Echocardiographic evaluation of AR

1. Echocardiographic evaluation of
Aortic regurgitation
Dr.S.R.Sruthi
Meenaxshi.MBBS,MD,PDF

2. Aortic Regurgitation
• In contrast to the mitral, tricuspid, and pulmonic
valves, trivial aortic regurgitation is far less common in
healthy young adults.
• As the aortic valve becomes thickened or sclerotic,
mild degrees of aortic regurgitation may develop.
• Pathologic aortic regurgitation may arise from a variety
of aortic valve and aortic root abnormalities.
• It may coexist with aortic stenosis

3. AORTIC MEASUREMENTS

5. CAUSES OF AORTIC REGURGITATION

6. ETIOLOGY OF AORTIC REGURGITATION

7. M MODE IN AORTIC REGURGITATION
Diastolic fluttering of the anterior mitral valve
leaflet, which occurs when the regurgitant jet is
directed posteriorly, was the first M-mode
echocardiographic observation permitting the
detection of aortic regurgitation.
This sign is less relevant today since Doppler is
more accurate for all degrees of aortic
regurgitation, including the most trivial.

8. M mode anterior mitral leaflet fluttering / septal diastolic fluttering
Premature diastolic closure due to hemodynamic impact of Aortic
regurgitaion

9. Acute aortic regurgitation
Causes of acute severe aortic regurgitation include
❖ aortic valve endocarditis,
❖ aortic dissection involving the aortic valve
❖ and chest trauma/deceleration injury
Echocardiographic signs of rapid equilibration of aortic and LV diastolic
pressures include premature closure of the mitral valve before the
onset of the QRS as seen on M-mode.
Premature mitral valve closure is a sign indicating that valve closure is
caused by an inappropriate rise in LV diastolic pressure due to filling
from aortic regurgitation rather than by pressure generated by
isovolumic contraction

10. Chronic aortic regurgitation
In asymptomatic patients with hemodynamically
significant aortic regurgitation, it is important to obtain
accurate linear measurements of left ventricular
dimensions at end-diastole (LVIDd) and end-systole
(LVIDs).
• It is preferable to make the measurements directly on
the two-dimensional image to ensure that they are
perpendicular to the long axis of the ventricle.
Indications for aortic valve surgery (including LVIDs and
LVIDd thresholds) are discussed separately.

11. 2 D ECHOCARDIOGRAPHY
• The two-dimensional echocardiogram is important for
establishing the etiology and mechanism for the aortic
regurgitation
• Aortic regurgitation may be due to valvular pathology or
aortic root pathology.
• features of the valve include:
• the number of leaflets,
• the presence of cusp prolapse
• , leaflet destruction or perforation, or
• vegetations interfering with leaflet closure

12. • The aortic root may be dilated due to annuloaortic
ectasia
• connective tissue disease,
• the aortopathy associated with bicuspid aortic valve, or
inflammatory disease.
• In aortic dissection, aortic regurgitation may be due to
the intimal flap interfering with cusp closure, root
dilation, or loss of valve support with extension of the
dissection to the annulus.
• When transthoracic echocardiography (TTE) is
inadequate, transesophageal echocardiography may
provide additional information.

13. • Quantitation of total LV stroke volume from two
dimensional echocardiography planimetry of the LV or
from the LV outflow tract (LVOT) flow can be compared
with the effective forward systemic flow as estimated
from transmitral or transpulmonic flow so that
regurgitant volume and regurgitant fraction can be
calculated from their difference
• Using the continuity principle, effective regurgitant
orifice can also be computed
.

