Valvular Heart Disease (VHD): AR/AS Flashcards
the most common etiology of AS in the US is _____
calcific AS of a normal trileaflet valve
AS is the most common primary valve disease and is best evaluated with echo. T or F ?
T
aortic _____ is a thickened AoV that still opens well, with a peak velocity < or = 2.5 m/s
sclerosis
*note:
- sclerosis: thickened AoV without decreased excursion. it may or may not become stenotic in the future.
- stenosis: thickened AoV with decreased excursion
- peak velocity > or = 2.6 m/s
bicuspid AS usually becomes symptomatic between the ages of ______
20-50 years
____ AS originates at the aortic valve cusps and moves out toward the commissures
Rheumatic
what type of murmur is associated with AS ?
systolic crescendo decrescendo murmur
serial echocardiograms track changes in the AS patient, to include____
- AS peak velocity
- CO
- pressure half time
- RVSP
1
the echo report on AS should include details regarding the _______ (3 parameters)
- level of obstruction
- LV size, wall thickness, and EF
- cusps mobility, thickness, calcification
_____ is a minimally invasive procedure that uses a balloon catheter with a stent-mounted valve crimped on its tip.
TAVR
what is TAVR ?
Transcatheter aortic valve replacement (TAVR) is a procedure that replaces a diseased aortic valve with a man-made valve. Aortic valve replacement can also be performed with open-heart surgery; this procedure is surgical aortic valve replacement (SAVR).
the patient is 84 years old and echo findings include thickened, calcified AoV cusps, LVH, LV enlargement, decreased LV systolic function, and post stenotic dilatation of the AoR; what is most likely the diagnosis?
degenerative AS
when is raphe present?
BAV
what would you expect to see on the M-mode of a BAV ?
eccentric closure *either higher or lower
in the echo lab, we use Bernoulli’s equation to describe the relationship between pressure and velocity. the simplified Bernoulli’s equation = ________
4 (V)2
the AV Doppler waveform is below the baseline from every window. T or F ?
F
above the baseline
in order to acquire a quick maximum PG, the sonographer can utilize the modified Bernoulli’s equation (4V). T or F ?
F
use VTI with CW
according to the continuity equation, AVA = _______
AVA = (VTI LVOT) (CSA LVOT) / (VTI AoV)
what are the 3 parameters required to assess AS ?
- LVOT diameter - used to calculate CSA = Pi (D LVOT/2)2
- AoV CW VTI - acquire AoV peak velocity
- LVOT PW VTI - acquire LVOT peak velocity
*note: continuity equation
V1 A1 = V2 A2
(VTI LVOT) (CSA LVOT) = (VTI AoV) (AVA)
solving for AVA..
AVA = (VTI LVOT) (CSA LVOT) / (VTI AoV)
the AVA by the continuity equation requires _____
VTI AoV with CW or PEDOF (required to get the highest velocity possible)
what is the simplified continuity equation for AVA ?
AVA = [(.785)(D LVOT)2] (V LVOT) / (V AoV)
For AS assessment measurement, acquire ___ beats for normal sinus rhythm and ___ consecutive beats for irregular rhythm.
3+
5+
what is the normal range of LVOT ?
1.8 - 2.2 cm
AS assessment:
acquire peak AoV velocity (VTI) with CW/PEDOF at multiple location: ___, ___, ___, & _____.
5C
3C
suprasternal
right parasternal
AS can be over or underestimated by _____.
- 3-4+ AR
- improperly measured LVOT diameter
- tachycardia
- all of the above
4
_____ seriously impact the AS severity scale and underestimates the AS peak velocity, consider using the AS velocity ratio.
reduced EF
_____ would most likely cause chronic AR.
AS
regular AR murmur vs severe AR murmur ?
regular: a high-pitched, blowing diastolic decrescendo murmur at the left sternal border
severe: a low-pitched, mid-diastolic, rumble at the apex
another name for sever AR murmur ?
Austin Flint murmur
echo findings include diastolic flutter of the AMVL and AoV cusps, early closure of the MV, and early opening of the AoV; what is most likely the diagnosis?
AR
mild AR creates a flatter Doppler waveform with a higher pressure half-time. T or F ?
T
severe, acute AR creates a sudden increase in preload and the heart is unable to compensate. increased preload causes the LVEDP (LV end-diastolic pressure) to exceed the LAP so the ____ closes early and ____ opens_____.
MV
AoV
On M-mode, when AR travels through the closed cusps it creates _______.
abnormal diastolic flutter of AoV
severe AR causes the aorta’s pressure to drop quickly, this creates a more rapid LV pressure increase and higher pressure half time. T or F ?
F
*severe AR - lower pressure half time
the AR pressure half time is 300 m/s; what is most likely the diagnosis ?
moderate AR
the AR peak velocity us usually 3+ m/s due to the pressure difference between the LV and aorta. T or F ?
