Aortic Regurgitation Jet Research Articles

PP-191 Left Atrium Fistula on Mitral-Aortic Intervalvular Fibrosa Secondary to Eccentric Aortic Regurgitation

Mitral-aortic intervalvular fibrosa is a thin and translucent junctional zone between mitral and aortic valve annulus. Aortic regurgitation jet flow or infection of this tissue may result in fistula or pseudoaneurysms. 44-year-old male patient was admitted to the hospital 5 months ago with shortness of breath, fever and excessive sweating complaints. in our case most applied surgical procedure is an aortic valve replacement and the aneurysm was closed through the aortic side of the aortic annulus with a bovine pericardial patch. The patient recovered well and was discharged on the tenth postoperative day.

Echocardiographic and angiographic assessment of paravalvular regurgitation after TAVI: optimizing inter-technique reproducibility

Aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) is often first diagnosed by angiography and then confirmed and followed-up by transthoracic echocardiography (TTE). Consistency between both methods is important for follow-up. We sought to determine inter-technique reproducibility of the assessment of paravalvular AR after TAVI. The study included 165 patients treated with a self-expanding bioprosthesis and had angiography and TTE performed at a median interval of 4 days. TTE parameters of AR severity included VARC score (the average AR grade determined by the echocardiographic VARC-II criteria), pressure half time (PHT), regurgitation jet features in long-axis views (LAX score) and colour Doppler (CD) score (=paravalvular AR jet circumferential extent (%) + LAX score). Using receiver-operating characteristics curves, the cut-points that best defined an angiographic >mild AR were identified.On TTE, AR was paravalvular in all cases, multi-jet in 28%, and predominantly (64%) detected in the commissural region between the right and left coronary sinuses. Using VARC-II criteria (combining at least two), TTE agreed with angiographic classification in 53% of cases (k = 0.14). Greater than mild AR could better be defined by one of the following combinations of criteria: (i) LAX score >4.25 and VARC-II score >1.33; (ii) CD score >11.5 and PHT <400 ms. The combination of the CD score with PHT gave the best sum of sensitivity, specificity, positive, and negative predictive values. Agreement between angiography and TTE (using the VARC-II criteria) in the grading of post-TAVI AR is modest, and this might have contributed to the inconsistency of data on the rate and fate of paravalvular AR. Inter-technique reproducibility can be improved using a combination of CD and hemodynamic parameters.

Imaging Aortic Regurgitation: The Incremental Benefit of Speckle Tracking Echocardiography.

Aortic regurgitation (AR) affects global left ventricular mechanics. However, limited literature is available on how it may affect regional longitudinal strain. We present a case where severe AR jet is thrashing the anterior-septal wall and reducing its overall longitudinal performance most likely secondary to increased wall shear stress in diastole. This new insight into patho-physiological process using deformation study may have supplementary impact in decision making for surgical intervention. Transthoracic echocardiography is the primary imaging modality for the assessment of AR as it offers evaluation of severity of AR, aetiology of AR, left ventricular (LV) dilatation, LV systolic function, left ventricular mass, diastolic function and global strain. This case highlights the regional disturbances in longitudinal strain in eccentric AR.

Abstract 18009: Clinical-officer Led Echocardiographic Screening is Sensitive for Diagnosing Rheumatic Heart Disease in Malawi, Africa

