aortic regurgitation and stenosis

predominate AS

80% have coexisting AR (dilated AoV Annulus, Bicuspid/Congenitally Malformed AoV or Endocarditis)

Congenital Leaflet Abnormalities causing AR

AoV is Unicuspid, Bicuspid, Quadracuspid or has a VSD

Acquired Leaflet Abnormalities causing AR

Senile Calcification, Infective Endocarditis, Rheumatic D or Radiation/toxin Induced Valvulopathy

Congenital/Genetic Aortic Root Abnormalities causing AR

Annuloaortic ectasia (enlarged/dilated ascending Ao) or Connective Tissue D

Acquired Aortic Root Abnormalities causing AR

idiopathic aortic root dilation, Aortic Dissection, systemic HTN, Autoimmune D or Aortitis (Syphilitic or Takayasus)

type 1 AR

NORMAL CUSP MOTION with cusp perforation or aortic dilation (STJ enlargement/dilation or SoVA dilation)

dec coronary flow causes

venturi effect (inc velocity but dec P) and inc intramyocardial P

AR causes

dec aortic elasticity/compliance, inc stroke work/wall stress (also from inc LV vol) and inc LV stiffness (LVH)

inc stroke work/wall stress causes

fibrosis

Severe AR PHT

PHT <200 is severe AR

what to look for in AR

Inc Transaortic Flow Velocity, AR Deceleration Slope Signal (PHT) and flow reversal in the Abdominal aorta/Descending thoracic aorta

severe AR jet width

jet width >65% of the LVOT is severe AR

jet width/lvot diameter limitations

underestimates AR eccentric jets but overestimates AR central/transient jets and is affected by LVOT size

severe AR vena contracta width

VC >0.6 is severe AR

jet area/lvot area pitfalls

direction/shape of the jet can over/under estimate the jet area

VC pitfalls

doesnt work with multiple jets or a bicuspid AoV

a to a

vena contracta

dilated ascending aorta

red arrows

jet height

white arrows

flow convergence (FC)

pisa also refers to

flow convergence

normal/Antegrade flow

AR flow

Abdominal Flow Reversal

descending Thoracic flow Reversal

Abdominal Flow Reversal

Descending Thoracic Flow Reversal

observe if

LVESDI <20 and LVEF >60%

opperate if

LVESDI >25 and LVEF <55%

mild AR characteristics

normal LV size with small/no flow convergence

Moderate Grade 2 AR

Rvol 30-44, RF 30-39% and EROA 0.1-0.19

Moderate Grade 3 AR

Rvol 45-59, RF 40-49% and EROA 0.2-0.29. if all 3 then severe AR

specific criteria for mild AR

VC width <0.3, central jet width <25% of the LVOT, PHT >500, RVOL <30, RF <30% and EROA <0.1

specific criteria for severe AR

VC width >0.6, central jet width >65% of the LVOT, PHT <200, RVOL >60, RF >50% and EROA >0.3

Severe AR characteristics

flail valve, large flow convergence and an enlarged LV with normal function

Pulse Pressure

difference between systolic and diastolic P

Pulse Pressure AR

wide pulse P in AR and a Bounding/bifid arterial pulse

Pulse Pressure AS

narrow pulse P in AS

Bicuspid Aortic Valve

(PSAX systole) appears football shaped and is domed/tethered. eccentric closure on M Mode

Bicuspid Aortic Valve might have coexisting

aortic coarctation, stenotic dilation or LVH

for AoV peak velocity

use CW pedof

views for peak AoV velocity

AP, subcostal, ssn, RCL and RPS

AVA

depends on LVOT^2 so a large LVOT measurement can underestimate AS

Peak Pressure Gradient

Peak PG is the same as the Peak Instantaneous Gradient

Mean Pressure Gradient correlates with

Mean PG correlates with Cath Peak to Peak Gradient

VTI

Velocity Time Integral

VTI is good for

patients with poor LV function or who have moderate to severe AI

in VTI

trace the waveform

Dimensionless Index (DI)

ratio of LVOT and AS velocities or VTI

use DI for when

LVOT diameter cant be accurately measured or if LV dysfunction is present

Aortic Stenosis in the Cath Lab

peak instantaneous P is obtained with Doppler and echo gradients are usually higher than cath gradients

AR murmur

Diastolic blowing murmur thats high pitched at the
left sternal border (LSB)

AR symptoms

CHF, DOE, angina and syncope

Severe acute AR

causes premature MV closure FROM ELEVATED LVEDP

AR can cause

PRE SYSTOLIC OPENING of the aortic leaflets and HYPERDYNAMIC (for acute) or HYPODYNAMIC (for chronic) LV contractility

TEE

TEE is best for diagnosing aortic dissection

AR can also cause

LV dilation

Ao P ½ Time

time it takes for the initial AoV PG (during diastole) to dec by half

PHT grading

steeper waveform = more severe