ECHO - Aortic Regurgitation Flashcards
Characteristic of ACUTE AR vs chronic AR
- LV usually not dilated
- Murmur and Color jets - not impressive
- Vena COntracta more reliable
- Diagnosis on high clinical suspicion on what is going on, consider TEE
difference of CHRONIC MR vs CHRONIC AR? in term of hemodynamics
MR - PURE Volume overload
- Eccentric LVH and LV dilatation
- low afterload
AR.- Volume and pressure overload
- almost never too late to operate on AR because after you operate, you will relieve the pressure overload.
what’s the difference between Asymptomatic severe AR C1 vs C2
C1 - LVEF >55% and mild to moderate LV dilatation (LVSED ≤50mm)
C2 - LVEF <55% OR LVESD ≥50mm of indexed LVESD ≥25mm/m2
What are the three Class I indications in AV surgery for AR (AHA)
- Symptomatic Severe AR (D1) regardless of LV systolic function
- severe AR (C or asymptomatic and D) who are undergoing cardiac surgery for other indications
- asymptomatic chronic AR and LVEF <55% (C2) and if no other causes for systolic function is identified
***Class 2a - for asymptomatic chronic AF, LVEF >55% AND LVSED >50mm or indexed LVESD >25mm/m2 (C2)
VALVE Hemodynamics: Severe AR (9)
- jet width ≥65% of LVOT
- Vena contracta >6mm
- Holodiastolic flow reversal in proximal abdominal aorta
- Regurgitant volume of ≥60ml/beat
- Regurgitant fraction of ≥50%
- effective regurgitant orifice of ≥ 0.3cm2
- Angiography grade of 3+ to 4+
- REQUIRES evidence OF LV dilatation
VALVE Hemodynamics: Moderate AR (6)
- Jet width 25-64% ogf LVOT
- Vena contracta of 0.3-0.6cm
- regurgitant volume of 30-59 ml/beat
- RF of 30-49%
- effective regurgitant orifice of 0.1 - 0.29cm2
- Angiography grade 2+
What are the three Class I indications in AV surgery for AR (ESC)
- symptomatic severe AR
- asymptomatic severe AR with LVSED >50mm or indexed LVESD ≥25mm/m2 or LVEF ≤50%
- severe AR undergoing CABG or surgery of the ascending aorta or another valve
***CLASS 2B
- asymptomatic severe AR with LVESD >20mm/m2 BSA OR resting LVEF ≤55% if surgery is low risk
Typical hemodynamic findings of AR
- widened aortic pulse pressure
- rapid upstroke of LV diastolic filling pressure
- near equilibration of end diastolic aortic and LV pressure
Pressure-volume loop relationship in AR
- Rightward shift due to increased EDV from the regurgitant flow
- Widened loop- reflecting the increased SV as the ventricle ejects more blood to compensate for the regurgitation
- loss of isovolumetric phase - the absence of the true isovolumetric contraction and relaxation phases due to continuous volume changes during these periods
Follow up echo for Mild AR and Moderate AR?
mild AR - every 3 years
moderate AR - every 12 months
routine surveillance of moderate or severe valvular regurgitation without change in clinical status or cardiac exam?
≥ 1yr
AV is a stentless valve within the aortic root complex.
two most common support of of AV - AV annulus and ST junction
in echo, what to look for in AR?
- define anatomy (BAV bs TAV)
- Mechanism and severity
- and look at the AORTA
Why use ESD in monitoring for AR?
***c- point of maximum contraction. where the ESD – End Systolic Diameter.
LVSED >50mm - associated with increase sudden cardiac death in severe AR - 19%
bicuspid aortic valve in PLAX view
Dooming of the RCC (in RCC and LCC fusion)
bicuspid aortic valve in PSAX view
opens like a american
in BAV, look for Coarctation of Aorta
7% of BAV has CoA
Classification of AR based on mechanisms
Type 1 - Normal Cusp Mobility
type 2 - prolapse/ excessive cusp mobility
type 3 - retraction/ limited cusp mobility
what are the most common mechanism of AR
- 70% are mixed mechanism - root dilatation and cusp prolapse (conjoined BAV and TAV-right )
Mechanism of AR in Aortic Dissection
Type 1 - related to dilatation of aorta
Type 2 - there is prolapse of the cusp at the same side of the dissection
Specialc- invagination of tear to the dissection into the AV
in ACUTE severe AR, Steep PHT/ <200msec
very helpful in acute rather than in chronic where there is already compensation of the LV
Specific Criteria for MILD AR
- VC width of <0.3cm
- central jet - width of <25% of LVOT
- small or no flow convergence
- soft of incomplete jet by CW
- PHT >500ms
- normal LV size
** ≥4 of these criteria -> definitively mild
Holodiastolic flow reversal in the DESCENDING AORTA
see pic
Specific Criteria for Severe AR
- Flail Valve
- VC width of 0.6cm
- Central jet - width of ≥65% of LVOT
- large flow convergence
- PHT <200msec
- Prominent holodiastolic flow reversal in the descending aorta
- enlarged LV with normal function
** ≥4 of these criteria - definitively severe