Malawi, Africa has a high prevalence of rheumatic heart disease (RHD). Echocardiographic (echo) screening for RHD in asymptomatic children may enable early diagnosis and treatment in order to prevent progression of RHD. Malawi has few physicians, and no pediatric cardiologists in the country. Therefore, physician-led RHD screening is not feasible. Clinical officers (CO’s) are mid-level providers who may be able to perform RHD echo screening. Hypothesis: After training, CO’s will have similar results in identifying RHD by echocardiography as a pediatric cardiologist. Methods: 8 CO’s with no previous echo experience completed 3 half-days of didactic and computer-module based training as well as 2 days of clinical attachments at a local school. On the attachments, CO’s completed an average of 60 mentored RHD screening echos with a Philips portable CX50 echo machine. CO’s were evaluated by performing screening echos on 20 children with and without RHD who were screened in the previous year. They indicated whether the children should be referred for follow-up. Screening protocol called for referral if a mitral regurgitation jet measured more than 1.5 cm or an aortic regurgitation jet measured more than 1 cm. Kappa statistic was calculated based on agreement with a pediatric cardiologist’s screening result (referral vs. no referral). Sensitivity and specificity were estimated using a generalized linear mixed model. Results: The mean kappa statistic comparing CO reads to the pediatric cardiologist was 0.72 (95% CI: 0.62, 0.82). Kappa ranged from a minimum of 0.57 to a maximum of 0.90. Overall, sensitivity was 0.92 (95% CI: 0.86, 0.95), and specificity was 0.80 (95% CI: 0.68, 0.88). Conclusion: There is substantial agreement between the CO and pediatric cardiologist diagnoses. In addition, CO’s had a high sensitivity in detecting RHD. With short-course training, CO-led echo screening for RHD is a viable alternative to physician-led screening in resource-limited settings.

Perforation of anterior mitral leaflet aneurysm: A rare cause of severe mitral regurgitation

Abstract Mitral valve perforation is a rare cause of severe mitral regurgitation. Infective endocarditis, connective tissue disease, cardiac surgery and aortic regurgitation jet are blaming causes of mitral valve perforation. We present a case of anterior mitral leaflet perforation accompanied with mitral valve prolapse identified by real-time three-dimensional transesophageal echocardiography.

Clinical and echocardiographic evaluation of mitral valve aneurysms: a retrospective, single center study

Mitral valve aneurysms (MVAs) are rarely encountered in echocardiography laboratories. Although they are commonly associated with endocarditis of the aortic valve, various mechanisms have been suggested for the etiopathogenesis of MVAs associated with non-infectious conditions. 5,887 patients who underwent transesophageal echocardiography (TEE) between 2007 and 2012 were evaluated retrospectively for MVA. Mitral valve aneurysm is defined as a localized saccular bulging of the mitral leaflet towards the left atrium with systolic expansion and diastolic collapse. The color flow Doppler image of a perforation was described as a high-velocity turbulent jet traversing a valve leaflet in systole. We found that 12 of 5,887 patients (0.204 %) had MVA in TEE examinations. The mean age of patients with MVA was 53 years (range 21-80 years), including four females and eight males. Nine patients presented with symptoms of endocarditis. On TEE, aneurysms were located in the anterior mitral leaflet in 11 patients, and in the posterior mitral leaflet in one patient. Eight patients had severe, three had moderate, and one had trace mitral regurgitation. Of the nine patients with perforated leaflets, eight patients had severe and one patient had moderate mitral regurgitation. Aortic regurgitation was present in nine patients, being severe in three, moderate in two, mild in two, and trace in two patients. Two patients without severe mitral regurgitation were followed-up conservatively, while nine patients underwent surgery. Two patients died from septic shock, one in the postoperative period and the other one prior to surgery. Although MVAs occur during the course of aortic valve endocarditis and, in particular, due to aortic regurgitation jet, it should be borne in mind that they may develop as an isolated valvular pathology and may be misdiagnosed as chordal rupture, other cardiac masses, or vegetation. Thus, MVAs may not be so infrequent as they are thought; they may justify to be considered in the differential diagnosis of masses seen on the mitral valve on echocardiographic examination.

Altered Mitral Inflow Orifice in Severe Aortic Regurgitation: Real Time Three-Dimensional Echocardiographic Findings

We present the case of a young man with severe eccentric aortic regurgitation, obstructing mitral inflow and provoking an audible Austin Flint murmur at clinical examination. Two-dimensional color Doppler echocardiography depicts the remarkable mechanical interaction between aortic regurgitant jet and anterior mitral leaflet opening. Three-dimensional transesophageal echocardiography aids in understanding the geometric and hemodynamic consequences of the regurgitant jet and in the genesis of the Austin Flint murmur. This case accentuates the incremental value of three-dimensional echocardiography when evaluating valvular pathology, and offers more insight in the interaction between aortic regurgitant flow and mitral leaflet dynamics.

