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Aortic Stenosis
Kunjan Bhatt MD
Austin Heart
Let’s Start off with
some questions!
Question 1
Components for the continuity equation for
AVA include all the following except?
1.MV annular diameter
2.MV annular VTI
3.AV VTI
4.LVOT diameter
5.All can be used in the continuity equation for the
aortic valve
Question 2
Which of the following is not a marker of
severe aortic stenosis?
1.
2.
3.
4.
5.
Vmax across the Aortic valve is > 4m/s
Calculated aortic valve area of 1.34 cm2
LVOT Vmx / AV Vmx ratio < 0.25
Mean gradient = 55 mmHg
The cardiologist said the valve was friggin’ tight!
Question 3
Which is a true statement
1. Echo has become the gold standard for the
assessment of Aortic valve stenosis
2. Cath is still the gold standard for the
diagnosis of Aortic stenosis
3. No valve is too tight until the patient has
syncope…
Question 4
• At maximal dobutamine infusion, in an AS
patient, the peak LVOT velocity increased from 50
to 90 cm / sec., while the peak transaortic valve
velocity increased from 2 to 2.3 m/sec. The LVOT
diameter is 2 cm. This study suggests that:
• 1. The baseline ejection fraction was < 20%.
• 2. There is significant AR.
• 3. AS is not severe.
• 4 LV motion did not improve.
Question 5
The valve area is?
a) 0.3
b) 0.5
c) 0.8
d) 1.0
Question 6
A patient with severe aortic stenosis has MR.
Which one of the following statements is
incorrect?
1. The peak mitral regurgitation jet velocity is
higher than the peak trans-aortic valve flow
velocity.
2. The aortic transvalvular flow duration is shorter
than the MR jet duration.
3. The LVOT flow duration is longer than the MR jet
duration.
Question 7
A patient with valvular AS has severe LVOT
obstruction (HOCM). The best way to evaluate
AS severity in this patient is:
1.Dobutamine echo.
2.Aortic valve area by planimetry (TEE)
3. Valve area using the continuity equation.
4. Mean aortic gradient (Bernouilli formula).
Lets talk about Aortic
stenosis…
January 2009, JASE
Cath Vs Echo
There are many Echo criteria for Aortic
stenosis
Let’s focus on the ones used in daily
practice.
How do we assess the Aortic Valve
•
•
•
•
•
AS jet velocity
Mean trans-aortic gradient
Valve area by continuity equation.
Velocity Ratio (VTI ratio)
Planimetry
Jet Velocity
• This is measured with Continuous wave
doppler
• Multiple windows and “non-standard views”
to look for the highest Vmax
• Apical and suprasternal or right parasternal
most frequently yield the highest velocity;
• subcostal or supraclavicular windows may be
required.
Aortic Jet Velocity
• Careful patient positioning and adjustment of transducer
position and angle are crucial as velocity measurement
assumes a parallel intercept angle between the
ultrasound beam and direction of blood flow, whereas the
3D direction of the aortic jet is unpredictable and usually
cannot be visualized.
• AS jet velocity is defined as the highest velocity signal
obtained from any window after a careful examination
• Lower values from other views are not reported. The
acoustic window that provides the highest aortic jet
velocity is noted in the report and usually remains constant
on sequential studies in an individual patient.
Aortic Jet Velocity Pitfalls
• Why multiple views?? Any deviation from a parallel intercept angle
results in velocity underestimation; however, the degree of
underestimation is 5% or less if the intercept angle is within 15° of
parallel.
• “Angle correction”should not be used because it is likely to
introduce more error given the unpredictable jet direction.
• A dedicated small dual-crystal CW transducer is recommended
both due to a higher signal-to-noise ratio and to allow optimal
transducer positioning and angulation, particularly when
suprasternal and right parasternal windows are used.
• However, when stenosis is only mild (velocity 3 m/s) and leaflet
opening is well seen, a combined imaging-Doppler transducer may
be adequate.
