AR

Question 1

What is the VC severity scale in AR diagnosis?

Answer 1

• Mild = < 0.3cm
• Moderate = 0.3 - 0.6cm
• Severe = > 0.6cm

Question 2

Describe the severity scale in diagnosis of AR:

• jet width and cross-sectional area

Answer 2

• Mild = < 25%
• Moderate = 25-65%
• Severe = > 65%

Question 3

What are the best views and velocity scale settings for diagnosis of AR?

Answer 3

• parasternal long axis (2D) or long axis - 120 (TEE)
• Nyquist limit 50-60cm/s

Question 4

What are the steps/parameters to evaluate AR severity?

Answer 4

• Specific signs
  
  • Jet width/LVOT width
  • Vena contracta
  • Diastolic flow reversal in descending aorta
• Quantitative parameters
  
  • Regurgitant volumes
  • Regurgitant fraction
  • EROA
• Supportive signs
  
  • Pressure-half time
  • LV dimensions (LVEDD, EF)

Question 5

In addition to severity of AR what other parameters should be assessed/obtained in the evaluation?

Answer 5

• AS severity
  
  • AVA (using continuity equation)
  • Mean pressure gradient
  • Peak transvalvular velocity

Question 6

Describe the severity scale in diagnosis of AR:

• diastolic flow reversal

Answer 6

• Mild = no or brief early diastolic flow reversal in the descending aorta
  
  • obtained from suprasternal view
• Severe = holodiastolic flow reversal in descending thoracic/abdominal aorta
  
  • obtained in suprasternal or subcostal view
  • > 25 cm/s consistent with severe AR

Question 7

Answer 7

• Severe AR
  
  • holodiastolic flow reversal obtained from TTE PW doppler at the suprasternal notch

Question 8

Define AR pressure half-time?

Answer 8

measure of how quickly the aortoventricular pressure gradient equalizes during diastole

Question 9

Answer 9

• Moderate AR
  
  • CW doppler assessing pressure-half time of the regurgitant jet

Question 10

What are two factors that may influence PHT in AR?

Answer 10

• Systemic vascular resistance
• Ventricular compliance

Question 11

Describe the severity scale in diagnosis of AR:

• Pressure-half time

Answer 11

• Mild = > 500msec
• Moderate = 200-500msec
• Severe = < 200 msec
  
  • or a decay slope of > 3 m/sec²

**Obtained using CW doppler

Question 12

What are the quantitative measures of AR severity?

Answer 12

• Regurgitant volume
• Regurgitant fraction
• EROA

Question 13

Describe the severity scale in diagnosis of AR:

• Regurgitant volume

Answer 13

• Mild = < 30 mL/beat
• Moderate = 30 - 44 mL/beat
• Moderately severe = 45 - 59 mL/beat
• Severe = > 60 mL/beat

Question 14

Describe the severity scale in diagnosis of AR:

• Regurgitant fraction

Answer 14

• Mild = < 30%
• Moderate = 30 - 39%
• Moderately Severe = 40 - 49%
• Severe = > 50%

Question 15

Describe the severity scale in diagnosis of AR:

• EROA

Answer 15

• Mild = < 0.10 cm²
• Moderate = 0.10 - 0.19 cm²
• Moderately Severe = 0.2 - 0.29 cm²
• Severe = > 0.30 cm²

Question 16

What is the recommended monitoring in patients with:

• Mild MR
• normal LV systolic function
• near normal LV end-diastolic dimension

Answer 16

• Clinical exam yearly
• Echo every 2-3 years

Question 17

What is the recommended monitoring in patients with:

• Severe MR
• normal LV systolic function
• evidence of LV dilatation (LV end-diastolic dimension > 60mm)

Answer 17

• Clinical exam - 6 months
• Echo - 6-12 months

Question 18

What is the recommended monitoring in patients with:

• Severe MR
• normal LV systolic function
• advanced LV dilatation (LVEDD > 70mm, LVESD > 50mm)

Answer 18

• Clinical exam - < 6months
• Echo - < 6 months

Question 19

What are the indications for aortic valve replacement in:

• Severe AR
• Asymptomatic

Answer 19

• LV systolic dysfunction (EF < 50%)
• Severe LV enlargement (regardless of LV function)
  
  • LVEDD > 75mm
  • LVESD > 55mm

Question 20

What is the normal diameter: aortic annulus (BSA index)

Answer 20

• 20 - 31 mm (13 +/- 1 mm/m²)
• Upper limit normal:
  
  • men = 32 mm
  • women = 27 mm

Question 21

What is the normal diameter: aortic root/sinus of valsalva (BSA index)

Answer 21

• 29 - 45 mm (19 +/- 1 mm/m²)
• Upper limit of normal:
  
  • men = 40 mm
  • women = 36 mm

Question 22

What is the normal diameter: sinotubular junction (BSA index)

Answer 22

• 22 - 36 mm (15 +/- 1 mm/m²)
• Upper limit of normal:
  
  • men = 36 mm
  • women = 32 mm

Question 23

What is the normal diameter: proximal ascending aorta (BSA index)

Answer 23

• 22 - 36 mm (15 +/- 1 mm/m²)
• Upper limit of normal:
  
