Echo ConferenceEcho ConferenceAortic Aortic

RegurgitationRegurgitationSeptember, 2007September, 2007

Christopher Dibble, M.D.Christopher Dibble, M.D.

Aortic Regurgitation:Aortic Regurgitation:SymptomsSymptoms

Dyspnea, orthopnea, PNDDyspnea, orthopnea, PND Chest pain.Chest pain.

Nocturnal angina >> exertional angina Nocturnal angina >> exertional angina (( diastolic aortic pressure and increased diastolic aortic pressure and increased

LVEDP thus LVEDP thus coronary artery diastolic flow) coronary artery diastolic flow) With extreme reductions in diastolic With extreme reductions in diastolic

pressures (e.g. < 40) may see anginapressures (e.g. < 40) may see angina

Peripheral Signs of Peripheral Signs of Severe Severe

Aortic RegurgitationAortic Regurgitation Quincke’s sign: Quincke’s sign:

capillary pulsationcapillary pulsation Corrigan’s sign: water Corrigan’s sign: water

hammer pulsehammer pulse Bisferiens pulse Bisferiens pulse

(AS/AR > AR) (AS/AR > AR) De Musset’s sign: De Musset’s sign:

systolic head bobbing systolic head bobbing Mueller’s sign: Mueller’s sign:

systolic pulsation of systolic pulsation of uvulauvula

Durosier’s sign: Durosier’s sign: femoral retrograde femoral retrograde bruitsbruits

Traube’s sign: pistol Traube’s sign: pistol shot femoralsshot femorals

Hill’s sign:BP Lower Hill’s sign:BP Lower extremity >BP Upper extremity >BP Upper extremity by extremity by > 20 mm Hg - mild AR> 20 mm Hg - mild AR > 40 mm Hg – mod AR> 40 mm Hg – mod AR > 60 mm Hg – severe > 60 mm Hg – severe

ARAR

Wave Sound

Aortic RegurgitationAortic Regurgitation

Can be a caused by:Can be a caused by: Valve DiseaseValve Disease Aortic root diseaseAortic root disease

Percentage of aortic root disease steadily Percentage of aortic root disease steadily increasing over past few decadesincreasing over past few decades

Root disease now accounts for >50% of all Root disease now accounts for >50% of all AVRsAVRs

AR – Valvular diseaseAR – Valvular disease

Rheumatic diseaseRheumatic disease Cusps become fibrotic and retractCusps become fibrotic and retract Usually also stenoticUsually also stenotic MV is involvedMV is involved

Calcific ASCalcific AS At least mild AR in 75% of patientsAt least mild AR in 75% of patients

AR – Valvular disease IIAR – Valvular disease II

Infective endocarditisInfective endocarditis Leaflet perforationLeaflet perforation Vegetation interferes with coaptationVegetation interferes with coaptation

TraumaTrauma Bicuspid ValveBicuspid Valve

Can isolated regurgitation or stenosis, or Can isolated regurgitation or stenosis, or bothboth

Complication of catheter based Complication of catheter based ablationablation

AR – Valvular disease IIIAR – Valvular disease III Myxomatous degenerationMyxomatous degeneration Structural deterioration of bioprosthesisStructural deterioration of bioprosthesis Less common causes:Less common causes:

SLE, RASLE, RA Ankylosing spondylitisAnkylosing spondylitis Jaccoud arthropathyJaccoud arthropathy Takayasu diseaseTakayasu disease Whipple’s diseaseWhipple’s disease Anorectic drugsAnorectic drugs Congential (rare, usually associated with Congential (rare, usually associated with

bicuspid valve)bicuspid valve) Membranous subaortic stenosisMembranous subaortic stenosis

Aortic root diseaseAortic root disease

Between aorta Between aorta proper and the proper and the annulus is a tube annulus is a tube composed of composed of collagen that forms collagen that forms sinuses of valsalvasinuses of valsalva

Dilation here is rare

Dilation here is common; especially in AS; does not lead to AR

As little as 2mm of

dilation here can cause AR

Dilation of the Dilation of the aortic ridge aortic ridge eliminates the eliminates the normal overlap of normal overlap of the valvesthe valves

Aortic root diseaseAortic root disease

AR – Aortic Root DiseaseAR – Aortic Root Disease

Age related (degenerative)Age related (degenerative) Systemic HypertensionSystemic Hypertension Aortic dissectionAortic dissection Cystic medial necrosis Cystic medial necrosis

either isolated or associated with either isolated or associated with Marphan syndromeMarphan syndrome

Bicuspid valveBicuspid valve

AR – Aortic Root Disease AR – Aortic Root Disease IIII

Syphilitic aortitisSyphilitic aortitis Osteogenesis imperfectaOsteogenesis imperfecta Ankylosing spondylitisAnkylosing spondylitis Relapsing polychondritisRelapsing polychondritis Ehlers-DanlosEhlers-Danlos Inflammatory bowel diseaseInflammatory bowel disease

