Echo assessment of Aortic Regurgitation

Identification, etiology, qualitative and quantitative assessment of severity of AR by Echocardiography

1. Echocardiographic Assessment of AR Dr. Md. Mashiul Alam Phase B resident Chairperson: Assoc. Prof. N. Sheikh

2. Aortic valve anatomy 3 cusp, 3 commisure 3-4 cm sq

3. RCC NCC

4. NoRmaL – clock wise

5. Common Causes of AR Bicuspid aortic valve Rheumatic disease Calcific degeneration Infective endocarditis Idiopathic aortic dilatation Myxomatous degeneration Dissection of the ascending aorta

6. Options TTE TEE 3D echocardiography

7. Echocardiographic Views PLAX PSAX at the level of great vessels Apical views – A4CV, Apical long axis views

8. Aim of echocardiographic evaluation Define the cause of stenosis Quantification of severity Evaluation of co existing valvular lesions Assessment of LV systolic function Detection of response of chronic volume load over cardiac chambers

9. 2 D assessment of AR Leaflets Prolapse Number Vegetation Calcification

10. PSAX view

11. Vegetation

12. Calcification

13. Aortic root Dilation? 18-40 yrs: 0.97+(1.12 BSA) >40yrs: 1.92+(0.74 BSA) Always abnormal If > 5 cm

14. Any dissection? In PLAX, PSAX, Suprasternal view

15. Left ventricular dimension and function In chronic AR LVESD <50-55 mm LVEDD <70-75 mm Eccentric hypertrophy LVEF <50% Acute AR normal dimension and hyperdynamic LV

16. Doppler Assessment of AR (Qualitative) Color doppler jet width Color jet width vs LVOT width in PLAX or PSAX view Overestimated in apical views Mild AR <25% Severe AR ≥65 % Length of AR jet should not be used to assess AR severity

17. Vena contracta width Reflects diameter of regurgitant orifice Avoids erroneous measurement of jet when it expands in LVOT PLAX or PSAX zoomed view Mild AR < 0.3 cm Severe AR> 0.6 cm

18. Three components Of regurgitant jet: PFC VC Broadening in LVOT

19. Pressure half time (PHT) CW doppler in Apical three or five chamber views Mild AR >500 ms Severe AR < 200 ms Density of signal of doppler envelope also a sign of severity

20. Steeper is severe

21. Diastolic flow reversal in aorta PW doppler in suprasternal (descending thoracic aorta) or subcostal (abdominal aorta) view ECG gated echo needed Holodiastolic flow reversal is abnormal. Brief flow reversal may be present normally.

22. Doppler Assessemnt of AR (Quantitative) Not frequently done Often be determined by combination of qualitative methods and 2D assessment Options: PISA (Proximal Isovelocity Surface Area) Regurgitant volume Regurgitant fraction Effective regurgitant orifice area (EROA)

23. PISA It’s the surface area of blood moving back from the aorta towards the closed aortic valve at the given aliasing velocity

24. Zoomed A3CV or A5CV Decreasing the depth Narrow sector PISA = 2 π r2

25. Regurgitant Volume = Volume of blood that regurgitates across the valve per beat V olumes calculated according to continuity e quation RegrugV = SV total – SV forward SV total = Transaortic volume =CSA LVOT x VTI LVOT SV forward = Transmitral volume = CSA mitral annulus x VTI mitral annulus

26. SV total can be measure by LVEDV – LEVSV (Simpsons method) For SV forward or transmitral volume PW doppler at the level of MV; should be used not at mitral tip

27. Regurg . Volume calculated by PISA method Regurg Volume = EROA x VTI AR jet Mild AR < 30ml/ beat Severe AR ≥ 60ml/ beat

28. Regurgitation fraction = Regurg V/ SV total Mild AR < 30 % Severe AR ≥ 50%

29. EROA (Effective regurgitation orifice area) = PISA x aliasing velocity / AR Vmax or = Regurg V / VTI AR jet Mild AR < 0.1 cm sq. Severe ≥ 0.3 cm sq.

30. TEE in AR Complement TTE Better visualization of valve morphology and aortic root dimensions e.g., Endocarditis Aortic dissection

31. Indirect sign of AR Increased EPSS Fluttering of mitral leaflet Reverse doming of the anterior mitral leaflet

32. Associated valvular lesion in AR Aortic stenosis Mitral stenosis or mitral regurgitation MAC