Echocardiographic Evaluation of the Etiology and Mechanism of Native Aortic Valve Regurgitation

Figures

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  Figure 1. Basic anatomical concepts. (A) Within the functional aortic annulus (FAA), the cusps insert into the aortic wall in a semilunar fashion with the superior border at the STJ and inferior border at the aortic annulus (AoA). The AoA is best envisioned from an imaging perspective as a virtual plane joining the most basal portion or nadir of the aortic cusps (panel A is adapted from Piazza et al.5). Downstream to the AoA is the anatomic ventricular aortic junction, which is the transition area between the ventricular septum and the wall of the sinus of Valsalva (not illustrated in this diagram). (B) Components of the FAA should be measured at the different levels and dimensions compared with echocardiographic normal ranges.6 The AoA is measured inner edge to inner edge from the leaflet insertion point in midsystole. In contrast, the aortic root and STJ are measured leading edge to leading edge at end diastole perpendicular to the long axis of the ascending aorta. (C) The effective height, measured as the orthogonal distance between the AoA and the central free margin of each cusp during diastole, is an important parameter in assessing cusp coaptation. Not well depicted in these images…

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  Figure 2. Type Ia AR. (A, B) Two-dimensional TTE parasternal long-axis view, diastolic phase, without and with color demonstrating moderate AR (Video 1). (C) Transthoracic echocardiographic long-axis view depiction showing distal ascending aorta enlargement including the STJ with normal aortic root size leading to a failure of central coaptation and a central jet of AR.

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  Figure 3. Type Ib AR. (A) Two-dimensional TEE midesophageal long-axis view, 130°, diastolic phase, without and with color demonstrating severe AR (Video 2). (B) Transesophageal echocardiographic long-axis view depiction showing aortic root (and STJ) enlargement with a central jet of AR.

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  Figure 4. Type Ic AR. (A, B) Two-dimensional TEE midesophageal long-axis view, 121°, diastolic phase, without and with color Doppler, demonstrates severe AR (VCW 0.8 cm; Video 3). (C) Transesophageal echocardiographic long-axis view depiction showing isolated enlargement of the AoA with a central jet of AR.

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  Figure 5. Type Id AR. (A) Two-dimensional TEE midesophageal long-axis view, 133° degrees, diastolic phase, without and with color Doppler, demonstrates two filamentous linear structures on the LV side of the AV leaflets (perforated diverticulum; arrow). With color Doppler, severe AR is demonstrated (VCW, 0.8 cm; Video 4). (B) Transesophageal echocardiographic long-axis view depiction showing that the jet originates in the body of the noncoronary cusp and not at the site of coaptation.

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  Figure 6. Type II AR. (A, B) Transthoracic echocardiographic parasternal long-axis, diastolic phase without and with color demonstrating an eccentric jet of severe AR directed toward the anterior mitral valve leaflet (Video 5). (C) Transthoracic echocardiographic long-axis view depiction showing right coronary cusp prolapse (arrow), resulting in an eccentric jet of AR.

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  Figure 7. Type III AR. (A, B) Two-dimensional TEE midesophageal long-axis views, 130°, diastolic phase, without and with color Doppler showing an eccentric jet of severe AR directed toward the anterior mitral valve leaflet (Video 6). (C) Transesophageal echocardiographic long-axis view depiction showing asymmetric cusp degeneration resulting in noncoronary cusp restriction (arrow) and an eccentric jet of AR.