14. Doppler echocardiography
• Doppler echocardiography is the principal
method for evaluation of the patient
suspected of having aortic regurgitation
• Color flow Doppler of the aortic valve from
the parasternal long and short axis views is
highly sensitive to aortic regurgitation and will
demonstrate very mild to severe regurgitation

15. A 26 yr old with aortic root dilatation .
Inadequate Central coaptation of valve
leaflets

16. 2017 American Society of
Echocardiography (ASE) on evaluation
of valvular regurgitation
semiquantitative methods of grading the severity of
aortic regurgitation
• The width of the vena contracta,
• the jet width and area,
• the rate of decay of the continuous wave diastolic
velocity (as measured by the pressure half-time),
• the density of the continuous wave jet,
• and the duration of reverse flow in the descending
aorta].

17. Jet area width – semi quantitative
method for assessing severity

18. COLOR FLOW DOPPLER OF AORTIC
REGURGITATION

19. Vc width

20. COLOR FLOW DOPPLER OF AR JET

21. Asssesment of severity by CF Mapping

23. Signal intensity – CW Doppler

24. Aortic Flow diastolic reversal severe AR

25. Deceleration slope in assessing
severity of Aortic Regurgitation

26. Regurgitant volume and fraction
assessment

27. QUANTITATIVE METHODS FOR
• Quantitative methods include the effective
regurgitant orifice area (EROA) and the
regurgitation volume

28. SEVERITY OF AORTIC REGURGITATION

30. • Evidence of aortic and LV diastolic pressure
equilibration seen with acute severe aortic
regurgitation includes a short aortic
regurgitation pressure half-time, a short mitral
deceleration time (waveform 2), as well as
premature closure of the mitral valve as
mentioned above.

31. RESTRICTIVE MITRAL INFLOW SHORT
PHT

32. WIDTH OF VC
• The vena contracta is the narrowest neck of the color flow jet as it passes
from the aortic valve and enters the LVOT (receiving chamber).
• The width of the vena contracta correlates with the severity of aortic
regurgitation
• Mild aortic regurgitation is present when the vena contracta width is less
than 0.3 cm and severe regurgitation is present when the vena contracta
width is greater than 0.6 cm
• This method may be more robust than jet width, particularly in the
presence of eccentric jets.
• In the above cited study comparing vena contracta with effective
regurgitant orifice area, a vena contracta ≥0.6 cm was 81 percent sensitive
and 83 percent specific for severe aortic regurgitation

33. JET WIDTH
• A related but distinct parameter is the ratio of the jet width
to the width of the LVOT.
• The width of the jet is measured just proximal to (below)
the vena contracta within 1 cm of the aortic valve leaflets.
A ratio of less than 25 percent is considered mild and 65
percent or greater is considered severe
• A ratio of the cross-sectional area of the jet to the cross-
sectional area of the LVOT of <5 percent is categorized as
mild and ≥60 percent is categorized as severe. The accuracy
of jet width and area estimates may be limited when an
eccentric jet is present

34. REVERSAL OF AORTIC FLOW
• Normally, when flow is sampled in the descending aorta, most flow occurs
during ventricular systole and is antegrade.
• Using magnetic resonance (MR) imaging phase velocity methods, forward
flow is seen to stop in the descending aorta during diastole.
• On pulsed wave Doppler of the descending aorta in normal individuals,
there is brief early diastolic reversal of flow
• In aortic regurgitation, retrograde flow can be detected and its quantity
and duration is proportional to the degree of severity of the lesion
• The retrograde flow signal may become holodiastolic and the velocity
time integral of retrograde diastolic flow may approach that of systolic
flow.

36. • There are several pitfalls in using this sign for evaluating AR severity.
Diastolic flow reversal may become more prominent with decreases in
aortic compliance as occurs with normal aging. Diastolic flow reversal in
the descending thoracic aorta may also be due to an upper extremity
arteriovenous fistula for dialysis or a cerebral arteriovenous
malformation.
• In the above cited study comparing diastolic flow reversal with effective
regurgitant orifice area, a diastolic flow reversal ≥18 cm/sec was 45
percent sensitive and 87 percent specific for severe aortic regurgitation
• Thus, the presence of this finding must be integrated with other measures
of AR severity.
• In the quantitative application of relative antegrade and retrograde flows,
one must also account for changes in aortic diameter which must be
measured in diastole and systole