Continuous-wave
Doppler of severe aortic
stenosis jet
showing measurement
of maximum velocity
and tracing of the
velocity curve to
calculate mean
pressure gradient.
Mean Gradients
•
•
•
•
The difference in pressure between the left ventricular (LV) and aorta in systole, or
transvalvular aortic gradient, is another standard measure of stenosis severity.
Gradients are calculated from velocity information, and peak gradient obtained
from the peak velocity does therefore not add additional information as compared
with peak velocity.
However, the calculation of the mean gradient, the average gradient across the
valve occurring during the entire systole, has potential advantages and should be
reported.
The maximum gradient is calculated from maximum velocity – modified Bernoulli
equation.
• (assuming that viscous losses and acceleration effects are negligible)
•
Mean gradient is calculated by averaging the instantaneous gradients over the
ejection period, a function included in most clinical instrument measurement
packages using the traced velocity curve.
Continuity Equation
Schematic diagram of continuity equation. The
assumption is that SV LVOT = SV Aortic Valve
Continuity Equation
• Calculation of continuity-equation valve
area requires three measurements:
– AS jet velocity by CWD
– LVOT diameter for calculation of a circular
CSA
– LVOT velocity recorded with pulsed Doppler.
Continuity Equation
• LVOT diameter and PW of the LVOT needs to
taken from the same location in the LVOT.
• LVOT diameter measured off of PLAX.
• LVOT velocity (or VTI) is measured apically –
beware of distance error.
• The pulsed-Doppler sample volume is
positioned just proximal to the aortic valve so
that the location of the velocity recording
matches the LVOT diameter measurement.
LVOT Diameter
• Left ventricular outflow tract
diameter is measured in the
parasternal long-axis view in midsystole from the white–black
interface of the septal
endocardium to the anterior
mitral leaflet, parallel to the aortic
valve plane and within 0.5–1.0 cm
of the valve orifice.
Velocity or VTI measurement
LVOT velocity is measured from the
apical approach either in an apical
long-axis view or an anteriorly
angulated four-chamber view An
optimal signal shows a smooth
velocity curve with a narrow
velocity range at each time point.
Maximum velocity is measured as
shown. The VTI is measured by
tracing the modal velocity (middle
of the dense signal)
Pitfalls of the Continuity Equation
1.
2.
3.
4.
Depends on the variability in each of the three measurements,
including both the variability in acquiring the data and variability
in measuring the recorded data.
AS jet and LVOT velocity measurements have a very low intra- and
inter-observer variability (3–4%) both for data recording and
measurement in an experienced laboratory.
However, the measurement variability for LVOT diameter ranges
from 5% to 8%. When LVOT diameter is squared for calculation of
CSA, it becomes the greatest potential source of error in the
continuity equation.
When trans-thoracic images are not adequate for the
measurement of LVOT diameter, TEE measurement is
recommended if this information is needed for clinical decisionmaking.
Pitfalls of the continuity Equation
•
•
•
•
When subaortic flow velocities are abnormal, for example,
with dynamic subaortic obstruction or a subaortic
membrane, SV calculations at this site are not accurate.
Another limitation of valve area as a measure of stenosis
severity is the observed changes in valve area with
changes in flow rate.
In adults with AS and normal LV function, the effects of
flow rate are minimal and resting effective valve area
calculations are accurate.
This effect may be significant when concurrent LV
dysfunction results in decreased cusp opening and a small
effective orifice area even though severe stenosis is not
present.
Velocity Ratios
• Another approach to reducing error related to
LVOT diameter measurements is removing
CSA from the simplified continuity equation.
This dimensionless velocity ratio expresses the
size of the valvular effective area as a
proportion of the CSA of the LVOT.
• Can use VTI as well.
Velocity Ratios
• Severe stenosis is present when the velocity ratio
is 0.25 or less, corresponding to a valve area 25%
of normal.
