Aortic Valve Flashcards by Kyle Kravetz

Label the Aortic Valve Cusps in the Aortic Valve Short Axis

Non-Coronary Cusp nearest to the interatrial septum (Does not have a coronary artery)

Left Coronary Cusp is NOT on the Right side

Right coronary cusp near the right heart at the bottom of the screen

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What are the 5 views to evaluate the aortic valve?

Mid-esophageal Aortic Valve Short Axis

Mid-esophageal Aortic Valve Long Axis

Mid-esophageal 5 chamber view

Deep Transgastric Long Axis

Transgastric Long Axis

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How do you determine which coronary cusp is which in the long axis?

Right Coronary Cusp = Bottom of the Screen

Left or NON Coronary Cusp = Top of the Screen

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What is the measurement seen here?

Sinus of Valsalva

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What is the blue arrow indicating?

Sinotubular Ridge or Sinuotubular Junction

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What is seen in red?

Aortic Annulus

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What is the normal size of the Aortic Root in an adult?

What measurement is termed dilated?

Normal = < 40 mm (4.0 cm)

Dilated = >40 mm

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Why is the deep transgastric long axis view used to assess the aortic valve? (2 major measurement reasons)

Align Doppler parallel to blood flow through aortic valve

1. Measure Cardiac Output

2. AV Area by continuity equation

3. Dimensionless index to assess Aortic Stenosis

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Draw a Pressure Volume loop of cardiac cycle labeling:

Systole

Diastole

Opening and closing of Mitral and Aortic Valves

Solid Line = Systole

Dotted Line = Diastole

MO and AO = Opening of Left sided valves

MC and AC = Closing of Left sided valves

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What are the 3 phases of LV change for aortic insuffiency?

Acute
Chronic Compensated
Chronic Uncompensated

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List what happens from the compensated AI form to the decompensated AI in terms of:

LV End Diastolic Volume

LV End Systolic Volume

Shortening Fraction

LVEF%

Summary:
LVEDD rises (Heart dilates)

LVESD rises (Due to dilation)
Sarcomere Fraction Drops (Falls of Frank Starling Curve)

EF% drops

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What is the initial medical/surgical management of AI patients?

Serial TTE to look for:

1. LV dysfunction

2. Dilation

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When you evaluate for AI, what are the goals of TEE?

Severity
Mechanism and Etiology of AI
Degree of Root Dilation
Effect of AI on the LV
Repairable? (If not already in surgery)

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What are the 7 ways to quantitatively assess severity of AI?

AI jet height / LVOT diameter
AI jet area / LVOT area
Jet Depth
Vena Contracta Size
Slope of AR Jet decay
Pressure Half TIme (PHT) of the jet decay
Holodiastolic flow reversal in the descending Aorta

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What TEE view is utilized to assess AI Jet / LVOT diameter to assess quantitatively for AI?

Mid Esophageal Aortic Valve Long Axis

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AI Jet / LVOT diameter to assess quantitatively for AI:

What determines:

Mild (1-2+) vs. Moderate (2-3+) vs. Severe (3-4+)?

Mild (1-2+) = <25%

Moderate (2-3+) = 25-64%

Severe (3-4+) = >65%

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What TEE view is utilized to assess AI area / LVOT area?

ME AV Short Axis

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A.I. area / LVOT area criteria for:
Mild AI?

Moderate AI?

Severe AI?

AI area / LVOT area criteria for:
Mild AI = <5%

Moderate AI = 5-59%

Severe AI = >60%

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What TEE view using jet depth is best used to quantify A.I. severity?

ME Long Axis

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How do you quantify Jet Depth in the Mid-Esophageal Long axis view?

Include:

Trivial

Mild

Moderate

Severe

Trivial = LVOT

Mild = Mid Anterior Leaflet of Mitral Valve

Moderate = Tip of Anterior Leaflet of Mitral Valve

Severe = Papillary Muscle Head

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What are the two TEE views you could assess vena contracta to determine A.I. severity?

