1. Aortic Regurgitation 2D and Doppler Assessment
Dr.Sohail Abrar Khan
MBBS,FCPS (Med), FCPS (Card)
Diplomate of American certification Board of Echo
Assistant Professor and Consultant Cardiologist
Aga Khan University Hospital Karachi

2. Introduction
Aortic regurgitation is a common and serious health problem
Echo is the most valuable tool in the diagnosis and management of AR
Echo evaluation of AR requires a comprehensive evaluation by an experienced person
Visual and qualitative assessment may be unreliable and misleading

3. Introduction cont…
Patients are often asymptomatic until AR becomes significant
AR murmur usually not heard until AR severity > mild
Detection of AR may be the first clue that aortic root or aortic valve disease is present

4. Role of Echo in Assessment AR
2D and Doppler echocardiography is indispensable in the diagnosis and management of patients with AR
This should be used to assess the severity of AR, the LV response to volume overload (systolic function, ejection fraction [EF] and end-systolic and diastolic dimensions).
Echocardiography may also identify the anatomic cause of AR, which is important for determining the surgical approach

5. Assessment of Regurgitation
2D Echo
CFI AR
Hemodynamics
ERO/R Vol
ERO/RV
CW Doppler
PW Doppler

6. Hemodynamics of AR Acute AR Chronic AR Rapid onset of AR
Progressive ↑ AR
Heart has time to compensate
↑ LV volume
↑ dilatation
↑ Stroke Volume
Acute AR
Rapid onset of AR
Insufficient time for heart to compensate
Leads to ↑ LVEDP
Pulmonary edema
Decreased effective forward Stroke vol

7. Hemodynamics of AR cont…
Acute AR
Chronic AR
Adapted From: Lilly L. Pathophysiology of Heart Disease

8. Aortic Regurgitation 2D Echo
Assess valvular function
Identification of functional anatomy
Assess LV size and function
Evidence of increased LVEDP

9. 2D Echo cont… Assessment of LV Serial reproducible findings
LV chamber enlargement
LV function assessment
Predictors of preserved LV function after AVR
LVESD < 55 mm
LV EF > 50%

10. Conservative Rx for Severe AR Survival vs Indexed LV Systolic Diameter
Years
Survival (%)
LVS/BSA <25
81±5%
89±3%
34±10%
50±9%
LVS/BSA ³25
Dujardin KS: Circ,99 CP

11. Aortic Regurgitation 2-D and M-Mode
Clues of AR
Diastolic fluttering of anterior MV leaflet
Reverse “doming” of anterior MV leaflet
Diastolic flutter of aortic valve
Evidence for increased LVEDP
Presystolic (premature) closure of MV
Presystolic (premature) opening of AV

13. Aortic Regurgitation Functional Anatomy
Valvular
Congenital (bicuspid)
Degenerative
Rheumatic
Endocarditis
Cusp rupture

17. Functional Anatomy cont…
Aortic Root
Chronic Dilatation
Marfan syndrome
Senile/hypertensive
Chronic aortitis
Idiopathic Annuloaortic ectasia
Sinus of valsalva aneurysm
Acute Disruption
Dissection
Chest trauma
Endocarditis
Post-procedure

20. Aortic Regurgitation Color Flow Imaging
Jet area ¸ LVOT area
Jet width ¸ LVOT width CP

21. Color Flow Imaging cont… Jet Width/LVOT Width
Perry et al. JACC 1987

22. Color Flow Imaging cont… Jet area/LVOT area
AR jet area and LVOT area from parasternal short axis view
Correlates best with angiographic severity of AR
Assess AR at the level of the aortic annulus, just below the AV
Oh, Seward,Tajik: The Echo Manual

23. Color Flow Imaging cont… Jet area/LVOT area
Grade I < 5%
Grade II %
Grade III %
Grade IV > 60%

24. Vena Contracta Measure from PLAX (zoom) Use standard color scale
No baseline shift
Measure width of AR jet at the narrowest point
Measure just below flow convergence
Vena contracta < 6 mm = severe AR
Vena contracta < 3 mm = mild AR

25. Vena Contracta cont… VC Width 5 mm 6 mm 7 mm Sn Sp 100 73 95 90 84 96
ERO≥0.3 cm 2
100 73 95 90 84
RegVol≥60 ml 96 81 94 65
Tribouilloy et al: Circulation, 2000

26. Vena Contracta
Optimize the flow convergence zone

27. Vena contracta is usually smaller than LVOT jet height
Measure width of AR at narrowest point of emitting jet
Vena contracta is usually smaller than LVOT jet height

28. Aortic Regurgitation CW Doppler Assessment
Density of CW signal reflects Reg Vol
Pressure half-time
Mild AR > 400 msec
Severe AR < 250 msec
Oh,Seward, Tajik: The Echo Manual

29. Align Doppler parallel to flow
Move lateral or try a lower rib space

30. CW Doppler Assessment cont…
Pressure Half Time PHT
Mild AR > 400 msec
Otto and Pearlman: Textbook of Clinical Echocardiography

