 So this is our 19th T symposium and I've had the honor of being a speaker at all of our symposiums and I'd like to thank Azad in particular for organizing this virtual symposium today. And the plan here is to make it very practical and interactive and we're going to use virtual cases and we reach assigned cases and topics for which we'll cover material for. And I was assigned aortic insufficiency, and I think it's important to look just at this initial slide and look at the graphic of the aortic valve. One is a pictorial demonstration of how the aortic valve moves during the cardiac cycle. And the other one, which is the blue image there is actually a model that was reconstructed from T data. And you can see again that the aortic valve and the aortic complex is not a static structure. It's actually a structure that moves during the cardiac cycle. I have no competing interests. So the first case I'm going to present is that of an 80 year old female. She's asymptomatic. She has comorbidities of hypertension. On trans thoracic echo she had the incidental finding of an aortic aneurysm and some aortic insufficiency. Her CT scan confirmed the presence of an aortic aneurysm of the ascending aorta and proximal arch and she appears in our operating room. And the first image you get is a four chamber view and my apologies if the image quality is suboptimal, but we have to sort of modify our clips a little bit for this type of virtual presentation. And while I've labeled this a four chamber view you can see that the fourth chamber here is not your traditional fourth chamber it's not actually the right each room but it's in fact the aortic route here. And this should put you into maybe there might be a little bit of a problem with the aortic route. You can see the left ventricle is not particularly large neither is the left atrium or the right ventricle and the ventricular function seems to be reasonable. In this midisophageal long axis view you can see again that the ventricle seems to be functioning well the aortic route seems to be a little bit large, and the left atrium and right ventricle seems seem to be equally function well. So this is a trans-gastric view and I've chosen these first three views just to give you an overview of the heart and the cardiac function. And you can see here, this is a X plane view or biplane view in the trans-gastric mid short axis view showing you the mid popular view as well as a long axis view or two chamber view. And you can see that again the heart's non exceptionally large the global function seems to be intact without any regional wall motion abnormalities. Now here's the money image and you can see quite obviously that there are at least one abnormality present and you can probably spot a second abnormality. Just look at this image it's a midisophageal aortic valve long axis view. We've eliminated most of the left ventricle. We've actually decreased the angle a little bit to 118 degrees and you can see that there are at least two abnormalities present here. And I'm sure you've spotted the first abnormality not a problem. You can see here the ascending aorta appears dilated. The second abnormality is the subnormality with the single arrow, and that actually is a displaced coronary artery. This happens to be left coronary artery normally you wouldn't necessarily see it in this particular view, but in this patient you do. So identifying coronary anatomy can be important when you're assessing aortic insufficiency. If we turn color on here we can see that not only is the aortic root dilated, but the aortic valve is dysfunctional as well. There seems to be some AI. And the question that's often asked in this view is well how much AI is there. And I'm sure everybody's going to guesstimate and say oh it's probably maybe moderate. It could be severe. We're probably going to have to do a little bit of better assessment and look at some other parameters to determine how much AI there might be. And we look in the short axis view here this is the midisophageal aortic valve short axis view with a color compare and we can see that the aortic root seems or the aortic valve and root seem to be really a relatively normal size here. We can see three cusps of the aortic valve they seem to open well. We can see that, however, when they close there's malcoaptation in the middle or central malcoaptation and not surprisingly this is where the JETF AI originates from. So we have a patient with central AI here. So when we put the money shots together we see we've got a dilated aortic root. We have aortic insufficiency that appears to be central and relates to central cost malcoaptation. And we've identified three cusps of normal three cusp aortic valve. So question number one and remember these questions will come up in the MCQ session later on today. You may find the answer as we go through the talk, but they're important questions just in terms of improving perhaps your assessment as you as you perform interoperative acetyl echo. So the question is which component of the aortic root is measured insistently. Is it the annulus, sinus obal salva, the sinus tubular junction or the ascending aorta. So what's an