T
AS severity scale: peak velocity
mild value ?
severe value ?
mild: 2.6 - 2.9 m/s *note: 2.5 m/s = sclerosis
severe : > 4.0 m/s
AS severity scale: mean PG
mild value ?
severe value ?
mild: < 20 mmHg
severe > 40 mHg
AS severity scale: AVA
mild value ?
severe value ?
mild: > 1.5 cm2
severe: < 1.0 cm2
AS severity scale: max PG
mild value ?
severe value ?
mild: 27-34 mmHg
severe: > 64 mmHg
reduced EF underestimates the AoV peak velocity ad seriously impact the AS severity scale; with reduced EF, consider using the AS velocity ratio = __________ *unitless ratio
AS velocity ration = V LVOT / V AoV
*note:
mild AS: > 0.5
severe AS: < 0.25
AR severity scale: pressure half time
mild value ?
severe value ?
mild: > 500 mmHg
severe: < 200 mmHg
AR Doppler waveform vs MS waveform:
AR waveform is similar to the MS; however, contrary to the MS waveform where ______ (shape) is more severe, the ______ (shape) the AR waveform the more severe AR.
flatter
steeper
What are are the abnormalities usually associated with quadricuspid valve?
PDA (patent ductus arteriosus)
Hypertrophic cardiomyopathy
Subaortic stenosis (thickening right before LVOT)
Ehler-Danlos syndrome
Coronary ostium displacement
Ventricular septal decect
*Note: coronary ostium (opeing to vessels)
The ostia of the left and right coronary arteries are located just above the aortic valve, as are the left and right sinuses of Valsalva.
Function:
Oxygenated blood is pumped into the aorta from the left ventricle; it then flows into the coronary artery ostia. Blood flow into the coronary arteries is greatest during ventricular diastole.
What is Ehler-Danlos symdrome?
A group of inherited disorders that affect your connective tissues with 16 subtypes - primarily your skin, joints and blood vessel walls. Cardiac valvular type affects AoV & MV
what are the etiologies of AR?
*primary leaflet abnormality
- congenital: BAV, quadricuspid/unicuspid valve, Rheumatic valvular disease
- degenerative: thickening/calcification due to age, myxomatous degeneration, leaflet damage due to membraneous subaortic stenosis
- infectious: bacterial endocarditis
- inflammatory: Rheumatic valvular disease, nonbacterial thrombotic endocarditis
- neoplastic: papillary fibroelastoma (benign cardiac tumor)
- traumatic: iatrogenic (relating illness caused by medical examination or treatment) cardiac catherization
- toxic: anorexigen (a drug that suppress the appetite) exposure
what are the etiologies of AR?
*aortic root abnormalitiy
- genetic: Marfan syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome, Turner syndrome, familial thoracic aortic aneurysm syndrome)
- degenerative: aging, hypertension, atherosclerosis
- infectious: Syphilis, Salmonella, Staphylococci Mycobacteria
- inflammatory: Giant celll arthritis, Takayasu arthritis, RA, Spondyloathropathies
- traumatic: aortic dissection, VSD with cusp proplase
acute vs chronic AR
what are the causes?
acute: dissection, infective endocarditis, trauma
chronic: aortic dilatation (Marfan syndrome, hypertension, Syphilis etc), AS, BAV, RHD, infective endocarditis, prosthetic valve dysfunction, other congenital anamolies
acute vs chronic AR
what are the clinical presentation?
acute: pulmonary edema, refractory heart failure
chronic: often asymptomatic
acute vs chronic AR
LV end-diastolic pressure
acute: markedly elevated; exceed LA pressure causing early MV closure & earlier AoV opening
chronic: normal to slightly elevated
acute vs chronic AR
heart rate
acute: elevated
chronic: normal to slightly elevated - long-standing AR causes decreased LV function
acute vs chronic AR
cardiac output
acute: decreased
chronic: normal
acute vs chronic AR
diastolic pressure
acute: normal to slightly elevated
chronic: decreased
acute vs chronic AR
systolic pressure
acute: normal to slightly decreased
chronic: elevated
acute vs chronic AR
pressure and size difference
acute: size - normal, pressure - decreased in LV & increased in LA
chronic: size - increased, pressure - increased in LV & LA
simplified Bernoulli Equation
ΔPmax (maximum pressure gradient) = 4 (Vmax)2
modified Bernoulli Equation
ΔPmax = 4 (Vmax2 –VLVOT2)
What does PISA stand for?
Proximal Isovelocity Surface Area
Explain the steps for PISA
- Align direction of flow with insinuation beam 2. Zoom view & variance off 3. Change baseline/Nyquist limit low in direction of jet 4. Measure radius *Make sure AoV is closed!
Explain the steps to measure vena contracta
- PLAX zoom view 2. Align jet to optimize VC imaging 3. Measure the narrowest jet diameter at or just apical to valve *Good at identifying mild or severe AR
*Assessment of AR Explain the steps to quantify AR by CW
- Optimize Doppler angle with CW 2. Increase sweep speed 100m/s 3. Acquire AR peak velocity (average 3-5) 4. Acquire AR deceleration slope (average 3-5) *machine will calculate the AR pressure half time
What is EROA ?
Effective Regurgitant Orifice Area *cross sectional area of VC = the narrowest area of actual flow
EROA equation
EROA = regurgitant flow / peak velocity
Regurgitant flow equation
Regurgitant flow = 2πr2 x VA (←color scale)
*AR severity Color Doppler Mild & sever value?
Mild: < 25% Severe: > 65%
*AR severity VC Mild & severe value ?
Mild: < 0.3 cm Severe: > 0.6 cm
*AR severity EROA value Mild & severe?
Mild: < 0.1 cm2 Severe: > 0.3 cm2
*AR severity PHT Mild & severe value ?
Mild: > 500m/s Severe: < 200m/s
