aortic regurgitation 2d and doppler assessment
DESCRIPTION
Aortic Regurgitation 2D and Doppler Assessment. Dr.Sohail Abrar Khan MBBS,FCPS (Med), FCPS (Card) Diplomate of American certification Board of Echo Assistant Professor and Consultant Cardiologist Aga Khan University Hospital Karachi. Introduction. - PowerPoint PPT PresentationTRANSCRIPT
Aortic Regurgitation
2D and Doppler Assessment
Dr.Sohail Abrar KhanMBBS,FCPS (Med), FCPS (Card)
Diplomate of American certification Board of EchoAssistant Professor and Consultant Cardiologist
Aga Khan University Hospital Karachi
Introduction
Aortic regurgitation is a common and serious health problem
Echo is the most valuable tool in the diagnosis and management of AR
Echo evaluation of AR requires a comprehensive evaluation by an experienced person
Visual and qualitative assessment may be unreliable and misleading
Introduction cont…
Patients are often asymptomatic until AR becomes significant
AR murmur usually not heard until AR severity > mild
Detection of AR may be the first clue that aortic root or aortic valve disease is present
Role of Echo in Assessment AR
2D and Doppler echocardiography is indispensable in the diagnosis and management of patients with AR
This should be used to assess the severity of AR, the LV response to volume overload (systolic function, ejection fraction [EF] and end-systolic and diastolic dimensions).
Echocardiography may also identify the anatomic cause of AR, which is important for determining the surgical approach
Assessment of Regurgitation
ERO/RV
2D Echo CFI
PW Doppler
ERO/R VolHemodynamics
CW Doppler
AR
Hemodynamics of AR
Chronic AR Progressive ↑ AR Heart has time to
compensate ↑ LV volume ↑ dilatation ↑ Stroke Volume
Acute AR Rapid onset of AR Insufficient time for
heart to compensate Leads to ↑ LVEDP Pulmonary edema Decreased effective
forward Stroke vol
Hemodynamics of AR cont…
Adapted From: Lilly L. Pathophysiology of Heart Disease
Chronic ARAcute AR
Aortic Regurgitation
2D Echo Assess valvular function Identification of functional anatomy Assess LV size and function Evidence of increased LVEDP
2D Echo cont…
Assessment of LV Serial reproducible findings LV chamber enlargement LV function assessment Predictors of preserved LV
function after AVRLVESD < 55 mmLV EF > 50%
0
20
40
60
80
100
0 2 4 6 8 10
Years
Sur
viva
l (%
)
LVS/BSA <25
81±5%
89±3%
Conservative Rx for Severe AR Survival vs Indexed LV Systolic Diameter
CP993609-9Dujardin KS: Circ,99
34±10%
50±9%LVS/BSA 25
Aortic Regurgitation2-D and M-Mode
Clues of ARDiastolic fluttering of anterior MV leafletReverse “doming” of anterior MV leafletDiastolic flutter of aortic valve
Evidence for increased LVEDPPresystolic (premature) closure of MVPresystolic (premature) opening of AV
Aortic Regurgitation Functional Anatomy
Valvular Congenital (bicuspid) Degenerative Rheumatic Endocarditis Cusp rupture
Functional Anatomy cont…
Aortic Root Chronic Dilatation Marfan syndrome Senile/hypertensive Chronic aortitis Idiopathic
Annuloaortic ectasia Sinus of valsalva
aneurysm
Acute Disruption Dissection Chest trauma Endocarditis Post-procedure
Aortic RegurgitationColor Flow Imaging
Jet area LVOT area
Jet width LVOT width
Jet area LVOT area
Jet width LVOT width
CP993609-12
Color Flow Imaging cont…Jet Width/LVOT Width
Perry et al. JACC 1987
Color Flow Imaging cont…Jet area/LVOT area
AR jet area and LVOT area from parasternal short axis view
Correlates best with angiographic severity of AR
Assess AR at the level of the aortic annulus, just below the AV
Oh, Seward,Tajik: The Echo Manual
Color Flow Imaging cont…Jet area/LVOT area
Grade I < 5%Grade II 5 - 24%Grade III 25 - 59%Grade IV > 60%
Vena Contracta Measure from PLAX (zoom) Use standard color scale
No baseline shift Measure width of AR jet at the narrowest point
Measure just below flow convergence Vena contracta < 6 mm = severe AR Vena contracta < 3 mm = mild AR
Tribouilloy et al: Circulation, 2000
5 mm 6 mm 7 mm
VC Width
Vena Contracta cont…
Sn Sp Sn Sp Sn Sp
ERO≥0.3 cm2 100 73 95 90 84 95
RegVol≥60 ml 96 81 81 94 65 96
Vena Contracta
Optimize the flow convergence zone
Vena Contracta
Vena contracta is usually smaller than LVOT jet height
Measure width of AR at narrowest point of emitting jet
Aortic Regurgitation CW Doppler Assessment
Density of CW signal reflects Reg Vol
Pressure half-timeMild AR > 400 msecSevere AR < 250 msec
Oh,Seward, Tajik: The Echo Manual
Align Doppler parallel to flow
Move lateral or try a lower rib space
CW Doppler Assessment cont…
