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Dr Alan Japp

Edinburgh Heart Centre

Advanced Echo 2018

Aortic Regurgitation

Aortic Regurgitation

• Causes and Consequences of AR

• AR Guidelines

• Assessment of AR severity

• Illustrative cases

AR: Causes, classification & consequences

Primary valve disease Aortic root pathology

Rheumatic Dilatation: Marfan’s bicuspid etc

Congenital (e.g. bicuspid) Aortic dissection*

Degenerative / calcific

Endocarditis*

Traumatic (e.g. leaflet rupture)*

Inflammatory e.g. SLE

*Cause of acute aortic regurgitation

Carpentier Classification Type 1: normal cusps; poor coaptation due to root enlargement

Type 2: cusp prolapse Type 3: poor cusp tissue quality or quantity (retraction, erosion)

Valve morphology

Unicuspid (unicommisural) Quadricuspid

Tricuspid Bicuspid

AR: Causes, classification & consequences

Primary valve disease Aortic root pathology

Rheumatic Dilatation: Marfan’s bicuspid etc

Congenital (e.g. bicuspid) Aortic dissection*

Degenerative / calcific

Endocarditis*

Traumatic (e.g. leaflet rupture)*

Inflammatory e.g. SLE

*Cause of acute aortic regurgitation

Carpentier Classification Type 1: normal cusps; poor coaptation due to root enlargement

Type 2: cusp prolapse Type 3: poor cusp tissue quality or quantity (retraction, erosion)

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ESC 2017 algorithm for management

of AR

ESC 2017 guidelines: the role of echo

Aorta

Valve

LV

ESC Guidelines 2017 Assessing AR severity

ESC BSE

ESC 2017 guidelines: the role of echo

Aorta

Valve

LV

TOE, MRI, aortogram

ESC Guidelines 2017

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Dujardin et al. Circulation. 1999;99:1851-1857

Post AVR outcomes

Outcomes with conservative therapy

Bonow RO et al. Circulation. 1985;72:1244–56.

ESC 2017 guidelines: the role of echo

Aorta

Valve

LV

TOE, MRI, aortogram

MRI

ESC Guidelines 2017 ESC 2017 guidelines: the role of echo

Aorta

Valve

LV

TOE, MRI, aortogram

MRI

CT, MRI

Case 1: A full house (almost)

• 20 y/o male

• Presents with palpitation. No SOBOE

• Short stature, slight build, previous drug use (?IV)

• Displaced apex++, collapsing pulse, , carotid

pulsations, EDM

• TTE

Case 1: A full house (almost)

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Case 1: A full house (almost) Case 1: huge coaptation defect

Case 1: LVOT jet width area

Jet width / LVOT diam = 67%

Case 1: Pressure half time

PHT = 206 ms

Case 1: Descending aorta Case 1: Descending aorta

End-diastolic velocity = 100 cm/s

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Case 1: Abdominal aorta Case 1: LV remodelling (1)

BSA = 1.6 cm2

Indexed LVESV = 31 mm/m2

Case 1: LV remodelling (2)

LVEF = 47%

Case 1: LV Recovery

Pre AVR Post AVR

Case 1: LV Recovery

Pre AVR Post AVR

Case 2: Extreme Measures

• 38 y/o man; mild exertional SOB

• Tall, some marfanoid features

• Displaced apex, EDM

• TTE

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Case 2: Extreme Measures Case 2: Extreme Measures

Case 2: Central coaptation defect Case 2: colour assessment

Case 2: LVOT jet width

Jet width / LVOT diam = 48%

Case 2: Poor CW signal

PHT approx 350 ms

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Case 2: Descending aorta Case 2: Descending aorta

End-diastolic velocity = ?

Case 2: Descending aorta

End-diastolic velocity = ?

Case 2: Advanced LV remodelling

End-diastolic velocity = ?

LVEF = 30%

PISA radius 8mmAliasing velocity 45 cm/s

Case 2: TOE - EROA & Regurgitant volume Case 2: EROA & Regurgitant volume

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PISA radius 0.8 cmAliasing velocity 45 cm/sAV max 410 cm/sAV VTI 181 cm

EROA = PISA area x aliasing velocity / VmaxEROA = (2 x 3.14 x 0.82 x 45) / 410

EROA = 181 / 410 = 0.45 cm2

Regurgitant vol = EROA x AR VTI

Regurgitant vol = 0.45 x 181 = 81 mL

PISA radius 8mm

Aliasing velocity 45 cm/s

Case 2: EROA & Regurgitant volume Case 2: Outcome

• Successful root and valve replacement (significant leaflet disease at operation)

• Post-op LV still severely dilated and impaired

• Symptomatically well

• Sudden (presumed arrhythmic) death in hospital at day 14 post-op

Case 2: Outcome

Chaliki et al. Circulation . 2002;106:2687-2693

Case 3: A high pressure case

• 23 y/o male IV drug user

• Staph aureus sepsis

• TTE 36 hours ago – no clear evidence of endocarditis

• Haemodynamic deterioration

• Inotropic / pressor support; not ventilated

• Scanned at bedside in ICU by cardio registrar

Case 3: A high pressure case Case 3: A high pressure case

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Case 3: A high pressure case Case 3: A high pressure case

Case 3: A high pressure case Case 3: A high pressure case

PHT = 93 ms

Case 4: Severe LV; Severe AR?

• 49 y/o man; palpitation!!

• Ventricular ectopics++

• Moderate alcohol excess; No CVS hx

• No limiting SOB

• Soft EDM; displaced apex; no other physical signs

Case 4: Severe LV; Severe AR?

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Case 4: Severe LV; Severe AR? Case 4: Severe LV; Severe AR?

Case 4: Not a short PHT Case 4: No holodiastolic flow reversal

Case 4: Very eccentric! Case 4: Very eccentric!

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Case 4: TOE Case 4: TOE

Case 4: Very eccentric!

Vena contracta 0.4 cm

PISA radius 0.6 cm

EROA 0.29cm2 (!!)

Regurgitant vol 47 mL

Case 4: MRI assessment

• LVEF 19%

• Global wall thinning; normal indexed LV mass

• Regurgitant volume 38 mL

• Regurgitant fraction 31%

• No myocardial fibrosis

• No aortic dilatation

Case 4: MRI assessment

• LVEF 19%

• Global wall thinning; normal indexed LV mass

• Regurgitant volume 38 mL

• Regurgitant fraction 31%

• No myocardial fibrosis

• No aortic dilatation

Conclusion: Severe DCM. Moderate aortic regurgitation

Does strain have a role?

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Take home messages

• Valve, ventricle, aorta

• Severity challenging; acknowledge uncertainty

• Track the LV carefully (GLS? Biomarkers?)

• Increasing role for multi-modality imaging (esp MRI)

• Acute severe AR a life-threatening emergency