ADULT ECHOCARDIOGRAPHY Lesson Nine Valvular Heart Disease Harry H. Holdorf PhD, MPA, RDMS, RVT, LRT, N.P.

Aortic Regurgitation Etiology Primary cusp disease (stenosis, endocarditis, ankylosing spondylitis) Dilated aortic annulus and root (Marfan, aortitis, HTN, aneurysm) Los of commissural support (trauma, aortic dissection, membranous VSD) Prosthetic valve dysfunction

Aortic dissection & Flap in descending AO

Which anomaly goes with aortic dissection? NOTES: Which anomaly goes with aortic dissection? Marfan Syndrome If you have a uniformly dilated aortic root, which term best describes this? Fusiform

Sinus of Valsalva Aneurysm

Pathophysiology Left ventricular volume overload leads to LV dilatation Decreased ejection fraction with long standing regurgitation Increased risk of endocarditis Physical Signs Bounding (bifid (bisferious) atrial pulse High-pitched diastolic “blowing” murmur left sternal border (LSB) Symptoms of CHF, DOE, angina, and or syncope. Wide pulse pressure (big difference between systolic and diastolic numbers during BP readings.

Know diastolic “blow” (the classic aortic regurgitation murmur) NOTES Which is the most common chamber for a sinus of Valsalva aneurysm to rupture into? Right atrium What kind of murmur would you hear in a patient with a rupture of a sinus of Valsalva aneurysm? Continuous Know diastolic “blow” (the classic aortic regurgitation murmur)

Ao Regurg Echo M-mode may show diastolic fluttering of the mitral valve leaflets (mostly anterior) or interventricular septum Mitral valve “pre-closure” with severe acute AR Diastolic fluttering or lack of closure of he aortic leaflets Decreased excursion of the anterior MV leaflet LV dilatation with increased LV mass

Aortic valve or root abnormalities may be present Pre-systolic opening of the aortic leaflets LV contractility may be hyper or hypo-dynamic (acute vs. chronic) TEE best for diagnosing aortic dissections Chronic AR patients should have serial echoes to follow changes in diastolic and systolic size.

M-mode of Diastolic MV Fluttering NOTE: know diastolic mitral valve fluttering from aortic regurgitation by M-mode

M-mode of Premature MV closure NOTE: What causes MV pre-closure? An elevated LVEDP The line in the QRS: MV pre-closure should be in the middle.

Normal MV closure is in the middle to the end of the QRS complex

Doppler Diastolic turbulence in the LVOT Diastolic flow reversal in the descending Ao (Mod to Sev AR) Obtain the end diastolic gradient from CW Doppler to estimate the LVEDP (diastolic BP – end diastolic gradient Map the regurgitant area with pulsed or color flow Doppler Try to determine the regurgitant area in LAX and SAX to estimate severity

NOTE: Know Color Doppler M-Mode of aortic insufficiency JH/LVOT (ratio) Mild = <25% Mod = 25-65% Sev = >65% JH (Jet height) Ao P ½ time Mild = > 500 msec Mod = 500-200 msec Sev = <200 msec

Images showing Ao P ½ time

B is more severe because Ao & LV pressures are equal at end diastole. LVEDP = diastolic BP – end diastolic gradient Ex. Patient w/ BP of 120/50 and end diastolic velocity of 2 m/sec LVEDP = 50-16 (converting the 2 m/sec using 4V2 = 34 mmHg

AI diastolic flow reversal –Descending Ao

NOTE: Know descending aorta diastolic flow reversal (also called retrograde) Antegrade = normal flow direction Retrograde = flow in opposite direction NOTE: Mild aortic regurgitation has an incomplete spectral trace

Mild Ao regurgitation incomplete spectral trace

Pulmonary Regurgitation NOTE: Flick your bick Candle flame is normal regurgitation Etiology Primary valve disease (stenosis, endocarditis) Pulmonary hypertension Carcinoid heart disease Trivial/mild regurgitation is common.

PATHOPHYSIOLOGY RV volume overload may lead to RV dilatation. Severe regurgitation may cause right heart failure Evan moderate regurgitation will be well tolerated for years Increased risk for endocarditis Physical signs Low-pitched diastolic murmur (LSB) may increase with inspiration With pulmonary hypertension a high-pitched blowing diastolic murmur (Graham-Steele) may be heard (LSB)

ECHO RV dilatation with displacement of LV septum posteriorly. Tricuspid valve fluttering is rare Doppler Diastolic turbulence in the RVOT Map the regurgitant area with pulsed or color flow Doppler Severe PI spectral trace is NOT holodiastolic

Severe PI

Calculating PA End Diastolic Pressure NOTE: How would you calculate pulmonary artery end diastolic pressure? Pulmonic insufficiency velocity Know how to calculate PAEDP when given a Right Atrial Pressure (RAP) of 10 mmHg and from the PI spectral trace an End Diastolic velocity (EDV) of 1.5 m/sec.

PAEDP RAP + EDP (end diastolic pressure) converted from the DEV 10 +4 (1.5) sq. 10 +4 (2.25) 10 +9 = 19 mmHg

Tricuspid Regurgitation Etiology Primary valve abnormalities (rheumatic, prolapse, endocarditis, carcinoid) Elevated pulmonary pressure Annular dilatation/calcification Congenital valve abnormalities (Ebstein’s) Prosthetic valve dysfunction Trivial/mild TR is common

Pathophysiology Right atrial volume overload lends to right atrial dilatation Increased risk for endocarditis Physical signs Holosystolic murmur which increases with inspiration may be present Jugular venous distension Symptoms of right heart failure Echo Valvular abnormalities may be seen Right atrial dilatation RV dilatation with displacement of LV septum posteriorly Dilatation of IVC Contrast: systolic appearance of bubbles in IVC

TR vs. Tamponade by Saline Contrast (M-mode) NOTE: Systolic flow reversal of bubbles in the IVC-TR of tamponade?

TR or Tamponade

Dilated RV & IVC

Carcinoid Heart Disease-Fixed leaflets

NOTE: What is the most common valvular abnormality associated with carcinoid syndrome? Tricuspid regurgitation END PAGE 88

Next: Prosthetic Valves End lesson Nine Next: Prosthetic Valves