Identification, etiology, qualitative and quantitative assessment of severity of AR by Echocardiography

1. Echocardiographic Assessment of
AR
Dr. Md. Mashiul Alam
Phase B resident
Chairperson: Assoc. Prof. N. Sheikh

2. Aortic valve anatomy
• 3 cusp, 3 commisure
• 3-4 cm sq

3. RCC
NCC

4. NoRmaL – clock wise

6. Common Causes of AR
• Bicuspid aortic valve
• Rheumatic disease
• Calcific degeneration
• Infective endocarditis
• Idiopathic aortic dilatation
• Myxomatous degeneration
• Dissection of the ascending aorta

7. Options
• TTE
• TEE
• 3D echocardiography

8. Echocardiographic Views
• PLAX
• PSAX at the level of great vessels
• Apical views – A4CV, Apical long axis views

9. Aim of echocardiographic evaluation
• Define the cause of stenosis
• Quantification of severity
• Evaluation of co existing valvular lesions
• Assessment of LV systolic function
• Detection of response of chronic volume load
over cardiac chambers

10. 2 D assessment of AR
• Leaflets
 Prolapse
 Number
 Vegetation
 Calcification

11. PSAX view

13. Vegetation

15. Calcification

16. • Aortic root
Dilation?
18-40 yrs:
0.97+(1.12 BSA)
>40yrs:
1.92+(0.74 BSA)
Always abnormal
If > 5 cm

19. Any dissection?
In PLAX, PSAX, Suprasternal view

22. • Left ventricular dimension and function
In chronic AR
LVESD <50-55 mm
LVEDD <70-75 mm
Eccentric hypertrophy
LVEF <50%
Acute AR normal dimension and hyperdynamic LV

24. Doppler Assessment of AR
(Qualitative)
• Color doppler jet width
Color jet width vs LVOT width in PLAX or PSAX view
Overestimated in apical views
Mild AR <25%
Severe AR ≥65 %
Length of AR jet should not be used to assess AR
severity

26. • Vena contracta width
Reflects diameter of regurgitant orifice
Avoids erroneous measurement of jet when it
expands in LVOT
PLAX or PSAX zoomed view
Mild AR < 0.3 cm
Severe AR> 0.6 cm

27. Three components
Of regurgitant jet:
1. PFC
2. VC
3. Broadening in
LVOT

28. • Pressure half time (PHT)
CW doppler in Apical three or five chamber
views
Mild AR >500 ms
Severe AR < 200 ms
Density of signal of doppler envelope also a sign
of severity

29. Steeper is
severe

31. • Diastolic flow reversal in aorta
PW doppler in suprasternal (descending thoracic
aorta) or subcostal (abdominal aorta) view
ECG gated echo needed
Holodiastolic flow reversal is abnormal. Brief
flow reversal may be present normally.

35. Doppler Assessemnt of AR
(Quantitative)
Not frequently done
Often be determined by combination of
qualitative methods and 2D assessment
Options:
PISA (Proximal Isovelocity Surface Area)
Regurgitant volume
Regurgitant fraction
Effective regurgitant orifice area (EROA)

36. PISA
It’s the surface area of blood moving back from
the aorta towards the closed aortic valve at
the given aliasing velocity

38. Zoomed A3CV or A5CV
Decreasing the depth
Narrow sector
PISA = 2πr2

40. • Regurgitant Volume =
Volume of blood that regurgitates across the valve
per beat
Volumes calculated according to continuity
equation
RegrugV = SV total – SV forward
SV total = Transaortic volume =CSA LVOT x VTI LVOT
SV forward = Transmitral volume = CSA mitral
annulus x VTI mitral annulus

41. • SV total can be measure by LVEDV – LEVSV
(Simpsons method)
• For SV forward or transmitral volume PW
doppler at the level of MV; should be used not
at mitral tip

44. Regurg. Volume calculated by PISA method
Regurg Volume = EROA x VTI AR jet
Mild AR < 30ml/ beat
Severe AR ≥ 60ml/ beat

45. • Regurgitation fraction = Regurg V/ SV total
Mild AR < 30 %
Severe AR ≥ 50%

46. • EROA (Effective regurgitation orifice area)
= PISA x aliasing velocity / AR Vmax
or
= Regurg V / VTI AR jet
Mild AR < 0.1 cm sq. Severe ≥ 0.3 cm sq.

48. TEE in AR
• Complement TTE
• Better visualization of valve morphology and
aortic root dimensions
e.g., Endocarditis
Aortic dissection

49. Indirect sign of AR
• Increased EPSS
• Fluttering of mitral leaflet
• Reverse doming of the anterior mitral leaflet

52. Associated valvular lesion in AR
• Aortic stenosis
• Mitral stenosis or mitral regurgitation
• MAC