Accuracy of Three-Dimensional Versus Two-Dimensional Echocardiography for Quantification of Aortic Regurgitation and Validation by Three-Dimensional Three-Directional Velocity-Encoded Magnetic Resonance Imaging

Quantitative assessment of aortic regurgitation (AR) remains challenging. The present study evaluated the accuracy of 2-dimensional (2D) and 3-dimensional (3D) transthoracic echocardiography (TTE) for AR quantification, using 3D 3-directional velocity-encoded magnetic resonance imaging (VE-MRI) as the reference method. Thirty-two AR patients were included. With color Doppler TTE, 2D effective regurgitant orifice area (EROA) was calculated using the proximal isovelocity surface area method. From the 3D TTE multiplanar reformation data, 3D-EROA was calculated by planimetry of the vena contracta. Regurgitant volumes (RVol) were obtained by multiplying the 2D-EROA and 3D-EROA by the velocity-time integral of AR jet and compared with that obtained using VE-MRI. For the entire population, 3D TTE RVol demonstrated a strong correlation and good agreement with VE-MRI RVol (r = 0.94 and -13.6 to 15.6 ml/beat, respectively), whereas 2D TTE RVol showed a modest correlation and large limits of agreement with VE-MRI (r = 0.70 and -22.2 to 32.8 ml/beat, respectively). Eccentric jets were noted in 16 patients (50%). In these patients, 3D TTE demonstrated an excellent correlation (r = 0.95) with VE-MRI, a small bias (0.1 ml/beat) and narrow limits of agreement (-18.7 to 18.8 ml/beat). Finally, the kappa agreement between 3D TTE and VE-MRI for grading of AR severity was good (k = 0.96), whereas the kappa agreement between 2D TTE and VE-MRI was suboptimal (k = 0.53). In conclusion, AR RVol quantification using 3D TTE is accurate, and its advantage over 2D TTE is particularly evident in patients with eccentric jets.

SEVERITY OF AORTIC REGURGITATION ASSESSED BY AREA OF VENA CONTRACTA- A CLINICAL COLOR DOPPLER IMAGING STUDY

Quantitation of aortic regurgitation (AR) using echocardiography including the width of vena contracta (VC-W) is challenging. Three-dimensional (3D) echocardiography can directly measure the size of vena contracta area of AR jet regardless of rheological characteristics. We intended to assess the

Abstract 9177: Mitral Valve Adaptation in Chronic Aortic Regurgitation with Preserved Systolic Function: A Three-Dimensional Echocardiographic Study

Introduction: Chronic aortic regurgitation (AR) causes left ventricular (LV) remodeling and ultimately heart failure. This creates the potential for functional mitral regurgitation (MR) caused by papillary muscle displacement and mitral valve tethering. However, MR is typically absent during the compensated stage of AR despite substantial LV dilatation. Increased mitral leaflet area has been identified in ischemic and non-ischemic heart failure. It is unknown whether increased mitral valve size could represent a compensatory mechanism capable of preventing MR in patients with LV dilatation due to chronic AR. Hypothesis: Chronic AR is associated with mitral valve enlargement and this can prevent functional MR in patients with LV dilatation. Our objective is to compare mitral valve leaflet area in patients with chronic AR and preserved systolic function to that of normal patients using 3D-echocardiography. Methods: From January to April 2011, we prospectively enrolled 44 patients (22 with at least moderate aortic regurgitation and 22 controls). 3D echocardiograms were performed to assess mitral valve geometry including total diastolic leaflet area measured by a previously validated method. Results: Both groups had normal ejection fraction (60 ± 7 % in AR vs 63 ± 7 % in normals, p=0.17). Only 1 AR patient had significant (more than mild) functional MR. LV volume by 3D echocardiography was significantly larger in the AR group (LV end-diastolic volume index: 80 ± 23 cm3/m2 vs 49 ± 12 cm3/m2, p&lt;0.01). The mitral valve leaflet area indexed for body surface area was significantly increased in the AR group (8.9 ± 1.7 cm2/m2 vs 7.4 ± 1.2 cm2/m2, p&lt;0.01). Patients with AR also had increased mitral leaflet thickness (2.3 ± 0.3 mm vs 2.0 ± 0.3 mm, p&lt;0.01) regardless of AR jet impact on the valve. Mitral valve leaflet area significantly correlated with LV end-diastolic LV volume (p&lt;0.01). Conclusion: Mitral valve leaflet area and thickness are significantly increased in patients with chronic AR and preserved ejection fraction. Area enlargement is proportional to LV volume, and can potentially explain why functional MR is uncommon in this population. Understanding the mechanisms underlying this adaptation could lead to new therapeutic interventions for functional MR.