  • men = 38 mm
  • women = 35 mm

Question 24

Answer 24

• Prolapse of the distal right coronary cusp
• TEE with scalloped appearance

Question 25

Describe the algorithm to distinguish mild or severe AR

Answer 25

1. Is the color Doppler width \< 25% of the LVOT width? * YES = Mild AI, if CW Doppler is also faint * No (o not central jet), continue to 2 2. What is the VC? * \< 3 mm = mild AI * \> 6mm = SEVERE AI * 3-6mm (or not obtainable), continue to 3 3. Is there *abdominal* aortic flow reversal with PW? * YES = SEVERE AI * NO, continue to 4 4. PW quantification? * RV \> 60% or RF \> 50% = SEVERE AI * NO (or unobtainable): consider other imaging modality or invasive evaluation.

Question 26

What finding on imeediate post-procedure intraoperative TEE would be the most strongly associated with the risk of recurrence of severe AR after AV repair?

Answer 26

distance of the cusp coaptation to the aortic annulus

Question 27

What are the levels of severity in the jet width/LVOT ratio or JWR (jet/width ratio) for evaluation of AR?

Answer 27

* Mild * \< 25% * Moderate: * 25-44% (Grade II) * 45-64% (Grade III) * Severe * \> 65%

Question 28

What is the downside of the JWR in evaluation of AR?

Answer 28

* Eccentric AR may be underestimated by this method * Should not be used with eccentric or multiple jets as it can overestimate severity with rapidly expanding jets

Question 29

Answer 29

* Diastolic flow reversal in the abdominal aorta and descending thoracic aorta * Supportive signs of severe AR

Question 30

In what scenario may a patient have a PHT \>200ms and still have chronic, severe AR?

Answer 30

* PHT typically shortens with increasing severity of AR * However, as LV remodels and LV diastolic pressure decreases over time, a subject with severe chronic AR can have a PHT \> 200ms

Question 31

What are two M-mode findings of AR (mainly acute)?

Answer 31

* fluttering of the anterior mitral valve leaflet during diastole due to aortic regurgitant jet hitting the anterior leaflet * premature closure of the MV due to increased LV diastolic pressure

Question 33

What are common differences between acute and chronic AR?

Answer 33

* LV usually not dilated * Murmur and color jets not impressive * Vena contracta more reliable * Diagnosis on high clinical suspicion, context

Question 34

What is the general pathophysiologic mechanism of AR?

Answer 34

Volume and pressure overload * * almost never too late to operate *

Question 35

What is the EF cutoff for symptomatic patients with AR and low EF?

Answer 35

Almost no cutoff * even EF \< 25% may benefit * prognosis without surgery very poor

Question 36

What is the LVESD

Question 37

What is the formula for Jet width ratio (%)?

Answer 37

Jet Width Ratio (%) = ((AR Jet Width (cm)/(LVOT Diameter (cm)) x 100

Question 38

What is the formul for Jet Area/LVOT Area Ratio? What are the cutoffs?

Answer 38

* Jet Area Ratio (%) = ((AR Jet Area (cm2 )/(LVOT Area (cm2)) x 100 * Severity: * mild \< 5% * sever \> 60%

Question 39

What are the two findings on M-mode that identify the presence of AR?

Answer 39

* Fluttering of the anterior mitral valve * occurse during diastole due to the presence of a pressure gradient across tha tnerior mitral leaflet * Premature diastolic closure of the mitral valve * due to increased LV diastolic pressure * an create murmur similar to MS --\> "Austin-Flint" murmur

Question 40

Answer 40

* Severe AR effecting the MV on M-mode * diastolic fluttering of MV * premature diastolic closure (yellow)

Question 41

What type of remodeling takes place in chronic AR? Why is this important to assess?

Answer 41

* LV dilatation --\> eccentric hypertrophy * in order to normalize afterload and wall stress * Excessive LV dilatation and reduced LVEF may lead to LV fibrosis that will not undergo reverse remodeling even with AVR

Question 42

In the setting of severe AR, what are the class I recommendations for AVR?

Answer 42

* Symptomatic * Asymptomatic, LVEF \< 50% * Undergoing other cardiac surgery

Question 43

In the setting of severe AR, what are the class IIa recommendations for AVR?

Answer 43

* LVESD \> 50 mm or indexed LVESD \> 25 mm/m2 * Undergoigoing other cardiac surgery * Moderate AR\*\*\*

Question 44

In the setting of severe AR, what are the class IIb recommendations for AVR?

Answer 44

LVEDD \> 65 mm and low surgical risk

Question 45

What is the initial medical therapy for acute AR?

Answer 45

* IV vasodilators (nitroglylcerin) * Afterload reduction * IV diuretics * to reduce congestion * IV inodilators (Dobutamine) * in cardiogenic shock * LV mechanical support * IABP contraindicated in more than mild AR \*\*\*Definitive therapy --\> surgery

Question 46

What is the medical therapy for chronic AR?

Answer 46

* Vasodilators * to treat systemic arterial hypertension (class I) * Beta-blockers (class IIa) \*\*\*\*Definitive therapy --\> surgery