Aortic Regurgitation

 

 Rheumatic Heart Disease

Mitral Stenosis, Marfan's

Mild stenosis, moderate stenosis, severe stenosis

acute, chronic

what is prognosis?

Neck of regurgitant

VC: Vena Contracta

full convergence

Jet height, Jet length

LVOT to determine degree of aortic regurgitation

excellent methods, location of aortic regurgitation, quantity and volume

associated findings of LV, Aorta, other structures

mild AR, no other associated condition. LV size is normal

LVED is normal

end diastolic is normal

Mild: Left ventricular size and thickness is normal. LVED is normal mild aortic regurgitation

Chronic severe Aortic regurgitation. Whatever the underlying cause, moderate aortic regurgitation many years, left ventricular volume overload. Over a period of many months to years, ventricle accomodates by increasing left ventricular size. Increased left ventricular volume, end diastolic diameter

preserved left ventricular function

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hooks on calcific annulus, nothing to hook onto, aortic valvular regurgitation orifices, quite wide and irregular. Sizing of valves difficult, annulus too large to find appropriate size. Aortopathy good etiology. 

 

 

J valve and jenna valving.

Jenna valving promising.

 

 

Symptomatic severe aortic regurgitation

 

 

 

Valve technology

 

Aortic annulus and LVOT

Not deemed candidate for TAVR

Medically optimized from heart failure perspective w/ diuresis and GDMT plans to f/u w/ CT surgery and cardiology

Aortic regurigation difficult target

Interstitial lung diseases

MRI of the heart

Whatever processes

Ischemic heart disease

Lungs, 

Flutter medical management

AI

Autoimmune 

ILD interstitial lung disease, atrial flutter managed

AR perspective no options

Atrial flutter

Aflutter

Shortness of breath

Cellcept or immunosuppressives.

Outpatient

 

hello ladies and gentlemen welcome to triple n media i am dr nick nick i'm a

cardiologist in houston i've been practicing for more than 40 years the focus of this presentation is acc

aha 2020 guidelines for aortic regurgitation evaluation and

management so let us begin with the feature presentation you can follow my green

arrow here the aortic valve separates the aorta from the left ventricle and

usually the valve is functioning in such a manner when the

ventricle squeezes the blood is pushed into the aorta but when the aortic valve closes there is no leak of blood into

the ventricle however if the aortic valve is incompetent if the leaflets do

not coax together as they are supposed to they do not go up if they do not go

up together then there may be a leak across the aortic valve there are a

number of conditions that can lead to aortic valve leak which i'm going to talk about in a minute

then it's going to have significant effect on the left ventricular size left ventricular thickness left ventricular

function and it may also be associated with the diseases involving the your tire

so there are a number of factors that we need to look into when we are dealing with a patient with an iot regurgitation

we're going to go through systematically as how we evaluate a patient with aortic regurgitation

and then decide what is the appropriate treatment pathway that we need to follow

generally speaking the aortic regurgitation is not found as an isolated event

even though it can be but it is most often seen in association with other conditions like rheumatic heart disease

or patients with aortic stenosis or if the person has been diagnosed to have bicuspid aortic valve in the past

or through a family history of bicuspid aortic valve or marfan's

syndrome these are some of the conditions that can be associated with aortic regurgitation so let us move on

to the next slide and here is the 2d echocardiography

including three-dimensional cardiography trans-iso cardiography or the gold standard for

determining the degree of iotic regurgitation the quantity of regurgitant volume

the regurgitant fraction and many other parameters which will enable us to

decide as you know what is the patient condition are we just dealing with a mild stenosis moderate stenosis severe

stenosis is it acute is it chronic and what is the prognosis based on all of

these mumbo jumbo conditions so the here is uh certain points

are worth noting this is called the the neck of this regurgitant object which is

called the vinay contractor and then we have the the flow convergence which looks like a

dome here after that we have the jet height

and we also have the jet length and this is compared to the left ventricular outflow track