37. CONTINUOUS WAVE DOPPLER
• Continuous wave Doppler of the regurgitant jet
acquired from the apical five chamber or apical
three long axis can be used to qualitatively grade
the severity of aortic regurgitation
• . The more rapidly the signal decays, the more
severe the regurgitation
• A deceleration time of less than 200 msec or a
decay slope greater than 3 m/sec2 is indicative of
severe aortic regurgitation

38. DIASTOLIC DECELERATION OF AORTIC
REGURGITATION

39. PRESSURE HALF TIME METHOD
ASSESSMENT OF SEVERITY OF AR

40. • However, the pressure half-time has limited
sensitivity for detection of severe aortic
regurgitation, particularly in the chronic setting.
• In the above cited study comparing pressure half
time with effective regurgitant orifice area, a
pressure half time <200 msec was 12 percent
sensitive and 100 percent specific for severe
aortic regurgitation

41. • The pressure half-time can be confounded in situations such as
severe heart failure, where the filling pressure in the LV is elevated
and mean aortic pressure reduced.
• It can also be influenced by changes in systemic vascular resistance
and LV compliance. Increasing the systemic vascular resistance
increases the rate of decay without any change in valve orifice;
reduced LV compliance produces a more rapid rise in LV pressure,
which influences the diastolic slope without reflecting the severity
of aortic regurgitation.
• In patients with compensated chronic severe aortic regurgitation,
the dilated ventricle may have near normal filling pressures and the
rate of diastolic velocity decline is often intermediate

42. SEVERITY OF AORTIC REGURGITATION
• Severe aortic regurgitation is considered to be present
if at least four of the following findings are present on
echocardiography
❖●Vena contracta width >6 mm
❖●Flail valve
❖●Central jet width ≥65 percent of LVOT
❖●Prominent holodiastolic flow reversal in the
descending aorta
❖●Large flow convergence
❖●Enlarged LV with normal systolic function
❖●Pressure half-time <200 msec

43. • If only two or three of the above criteria are
present, quantitation is performed to
determine if one or more of the following
criteria for severe aortic regurgitation are
present
●A regurgitant fraction ≥50 percent
●A regurgitant volume ≥60 Ml
●An effective regurgitant orifice area ≥0.30 cm2

46. AORTIC ROOT DISEASE
• Aortic root dilatation is a common cause of aortic regurgitation.
• Aortic root dilation is often idiopathic.
• Causes of aortic root dilation include dilation associated with
bicuspid aortic valve,
• Marfan syndrome,
• sinus of Valsalva aneurysm (with and without fistulous connection),
• annuloaortic ectasia
• luetic aortitis
• aortic root dilation in association with ankylosing spondylitis.
Dilation of the aortic root and thickening of its walls are, however,
common echocardiographic findings.

47. Aortic root dilatation

50. • Bicuspid aortic valve — Aortic regurgitation
commonly arises in non-stenotic bicuspid aortic
valves.
• These valves can often be recognized by two
dimensional imaging of the aorta in the
precordial short axis view
• . The mechanism for aortic regurgitation in the
setting of bicuspid aortic valve may be due to
associated aortic root dilatation, endocarditis, or
cusp prolapse.

52. Bicuspid aortic valve – fish mouth
appearance
causing aortic regurgitation

53. M mode eccentricity of closure

54. Marfan syndrome
The Marfan syndrome is associated with aortic
regurgitation due to aortic dilatation as well as mitral
valve prolapse.
In Marfan syndrome, the appearance of the aortic valve
and root may be distinctly different from that in other
conditions
In the Marfan patient, isolated dilation of the sinuses of
Valsalva with sparing of the ascending aorta and a
nonprolapsing aortic valve are typical, although diffuse
fusiform dilatation may be present

55. Marfans syndrome

56. Marfans syndrome

58. Aortic root dilatation

59. Aortoannular ectasia

60. AORTIC DISSECTION
• Dissection of the proximal aorta is a major cause
of acute severe aortic regurgitation.
• Transesophageal echocardiography (TEE),
computed tomography, and magnetic resonance
imaging are the methods of choice for the
emergency diagnosis of aortic dissection .
• By transthoracic echocardiography (TTE), the
intimal flap can be very difficult to image, but
some degree of root dilation is usually present.

