AORTIC REGURGITATION QUALITATIVE ASSESSMENT Unit 1

what is Aortic Regurgitation

Aortic Regurgitation is the backflow of blood

from the aorta into the left ventricle during

diastole

what can regurgitation result from

Regurgitation can result from disorders of

the aortic valve or aortic root or both

Aortic valve and root abnormalities results

in what?

Aortic valve and root abnormalities results

in malcoaptation

what are the congenital leaflet abnormalities of AR (5)

Bicuspid

• Unicuspid

• Quadricuspid

• Aortic Valve Prolapse

• Ventricular Septal Defects with prolapse

What are the AV leaflet abnormalities (5)

Senile calcification

• Infective Endocarditis

• Rheumatic disease

• Toxin induced Valvulopathy: Anorectic drugs,

Carcinoid

• Aortic leaflet perforation

CONGENITAL/GENETIC AORTIC ROOT what disorder and give example

Annuloaortic ectasia from connective

tissue disorders

• Connective tissue disorders: Loeys Deitz,

Ehlers-Danlos, Marfan Syndrome, osteogenesis

imperfecta

ACQUIRED AORTIC ROOT what are the different types of disease

Idiopathic aortic root dilatation

• Systemic hypertension

• Autoimmune disease: systemic lupus,

ankylosing spondylitis, Reiter’s syndrome

Aortitis syphilitic, Takayasu’s arteritis

• Aortic dissection

• Trauma

AR types 1,2,3 classification

what are the congenital leaflet abnormalities

quadricuspid,

aortic valve prolapse, and VSDs

what is A quadricuspid aortic valve (QAV)

A quadricuspid aortic valve (QAV) is a rare congenital

heart defect where the aortic valve has four cusps

instead of three

how does a A quadricuspid aortic valve (QAV) how does it result from

It's a result of an error during the development of

the aortic valve during pregnancy

Regurgitation is caused by?

Regurgitation is caused by the inadequate

closing of the four cusps at the end of systole

There are 7 variations that may occur... what are they

Aortic Valve Prolapse define

Aortic valve prolapse is a condition where the aortic valve's cusps move down

below the line that connects the valve leaflets to the annulus Highly associated with eccentric AR

what is Aortic Valve Flail

Diastolic fluttering of the aortic cusp echoes,

abnormal systolic aortic leaflet movement, and

abnormal diastolic fluttering echoes in the left

ventricular outflow tract

VSD with Aortic Prolapse

Define in systole

In early systole (left), blood ejected from the

left ventricle will be shunted through the

ventricular septal defect

The unsupported right coronary cusp and

right aortic sinus are driven into the right

ventricle. This limits left to right shunting of

VSD flow

This is known as the Venturi effect

VSD with Aortic Prolapse

in diastole

In diastole (right), the intra-aortic pressure

forces the aortic valve leaflet to close, but

the unsupported right coronary cusp is

pushed down into the left ventricular

outflow tract away from the opposed

coronary cusp, resulting in regurgitation

This is best evaluated in PLAX

whats the most frequent concomitant valve disease

Mixed aortic stenosis (AS) and aortic regurgitation (AR) is

the most frequent concomitant valve disease

Aortic Regurgitation with

Aortic Stenosis This valve disease ranges from

This valve disease ranges from mild AS with severe AR to

mild AR with severe AS

Patients with moderate mixed AS/AR have outcomes

Patients with moderate mixed AS/AR have outcomes

similar to those with isolated severe AS

Aortic Regurgitation with Aortic Stenosis

Coexistent with what overload

Patients with severe mixed AS/AR have what affects to there heart

Coexistent pressure and volume overload

Patients with severe mixed AS/AR have

smaller LV dimensions and volumes then a

severe aortic regurgitation patient

Rheumatic aortic valve disease

is a condition that occurs when

the aortic valve of the heart is?

Rheumatic heart disease is the most common heart disease in people what age

its especially common in what sex and which countries

Rheumatic aortic valve disease

is a condition that occurs when

the aortic valve of the heart is

permanently damaged by

rheumatic fever

Rheumatic heart disease is the

most common heart disease in

people under 25

It's especially common in women

from low- and middle-income

countries

Rheumatic AV includes what’s on the commissures of the cusps? you may see what during opening in PLAX? what is Rheumatic AV disease associated with?

Rheumatic AV includes symmetric

fibrosis, retraction and partial fusion of

the commissures of the cusps

May see doming during opening in PLAX

Associated aortic regurgitation, aortic

stenosis, and rheumatic mitral valve

disease

Valve Endocarditis- what kind of condition is this, what does it do to the blood stream, without quick treatment what can endocarditis do, what are the treatment options,

Endocarditis is a life-threatening condition that occurs

when the endocardium becomes inflamed

Bacterial germs get into the bloodstream and attach to

damaged areas in the heart

Without quick treatment, endocarditis can damage or

destroy the heart valves

Treatments for endocarditis include medications and

surgery

Aortic Leaflet can Perforation from?

Aortic leaflets can

perforate from blunt

force trauma or from

mitral valve repairs

what is Annuloaortic ectasia is a

condition that causes, what is it highly associated with ?what syndrome

Annuloaortic ectasia is a

condition that causes the

ascending aorta and aortic

annulus to widen, or dilate

Highly associated with

connective tissue disorders

like Marfan’s Syndrome

Your connective tissue supports many different

parts of your body, such as, if you have a connective tissue disease these connecting structures are affected how

Your connective tissue supports many different

parts of your body, such as your skin, eyes, and

heart

It is like a "cellular glue" that gives your body

parts their shape and helps keep them strong

When you have a connective tissue disease, these

connecting structures are negatively affected

Connective Tissue Disorders, They fall into three main categories: what are they

Autoimmune diseases

Genetic disorders

cancers (sarcomas)

Marfan syndrome is caused by?