Mid Esophageal Long Axis

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What are the two criteria used to measure the vena contracta to determine A.I. severity?

Width = > 6mm

Area = > 7.5 mm²

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What TEE views are used to determine slope of the AR Jet Decay?

TG Deep Long Axis

TG Long Axis

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What are the criteria for determining AI severity using slope of the AR Jet Decay in the TG TEE views?

>/= 2 m/s for Moderate A.I.

>/= 3 m/s for Severe A.I.

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Using Pressure Half time, what is the criteria of using AI jet decay?

Mild = \>500 ms Moderate = 200-500 ms Severe = \<200 ms

What would determine severe AI for: Effective Regurgitant Orifice Area

Effective Regurgitant Orifice Area = **\> 0.3 cm²**

What would determine severe AI for: *_Regurgitant Fraction_*

Regurgitant Fraction = **\> 50%**

What would determine severe AI in terms of: Regurgitant Volume?

Regurgitant Volume = **\> 60 mL/beat**

What are the 2 ways to measure A.I. using AI jet / LVOT diameter?

1. ME AV Long Axis direct measurements 2. M-Mode of ME AV Long Axis

What is the pathophysiology of Pressure Half Time when evaluating Aortic Insufficiency?

High PHT = Trivial / Mild AI Low PHT = Severe AI **PHT** is the time is takes to go from max pressure gradient to 1/2 max pressure gradient **Pathophysiology**: The larger the hole, the faster the equilibriation between two chambers (LV and Aorta) and the less time it takes for PHT to occur

Why is pressure half time not the best measurerment of Aortic Insufficiency?

1. Diastolic Function 2. Compliance of the Heart 3. Relaxation of the hearrt

How do you logistically obtain a pressure half time measurement for Aortic Insufficiency?

1. Deep Transgastric Long Axis view 2. Continuous Wave Doppler on the Aortic Valve 3. Look at Diastolic Regurgitant Flow

How do you logistically obtain the slope of the AR jet decay?

1. TG Deep Long Axis View 2. CWD spectal profile through Aortic Valve 3. Rate the slope

Explain the slope and how it correlates to the degree of A.I. when using slope of AI jet decay of TG Long axis view using CWD.

Steeper the slope = Worse the A.I = Faster the chambers equilibriate (Aorta vs. LV)

What is seen in this image?

Holodiastolic Flow reversal in the Descending Thoracic Aorta

What are the 3 factors that influence prognosis of a patient with aortic insufficiency?

1. LV Dysfunction 2. *_LV_* **Dilation** 3. **Dilation** of the Ascending Aorta

What are the characteristitics of high risk patients with Aortic Insufficiency?

1. Symptomatic Patients 2. LVEF \<55% 3. End Systolic Diameter normalized to body surface area \> 25 mm/m²

What is the normal measurement of the sinus of valsalva?

25 - 31 mm

What is the threshold value of dilation of the sinus of valsalva?

No consensus \>50-55 mm then replace the valve regardless of the level of Aortic Insufficiency

What is the low risk group of AI?

Pertains to Patients with **Marfans Disease** **Ao ratio of \< 1.3** (Sinus of Valsalva diameter actual / Predicted) - Predicted is determined by age of the patient **Annual Rate of Change of \<5%**

When you have a patient with Aortic Insufficiency, when should you replace the valve?

1. **Symptomative** *_Severe AR_* OR 1. **Asymptomatic** - *_Dilated Heart_* *_- Decreased EF_* *_- Dilated Aortic Root_*

What is the only indication for Sinotubular Junction Annuloplasty?

