#1: Where do you measure the width of the aortic regurgitant jet?
#2: Where and when do you measure the LVOT diameter?
#3: What is the severity of the aortic regurgitation?
#4: Should this patient have an AVR if they are asymptomatic? Symptomatic?
Explanation: The AR jet should be measured as close to the aortic valve annulus as possible. The LVOT diameter should be measured in mid systole when the LVOT is at it's widest. The AR jet should be measured during diastole when it is it's widest which is the early part of diastole when the gradient is the highest. That ratio helps determine the severity (ARdiameter/LVOT diameter) of the aortic regurgitation.
If the ratio is less than 25% then trace AR is present. If the ratio is less than 46% then mild AR is present. If the ratio is less than 64% then moderate AR is present. Any ratio > 64% is considered severe AR.
In this patient the jet is not of uniform width. The jet is very thin and then widens in the LVOT. It appears, without directly measuring the jet and LVOT width's, that the jet is less than 64% but greater than 25% of the LVOT diameter. Therefore, it appears that the AR is moderate.
While many discussion occur about when to operate on AR, the current recommendations are to only operate when the LV severely dilates, when the LVEF falls, or when symptoms appear. In the asymptomatic pateint with a normal LVEF, an AVR is not indicated until the LVEDD > 70-75 mm or the LVESD > 50-55 mm. If the LVEF is < 50% or symptoms appear with significant AR apparently the etiology, an AVR is indicated.
Patients with decreased LVEF due to untreated AR have a much high mortality rate.
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