Aortic Regurgitation Mohammed AL Ghamdi

Definition AR is resulting of aortic valve lesion That make the blood return back through the aortic valve to the LV

Pathophysiology Tachycardia is compensatory Increased LVEDP leads to: Increase or decrease CO? Increased LVEDP leads to: Early closure of mitral valve Increased LA pressures, which then lead to pulmonary edema Myocardial ischemia Diminished myocardial perfusion pressure 3

Acute AR: Echo Color doppler demonstrates the regurgitant flow and aids grading. Severe acute AR: Vena contracta width >6mm. Diastolic pressure half-time <200ms. Holodiastolic flow reversal in desc. aorta. TEE/ TOE to diagnose IE, dissection. 4

Treatment Death without tx is common: Any severity of acute AR: Urgent aortic valve replacement 5

Chronic AR: Etiology Leaflet Abnormalities: Rheumatic fever Endocarditis Trauma Bicuspid aortic valve Rheumatoid arthritis Myxomatous degeneration Acromegaly Fenfluramine-phentermine 6

Chronic AR: Echo Characteristic Findings: If primary valvular, can see leaflet thickening, vegetations, calcification, and prolapsed or flail leaflets Aortic root dilatation or evidence of aneurysm (either dissecting or saccular) High frequency, diastolic fluttering of anterior mitral leaflet from AR jet Doppler is highly sensitive for detecting AR jet Increased LVESV and LVEDV 7

Chronic AR: Severity Assessment Severe AR present by echo with at least one of the following findings: Regurgitant fraction ≥50% Vena contracta width >6mm Regurgitant volume ≥60mL Central jet width ≥65% OF LVOT ERO area ≥0.30cm2 8

Chronic AR: Echo Severity Other indirect measures: Rate of decline in regurgitant slope The sharper the decline, the more severe Degree of reversal in pulse wave velocity in the descending aorta Magnitude of LV outflow tract velocity 9

Chronic AR: Severity 10

Severe AR: Management Asymptomatic with normal LV function First question if truly asymptomatic??? Consider exercise testing if sedentary or equivocal symptoms Medical therapy (i.e. vasodilators) Not recommended Serial monitoring Symptoms and LV dimensions and function 11

Management strategy for patients with chronic severe aortic regurgitation 12

Quantification of Aortic Regurgitation Continuity Method PISA Vena Contracta

What is PISA ? Derived from the hydrodynamic principle stating that, as blood approaches a regurgitant orifice, its velocity increases forming concentric, roughly hemispheric shells of increasing velocity and decreasing surface area

PISA Calculations 2 * r2 * v Flow (cc/sec) = 6.28 x [r (cm)2 x Va (cm/sec) ERO (cm2) = Flow (cc/sec) V (cm/sec) RV (cc) = ERO (cm2) x TVI (cm) ERO = effective regurgitant orifice; RV regurgitant volume

PISA Method for AR Obtain optimal regurgitant jet with CW Doppler Use alternate windows to be parallel to flow Measure peak regurgitant velocity Trace regurgitant TVI AR

PISA Method For AR Move baseline “up” Measure radius (cm) Toward regurgitant jet direction Measure radius (cm) Measure in early diastole to correspond to peak AR velocity Note alias velocity Flow (cc/sec) = 6.28 x [r (cm)]2 x Va (cm/sec)

Eccentric AR Jets: PISA Parasternal Long-axis View

Values for Aortic Regurgitation Grade AR ERO(cm2) RV (cc) Mild <0.1 <30 Moderate (Gr II) 0.1-0.2 30-44 Moderate (Gr III) 0.2-0.3 45-59 Severe >0.3 >60 19

Vena Contracta Narrowest portion of a jet that occurs at or just downstream from the orifice

Semiquantification Color Flow-Vena Contracta ≥6 mm association with severe AR < 3 mm mild AR 21

Reversal of Flow Descending Thoracic Aorta

Pulsed Wave Doppler Descending Aorta TVI Mild AR Moderate AR > 15 cm – Severe AR If there are holodiastolic reversals and the absolute reversal TVI is > 15cm OR more than 50% of forward flow consistent with severe. 23

Normal Aortic Valve A B L R N

Unicuspid Aortic Valve B Raster Image \rasters\1009156-9a.tif; 1009156-9b.tif (originals: EL019-14-009.tga)

Bicuspid Aortic Valve

Quadricuspid Aortic Valve 27

3D Live TEE 28

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