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ADULT ECHOCARDIOGRAPHY Lesson Nine Valvular Heart Disease Harry H. Holdorf PhD, MPA, RDMS, RVT, LRT,...
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Transcript of ADULT ECHOCARDIOGRAPHY Lesson Nine Valvular Heart Disease Harry H. Holdorf PhD, MPA, RDMS, RVT, LRT,...
ADULT ECHOCARDIOGRAPHYLesson Nine
Valvular Heart DiseaseHarry H. Holdorf PhD, MPA, RDMS, RVT, LRT, N.P.
Aortic Regurgitation
• Etiology– Primary cusp disease
(stenosis, endocarditis, ankylosing spondylitis)
– Dilated aortic annulus and root (Marfan, aortitis, HTN, aneurysm)
– Los of commissural support (trauma, aortic dissection, membranous VSD)
– Prosthetic valve dysfunction
Aortic dissection & Flap in descending AO
• NOTES:– Which anomaly goes with
aortic dissection?• Marfan Syndrome
– If you have a uniformly dilated aortic root, which term best describes this?• Fusiform
Sinus of Valsalva Aneurysm
• Pathophysiology– Left ventricular volume
overload leads to LV dilatation– Decreased ejection fraction
with long standing regurgitation– Increased risk of endocarditis
• Physical Signs• Bounding (bifid (bisferious)
atrial pulse• High-pitched diastolic
“blowing” murmur left sternal border (LSB)
• Symptoms of CHF, DOE, angina, and or syncope.
• Wide pulse pressure (big difference between systolic and diastolic numbers during BP readings.
• NOTES– Which is the most
common chamber for a sinus of Valsalva aneurysm to rupture into?• Right atrium
– What kind of murmur would you hear in a patient with a rupture of a sinus of Valsalva aneurysm?• Continuous
– Know diastolic “blow” (the classic aortic regurgitation murmur)
Ao Regurg
Echo– M-mode may show
diastolic fluttering of the mitral valve leaflets (mostly anterior) or interventricular septum
– Mitral valve “pre-closure” with severe acute AR
– Diastolic fluttering or lack of closure of he aortic leaflets
– Decreased excursion of the anterior MV leaflet
– LV dilatation with increased LV mass
• Aortic valve or root abnormalities may be present
• Pre-systolic opening of the aortic leaflets
• LV contractility may be hyper or hypo-dynamic (acute vs. chronic)
• TEE best for diagnosing aortic dissections
• Chronic AR patients should have serial echoes to follow changes in diastolic and systolic size.
M-mode of Diastolic MV Fluttering
M-mode of Premature MV closure
• NOTE: What causes MV pre-closure?– An elevated LVEDP
The line in the QRS: MV pre-closure should be in the middle.
Normal MV closure is in the middle to the end of the QRS complex
• Doppler– Diastolic turbulence in the
LVOT– Diastolic flow reversal in
the descending Ao (Mod to Sev AR)
– Obtain the end diastolic gradient from CW Doppler to estimate the LVEDP (diastolic BP – end diastolic gradient
– Map the regurgitant area with pulsed or color flow Doppler
– Try to determine the regurgitant area in LAX and SAX to estimate severity
• NOTE: Know Color Doppler M-Mode of aortic insufficiency
• JH/LVOT (ratio)– Mild = <25%– Mod = 25-65%– Sev = >65%– JH (Jet height)
– Ao P ½ time• Mild = > 500 msec• Mod = 500-200 msec• Sev = <200 msec
Ao P ½ time
• Homework: show images demonstrating aortic pressure half-time
• B is more severe because Ao & LV pressures are equal at end diastole.
• LVEDP = diastolic BP – end diastolic gradient– Ex. Patient w/ BP of
120/50 and end diastolic velocity of 2 m/sec
– LVEDP = 50-16 (converting the 2 m/sec using 4V2
= 34 mmHg
AI diastolic flow reversal –Descending Ao
• NOTE:– Know descending aorta
diastolic flow reversal (also called retrograde)
– Antegrade = normal flow direction
– Retrograde = flow in opposite direction
NOTE: Mild aortic regurgitation has an incomplete spectral trace
Moderate Ao regurgitation incomplete spectral trace
Pulmonary Regurgitation
• NOTE: Flick your bick– Candle flame is normal
regurgitation
EtiologyPrimary valve disease (stenosis, endocarditis)Pulmonary hypertensionCarcinoid heart diseaseTrivial/mild regurgitation is common.
• PATHOPHYSIOLOGY– RV volume overload may lead
to RV dilatation.– Severe regurgitation may cause
right heart failure– Evan moderate regurgitation
will be well tolerated for years– Increased risk for endocarditis
• Physical signs– Low-pitched diastolic murmur
(LSB) may increase with inspiration
– With pulmonary hypertension a high-pitched blowing diastolic murmur (Graham-Steele) may be heard (LSB)
• ECHO– RV dilatation with
displacement of LV septum posteriorly.
– Tricuspid valve fluttering is rare
• Doppler– Diastolic turbulence in the
RVOT– Map the regurgitant area
with pulsed or color flow Doppler
– Severe PI spectral trace is NOT holodiastolic
Severe PI
Calculating PA End Diastolic Pressure
• NOTE:– How would you calculate
pulmonary artery end diastolic pressure?• Pulmonic insufficiency
velocity– Know how to calculate
PAEDP when given a Right Atrial Pressure (RAP) of 10 mmHg and from the PI spectral trace an End Diastolic velocity (EDV) of 1.5 m/sec.
• PAEDP– RAP + EDP (end diastolic
pressure) converted from the DEV
10 +4 (1.5) sq.10 +4 (2.25)10 +9 = 19 mmHg
Tricuspid Regurgitation
• Etiology– Primary valve
abnormalities (rheumatic, prolapse, endocarditis, carcinoid)
– Elevated pulmonary pressure
– Annular dilatation/calcification
– Congenital valve abnormalities (Ebstein’s)
– Prosthetic valve dysfunction
– Trivial/mild TR is common
• Pathophysiology– Right atrial volume overload
lends to right atrial dilatation– Increased risk for endocarditis
• Physical signs– Holosystolic murmur which
increases with inspiration may be present
– Jugular venous distension– Symptoms of right heart failure
• Echo– Valvular abnormalities may be
seen– Right atrial dilatation– RV dilatation with displacement
of LV septum posteriorly– Dilatation of IVC– Contrast: systolic appearance
of bubbles in IVC
Dilated RV & IVC
Carcinoid Heart Disease-Fixed leaflets
• NOTE:– What is the most common
valvular abnormality associated with carcinoid syndrome?• Tricuspid regurgitation
NEXT: PROSTHETIC VALVES
End lesson Nine