Valvular Regurgitation - Aortic Insufficiency

Definition: AI

• The backflow of blood through the aortic valve during diastole

AI can be

acute or chronic

• Murmur: AI (3)

• When heard

• sounds like

• how does it sound for severe AI

• Which intercostal space

o Diastolic, blowing, decrescendo

o May be holodiastolic in severe aortic regurgitation

o Heard in the third intercostal space

INDIRECT SIGNS OF AI

• EPSS

• AMVL Diastle fluttering

  • AI jet hitting AMVL

• AMVL Reverse doming

  • AI Hits MV into LA!

  • will cause MV in shorts to look weird

when to do valsalva (LVOT)

DO VALSALVA WHEN LVOT IS >1.5 m/s

• This will evaluate whether its dynamic or not

why does AI cause diastolic BP to be low

because the blood is just falling out through the aortic valve

• severe AI

Quadracusp aortic valve-clover

severe AI

• STEEP

• GET A DOC!

• DONT LET THEM LEAVE

• SPIKE IS DURING DIASTOLE

Severe AI murmur AKA

Austin Flint murmur BOARD QUESTION

Etiology (causes) AI (2)

• Leaflet Abnormalities (changes in leaflet flexibility and shape)

• Aortic Root Abnormalities

• Leaflet Abnormalities (changes in leaflet flexibility and shape) (6)

  • causes (etiology)

o Rheumatic heart disease

o Bicuspid aortic valve

o Calcific valve disease

o Myxomatous valve disease

▪ Sagging or slipping of one or both of the leaflets in diastole

▪ Leaflets are thickened and redundant on two-dimensional echo

o Endocarditis

o Nonbacterial thrombotic endocarditis

• Aortic Root Abnormalities (4)

• causes (etiology)

o Systemic hypertension

▪ Causes dilation of the aortic annulus

o Dissection

▪ Valve leaflets may be normal or flail leaflet

▪ Annular dilation causing leaflet displacement (altered geometry)

o Sinus of Valsalva aneurysm

▪ Dilation of the annulus and sinuses of Valsalva

o Trauma (acute)

o Marfan syndrome

bicuspid aortic valve- most common way it happens

• football

this type of bicuspid aortic valve is less common

• football

Myxomatous valve disease

▪ Sagging or slipping of one or both of the leaflets in diastole

▪ Leaflets are thickened and redundant on two-dimensional echo

o Systemic hypertension leads to

▪ Causes dilation of the aortic annulus

o Dissection leads to (3)

▪ Valve leaflets may be normal

▪ Annular dilation causing leaflet displacement o Sinus of Valsalva aneurysm

▪ Dilation of the annulus and sinuses of Valsalva

Segments of the proximal aorta: (4)

• Left ventricular outflow tract

• Sinus of valsalva

• Sinotubular junction

• Ascending aorta

Left Ventricular Response (due to chronic volume overload) (5)

• Progressive dilation of the left ventricle

• Left ventricular function is normal, not hyperdynamic

• Increased sphericity

• Initially, systolic function remains normal

• Systolic dysfunction will develop over time due to the significant chronic volume overload

Indirect Signs of Aortic Regurgitation (4)

• Increased E-point septal separation (EPSS)

• High-frequency fluttering of the anterior mitral leaflet

• Reverse doming of the anterior mitral leaflet

• Jet lesion on the septum or mitral valve

Two-Dimensional evaluation of AoV

• WHAT SETTINGS

• WHAT VIEWS

• Obtain careful, high resolution imaging focusing on the aortic valve in both harmonics and fundamental modes in the parasternal long axis view and short axis view

o Use magnification (zoom)

Mitral valve m-mode

o Fine diastolic flutter of the anterior mitral valve leaflet o Diastolic damping of the anterior mitral valve leaflet with decreased D-E amplitude and increased Epoint septal separation

• Left ventricle m-mode

o Volume overload pattern

o Dilatation

o Determine parameters carefully; especially the end-systolic dimension, fractional shortening, ejection fraction

Color Doppler Evaluation (3)

• Parasternal Long-Axis View

o Jet Height/Width: Assess the color Doppler height/width of the aortic valve in relation to the left ventricular outflow tract for central jets

o Extent of Jet: in relation to the left ventricular area

o Vena Contracta Width:

o Vena Contracta Width:

▪ Parasternal long axis view

▪ Magnify/zoom

▪ Measure the narrowest segment of the regurgitant signal

▪ A vena contracta width less than 0.3 cm indicates mild regurgitation

▪ A vena contracta width greater than 0.6 cm indicates severe regurgitation

color doppler evaluation

• Parasternal Short-Axis View

• jet area

PSAX

o Jet Area :

▪ A central color Doppler jet that takes up less than 25% of the aortic valve indicates mild aortic regurgitation

▪ A central color Doppler jet ≥ 65% of the aortic valve indicates severe aortic regurgitation

Color doppler evaluation

Apical Views - Color Doppler Jet Mapping

• extent of jet and jet area

• eccentric or central

o Extent of Jet and Jet Area: (2)

▪ How far back does the jet travel into the left ventricle?

