Is Aortic Insufficiency a pressure overload or a volume overload?
Is Aortic Insufficiency a preload or an afterload issue?
a preload issue
What are 6 causes of Aortic Insufficiency?
- 1.) Rheumatic
- 2.) Congenital- bicuspid AV
- 3.) Infective endocarditis
- 4.) Aortic root dilatation
- 5.) Aortic
What should the scale be at for aortic insufficiency?
What is Bicuspid AV?
a congenital abnormality when the AV has two leaflets and one is usually larger than the other.
What is the 2 possible arraignments of Bicuspid AV?
- 1.) vertical from 12 to 6 oclock
- 2.) horizontally from 9 to 3 oclock
What is the name of the small malformated cusp with Bicuspid AV?
What are raphe also called?
What percent of the population is said to have a bicuspid AV?
Are the cusps equal in size when Bicuspid AV?
What are 2 2D echo findings of Bicuspid AV?
- 1.) Eccentric closure in diastole in PLAX
- 2.) Best view too view the cusps is SAX
What is the M-Mode echo findings of Bicuspid AV?
Eccentric closure line
What are 2 Doppler echo finding of Bicuspid AV?
What are some Complications and usually go hand in hand with Bicuspid Aortic Valve? (4)
- 1.) AS
- 2.) AI
- 3.) Infective endocarditis
- 4.) High association of coarctation of aorta
Where is the most common area of coarctation of the aorta?
Descending AO at Isthmus
What causes Infective endocarditis?
Staph or Strep bacteria can get into the bloodstream and vegetations will form on the valves of the heart and eat away at them.
In what common way does bacteria enter the bloodstream to cause Infective endocarditis?
Drug addiction and using dirty needles.
What measure is considered to be Aortic Root Dilatation?
Any aortic root measuring over 3.7 cm is dilated.
What are 6 causes of Aortic Root Dilatation?
- 1.) Marfan's syndrome
- 2.) Aortic aneurysm
- 3.) Dissecting aneurysm
- 4.) Aneurysm of sinuses of valsalva
- 5.) Hypertension
- 6.) Atherosclerosis
What is Aortic Valve Prolapse?
the leaflets fall backward into the LV
What are some things that can cause Acute or Sudden AI? (3)
- 1.) Infective endocarditis
- 2.) Dissecting aneurysm
- 3.) Rupture or prolapse of aortic leaflets
What happens when there is an event that causes Acute or Sudden AI? (4)
- 1.) The LV has an increase in volume and workload without time to hypertrophy or dilate.
- 2.) So will have an increase in pressure overload.
- 3.) Will have a very high LV end diastolic pressure which will cause...
- 4) Murmur will be difficult or impossible to hear.
What can Flail Aortic Leaflets be caused by?
endocarditis eating away at the leaflets.
What is the movement of Flail Aortic Leaflets with the cardiac cycle?
It follows the direction of blood flow.
- Leaflets point into LV during diastole.
- Leaflets point into AO during systole.
What is the m-mode echo finding of Flail Aortic Leaflets?
high frequency flutter on the valve in diastole.
What are some symptoms of AI? (6)
- 1.) precordial pain (sharp, sudden chest pain)
- 2.) occasional dizziness
- 3.) syncope
- 4.) exertional or paroxysmal dyspnea (shortness of breath with exertion)
- 5.) high pitched, blowing, decrescendo diastolic murmur
- 6.) possible Austin Flint murmur with severe AI
What is the description of the murmur of AI?
High pitched, blowing, decrescendo, diastolic murmur
When will there be an Austin Flint murmur?
low pitched, mid diastolic rumble
best heard at apex
What is the method of choice for determining severity of AI?
Is AI a volume overload or a pressure overload?
Which is assciocated with?
a volume overload
How can we tell the different between AS and AI?
Look at the EKG.
AS during systole
AI during diastole
What is True with Volume and pressure overload relationship?
Volume overload problems eventually led to pressure overload problems.
What is the Physiology of AI? (4)
- 1.) Increase in LV volume = preload
- 2.) Increase in SV = LVVO
- 3.) Increase in LV dilation = cardiac failure
- 4.) Increase in LV pressure
Hemodynamics of AI (8)
- 1.) Initially LVVO
- 2.) Enlarged left ventricle
- 3.) Hyperdynamic LV
- 4.) Later stage LVH
- 5.) Ultimately LV failure
- 6.) LA remains normal unless severe AI
- 7.) May cause cerebral insufficiency= dizziness
- 8.) Headaches (due to dilated aorta and increased stroke volume)
Echo findings that indicate surgery for AI (3)
- 1.) When the end-diastolic LV diameter exceeds 7.0 cm or end-systolic LV measurement exceeds 5.0 cm
- 2.) Fractional shortening drops below 30%
- 3.) Patient is extremely symptomatic
What are 3 things used to assess the severity of AI with doppler waveforms?
- 1.) the steeper the slope the more severe
- 2.) the intensity of the waveform (increase in spectral boardening)
- 3.) the lower the Pressure half time the more severe
If the steeper the slope of AI what happens to the Pressure half time?
decreases the pressure half time
What color with AI be...
PLAX = blue jet
PSAX = should be red but is probably going to be blue
Pressure Half Time
Moderate, mod to severe =
- Mild = > 500 ms
- Moderate, mod to severe = 500 - 200 ms
- Severe = < 200 ms
What views are used to look for AI? (6)
- 1.) PLAX
- 2.) PSAX
- 3.) 5 chamber
- 4.) 3 chamber
- 5.) suprasternal views
- 6.) subcostal
What should be looked at in PLAX with AI? (4)
- 1.) Width of the jet
- 2.) the color of the jet
- 3.) how far back into the LV
- 4.) if it causes the mitral valve to close early -hits the ALMV
What should be looked at in PSAX with AI? (1)
the diameter of the jet
tip back and forth in and out of the valve to get all the AI
What should be looked at in 5 CH with AI? (3)
- 1.) How wide the jet?
- 2.) How far back into the LV?
- 3.) Do pressure half time here!
In what view should pressure half time be taken?
in apical 5 chamber
What can be the best view to see AI?
What should be looked at in the suprasternal notch view with AI?
Look at the Descending AO to see if there is a reversal of flow during diastole. (abnormal- red flow)
What are some 2D findings of AI? (6)
- 1.) thickened aortic leaflets
- 2.) dialted Ao Root
- 3.) Lack of leaflet coaptation
- 4.) Aortic Valve prolapse
- 5.) Flail aortic leaflets
- 6.) LVVO
M-Mode findings of AI? (4)
- 1.) MV pre-closure will occur before the QRS
- 2.) AV premature opening will occur right on or before the QRS
- 3.) Diastolic fluttering on the ALMV, IVS, AV
- 4.) Decreased MV excursion
What is Decreased MV excursion mean?
the MV is not allowed to snap open as usual because of the extra pressure exerted on it.
Doppler Findings of AI? (4)
- 1.) Color to locate the jet.
- 2.) CW to get velocities
- 3.) M-mode to make sure the jet is in diastole.
What is the severity of AI quantitated by?
the width and the length of the jet into the LV
the steeper the slope of AI with CW
Mild, Mod, and Severe AI with jet length into LV
Mild AI = tips of the PM
Mod. AI = base of the PM
Severe AI = ventricular apex
What is it called when measuring the width of the AI jet?
Where is it measured at?
Measure the diameter right at the valve.
What are 3 Pitfalls of pressure Half-time?
- 1.) LV diastolic compliance
- 2.) LA pressure
- 3.) HR (brady or tachy)
Can alter the LV diastolic filling pressure causing the deceleration rate and half-time unreliable.