (cm2)) x 100
  • Severity:
    • mild < 5%
    • sever > 60%
39
Q

What are the two findings on M-mode that identify the presence of AR?

A
  • Fluttering of the anterior mitral valve
    • occurse during diastole due to the presence of a pressure gradient across tha tnerior mitral leaflet
  • Premature diastolic closure of the mitral valve
    • due to increased LV diastolic pressure
    • an create murmur similar to MS –> “Austin-Flint” murmur
40
Q
A
  • Severe AR effecting the MV on M-mode
    • diastolic fluttering of MV
    • premature diastolic closure (yellow)
41
Q

What type of remodeling takes place in chronic AR?

Why is this important to assess?

A
  • LV dilatation –> eccentric hypertrophy
    • in order to normalize afterload and wall stress
  • Excessive LV dilatation and reduced LVEF may lead to LV fibrosis that will not undergo reverse remodeling even with AVR
42
Q

In the setting of severe AR, what are the class I recommendations for AVR?

A
  • Symptomatic
  • Asymptomatic, LVEF < 50%
  • Undergoing other cardiac surgery
43
Q

In the setting of severe AR, what are the class IIa recommendations for AVR?

A
  • LVESD > 50 mm or indexed LVESD > 25 mm/m2
  • Undergoigoing other cardiac surgery
    • Moderate AR***
44
Q

In the setting of severe AR, what are the class IIb recommendations for AVR?

A

LVEDD > 65 mm and low surgical risk

45
Q

What is the initial medical therapy for acute AR?

A
  • IV vasodilators (nitroglylcerin)
    • Afterload reduction
  • IV diuretics
    • to reduce congestion
  • IV inodilators (Dobutamine)
    • in cardiogenic shock
  • LV mechanical support
    • IABP contraindicated in more than mild AR

***Definitive therapy –> surgery

46
Q

What is the medical therapy for chronic AR?

A
  • Vasodilators
    • to treat systemic arterial hypertension (class I)
  • Beta-blockers (class IIa)

****Definitive therapy –> surgery

47
Q
A

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