Aortic Regurgitation

Question 1

Infective endocarditis (a known cause of AR) may be associated with what?

Answer 1

Aortic root abscess.

Question 2

Why does myxomatous disease cause AR?

Answer 2

Redundant leaflets sag in diastole.

Question 3

What is the main cause of Ao root dilatation?

Answer 3

Hypertension.

Question 4

What type of aortic dissection cause AR?

Answer 4

Type A

Question 5

Type A dissections involve which part of the Ao?

Answer 5

The Ascending Ao.

Question 6

Type B dissections involve which part of the Ao?

Answer 6

The Descending Ao.

Question 7

True of False; Type B dissections cause AR.

Answer 7

False.

Question 8

A common sign of AR is a collapsing pulse or a slow-rising pulse?

Answer 8

A collapsing pulse.

Question 9

A common sign of AR is a low diastolic BP and wide pulse pressure, or a low systolic BP and a narrow pulse pressure?

Answer 9

A low diastolic BP and wide pulse pressure.

Question 10

A common sign of AR is sustained apex beat or a displaced apex beat?

Answer 10

A displaced apex beat.

Question 11

A sustained apex beat occurs as a result of what?

Answer 11

LVH

Question 12

A displaced apex beat occurs as a result of what?

Answer 12

LV Dilatation.

Question 13

What kind of murmur can be heard with AR?

Answer 13

An early diastolic murmur.

Question 14

In terms of the LV, what are common echo findings with AR?

Answer 14

LV dilatation/impairment.

Question 15

What can be seen on m-mode with AR?

Answer 15

High frequency fluttering of the aMVL as the AR hits it.

Question 16

An diastolic Austin flint murmur can be heard with AR, what is this caused by?

Answer 16

Function MS due to AR.

Question 17

The aMVL may show what in the presence of AR; and what might this cause?

Answer 17

Reverse doming and premature closure of the mitral valve.

Question 18

Increased EPSS (E-point septal separation) can be seen in the presence of AR, what is this due to?

Answer 18

LV dilatation or because of restriction in opening of the aMVL due to the AR jet.

Question 19

What parameters are used to assess AR severity?

Answer 19

End diastolic Velocity (upper DAo), Jet width/LVOT diameter, PHT, Regurgitant fraction, ROA, Regurgitant volume and Vena contracta.

Question 20

What is considered severe for end diastolic Velocity (upper DAo)?

Answer 20

≥20cm/s

Question 21

What is considered mild and severe for jet width/LVOT diameter?

Answer 21

Mild; <25%, Severe; ≥60%

Question 22

What is considered mild and severe for PHT?

Answer 22

Mild; >500ms, Severe; <200ms.

Question 23

What is considered mild, moderate and severe for regurgitant fraction?

Answer 23

Mild; ≤30%, Moderate; 31-49%, Severe; ≥50%.

Question 24

What is considered mild, moderate and severe for ROA?

Answer 24

Mild; ≤0.10cm2, Moderate; 0.11-0.19cm2, Severe; ≥0.30cm*2.

Question 25

What is considered mild, moderate and severe for regurgitant volume?

Answer 25

Mild; ≤30mL/beat, Moderate; 31-59mL/beat, Severe; ≥60mL/beat.

Question 26

What is considered mild and severe for vena contracta?

Answer 26

Mild; <0.3cm, Severe; >0.6cm.

Question 27

Where should jet width/LVOT diameter measurements be taken?

Answer 27

Just below (0.5-1cm of the level of) the AOV.

Question 28

Measuring the width of the AR jet too far below the AOV can lead to an overestimation or underestimation of AR?

Answer 28

An overestimation.

Question 29

Why can measuring the width of the AR jet too far below the AOV lead to an overestimation of AR severity?

Answer 29

Because the jet starts to "spread out".

Question 30

In what situation can jet width/LVOT diameter measurements be underestimated?

Answer 30

In eccentric jets.

Question 31

True or false; vena contracta can or cannot be used in the presence of eccentric jets.

Answer 31

True.

Question 32

How should vena contracta measurements be taken in eccentric jets?

Answer 32

Perpendicular to the direction of the jet.

Question 33

When must vena contracta measurements not be used?