accurate aortic root measurement and what will it entail? Well, you've got to decide whether you're going to measure the root insistently or diastole. That's the first thing. So you've got to look and make sure that you're aligned perpendicular, preferably to the walls of the root and the aorta. And finally, you've got to understand what the standards might be. There are some sex, age and body surface area measurements that actually are related to normals. So this is the table from Lang's paper. This is the quantitative paper from 2015. And you can see here what the absolute values are. They do differ slightly men to women, and they do differ according to age and body surface area. There are nomograms and you can see as you age your, your root in particular these this is a sinus of al salva. There's a larger range over which normal occurs. So it's important when you assess aortic insufficiency to look for the mechanism of aortic insufficiency. And here you can see the root picture I showed you before. It's more important though to look at the actual root itself and to determine how well the cuffs co-op together. And here you can see normal co-optation. It's important to have in your mind what normal is because recognizing abnormal assumes you know what normal is. So other than the sort of displaced coronary that you see there, this would be relatively normal co-optation. And when we do our measurements here, we find these measurements. We find in an 80-year-old female the annulus measures 2.2, the sinus is 2.9, the sinotubular junction at 3.3, and the ACE ending aorta not surprisingly is quite large at 6.09. So the phobology relates to both the sinotubular junction as well as the ACE ending aorta. And that is in fact why this patient has AI. If the sinotubular junction was spared, it's very common for these patients not to have any AI at all and just have aortic root or a sending aorta depletion. So when we think about aortic insufficiency, we classify it commonly now using something called the alchory classification. And this looks at the structural abnormality that might be present causing aortic insufficiency. And it's based similar to the carpentry classification into type 1, 2, and 3. Type 1 relates to normal cusp motion, type 2 to cusp prolapse, and type 3 to cusp restriction. And you can see in this patient, the patient would have had a type 1A. And this pictorial is a little bit problematic I found. I prefer this actual image here, which suggests that the problem exists from the STJ and above. So the sinotubular junction and the ACE and aorta with sparing of the root, but there's still AI present. It's important to remember that etiology and mechanism are two different concepts. Etiology is the cause of the problem. Mechanism is the structural abnormality that is present. So you can have cusp problems, such as prolapse by cuspid perforation, entercarditis, calcific aromatic disease. You can have an aortic aneurysm. And you know, we think of aortic aneurysms as just being common, sort of all as a result of a single cause, but it is they aren't. We see a lot of patients with genetic problems. We see congenital problems, systemic and connective tissue disease. And the most common that we see are related to hypertension and age. And you can have loss of support. So trauma and dissection can cause AI as well. When we grade chronic aortic insufficiency, we use multiple parameters. And this is a rather complex table that was that's in Sogubi's JACE paper for assessment of native valve regurgitation from 2017. And really, there's multiple parameters that are used. They're qualitative parameters, semi quantitative and quantitative parameters. And sometimes it's very challenging to remember all the details in this table. It's probably better to remember what severe is and understand if you remember numbers like six. So greater than six for the width, greater than 65% for the JET LVOT to LVOT with ratio. All of these will help you understand what's severe. But there are many limitations to AI assessment. So there's some technical limitations related to what you use as a Nyquist limit. There's spectral limitations for alignment. If you have different JET types such as eccentric or multiple, then it can be quite time consuming. There's also hemodynamic variables that go into this, whether there's a significant pressure difference or low difference, the duration, whether it's pan systolic or pan diastolic as it happens to be in AI, and whether it's an acute or chronic problem. And in fact, you end up with this very complex diagram here from Sogabee, which sort of helps you try to understand what's mild, moderate and severe. And I don't think anybody has the capacity to remember this off the top of their head without having to look it up. So when we grade AI severity as we would do in this case, we look at things like being a contractor with and JET height to LVOT ratio. And if we do the math, this is what we add. And again, I emphasize it's really important to know the technical nuances that go on when you're assessing these JETs. And here what I've done is zoomed and superimposed what should be the actual JET that you