Most people with this syndrome get it how?

Marfan syndrome is caused by a defect in

the gene that enables your body to produce

a protein that helps give connective tissue

its elasticity and strength

Most people with Marfan syndrome inherit

the abnormal gene from a parent who has

the disorder

Marfan syndrome affects which groups of people

Marfan syndrome affects men

and women equally and

occurs among all races and

ethnic groups

what is the most specific MFS

finding, whats the shape and what should be measured

Aortic root dilatation is the most specific MFS

finding

“Onion shape” AORTIC ROOT

The aortic sinus, the sinotubular junction, aortic

annulus, and ascending aorta should be measured

In Marfans syndrome what is frequenctly observed in MFS PT and what may progress and the regurgitation flow is often what

Mitral valve involvement is frequently observed in

MFS patients

MVP may progress to MV Flail

The regurgitation flow is often extremely eccentric

as well

Acquired Root Dilatation may occur in

______parts of the aorta?

Idiopathic describes

Acquired Root Dilatation may occur in different parts of the aorta.

Idiopathic describes a disease of unknown cause

What is systemic Hypertension is what condition that occurs when what? the aorta will experience what

Systemic hypertension is a

chronic condition that occurs

when blood pressure in the

arteries is too high. Aka high

blood pressure or hypertension

The aorta will experience

effacement of the ST junction

and dilatation of the ascending

aorta

what is Autoimmune Diseases and what can it cause

An autoimmune disease occurs when the body's

immune system mistakenly attacks its own

healthy cells, tissues, and organs

It can cause inflammation of the aorta which may

cause complications like aneurysms and

dissections

Aortic Dilatation

from Trauma

also…Aortic Dissection

And last but definitely not

least...Aortic dissection

Always look for the presence and

severity of aortic regurgitation

AORTIC

Regurgitation

CHRONIC what happens to the LV volume and what else

For chronic AR the LV is being filled by ___ sources which are?

The left ventricle is being

filled by 2 sources...the

left atrium and the aortic

regurgitation

for chronic AR what happens to the SV, CO, and function

For chronic AR increase LVEDP leads to?

Pressure Changes for chronic AR, changes in what

Changes in the aortic

pressure, LVP and LAP

can be observed with

aortic regurgitation

what are the Clinical

Presentation for chronic AR

Asymptomatic

It’s a slow progressive disease that

leads to dyspnea and decrease

exercise capacity

Most cases are trace to mild

With severe aortic regurgitation...

what are the chronic AORTIC Regurgitation Patient Symptoms (5)

Fatigue

Syncope (uncommon)

Shortness of Breath

Palpitations

Chest pain

AORTIC Regurgitation Physical Examination

Wide pulse Pressure

• Bounding Peripheral pulses

• Displaced hyperdynamic left

ventricle impulse

AR physical examination

what are the Murmurs

what S sounds and this will indicate what

and what are other associated murmus

Murmurs

Early, high pitched, blowing, diastolic

decrescendo murmur

– Left sternal border

S3 S4 gallop *heart failure

Other associated murmurs

– Austin-Flint murmur (severe)

– Mid to late diastolic rumble at the cardiac apex

what are the ECG

Changes for AR??????

Shows LV hypertrophy

with ST segment

elevation, left atrial

enlargement, and

possibly ventricular

tachycardia

what is the CHRONIC AORTIC

REGURGITATION

QUALITATIVE

ASSESSMENT….indicators of AI severity

Interrogation

of Aortic

Regurgitation

combines... (AR assessment)

Color flow imaging

• Spectral Doppler Assessment

• And Indirect signs

Assessment begins in what view

Color doppler shows the presence of what

measure what

Assessment begins in PLAX

Color Doppler shows the presence of

aortic regurgitation

Measure the LVEDD for LV dilatation

Aorta measurements including Sinus of

Valsalva, ST junction, and proximal aorta

Valve etiology

what is this showing

Austin-Flint murmur (severe)

which one is central VS eccentric AR

Central is the 1st pic

eccentric is the 2nd pic

AR via color flow may be unreliable due to what

Unreliable due to

diastolic blood pressure

and acute AR

what is this showing

Doming of the anterior leaflet

Chronic AR significant compensatory are what and seen in which view with what

Significant compensatory LV dilation and

increased sphericity of the LV are seen in the

apical four-chamber view with chronic severe

AR

CW Doppler

Density proportional to what

Sensity of signal increase as what increase

how does Mild regurgitation show up

how does Severe Regurgitation show up

Sensity proportional to RBC’s

Density of signal increase as RV increase

Mild R

Faint Doppler signal

Difficult to obtain

Severe R

Dense Doppler signal

Shape of CW Doppler reflects?

Severe AR may become asymmetrical

reflecting

Shape of CW Doppler reflects pressure

changes

Severe AR may become asymmetrical

reflecting rapid equalization of pressure

ECHO FEATURES

Left atrium dilated *chronic

– Increased diastolic filling pressures

Pulsatile aorta

- Flow reversal in aorta (descending

and abdominal)

Evidence of pulmonary hypertension

- Elevated TR velocity

- Dilated IVC/hepatic veins

PW DOPPLER

INTERROGATION

OF REVERSALS

REVERSALS IN THE AORTA