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Echo 2 > C7: AV Regurg > Flashcards

C7: AV Regurg Flashcards

1
Q

4 groups of mechanisms that cause AI

A

cuspal abnormalities
AO root dilation
AO root distortion
loss of commissural support

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2
Q

4 causes of cuspal abnormalities

A

congential
rheumatic AV disease
AV prolapse
infective endocarditis

…. eg, any congenital disorder or disease process that affects the Av cusps

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3
Q

which congenital, cuspal, abnormalities can commonly cause AR

A

bicuspid, uni or quadricuspid AV

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4
Q

is a quadricuspid AV rare?

what other abnormality is it associated with?

A

yes

anomalous coronary artery origin

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5
Q

describe how rheumatic AV disease causes cuspal abnormalities which lead to AR

A

-cusp tissue is infiltrated w/ fibrous tissue which causes them to contract and shorten, this prevents cuspal apposition which leads to AI

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6
Q

is rheumatic AV disease usually also associated w/ some degree of AS

other associations

A

yes

MR and MS

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7
Q

causes of AV prolapse leading to cuspal abnormalities and AR

A

myxomatous degeneration
rheumatic disease
Ao root dilation
trauma

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8
Q

what type of AR jet would you get w/ AV prolapse

A

eccentric

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9
Q

how does AO infective/bacterial endocarditis cause cuspal abnormalities that lead to AR

A

vegetation destroys AV and can cause perforations/holes in the cusps

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10
Q

how does AO root dilation lead to AR

A

prevents leaflet coaptation during diastole

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11
Q

list some causes of AO root dilation

A 
systemic HTN
atherosclerosis
c-tissue disorders (marphans)
bicuspid AV
sinus of valsalva aneurysms
idopathic
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12
Q

how does AO root distortion occur and lead to AR

A

root becomes distorted due to infammation that can eb cause by:
ankylosing spondylitis
takayasu’s arteritis
rheumatoid arthritis

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13
Q

what 3 things might cause a loss of commissural support

A

VSD
AO dissection
AO trauma

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14
Q

causes of acute, severe, AI

does it cause an increase in filling pressures?

A

trauma, infective endocarditis, AO dissection

yes, mainly LVEDP

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15
Q

describe the pathophysiology of acute, severe, AI

why does acute, severe, AI cause an increase in LVEDP

A
  • regurgitant volume (RV) leaks back into the LV as well as the norm blood volume entering from the LA….
  • because his is acute, LV hasn’t had time to dilate yet to accommodate the extra volume so LVEDP increase dramatically
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16
Q

how does acute, severe, AI effect the MV

A

may cause early closure, press is rising faster due to regurg volume

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17
Q

describe the pathophysiology of chronic, severe, AI

what will filling pressure be like

A
  • regurgitant volume causes the LV chamber volume to increase due to dilation which may lead to increase ejection volume through the AO (starlings principle)
  • filling press may by norm or slightly elevated
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18
Q

how will LV mass change w/ chronic, severe, AI

A

increase - eccentric hypertrophy

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19
Q

what will happen to the LV over time w/ chronic, severe, AI

A

will start to fail, and then the LVEDP will increase at this point

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20
Q

symptoms of AI (acute and chronic)

A 
dizziness
syncope
fatigue, SOBOE
CHF signs
diastolic murmur, w/ S3 and S4 heard
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21
Q

complications of AR

A
  • increase LV and LA size due to press and volume overload
  • pulm venous congestion…. leading to pulm edema, RH faliure, systemic venous congestion and edema
  • embolization
  • death
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22
Q

what is the pulse press

A

SBP-DBP

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23
Q

4 roles of echo w/ AR

A
  1. determine etiology
  2. assess LV function and size
  3. measure AO dimensions
  4. estimate severity of AI
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24
Q

etiologies of AR

A

congenital, degenerative, rheumatic

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25
Q

what will the direction of AR often be if the cause is due to a bicuspid AV

A

eccentric… regurg will get worse over time

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26
Q

how does a bicuspid AV effect the commissure lines

A

they calcify earlier

27
Q

most common cause of acute severe AI

how will it appear

A

infective/bacterial endocarditis

hypermobile mass on the underside of the AV (LV side) that will have different echo characteristics than surrounding tissue

28
Q

how does infective/bacterial endocarditis cause AR

A

by destroying one or more of the valve cusps

29
Q

why does the mass causes by infective/bacterial endocarditis grow on the LV side

A

mass always grows on the low pressure side of the valve

30
Q

how can a VSD lead to AR

A

the defect affects the supporting structures of the AO root, leading to AR
(Especially if a membranous VSD)