to determine the degree of aortic regurgitation so we have super excellent

methods to determine the location of the aortic regurgitating the quantity of the

iot regurgitation and the the volume of the aortic regurgitation

along with the associated findings in the left ventricle in the aorta and many

other structures to make a very meaningful judgment as what needs to be done with these patients as i told you

the aortic regurgitation comes in many different forms the aortic regurgitation could be a mild

iot regurgitation which may be found in patients with dilated aortic root or even a mild regurgitation murmur may be

heard in severely hypertensive patients and iot regurgitation is

frequently seen in patients with critical iot stenosis if the leaflets are immobile and if the leaflets don't

move and close properly during systole there could be there could be a mild aortic leak

and in patients with mild aortic regurgitation if there is no other associated condition their left

ventricular size is normal their left ventricular and diastolic nor volume is

normal and the left ventricular end diastolic diameter is going to be normal

you need to pay attention to every one of these sentences i am seeing it is based on 20 30 years of dealing with

cardiac patients at bedside looking at the record cardiograms and deciding what

are the parameters that we use to see who has mild iot regurgitation and who

had severe aortic regurgitation so let me recap again you you are dealing with a mild aortic regurgitation if the left

Mild AR

ventricular size is basically normal if the thickness is normal and the left

ventricular and diastolic pressure is normal and you see a mild aortic regurgitation a

slight jet based on the color flow doppler on the echo cardiography

on the other hand if you are dealing with a chronic severe aortic regurgitation this is somebody who has

whatever the underlying cause may be we're going to talk about that in a minute whatever underlying cause maybe has moderate aortic regurgitation over a

period of many years which leads to

Chronic AR

left ventricular volume overload and as a result since this is happening over a

period of many months and years this ventricle accommodates that by

increasing its left ventricular size there's an increase in left ventricular

volume there is an increase in left ventricular end diastolic diameter

but with a preserved left ventricular function so the end diastolic pressure may be mildly

elevated but nonetheless it is not severely elevated and they may have some

hypertension which could be one of the causes for elevated uh systolic pressure but they have

that low diastolic pressure it is one of the hallmarks of iotic regurgitation

that's why we get what is known as the hammer pulse where the blood regurgitates and there's a sudden

decrease in the aortic volume which leads to this significant drop in the

dicrotic notch causing the water hammer pulse that's where we put a

hand like this and we can feel like that hammer pulse that's the

bedside examination of aortic regurgitation okay now let's talk about acute iot

regurgitation 

Acute Aortic Regurgitation into the ventricle

no time to adapt, Left ventricle size remains normal, so much volume End diastolic pressure normalizes with aorta.

acute iotic regurgitation can happen in the setting of an aortic

dissection or it can happen in patients with a severely dilated aortic root if there is

some disruption of the aortic leaflets it can be secondary to endocarditis

and in these situations when there is significant regurgitation into the ventricle the ventricle has no

time to adapt itself as a result the left ventricular size remains normal but

because it is getting so much volume the left ventricular end diastolic pressure becomes high and it normalizes the left

ventricular end diastolic pressure with that of the aorta and this is a hallmark

of acute severe aortic regurgitation and we're going to find out how we're going to

identify patients with acute aortic regurgitation based on echocardiography pulse doppler and continuously of doppler and other findings the features of acute severe iotic regurgitation are

normal-sized ventricle severe aortic regurgitation and

normalized significantly elevated left ventricular and diastolic pressure so these are

things which are going to help you to identify because they may give some of these parameters saying the patient presents with acute shortness of breath has pulmonary edema and here is the aortic pressure here's the left ventricle of size here's the left ventricle and diastolic pressure and there is iota regurgitation what is the degree of aortic regulation what kind of aortic regurgitation are we dealing with anyway let's move on 

chronic severe decompensated aortic regurgitation remember when i was talking about this compensated one i said the lv systolic

