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The presentation describes how to asses aortic valve during Transesophageal Echocardiography

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- 1. TEE Quantification of Aortic Stenosis and Aortic Regurgitation<br />Dr PK Neema<br />
- 2. Normal Aortic valve<br />ME Sax view transducer at 40o<br />
- 3. Normal flow-dynamics<br />Aortic velocity <br /> Vmax 1-1.2m/sec<br />LVOT max velocity <br /> 0.9-1.1 m/sec<br />P2<br />V1 = V2<br />P1 = P2<br />V2<br />V1<br />P1<br />
- 4. AS and its effect on Flow-dynamic<br />P1 > P2<br />V2 > V1<br />
- 5. Doppler principle<br />
- 6. Effect of interrogation angle on frequency shift<br />
- 7. Ultrasound beam should be parallel to the flow under study<br />The ultrasound should intercept the center of the flow not the periphery<br />The interrogation angle should be < 15o<br />The view optimal for the imaging may not be the optimal view for the Doppler study <br />Essentials during Doppler study <br />
- 8. Transgastric Lax view (Transducer at 130o)<br />TEE Views for Doppler study <br />
- 9. Deep Transgastric Lax view<br />TEE Views for Doppler study <br />
- 10. Simplified Bernoulli equation<br />Continuity equation<br />Methods to quantify AS<br />
- 11. Simplified Bernoulli equation<br />P = 4V2 2<br />P – Pressure gradient<br />Severe AS = P > 75 mmHg<br />
- 12. Deep Transgastric Lx View<br />
- 13. Peak velocity<br />Mean velocity<br />Peak gradient 4V2<br />Mean gradient<br />Velocity time integral (VTI) or TVI<br />Measurements<br />
- 14. Continuity equation<br />
- 15. Continuity equation<br />Blood flow through LVOT = <br /> Blood flow through AoV<br />Blood flow through LVOT = <br /> CSA LVOT X TVI LVOT<br />Blood flow through AoV = <br /> CSA AoV X TVI AoV<br />CSA LVOT X TVI LVOT = <br /> CSA AoV X TVI AoV<br />CSA AoV = LVOT flow/TVI AoV <br />
- 16. The LVOT diameter is measured in ME Lax view at 130o and measured from endocardium to endocardium at the level of insertion of AV leaflets in midsystole<br />Inaccuracy in the measurement of diameter can result in gross error since the radius of the LVOT is squared for calculating area (CSA = πr2)<br />Assessment of LVOT area<br />ME Lax View Xducer at 130o<br />
- 17. The TVI is measured by Doppler interrogation through LVOT using pulse wave Doppler (PWD) <br />The sample volume is assessed just proximal to the aortic valve within the LVOT where the annular dimension is measured<br />TVI Measurement in LVOT <br />Transgastric Lax view<br />
- 18. Severity of AS<br />
- 19. AS and <br />Mitral regurgitation<br />Low cardiac output <br />Aortic regurgitation<br />Fallacies<br />
- 20. The MR jet can be mistaken for that of AS. <br />How to avoid the MR jet? <br />The MR jet should be visualized during colour Doppler imaging and the MR jet path should be consciously avoided. <br />How to confirm?<br />The MR jet starts early with LV contraction, the AS jet starts later in systole. <br />The MR jet starts in the early portion of QRS complex while AS jet starts in the mid or late portion of QRS complex. Determination is facilitated by recording the jets at a faster sweep speed (100 mm/s)<br />AS and Mitral regurgitation (MR)<br />
- 21. Gorlin formula <br />(AVA = Cardiac output/ 44.3 (SEP) (HR) √mean gradient<br />The CO is an important determinant of valve area and a decrease in CO result in a decrease in the peak aortic gradient and the severity of AS Accordingly, one should assess LV function before ‘small gradients’ are reported as insignificant. <br />Dobutamine stress test and dimensionless index are evaluated to assess AS severity in presence of low CO.<br />AS and Low cardiac output<br />
- 22. High CO, similar to low CO, result in over estimation of peak gradient and AS severity.<br />The discrepancy is corrected by measuring the blood flow velocity in the LVOT and applying a correction if the measured LVOT peak velocity exceeds 1.5 m/s. <br />Peak gradient in presence of significant aortic regurgitation = <br />4 [(peak velocity)2 – (LVOT velocity)2]<br />AS and Aortic regurgitation<br />
- 23. Dobutamine (5-10 μg/kg/min) is infused to increase CO<br />An increase in pressure gradient suggests severe valvular disease. <br />No or borderline increase in pressure gradient suggest primary myocardial disease as the cause of low gradient and contraindicate valve replacement as the primary therapy; <br />However, AS is a unique cardiovascular disease where patients with a low EF may normalize after valve replacement.<br />Dobutamine stress test<br />
- 24. LVOT and aortic TVI ratio or peak LVOT and aortic velocity ratio of 0.25 or less indicates critical AS. <br />Useful in evaluation of patients with prosthetic aortic valves where measurement of aortic annular dimensions is not clear.<br />Dimensionless index<br />
- 25. Aortic Regurgitation<br />ME Lax view Transducer at 130o<br />
- 26. Based on<br />Color flow Doppler (Jet width and jet area measurement)<br />Continuity equation<br />Regurgitant jet velocity assessment<br />AR quantification<br />
- 27. TEE view for jet width measurement<br />ME Lax view Transducer at 130o<br />
- 28. Jet width to LVOT diameter ratio <br />Jet width-LVOT diameter ratio > 65% indicate severe AR<br />
- 29. Color M mode<br />75/<br />214<br />=0.35<br />
- 30. LVOT Shadowing<br />Aortic prosthesis<br />Mitral prosthesis<br />Site and shape of the orifice (Eccentric jet, multiple jet)<br />Jet width limitations<br />
- 31. TEE views for jet area measurement<br />ME Sax view Transducer at 40o<br />
- 32. 1+ < 4% (trivial)<br />2+ 4-24 (mild) <br />3+ 25-59 (moderate) <br />4+ >60 (severe)<br />Jet area/LVOT area<br />
- 33. Vena Contracta<br />Vena Contracta width of<br /> > 6 mm indicate Severe AR<br />
- 34. Blood flow through LVOT = <br />CSA LVOT X TVI LVOT <br />Blood flow through RVOT = <br />CSA RVOT X TVI RVOT<br />Regurgitant volume = <br />CSA LVOT X TVI LVOT – CSA RVOT X TVI RVOT<br /> EROA = Regurgitant volume/VTI<br /> (VTI measured by PWD) <br />Continuity equation<br />
- 35. Deceleration Slope and Pressure-half time<br />The velocity of regurgitant jet during diastole is directly related to pressure gradient between aortic root and LV.<br />A large regurgitant defect will rapidly decrease pressures gradient and the velocity of regurgitant jet, hence slope of AR jet indicate severity of AR<br />CWD analysis of AR jet transgastric<br /> or deep transgastric view<br />
- 36. Regurgitant jet Slope Decay<br />Mild AR<br />Severe AR (>3m/sec2)<br />CWD LVOT<br />Ao<br />Ao<br />LV pressure<br />LV<br />
- 37. LVEDP – Ischemia, LV dysfunction<br />Low Aortic diastolic pressure<br />Eccentric jets<br />Acute AR vs. C/c AR<br />CWD-Deceleration slope limitations<br />
- 38. Holo-diastolic flow reversal<br />Severe AR<br />
- 39. Severity of Regurgitation<br />3-6 mm<br /><3 mm<br />

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