oThis should be performed for coronary angiography studies before AVR in patients at risk for CAD, including men older than 35 years, premenopausal women older than 35 years with coronary risk factors, and postmenopausal women.



oIt can be used to assess the severity of regurgitation when noninvasive test results are inconclusive or discordant with clinical findings regarding the severity of regurgitation or the need for surgery.

oUse cardiac catheterization to assess LV function when noninvasive test results are inconclusive or discordant with clinical findings LV dysfuncation and the need for surgery in patients with severe AR.

Qualitative assessment (Aortic Angiogram):

oIn mild AR (1+), a small amount of contrast enters the left ventricle during diastole and clears with each systole.

oIn moderate AR (2+), more contrast enters with each diastole, and faint opacification of the entire LV chamber occurs.

oIn moderately severe AR (3+), the LV chamber is well opacified and equal in density when compared with the ascending aorta.

oIn severe AR (4+), complete dense opacification of the LV chamber occurs on the first beat and the left ventricle is more densely opacified than the ascending aorta.

Simultaneous aortic and LV pressure tracing (signs of severe AR):

oWide pulse pressure may be present.

oLV diastolic pressure increases rapidly.

oNear quilibration of aortic and LV pressure occurs at diastole.

Imaging Studies:

M-mode features of AR include the following.

oDiastolic flutter of the mitral valve (can be both anterior and posterior mitral valve leaftlet)

oDiastolic flutter of the aortic valve

oPremature closure of the mitral valve (severe AR)

oPremature opening of the aortic valve (severe elevated LV end-diastolic pressure)

oDiastolic LV septal fluttering

oLV volume overload (hyperkinesis of the LV walls LV dilation)

oLVESD (>55mm indicates poorer surgical outcome)

On 2 Dimensional echocardiography, look for the following features:

oFlail aortic aneurysm.

oDilatation of the sinuses of Valsalva (particularly in patients with Marfan syndrome or bicuspid aortic valve problem).

oAscending aortic aneurysm.

oIncomplete closure of the aortic valve cusps on the parasternal short axis view of the aortic valve.

oHigh frequency diastolic fluttering of the anterior leafleft of the mitral valve during diastole.

oReverse doming of the anterior mitral valve leafleft.

oLV volume overload pattern.

oMeasurements of LV end diastolic and end-systolic dimensions and volumes. Shortening fractions and EFs - Criticall in determining the optimal time for valve replacement.

oMeasurement of aortic regurgitant fraction, reguirgitant orifice size, and regurgitant volumes ? Now available with Doppler echocardiography.