size is increased but the systolic function is preserved the rejection

fraction is greater than 55 or maybe even 60 percent but

when the chronic aortic regurgitation progresses there comes a time when the

ventricle gets much bigger and it leads into left heart

failure resulting in reduced left nuclear ejection fraction and along with

that there may be a significant increase in the left ventricular end diastolic

diameter 

which is a poor prognosis so in these patients with chronic severe

aortic regurgitation who decompensate they when they decompensate

that means they don't have the ability to adapt they don't have the ability to pump the blood forward as a result their end diastolic volume end diastolic pressure goes up but they have large ventricles with

increasing left ventricular end diastolic diameter increasing left ventricular volume and all of these

features will help us to differentiate among these four different types of

aortic stenosis regurgitation so we talked about the dilated root

endocarditis iodine ism mild moderate severe acute chronic and of course you

see acute regurgitation in patients with iotic dissection or in patients with

endocarditis or in sometimes it may be seen in patients with trauma chest trauma okay how do we diagnose

aortic regurgitation and determine the degree of aortic regurgitation as i told

you the two dimensional choreography three-dimensional cardiography and of course t-e-e

all modalities will be the gold standard in trying to determine the degree of aortic

regurgitation whenever there is aotic regurgitation into the left ventricle we

see a waveform that is in the diastolic phase of the cardiac cycle that is in

the aortic valve region the pressure half time is one of the numbers that are used

to do to determine the degree of iotic regurgitation and i will point

i'll bring that up in the next slide to show what numbers represent what

we can look at the leaflets see if there is thickening adhesions where the leaflets are immobile the calcification

restricted mobility of the leaflets then we look at the dilatation of the left ventricle it

should be then we look at the pressure half time which i talked to you we

use a color flow doppler to look at the aortic jet look for the vna contractor

and the floor convergence and the beam and see how much it covers which i

talked to you about just a minute ago as i said we also look at the left ventricular size thickness diameter

and wall motion abnormalities in case this patient has concomitant coronary artery disease along with that if this

person has rheumatic heart disease we look for problems in the mitral valve

pulmonic valve or the tricuspid valve also in addition to that the echocardiography will help us to

determine if this patient has already developed the symptoms of worsening heart failure with development

of pulmonary hypertension the other test that we could use would be chest cta to look at the aorta itself

look at the morphology of the aorta look for aneurysms or dissections and

similarly cmr can also look at the iota it can also look at the left ventricular

size and thickness and wall motion abnormalities along with any other things that we might see in the cardiac

structure in old days in the 80s and 90s when i was practicing you know we were taught

the early diastolic low frequency murmur is characteristic

of aortic regurgitation if the aortic regurgitation is

severe then this diastolic murmur would be short because

once there is equalization of pressure in the aorta and in the left ventricular cavity there is no more flow of blood as

a result the shorter the aortic diastolic

murmur that's an indication that it could be really we are dealing with acute aortic regurgitation but you know

unless you do a phonocardiogram it would be hard to know but the echocardiography is is much more

sensitive in determining whether we are dealing with a mild or a severe or an

acute aortic regurgitation i just put that up because that is something

that we all started learning here coming back to this

echocardiographic features that are used to determine the degree of aortic stenosis as i said the size of the

vena cava determines the degree of aortic regurgitation

the width and the the volume of this jet that is

covering the outflow track this is the outflow track of the ventricle and it see here it's covering more than 50

percent of the outflow track all these things signify the degree of

you know regurgitation they've been a contractor here and of course the jet area

compared to the outflow track which is the area here just below the aortic valve and same thing with the jet length

also if it covers the entire outflow track that's an indication that we are dealing with a severe aortic

regurgitation one of the criterias that is used to say whether the why iot

regurgitation is mild moderate or severe is based upon just one number here the

winner contractor that is that neck of the jet let's go back here it is this

neck and if this is less than three millimeters i'm talking about this vinai

contract on the neck less than three millimeters that means it is very narrow

that means we are dealing with the mild aortic stenosis if it's between

three and six centimeters we are dealing with moderate aortic regurgitation if it's greater

than six millimeters in other words if this jet is like more than six millimeters like it's twice it's nice if

