Aortic Regurgitation

How to Evaluate, When to Operate

Points to Cover
Classification and Pathophysiology. Evaluation.
Evaluation by Echocardiography.

Management.
When to operate.

Classification Considerations.

Valve

Aorta

Primary Valve Pathology.

Active or healed endocarditis. Rheumatic fever. Degenerative valve disease.

Bioprosthetic and mechanical valve dysfunction.

Aortic Root Pathology

Chronic Systemic Hypertension. Trauma. Cystic medial necrosis.
Isolated. Marfans.

Ankylosing Spondylitis. Inflammatory Aortitis.

Overlap
Aortic Dissection.
Root dilatation. Flail valve leaflet.

Congenital bicuspid valve and root dilatation. Dilation of root causes tension and bowing of valve cusps.

Capentier Functional Classification.

Type 1.
Annular dilatation.

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.

Stroke volume and LV filling pressures maintained.

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.

ECG. Radiology. Echocardiography. Cardiac catheterisation. Other imaging modalities.

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.

Non Echo Imaging Modalities.

CXR, CT.
Marked cardiac enlargment. Dilated Aortic Root. Widened mediastinum.

MRI
Accurate measurement of regurgitant volume and orifice. Accurate measurement of LV systolic and diastolic volumes and LV mass.

Non Echo Imaging Modalities.

Radionucleotide Imaging. Cardiac Catheterisation.
LV Aorta Regurgitation Severity Coronary arteries.

Echocardiography.
Echo is key technology to
Confirm the diagnosis of aortic regurgitation Assess its severity. Determine its underlying cause and consequences.
Valve. Aorta. Ventricle.

Overall integrative approach is needed.

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.

Complete Echo Study.

Aorta. Other co-existing pathology.

Colour Flow Imaging.

Jet area and length. Vena contracta diameter. Jet/LVOT ratio. PISA
Regurgitant volume. Effective regurgitant orifice.

Colour Flow Imaging.

Provides only a limited and semi quantitative approach to AR severity.
Jet area & length correlate weakly with AR severity. Colour scale and gain settings influence image.

Colour Flow Imaging.

PLAX/PSAX view.
Assess origin of regurgitant jet. Jet width and LVOT dimensions.

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.

Vena Contracta Width.

Measurement of AR jet at its smallest flow diameter just below the flow convergence region as it traverses the aortic orifice .
Measure from PLAX view. Narrow colour sector scan and zoom mode to optimise temporal and spatial resolution. At nyquist limit of 50-60 cm/s.

Vena Contracta Width.

Eccentric jets can be quantified.
Ensure diameter is measured perpendicular to jet long axis and not LVOT.

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.

AR Jet Width/LVOT Ratio.

Maximum colour jet width is measured in diastole immediately below the aortic valve at the junction of the LVOT and aortic annulus. Measure in PLAX view. If orifice is irregular colour jet width is less related to AR severity. Dividing jet width by LVOT diameter improves accuracy. < 25% mild. 25-64% moderate. > 65% severe.

AR Jet Width/LVOT Ratio.

Cross sectional area of jet from PSAX view and its ratio to LVOT area is also an indicator of AR severity. < 5% mild. 5-59% moderate. > 60% severe.

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.

Effective regurgitant orifice area (cm2).

<0.10 mild. 0.10-0.29 moderate. >0.30 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.

Aortic Diastolic Flow Reversal

AR leads to diastolic flow reversal in the aorta and peripheral arteries. The duration of flow reversal in the diastolic phase and its peak velocity is maximal in the most proximal aorta. Moving distally its presence becomes more indicative of severe AR. Descending thoracic aorta. Abdominal aorta.

Aortic Diastolic Flow Reversal.

Suprasternal view. PW doppler. Sample volume is placed in descending thoracic aorta distal to L subclavian artery aligned to the major longitudinal axis of aorta. Alternatively sample volume is placed in abdominal aorta from subcostal view. Doppler filter is decreased to lowest settings to detect low velocities < 10 cm/s.

Aortic Diastolic Flow Reversal.

Descending aortic holodiastolic flow reversal at a velocity exceeding 20 cm/s is validated as a marker of severe AR. Holodiastolic flow reversal at velocity > 20 cm/s is 100% sensitive for severe AR. Specificity is lower as some flow reversal can be seen in lesser degrees of AR

Aortic Diastolic flow reversal

Holodiastolic flow reversal in abdominal aorta measured from subcostal view with PW is also 97% specific.

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

CW Doppler and PHT.

CW doppler of AR jet reflects the pressure difference between the aorta and the LV during diastole. Classically A5C view is best. For eccentric jet other views may provide better beam alignment, eg right parasternal window.

CW Doppler and PHT.

CW density does not allow AR severity assessment. Dense holodiastolic signal may be seen in moderate and severe AR. Faint incomplete signal suggests trace or mild AR.

CW Doppler and PHT.

Rate of CW AR jet deceleration reflects the degree of regurgitation and the LVEDP. As AR increases, aortic diastolic pressure decreases and LVEDP increases, hence the late diastolic jet velocity is reduced and this produces a shortened pressure half time.

CW Doppler and PHT.

A significant limitation is that other factors affecting aortic and LV diastolic pressures and compliance will influence trace and measured parameters. In chronic severe AR LV chamber adaptation can normalise trace leading to underestimation. PHT >500 mild. 500-200 moderate. <200 severe.

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.

Other Supportive Signs.

High frequency fluttering of anterior mitral valve leaflet.
Best appreciated on M mode temporal resolution.

Other Supportive Signs.

Premature mitral valve closure may be seen on m mode in acute severe AR with increased LV diastolic pressure. Reverse doming of anterior mitral valve leaflet.

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.

Assessment of the Left Ventricle.

Crucial information on the haemodynamic consequences of AR. Assessment of LV is vital component in overall patient evaluation and in the use of guidelines to determine timing of surgery.
LV parameters correlate with likelihood of heart failure post AVR.

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.

When to send for surgery.

Points to note for follow up and surveillance and referral timing.
Avoiding LV systolic dysfunction and aortic complications are the primary goal. Be aware of long asymptomatic phase with stable LV function. Once criteria are met do not delay referral or use medical therapy as holding measure.

When to send for surgery.

Mild/moderate AR, normal LV, aysmptomatic.
Echo follow up 12/24 m.

AR of any severity with significant aortic dilatation.

>45 mm Marfans. >50 mm Bicuspid valve. >55 mm all other patients. I IIa IIa C C C

When to send for surgery

Severe AR, asymptomatic, normal LV.
Defer surgery. Regular follow up.

Severe AR, asymptomatic, resting LVEF <50%.

Refer for surgery. I B.

Severe AR, asymptomatic, resting LVEF > 50% but LVEDD >70 mm and/or LVESD > 50 mm.
Refer for surgery. IIa C.

When to send for surgery

Severe AR and symptomatic (NYHA class II-IV or angina).
Refer for surgery. I B.

Severe AR, undergoing CABG, ascending aorta or other valve surgery.

Refer for surgery. I C.