Assessment of Mitral & Aortic Regurgitation At Bed Side ,...
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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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24ECHO-Doppler Grading
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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