1. Aortic Regurgitation
Mohammed AL Ghamdi

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

3. 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

4. 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

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

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

7. 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

8. 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

9. 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

10. Chronic AR: Severity 10

11. 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

12. Management strategy for patients with chronic severe aortic regurgitation12

13. Quantification of Aortic Regurgitation
Continuity Method
PISA
Vena Contracta

14. 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

15. 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

16. 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

17. 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)

18. Eccentric AR Jets: PISA
Parasternal Long-axis View

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

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

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

22. Reversal of Flow Descending Thoracic Aorta

23. 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

24. Normal Aortic Valve A B L R N

25. Unicuspid Aortic ValveB
Raster Image \rasters\ a.tif; b.tif (originals: EL tga)

26. Bicuspid Aortic Valve

27. Quadricuspid Aortic Valve27

28. 3D Live TEE 28

29. Thank You