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Insufficienza aortica
The aortic root may be defined as the portion of the aorta that supports the
leaflets of the aortic valve, delineated superiorly by the sino-tubular junction or
ridge (STJ) and inferiorly by the aorta-ventricular junction (AVJ). It comprises
the sinuses, the leaflets, the commissures, and the interleaflet triangles
Giunzione sinotubulare
Commissure
Seni di Valsalva
Triangoli tra
le cuspidi
“Annulus”
The aortic root: structure, function, and surgical reconstruction. M J Underwood,
Functional aortic anulus
Cuspidi
AORTIC VALVE:
ANATOMY
FAA:
functional
aortic
anulus
Mechanism of Aortic Regurgitation
Valvular disease
Aortic root disease
Functional classification of aortic root/valve abnormalities
and their correlation with etiologies and surgical
procedures
G. El Khoury, Curr Probl Cardiol 2005
Mechanism of Aortic Regurgitation
Functional Anatomy of Aortic Regurgitation Accuracy,
Prediction of Surgical Repairability, and Outcome
Implications of Transesophageal Echocardiography.
Circulation. 2007, le Polain de Waroux JB
Aorta normale e Ao ectasica mancata
coaptazione
Ascendente
Seni di valsalva
Ginzione ST
Anulus
Cusp prolapse or fenestration
Poor cusp prolapse or fenestration
Poor retraction and thickening
Diastole
Sistole
Gravità dell’insufficienza
 Anatomia funzionale
 Doppler
 Ventricolo e atrio sinistro
 Pressione polmonare, ventricolo destro
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER
AO flow reversal
Flow disturbance Vena contracta
(jet size)
PISA
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER
AO flow reversal
Flow disturbance Vena contracta
(jet size)
PISA
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER:
JET SIZE
parasternale asse lungo
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER:
JET SIZE
parasternale asse lungo
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER:
JET SIZE
parasternale asse corto
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER:
JET SIZE
parasternale asse corto
Evaluation of aortic insufficiency by Doppler color flow mapping.
Perry GJ, JACC 1987
The color Doppler echocardiographic studies and aortic angiograms of all patients who had these
procedures performed within 2 weeks of each other between October 1984 and August 1985 were
reviewed to determine whether any parameters of the regurgitant jet visualized by color Doppler study
predicted the severity of aortic insufficiency as assessed by angiographic grading. Patients with an
aortic valve prosthesis were excluded. Twenty-nine patients had aortic insufficiency and had adequate
color Doppler studies for analysis. The mean time between color Doppler examination and
angiography was 2.3 days (range 0 to 12). The maximal length and area of the regurgitant jet were
poorly predictive of the angiographic grade of aortic insufficiency. The short-axis area of the
regurgitant jet from the parasternal short-axis view at the level of the high left
ventricular outflow tract relative to the short-axis area of the left ventricular
outflow tract at the same location best predicted angiographic grade, correctly
classifying 23 of 24 patients. However, the jet could be seen from this view in only 24 of the
29 patients. The height of the regurgitant jet relative to left ventricular outflow tract height measured
from the parasternal long-axis view just beneath the aortic valve correctly classified 23 of the 29
patients. Mitral stenosis or valve prosthesis, which was present in 10 patients, did not interfere with
the diagnosis or quantitation of aortic insufficiency by these methods
Evaluation of aortic insufficiency by Doppler color flow mapping.
Perry GJ, JACC 1987
8
Jet short axis area/LVO area (%)
100
Length (cm)
6
4
2
0
80
60
40
20
0
I
II
III
Angiographic Grade
IV - V
I
II
III
IV - V
Angiographic Grade
“The short-axis area of the regurgitant jet from the parasternal short-axis view at the
level of the high left ventricular outflow tract relative to the short-axis area of the left