**Ic Type 1 A.I.** | (Normal cusp motion with FAA dilatition or cusp perforation)

Aortic insufficiency is a "x" problem Aortic Stenosis is a "y" problem

X = Volume overload Y = Pressure overload

Show a PV loop of Aortic Stenosis

Aortic Stenosis Grading: **Mild** Peak Velocity (M/Sec)

2.6 - 2.9 m/s

Aortic Stenosis Grading: **Moderate** Peak Velocity (M/Sec)

3 - 3.9 m/sec

Aortic Stenosis Grading: **Severe** Peak Velocity (M/Sec)

\>4.0 m/sec

Aortic Stenosis Grading: **Mild** **Mean** Peak Gradient (mmHg)

15 - 29 mmHg

Aortic Stenosis Grading: **Moderate** **Mean** Peak Gradient (mmHg)

30 - 49 mmHg

Aortic Stenosis Grading: **Severe** **Mean** Peak Gradient (mmHg)

**\>50 mmHg**

Aortic Stenosis Grading: **Mild** **Max** Peak Gradient (mmHg)

20 - 39 mmHg

Aortic Stenosis Grading: **Moderate** **Max** Peak Gradient (mmHg)

40 - 69 mmHg

Aortic Stenosis Grading: **Severe** **Max** Peak Gradient (mmHg)

\> 70 mmHg

Aortic Stenosis Grading: Mild Dimensionless INdex (TVI_LVOT / TVI_AV ratio)

\> 0.5

Aortic Stenosis Grading: **Moderate** Dimensionless INdex (TVI_LVOT / TVI_AV ratio)

0.25 - 0.5

Aortic Stenosis Grading: Severe Dimensionless INdex (TVI_LVOT / TVI_AV ratio)

\< 0.25

Aortic Stenosis Grading: **Normal** Aortic Valve Area (AVA) cm²

3 - 4 cm²

Aortic Stenosis Grading: Mild Aortic Valve Area (AVA) cm2

1.6 - 2.9 cm²

Aortic Stenosis Grading: **Moderate** Aortic Valve Area (AVA) cm2

1 - 1.5 cm²

Aortic Stenosis Grading: Severe Aortic Valve Area (AVA) cm2

\< 1.0 cm²

Aortic Stenosis Grading: Mild Aortic Valve Area (AVA) cm2 / BSA (m2)

\>0.85

Aortic Stenosis Grading: Moderate Aortic Valve Area (AVA) cm2 / BSA (m2)

0.6 - 0.85

Aortic Stenosis Grading: Severe Aortic Valve Area (AVA) cm2 / BSA (m2)

\< 0.6

What pressure gradient is the best gradient to measure when evaluating Aortic Stenosis?

**Mean** Gradient

If you have a low pressure gradient, is aortic stenosis still possible? What would you use to determine?

AS still possible if low **SV** Use = **Continuity Equation**

What equation do you use if you have small AVA, but not have aortic stenosis?

**Modified Gorlin Equation** *_AVA = CO / (Mean Gradient)^1/2_* AVA = CO / Peak Grad *_Rearranged_* - Peak Grade = CO / AVA

What view do you use to determine Dimensionless Index?

Deep TG Long Axis

Derive the Dimensionless Index from the Continuity Equation.

Q1 = Q2 Q AV = Q LVOT Area_AV \* TVI_AV = A_LVOT \* TVI_LVOT Area_AV = [A_LVOT \* TVI_LVOT] / TVI_AV

Continuity equation: What do we substitute for TVI?

V_peak

Continuity equation: What do we substitute for Area _LVOT?

Pie (π) r2

Rate the severity of Aortic Insufficiency. LVOT diameter = 2.3 cm Jet diameter = 1.0 cm

**Moderate**: In this equation, we have 1/2.3 = **43%** Remember, **Moderate** (2-3+) = 25-64%

List 4 advantages of using a dimnesionless index to determine degree of aortic stenosis.

1. Not affected by cardiac left sided regurgitant disease 2. Not affected by decreases in LV Stroke volume 3. Independent of Patient's size 4. Avoids errors due to inaccurate measurements of LVOT radius

What is the most common type of VSD?

**Membranous VSD**

What is structure 1?