Download Adult Echocardoigraphy. Lecture 9 Valvular Heart Disease

ADULT
ECHOCARDIOGRAPHY
Lesson Nine
Valvular Heart Disease
Harry 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 preclosure?
– An elevated LVEDP
The line in the QRS: MV preclosure 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 MMode 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
Etiology
Primary valve disease (stenosis,
endocarditis)
Pulmonary hypertension
Carcinoid heart disease
Trivial/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 DiseaseFixed leaflets
• NOTE:
– What is the most common
valvular abnormality
associated with carcinoid
syndrome?
• Tricuspid regurgitation
End lesson Nine
NEXT: PROSTHETIC
VALVES