should see. And you can see there are three components to this JET. There's the real proximal component, which is the flow acceleration. There's the narrow component, the vena contracta, and finally the JET area. And where you measure and when you measure can be quite variable. So it's important to spend a little bit of time to zoom in, make sure you have a very nice judge that has all three components before you start measuring and quantifying AI severity. You can do pressure halftime and this is done in the stomach through a transgastric view, either deep transgastric or long access view and you can see a pressure halftime of 405. Some aortic flow reversal and this patient did not have significant aorta reversal. So when you put it all together, the vena contracta width is seven millimeters, which would suggest the patient has severe when you compare all the other ones. Again, you have what's fairly common, which are parameters that support either moderate or severe. So whether you classify this as moderate or severe really depends on other parameters that you can use. The only thing you can do that's fairly simple is to do a an ear away or pizza based on a pizza calculation and you do this in the deep transgastric view. Everybody gets a jet of AI and just change your baseline and move it upwards so that you make the hemisphere bottom where the flow acceleration is as large as you can. You can measure this and the radius and this patient happens to be point six. In the non pressure halftime you already have the AI jet and the recording of the CW of the AI jet. And all you do is trace that AI jet around and there's software within your machine if you know how to activate it that will automatically do these calculations for you. So in this patient when you look at the quantification methods that we use, the patient had an ear away of point one eight and a regurgent volume of 46 ccs, which probably went with your initial gut feeling when I showed you the aortic valve long axis you with color. And both of these measures suggest the patient has moderate AI. It gets very complicated. Can we simplify it and this is an attempt from the American Society of echocardiography to create guidelines that help us in in assessing patients in the operating room. And this is what they suggest for AI pre assessment. So evaluate the audit valve anatomy, identify the cornea coronary osteo which we did look at the audit valve function in terms of assessment of severity and look at global function and regional function of the LV all of which we've done. And there's post parameters that you can look at as well. I would highly recommend this paper as a good read for people who are just starting out in echocardiography. So what is the surgeon going to do. So here we have an ascending aortic aneurysm with AI. And this is what the surgeon would be looking at. Question is, does he need to replace the valve and the order just replace the order to a valve sparing procedure, or just do an aortic valve replacement, I fixed what's wrong, which is the leaky valve and not do anything to the ascending order. Well, not surprisingly, the surgeon chooses to just replace the ascending order here. He would open inspect the bell, put in a Dachron graph and be done. And this is what was done in this case. And you can see here, I've marked with the yellow errors where the Dachron graft is and the patient actually in long axis initially had what looked like a good result. So when we looked at it in short axis, however, we recognize the patient still had some AI. But remember the surgeon, the reason the patient was in the operating room was because of that six centimeter dilated ascending order, which is no longer there. And this is an acceptable amount of AI that the patient can can no doubt live with. So case number two. The patient a 62 year old male, also asymptomatic, a few more comorbidities this is a patient with hypertension. This is a current smoker diabetes, had a history of SVT as well on TTE was found to have a dilated aorta and AI, but how to the start of a dilated ventricle so the left ventricular internal diameter was 63 millimeters, and on how to 50% LED. And again, when we look at the four chamber view we don't really get a four chamber view for chamber here again is the aortic route. You can see the LV is a little bit more dilated than the other patient with a preserve ventricular function. And this is confirmed in the long axis view you can see the LV is maybe a little bit dilated the route is quite prominent. The right ventricle seems small and well functioning as does the left each room. LV again, maybe we're not quite perpendicular but this is the trans gaseous mid short axis you and to chamber view you can see that the heart seems to be functioning well. And then we go to the money shot here which is the aortic valve long axis view, and you can see how different this route is compared to the previous route. The architecture and structures is distorted. There's now dilatation of the route itself. You don't see a very specific sinus tubular junction. And when you look at the coaptation of those leaflets, you can see they barely co apt. So