Radiographic Evaluation of Aortic Insufficiencyeradiology.bidmc.harvard.edu/LearningLab/cardio/Vazquez.pdf · Radiographic Evaluation of Aortic Insufficiency Jesus Vazquez, Harvard

Jesus Vazquez HMS IIIGillian Lieberman, MD

Radiographic Evaluation of Aortic Insufficiency

Jesus Vazquez, Harvard Medical School Year IIIGillian Lieberman, MD

May 2003

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Plan of Attack

• Patient Presentation• Radiographic Findings• Summary of used and unused radiographic

arsenal with their indications• Evolving advances in cardiac imaging

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Mr. R’s Headache

• 43 year old Male• Two day History of:

• Headache• Nausea• Vomiting• paraphasic errors

• LP: WBC 235, RBC 355, Protein 52, Glucose 61

• Sent for: CXR and CT

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Radiographic Findings on PresentationLungs clear

Heart: normal size; Rotated left Intraparenchymal hemorrhageImages Courtesy of Dr. Applebaum BIDMC

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Mr. R’s first 24hours

• Vitals:• Fever 102F• SBP 170• HR 130

• Deteriorating Neurologic exam• Decreased Level of consciousness• Extensive Posturing on left• Withdrawl on Right

• Repeat: CXR and CT

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Radiographic Findings on Day #2Perihilar

Opacities

Basilar Opacities Hemorrhage into Right Ventricle

Images Courtesy of Dr. Applebaum BIDMC

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Mr. R’s Care

• OR for hematoma evacuation

• Post-op: CPK 38 with elevated CK-MB

• Cardiology Consult for Suspected Septic Emboli

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Differential Diagnosis of Cerebral Abcess

• Blood-borne metastases: Heart and Lung Most Common• Direct extension from parameningeal sites (otitis, cranial

osteomyelitis, sinusitis)• Recent or remote head trauma • Recent neurosurgical procedures• Infections associated with cyanotic congenital heart

disease• Iatrogenic: Indwelling IV Catheter• IV Drug Use

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Etiologies of Aortic Insufficiency

• Intrinsic to the Aortic Valve• Congenital Bicuspid Valve• Rheumatic Endocarditis• Bacterial Endocarditis• Myxomatous valve with Cystic Medial Necrosis

• Primary Disease of Ascending Aorta– Dilated Aortic Annulus

• Syphilitic Aortitis• Ankylosing Spondylitis• Reiter Disease• Rheumatic Arthritis• Marfan Syndrome

– Laceration/Aortic Dissection• Deceleration trauma• Hypertension


Evaluation of Aortic Insufficiency

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Clinical Findings• Patient Presentations

• Asymptomatic for many years• Physical Exam: Bisiferious Pulse, Water-Hammer Pulse, Quincke’s

Pulse, Musset’s Sign, Muller’s Sign, Traube’s Sign, Duroziez’s Sign• Eventually CHF (PND, Orthopnea, DOE, pulmonary edema)

• Non-Radiologic findings• Wide Pulse Pressure• Bounding Pulses• Diastolic Blowing murmur: first early diastolic, then holodiastolic,

and eventually softens/disappears as approach heart failure• S3• Systolic Ejection Murmur due to aortic distension from increased

stroke volume• Austin Flint Murmur: mid diastolic murmur heard at apex• EKG: Evaluate LVH and coronary ischemia

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Radiographic Evaluation

• Chest X-Ray: Gross identification of Cardiomegaly and Pulmonary involvement

• Echocardiography: Diagnosis, Etiology, Heart Morphology, and Severity

• Angiography: evaluation of volume and function when echo suboptimal

• Cardiac Catheterization: Prior to Surgery if patient is at risk for CAD

• Exercise Testing: assessment of functional capacity

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Anatomy of the Aortic Valve

Clemente, Carmine D. Anatomy: A regional Atlas of the Human Body, 4th Ed., Urban &Schwartzenberg 1997

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Visualizing a Normal heart on CXR

Wicke, Lothar. Atlas of Radiographic Anatomy. 6th

English Ed. Williams & Wilkins 1998

Left Ventricle

Aortic ArchPulmonary Vessels

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Classic CXR of Aortic Insufficiency

Chronic AIAcute AIJefferson, Keith. Clinical Cardiac Radiology. 2nd

Edition. Butterworth & Co. 1980

Pulmonary EdemaDilated Left Ventricle

Prominent Aorta

Left Atrial Enlargement in Heart Failure

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Echocardiography

• Can be used to evaluate:– Valve Anatomy: thickening,

vegetations, calcification, movement, and Valve Area

– Aortic root dilatation– Wall thickness– Cavity Size– Cardiac Output– Semiquantitative measurement of

regurgitation • Weakness:

– Acoustic windows– Semiquantitative measurements

Higgins, Charles B. Essentials of Cardiac Radiology and Imaging. J.B. Lippincott 1992

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Angiography

• Increased Left Ventricle Cavity, EDV, ESV, Stroke Volume, and Aortic Dilatation

• Structural Abnormalities: Valve, Septum, or Bodies

• Regurgitation of Blood– Tivial:Contrast cleared with each systole– Moderate: incomplete clearance but

without accumulation– Severe: Accumulation with each beat– Gross: Completely filled with first

diastoleHiggins, Charles B. Essentials of Cardiac Radiology and Imaging. J.B. Lippincott 1992