the jet is like this they've been a contractor then you're talking about severe aortic

regurgitation this is a very important number and a parameter that is going to be used in determining the clinical

pathways that's why i'm spending more time in trying to explain this even though you may not read echocardiography

even though you may never be able to interpret what the numbers mean

but at least it's it's nice to know the knowledge okay here is a like a diagrammatic

representation of what we are talking about as i said if the jet is covering only

about 25 of the outflow track it is one plus if it is covering like 30 percent

of the outflow track it is like two plus and as you can see as it covers more and

more of the ventricle the degree of mitral regurgitation gets worse

so this is a sort of a diagrammatic representation combined with vna contractor

and the length of this jet and the width of this jet will tell us as whether we

are dealing with mild moderate or severe aortic regurgitation now putting all

this information together i talked about the jet if the jet covers only 25 percent of the left ventricular

outflow track that's what it means then we're dealing with mild the vena contract is three millimeters and the

pressure half time if the pressure half time is like 500 milliseconds it is

taking 500 milliseconds to come down that means we are dealing with a mild

aortic regurgitation and if the regurgitant volume is 30 ml or

regurgitant fraction is less than 30 percent then we are dealing with mild aortic

regurgitation on the other hand let's look at the severe aortic regurgitation

basically when we are dealing with aortic regurgitation we need to know what is mild iot regurgitation so

these patients can be followed clinically with serial echocardiograms and clinical

examination it is a moderate and severe aortic stenosis that needs

interventions and we are talking about going to talk about what interventions they need so let's look at severe in

severe iotic regurgitation width of the jet 65 percent of the left ventricular outflow track that means two thirds of

the left ventricular outflow track i'm talking about here we have the left ventricular outflow track and if this

jet occupies two thirds of that width then we are talking about the severe aortic regurgitation vena contracted

more than six millimeters which i already talked about and if the pressure half time is 200 milliseconds it takes

only 200 milliseconds for the pressures to equalize that means the pressure in the ventricle is rapidly going up which

is the reason why the ventricle and the aortic diastolic pressures equalize thus the pressure

half time is cut short then the regurgitant volume is almost twice that of the mild and the

regurgitating fraction is almost 50 percent so it's 50 of the blood that's being pumped into the aorta is coming

back that's an indication we are dealing with severe aortic regurgitation so

these knowing these numbers it will help us to determine how we proceed further

this is a more elaborate way of looking at if you are a cardiographer and you

can spend a whole day analyzing a patient with iot regurgitation by getting fantastic images fantastic

pulse dopplers and color flows and then decide what is going on so let us look

at the mild one which already i talked to you about you know being a contractor less than 0.3 and the jet less than 25

and the pressure half time greater than normal size lv normal systolic function

that's why i am giving you the fundamentals that are used in making clinical pathway decisions so that when

you understand the fundamentals the clinical pathway just becomes automatic

let's look at the severe case which needs intervention we have flail valve

that's a pretty significant indication being a contractor greater than six 65

percent of the outflow track the jet width pressure half time less than 200 hollow systolic flow and

reversal of flow in the descending aorta and of course because so much blood is coming back into the ventricle you see

the blood instead of going downwards in the aorta in the descending iota you see the flow reversal flow

going back into the other direction of course along with that we see enlarged left ventricle with maybe

normal or abnormal systolic function and these are all minor variations to look at uh

whether we are dealing with a moderate case but i would just stick to these two ends and you can pause the slide and

look at it i just put this one for reference so that if you are a choreography fellow or if

you are a choreographer where you are interested in choreography you can go in depth and analyze yourself

again recapping we have early mild aortic regurgitation which

the parameters we talked about then we have the chronic severe aortic regurgitation

compensated acute severe iotic regurgitation where there is

no time for the ventricle to dilate so diastolic pressures equalize with the normal size ventricle and of course