again, very abnormal structure here. And not surprisingly when we turn color on, we see leakage of the valve. And again there's a central jet of AI here. This is a more zoomed in picture and we're seeing sort of just a bit of the aortic valve here, the LV OT, and you can see there's central AI here. And when we look at the short axis view, we see again the root is dilated so you can notice how large that aortic valve looks. And again there's three cusps they seem to open well, but unfortunately there's malcoaptation in the center so again you have this central jet of AI. So again when we look at this we have a dilated route now we haven't yet assessed the ascending order, but we do see central AI from central malcoaptation. So a similar problem to the first patient, except now we've got the aortic route involved. And when we look at the mechanisms here we see the measurements are done, the annulus is preserved, it's 2.4, the sinuses are large at 52 millimeters or 5.2 centimeters, sinotubular junction, which is a bit of a guess here is five centimeters. And to actually get a good measurement of the ascending order we pull the probe back reduced our angle by 20 degrees so that we're seeing the right pulmonary artery circular structure. And then we're measuring the ascending order which is also dilated at 4.2. So we think about the mechanism in this patient. This patient has AI based on the type one B. So not only do we have dilation of the ascending order and STJ, but we now have dilation of the route as well. The annulus however is preserved. So we see something like this where this is just a cartoon representation of what the mechanism would be. So type two type one, we have mostly ascending order type two we have route type three, which will come to or type sort of one B one C is annular dilation, and then cusp preparation so these are all pathologies related, or the mechanisms related to type one. So with AI severity again, we measure the Vina contractor which is 3.2 millimeters here. And the ratio is 28%. The pressure half time is not a significant it's 561. And there appears to be a bit of aortic flow reversal. So these indicate mild to moderate AI. We can do PISA again, which we try and do here. I find that when I'm doing PISA, the less the AI, the more error you tend to introduce because it's very hard to get a good piece of radius sometimes even if you shift the baseline. But here we're able to see that the quantitative measures also confirm mild to moderate AI here. So the ROI was 0.13 and the regurgitation of volume is only 24 CCs. So, the question is, what does the surgeon do with this type of patient, and I would highly recommend this paper. It's a recent paper from 2019 that looks at what aortic valve repair measurements and acro cardiographer needs to take prior to a surgeon debating whether to do any sort of mild sparing procedure. And I know that my colleagues will be discussing this in detail a little bit further on, but these are just some of the measurements that you would be looking at. So you would do an annual measurement and dilation would be considered greater than 25. You can look at the geometric height, which is the length of the leaflets themselves which greater than 16 millimeters is considered abnormal. The co-optation length or co-optation height, which is the length of co-optation. And again, five millimeters is considered abnormal and this patient obviously have less than five millimeters. And you would look at the effective height, which is the distance between the annulus and the distal portion of co-optation and anything less than nine millimeters is a problem. So what's the surgeon going to do with this particular patient? And again, the options are very much the same as the first patient, younger patient, however, and recognizing the center you're at. The choices are dental with an aortic valve replacement and replacement of the aorta, replacement just of the aorta, valve sparing root or aortic valve replacement. And I would have to say when in our house, we do any valve sparing procedure. So the patient underwent a re-implantation procedure here. You can see the cast would be inspected. The diseased aorta is taken away. The pillars of these commissures are then sewn into this Dachron graft here. And you can see them sort of the geometry is trying to be preserved here. The surgeon suturing in the pillars, he instills a bit of saline and this is what they often call the poor man's echo. If it doesn't leak, they figure it's going to be good. They put in the coronary buttons and finally do the rest of the aorta and they've finished the procedure. And post pump, you get pictures that look like this. They're not aesthetically pleasing and you're asked to comment about whether this is a satisfactory result or not. And again, I think my colleagues will look at this in a little bit more detail in some of the upcoming sessions, but you can see functionally here there doesn't appear to be any AI and the result seems to be acceptable. And here it is in short axis. So question number two, this normal spectral Doppler trace is imaged from which segment of the aorta. So this is a PW that the