Three-Dimensional Echocardiography in Paravalvular Aortic Regurgitation Assessment after Transcatheter Aortic Valve Implantation

Paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) is common, but the evaluation of its severity by two-dimensional (2D) transthoracic echocardiography (TTE) presents several constrains. The aim of this study was to assess the usefulness of a new methodology, using three-dimensional (3D) TTE, for better assessment of paravalvular AR after TAVI. Two-dimensional and 3D TTE was performed in 72 patients, 5 months after TAVI, using the X5-1 PureWave microbeamforming xMATRIX probe. The position and severity of the paravalvular AR jets were described using 2D and 3D TTE, and a model was designed for paravalvular AR systematic location description. Vena contracta width was measured using 2D transthoracic echocardiographic views, and the planimetry of the vena contracta was assessed after the perfect alignment plane was obtained using the multiplanar 3D transthoracic echocardiographic reconstruction tool. AR volume was calculated as the difference between 3D TTE-derived total left ventricular stroke volume and right ventricular stroke volume estimated using 2D TTE. Diagnostic efficiency for moderate AR was assessed using receiver operating characteristic curve analysis. Forty-three patients (57.4%) presented with AR; 10 (13.3%) had central AR, and 33 (44.0%) had paravalvular AR jets. Vena contracta widths were similar between patients with moderate and mild AR (2.1 ± 0.53 vs 1.9 ± 0.16 mm, P = .16), but vena contracta planimetry was larger in patients with moderate AR than in those with mild AR (0.30 ± 0.12 vs 0.09 ± 0.07 cm(2), P = .001). Vena contracta planimetry on 3D TTE was better correlated with AR volume than vena contracta width on 2D TTE (Kendall's τ = 0.82 [P < .001] vs 0.66 [P < .001]). The areas under the receiver operating characteristic curves were 0.96 for vena contracta planimetry and 0.35 for vena contracta width. This study proposes an alternative methodology for paravalvular AR assessment after TAVI. Using vena contracta planimetry on 3D TTE, an accurate methodology for paravalvular AR jet evaluation and moderate AR classification is described.

Impressive Echocardiographic Images of a Mitral Valve Aneurysm

A 77-year-old woman with a fractured femur was referred to our hospital because preoperative echocardiography raised suspicion of a mitral valve tumor. She had no history of unknown fever or heart murmur. Transthoracic and transesophageal echocardiography showed severe mitral regurgitation and aortic regurgitation. A mobile lesion that appeared to be a cystic tumor (14×15 mm) was on the posterior mitral leaflet (Figure 1 and Movie in the online-only Data Supplement). The lesion had no color Doppler signal inside. Computed tomography showed a cystic mass with homogeneously enhanced contents (Figure 2). During the period of recovery from her hip surgery, the patient developed a sporadic febrile illness, and Enterococcus faecium was cultured from a blood …

The Correlation between Three‐Dimensional Vena Contracta Area and Aortic Regurgitation Index in Patients with Aortic Regurgitation