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Healthy Coronary Arteries

Wicke, Lothar. Atlas of Radiographic Anatomy. 6th English Ed. Williams & Wilkins 1998

Right Coronary ArteryLeft Coronary ArteryCatheter

Anterior IV Branch

Circumflex

PDA

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Surgical Indications for Aortic Valve Replacement

• NYHA functional Class III or IV symptoms With Normal systolic function (ejection fraction >0.50 at rest)

• NYHA functional Class II, III, or IV symptoms and with mild to moderate LV systolic dysfunction (ejection fraction 0.25 to 0.49)

• patients with severe LV dilatation (end-diastolic dimension >75 mm or end-systolic dimension <55 mm), even if ejection fraction is normal

• New York Heart Association Functional Classification• Class I - No symptoms or minimal symptoms with ordinary

physical activity• Class II - Symptoms with ordinary activity; slight limitation of

activity• Class III - Symptoms with less than ordinary activity; marked

limitation of activity• Class IV - Symptoms with any physical activity, or even at rest


What Happened to Mr. R.?

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Hospital Course

• He gradually became less responsive over the nex week with worsening BP control and elevated temperatures

• CXR 10 days after admission

• Surgery Consulted But unable to assist because of therapeutic heparinization requirement

• Patient expired on hospital day 11

Diffuse Pulmonary Vessel Engorgement

Possible Effusion

Enlarged Cardiac SilhouetteImages Courtesy of Dr. Applebaum BIDMC


Up-and-Coming Non-Invasive Studies

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Computed Tomography

• Most Sensitive study for identifying calcification• High accuracy in differentiating thrombus from

tumor• Contrast allows evaluation of: Chamber Volume,

Chamber Shape, Wall Thickness, and Myocardial Mass

• Speed of study allows for lack of EKG gating

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CT of Heart

Rozenshtein, A. Boxt, M.B. Computed Tomography and Magnetic Resonance Imaging of Patients with Valvular Heart Disease. Jounal of Thoracic Imaging 15:252-264, 2000

Mild thickening of myocardiumDilated Left VentricleDilated Ascending Aorta

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MRI

• Simultaneous Structure and Function• Accurate measurement of : EDV, ESV, EF, SV,

CO, and Myocardial Volume• Quantitative evaluation of regurgitation (flow vs.

time)• No difficulties with image plane• Requires EKG gating (TR must equal R-R

multiple)

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MRI of Regurgitation

Left VentricleRight Ventricle

Left AtriaAorta

Regurgitation Jet

IVCImages Courtesy of Dr. Averbach, BWH

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Summary• Aortic Insufficiency

– Acute with drastic health changes– Chronic with an insidious onset

• Current Process of Diagnosis:1. Physical Exam2. CXR3. Echo with Doppler4. Aortogram5. Cardiac Catheterization

• Advances in CT and MRI are promising in filling wholes in non-invasive studies

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References• Goldman: Cecil Textbook of Medicine, 21st ed• Clemente, Carmine D. Anatomy: A regional Atlas of the Human Body, 4th Ed., Urban &Schwartzenberg

1997• Wicke, Lothar. Atlas of Radiographic Anatomy. 6th English Ed. Williams & Wilkins 1998• Jefferson, Keith. Clinical Cardiac Radiology. 2nd Edition. Butterworth & Co. 1980• Higgins, Charles B. Essentials of Cardiac Radiology and Imaging. J.B. Lippincott 1992• Stern, E.J., White, C.S.Chest Radiology Companion. Lippincott Williams & Wilkins. 1999• Rozenshtein, A. Boxt, M.B. Computed Tomography and Magnetic Resonance Imaging of Patients with

Valvular Heart Disease. Jounal of Thoracic Imaging 15:252-264, 2000• Dahnert, W. Dahnert’s Radiology Review Manual, 4th ed. Lippincott Williams & Wilkins. 1999• Didier D. Ratib O. Lerch R. Friedli B. Detection and quantification of valvular heart disease with dynamic

cardiac MR imaging. Radiographics. 20(5):1279-99. • Lipton, M.J. Coulden, R. Valvular Heart DiseaseCardiac Radiology. 37 (2): 319-339 1997• Romero, R.C., Boxt, L. Plain-Film Evaluation of Valvular Heart Disease. Seminars in Roentgenology. 37(3):

219-227. 1999• Assi, E., Tak, T. Assessment of Valvular Heart Disease Why Eechocardiography is an essential

component. Valvular Heart Disease. 104(6): 99-111. 1998• Up To Date: ACC/AHA guidelines for the management of patients with valvular heart disease: Aortic

regurgitation• Up To Date: Aortic Insufficiency

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Acknowledgements

Many Thanks to:• Larry Barbaras and Cara Lyn D’amour

our Webmasters• Dr. Applebaum (BIDMC)• Dr. Averbach (BWH)• Gillian Lieberman, MD• Pamela Lepkowski

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THE END

Documents

Radiographic Evaluation of Aortic Insufficiencyeradiology.bidmc.harvard.edu/LearningLab/cardio/Vazquez.pdf · Radiographic Evaluation of Aortic Insufficiency Jesus Vazquez, Harvard