ECHO 3 : Valvular Regurg

physiologic regurg is restricted to which area?

area immediately adjacent to valve closure

what are the semi quantitative measurements for valvular regurg

vena contracta width

CW doppler signal strength compared with antegrade flow

pressure half time (for AR)

Pulmonary venous flow (reversals) 

CW doppler for mitral regurg is best in which view?

apical view 

what are quantiative measures of valvular regurg?

regurgitant volume

regurgitant fraction

regurgitant orifice area

how does color doppler indicate mitral valve regurg?

vena contracta

jet area

flow convergence 

in what view is vena contracta measured?

PLAX (perpendicular to jet)

how do you measure vena contracta ?

narrowest portion of jet as it emerges from the orifice

what ranges for vena contracta indicate mild and severe mitral regurg?

mild : .3cm

severe : >/= .7cm

between .3 and .7 needs further evaluation (semi quant)

vena contracta is used for which valves?

mitral and aortic

what are the quantitative methods in mitral regurg?

PISA

stroke volume method

how do you obtain PISA measurement

1. 4ch view

2. zoom in on MV

3. color doppler

4. lower color scale below 40 

5. measure PISA radius 

6. measure max velocity of regurg jet using CW doppler

what numbers does the PISA measurement give us?

velocity of aliasing 

pisa radius

VTI trace

what is the stroke volume method?

stroke volume taken at two sites

what do these quantitative methods (PISA AND SV METHOD) give us?

lesion severity (EROA—> size of defect) and volume overload (Rvol → how much blood is regurgitant)

what is mild moderate and severe EROA (Cm²) 

mild <.2

moderate .2-.39

severe : >/= .4

what is mild moderate and severe Rvol?

mild <30

moderae 30-59

severe >/= 60 

what is proximal flow convergence and how is it measured?

as blood flows through constricted valve the blood converges and creates a hemispheric surface area

measured using PISA (proximal isovelocity hemispheric surface area) 

PISA is more accurate for what type of jets/orifice?

jets : central

orifice : circular 

(holosystolic MR)

how is valvular regurg assessed with CW doppler?

signal intensity relative to antegrade flow

antegrade flow velocity

shape of velocity curve

how do you calcular regurgitant volume? **

regurgitant volume = Total SV - Forward SV

total sv → antegrade flow rate across regurg valve

forward sv → stroke volume across competent valve

what are the primary causes of mitral regurg?

myxomatous mitral valve disease (MVP)

• degeneration of connective tissue

rheumatic disease

MAC

endocarditis 

what are the secondary causes of mitral regurg?

LV dilation (cardiomyopathy) 

ischemic MR (from pap muscle dysfunction) 

LV dysfunction 

what are the indicators of mitral valve regurg severity?

mitral valve pathology

color doppler (vena contracta, jet area, flow convergence) 

mitral E ; pulm venous flow

CW

LA/LV size 

what is an eccentric jet?

travels along atrial wall 

how does the severity of the mitral valve regurgitant jet change when it it eccentric?

severity is underestimated because energy dissipates when jet touches other structures

what is the coanda effect?

loss of momentum of eccentric reurgitant jet

what do you look for with pulmonary vein systolic flow reversal?

look for reversal of S wave

what is the most common cause of MR in developed countries? aka?

mitral valve prolapse

degenerative / myzomatous mitral valve disease

does prolapse cause regurg?

you can have prolapse without regurgitation

mitral valve prolapse involves which structure more often?

PMVL

how do the leaflets bulge in mitral valve prolapse?

upward and back into left atrium but tips still point into LV

what is flail mitral leaflet?

when there is chordal rupture

describe flail vs prolapse?

in prolapse chordal connections of leaflet to pap muscle are still intact so tip will still point to LV apex

in flail tip of leaflet will point towards the roof of the LA in systole

chronic MR leads to

left ventricular volume overload

how does chronic MR affect E/A velocity?

increased peak E velocity

due to additional regurg volume that must pass through MV during diastole 

how does ao regurg affect the LV

volume overload initially (LV dilates) 

then pressure and systolic dysfunction (hypertrophy)

what is this?

diastolic fluttering of the AMVL caused by ao regurg

what murmur is associated with fluttering amvl due to ao regurg?

austin flint murmur

what are the signs and symptoms of ao regurg?