▪ How much area of the LV does the jet involve?

o Eccentric or central

▪ eccentric jet implies aortic valve prolapse

▪ central jet implies aortic root dilatation or restricted valve motion

SPECTRAL DOPPLER OF AoV EVALUATES

• PHT (CW)

• AORTIC FLOW REVERSAL

Pressure Half-Time by Continuous-Wave Doppler

• AoV

o To assess aortic insufficiency severity

o Apical four-chamber or apical long axis view (three-chamber view)

o Obtain complete Doppler spectral waveform (3 – 5 meters per second)

o If velocity is low – probably not getting complete waveform

o Obtain pressure half-time on complete waveforms only

o Mild (flat) = greater than 500 milliseconds

o Severe (steep) = less than 200 milliseconds

o Assess the density of the spectral Doppler signal

Aortic Flow Reversal

o Pulsed-wave Doppler of the proximal descending aorta in the suprasternal notch view examining for retrograde flow

▪ Retrograde flow indicates moderate to severe aortic regurgitation

o Pulsed-wave Doppler of the descending aorta in the subcostal view examining for retrograde flow

▪ Retrograde flow indicates severe aortic regurgitation

o Velocity greater than 0.6 m/s, VTI greater than 15 cm, or end-diastolic velocity greater than 20 cm/s may indicate significant aortic regurgitation

Mild AI

• Jet height/width

• vena contracta

• PHT

• Spectral doppler waveform

• flow reversal

• jet area

• regurgitant oriface area

• LV size

• Jet height/width (LVOT) <25%

• Vena contracta width less than 0.3 centimeters

• Pressure half-time greater than 500 milliseconds

• Light or incomplete density of the spectral Doppler waveform

• Only brief or no diastolic flow reversal in the descending aorta

• Jet area less than 20% of the left ventricle

• Regurgitant orifice area less than 0.10 cm2

• Normal left ventricular size

Severe AI

• Jet height/width

• vena contracta

• PHT

• Spectral doppler waveform

• flow reversal

• jet area

• regurgitant oriface area

• LV size

• Jet height/width (LVOT) ≥ 65%

• Vena contracta width greater than 0.6 centimeters

• Pressure half-time less than 200 milliseconds

• Holodiastolic flow reversal is seen in the descending aorta (supraternal window)

• Jet area greater than 40% of the left ventricle

• Regurgitant orifice area ≥ 0.30 cm2

• Dense spectral Doppler signal

• Left ventricular enlargement

AI PHT

• mild

• moderate

• moderatley severe

• severe

jet height (PLAX)

• mild

• moderate

• moderatley severe

• severe

Jet height / LVOT Height (PLAX)

• mild

• moderate

• moderatley severe

• severe

Jet area / LVOT area (PSAX)

• mild

• moderate

• moderatley severe

• severe

Vena contracta width (cm) (PLAX)

• mild

• moderate

• severe

• mild

  • < 0.3 cm

• moderate

  • 0.3 - 0.6 cm

• severe

  • > 0.6 cm

Jet area / LVOT area (%) (PSAX)

• mild

• moderate

• severe

• mild

  • <4%

• moderate

  • 4 - 24%

  • 25 - 59%

• severe

  • >60%

Flow reversal (descending aorta, suprasternal notch)

• mild

• moderate

• severe

• mild

  • brief or none

• moderate

• severe

  • holodiastolic

AO PHT (ms)

• mild

• moderate

• severe

• mild

  • >500 ms

• moderate

  • 500 - 350 ms

  • 350 - 200 ms

• severe

  • < 200 ms

Spectral doppler waveform

• mild

• moderate

• severe

• mild

  • Light, may not be complete, parabolic

• moderate

• severe

  • Dense

AI Jet area

• mild

• moderate

• severe

• mild

  • < 20% of LV

• moderate

• severe

  • > 40% of LV

Regurgitation volume (mL/beat)

• mild

• moderate

• severe

• mild

  • <30 mL/beat

• moderate

  • 30 - 44 mL/beat

  • 45 - 59 mL/beat

• severe

  • ≥ 60 mL/beat

Regurgitaion fraction (%)

• mild

• moderate

• severe

• mild

  • < 30%

• moderate

  • 30 - 39%

  • 40 - 49%

• severe

  • ≥ 50%

Effective Regurgitant oriface area (cm²)

• mild

• moderate

• severe

• mild

  • < 0.10 cm²

• moderate

  • 0.10 - 0.19 cm²

  • 0.20 - 0.29 cm²

• severe

  • ≥ 0.30 cm²

LV Size

• mild

• moderate

• severe

• mild

  • normal

• moderate

• severe

  • Enlarged