• To some extent, the velocity ratio is normalized
for body size because it reflects the ratio of the
actual valve area to the expected valve area in
each patient, regardless of body size. However,
this measurement ignores the variability in LVOT
size beyond variation in body size.
Aortic valve area planimetry.
• Multiple studies have evaluated the method of measuring anatomic
(geometric) AVA by direct visualization of the valvular orifice, either
by 2D or 3D TTE or TEE.
• Planimetry may be an acceptable alternative when Doppler
estimation of flow velocities is unreliable.
• However, planimetry may be inaccurate when valve calcification
causes shadows or reverberations limiting identification of the
orifice.
• Caution is also needed to ensure that the minimal orifice area is
identified rather than a larger apparent area proximal to the cusp
tips, particularly in congenital AS with a doming valve.
• Effective orifice area, rather than anatomic, is the primary predictor
of outcome.
Planimetered Aortic VAvle
Brief summary thus far
• As with all patients with aortic stenosis , the
echocardiographic evaluation of adults with
aortic valve disease should include evaluation of
the aorta with measurement of diameters at the
sinuses of Valsalva and ascending aorta.
• Aortic root dilation is associated with bicuspid
aortic valve disease, the cause of AS in 50% of
adults and aortic size may impact the timing and
type of intervention. In some cases, additional
imaging with CT or CMR may be needed to fully
assess the aorta
.
Bicuspid valves
• A bicuspid valve most often results from
fusion of the right and left coronary cusps,
resulting in a larger anterior and smaller
posterior cusp with both coronary arteries
arising from the anterior cusp (80% of cases),
or fusion of the right and non-coronary cusps
resulting in a larger right than left cusp with
one coronary artery arising from each cusp
(about 20% of cases). Fusion of the left and
non-coronary cusps is rare.
Bicuspid Aortic Valves
• In Europe and the USA, bicuspid aortic valve
disease accounts for 50% of all valve
replacements for AS
• Calcification of a trileaflet valve accounts for
most of the remainder, with a few cases of
rheumatic AS.
• However, worldwide, rheumatic AS is more
prevalent.
Subvalvular Aortic Stenosis
• Dynamic subaortic obstruction, for example, with
hypertrophic cardiomyopathy, refers to
obstruction that changes in severity during
ventricular ejection, with obstruction developing
predominantly in mid-to-late systole, resulting in
a late peaking velocity curve.
• Dynamic obstruction also varies with loading
conditions, with increased obstruction when
ventricular volumes are smaller and when
ventricular contractility is increased.
Subvalvular AS
• Distinguished from valvular
stenosis based on the site of
the increase in velocity seen
with color or pulsed Doppler
and on the anatomy of the
outflow tract.
• Subvalvular obstruction may be
fixed, due to a discrete
membrane or muscular band,
with hemodynamics similar to
obstruction at the valvular
level.
Supravalvular stenosis
• Supra-valvular stenosis
is uncommon and
typically is due to a
congenital condition,
such as Williams
syndrome
• Persistent or recurrent
obstruction in
adulthood
Pressure recovery
• What is Pressure Recovery?
• The Aortic Pressure measured by cath Distal to the
orifice Is higher than at the orifice (pressure
recovery).
• Therefore The AoV gradient measured by cath is
LOWER then the the gradient measured by Doppler
(which measures the “unrecovered” pressure)
• Aortic Valve area Calculated by cath may be Larger.
• The pressure recovery phenomenon is more
prominent In patients with normal (not dilated) aortic
root
Some pearls
• In heavy calcific valves, measuring the LVOT
accurately may be difficult. In this situation,
use another nonregurgitant valve (MV, PV,
even TV) – remember in the spirit of
conservation of flow, no shunts, and in the
absence of significant regurgitation, the stroke
volume through each valve should be the
same!
More Pearls
• What to do in rhythms other than sinus.. Afib?
• Either average multiple beats for Vmax and
VTI (at least 5).