AR – M-ModeAR – M-Mode

As the aortic jet cascades across the As the aortic jet cascades across the anterior MV leaflet it can create a anterior MV leaflet it can create a high frequency flutteringhigh frequency fluttering

In acute AR premature closure of the In acute AR premature closure of the MV can be seenMV can be seen Due to rapidly increasing LV pressureDue to rapidly increasing LV pressure

AR - M-modeAR - M-mode

•Fluttering of Anterior Mitral Valve leaflet•Increased duration between E and A peaks•Early example of using M-mode to indirectly assess valve disease

AR – 2D imagingAR – 2D imaging

Detailed evaluation of valve and rootDetailed evaluation of valve and root Detailed evaluation of LV size and Detailed evaluation of LV size and

functionfunction Many important causes of AR easily Many important causes of AR easily

seen on 2D evaluationseen on 2D evaluation Even when AR is severe, sometimes Even when AR is severe, sometimes

2D imaging is suprisingly normal2D imaging is suprisingly normal

AR – 2D ImagingAR – 2D Imaging

AR – Doppler EvaluationAR – Doppler Evaluation

Pulsed, continuous wave, and color Pulsed, continuous wave, and color flow Doppler are highly sensitive for flow Doppler are highly sensitive for detection of regurgitation and are detection of regurgitation and are complementary studies complementary studies

Use of Doppler to Detect Use of Doppler to Detect Regurgitant JetsRegurgitant Jets

Most Most regurgitant regurgitant jets >1.5 jets >1.5 m/secm/sec

CW lacks CW lacks spatial spatial resolutionresolution

PW needed to PW needed to map location map location and direction and direction of jetof jet

Mitral Inflow

Helpful for flow profile; gradient

Identifies turbulence in an area; color flow

derived from PW data

AR – Pulsed DopplerAR – Pulsed Doppler

Early to assess severity of AR used Early to assess severity of AR used pulsed Doppler to “map” ARpulsed Doppler to “map” AR sample volume withdrawn towards apex sample volume withdrawn towards apex

to find length of regurgitant jetto find length of regurgitant jet Relies on turbulence during diastole on Relies on turbulence during diastole on

LV outflow side of AVLV outflow side of AV This assumes jet is centrally located This assumes jet is centrally located

and can be tracked towards apexand can be tracked towards apex Another possible source of error:Another possible source of error:

AR MS

•Presence of mitral stenosis or mechanical mitral valve

AR – Color FlowAR – Color Flow

Most common techniqueMost common technique Sensitivity >95%Sensitivity >95%

False positive negatives; occur in False positive negatives; occur in tachycardia with mild ARtachycardia with mild AR Frame rate allows only a few diastolic Frame rate allows only a few diastolic

frames to be displayedframes to be displayed Can be overcome by using CW which has Can be overcome by using CW which has

higher sampling ratehigher sampling rate

Specificity ~100%Specificity ~100%

AR – Color flow DopplerAR – Color flow Doppler

Detects even trivial ARDetects even trivial AR 1% of subjects under 40 y.o.1% of subjects under 40 y.o. 10-20% of patients greater than 60 y.o10-20% of patients greater than 60 y.o

Echo assessment: Vena Echo assessment: Vena ContractaContracta

Measurement of Measurement of the most narrow the most narrow portion of jet portion of jet behind the valve.behind the valve. Mild: <3.0mmMild: <3.0mm Moderate: 3.0-Moderate: 3.0-

5.9mm5.9mm Severe: Severe:

>=6.0mm>=6.0mm

Enriquez-Sarano et al. Aortic Regurgitation. NEJM; 351:1539-46.

Echo assessment: Jet / Echo assessment: Jet / LVOT heightLVOT height

Jet height to LVOT height Jet height to LVOT height ratioratio Mild: 1-24%Mild: 1-24% Moderate: 25-46%Moderate: 25-46% Moderate-severe: 47-Moderate-severe: 47-

64%64% Severe: >=65%Severe: >=65%

Limitations:Limitations: Lateral resolution of Lateral resolution of

color Dopplercolor Doppler Sensitive to angulation of Sensitive to angulation of

ultrasound transducerultrasound transducer

Ekery, DL et al. Aortic Regurgitation: Quantitative Methods by Echocardiography. Echocardiography: 2000. 17; 294-302

AR – Continuous wave AR – Continuous wave dopplerdoppler

Because AR jet is high velocity, CW Because AR jet is high velocity, CW Doppler necessary to record Doppler necessary to record envelope of jet.envelope of jet. The density of the jet compared with The density of the jet compared with

antegrade aortic flow is a (very simple) antegrade aortic flow is a (very simple) qualitative indication of the volume of qualitative indication of the volume of regurgitationregurgitation

Density is function of number of blood cells sampled Density is function of number of blood cells sampled and will generally increase with the regurgitant volumeand will generally increase with the regurgitant volume

Antegrade

AR

AR – Continuous wave AR – Continuous wave dopplerdoppler

AR – CW DopplerAR – CW Doppler

Aortic regurgitant fraction can be Aortic regurgitant fraction can be estimated by ratio of reversed flow VTI / estimated by ratio of reversed flow VTI / forward flow VTI in the distal aortic arch.forward flow VTI in the distal aortic arch.Ekery, DL et al. Aortic Regurgitation: Quantitative Methods by Echocardiography.