sample volume was positioned in a particular part of the aorta and giving this very normal trace. And this is something that, you know, you should probably be able to tease out does take a little bit of cerebral effort, but essentially, I think you probably can come up with an answer. So I was asked to talk about aortic flow reversal assessment of AI, and it does appear in the guidelines and these are the 2017 guidelines. The assessment reflects both trans thoracic and trans esophageal options for trans thoracic. The sample volume is actually placed in the proximal descending aorta. So this is done through a super sternal notch view. And you can see here, the abnormality is shown above the baseline. So this is full that goes towards the baseline towards the probe. And it's an opportunity for us to have some sort of qualitative verification. Aortic insufficiency. So the pathology here is if you have prominent hollow diastolic reversal, that's significant for severe AI. And you can read this little paragraph in the guidelines. What about trans esophageal? Well, in trans esophageal, it's very important to know what normal flow is again before you know what abnormal flow is. So when you look at it in the arch, these are all normal flows in the arch. And when you look at in short axis in the descending aorta, this is what you would see. And finally, if you look at it in the descending aorta and long axis, this is what you would see. So what is abnormal? So aortic flow reversal is flow that depending on where you're sampling is hollow diastolic reversal. So this is flow that happens to be here in the arch. This can be quite normal in the arch. As you go go more distally to the descending aorta, it becomes pathological. So if you have flow reversal in the descending aorta, it indicates either moderate to severe AI. And this is being long known. This is a 1994 classic paper by Sutton, which looked at all of this and was able to show that flow reversal was pathological. So you need to look at it in the descending aorta more so than the arch. How much? So these are all patients that have descending flow reversal. It has to be hollow diastolic and they all have hollow diastolic. If it's in the abdominal aorta, it's considered severe. You can look at the ratio of forward flow to reverse flow, and this can approximate the regurgitant volume. And this again is from Zoga Bees paper. It's important, however, to remember that there is a differential here, that there's other causes. And the elderly patient in particular with a reduced compliance in the aorta may have normally some flow reversal. So just because you see flow reversal in the aorta, don't assume the patient has AI. So cases one and two to wrap up key points, ascending aorta pathology may or may not have AI. I chose two examples that did have AI, but it doesn't necessarily have to have AI. It's important to identify the mechanism. So if you can look at whether it's type one, two or three, and then the etiology of the AI, you can determine severity quite easily. And if you see descending aorta, hollow diastolic flow, it's a qualitative support for severe AI. Thank you very much. Thank you Dr Vegas for an absolutely wonderful talk just to get this meeting going and you know, I think everything else kind of pale in comparison to that show of mastery. Does anyone have any questions. Do you have any questions at a time. If anyone wants to post a question or you can either type it or we can unmute you. I think is that is that okay. We can ask people to type them in below. Okay, so Andre to know is a is here. He's asking, can you clarify calls versus mechanism. Yeah, sure. Hey Andre. Welcome. I hope I hope you're well. Yeah, sure. It's a bit like carpante. You know what you're trying to do is look for the structural abnormality there so what's wrong with the complex. So the order valve it's not just the order valve it's the order valve complex so is there a problem with the order valve itself is there a problem with the root is there a problem with the order, much like you would do for the mitral valve. What is the underlying complex. What is really the underlying cause of this is that a problem with enter carditis is the problem with some connective tissue disorder, whatever the root causes. So I would say mechanism is kind of that global umbrella see you choose one of the three types, and then ideology is drilling down to see what what the actual cause of the problem is. I'm not sure if I see any other questions. There's a question in the chat hang on. I can read it out below. No, no problem. It says what about you people when they have elastic order can we expect some early diastolic flow reversal. Absolutely so it's important to distinguish early diastolic flow reversal from hollow diastolic flow reversal so the majority of patients will have some degree of early diastolic remember the the order recoils number one, number two closure of the order valve depends on some backwards flow. It's not that you're going to see a lot of it but you will see it perhaps in the arch. And it's not uncommon to see early diastolic flow reversal as being a normal in every patient actually.