VALVULAR REGURGITATION (copy)

What is regurgitation?

Backward flow of blood because a valve does not close completely.

What is another name for regurgitation?

Insufficiency.

Where does regurgitant blood flow?

Back into the chamber it just came from.

What causes regurgitation?

Valve, leaflet, or cusp problems that prevent complete closure.

What are the 2 types of regurgitation?

Primary and functional.

What is primary regurgitation?

Structural changes to the valve itself.

What can cause primary regurgitation?

Degeneration, infection, or trauma.

What is functional regurgitation?

Regurgitation caused by chamber remodeling.

How can chamber remodeling cause regurgitation?

It stretches the annulus and prevents the leaflets from closing completely.

What does etiology mean?

Cause.

What does coaptation mean?

Valve leaflets come together and touch when closing.

What is usually the first imaging test for regurgitation?

TTE with Doppler.

What does echo assess in regurgitation?

Anatomy, severity, location, surrounding chambers, and cause.

What are the 3 levels of regurgitation severity?

Mild, moderate, severe.

What valve abnormalities should be looked for?

Flail leaflet, vegetation, calcification, annular dilation, tenting, etc.

What are the main Doppler tools for assessing regurgitation?

Color Doppler, spectral Doppler, calculations, flow convergence, vena contract, jet area, and jet length.

Should regurgitation severity be based on only one measurement?

No, multiple parameters should be used.

What is flow convergence?

The small area of flow on the opposite side of the closed valve.

What is flow convergence look like?

A mushroom cap.

Where is flow convergence located in MR?

In the LV.

What is vena contracta?

The narrowest part of the regurgitant jet.

Where is vena contract located?

Immediately downstream from the regurgitant orifice.

What does the vena contracta look like?

A narrow neck.

What is the regurgitant jet area?

The actual jet area in the receiving chambers.

Where is the MR jet area measured?

In the LA.

What is regurgitant jet length?

How far the jet extends into the receiving chamber.

What does a good Doppler signal have?

A complete envelope and appropriate gain.

What happens if Doppler gain is too low?

Some of the signal may be missing.

What happens if Doppler gain is too high?

Regurgitation severity may be overestimated.

What happens if the spectral envelope is too small?

It may be unmeasurable.

What happens if the spectral envelope is too large?

It may be cut off on the screen.

When does MR/TR occur?

Systole.

When does AI/PI occur?

Diastole.

When do abnormal regurgitant flow patterns occur?

When the valve is closed.

What should be included in the echo report?

Height, weight, BP, sinus rhythm, and heart rate.

What valve anatomy should be reported?

Thickening, calcification, annular dilatation, prolapse, flail, tenting, vegetation, etc.

What chamber findings should be assessed?

Chamber size, function, and wall thickness.

What happens to a chamber receiving extra regurgitant volume? (chronic)

It eventually dilates.

Why should color Doppler be swept through the valve?

To avoid missing a regurgitant jet.

Why sweep in multiple directions with Color Doppler?

Echo only shows a 2D slice at a time.

When does aortic regurgitation occur?

Diastole.

What is a simple way to remember AI?

Leaky aortic valve in diastole.

What are the 2 types of AI?

Acute and chronic.

What can cause chronic AI?

Aortic dilation, aortic stenosis, endocarditis, BAV, and hypertension.

What can cause acute AI?

Trauma, dissection, and VSD.

What else can cause AI?

Prosthetic valve dysfunction.

What does chronic AI cause in the LV?

Volume overload and LV dilation.

What can long-standing AI do to LV EF?

Decrease it.

What is the classic AI murmur?

High-pitched diastolic blowing murmur.

What murmur can occur with severe AI?

Austin Flint murmur.

What type of murmur is the Austin Flint murmur?

Mid-diastolic rumble.

How can you remember Austin Flint?

Austin Flint = AI

What are symptoms of AI?

Shortness of breath, CHF, chest pain, and syncope.

How is AI commonly monitored?

Serial echocardiograms.

What does serial echo monitor in AI?

LV dilation and LV function.

When may aortic valve replacement be needed?

If symptomatic or LV size/function changes.

Why does LV dilation occur with AI?

Extra blood returns to the LV during diastole.

What happens to LV preload in AI?

It increases.

What is mitral valve pre-closure associated with?

Elevated LV end-diastolic pressure.

Why does LVEDP increase with AI?

The LV receives normal LA blood plus extra from AI.

What happens to the aortic valve with severe AI?

It may show pre-systolic opening.

Why does pre-systolic aortic valve opening occur?

The mitral valve closes prematurely.

How does LV contractility differ in acute vs chronic AI?

Acute = hyper; chronic = hypo

What aortic root problems can cause severe acute AI?

Dissection or aneurysm.

What can happen to LV size in acute severe AI?

It may remain normal.

What happens to LVEDP in acute severe AI?

It rises rapidly.

What can acute severe AI cause?

Hemodynamic compromise.

What happens with chronic AR?

Progressive LV volume overload and dilation.

What can eventually happen to systolic function in chronic AR?

It can decline.

What M-mode finding can occur with AI?

Diastolic fluttering of the anterior mitral valve leaflet.

What can severe or acute AI cause on M-mode?

Mitral valve pre-closure.

Why does the MV leaflet show decreased excursion with AI?

The regurgitant jet hits the MV and limits opening.

When does normal MV closure occur?

Middle to end of the QRS complex.

What does color M-mode assess in AI?

Jet width compared with LVOT width.

What else does color M-mode assess?

How long the regurgitation lasts during diastole.

What does AI color Doppler show?

Diastolic turbulent flow in the LVOT.

What should you assess with the AI jet?

How far it extends into the LV.

AI jet about 1/4 into LV means what?

Mild.

AI jet about 1/2 into LV means what?

Moderate.

AI jet more than 1/2 into LV suggests what?

Severe.

With moderate/severe AI, what additional finding should you look for?

Diastolic flow reversal.

Where can diastolic flow reversal be assessed?

Descending aorta and abdominal aorta.

What does an incomplete AI spectral trace suggest?

Mild AI.

What Doppler mode is used to obtain the AI end-diastolic gradient?

CW Doppler.

What can the AI end-diastolic gradient help estimate?

LVEDP.

What is the LVEDP formula?

Diastolic BP - end-diastolic gradient.

What is mild AI PHT?

>500 ms.

What is moderate AI PHT?

500-200 ms.

What is severe AI PHT?

What does a shorter AI PHT mean?

More severe AI.

What does a steeper AI slope mean?

Faster pressure equalization and more severe AI.

What was the mild AI example PHT?

541 ms.

What was the moderate AI example PHT?

351 ms.

What was the severe AI example PHT?

135 ms.

Can PHT be used alone to grade AR severity?

No.

Why should PHT not be used alone?

It is affected by hemodynamics.

What is another name for aortic diastolic flow reversal?

Retrograde flow.

How is descending aortic flow reversal obtained?

PW Doppler from the suprasternal notch.

How is abdominal aortic flow reversal obtained?

PW Doppler from the subcostal view.

When does pulmonic regurgitation occur?

Diastole.