• Alternatively use the highest velocity’s and
their ratios
Other pearls – high cardiac output
states
• High cardiac output in patients on Dialysis, with
anemia, AV fistula, or other high flow conditions
(tachycardia) may cause relatively high gradients
in the presence of mild or moderate AS.
• This may lead to misdiagnosis of severe disease
particularly when it is difficult to calculate AVA in
the presence of dynamic LVOT obstruction.
• In this situation, the shape of the CWD spectrum
with a very early peak may help to quantify the
severity correctly.
Diastolic dysfunction and Aortic
stenosis
• These patients generally have at least Stage I
diastolic dysfunction – impaired relaxation but
normal LV diastolic filling pressures
• As AS progresses, the diastolic function worsens
(stages II – III).
• Presently Diastolic function is not being utilized
for management for Aortic stenosis
• Diastolic function improves after AVR and this can
be seen with tissue doppler (increase in 2cm/s)
Pitfalls
• Remember Pitfalls – other systolic
phenomenon –
1.
2.
3.
4.
Mitral regurgitation
Tricuspid regurgitation
Dynamic outflow obstruction
Pulmonic stenosis
Mitral Regurgitation
• Differentiate from AS because the time duration
of the 2 are different.
• Longer – MR
• Shorter AS
• Why – Time interval for AS is only during ejection
of LV systole
• MR occurs during IVRT, CT, and IVCT.
• MR jet is usually ~ >4-5 m/s (unless LA pressure is
high)
Tricuspid regurgitation
• Hopefully knowledge of position will help
• Look for significant respirophasic variation
Pitfalls – Dynamic outflow tract
obstructions
Look for the late peaking dagger shaped profile. This should
increase with valsalva (can change with loading conditions.
Aortic Stenosis does not.
Stenosis – “Functional vs True”
• Low output, low gradient AS – is it the valve or
the stinky LV function?
• Dobutamine is well validated and very helpful if
done CAREFULLY!
• Dobutamine is a β - agonist and increases
inotropy and chronotropy. Start at 5mcg/kg/min.
Increase q3 minutes. Don’t go past 20
mcg/kg/min. Look for the LVOT velocity to
increase to 0.8 – 1.2 m/s or the VTI to increase to
20-25 cm.
Stenosis – “Functional vs True”
• In a truly stenotic valve, the LVOT and AV
velocities (and VTIs) increase proportionally.
• In pseudo - stenotic valve, the LVOT velocity
• (VTI) increases >>> AV VTI.
• Remember the ratio of ¼ (or 0.25) – the so
called “dimensionless index”
• Dobutamine can also help determine inotropic
reserve (an increase in stroke volume > 20%) –
prognostic implications for patients.
Watch Out for discrepancies
• AS Velocity is < 4m/s and AVA < 1cm2
•
•
•
•
Check LVOT diameter and compare to previous studies
Check LVOT velocity signal for distance from valve
Calculate a index AVA (AVA/BSA) when height is < 5’5”, BSA <1.5m2 or
BMI is <22
Evaluate for low trans-aortic flow volume
•
•
•
•
•
•
LVOT stroke volume
2D LV EF and Stroke volume
Mitral regurgitation
Mitral stenosis
If the EF is depressed – Consider dobutamine stress echo for assessment
Causes – low cardiac output, small body size, severe mitral regurgitation
Watch Out for discrepancies
• AS Vmax > 4m/s but AVA > 1 cm2
• Check Lvot Diameter and check it obtained on previous studies
• Check for flow acceleration in LVOT PW signal
• Calculate a index AVA (AVA/BSA) when height is < 5’5”, BSA
<1.5m2 or BMI is <22
• Evaluate the severity of AR
• Evaluate for high cardiac output
• LVOT Stroke volume
• 2D LV EF and stroke volume (LVEDV – LVESD)
• Possible causes are high output state, moderate-severe AR,
large body size
Classification – in summary
• Lets Wrap up those
questions…
Question 1
Components for the continuity equation for
AVA include all the following except?
