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Classification and Pathophysiology. Evaluation.
Evaluation by Echocardiography.
Management.
When to operate.
Classification Considerations.
Valve
Aorta
Overlap
Aortic Dissection.
Root dilatation. Flail valve leaflet.
Congenital bicuspid valve and root dilatation. Dilation of root causes tension and bowing of valve cusps.
Type 2.
Prolapse.
Type 3.
Poor cusp quality
PathoPhysiology.
Diastolic regurgitation of blood from the aorta back into the LV chamber. Acute. Chronic
Compensated. Decompensated. Severity, speed of onset, co existing pathology dictates compensation.
Compensatory Phase.
Diastolic regurgitation. Increasing LV end diastolic pressure. Compensatory hypertrophy. Increasing LV end diastolic volume. Increased LV mass.
Decompensatory Phase.
Fail to keep pace with haemodynamic load. Increasing LV end diastolic pressure. Maladaptive remodelling response and chamber dilatation. Falling LV stroke volume and ejection fraction. Rising LA, wedge and right sided pressures. Myocardial Ischaemia. Falling cardiac output.
Exercise and rest.
Evaluation
Clinical.
History & Examination. Primary diagnosis and comorbidities.
Clinical Considerations.
Long asymptomatic compensatory phase. Exertional dyspnoea Orthopnoea/PND. Pounding heart. Ischaemic symptoms occur late.
Clinical Considerations.
Wide pulse pressure
Elevated systolic arterial pressure. Decreased diastolic arterial pressure.
Abrupt distension and collapse of peripheral pulse. Diffuse hyperdynamic displaced apical beat. Early diastolic murmur. Ejection systolic murmur. Late diastolic apical murmur. S3 gallop and signs of pulmonary congestion.
ECG
Not an accurate predictor of aortic regurgitation.
Left axis deviation. LV strain pattern Diffuse T wave changes Ventricular ectopic beats.
MRI
Accurate measurement of regurgitant volume and orifice. Accurate measurement of LV systolic and diastolic volumes and LV mass.
Echocardiography.
Echo is key technology to
Confirm the diagnosis of aortic regurgitation Assess its severity. Determine its underlying cause and consequences.
Valve. Aorta. Ventricle.
Echocardiography.
AR Baseline screen.
Colour flow doppler.
AR Specific Parameters.
Vena contracta. Jet width/LVOT diameter ratio.
AR Quantitative Parameters.
Regurgitant volume. Effective regurgitant orifice. Regurgitant fraction.
Echocardiography.
AR Supportive Parameters.
Pressure half time. Aortic diastolic flow reversal. LV size, volume, function.
Apical views
Tends to overestimate jet area/length.
Recommendation
Colour flow jet area and length is not recommended for quantification of AR severity. Provides only a screening assessment and overview visual assessment of AR severity. More quantatitve approach is required when more than a small central AR jet is observed.
Multiple jet VC diameters are not additive. < 3mm mild. 3-6 mm. Intermediate. > 6 mm. Severe.
Recommendation
Where possible vena contracta width is recommended as the first line quantification modality to quantify AR. Intermediate width values require further quantification modalities.
PISA.
Feasibility and accuracy of PISA derived regurgitation quantification has been shown for AR.
Utsunomiya et al. JACCOL. 1993. 22. 277.
Smaller PISA region than for MR Difficulty to obtain parallel alignment of doppler beam in parasternal windows. PISA region can be obscured by calcified AV leaflets.
PISA
PLAX best for eccentric jet. A3C/A5C may be suitable for central jet. Zoom and narrow sector size. Nyquist limit shifted in direction of AR jet to optimise measurement of PISA radius. EROA and regurgitant volume are determined from interrogation AR jet CW doppler.
PISA
Regurgitant volume (ml/beat).
< 30 mild 30-59 moderate. >60 severe.
Recommendations.
When feasable the PISA method is highly recommended to quantify AR severity. It can be used in both central and eccentric jets. In eccentric jets the PLAX should be used. An EROA > 30 mm2 and R vol > 60 ml indicates severe AR.
Recommendations.
Measurement of the diastolic flow reversal in the descending aorta is recommended, when assessable. It should be considered as the strongest additional parameter for evaluating the severity of AR
Recommendations.
CW doppler density does not provide useful information about AR severity. PHT requires good doppler beam alignment. As PHT is influenced by other chamber compliance and pressure determinants it serves as only a complementary finding in the assessment of AR severity.
Recommendations.
Additional echo findings are used as complementary findings to assess the severity of AR. The assessment of the morphology and dimension of the aortic root is mandatory.
Recommendations.
LV diameters, volumes and ejection fraction should always be evaluated and reported. It is strongly recommended to index the LV diameters to the body surface area. ESC guidelines to note.
Resting LVEF < or > than 50%. LVEDD 70 mm LVESD 50 mm (25 mm/m2 BSA)
Exercise Echocardiography.
Response to exercise and development of symptoms is useful.
Severe AR with equivocal symptoms. Severe AR, asymptomatic at rest and equivocal LV parameters.
Specific role of echo stress imaging less well defined or useful than with other valve pathologies.
Severe AR, asymptomatic, resting LVEF > 50% but LVEDD >70 mm and/or LVESD > 50 mm.
Refer for surgery. IIa C.