decompensated aortic regurgitation i know i keep repeating this because the

same parameters are used to the clinical pathways which going to we are going to

look at in a minute one thing we need to understand about acute

deca acute aortic acute aortic acute aortic regurgitation

is there is rapid elevation in left ventricular and diastolic pressure and left atrial pressure the lb attempts to

maintain cardiac output with increased heart rate and increased contractility

because it is getting back so much blood maybe more than 50 percent it has to pump that blood back into the aorta it

can do only so with increased contractility and increased heart rate

in order in attempts to maintain forward stroke volume and cardiac output it may

not be able to do so and if it is not able to do so then the person will

develop pulmonary edema which is usually a common presentation in patients with acute regurgitation

they can also develop myocardial ischemia due to increased myocardial oxygen demand

if the forward flow is not adequate they can develop cardiogenic shock this is that's why i

said this is a medical emergency we had to make a diagnosis and we had to go to the operating room and try to fix the

leak how often do we need to do an echocardiogram in asymptomatic patients

with valve or heart disease and normal lv systolic function so let's look at for iot regurgitation here i just kind

of highlighted this one we need to check the echocardio these are the patients who have aortic regurgitation normal

left ventricular function this is not acute case so we need to do echo every three to five years for mild

mildly severe aortic regurgitation when it gets to be moderate we need to check the echo every one to two years and in

case of severe symptoms asymptomatic patients severe asymptomatic patients

every six to 12 months or if they develop new symptoms then we need to

check an echocardiogram and see if there has been anything structurally who are the people who need intervention we

talked about mild moderate and severe it is the moderate and the severe group who are symptomatic

who need treatment and here is a different way of looking at the same information this is what the

american college of cardiology and the american heart association recommends to characterize these patients into stage a

b c d we'll be mostly focused on sage stage c and d because these are the patients

who are having symptoms who are also having findings consistent

with moderate to severe aortic regurgitation and here as i told you

from the previous slide we need to follow them with the echocardiograms depending upon the

severity of the aortic regurgitation now let's take class c symptomatic severe

symptomatic patients who have criteria for normal rv or lv

systolic function so now we are talking about c1 with normal systolic function

c2 is someone with available heart disease with decompensated lb systolic function

so if you are having a a chronic atrial chronic iotic regurgitation patient who

had a normal ejection fraction to start with now you see a drop in the ejection fraction they fall in the category of c2

and finally d which is like a slam dunk a patient with severe symptoms who has

decompensated valuable heart disease okay taking all this information now all

this basic information then we put the whole thing together and

say okay what are the things that we need to it's like a cliff notes here

with the echocardiography we need to know what is the left ventricular end diastolic diameter that's a very

significant index of if the patient is decompensating and going to a point of

no return we look at the left ventricular volume left ventricular ejection fraction other

available or heart disease and 3d echocardiogram trans esophageal echo ct

of the chest and cmr when we have all this information and we know how

what degree of iotic regurgitation is present and what stage the patient's

iotic regurgitation is then the decision becomes fairly easy i won't say simple

so we are dealing with aortic regurgitation here severe aortic regurgitation and all these parameters

which i already mentioned that is why i spent most of the time in trying to make you understand what these parameters

they are using if you don't know what they are using then this becomes worthless

so if we on stage d i already showed you in the previous slide what is stage d

a patient with severe symptoms severe aortic regurgitation who has decompensated left ventricle class one

indication is aortic valve replacement and in symptomatic patients in stage c

if they have reduced ejection fraction that is a stage c2 which is

worse than stage c1 so they also go for aortic valve replacements

if they are going for concomitant other surgeries like mitral ring or tricuspid ring or coronary bypass surgery then of

course they need aortic valve replacement if in asymptomatic

asymptomatic stage 3 patient if the ejection fraction is greater than 55 percent

left ventricular end systolic diameter is greater than 50 millimeters that's an

important number which i was talking to that's a systolic diameter now we're looking at the diastolic diameter so

here they mentioned left integral end systolic diameter is greater than 50 then you consider aortic

value replacement which is a 2 a indication the same patients if they have a reduced ejection fraction between

