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5-2 Aortic valve disease.ppt

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Aortic Valve Disease Aortic Valve Disease

Normal Aortic Valve Parasternal long axis view Three cusps (right, left and non-coronary) Valve Normal Aortic Valve Parasternal long axis view Three cusps (right, left and non-coronary) Valve area: 3 -4 cm 2 Separation: 2 cm

Normal Aortic Valve Parasternal short axis view Three cusps (right, left and non-coronary) Valve Normal Aortic Valve Parasternal short axis view Three cusps (right, left and non-coronary) Valve area: 3 -4 cm 2 Separation: 2 cm

Normal Aortic Valve Apical five chamber view Three cusps (right, left and non-coronary) Valve Normal Aortic Valve Apical five chamber view Three cusps (right, left and non-coronary) Valve area: 3 -4 cm 2 Separation: 2 cm

Normal Aortic Valve M-Mode CW Doppler Separation: 2 cm Maximal Velocity (LVOT): 0. 7 Normal Aortic Valve M-Mode CW Doppler Separation: 2 cm Maximal Velocity (LVOT): 0. 7 -1. 1 m/s Maximal Velocity (Aorta): 1. 0 -1. 7 m/s

Congenital Anomaly Unicuspid valve Bicuspid valve Quadricuspid valve Congenital Anomaly Unicuspid valve Bicuspid valve Quadricuspid valve

Bicuspid Aortic Valve Most common congenital anomaly (population 1 -2%) Systolic doming: PLAX Fish Bicuspid Aortic Valve Most common congenital anomaly (population 1 -2%) Systolic doming: PLAX Fish mouth appearance : PSAX

Bicuspid Aortic Valve commissure raphe Combined aortic aneurysm or AS Normal (15%), stenosis(72%), regurgitation Bicuspid Aortic Valve commissure raphe Combined aortic aneurysm or AS Normal (15%), stenosis(72%), regurgitation (4%), endocarditis (9%) Doppler is important

Quadricuspid Aortic Valve Quadricuspid Aortic Valve

Aortic Stenosis Aortic Stenosis

2 D Echocardiography Normal Aortic Stenosis Cusp calcification and thickening Cusp motion limitation and 2 D Echocardiography Normal Aortic Stenosis Cusp calcification and thickening Cusp motion limitation and doming Left ventricular hypertrophy

2 D Echocardiography Normal Aortic Stenosis Cusp calcification and thickening Cusp motion limitation Commissural 2 D Echocardiography Normal Aortic Stenosis Cusp calcification and thickening Cusp motion limitation Commissural fusion (in rheumatic AS)

Etiology of Aortic Stenosis Euro Heart Survey on Valvular Heart Disease Congenital Post endocarditis Etiology of Aortic Stenosis Euro Heart Survey on Valvular Heart Disease Congenital Post endocarditis (ex. Bicuspid etc) 1. 3% 5. 6% Rheumatic 11. 2% Degenerative-calcific 81. 9% Eur Heart J 2003; 24: 1231

Morphologic Characteristics Degenerative-Calcific Thick, stiff leaflets No commissural fusion Rheumatic Multivalvular involvement Commissural fusion Morphologic Characteristics Degenerative-Calcific Thick, stiff leaflets No commissural fusion Rheumatic Multivalvular involvement Commissural fusion

Degenerative vs. Rheumatic AS Degenerative Thick, stiff leaflets No commissural fusion Rheumatic Multivalvular involvement Degenerative vs. Rheumatic AS Degenerative Thick, stiff leaflets No commissural fusion Rheumatic Multivalvular involvement Commissural fusion

Degenerative vs. Rheumatic AS Degenerative Thick, stiff leaflets No commissural fusion Rheumatic Multivalvular involvement Degenerative vs. Rheumatic AS Degenerative Thick, stiff leaflets No commissural fusion Rheumatic Multivalvular involvement Commissural fusion

Membraneous Subaortic Stenosis Membraneous Subaortic Stenosis

Doppler Examination Pressure (mm Hg) LV and Aortic Pressures measured with catheter in a Doppler Examination Pressure (mm Hg) LV and Aortic Pressures measured with catheter in a patient with severe AS Maximum gradient by Doppler exam Peak-to-peak gradient by Catheter exam Time (s) Mean gradient

