Aortic regurgitation 2d and doppler assessment
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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. Introduction.

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Aortic regurgitation 2d and doppler assessment

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


Introduction
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


Introduction cont
Introductioncont…

  • 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


Role of echo in assessment ar
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


Assessment of regurgitation
Assessment of Regurgitation

2D Echo

CFI

AR

Hemodynamics

ERO/R Vol

ERO/RV

CW Doppler

PW Doppler


Hemodynamics of ar
Hemodynamics of AR

Chronic 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


Hemodynamics of ar cont
Hemodynamics of AR cont…

Acute AR

Chronic AR

Adapted From: Lilly L. Pathophysiology of Heart Disease


Aortic regurgitation 2d echo
Aortic Regurgitation2D Echo

  • Assess valvular function

  • Identification of functional anatomy

  • Assess LV size and function

  • Evidence of increased LVEDP


2d echo cont
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%


Conservative rx for severe ar survival vs indexed lv systolic diameter

89±3%

LVS/BSA <25

81±5%

50±9%

LVS/BSA ³25

Survival (%)

34±10%

Years

Conservative Rx for Severe AR Survival vs Indexed LV Systolic Diameter

Dujardin KS: Circ,99

CP993609-9


Aortic regurgitation 2 d and m mode
Aortic Regurgitation2-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


Aortic regurgitation functional anatomy
Aortic Regurgitation Functional Anatomy

Valvular

  • Congenital (bicuspid)

  • Degenerative

  • Rheumatic

  • Endocarditis

  • Cusp rupture


Functional anat omy cont
Functional Anatomy cont…

Aortic Root

Chronic Dilatation

  • Marfan syndrome

  • Senile/hypertensive

  • Chronic aortitis

  • Idiopathic Annuloaorticectasia

  • Sinus of valsalva aneurysm

Acute Disruption

  • Dissection

  • Chest trauma

  • Endocarditis

  • Post-procedure


Aortic regurgitation color flow imaging
Aortic RegurgitationColor Flow Imaging

Jet area ¸ LVOT area

Jet width ¸ LVOT width

CP993609-12


Color flow imaging cont jet width lvot width
Color Flow Imaging cont…Jet Width/LVOT Width

Perry et al. JACC 1987


Color flow imaging cont jet area lvot area
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


Color flow imaging cont jet area lvot area1
Color Flow Imaging cont…Jet area/LVOT area

Grade I < 5%

Grade II 5 - 24%

Grade III 25 - 59%

Grade IV > 60%


Vena contracta
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


VC Width

5 mm 6 mm7 mm

Sn

Sp

Sn

Sp

Sn

Sp

2

ERO≥0.3 cm

100

73

95

90

84

95

RegVol≥60 ml

96

81

81

94

65

96

Vena Contractacont…

Tribouilloy et al: Circulation, 2000


Vena contracta1
Vena Contracta

Optimize the flow convergence zone


Vena contracta2
Vena Contracta

Vena contracta is usually smaller than LVOT jet height

Measure width of AR at narrowest point of emitting jet


Aortic regurgitation cw doppler assessment
Aortic RegurgitationCW 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


Align doppler parallel to flow
Align Doppler parallel to flow

Move lateral or try a lower rib space


Cw doppler assessment cont
CW Doppler Assessment cont…

Pressure Half Time PHT

  • Mild AR > 400 msec

Otto and Pearlman: Textbook of Clinical Echocardiography


Cw doppler assessment cont1
CW Doppler Assessment cont…

Pressure Half Time PHT

Severe AR < 250 msec

Otto and Pearlman: Textbook of Clinical Echocardiography


Cw doppler ass essment cont
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


Aortic regurgitation pw doppler assessment
Aortic RegurgitationPW Doppler Assessment

  • LV stroke volume

  • Mitral inflow

  • Descending thoracic aorta

  • Abdominal aorta


Pw doppler cont
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


Pw doppler cont1
PW Doppler cont…

Premature Cessation of Mitral Flow in Acute Severe AR

Pre-op

Post-op


Pw doppler cont2
PW Doppler cont…

CP993609-21


Pw doppler cont3
PW Doppler cont…

Descending Aorta

  • Diastolic flow reversal

  • Retrograde flow TVI

    Severe AR TVI > 14 cm


Pw doppler cont4
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


Indications for quantitative doppler
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


Quantitative doppler methods
Quantitative Doppler Methods

Continuity Equation

PISA Method

CSA

TVI


Continuity equation
Continuity Equation

Stroke volume

Valve area

Shunt lesions

Regurgitant volume

Regurgitant fraction


Continuity equation cont
Continuity Equation cont…

What goes in

(the ventricle)

must go out!!


Regurgitant volume
Regurgitant Volume

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


Continuity equation calculation
Continuity Equation Calculation

TVI

A

A

=

X

Area

TVI

Stroke volume

CP944143- 6


Continuity method cont
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


Continuity method cont1
Continuity Method cont…

Calculate SVLVOT

Measure LVOT diameter

Obtain PW Doppler signal in LVOT

Trace LVOT TVI

SVLVOT = CSALVOT x TVILVOT


Continuity method cont2
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


Regurgitant Volume and Fraction

SVLVOT = CSALVOT x TVILVOT

SVMV = CSAMV x TVIMV

RVAR =SVLVOT- SVMV

RFAR=RVAR/SVLVOT


Pitfalls of continuity method
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


PISA

Proximal

Isovelocity

Surface

Area


Advantages of pisa method
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)


Pisa method
PISA Method

Shift color baseline in the direction of flow

Alias velocity varies (range of 20-40 cm)

Note alias velocity

Adapted from Oh, et. al.


Ar peak velocity and vti
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


Pisa calculations
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)


E ffective r egurgitant o rifice
Effective RegurgitantOrifice

Size of orifice through which regurgitation passes

Also referred to as ROA (regurgitant orifice area)


Pitfalls of pisa method
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


Severity of ar
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


Summary
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



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