Optimizing Echocardiographic Assessment of Aortic Regurgitation

Figures

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  Visual Summary. Comprehensive and Quantitative Assessment of AR With Integration of Multiple Echocardiographic and Doppler Windows A systematic, step-by-step scanning protocol enhances diagnostic confidence and guides timely intervention.

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  Figure 1. Parasternal Long Axis View of the Left Ventricle Parasternal long-axis view showing measurements of the left ventricular diameter in (A) end-diastole and (B) end-systole. Ao = aorta; LA = left atrium; LV = left ventricle; RV = right ventricle.

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  Figure 2. Zoomed Parasternal Long Axis View of the Aortic Valve (A) Zoomed image of aortic valve measurements of the LVOT diameter (dotted pink line). In this zoomed image, (B) color Doppler can also be used to measure regurgitant jet vena contracta width (red line). (C) In central regurgitant jets, the ratio of the regurgitation jet width (solid pink line) to the LVOT diameter (dotted pink line) or the ratio of the jet cross-sectional area to the LVOT cross-sectional area can also be obtained. (D) The ascending aorta should also be evaluated for aortopathy dilation and measured (blue line). Ao = aorta; LA = left atrium; LVOT = left ventricular outflow tract; RV = right ventricle.

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  Figure 3. Evaluating the Aortic Valve in the Parasternal Short-Axis View (A) Zooming in on the aortic valve allows for identification of the individual cusps. (B) The noncoronary cusp (NCC), left coronary cusp (LCC), and right coronary cusp (RCC) are best seen in systole where the commissures can be identified, avoiding confusion with raphe in patients with bicuspid valves. (C) Color Doppler can show the origin of the regurgitant jet. Ao = aorta; LA = left atrium; RA = right atrium; RV = right ventricle.

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  Figure 4. 2-Dimensional and 3-Dimensional Echocardiographic Assessment of Left Ventricular Ejection Fraction Left ventricular (A) end-diastolic and (B) end-systolic volume are measured to determine left ventricular systolic function and also chamber size. With chronic, severe aortic regurgitation, left ventricular chamber dilation may occur and is an important clinical marker. (C) Evaluation of chamber size and function can also be performed using a 3-dimensional data set of the left ventricle. (D) Left ventricular strain measurements can also be obtained using the apical 4-chamber, 2-chamber, and 3-chamber views.

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  Figure 5. Using the Continuity Equation to Calculate Aortic Regurgitant Volume (A) The LVOT diameter (blue line) and (B) PW Doppler are used to determine LV stroke volume. (C) The mitral valve stroke volume is calculated using the MV annular diameter (red line) and (D) PW Doppler located at the mitral annulus. Subtracting the mitral valve stroke from the LV stroke volume will yield the regurgitant volume. LV = left ventricular; LVOT = left ventricular outflow tract; MV = mitral valve; PW = pulse wave.

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  Figure 6. Measuring the Effective Orifice Area of the AR Jet With the PISA Method (A) Color Doppler is first used to best locate the jet, and the Nyquist baseline is shifted in the direction of the regurgitation to ∼30 to 40 cm/s. The radius of the color flow convergence hemisphere is measured in diastole from the blue/yellow interface to the leaflet tips, coaxial to the ultrasound beam (red line). Using color compare Doppler may be helpful in identifying the location of the leaflet tips. This method becomes challenging in the presence of eccentric or multiple jets and may lead to underestimation of regurgitation severity. (B) Tracing the CW Doppler envelope yields the AR velocity time integral (yellow tracing), which when multiplied by the effective orifice area will provide the regurgitant volume. AR = aortic regurgitation; CW = continuous wave; PISA = proximal isovelocity surface area.

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  Figure 7. Using Color Doppler in the 5-Chamber View to Assess the Degree of Aortic Regurgitation (A) The CW cursor is aligned with the main regurgitant jet (dotted white line). (B) Pressure half-time is the time for the aortic–left ventricular pressure gradient to decrease by half and is measured from the slope of the CW Doppler envelope. If there is an abrupt initial drop, the slope of the steady declaration, not the initial drop, is used. CW = continuous wave.

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  Figure 8. Doppler Evaluation of Aortic Regurgitation in the 3-Chamber View (A) Apical 3-chamber assessment of the AV including PW Doppler, which can be used in the continuity equation for regurgitant volume quantification, and (B) CW Doppler, where jet density and slope (pressure half-time) are assessed. AV = aortic regurgitation; CW = continuous wave; PW = pulse wave.

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  Figure 9. Use of the Suprasternal Notch View In the suprasternal notch view, color Doppler can be used to guide imaging and place a PW spectral Doppler sample volume in the proximal descending aorta just distal to the left subclavian artery. Holodiastolic flow reversal (red arrow) is associated with severe aortic regurgitation. PW = pulse wave.