Doppler Examination Peak pressure gradient 4 x 4. 622 = 85. 3 mm. Hg Doppler Examination Peak pressure gradient 4 x 4. 622 = 85. 3 mm. Hg Mean pressure gradient 60. 9 mm. Hg Modified Bernoulli Equation Tracing of Velocity Curve Pressure Gradient = 4 x Vmax 2 Mean Pressure Gradient

Doppler Examination Angle Dependency Doppler Examination Angle Dependency

Differential Diagnosis of LVOT Obstruction Valvular Aortic Stenosis Subaortic Membrane Hypertrophic Cardiomyopathy Differential Diagnosis of LVOT Obstruction Valvular Aortic Stenosis Subaortic Membrane Hypertrophic Cardiomyopathy

Other High Velocity Systolic Jets that May Be Mistaken for Aortic Stenosis Mitral regurgitation Other High Velocity Systolic Jets that May Be Mistaken for Aortic Stenosis Mitral regurgitation Tricuspid regurgitation Supravalvular stenosis Ventricular septal defect Pulmonic or branch pulmonary artery stenosis Peripheral vascular stenosis IVCT (e. q. , subclavian artery) Aortic Stenosis Mitral Regurgitation

Calculation of Valve Area 2 D Planimetry Continuity equation Calculation of Valve Area 2 D Planimetry Continuity equation

2 D Planimetry Severe calcification: difficult to measure AVA (should trace 80% of AVA) 2 D Planimetry Severe calcification: difficult to measure AVA (should trace 80% of AVA)

2 D Planimetry Orifice Tip Subvalvular Area 0. 76 cm 2 Should measure oritice 2 D Planimetry Orifice Tip Subvalvular Area 0. 76 cm 2 Should measure oritice tip of AV 1. 30 cm 2

Continuity Equation LVOT X CSA AVA TVI LVOT Stroke Volume = AS-Jet Stroke Volume Continuity Equation LVOT X CSA AVA TVI LVOT Stroke Volume = AS-Jet Stroke Volume LVOT CSA x LVOT TVI = AVA x AS-Jet TVI CSA = AV AVA = (LVOT CSA x LVOT TVI) / AS-Jet TVI

Continuity Equation LVOT 2 D Measure LVOT PW Doppler LVOT Diameter = 1. 74 Continuity Equation LVOT 2 D Measure LVOT PW Doppler LVOT Diameter = 1. 74 cm LVOT TVI = 33 cm LVOT CSA LVOT Flow (π x [D/2]2) (LVOT CSA x Velocity) 3. 14 x 0. 872 = 2. 4 cm 2 2. 4 x 33 = 79. 2 m. L

Continuity Equation AV CW Doppler AV TVI = 107 cm Aortic Valve Area (LVOT Continuity Equation AV CW Doppler AV TVI = 107 cm Aortic Valve Area (LVOT Flow / AV TVI) = 79. 2 m. L / 107 cm = 0. 74 cm 2 AVA by Planimetry 0. 71 cm 2

Severity of Aortic Stenosis Mild Moderate Severe Severity of Aortic Stenosis Mild Moderate Severe

Quantification of Stenosis Severity Mild Moderate Severe Peak AV velocity (m/sec) < 3. 0 Quantification of Stenosis Severity Mild Moderate Severe Peak AV velocity (m/sec) < 3. 0 -4. 0 > 4. 0 Mean pressure gradient (mm. Hg) < 25 25 -40 > 40 Valve area (cm 2) > 1. 5 1. 0 -1. 5 < 1. 0 LVOT/AV TVI ratio > 0. 5 0. 25 -0. 5 < 0. 25

AS with Low Pressure Gradient Low Output with Low Pressure Gradient (AVA < 1. AS with Low Pressure Gradient Low Output with Low Pressure Gradient (AVA < 1. 0 cm 2 and PG < 30 mm. Hg) Dobutamine Stress Echocardiography Mild AS LV dysfunction due to other causes Ejection fraction Increased VS. LV dysfunction due to tight AS Increased No change LVOT/AV TVI ratio No change Increased No change Pressure Gradient > 40 mm. Hg < 30 mm. Hg Severe AS Mild AS No myocardial reserve (? ) Emergent operation

Aortic Regurgitation Aortic Regurgitation

Etiology of Aortic Regurgitation Cusp pathology Aortic wall pathology including aortitis Congenital Etiology of Aortic Regurgitation Cusp pathology Aortic wall pathology including aortitis Congenital