Echocardiography:2000. 17; 294-302

Antegrade

Retrograde

AR – Continuous wave AR – Continuous wave dopplerdoppler

Absolute gradient Absolute gradient does not closely does not closely reflect amount of ARreflect amount of AR

Severity of AR can be Severity of AR can be described by the described by the slope or the pressure slope or the pressure half timehalf time

Pressure half time of Pressure half time of less than 250 msec is less than 250 msec is an indicator of an indicator of severe ARsevere AR

AR - pressure half-timeAR - pressure half-time

Limitations:Limitations: Pressure half-time sensitive to chronicity of Pressure half-time sensitive to chronicity of

ARAR acute AR leads to much shorter values than acute AR leads to much shorter values than

chronic AR when ventricle is dilated with chronic AR when ventricle is dilated with increased compliance and can accommodate increased compliance and can accommodate large regurgitant volumes.large regurgitant volumes.

Pressure half-time varies with systemic Pressure half-time varies with systemic vascular resistancevascular resistance vasodilators may shorten the pressure half-time vasodilators may shorten the pressure half-time

even as the aortic regurgitant fraction improveseven as the aortic regurgitant fraction improves..

AR- Regurtitant volumeAR- Regurtitant volume

AR - Regurgitant Volume or AR - Regurgitant Volume or FractionFraction

Compare flow through aortic valve Compare flow through aortic valve versus mitral or pulmonary valve.versus mitral or pulmonary valve.

Regurgitant volume (fraction):Regurgitant volume (fraction): Mild: <30cc (<30%)Mild: <30cc (<30%) Mild to moderate: 30-44cc (30-39%)Mild to moderate: 30-44cc (30-39%) Moderately severe: 45-59cc (40-49)Moderately severe: 45-59cc (40-49) Severe: >=60cc (>=50%)Severe: >=60cc (>=50%)

Limitations:Limitations: Assumes normal flow through Assumes normal flow through

comparison valve.comparison valve. Cannot be used in presence of shunts.Cannot be used in presence of shunts. Sensitive to small measurement errors.Sensitive to small measurement errors.

AR - Regurgitant Volume AR - Regurgitant Volume or Fractionor Fraction

AR - Proximal isovelocity AR - Proximal isovelocity surface areasurface area

The PISA method can estimate The PISA method can estimate regurgitant flow rate, and regurgitant flow rate, and subsequently regurgitant orifice subsequently regurgitant orifice area).area).

AR - Proximal isovelocity AR - Proximal isovelocity surface areasurface area

Limitations of PISALimitations of PISA Isovelocity contour flattens as it Isovelocity contour flattens as it

approaches the orifice, underestimating approaches the orifice, underestimating flow.flow.

Proximal structures can distort the Proximal structures can distort the isovelocity contour.isovelocity contour.

Sensitive to errors in radius Sensitive to errors in radius measurementmeasurement 10% error in radius leads to 21% error in 10% error in radius leads to 21% error in

flowflow

SummarySummary

Severe AR - Surgical Severe AR - Surgical IndicationsIndications

Symptomatic patients (dyspnea or Symptomatic patients (dyspnea or angina)angina) Normal, mildly depressed or moderately Normal, mildly depressed or moderately

depressed LVdepressed LV Surgery.Surgery.

Severely depressed or dilated LV Severely depressed or dilated LV (EF<25% or LVESD>60mm)(EF<25% or LVESD>60mm) High surgical risk (~10% operative High surgical risk (~10% operative

mortality) but also poor outcomes with mortality) but also poor outcomes with medical therapy.medical therapy.

Asymptomatic Severe AR Asymptomatic Severe AR - Surgical Indications- Surgical Indications

Preserved LVPreserved LV Observe with serial echocardiograms.Observe with serial echocardiograms.

Abnormal LVAbnormal LV ““Rule of 55”: Surgery if:Rule of 55”: Surgery if:

LVEF <55% (ACC/AHA guidelines <50%)LVEF <55% (ACC/AHA guidelines <50%) LVESD > 55mm (or > 25 mm/m2).LVESD > 55mm (or > 25 mm/m2).

Also surgery if LVEDD >70-75 mmAlso surgery if LVEDD >70-75 mm Uncertainty on which combination of Uncertainty on which combination of

criteria most useful.criteria most useful.

AR – Surgical IndicationsAR – Surgical Indications