1.MV annular diameter
2.MV annular VTI
3.AV VTI
4.LVOT diameter
5.All can be used in the continuity equation for the
aortic valve
Question 1
Components for the continuity equation for
AVA include all the following except?
1.MV annular diameter
2.MV annular VTI
3.AV VTI
4.LVOT diameter
5.All can be used in the continuity equation for the
aortic valve
Question 2
Which of the following is not a marker of
severe aortic stenosis?
1.
2.
3.
4.
5.
Vmax across the Aortic valve is > 4m/s
Calculated aortic valve area of 1.34 cm2
LVOT Vmx / AV Vmx ratio < 0.25
Mean gradient = 55 mmHg
The cardiologist said the valve was friggin’ tight!
Question 2
Which of the following is not a marker of
severe aortic stenosis?
1.
2.
3.
4.
5.
Vmax across the Aortic valve is > 4m/s
Calculated aortic valve area of 1.34 cm2
LVOT Vmx / AV Vmx ratio < 0.25
Mean gradient = 55 mmHg
The cardiologist said the valve was friggin’ tight!
Question 3
Which is a true statement
1. Echo has become the gold standard for the
assessment of Aortic valve stenosis
2. Cath is still the gold standard for the
diagnosis of Aortic stenosis
3. No valve is too tight until the patient has
syncope…
Question 3
Which is a true statement
1. Echo has become the gold standard for the
assessment of Aortic valve stenosis
2. Cath is still the gold standard for the
diagnosis of Aortic stenosis
3. No valve is too tight until the patient has
syncope…
Question 4
• At maximal dobutamine infusion, in an AS
patient, the peak LVOT velocity increased from 50
to 90 cm / sec., while the peak transaortic valve
velocity increased from 2 to 2.3 m/sec. The LVOT
diameter is 2 cm. This study suggests that:
• 1. The baseline ejection fraction was < 20%.
• 2. There is significant AR.
• 3. AS is not severe.
• 4 LV motion did not improve.
Question 4
• At maximal dobutamine infusion, in an AS
patient, the peak LVOT velocity increased from 50
to 90 cm / sec., while the peak transaortic valve
velocity increased from 2 to 2.3 m/sec. The LVOT
diameter is 2 cm. This study suggests that:
• 1. The baseline ejection fraction was < 20%.
• 2. There is significant AR.
• 3. AS is not severe.
• 4 LV motion did not improve.
Question 5
The valve area is?
a) 0.3
b) 0.5
c) 0.8
d) 1.0
Question 6
A patient with severe aortic stenosis has MR.
Which one of the following statements is
incorrect?
1. The peak mitral regurgitation jet velocity is
higher than the peak trans-aortic valve flow
velocity.
2. The aortic transvalvular flow duration is shorter
than the MR jet duration.
3. The LVOT flow duration is longer than the MR jet
duration.
Question 6
A patient with severe aortic stenosis has MR.
Which one of the following statements is
incorrect?
1. The peak mitral regurgitation jet velocity is
higher than the peak trans-aortic valve flow
velocity.
2. The aortic transvalvular flow duration is shorter
than the MR jet duration.
3. The LVOT flow duration is longer than the MR
jet duration.
Question 7
A patient with valvular AS has severe LVOT
obstruction (HOCM). The best way to evaluate
AS severity in this patient is:
1.Dobutamine echo.
2.Aortic valve area by planimetry (TEE)
3. Valve area using the continuity equation.
4. Mean aortic gradient (Bernouilli formula).
Question 7
A patient with valvular AS has severe LVOT
obstruction (HOCM). The best way to evaluate
AS severity in this patient is:
1.Dobutamine echo.
2.Aortic valve area by planimetry (TEE)
3. Valve area using the continuity equation.
4. Mean aortic gradient (Bernouilli formula).
What do the guidelines say??
THE GLORIOUS
END!!!