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Assessment of Mitral & Aortic Regurgitation At Bed Side , Echo Lab &

Cath Lab

Dr. Dayasagar Rao .VDM CardiologyFRCP (Canada)

FRCP (Edinburgh)KIMS Hospital – Hyderabad

Telangana

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Valvular Regurgitation Quantification – severity Regurgitant -Volume(ml/beat)

-Fraction (RV/SV%) Regurgitant volume

- Regurgitant orifice area (EROA) - pressure gradient (between chambers) - SVR –HR - Compliance (Receiving chamber) - LV function

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Valvular RegurgitationRegurgitant: - Severity

- Re Volume - Re Fraction

Consequences: - LV dilatation - LV function - LA dilatation

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Valvular regurgitationNative valve:

- Primary : Chronic Acute Acute on chronic

Secondary :

Prosthetic valve

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PARAMETERSSymptoms/ HistoryPhysical signs: -JVP

-Pulse -BP

Chamber enlargementCardiac murmursDynamic auscultation

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PHYSICAL SIGNS

Influenced by : - Heart rate - Blood pressure - Cardiac output - Heart failureVolume & volume of Blood flow – Cardiac murmursLow output – Alters the murmurs (intensity & duration)

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- Filling pressures: (LA/RA) - Cardiac output : Low output

Extent of disability: Self care Activity : 3 Mets Household Activity Leisure Activity Sport Activity : 10 Mets

More symptomatic - More severe lesionDiscrepancy - Symptoms & Severity

- Co- Morbidities : Anemia Infections Thyroid Etc.

SYMPTOMS

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COMPLICATIONS - Cardiomegaly - CHF / Ventricular Dysfunction - PAH - Atrial Fibrillation/Dysrhythmias

Related – Severity & Duration of valvular Disease

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MITRAL REGURGITATIONCardiomegaly / LV apex / PHWide splitting II, Early closure of A2S3Auscultatory findings – severity MR & valve morphologyPSM – Grade IV Conducted Axilla & Interscapular regionMDM

+

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Murmur is harsh (instead of soft blowing) indicating low & medium frequency. usually indicates lot of flow & thus significant regurgitationVariable correlation between intensity of MR murmur & severity of regurgitation.Loud murmur associated with thrill (grade IV / greater)Specificity : 91% Severe MRSensitivity : 24%

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Aortic RegurgitationPulse pressure >60 mm HgSystolic HTNDiastolic BP lowHills Sign : (?)Paradoxical split II sound in absence of LBBB indicates large LV stroke volume which indicates severe AR.Soft S1 elevated LV edp which is consequence of severe AR & LV Dysfunction.

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EDM : Length of murmur Location : LSE/RSE

Intensity : poor correlationHarsh QualityAustin FlintII sound: Root disease : loud

Valve disease: Soft / AbsentCardiomegaly – Apex HyperdynamicS3 is a sign of LV Dysfunction (not of severity of AR)

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CLINICAL ASSESSMENT OF VALVULAR HEART DISEASE

Symptom evaluation : severity Complications – AF,PH, CHF Cardiomegaly – chamber enlargement Sounds :S1&S2

S4/S3

Cardiac murmurs: - length of murmur - Intensity - Conduction

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ECHO Doppler evaluation-Regurgitation- valvular

M-mode – temporal resolution2DE: TTE Multiple views

TOEPulse Doppler/CW Doppler -Flows/VTIColour Doppler - Qualitative jet parameters

- Quantitative - Vena Contracta - PISA(for EROA)

Tissue Doppler - for LV functionStress Echo : - Physical

- PharmacologicRT3DE

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ECHO Doppler: valvular regurgitationAnatomy : Valve

Size of LV Aorta

Function:Complications:

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Severity MR PrimaryQualitative

MR JetLength 1/2 Length LAArea <4cm2 - >10cm2

Area/LA area <20% - > 40%Semi Quantitative

VC width (mm) <3 >7mmVTI: Mitral/Aorta <1 >1.4

Mitral Flow A>E E>1.5cm/secPulm Vein Flow Systolic Dominance Systolic flow reversal

QuantitativeEROA (mm2) <20 >40Reg Volume <30 >60

LA/LV Size/PA pressureEuropean Association Imaging - 2013

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Mitral Regurgitation Index

Six parameters : Jet lengthPISAJet DensityPulm venous flow patternPA pressure (RVSP)LA Size

Each Parameter Grade: 0-3/6MR index: <1.6 >2.1

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2DE – Doppler Quantification:AR

Colour flow imaging : - jet area: presence , Qualitative assessment- Central jet : rheumatic- eccentric jet : prolapse perforation

Jet width : Normalizing with LVOT Diameter >65% - severe AR

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ECHO Doppler:AR - summaryColour doppler :

Jet : -LVOT (presence) -vena contracta (quantification) -PISA : EROA regurg volume

Adjunctive parameters:-Diastolic flow reversal – aorta-PHT < 200msec

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ECHO Doppler GradingSeverity AR

QualitativeColour flow jet Width

LengthDiastolic Flow reversal

(Desc Thor Aorta)Abd Aorta

Pan diastolic

Semi QuantitativeVC (width) <3mm >6mmPHT (msec) >500 <200

QuantitativeEROA (mm2) <10 >30

Reg Volume (ml) <30 >60

LV Size/Function

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Cath lab – Evaluation -Severity regurgitation

Cardiac cath - Symptomatic patient Non invasive tests – inconclusive Discrepancy Non invasive test & physical exam (Severity of lesion) -Asymptomatic Exercise testing - confirm absence of symptoms - Assess Hemodynamic response to exercise - prognosis

ACC/AHA Guidelines – 2014Management of patients Valvular heart Disease

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Angiographic Assessment of Severity by Left Ventriculography

LA opacification

Time required

Clearance of LA opacification

Comparison with opacification of LV

1+ (Mild) Partial (Never complete)

----- Single beat Less

2+ (Moderate)

Faint complete Several beats Several beats Less

3+ (moderately severe)

Complete Several beats Several beats Same

4+ (severe) Complete Single beat Several beats More dense with each beatReflux of contrast in pulmonary veins

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Valvular RegurgitationSeverity Assessment

Clinical : Physical exam ECG CxR-PA

2DEcho + Doppler Qualitative Quantitative

Cath lab :Data Obsolete for many

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