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