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Aortic Regurge Flashcards

(41 cards)

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1
Q

What are the two possible causes of AR?

A
  1. Leaflet Issues (prolpase, restriction, perforation)
  2. Aortic Root Dilation
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2
Q

What are two Acute Causes of AR?

A

Dissection or Infective Endocarditis

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3
Q

What is the Classification of AR?

A

Group A: risk of AR (bicuspid AV or dilated Aortic Sinus)

Group B: mild/moderate AR

Group C: Severe Asymptomatic AR

Group D: Severe Symptomatic AR

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4
Q

What are the Indications for Surgery (repair or replacement) in AR?

A
  1. Symptomatic Severe AR
  2. Asymptomatic Severe AR + Decreased LVEF
  3. Mod/Severe AR + Other Cardiac Surgery
  4. Severe LV Dilation (+ asymptomatic, normal LVEF)
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5
Q

What are the three main areas to assess on TOE in AR?

A
  1. Leaflets (thickened/calcified/restricted/prolapse)
  2. Aortic Root/Proximal Aorta Dilation
  3. LV Size and Function
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6
Q

What are the goals of TOE evaluation of AI?

A

Severity of AI
Mechanism and Aetiology of AI
Degree of Aortic Root Dilation
Effect of AI on the LV
? Repairable issue

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7
Q

What are the main types of AR Jet seen with Colour Doppler and what are their causes?

A
  1. Central Jet:
    - symmetrical cusp restriction /comissural fusion
    - dilation of the aortic root with a cusp perforation
  2. Eccentric Jet:
    - towards affected leaflet: asymmetrical cusp restriction
    - away from affected leaflet: cusp prolapse
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8
Q

What are the different classifications for AR Jet Length?

A

Mild AR: < 25% of LVOT
Moderate AR: 25-50% of LVOT
Severe AR: > 50% of LVOT

< 2cm from AV = Mild
aMVL = Moderate
Beyond Origin of Pap Muscles = Severe

length is a less reliableiable marker of Severity of AR (used VC instead)

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9
Q

What are the different classifications for AR Jet Width?

A

Ratio Jet Width: LVOT Width

Mesausre using Standard Coppler Doppler or M-Mode

< 25% =0.25 mild

> 65% =0.65 severe

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10
Q

Where do you measure AR Jet Width?

A

immediately below the AV (circular jets)

If you measure more distally in the LVOT -> there will be an overestimation as the jet will have already splayed out

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11
Q

What types of AR Jets Widths should not be measured?

A

Elliptical (eg. BAV or Irregular Orificies from calcification)

Highly Eccentric Jets that impinge on the wall of the LVOT

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12
Q

What is the Vena Contracta?

A

The narrowest part of the regurge jet as it crosses the aortic orifice

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13
Q

What does the VC represent?

A

VC approx the Effective Regurge Orifice Area

(assuming a circular shape to the regorge orifice)

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14
Q

What are the classification distances of VC in AR?

A

<3mm =0.118 in mild AR and >6mm = severe AR

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15
Q

Can you use VC in eccentric jets?

A

Yes, but not if multiple jets

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16
Q

What is the Flow Convergence Method?

A
  • When blood flows through a narrow orifice (e.g., a regurgitant valve), it accelerates and forms concentric hemispherical shells of increasing velocity before reaching the orifice.
  • These shells, known as isovelocity surfaces, can be visualized with color Doppler.
  • By measuring the radius of the PISA zone, the effective regurgitant orifice area (EROA) and regurgitant volume can be calculated.
  • measured on the aortic side of the valve in diastole to quantify the AR
  • PISA >7mm radius @ aliasing velocity of 33cm/s = Severe AR
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17
Q

What are the issues with Flow Convergence/PISA?

Study These Flashcards
A
  1. Acoustic Shadowing
  2. Must measure Peak Regurge Velocity with CW Doppler (? unreliable with TOE)
18
Q

Formula for PISA

Study These Flashcards
A

FlowRate = 2πr-2 × Valiasing

EROA = Flow Rate/ Peak of Velocity Regurge Jet

Radius of PISA (measured from regurgitant orifice to the first aliasing velocity contour)

V_aliasing = Aliasing velocity (set in Doppler color flow settings)

Peak Velocity of Regurgitant Jet (V_max) = Measured with Continuous-Wave Doppler

19
Q

Regurgitant Volume (RV) Calculation

Study These Flashcards
A

RV = EROA × RegurgitantVTI

20
Q

What are the Clinical Applications of PISA in TOE?

Study These Flashcards
A
  • Mitral Regurgitation (MR): Most common use of PISA in TOE, especially in surgical planning.
  • Aortic Regurgitation (AR): Less commonly used but applicable.
  • Mitral Stenosis (MS): Can be used to estimate the mitral valve area in some cases.
21
Q

What are the Advantages of PISA?