ventricular outflow tract at the same location best predicted angiographic grade,
correctly classifying 23 of 24 patients”
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER
AO flow reversal
MILD
Moderate
StructuralFlow
parameters
disturbance Vena contracta PISA
LV size
Normal
Normal or dilated
(jet
size)
Aortic leaflets
Normal or abnormal Normal or abnormal
Doppler parameters
Color flow jet width in
LVOT
Small in central Jet
Intermediate
MILD
Moderate
Structural
Jet densityparameters
- CW
LVdec
size
Jet
- CW (PHT, ms)
Aortic leaflets
Diastolic
reversal flow
in descending Ao - PW
Doppler parameters
Color flow
jet
width in
Quantitative
parameters
Structural
parameters
LVOT
VC
LVwidth
size (cm)
Jet/LVOT
width, %
Aortic leaflets
Jet density area,
- CW%
Jet/LVOT
Incomplete or faint
Normal
Slow
> 500
Normal
or abnormal
Brief,
early
diastolic
reversal
MILD
Small in central Jet
< 0.3
Normal
Normal <or25
abnormal
Incomplete
< 5 or faint
Dense
Normal
dilated
Mediumor500-200
Normal
or abnormal
Intermediate
Severe
Usually dilated
Abnormal/flail/wide
coaptation defect
Large in central jet,
variable in eccentric jet
Severe
Dense
Usually
Steep <dilated
200
Abnormal/flail/wide
Prominent
holodiastolic
coaptation
defect
reversal
(diastolicTVI
Moderate
similarSevere
to systolic)
Intermediate
Large in central jet,
variable
in
eccentric
0.3 -or0.60
 0.6
Normal
dilated
Usually
dilated jet
25
-45 or abnormal
46 - 64
 65
Normal
Abnormal/flail/wide
Dense
5 - 20 Dense21 - 59
coaptation
 60 defect
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER
AO flow reversal
Flow disturbance Vena contracta
(jet size)
PISA
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER
PISA (Proximal Isovelocity Surface Area)
Flusso istantaneo = 2r2 * va (2r2 = Area PISA, va = velocità aliasing):
6,28 * (0.8 * 0.8) * 34 = 137 ml/sec
Orifizio di rigurgito = flusso istantaneo / velocità:
137 ml/sec / 400 cm/sec = 0.34 cmq
Volume di rigurgito = orifizio di rigurgito * integrale di velocità:
0.34 cmq * 165 cm = 54 ml
Application of the Proximal Flow
Convergence Method to calculate the
Effective Regurgitant Orifice Area in Aortic
Regurgitation
Trimbouilloi CM (JACC 1998)
Application of the Proximal Flow
Convergence Method to calculate the
Effective Regurgitant Orifice Area in Aortic
Regurgitation
Trimbouilloi CM (JACC 1998)
Metodi per quantizzare l’insufficienza aortica
MILD
Moderate
Severe
COLOR
DOPPLER
Structural parameters
LV size
Aortic leaflets
Normal
Normal or abnormal
Normal or dilated
Usually dilated
AO flow reversal
Normal or abnormal
Abnormal/flail/wide
coaptation defect
Flow disturbance Vena contracta PISA
Doppler parameters
Color flow
jet size)
width in Small in central Jet
Intermediate
(jet
LVOT
Large in central jet,
variable in eccentric jet
Jet density - CW
Jet dec - CW (PHT, ms)
Diastolic reversal flow
in descending Ao - PW
Incomplete or faint
Slow > 500
Brief, early diastolic
reversal
Dense
Medium 500-200
Intermediate
Dense
Steep < 200
Prominent holodiastolic
reversal (diastolicTVI
similar to systolic)
Quantitative parameters
VC width (cm)
Jet/LVOT width, %
Jet/LVOT area, %
R
Vol (ml/beat)
Structural
parameters
RF
(%)
LV size
ERO
Area
(cmq)
Aortic
leaflets
< 0.3
< 25
MILD
<5
< 30
< 30
Normal
0.10
Normal<or
abnormal
0.3 - 0.60
25 -45
46 - 64
5 - 20Moderate
21 - 59
30 - 44
45 - 59
30Normal
- 39 or dilated
40 - 49
0.10-0.19
0.20-0.29
Normal or abnormal
 0.6
 65
Severe
 60
 60
 50
Usually
dilated
Abnormal/flail/wide
 30
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER
AO flow reversal
Flow disturbance Vena contracta PISA
(jet size)
Zona di convergenza
Zona post stenotica
flusso laminare13:
che converge
flusso
turbolento
Figura
Flusso
attraverso
una
regione steno
verso l’orifizio
Vena contracta
Nella zona prestenotica il flusso converge vers
l’orifizio stenotico accelerando fino al punto d
massima velocità, subito al di là della stenosi.
dopo la stenosi il flusso acquista caratteristich
flusso turbolento.
VC: il colletto più stretto del flusso di rigurgito, subito al di sotto
della regione di convergenza in proto-meso diastole.