31
Q

how can a proximal AO dissection lead to AR

A

stretched out the annulus so leaflets don’t coapt

32
Q

when the LV is severely dilated, what shape does it take on

what should you look for when this happens

A

spherical instead of conical…

-look for eccentric hypertrophy and calculate LV mass

33
Q

what is jet height

When is it less accurate for severity of AI

A

the height of the regurg jet on the LVOT of the AV

With eccentric jets

34
Q

what is the vena contracta width

in what view is it measures

A

the height of the regurg jet at the narrowest point, usually just on the LV side

PLAX, LVOT zoom

35
Q

which is more accurate, jet height or vena contracta width

why

A

vena contracta width, its less influenced by loading conditions than jet height

36
Q

what ratio can be used to determine the severity of AR

what does it measure

A

jet height/LVOT diameter ratio, measures how much of the LVOT diameter the jet covers

37
Q

jet height/LVOT diameter ratio for mild AR

severe AR

A

mild: <25%
severe: >/= 65%

38
Q

when will the jet height/LVOT diameter ratio underestimate the AR jet severity

A

when its eccentric

39
Q

in what view do you measure jet area/LVOT area ratio

what does it measure

A

in the PSAX AV/BASE view, w/ zoom, w/in 1 cm of the vena contracta width

measures/estimates the regurgitant orifice area

40
Q

jet area/LVOT area ratio w/ mild AR

severe AR

A

mild: < 5%
severe: >60%

41
Q

when may the jet area/LVOT area ratio be in accurate

A

may be inaccurate based on the direction of the jet

42
Q

when is the vena contract width/zone the most accurate

A

for single, central jets

43
Q

vena contract width for mild AR

severe AR

A

mild: <3mm
severe: >/= 6mm

44
Q

how does brightness of the CW AR tracing related to severity of AR

how do you determine brightness

A

brighter = more significant AR (more RBCs moving at a that velocity)

compare it to the brightness of the AO outflow

45
Q

if flow reversal is seen in the Abdo AO what does this usually indicate for severity of AR

A

severe

46
Q

if flow reversal is seen in the descending AO what does this usually indicate for severity of AR

A

moderate

47
Q

if flow reversal is seen in the ascending AO what does this usually indicate for severity of AR

A

mild

48
Q

what is pressure half time (PHT or P1/2)

A

time it takes for the press gradient to fall by 1/2

49
Q

how do measure the PHT

which window is usually best

A

use CW, align to the AR and measure the deceleration rate of the AR

Apical

50
Q

what does the steepness of the AR slope tell you about severity of the regurg

what determines this steepness

A

steeper = more severe

press gradient b/w LV and AO….. higher LVEDP and relatively low AO press will create a steeper slope

51
Q

at what severity does AR become hemodynamically significant

A

if it moderate or greater

52
Q

PHT value for mild AR

severe

A

mild: >500 ms
mod: 200-500
severe: <200 ms

53
Q

regurgitant volume measurement principle

A

in the abscence of regurg, SV across any valve in the heart should be the same….. but if there is regurg, the SV of the RV will be higher than the SV of a non-regug valve

54
Q

regurgitant volume and regurgitant fraction can be calculated using which 2 methods

A

stroke volume or PISA

55
Q

SV formula for regurgitant volume

A

RVolume = SV of regurg valve - SV of control valve
or
RVolume = RV (pie (r^2) x VTI) - CV (pie (r^2) x VTI)

units = cm^3 or ml

56
Q

what does PISA stand for

A

proximal isovolocity surface area

57
Q

AV regurgitant fraction % for mild AR

severe

A

mild: <30%
severe: >/=50%

58
Q

AV regurgitant fraction

formula

A

% of blood leaking back across the valve

RF = [ (SV of RV - SV of CV) / SV of RV ] x 100

59
Q

effective regurgitant orifice area (EROA) value for mild AR

severe

A

mild: <0.1 cm^2
severe: >/= 0.3 cm^2

60
Q

2D and Mmode finding of the MV w/ severe AR

A
  • AML reverse doming due to a severe AR jet hitting the AML
  • may lose double bump in severe cases
  • AML fluttering during diastasis
61
Q

if the vena contracta is > 6mm and flow reversal is seen in the descending AO, do you need to measure more parameters to grade AR

A

no, automatically severe

62
Q

if central jet width was < 25% and the LVOT CW is not intense, how would you grade the AR

A

mild

63
Q

regurgitant volume value for SV and PISA, for mild AR

severe

A

mild: <30 ml
severe: >/=60ml

64
Q

order of assessment for AR

A

AR colour flow images
vena contracta
abdo AO PW (if moderate-severe is seen)

Echo 2 (15 decks)

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