61. Dissecting aorta

62. • Sinus of Valsalva aneurysm — Sinus of Valsalva
aneurysm, a form of aortic root aneurysm, is
characterized by asymmetric dilation involving
one of the sinuses.
• The dilated sinus will often bulge in systole,
facilitating detection.
• In the setting of a sinus of Valsalva aneurysm, a
Doppler examination should be performed and
both aortic regurgitation and an intracardiac
communication at the site of the aneurysm
sought.

63. Rheumatic disease
• Aortic regurgitation in association with rheumatic
mitral involvement can be readily appreciated by
Doppler echocardiography.
• In this setting, the aortic valve leaflet edges are
thickened along their entire border and the aortic
ring is small and normal in appearance.
• While this type of aortic regurgitation is often
mild, it can occasionally be moderate or even
severe.

64. Endocarditis of aortic valve
• Endocarditis of the aortic valve is a leading cause of
acute severe aortic regurgitation.
• Classically, dense mobile echoes prolapsing into the left
ventricular outflow tract are diagnostic when present.
However, approximately 25 percent of patients with
clinically diagnosed infective endocarditis have no
vegetations detected by TTE.
• The presence of a pre-existing abnormality serving as a
nidus for infection, especially if calcified, can make
vegetation detection difficult by TTE
• TEE, with its superior resolution, has greatly improved
the detection rate of vegetations of the aortic valve

65. Endocarditis of aortic valve

67. Infective endocarditis of aortic valve

68. • Secondary involvement of the mitral valve in patients
with primary aortic valve endocarditis has been
demonstrated on TEE in 10 percent of patients.
• This can arise from large aortic vegetations (>6 mm)
that prolapse into the left ventricle during diastole
and contact the anterior mitral leaflet, causing it to be
secondarily infected (mitral kissing vegetation) .
• Mitral valve involvement can also result from direct
extension of infection through the continuous central
fibrous body.

69. AR ASSOCIATED SUB AORTIC STENOSIS
• Aortic regurgitation can arise in association
with jet lesions from subaortic stenosis
• In this situation, dynamic or fixed outflow
tract narrowing produces a jet of high velocity
blood that strikes the aortic valve.
• The resulting damage may alter the valve
architecture and produce aortic regurgitation.

70. MYXOMATOUS DISEASE
• Aortic regurgitation in association with mitral valve
prolapse can be due either to myxomatous changes in
the leaflets themselves or to aortic root disease.
• Although very uncommon, aortic valve prolapse due to
myxomatous degeneration can be seen in association
with mitral prolapse.
• The most common manifestation of aortic root disease
is general dilatation of the sinuses. Dilatation limited
to one sinus is called a sinus of Valsalva aneurysm,
which is a form of aortic root aneurysm.

71. • Rheumatoid arthritis —
• Rarely, aortic regurgitation can arise from a
rheumatoid nodule on the valve

72. • Leaflet fenestrations — Leaflet fenestrations
are said to be common among post mortem
specimens. They can be inferred by color flow
Doppler detection of an unusual site of
regurgitation.

73. Ventricular septal defect
• Small ventricular septal defects in the
perimembranous region frequently close during
childhood. They can be associated with aortic
regurgitation that can persist after closure.
• Infundibular (also known as supracristal)
ventricular septal defects are also associated with
aortic regurgitation and are more likely to be
associated with hemodynamically significant
aortic regurgitation due to undermining of the
right coronary cusp, resulting in prolapse.