Mild AR > 400 msecOtto and Pearlman: Textbook of Clinical Echocardiography
Pressure Half Time PHT
CW Doppler Assessment cont…
Severe AR < 250 msecOtto and Pearlman: Textbook of Clinical Echocardiography
Pressure Half Time PHT
CW Doppler Assessment cont…
AR PHT may be shortened due to other causes of elevated LVEDP i.e LV systolic and diastolic dysfunction and Mitral Regurgitation
It can be increased due to Mitral Stenosis
Aortic Regurgitation PW Doppler Assessment
LV stroke volume
Mitral inflow
Descending thoracic aorta
Abdominal aorta
PW Doppler cont…
Mitral Inflow High LA Pressure & LVEDPRestrictive mitral inflow Mitral pattern dependent
on compliance of ventricle
Oh,Seward, Tajik: The Echo Manual
PW Doppler cont…
Pre-op
Post-op
Premature Cessation of Mitral Flow in Acute Severe AR
CP993609-21
PW Doppler cont…
PW Doppler cont…
Descending AortaDiastolic flow reversal
Retrograde flow TVI
Severe AR TVI > 14 cm
PW Doppler cont…
Abdominal Aorta Place PW sample volume in
abdominal aorta Diastolic flow reversal
consistent with significant aortic regurgitation
Otto and Pearlman: Textbook of Clinical Echocardiography
Indications for Quantitative Doppler When regurgitation appears moderate or
more by CFI/qualitative assessment Serial assessment
Assess LV size & functionAssess regurgitation
Assist clinician/surgeonClinical managementTiming of surgery
Quantitative Doppler Methods
Continuity Equation
PISA Method
CSA TVI
Continuity Equation
Stroke volume Valve area Shunt lesions Regurgitant volume Regurgitant fraction
Continuity Equation cont…
What goes in (the ventricle)
must go out!!
Regurgitant Volume
Volume of blood that regurgitates through an incompetent valve with each heart beat
CP944143- 6
Continuity Equation Calculation
Stroke volumeStroke volumeStroke volumeStroke volume AreaAreaAreaArea TVITVITVITVI
AA TVI= X
Continuity Method cont…
“What goes in must go out” Measurements required
LVOT diameter & TVIMV annulus diameter & TVI
Limitation of continuity method Unable to use with multiple regurgitant lesions > mild
and shunt lesions
Continuity Method cont…
Calculate SVLVOT
Measure LVOT diameter Obtain PW Doppler signal in LVOT
Trace LVOT TVI
SVLVOT = CSALVOT x TVILVOT
Continuity Method cont…
Calculate SVMV
Measure diameter of mitral annulus Obtain PW Doppler signal at level of
mitral annulus Trace MV annulus TVI
SVMV = CSAMV x TVIMV
SVMV = CSAMV x TVIMV
SVLVOT = CSALVOT x TVILVOT
RVAR = SVLVOT - SVMV
Regurgitant Volume and Fraction
RFAR = RVAR/SVLVOT
Pitfalls of Continuity Method Learning curve of the operator Incorrect placement of sample volume Incorrect annulus measurement Requires 4 separate measurements
Introduces 4 possible errors Diameters are squared in the equation so any small error
will be magnified and spoil the result Invalid with multivalvular regurgitation or intracardiac
shunts
PISA
Proximal
Isovelocity
Surface
Area
Advantages of PISA Method
Can be used in the presence of other valvular regurgitation or shunts
Can be used in the presence of valve stenosis or prosthetic valves
Uses fewer variables (2 measurements)
PISA Method
Shift color baseline in the direction of flow
Alias velocity varies (range of 20-40 cm)
Note alias velocity
Adapted from Oh, et. al.
AR Peak Velocity and VTI
Using CW Doppler, obtain optimal regurgitant jet
Use alternate windows to be parallel to flow
Measure peak regurgitant velocity
Trace regurgitant TVI
PISA Calculations
Flow (cc/sec) = 6.28 x [r (cm)]2 x Va (cm/sec)
ERO (cm2) = Flow (cc/sec) V (cm/sec)
RV (cc) = ERO (cm2) x TVI (cm)
Effective Regurgitant Orifice
Size of orifice through which regurgitation passes Also referred to as ROA (regurgitant orifice area)
Pitfalls of PISA Method Learning curve of operator Assumption of hemispherical
flow convergence area Inability to accurately measure
radius Inability to obtain complete MR
jet by CW Doppler
Severity of ARMild Severe
Jet/LVOT area <2 5% > 60%
Jet/LVOT Width < 25% > 60%
Vena Contracta < 3 mm > 6 mmCW Doppler faint denseAR PHT > 400 msec < 250 msecDescending Aorta early holodiastolic
diastolicReversal TVI > 14 cm
Summary
Aortic regurgitation is a common and serious health problem Echo is the most valuable tool in the diagnosis and
management of AR Echo evaluation of AR is complex and often suboptimal Visual and qualitative assessment is is often misleading It is now very reliable by the use of quantitative methods An organized and comprehensive approach by using all the
available qualitative and quantitative methods is required for proper assessment of AR
Thank You