31. CW Doppler Assessment cont…
Pressure Half Time PHT
Severe AR < 250 msec
Otto and Pearlman: Textbook of Clinical Echocardiography

32. CW Doppler Assessment cont…
AR PHT may be shortened due to other causes of elevated LVEDP i.e LV systolic and diastolic dysfunction and Mitral Regurgitation
It can be increased due to Mitral Stenosis

33. Aortic Regurgitation PW Doppler Assessment
LV stroke volume
Mitral inflow
Descending thoracic aorta
Abdominal aorta

34. PW Doppler cont… Mitral Inflow High LA Pressure & LVEDP
Restrictive mitral inflow
Mitral pattern dependent on compliance of ventricle
Oh,Seward, Tajik: The Echo Manual

35. Premature Cessation of Mitral Flow in Acute Severe AR
PW Doppler cont…
Premature Cessation of Mitral Flow in Acute Severe AR
Pre-op
Post-op

36. PW Doppler cont… CP

38. PW Doppler cont… Descending Aorta Diastolic flow reversal
Retrograde flow TVI
Severe AR TVI > 14 cm

39. PW Doppler cont… Abdominal Aorta
Place PW sample volume in abdominal aorta
Diastolic flow reversal consistent with significant aortic regurgitation
Otto and Pearlman: Textbook of Clinical Echocardiography

40. Indications for Quantitative Doppler
When regurgitation appears moderate or more by CFI/qualitative assessment
Serial assessment
Assess LV size & function
Assess regurgitation
Assist clinician/surgeon
Clinical management
Timing of surgery

41. Quantitative Doppler Methods
Continuity Equation
PISA Method
CSA
TVI

42. Continuity Equation Stroke volume Valve area Shunt lesions
Regurgitant volume
Regurgitant fraction

43. Continuity Equation cont…
What goes in
(the ventricle)
must go out!!

44. Regurgitant Volume
Volume of blood that regurgitates through an incompetent valve with each heart beat

45. Continuity Equation Calculation
TVI A = X
Stroke volume
Area
TVI CP
Raster: tif 45

46. Continuity Method cont…
“What goes in must go out”
Measurements required
LVOT diameter & TVI
MV annulus diameter & TVI
Limitation of continuity method Unable to use with multiple regurgitant lesions > mild
and shunt lesions

47. Continuity Method cont…
Calculate SVLVOT
Measure LVOT diameter
Obtain PW Doppler signal in LVOT
Trace LVOT TVI
SVLVOT = CSALVOT x TVILVOT

48. Continuity Method cont…
Calculate SVMV
Measure diameter of mitral annulus
Obtain PW Doppler signal at level of mitral annulus
Trace MV annulus TVI
SVMV = CSAMV x TVIMV

49. SVLVOT = CSALVOT x TVILVOT
Regurgitant Volume and Fraction
SVLVOT = CSALVOT x TVILVOT
SVMV = CSAMV x TVIMV
RVAR = SVLVOT - SVMV
RFAR = RVAR/SVLVOT

50. Pitfalls of Continuity Method
Learning curve of the operator
Incorrect placement of sample volume
Incorrect annulus measurement
Requires 4 separate measurements Introduces 4 possible errors
Diameters are squared in the equation so any small error will be magnified and spoil the result
Invalid with multivalvular regurgitation or intracardiac shunts

51. PISA
Proximal
Isovelocity
Surface
Area

52. Advantages of PISA Method
Can be used in the presence of other valvular regurgitation or shunts
Can be used in the presence of valve stenosis or prosthetic valves
Uses fewer variables (2 measurements)

53. PISA Method Shift color baseline in the direction of flow
Alias velocity varies (range of cm)
Note alias velocity
Adapted from Oh, et. al.

54. AR Peak Velocity and VTI
Using CW Doppler, obtain optimal regurgitant jet
Use alternate windows to be parallel to flow
Measure peak regurgitant velocity
Trace regurgitant TVI

55. PISA Calculations 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)

56. Effective Regurgitant Orifice
Size of orifice through which regurgitation passes
Also referred to as ROA (regurgitant orifice area)

57. Pitfalls of PISA Method
Learning curve of operator
Assumption of hemispherical flow convergence area
Inability to accurately measure radius
Inability to obtain complete MR jet by CW Doppler

58. Severity of AR Mild Severe Jet/LVOT area <2 5% > 60%
Jet/LVOT Width < 25% > 60%
Vena Contracta < 3 mm > 6 mm
CW Doppler faint dense
AR PHT > 400 msec < 250 msec
Descending Aorta early holodiastolic
diastolic
Reversal TVI > 14 cm

59. Summary Aortic regurgitation is a common and serious health problem
Echo is the most valuable tool in the diagnosis and management of AR
Echo evaluation of AR is complex and often suboptimal
Visual and qualitative assessment is is often misleading
It is now very reliable by the use of quantitative methods
An organized and comprehensive approach by using all the available qualitative and quantitative methods is required for proper assessment of AR

60. Thank You