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MIDS 247 > Ch 5 AoV Regurg > Flashcards

Ch 5 AoV Regurg Flashcards

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1
Q

AoV regurg is caused by what?

A

Leaflet abnormalities:
-alterations in leaflet flexibility or shape leads to inadequate diastolic coaptation
-calcific valve disease, myxomatous valve disease, congenital bicuspid valve, rheumatic disease + endocarditis

Abnormalities of the Ao:
-leaflets are normal, but there are alterations in the geometry of the structures supporting the leaflets
-dilation at the base of the Ao (annular dilation), resulting in poor coaptation of stretched leaflets

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2
Q

AR frequently develops in pt’s with what?

A

-Bicuspid AoV
-Degenerative processes related to aging
-Diseases of the Ao root + Asc Ao

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3
Q

AR causes a pressure or volume overload on the LV?

A

Both!

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4
Q

The m/c congenital AoV anomaly is what?

A

Bicuspid valve

(they are predisposed to regurg + stenosis, and are associated with Asc Ao dilation + Ao sinuses)

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5
Q

What is myxomatous valve disease? How does this cause AR?

A

This disease is when the leaflet tissues + chordae are abnormally stretched

-Leaflets are thickened
-Slight sagging of leaflets into the LVOT in diastole
-Affects AoV + MV

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6
Q

What is endocarditis? How does this cause AR?

A

Endocarditis is vegetation’s on the AoV, located on the LV side (best analyzed in PLAX)

-Can cause AR due to leaflet perforation due to this infectious process
-Can cause AR due to deformity of diastolic leaflet closure due to the vegetation

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7
Q

What abnormalities of the Ao cause AR?

A

-Dilation of the Ao root (leads to poor coaptation)
-Degenerative changes (m/c due to thoracic Ao aneurysm)
-Genetic disorders (ex. marfan’s syndrome + familial thoracic Ao aneurysm syndrome), as they can cause the Asc Ao + sinuses of valsalva to become dilated

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8
Q

What is Marfan syndrome?

A

-Inherited disorder that affects the connective tissue
-Physical characteristics include tall + thin with long arms, legs, fingers + toes
-Becomes serious when the connective tissue expands + weakens the Ao wall

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9
Q

Ao aneurysms m/c occur where?

A

Ao root

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10
Q

What is an Ao dissection?

A

Small tear in the innermost layer of the Ao wall, allowing blood to enter it which can lead to rupture

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11
Q

Stretching of leaflets leads to what?

A

Poor coaptation of leaflets

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12
Q

Is marfan syndrome common to see on a req? What should we look for when scanning?

A

Yes! Is common to see on req

Look for anything abnormal in the AoV + Ao:
-Ao aneurysms
-Ao dissection
-AoV malformations

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13
Q

What is pectus excavatum?

A

When the chest + rubs are sunken in (seen with marfan syndrome)

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14
Q

List 3 common symptoms of chronic AR?

A

-Dyspnea on exertion (SOB)
-Fatigue
-Decreased exercise tolerance

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15
Q

In severe AR, the murmur is termed ____?

A

Austin Flint (mid diastolic low-pitched rumbling)

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16
Q

AR produces a crescendo or decrescendo murmur?

A

Decrescendo murmur that starts after S2

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17
Q

List 3 physical changes that occur with chronic AR?

A

-LV EDP will rise
-Increase in LV afterload will cause a decreased LV stroke volume
-LV will reach a preload reserve where the sarcomeres of the LV are max distended

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18
Q

What 2 factors mainly affect regurg volume?

A

-ROA (regurg orifice area)
-Diastolic pressure gradient b/w Ao + LV

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19
Q

How does the LV respond to chronic AR?

A

-LV progressively dilates + becomes more spherical (bolded)

-LV compliance increases at first
-LV compliance then decreases as eccentric + concentric hypertrophy + LV stiffness occurs to maintain normal filling pressures
-LV dilates to allow for preserved SV
-LV systolic dysfunction occurs due to chronic volume overload

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20
Q

How does the pt respond to chronic AR?

A

They may begin to experience heart failure symptoms, such as dyspnea + lower extremity edema

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21
Q

How does chronic AR affect the Ao?

A

It decreases the Ao elasticity + distendibility

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22
Q

What is acute AR?

A

Abrupt development of severe LV volume overload that the heart does not have time to adapt to

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23
Q

How does the heart respond to acute AR?

A

-Significant increase in preload + afterload
-Excessive load on LV causes decreased LVEF + a drop in SV
-Rapid increase in LVEDP + LAEDP

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24
Q

How does the pt respond to acute AR?

A

-Development of tachycardia to maintain low CO
-Can present with pulmonary edema or cardiogenic shock