The aims of this study are to explore the correlation between the three-dimensional vena contracta (3D VC) area and the aortic regurgitation (AR) index and to determine AR severity using the 3D VC area. The geometry of regurgitant jets is complex in patients with AR. The 3D VC area can be easily cropped using any plane and we can obtain the complex geometry of the VC area. Full-volume three-dimensional (3D) color flow datasets were generated using the trans-thoracic parasternal approach. The AR jet could be well visualized and analyzed in three orthogonal planes using dedicated software. We consecutively analyzed 77 AR patients with comprehensive 2D and 3D echocardiographic data. The 3D VC area increased proportionately with increasing AR severity using the AR index method (F = 86.1, P < 0.001) and correlated well with effective regurgitant orifice (P < 0.001). The cutoff value of the VC area was < 30 mm(2) (sensitivity = 90% and specificity = 88%) for predicting mild AR and > 50 mm(2) (sensitivity = 92% and specificity = 87%) for predicting severe AR. 3D color flow VC area measurement provides a simple and accurate method for assessing the severity of AR.

An Unusual Cause of Aortic Regurgitation

HomeCirculation: Cardiovascular ImagingVol. 1, No. 2An Unusual Cause of Aortic Regurgitation Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBAn Unusual Cause of Aortic Regurgitation Sherif F. Nagueh, MD Sherif F. NaguehSherif F. Nagueh From the Department of Cardiology, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, Tex. Search for more papers by this author Originally published1 Sep 2008https://doi.org/10.1161/CIRCIMAGING.108.790931Circulation: Cardiovascular Imaging. 2008;1:e13–e14A 42-year-old man presented with acute onset of severe dyspnea, fever, and positive blood cultures for Staphylococcus aureus. His medical history was relevant for aortic root surgery, including replacement of the aortic root and aortic valve with a homograft 3 years ago. His physical examination revealed sinus tachycardia, a heart rate of 120 bpm, and a blood pressure of 84/45 mm Hg. Bibasilar rales were present, and the jugular veins were distended to the angle of the mandible. Transesophageal echocardiography was performed to examine the underlying reasons for his acute deterioration.Transesophageal echocardiography revealed the presence of a dehiscence of the homograft, with flow occurring between the left ventricular outflow tract and a pseudoaneurysm in the plane of the intervalvular fibrosa, without vegetations on the aortic valve. Hemodynamically significant aortic regurgitation (AR) was present through the site of the dehiscence, but not the aortic valve itself (Data Supplement Movies I-IV), and pulsed wave Doppler of the descending aorta revealed holodiastolic flow reversal (Figure 1). Continuous wave Doppler signal of the AR jet was consistent with significant AR, showing a short pressure half-time (Figure 2). In addition, echolucent areas with septations were seen surrounding the homograft (Data Supplement Movie I), consistent with multiple abscess cavities. Doppler interrogation showed early closure of the mitral valve and diastolic mitral regurgitation (Figure 3, left). Pulmonary venous flow (Figure 3, right) revealed a reduced systolic velocity to diastolic velocity ratio and a prominent atrial reversal signal. Collectively, these Doppler findings are consistent with a highly elevated left ventricular end-diastolic pressure (atrial reversal >50 cm/s, premature closure of the mitral valve, and diastolic mitral regurgitation), as well as an increased mean left atrial pressure (systolic/diastolic, <1) due to AR. Download figureDownload PowerPointFigure 1. Pulsed wave Doppler recording from the descending thoracic aorta shows forward flow in systole (above the baseline), with holodiastolic flow reversal (below the baseline and delineated by the arrows). This finding is consistent with hemodynamically significant AR.Download figureDownload PowerPointFigure 2. Continuous wave Doppler of the AR jet. Notice the rather dense signal when compared with forward flow across the aortic valve and the steep deceleration, leading to a very short pressure half-time (95 ms, arrow).Download figureDownload PowerPointFigure 3. Left side shows mitral inflow by pulsed wave Doppler. Diastolic flow is abbreviated with premature closure of the mitral valve (arrow above baseline) and diastolic mitral regurgitation (arrow below baseline). Both observations are diagnostic of highly elevated left ventricular end-diastolic pressure. On the right, is a recording from the left pulmonary vein. Forward flow in systole (S) is reduced, whereas forward flow in diastole (D) is increased. This finding indicates increased mean left atrial pressure. In addition, the increased atrial reversal velocity with left atrial contraction confirms the increased left ventricular end-diastolic pressure.Aortic graft dehiscence is a rare complication after aortic root surgery, whether with composite grafts or homografts. The hemodynamic consequences depend on the extent of dehiscence and can lead to severe perivalvular regurgitation and acute heart failure, as in this case. Aortography may not visualize a single site dehiscence, nor the mechanism of regurgitation. On the other hand, transesophageal echocardiography has a high accuracy in identifying the location and extent of the dehiscence, the presence of aortic root and aortic valve pathology, and the severity of regurgitation, as seen in this case.The online-only Data Supplement is available at http://circimaging.ahajournals.org/cgi/content/full/1/2/e13/DC1DisclosuresNone.FootnotesCorrespondence to Sherif F. Nagueh, MD, Methodist DeBakey Heart Center, 6550 Fannin, SM-677, Houston, TX 77030. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetails September 2008Vol 1, Issue 2Article InformationMetrics Download: 285 https://doi.org/10.1161/CIRCIMAGING.108.790931PMID: 19808521 Originally publishedSeptember 1, 2008 PDF download Advertisement SubjectsCongenital Heart DiseaseEchocardiographyHeart FailureValvular Heart Disease

