Rheumatic Valvular Heart Disease Assessment of Severity

1. Rheumatic Valvular Heart Disease Assessment of Severity Prof. P. Krishnam Raju Care Hospitals, Hyderabad

2. Focus on Severity assessment Pitfalls / caveats Role of Exercise Echo Value of BNP Gender differences

3. VHD Severe VHD + Symptomatic Severe VHD + Asymptomatic Mild VHD + Symptomatic Mild VHD + Asymptomatic

4. VHDAssessment EKG Physical Exam History CXR Cath Angio VHD 2D Echo CT MRI Stress Echo TDI SRI TEE

9. Classification of Aortic Stenosis Severity * AHA / ACC Guidelines, ** ESC Guidelines

19. Exercise Echo Aortic Valve Stenosis ? WHICH PARAMETERS Total Exercise Time Maximum work load Peak HR TVI/ STRAIN/SRI Peak BP Symptoms Low flow / Low Gradient AS > 20% ↑ Forward SV = Good Contractile Reserve > 20% ↑ LVOT TVI = as above Peak Aortic Velocity P mean A.V.A

27. Grading of Aortic Regurgitation Severity 2

28. Grading of Aortic Regurgitation Severity Quantitative Parameters 1 At a Nyquist limit of 50-60 cm/s. 2 LV size applied only to chronic lesions 3. In the absence of other etiologies of LV dilatation’ . AR = aortic regurgitation; EROA = effective regurgitant office area; LV = left ventricle: LVOT = left ventricular outflow tract; R Vol = regurgitant volume; RF = regurgitant fraction 2

29. The information that can be obtained by echo includes Valve disease – Present or absent Valve morphology Severity of regurgitation Mechanism Hemodynamics Etiology Complications Effect on neighbouring structures Choice of therapy – Medical / repair or replacement

30. Factors affecting assessment of AR by Doppler Color flow imaging include Physiologic Factors Loading conditions Chamber compliance Orifice size Driving pressure Gradient Entrainment Viscosity Temporal variability Technical Factors Gain settings Carrier frequency Frame rate Sector size Scanning depth PRF Nyquist Limit Processing algorithms (Maps) Doppler angle

31. Doppler quantification – Limitations Eccentric jets Poor sonic windows Angle error Pit falls in assessment of RV / RF a. Operator b. Sample volume not at annulus c. Not tracing envelope properly d. Not averaging e. Incorrect annulus diameter f. Multivalvular lesions g. Shunts h. Dense calcification of valve i. Prosthetic valve shadowing

32. Severe AR Jet width / LVOT diameter ratio ≥ 60% Jet area / LVOT area ratio ≥ 60% Jet width at origin ≥ 12mm PHT of AR jet ≤ 250ms Restrictive MV flow pattern (Acute AR) Holo diastolic flow reversal in desc aorta Dense CW signal RF ≥55% RV ≥ 60% LV enddiastolic dimension ≥ 7.5 cm (chronic AR) LV endsystolic dimension ≥ 5.5 cm ERO ≥ 0.3 sqcm

33. Aortic regurgitation severity : Utility, advantages, and limitations I

34. Aortic regurgitation severity : Utility, advantages, and limitations II

35. Aortic regurgitation severity : Utility, advantages, and limitations III

36. Exercise Echo AR ? WHICH PARAMETERS LV EDV LV ESV EF Annular Systolic Velocities TVI SR SRI ? BNP

42. Classification of Mitral Stenosis Severity * at heart rates between 60 to 80 beats per minute and in sinus rhythm

49. Exercise Echo Mitral Stenosis ? WHICH PARAMETERS Exercise Tolerance Trans Mitral Velocities / Gradients Trans Tricuspid Velocities / Gradients RVSP = PASP