Preliminary Diagnosis: Aortic Insufficiency

I. What imaging technique is first-line for this diagnosis?

  • Gray scale and color Doppler echocardiography (transesophageal offers better resolution than transthoracic)

II. Describe the advantages and disadvantages of this technique for diagnosis of aortic insufficiency.

Advantages
  • Highly portable, fast, and relatively inexpensive imaging modality

  • Does not expose patients to ionizing radiation

  • Offers exquisite visualization of delayed opening of the mitral valve and details the dilatation and decreased function of the left ventricle seen in aortic insufficiency

Disadvantages
  • Highly operator dependent.

  • Echocardiography cannot be used for intervention.

III. What are the contraindications for the first-line imaging technique?

No specific contraindications to echocardiography exist.

IV. What alternative imaging techniques are available?

  • Cardiac CTA

  • Cardiac MRI

  • Conventional cardiac angiography

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of aortic insufficiency.

Cardiac CTA
Advantages
  • Offers more exquisite detail of the surrounding soft tissues, osseous structures, and soft tissues than echocardiography

  • More sensitive and specific in evaluating for calcification, thickening of the leaflets

Disadvantages
  • Does not offer dynamic imaging capability

  • Exposes patients to ionizing radiation

  • May miss mild aortic insufficiency

Cardiac MRI
Advantages

Gold standard for functional assessment: left ventricular ejection fraction, ventricular volume, and myocardial mass

Disadavantages
  • Must be cardiac gated and may be subject to motion artifact and flow artifact from inadequate gating

  • May not be performed in patients with non-MR-compatible hardware

Conventional Cardiac Angiography
Advantages
  • Useful in diagnosis and treatment in patients with aortic insufficiency

  • Offers exquisite dynamic imaging capabililty and delivers highly specific information on valvular flow

Disadvantages
  • Less exquisite in detailing the anatomy of the surrounding soft tissues, vascular structures, and osseous structures

  • Exposes patients to large amounts of ionizing radiation

  • Highly invasive and is associated with more morbidity and mortality compared with companion noninvasive imaging techniques

VI. What are the contraindications for the alternative imaging techniques?

Cardiac CTA
  • May not be performed in pregnant patients

Cardiac MRI
  • Contraindicated in patients with non-MR-compatible hardware

Conventional Cardiac Angiography
  • Contraindicated in patients who are in a severe hypocoaguable state

  • Non-iodine-based contrast agents such as CO2 may have to be used in patients with a contrast allergy.