Determinants of the degree of functional aortic regurgitation in patients with anatomically normal aortic valve and ascending thoracic aorta aneurysm. Transoesophageal Doppler echocardiography study

Objectives: To identify functional aortic regurgitation (FAR) determinants in patients with ascending thoracic aortic aneurysm (ATAA) and surgically confirmed normal aortic valve anatomy. Design: Case–control study. Setting: Non-invasive Cardiology and...

Real-time three-dimensional color doppler flow imaging: An improved technique for quantitative analysis of aortic regurgitation

The recently introduced real-time three-dimensional color Doppler flow imaging (RT-3D CDFI) technique provides a quick and accurate calculation of regurgitant jet volume (RJV) and fraction. In order to evaluate RT-3D CDFI in the noninvasive assessment of aortic RJV and regurgitant jet fraction (RJF) in patients with isolated aortic regurgitation, real-time three-dimensional echocardiographic studies were performed on 23 patients with isolated aortic regurgitation to obtain LV end-diastolic volumes (LVEDV), end-systolic volumes (LVESV) and RJV, and then RJF could be calculated. The regurgitant volume (RV) and regurgitant fraction (RF) calculated by two-dimensional pulsed Doppler (2D-PD) method served as reference values. The results showed that aortic RJV measured by the RT-3D CDFI method showed a good correlation with the 2D-PD measurements (r = 0.93, Y = 0.89X + 3.9, SEE = 8.6 mL, P < 0.001); the mean (SD) difference between the two methods was--1.5 (9.8) mL. % RJF estimated by the RT-3D CDFI method was also correlated well with the values obtained by the 2D-PD method (r = 0.88, Y = 0.71X + 14.8, SEE = 6.4%, P < 0.001); the mean (SD) difference between the two methods was--1.2 (7.9) %. It was suggested that the newly developed RT-3D CDFI technique was feasible in the majority of patients. In patients with eccentric aortic regurgitation, this new modality provides additional information to that obtained from the two-dimensional examination, which overcomes the inherent limitations of two-dimensional echocardiography by depicting the full extent of the jet trajectory. In addition, the RT-3D CDFI method is quick and accurate in calculating RJV and RJF.