Answer 33

In the presence of multiple jets.

Question 34

What may affect PHT calculations?

Answer 34

Changes in aortic and LV diastolic pressures.

Question 35

A raised LV EDP will affect PHT how; and will it overestimate of underestimate the severity of AR?

Answer 35

PHT will shorten and the severity of AR will be overestimated.

Question 36

True or false; PHT measurements are still valid in acute AR.

Answer 36

True.

Question 37

With regards to end diastolic velocity (upper DAo), where should the sample volume be placed?

Answer 37

Just distal to the origin of the left subclavian artery.

Question 38

What are the names of the three vessels that come off the Ao Arch (from left to right)?

Answer 38

Innominate Artery; Left Carotid Artery and Left Subclavian Artery.

Question 39

With regards to the ECG, the end diastolic velocity (upper DAo) should be measured where?

Answer 39

At peak R wave.

Question 40

Reverse doming of the aMVL and an Austin flint murmur (because of functional MS) are indicators of what?

Answer 40

More severe AR.

Question 41

True or false; how far the AR jet extends back into the LV is a reliable indicator of severity.

Answer 41

False - it is unreliable.

Question 42

Denser CW Doppler jets are seen in moderate/severe AR. Can density be used to distinguish moderate from severe AR?

Answer 42

No.

Question 43

True of false; it is normal to see brief reversal of aortic flow in diastole in the suprasternal view.

Answer 43

True.

Question 44

In the suprasternal view, what may indicate at least moderate AR?

Answer 44

PAN- OR HOLODIASTOLIC flow reversal (throughout the whole of diastole).

Question 45

What may increase duration and velocity of flow reversal?

Answer 45

Reduced aortic compliance (with advanced age) and increased HRs.

Question 46

Severe acute AR will show no end diastolic velocity, why?

Answer 46

Because flow reversal will decrease rapidly.

Question 47

Pandiastolic flow reversal seen where is a specific indicator of severe AR?

Answer 47

In the abdominal Ao.

Question 48

A VTI of diastolic flow reversal of what indicates severe AR?

Answer 48

>15cm.

Question 49

Calculation of regurgitant volume, regurgitant fraction and ROA is not appropriate when?

Answer 49

If there is significant coexistent mitral regurgitation (more than mild).

Question 50

How is regurgitant volume calculated?

Answer 50

RV = SVlvot - SVmv

Question 51

How is regurgitant fraction calculated?

Answer 51

RF = (RV/SVlvot) X 100

Question 52

How is regurgitant orifice area (ROA) calculated?

Answer 52

ROA = RV/VTIar

Question 53

True or False; the PISA method in the assessment of AR is not as common as it is for mitral regurgitation.

Answer 53

True.

Question 54

Why is the PISA method in the assessment of AR is not as common as it is for mitral regurgitation?

Answer 54

It is technically more challenging and the technique has not been well studied in relation to the AOV.

Question 55

Mild-moderate aortic regurgitation should have follow up scans how often?

Answer 55

Every 2-years.

Question 56

Severe AR with normal LV function should have follow up scans how often?

Answer 56

Every 6months.

Question 57

Dilated aortic roots should have follow up scans how often?

Answer 57

Annually; or even more frequently if the AO is enlarging.

Question 58

What medications have a role to play in those with Marfan's syndrome?

Answer 58

Beta-blockers.

Question 59

Aortic valve surgery is indicated when?

Answer 59

1. For symptomatic acute aortic regurgitation; 2. In severe symptomatic chronic aortic regurgitation; 3. In asymptomatic chronic aortic regurgitation with LV impairment, LV dilatation or if other heart surgery is required.

Question 60

Regardless of AR severity, surgery is indicated for patients with aortic root dimensions of what, in Marfan's syndrome?

Answer 60

≥4.5cm

Question 61

Regardless of AR severity, surgery is indicated for patients with aortic root dimensions of what, with a bicuspid AOV?

Answer 61

≥5.0cm

Question 62

Regardless of AR severity, surgery is indicated for patients with aortic root dimensions of what?

Answer 62

≥5.5cm

Question 63

What parameters affect operative risk?

Answer 63

Right heart size and function, and PA pressures.