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER
AO flow reversal
Moderate
Flow disturbanceMILD
Vena contracta
PISA
Structural(jet
parameters
size)
LV size
Aortic leaflets
Severe
Normal
Normal or abnormal
Normal or dilated
Normal or abnormal
Usually dilated
Abnormal/flail/wide
coaptation defect
Doppler parameters
Color flow jet width in
LVOT
Small in central Jet
Intermediate
Large in central jet,
variable in eccentric jet
Jet density - CW
Jet dec - CW (PHT, ms)
Diastolic reversal flow
in descending Ao - PW
Incomplete or faint
Slow > 500
Brief, early diastolic
reversal
Dense
Medium 500-200
Intermediate
Quantitative parameters
VC
width (cm)
Structural
parameters
Jet/LVOT
LV size width, %
MILD
< 0.3
< 25
Normal
Moderate
0.3 - 0.60
25Normal
-45 or dilated
46 - 64
Dense
Steep < 200
Prominent holodiastolic
reversal (diastolicTVI
similar to systolic)
Severe
 0.6
Usually
dilated
 65
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER
AO flow reversal
Flow disturbance Vena contracta
(jet size)
PISA
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER:
Aortic flow reversal
Severa
Lieve
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER:
Aortic flow reversal
An end-diastolic flow velocity > 20 cm/s is indicative of severe AR
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER
AO flow reversal
Flow disturbance Vena contracta PISA
(jet size)
MILD
Moderate
Structural parameters
LV size
Aortic leaflets
Severe
Normal
Normal or abnormal
Normal or dilated
Normal or abnormal
Usually dilated
Abnormal/flail/wide
coaptation defect
Doppler parameters
Color flow jet width in
LVOT
Small in central Jet
Intermediate
Large in central jet,
variable in eccentric jet
Jet density - CW
Jet dec - CW (PHT, ms)
Diastolic
flow
Structuralreversal
parameters
inLV
descending
Ao - PW
size
Aortic leaflets
Quantitative parameters
Incomplete or faint
Dense
MILD
Moderate
Slow
> 500
Medium
500-200
Brief, early diastolic
Intermediate
reversal
Normal
Normal or dilated
Normal or abnormal Normal or abnormal
Dense
Severe
Steep
< 200
Prominent holodiastolic
reversal
(diastolicTVI
Usually
dilated
similar to systolic)
Abnormal/flail/wide
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER
Flow disturbance Vena contracta
(jet size)
PISA
CW:PHT
AO flow reversal
Metodi per quantizzare l’insufficienza aortica
Doppler continuo:pressure half time (PHT)
INSUFFICIENZA AORTICA
Doppler continuo
INSUFFICIENZA AORTICA: Doppler continuo
Lieve
Rilevante
INSUFFICIENZA AORTICA: Doppler continuo
Lieve
Rilevante
INSUFFICIENZA AORTICA: Doppler continuo
Influenzato dalla pressione diastolica ventricolare (funzione diastolica)
Lieve
Rilevante
Metodi per quantizzare l’insufficienza aortica
COLOR DOPPLER
Flow disturbance Vena contracta
(jet size)
PISA
CW:PHT
AO flow reversal
MILD
Moderate
Severe
Normal
Normal or abnormal
Normal or dilated
Normal or abnormal
Usually dilated
Abnormal/flail/wide
coaptation defect
Doppler parameters
Color flow jet width in
LVOT
Small in central Jet
Intermediate
Large in central jet,
variable in eccentric jet
Jet density - CW
Jet
dec - CW
(PHT, ms)
Structural
parameters
Diastolic
LV size reversal flow
MILDor faint
Incomplete
Slow > 500
Brief, early
diastolic
Normal
Moderate
Dense
Medium 500-200
Intermediate
Normal
or dilated
Severe
Dense
Steep < 200
Prominent
Usuallyholodiastolic
dilated
Structural parameters
LV size
Aortic leaflets
Gravità dell’insufficienza
 Anatomia funzionale
 Doppler
 Ventricolo e atrio sinistro
 Pressione polmonare, ventricolo destro
Aortic regurgitation severity
(ASE - 2003; ACC/AHA Guidelines for Valvular Heart Disease – 2006)
MILD
Moderate
Severe
Normal
Normal or abnormal
Normal or dilated
Normal or abnormal
Usually dilated
Abnormal/flail/wide
coaptation defect
Doppler parameters
Color flow jet width in
LVOT
Small in central Jet
Intermediate
Large in central jet,
variable in eccentric jet
Jet density - CW
Jet dec - CW (PHT, ms)
Diastolic reversal flow
in descending Ao - PW
Incomplete or faint
Slow > 500
Brief, early diastolic
reversal
Dense
Medium 500-200
Intermediate
Dense
Steep < 200
Prominent holodiastolic
reversal (diastolicTVI
similar to systolic)
Quantitative parameters
VC width (cm)
Jet/LVOT width, %
Jet/LVOT area, %
R Vol (ml/beat)
RF (%)
ERO Area (cmq)
< 0.3
< 25
<5
< 30
< 30
< 0.10
0.3 - 0.60
25 -45
46 - 64
5 - 20
21 - 59
30 - 44
45 - 59
30 - 39
40 - 49
0.10-0.19 0.20-0.29
 0.6
 65
 60
 60
 50
 30
Structural parameters
LV size
Aortic leaflets
Camere cardiache
Insufficienza aortica severa
DTD > 80 mm, TS > 55 mm (25 mm/mq), VTS > 45 ml/mq; FE < 50%
Physiologic framework for assessing preoperative predictors
of surgical outcome in chronic aortic regurgitation
INDEX
Severity of AR
Preload Afterload HR Contractility
+
+
+
0
End_diastolic
Regurgitant
volume
Volume
+
+
+
0
Ejection phase
EF Rest
+
+
+
+
EF exercise
+
+
+
+
Volume
0
+
+/0
+
Pressure/
Volume
Wall stress/
Vcf
0
0
+/0
+
0
0
0
+
End-systolic
Schema for selecting asymptomatic patients
with aortic regurgitation for AVR
Borer JS, Bonow RO Circulation. 2003
(ACC/AHA
Guidelines for the
Management of
Patients with
Valvular Heart
Disease – 2006)
Insufficienza
aortica severa