Transesophageal Echocardiographic Recognition of Mitral Valve Aneurysm

Aneurysm of the mitral valve leaflet is typically a complication of aortic valve endocarditis because of the anatomic relationship between the anterior mitral leaflet and the left ventricular outflow tract. 1 - 4 The aortic regurgitant jet or vegetation prolapsing into the left ventricular outflow tract infects the anterior leaflet of the mitral valve. This occurrence has been termed the jet lesion or kissing lesions effect. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are the preferred diagnostic procedures. Transesophageal echocardiography offers better resolution of mitral valve morphologic characteristics and aneurysmal structure. Herein, we describe a case of infective endocarditis that had the typical features of aortic valve endocarditis coexisting with aortic valve regurgitation and aneurysm of the anterior mitral leaflet, which were diagnosed by TEE.

Mitral Valve Aneurysm With Infective Endocarditis

A case of mitral valve aneurysm associated with infective endocarditis is reported. Two-dimensional echocardiography revealed a saccular structure in the anterior leaflet that bulged into the left atrium throughout the cardiac cycle. During operation, the vegetation on the commissure of the right and left aortic leaflet and a 3-mm perforation on the noncoronary leaflet were found. The mitral valve and aortic valve were replaced with mechanical prosthesis. Pathology of the excised valves showed inflammation. For this patient, we considered that the infected aortic regurgitant jet striking the ventricular surface of the anterior mitral leaflet could be the mechanism of the leaflet aneurysm.

Effect of Regurgitant jet Direction on Left Ventricular Diastolic Performance in Patients With Aortic Regurgitation

Background. Left Ventricular (LV) diastolic performance is impaired in patients with aortic regurgitation (AR). The objective of this study is to determine the effect of AR jet direction on left ventricular diastolic performance.Methods. 20 patients with significant AR [regurgitant fraction (RF) > 30%] were studied by 2-dimensional, color, pulsed and tissue Doppler echocardiography. Subjects were divided into two groups based on jet direction as observed on the parasternal long-axis color flow image. Ten patients had the jet directed onto the anterior mitral leaflet (AML, mitral group) and 10 had the jet directed to the center of the LV (central group). Patients with significant mitral regurgitation or pseudonormal LV hemodynamics were excluded. The isovolumic contraction and relaxation times (ICT and IRT) were measured by combined mitral inflow and LV outflow velocity waves. Mitral annulus velocity was measured at the lateral annulus on the apical 4-chamber view by pulsed Doppler tissue imaging. The RF was calculated by combined use of pulsed Doppler and 2-dimensional echocardiography.Results. The two groups were similar in age, AR grade, LV end-diastolic volume, LV ejection fraction, and ICT; where-as, significant differences existed in the mitral inflow E/A ratio (mitral group, 0.59±0.17 vs. central group, 1.15±0.46, p<0.01), IRT (mitral group, 104±24 msec vs. central group, 83±15 msec, p<0.01), and mitral annulus velocity during early diastole (mitral group, 5.8±2.0 cm/sec vs. central group, 10.0±2.0 cm/s, p<0.01).Conclusions. LV diastolic performance is altered when a regurgitant jet is directed onto the AML in patients with significant AR.

Prediction of postoperative left ventricular systolic function with Doppler-derived dP/dt in patients with chronic aortic regurgitation

To evaluate the value of Doppler-derived dP/dt as a predictor of postoperative left ventricular (LV) systolic function in patients with chronic aortic regurgitation, we evaluated 29 patients who underwent aortic valve replacement (n = 17) or valve repair. Doppler-derived dP/dt was determined from the continuous wave Doppler signal of the aortic regurgitation jet preoperatively. Preoperative LV ejection fraction (LVEF) and Doppler-derived dP/dt were 48 ± 11% and 701 ± 204 mm Hg/s, respectively. LVEF decreased to 43 ± 12% at immediate postoperative period and improved to 54 ± 11% at late postoperative period. In multivariate analysis, only dP/dt was an independent predictor of late postoperative LVEF ( r = 0.59, P = .006). A dP/dt ≤700 mm Hg/s was the best predictor of late postoperative systolic dysfunction (LVEF <50%) with a sensitivity of 94% and a specificity of 75%. Doppler-derived dP/dt may be useful to predict postoperative LV systolic function.