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25
What 3 things cause acute AR?
-Infective endocarditis -Blunt trauma to chest -Ao dissection
26
How does the LV respond to acute AR?
-Sudden increase in LV EDV, LV is not compliant to dilate rapidly -Sudden increase in LV EDP, which causes elevated LAP + pulmonary edema
27
When is urgent intervention required in cases of acute AR?
Once SV has declined + tachycardia develops
28
List major differences b/w acute + chronic severe AR?
Acute: -symptoms include pulmonary edema + heart failure -LV normal or slightly enlarged -LVEDP elevated -CO is decreased -HR is elevated Chronic: -asymptomatic -LV enlarged -LVEDP normal or slightly elevated -CO is normal -HR is normal or slightly elevated (review chart in slides)
29
List indications for an echo with AR?
-To confirm presence + severity of AR (acute or chronic) -To diagnose + assess the cause of AR -To assess Ao root dimensions + AR severity in pt's with Ao root dilation -To assess LV dimensions + systolic function in chronic AR -To reassess LV dimenstion + systolic function periodically in asymptomatic pt's with chronic severe AR -To reevaluate mild, moderate or severe AR in pt's with new or changing symptoms
30
The definitive treatment of severe AR is generally ___?
Surgery
31
List indirect signs of AR on m-mode?
-Increased EPSS (on m-mode of MV) -High frequency fluttering of AMVL
32
List indirect signs of AR on 2D?
-Reversed diastolic curvature of AMVL (in MV PSAX) -Jet lesion on septum or MV -Hyperdynamic LV function -Eccentric LVH (due to increased afterload) -Mildly enlarged LA -MR (annular dilation)
33
What is the role of echo with AR?
-Determine cause of AR (congenital, degenerative, rheumatic) -Assess LV side + systolic function -Measure Ao dimensions -Estimate severity of regurg -Look for quantitative + qualitative signs
34
List some quantitative + qualitative signs of AR?
CD assessment: jet height, jet area, vena contracta width Spectral assessment: intensity of AR jet, diastolic flow reversal in desc + abdominal Ao, PHT Quantification: calculation of Ao regurg volume, fraction + EROA
35
List imaging windows to qualitatively assess AR with CD?
PLAX + PSAX at AoV level (best for identifying the exact origin of the regurg jet + for assessing the width + cross-sectional area)
36
List imaging windows for CW assessment of AR?
Apical windows (AP3 + AP5) (best window to line up cursor parallel to AR jet)
37
When using CD to evaluate AR severity, we must visualize what 3 components of the color jet?
-Flow convergence -Vena contracta -Jet area
38
How do we assess the severity of AR semi-quantitatively in PLAX?
-We compare the width of the AR jet to the size of the LVOT -Zoom into the LVOT in PLAX + measure the LVOT within 1cm from the vena contracta
39
List the ratios for mild, moderate + severe AR, when comparing the AR jet to the LVOT?
Mild: < 25% Moderate: 25-64% Severe: > 65%
40
In what view do we calculate the ratio of the area of the AR jet?
PSAX, zoomed in at the AoV level (can also measure the jet area to the LVOT area in this view)
41
When do we use the vena contracta as a quantification method to evaluate AR severity?
-Use when there is more than mild AR -Done in PLAX, zoomed in on the LVOT -Measured in early to mid diastole (VC is defined as the narrowest area of the jet, which occurs immediately distal to the anatomic orifice)
42
List the measurements for mild, moderate + severe AR according to the vena contracta?
Mild: < 0.3 cm Moderate: 0.3-0.6 cm Severe: > 0.6 cm (VC width is small, errors in measurements of 2mm or more will influence AR grading)
43
Which quantification method to evaluate AR severity can be used with eccentric jets?
Vena contracta
44
Is Ao diastolic flow reversal normal in the descending thoracic Ao?
-Brief early diastolic flow reversal is normal -Holodiastolic flow reversal is abnormal, indicating at least moderate AR (use PW from the SSN window)
45
Is Ao diastolic flow reversal normal in the abdominal Ao?
-No! Indicates severe AR -False positive results may be due to the presence of a patent ductus arteriosus (use PW in the SUB window)
46
Which windows are best used to evaluate AR with CW doppler?
-Apical window is best -Parasternal window can be used for eccentric jets
47
AR doppler signals reflect the pressure difference b/w what 2 structures during diastole?
B/w the Ao + LV
48
With CW, the intensity of the signal relative to the ____ velocity is an indicator of regurg severity ?
Antegrade velocity (AoV outflow)
49
With AR, a rapid increase in velocity occurs when?
At AoV closure (3-5 m/s), followed by a gradual decline in velocity during diastole
50
As PHT ____, AR severity ____?
Decreases, increases
51
What is the PHT method?
Time for pressure gradient to drop by half of its original value (note it can not be used alone to determine the severity of AR, b/c it is dependent on other factors)
52
How do we measure the PHT on AR?
-Place 1st caliper at highest velocity -Place ling along slope -Place 2nd caliper at the edge of the slope
53
The PHT will be longer or shorter for pt's with severe AR (< 200 msec)?
Shorter, due to rapid rise in LV pressure from the increased amount of regurg volume
54
The PHT will be longer or shorter for pt's with mild AR (> 500 msec)?
Longer, due to the gradual rise in LV pressure
55
List the mild, moderate + severe PHT values?
Mild: > 500 ms Moderate: 200-500 ms Severe: < 200 ms
56
Differentiate the shape of the CW doppler AR curve b/w mild + severe AR?
Mild: -Slow equalization of Ao to LV pressure -Flat (less steep) slope Severe: -Rapid equalization of Ao to LV pressure -Steep (increased) slope
57
List 3 symptoms of severe AR?
-Angina -Exertional dyspnea -Other signs/symptoms of heart failure
58
In asymptomatic pt's with severe chronic AR, surgery is indicated when?
-LVEF is diminished (<50%) or -LVEF is normal (>50%), but there is LV dilation (LVESD >50 mm or LVEDD > 65mm) Note: evidence for the use of LVESD cutoff value is stronger than the LVEDD
59
Symptomatic pt's with severe chronic AR should be considered for what type of surgery?
AoV surgery (w/o considering the LVEF + LV size)
60
Surgery for AR is only typically done for what grade?
Severe AR (moderate AR is only treated surgically when a pt is already undergoing cardiac surgery for other indications)
61
Surgery for severe acute AR is typically performed how fast?
Immediately, is considered a medical emergency and requires prompt surgical intervention
62
4 leading causes of acute severe AR include?
-Type A Ao dissection -Infective endocarditis -Blunt chest trauma -Iatrogenic complications of Ao catheterization
63
Is acute or chronic severe AR harder to diagnose?
Acute, especially with CD (due to its short duration, low AR velocity, eccentric jet + tachycardia)

MIDS 247 (7 decks)

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