Cusp Pathology (Including congenital) Rheumatic Degenerative Infective endocarditis Congenitally bicuspid valve Ass. with membraneous Cusp Pathology (Including congenital) Rheumatic Degenerative Infective endocarditis Congenitally bicuspid valve Ass. with membraneous subaortic stenosis Ass. with ventricular septal defect Aortic valve prolapse (Myxomatous or congenitally abnormal) Less common - Unicommissural and quadricuspid valve - Rupture of a fenestrated valve - SLE, RA, Ankylosing spondylitis, Takayasu disease, Whipple disease, Crohn disease etc

Rheumatic AR Rheumatic AR

Degenerative AR Degenerative AR

Infective Endocarditis Infective Endocarditis

Bicuspid Aortic Valve Bicuspid Aortic Valve

Quadricuspid Aortic Valve Quadricuspid Aortic Valve

Ventricular Septal Defect Anatomical and pathological features in 37 patients with acquired aortic regurgitation Ventricular Septal Defect Anatomical and pathological features in 37 patients with acquired aortic regurgitation Eur Heart J 1998; 19: 1573

Ventricular Septal Defect Ventricular Septal Defect

Aortic Valve Prolapse Best seen in parasternal long axis view Disruption of commissural support Aortic Valve Prolapse Best seen in parasternal long axis view Disruption of commissural support - Dissection - Dilatation - Ass. with VSD - Myxomatous or congenitally abnormality

Aortic Valve Prolapse (TTE) Aortic Valve Prolapse (TTE)

Aortic Valve Prolapse (TEE) Aortic Valve Prolapse (TEE)

Aortic Root Disease Aortic dilatation related with - Hypertension - Age-related (degenerative) - Bicuspid Aortic Root Disease Aortic dilatation related with - Hypertension - Age-related (degenerative) - Bicuspid AV Aortic dissection Cystic medial necrosis (Marfan syndrome) Takayasu arteritis Behcet’s disease Ankylosing spondylitis Less common - Syphilitic aortitis, psoriatic arthritis, UC, giant cell arteritis - relapsing polychondritis, Reiter syndrome

Effacement of the Sinotubular Junction Hypertension, Degeneration, Bicuspid AV Effacement of the Sinotubular Junction Hypertension, Degeneration, Bicuspid AV

Aortic Dissection Aortic Dissection

Marfan Syndrome-I Marfan Syndrome-I

Marfan Syndrome-II Marfan Syndrome-II

Behcet’s Disease Behcet’s Disease

Behcet’s Disease vs. Takayasu’s Arteritis Behcet’s disease Takayasu’s (n=7) arteritis (n=9) Aortic valve cusp: Behcet’s Disease vs. Takayasu’s Arteritis Behcet’s disease Takayasu’s (n=7) arteritis (n=9) Aortic valve cusp: elongation and redundant motion thickening and motion limitation 7 0 0 8 Echo-free space 4 0 Masslike lesion 2 0 Dilated aorta 0 4 Aortic wall thickening 4 9 Mitral valve involvement 1 0 JASE 2003; 16: 850

M-Mode AMVL fluttering in diastole Premature closure of MV and Diastolic opening of AV M-Mode AMVL fluttering in diastole Premature closure of MV and Diastolic opening of AV in severe AR

Estimating the Severity of AR Color Flow - Jet area/height - Vena contracta width Estimating the Severity of AR Color Flow - Jet area/height - Vena contracta width - Flow convergence or PISA Continuous Wave Doppler - Signal density - Pressure half time (P½t) or Slope Pulsed Wave Doppler - Regurgitant volume/fraction - Descending aortic flow reversal 2 D Echocardiography - LV end-diastolic dimension - LV end-systolic dimension

Color Flow Jet Area/Jet Height Mild Severe Jet width < 25 % ≥ 65 Color Flow Jet Area/Jet Height Mild Severe Jet width < 25 % ≥ 65 % Jet area <5% ≥ 60 %

Color Flow Jet Area/Jet Height Instrument (gain) dependent, Eccentric Jet, Temporal variability Multiple jets Color Flow Jet Area/Jet Height Instrument (gain) dependent, Eccentric Jet, Temporal variability Multiple jets or Jets with irregular shapes

Color Flow Vena Contracta Width (Semiquantification Method) Most narrow point : just below flow Color Flow Vena Contracta Width (Semiquantification Method) Most narrow point : just below flow convergence reflect regurgitant orifice area Measure at zooming parasternal long axis view Vertical to AR jet : measure vena contracta width

Color Flow Vena Contracta Width (Semiquantification Method) Mild Severe < 3 mm > 6 Color Flow Vena Contracta Width (Semiquantification Method) Mild Severe < 3 mm > 6 mm

