Asymptomatic Aortic Regurgitation...Anatomy of aortic leaﬂets and root! Presence and severity of...

Asymptomatic Aortic Regurgitation

Theodora Zaglavara, MD, PhDEuromedica Kyanous Stavros Hospital

Thessaloniki, GREECE

Wednesday, March 4, 15

No Disclosures

Pathophysiology of Chronic Aortic

2 Major Questions: - Is Aortic Regurgitation Severe? - Does the Patient have

Survival Free of Surgery for AR after Diagnosis in Asymptomatic Patients. Patients are Stratified According to Quantitative Criteria of the ASE for AR Grading

Survival without Surgery in 242 Patients with Chronic AR Demonstrating the Importance of Symptoms in Determining Outcome

Dujardin et al. Circulation 1999J Am Coll Cardiol Img 2008

! Anatomy of aortic leaflets and root! Presence and severity of AR! Additional echo findings ! Assessment of LV size and function! Assessment of the aorta

Valve Anatomy/Aetiology and Mechanisms of AR/Functional Classification Calcification Grade/Suitability for Repair in Pure AR/Aortic Root Assessment

! Congenital (bicuspid unicuspid)! Degenerative (fibrosis/sclerosis)! Rheumatic! Endocaritis! Miscellaneous

! Hypertension! Bicuspid valve! Annuloaortic ectasia! Marfan syndrome! Aortic dissection

Leaflet AbnormalitiesAortic Root Abnormalities

• Aortic dissection• Trauma• Infective endocaritis• Post – balloon or surgical

valvotomy

Acute events

valvotomy

Acute events

valvotomy

Acute events

valvotomy

Acute events

valvotomy

Acute events

valvotomy

Acute events

valvotomy

Acute events

Caution with Eccentric Jets!!

Vena Contracta! The narrowest portion of the flow region at

or just below valve level ! Provides an estimate of the size of EROA! Simple, quantitative, highly feasible! Less sensitive to haemodynamic changes

or instrument settings! Not useful for multiple or irregular AR jets! < 0.3 not severe AR! > 0.6 severe AR (Nyquist Limit of 50-60 cm/

How to do PISA Measurements in AR! Use apical views! Zoom on supravalvular region! Shift colour doppler baseline upwards to obtain a rounded

and measurable PISA! Select frame with largest PISA and measure aliasing radius! Obtain CW Doppler recording of the regurgitant flow and

measure AR VTI! EROA and RV will be automatically calculated by most current

ultrasound systems

The thresholds for severe AR are an EROA ≥ 30 mm² and RV ≥ 60 ml and for mild AR an EROA < 10 mm² and RV < 30 ml

Aortic Diastolic Flow Reversal

ED vel > 0.2 m/s

Consequences of Aortic Regurgitation

LVEDV: 229 ml, LVESV: 142 ml, EF: 38%

New 2015!!!!!!!

Wealth of published data!!

Established prognostic value!Vendor dependent!

Global Longitudinal Strain

3-D Volumes

Less published data on normal values!!

Natural History of Asymptomatic Aortic Regurgitation

>65 mm IIb AHA 20014

Indications for Surgery in Chronic Severe Aortic Regurgitation

J Am Coll Cardiol, 47 (2006), pp. 1012–1017

Survival After Aortic Valve Replacement for Aortic RegurgitationLong-term survival after valve replacement for aortic regurgitation demonstrating improved outcome with early surgery.

Long-term Post-operative Survival in Patients with AR, Stratified According to the Severity of Preoperative Symptoms and Preoperative LVEF

Klodas E et al. J Am Coll Cardio 1997

The Management of Asymptomatic AR Remains Challenging ! A balance needs to be reached between the competing risks

of chronic AR and having an artificial valve.

! Even if the risks of surgery were negligible, the need of either long-term anticoagulation for mechanical prosthesis or redo surgery for inevitable bioprosthetic valve degeneration imposes a significant disease burden.

! In contrast to MV repair AoV repair is limited to specific valve

Aortic Valve and/or Root Repair for ARKvitting JP et al. J Thorac Cardiovasc Surg 2013

Surgical Results for Aortic Valve Repair and Aortic Valve Replacement with A Bioprosthesis

A. Bovine B. Porcine Pericardial Bioprosthesis

B. Annals Thorac Surgery 1998Annals Thorac Surgey 2001

EF ≤ 50 %

LVDD >70 mm

LVSD > 50 mm (25 mm/m² BSA)

Impact of ESVI Level on Cardiac Events Rates after Diagnosis of Asymptomatic

LVESD : 53 mmSymptoms with Exercise

Lancellotti et al.Circulation: Cardiovascular Imaging. 2013; 6: 840-849

Limited Data Support the Use of Exercise Echocardiography in Patients with AR

Global LV StrainGlobal RV StrainExercise TAPSE

Survey in 120 departments performing Stress Echocardiography in the United Kingdom

Cut off value GLS< -18%

ACC/AHA 2014 Stages of Chronic Aortic Regurgitation A: At Risk of AR

B: Progressive AR

- Mild AR- Moderate AR

C: Asymptomatic severe AR1. Normal LVEF >50%, LVESD< 50 mm2. Abnormal LVEF <50%, LVESD>50 mm

Consider Exercise Testing to assess symptoms and haemodynamic response to exercise.

D: Symptomatic severe AR

Evidence of LV DilatationSymptomatic

ACC/AHA 2014

Consider Exercise Testing

Consider Strain

Measurements

34 year old patient: First diagnosis of bicuspid AoV and severe AR with mildly dilated LV and aorta in 2007.

2008 2010 2013

NOT Too Early….BUT Early Enough!

Timing of Surgery in Asymptomatic Severe Aortic Regurgitation

The Anatomy Lesson of Dr. Nicolaes Tulp Rembrandt 1632, The Hague Netherlands

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