Study These Flashcards
A
  1. Quantitative and less operator-dependent than subjective assessments.
  2. Useful in eccentric regurgitant jets that may not be well assessed by jet area methods.
  3. Applicable in TOE, where detailed imaging of the regurgitant orifice is possible.
22
Q

What are the Limitations of PISA?

Study These Flashcards
A
  1. Dependent on correct aliasing velocity setting.
  2. Assumes a hemispherical shape, which may not always be accurate (e.g., in elliptical orifices).
  3. Difficult in multiple jets (e.g., bileaflet mitral valve regurgitation).
  4. Not useful in very severe regurgitation where the PISA region is too large to measure accurately.
23
Q

As Severity of AR increases, what happens to flow reversal in aorta?

Study These Flashcards
A

increased severity of AR -> more prolonged reversal of diastolic flow

24
Q

What Flow Reversal in Proximal Descending Aorta indicates Severe AR?

Study These Flashcards
A
  • Holodiastolic
  • End-Diastolic Velocity > 20cm/s
25
What does the slope of the CW Doppler Regurge Waveform equal?
the rate of pressure equalisation between the aorta and the LV (is dependent on the degree of regurge) ≥ 2m/s = moderate ≥ 3m/s= severe
26
What does the Pressure Waveform represent?
diastolic pressure gradient between the Aorta and the LV in early diastole
27
What does the Pressure Half Time show?
the time (ms) for the peak transvalvular pressure gradient to fall by half quantifies the rate of decline (deceleration) of the diastolic pressure gradient
28
How is Pressure Half Time related to Regurgitant Orifice?
the pressure half time is invresely proportional to the regurgitant orifice size
29
What does a shorter pressure half time represent?
more severe regurge It shows a rapid fall in the diastolic pressure gradient Severe < 200ms Mild 500ms (longer to equalibrate)
30
What factors often affect the slope of the pressure waveform?
1. LV Compliance 2. Vascular Resistance 3. Loading Conditions 4. Clinically difficult to get a clear spectral envelope
31
Compare Acute and Chronic AR in terms of Pressure Half Time Measurements
Acute AR -> decreased LV Compliance and increased LV Diastolic Pressures the time for diastolic pressure equalisation between the AR and the LV is more rapid with acute AR vs. chronic AR So, there will be a shorter pressure half time for a given regurge volume
32
How does the heart compensate with Chronic AR?
The heart works with higher volumes in both Acute and Chronic AR normally EDV 100mls, in AR ESV 100mls In chronic AR the heart dilates to increase SV to increase effective forward flow (ie has to compensate for the regurgitant volume that falls back during systole) to achieve a better position on the Frank Starling Curve - to increase SV for end organ perfusion
33
When does chronic compensated AR progress to chronic decompensated AR?
when the optimum sarcomere length has been lost, fall off the Starling curve Decrease in LV systolic function -> decreased EF Decrease in effective forward SV -> increase in regurge volume -> increased dilation/pressure -> further stretch of sarcomeres (cycle continues)
34
What are the 3 pahses of LV Change in AR?
Acute (EF > 55%) Chronic Comp. (EF 50-55%) Chronic Uncom (EF < 50%) [LV dilates > 75mm] systolic dysfunction due to loss of effective sacromere length
35
What are the 9 possible ways to assess AI?
1. AI Jet width/LVOT diameter 2. AI Jet Area/LVOT Area 3. Jet Depth into LV 4. Vena Contracta radius 5. Slope of AR jet decay 6. Pressure half time of AR jet decay 7. Regurge Volume/Fraction 8. Effective Regurge Orifice Area 9. Holodiastolic Flow Reversal Descending Aorta
36
What factors are used to guide prognosis in AI?
1. LV dysfunction? 2. LV dilation? 3. Dilation of ascending aorta?
37
When is surgery indicated in AI?
"high risk patients" - symptomatic - asymptomatic with: - Decreased LVEF < 55% - ESD LV > 25mm/m2 - dilation of the ascending aorta
38
What is the issue with indexing EDV?
difficult to now normalise to body ratio with increasing obesity ratios 75% vs. 25% survival using this cut off value
39
What measurement is thought to be the best to show dilation of the ascending aorta?
Sinus of Valsalva Measurement normally 25-31mm > 50-55mm? replace regardless of AI severity
40
What group of patients are thought to be more "low risk" in terms of Aortic Dilation?
Marfan's Patients with an Aortic Sinus Ratio < 1.3 and an annual rate of change of <5% event-free survival is much higher and less dissection rates
41
What is Aortic Sinus Ratio? (Ao Ratio)
measured/predicted sinus diameter for a given BSA

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