Color Flow Convergence or PISA ERO = 6. 28 x r 2 x Aliasing Color Flow Convergence or PISA ERO = 6. 28 x r 2 x Aliasing velocity Regurgitant volume = Peak AR Velocity 6. 28 x r 2 x Aliasing velocity Peak AR Velocity x AR TVI Multiple measurements, Technically challenging AV calcification, Multiple jets, Aortic aneurysm, Limited experience

Continuous Wave Doppler CW Doppler Signal Density Qualitative Overlap between moderate and severe AR Continuous Wave Doppler CW Doppler Signal Density Qualitative Overlap between moderate and severe AR Aortic compliance, Blood pressure, LV size and compliance, etc An indicator of acuity rather than severity

Continuous Wave Doppler Diastolic Jet Deceleration Mild Severe Mild PHT Severe > 500 ms Continuous Wave Doppler Diastolic Jet Deceleration Mild Severe Mild PHT Severe > 500 ms < 200 ms

Pulsed Wave Doppler Descending Aorta Holodiastolic Flow Reversal Descending Thoracic Aorta Aortic compliance Sample Pulsed Wave Doppler Descending Aorta Holodiastolic Flow Reversal Descending Thoracic Aorta Aortic compliance Sample volume location Abdominal Aorta

Pulsed Wave Doppler Regurgitation Volume and Fraction CSAAV = πr 2 = 0. 785 Pulsed Wave Doppler Regurgitation Volume and Fraction CSAAV = πr 2 = 0. 785 x D 2 SVAV = CSA x TVI CSAMV = πr 2 = 0. 785 x D 2 SVMV = CSA x TVI Aortic Regurgitant Volume = SVAV - SVMV Regurtitant Fraction = (Aortic regurgitant volume / SVAV) x 100

Pulsed Wave Doppler Regurgitation Volume and Fraction Aortic flow CSAAV = 6. 2 cm Pulsed Wave Doppler Regurgitation Volume and Fraction Aortic flow CSAAV = 6. 2 cm 2 TVIAV = 37 cm SVAV = 230 cc Regurgitant volume 112 – 69 = 139. 4 cc Regurgitant fraction 43/112 = 60. 8% Mitral flow CSAMV = 7. 7 cm 2 TVIMV = 12 cm SVMV = 90 cc Require multiple measurements Assumes no regurgitation at reference valve Different stroke volume when atrial fibrillation exists

Quantification of AR Severity Mild Moderate Severe Regurgitant jet width / LVOT diameter (%) Quantification of AR Severity Mild Moderate Severe Regurgitant jet width / LVOT diameter (%) < 25 25 - 64 ≥ 65 Vena contracta width (mm) <3 3 -6 ≥ 6 Regurgitant jet area / LVOT area (%) <5 5 - 59 ≥ 60 Regurgitant volume (m. L per beat) < 30 30 - 59 ≥ 60 Regurgitant fraction (%) < 30 30 - 49 ≥ 50 < 0. 10 – 0. 29 ≥ 0. 30 LV size (cm) < 5. 5 – 7. 5 >7. 5 PHT of CW Doppler signal (msec) > 500 200 - 500 < 200 CW Doppler signal density Faint Dense Intermediate Holodiastolic Qualitative Quantitative Regurgitant orifice area (cm 2) Additional criteria Diastolic reversal flow in descending aorta Mild early diastolic Restrictive mitral flow pattern No Acute setting

Quantification of AR Severity Mild Regurgitant jet width/LVOT diameter Regurgitant jet area/LVOT area PHT Quantification of AR Severity Mild Regurgitant jet width/LVOT diameter Regurgitant jet area/LVOT area PHT of CW Doppler signal Moderate Severe

Acute versus Chronic AR Acute Etiology (example) LV Size LV End-Diastolic Pressure Pulse Pressure Acute versus Chronic AR Acute Etiology (example) LV Size LV End-Diastolic Pressure Pulse Pressure CW Doppler Slope Indicators of Acuity Chronic Endocarditis Aortic Dissection Trauma Several cause Normal Dilated Elevated Normal Narrow Wide Steep Flat Restrictive Mitral Inflow CW Doppler Density Premature Closure of MV Diastolic MR NA

Acuity of AR Shape of AR on CW Doppler Premature Closure of MV Diastolic Acuity of AR Shape of AR on CW Doppler Premature Closure of MV Diastolic MR