Priv.-Doz. Dr. med. Michael Kindermann

CaritasKlinikum Saarbrücken, St. Theresia Interventionelle Kardiologie und Angiologie

Echo assessment of

Aortic Regurgitation

and its mechanisms

Homburg, Wednesday, May 14th, 2014

Workshop: Reconstruction of the

Aortic Valve and Root

cts CaritasKlinikum Saarbrücken St. Theresia

cts Echo in aortic regurgitation - Objectives

• Confirm diagnosis

• Define mechanism of AR

• Define etiology of AR

• Quantify the degree of AR

• Evaluate LV response to p/v overload

• Identify associated abnormalities

cts Echo in AR - Mechanisms

Type Ia El Khoury G.: Curr Opin Cardiol 2005;20:115.

Type Ib Type Ic

Abnormalities of the aortic wall

Dilation of ST-junction

(and ascending aorta)

Dilation of AV-junction, sinus,

and ST-junction (= „functional

aortic annulus“)

Dilation of ST-junction and sinuses

(and ascending aorta)

cts Echo in AR - Mechanisms

Type Ia El Khoury G.: Curr Opin Cardiol 2005;20:115.

Type Ib Type Ic

Abnormalities of the aortic wall

Dilation of ST-junction

(and ascending aorta)

Dilation of ST-junction and sinuses

(and ascending aorta)

Dilation of AV-junction, sinus,

and ST-junction (= „functional

aortic annulus“)

cts Echo in AR - Mechanisms

Type Ia El Khoury G.: Curr Opin Cardiol 2005;20:115.

Type Ib Type Ic

Abnormalities of the aortic wall

Main Etiologies: • Genetically determined vascular connective tissue disease:

- Syndromes: Marfan, Ehlers-Danlos,

Loeys-Dietz, etc.

- Bicuspid valve

• Hypertensive aortic root dilatation

Dilation of ST-junction

(and ascending aorta)

Dilation of ST-junction and sinuses

(and ascending aorta)

Dilation of AV-junction, sinus,

and ST-junction (= „functional

aortic annulus“)

cts Echo in AR - Mechanisms

Dilation of ST-junction and ascending aorta

Dilation of AV-junction, sinus,

ST-junction and ascending aorta

Dilation of AV-junction, sinus,

and ST-junction (= „functional

aortic annulus“)

Type Ia El Khoury G.: Curr Opin Cardiol 2005;20:115.

Type Ib Type Ic

Abnormalities of the aortic wall

Central AR jet !

cts Echo in AR - Mechanisms

Abnormalities of the aortic valve cusps

Perforation Prolapse Restrictive cusp motion

Type Id Type II Type III

cts Echo in AR - Mechanisms

Abnormalities of the aortic valve cusps

Perforation Prolapse Restrictive cusp motion

Eccentric jet away from

the prolapsing cusp

Eccentric jet towards the

the more restricted cusp Paracentral jet

Type Id Type II Type III

cts Echo in AR - Mechanisms

Abnormalities of the aortic valve cusps

Perforation Prolaps Restrictive cusp motion

Type Id Type II Type III

cts Echo in AR - Mechanisms

Abnormalities of the aortic valve cusps

Perforation Prolaps Restrictive cusp motion

Endocarditis

- Bicuspid valve

- Myxomatous degeneration

- Fenestrations

- Disrupted commisure:

• Dissection • Trauma

- Rheumatic valve disease

- Degenerative calcification

Type Id Type II Type III

cts Echo in AR – Number of cusps

Tricuspid Bicuspid Unicuspid Quadricuspid

1-2% 0.02% 0.01% > 98%

cts Echo in AR – Useful measurements

1: Annulus ( 1.6 cm/m²)

2: Sinus ( 2.1 cm/m²)

3: ST junction ( 1.9 cm/m²)

4: Tubular aorta

eh: effective height

cl: coaptation length

eh

cl

TEE long axis-view:

Predictors of a durable repair:

Absence of more than mild residual AR

Effective height ≥ 9 mm

Coaptation length ≥ 4 mm

cts

Echocardiographic criteria of severe aortic regurgitation (III.° - IV.°)

• Jet width 65% of LVOT

• Vena contracta width 6 mm

• Pressure half time (CW-Doppler) 200 ms

• Holodiastolic flow reversal in descending aorta

• RV 60 ml, RF 50%, ERO 0.30 cm²

• Left ventricular enlargement

AR – Echo quantification

cts Case 1 – T.M. 61 year old male

NYHA II, LVEDD 62 mm, LVESD 47 mm, EF 47%

Annulus 2.7 cm (1.38 cm/m²), Sinus 3.8 cm (1.94 cm/m²), STJ 3.8 cm (1.94 cm/m²), Asc 3.7 cm

cts Case 2 – S.P. 28 year old male

NYHA I, LVEDD 67 mm, LVESD 45 mm, EF 59%

Annulus 3.9 cm (1.82 cm/m²), Sinus 5.6 cm (2.61 cm/m²), STJ 3.5 cm (1.63 cm/m²), Asc 3.4 cm

cts Case 3 – M.J.M. 23 year old male

NYHA II, LVEDD 76 mm, LVESD 49 mm, EF 63%

Annulus 2.8 cm (1.79 cm/m²), Sinus 3.8 cm (2.0 cm/m²), STJ 2.8 cm (1.47 cm/m²), Asc 4.0 cm

cts Case 4 – S.S. 49 year old male

NYHA II, LVEDD 59 mm, LVESD 42 mm, EF 55%

Annulus 3.2 cm (1.69 cm/m²), Sinus 3.6 cm (1.90 cm/m²), STJ 2.4 cm (1.27 cm/m²), Asc 3.7 cm

Thank you

for your

attention!

Akademisches Lehrkrankenhaus der Universität des Saarlandes

cts CaritasKlinikum Saarbrücken St. Theresia

cts

Additional

Slides

cts Bicuspid aortic valve – pathoanatomical classification

Sievers HH.: J Thorac Cardiovasc Surg 2007;133:1226.

Sievers classification

cts

Sabet HY.: Mayo Clin Proc 1999;74:14.

Bicuspid aortic valve – pathoanatomical classification

Schaefer BM.: Heart 2008;94:1634.

Sabet 1999 Schaefer 2008