millimeters on three studies i'm talking about this one greater than 65 millimeters on three

consecutive studies if that's the case then there if he's a low surgical risk

you consider aortic valve replacement whereas moderate aortic regurgitation if

a person is going for other cardiac surgeries like mitral valve replacement

or a mitral angular ring or tricuspid ring or bypass surgery then you replace the

aortic valve at the same time because you don't want to come back six months later or a year and try to do that again

this chart looks at the mortality rates for aortic valve replacement if it's aortic wave

replacement alone it is two point two percent if it's combined with cabbage it is four percent if it's combined with

microwave replacement it is nine percent so this is an important information we want to communicate with the patient and

the family before we decide to do the surgery okay we need to talk about

variable or heart disease and atrial fibrillation if we have a patient with aortic regurgitation and if this person

develops if this patient has a prosthetic valve and develops

by a prosthetic well and develops atrial fibrillation then after three months of

the procedure they can be treated with either no acts new newer oral anti-coagulant agents or

vitamin k antagonists based upon their child score

whereas the new onset atrial fibrillation is within three months of the valve

implantation they need to be started on vitamin k antagonist

anticoagulant therapy a couple of words about bicuspid aortic

valve bicuspid aortic valve is is not uncommon it is seen fairly

commonly by crispy diotic values associated with iot regurgitation in 13

to 30 percent of the patients about 12 to 37 of these patients have

aortic stenosis it also has aortic enlargement seen in 20 to 40 percent of

the patient's aortic steno bicuspid bicuspid valve and

aortic rotation go together if you see these two words in a cardiology board

question they are connected so that could be a clue that by crispy diotic

valve is usually associated with aortic workation it's prone for endocarditis and usually it is

associated with some type of iron top of the aortic dilatation aortic aneurysm

coarctation and many other things if that's the case we need to do you know

not only echocardiography we also need to evaluate their aorta thoroughly well

and we need to look at the aortic dimension if the aortic dimension exceeds certain number which we'll see

in the next slide then we have to make some decision and to this

we can add cta and cmr to give us much

more accurate information about the iotic root size aortic

sinus junction size or your ascending aortic size the presence of aneurysms and

coordination among others and if a patient with a bicuspid aortic valve with prior aortic valve

replacement then they need to be continued lifelong and looking for

changes in their aorta chart which is looking at bicuspid

aortic valve if the aortic sinus or the ascending aortic diameter is greater

than 5.5 centimeters they need replacement of the aortic root

along with the ascending aorta and the aortic valve whereas

if we have an aortic sinus or an ascending aortic diameter 5.0 to 5.5 with risk factors for

dissection then replace aortic sinuses and or ascending aorta during

cardiovascular surgery indications for surgical aortic valve

replacement iotic sinus and ascending aorta diameter is greater than 4.5

centimeters if so if you are dealing with the aortic valve problem and you decide to do an aortic

valve replacement if the aortic diameter is greater than 4.5 centimeters then

replacing the ascending aorta would be an important step in

these patients similarly ascending aortic sinus or ascending aortics root diameter is 5 to

replace aortic sinus and the ascending aorta if performed in low risk patients

at comprehensive valve centers that's what the c b c stands for so ladies and

gentlemen this is a very comprehensive review of aortic regurgitation what are the conditions

that cause aortic regurgitation how do we determine the degree of aortic regurgitation how do we classify the

stage in which the patient is with reference to aortic regurgitation not only based on cardiac

echocardiographic findings but upon the overall condition of the patient including that of the aortic root the

aortic sinuses the ascending aorta and all other factors and see what is the

most appropriate treatment how do how often do we follow them before how often do we follow them afterwards and a word

or two about anticoagulation if these patients develop atrial fibrillation

thank you so much for watching this presentation and please please do subscribe to our youtube channel we have

a series of lectures on acc aha guidelines on many topics and you can

watch them help you a great deal in terms of deciding what is the best

treatment plan based on sound medical knowledge i will see you in the next presentation

[Music]

you