fatigue (not enough blood going out to body bc its going back into LV)

syncope (fainting)

SOB

palpitation

widened pulse pressure 

how is color flow helpful in grading AI?

jet / LVOT width

• measure percentage of the left ventricular outflow tract occupied by the ai jet 

• assess how far AI is going into the LV 

is color flow quantitative or qualitative?

semi quant

what are the etiologies of aortic regurg?

bicuspid valve (primary leaflet issue → congenital)

rheumatic disease (primary leaflet issue → acquired)

endocarditis (primary leaflet issue → acquired)

calcific disease (primary leaflet issue → acquired)

aortic root dilation (seocndary → abnormalities of ao root )

aortic root enlargement could be due to

marfan syndrome (tall people)

familial aortic aneurysm

hypertension

aortic dissection

marfan syndrome is often cccompanied by

mitral valve prolapse

pulm art dilation

MAC

dilatation or dissection of descending thoracic ao/abd ao

label

A : aortic annulus

B : sinuses of valsalva

C : sinotubular junction

D : ascending ao 

how do quantify AI severity?

color flow doppler

vena contracta

CW doppler 

• descending ao diastolic flow reversal 

• pressure half time

• density of velocity signal retrograde vs antegrade

what does the cross sectional area of vena contract represent?

measure of the effective regurgitant orifice area (narrowest area of actual flow)

what measurements of vena contracta indicate mild, moderate and severe aortic regurg?

mild : <.3cm

moderate : .3 - .6cm

severe : > .6cm

what PHT values indicate severe mdeorate and mild ao regurg?

severe : steep slope <200ms

moderatie: 200-500 ms

mild : flat slope >500ms 

how does PHT compare in regurg vs stenosis

in stenosis a higher PHT = worse stenossi

in regurg a lower PHT = worse regurg 

what is PHT?

when initial max velocity of blood across valve drops to 70% of its initial value OR

when pressure difference across valve is half initial pressure

(intiially AO has high pressure so there is high velocity but as LV fills from AI jet and normal LV filling, LV pressure increases) 

why can PHT alone not be used to assess AO severity?

other factors such as chronicity of regurg, systolic BP, LV compliance can all influence how quickly the regurgitant jet can fill into the LV

how does density of CW doppler give us information on AI

dense signals → greater quantity

faint signals → mild regurg 

how is descending ao diastolic flow assesed?

taken at subcostal and SSN

look for evidence of holodiastolic flow reversal ( should not see SUSTAINED flow reversal thorugh diastole in aorta → severe regurg) 

tricuspid regurg may be due to 

primary valve disease

secondary to annular dilatation 

what are the primary causes of TR?

endocarditis, ebstein anomaly, rheumatic disease, carcinoid, and myxomatous disease 

what are the secondary causes of TR?

pulm hypertension

• mitral valve disease

• pulm parenchymal disease

• primary pulm hypertension 

**secondary based on presence of pulm hypertension and absence of structural abnormalities of leaflets 

what is the ebstein anomaly? (DONT FOCUS ON)

apical displacement of one or more leaflets 

• insertion of tricuspid leaflet downward into RV (greater than 10mm from mitral valve leaflets)

vena contracta of - indicates severe TR

>7mm

in what percentage of cases does rheumatic disease involve TV?

20-30% of cases

TR is often secondary to 

annular dilation due to primary RV dilatation and systolic dysfunction/pulm hypertension 

pathologic pumonic regurg is most often due to 

congenital heart diseases such as repaired TOF 

review qs

what are the primary and secondary etiologies of MR? 

primary

• myxomatous mitral valve disease (MVP)

• degeneration of connective tissue

• rheumatic disease

• MAC

• endocarditis 

secondary

• LV dilation (cardiomyopathy) 

• ischemic MR (from pap muscle dysfunction) 

• LV dysfunction 

review qs

what methods can assess mitral regurg?

PISA

stroke volume method

CW doppler

Color doppler (vena contracta, jet area, flow convergence)

Mitral E wave

Pulmonary venous systolic flow reversal

review qs

what methods can assess aortic regurg? 

Color flow (jet/LVOT width, Vena contracta)

CW doppler (descending ao diastolic flow reversal, PHT, density of velocity signal retro vs ante)

review qs

fluttering of anterior mitral valve leaflet can be caused by what pathology?

ao regurg