This document discusses the echocardiographic evaluation of aortic stenosis. It begins by describing normal aortic valve anatomy and various views used to visualize the aortic valve via 2D echocardiography. It then discusses the classification and causes of aortic stenosis, including calcific, rheumatic, and bicuspid aortic valve stenosis. Evaluation techniques covered include determining aortic valve area using the continuity equation and measuring transaortic jet velocity via continuous-wave Doppler. The document concludes by outlining the anatomical assessment of the aortic valve, methods for determining stenosis severity, and hemodynamic progression of untreated aortic stenosis over time.

1. ECHOCARDIOGRAPHIC
EVALUATION OF AORTIC
STENOSIS
Dr. Kazi Abul Fazal Ferdous
IMO, CCU, DMCH

3. Normal Aortic valve
 Three cusps, crescent shaped 3
commissures 3 sinuses supported by
fibrous annulus
3.0 to 4.0 cm2

7. 2D Echo-Long axis view
Diastole Systole

9. 2D Echo-Short axis view
Diastole Systole
Y or inverted Mercedes-Benz

12. 2D - Apical five chamber view

14. 2D – Suprasternal view

17. AORTIC STENOSIS
Most common :-
Bicuspid aortic valve with calcification
Senile or Degenerative calcific AS
Rheumatic AS
Less common:-
Congenital
Type 2 Hyperlipoproteinemia
EAE/ASE recommendations for Echocardiographic assessment of valve
stenosis, European Journal of Echocardiography 2009

18. CLASSIFICATION OF
AORTIC STENOSIS

19. Aortic sclerosis
 About 25% of all adults over age 65 yrs have aortic valve sclerosis.
 Thickened calcified cusps with preserved mobility.
 No significant obstruction to LV outflow.
 Typically associated with peak doppler velocity of < 2.5 m/sec.
 In Cardiovascular Health Study ,for group of patients ≥ 65
yrs,the aortic valve was normal in 70% of cases,sclerotic in 29% and
stenotic in 2%.
JACC.1997;29(3):630-4.
 In Euro Heart Survey of 4910 pts in 25 countries,AS was the most
frequent lesion,accounting for 43% of patients with VHD.
Eur Heart J.2003;24(13):1231-43.

21. Calcific Aortic Stenosis
 10-15% of aortic sclerosis patients progress to severe
AS.
 Nodular calcific masses on aortic side of cusps.
 No commissural fusion.
 Free edges of cusps are not involve
 Stellate- shaped systolic orifice.
d.
Cosmi et al,Arch Int Med 2002;162(20):2345-7.

22. Calcific Aortic Stenosis
 Plax (Parasternal long axis) view
showing echogenic and immobile
aortic valve.
 Marked increase in echogenicity.
 Reduced systolic opening.

23. Calcific Aortic Stenosis
 Parasternal short-axis view
showing calcified aortic valve
leaflets. Immobility of the
cusps results in only a slit like
aortic valve orifice in systole.
 Used for valve area
(planimetry).

24. Imp points.
 Directly planimetered aortic valve areas should be interpreted with
caution because of the complex anatomy of the orifice and calcific
shadowing and reverberation, even with 3D imaging.
 Direct measurement of valve area on imaging reflects anatomic
valve area, whereas the doppler data provide functional area.

27. Bicuspid Aortic valve

29. Bicuspid Aortic Valve (BAV)
 Accounts for 2/3rd of cases of severe AS in adults < 70 yrs.
 1/3rd of cases in adults > 70 yrs of age.
 Severe AS of a BAV is difficult to be differentiated from that of
tricuspid one.
 Usual view for differentiation is PARASTERNAL SHORT AXIS
VIEW at the level of great vessels in systole.
 PARASTERNAL Long axis view shows systolic bowing of the
leaflets into aorta – “Dome like”.
 M MODE – Eccentric closure line (to be taken at the tips of
bowed leaflets).

30.  Two cusps are seen in systole with only two commissures framing
an elliptical systolic orifice (the fish mouth appearance).
 Diastolic images may mimic a tricuspid valve when a raphe is
present.
Bicuspid Aortic valve

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32. Bicuspid Aortic valve
 In children, valve may be stenotic
without extensive calcification.
 In adults, stenosis typically is
due to calcific changes, which
often obscures the number of
cusps, making determination of
bicuspid vs. tricuspid valve

33. M mode of BAV

34. Types of BAV
FUSION OF
CUSPS
FREQUENCY LEAFLET
CLOSURE
LINE
REMARKS
RIGHT AND
LEFT
70 -80% Anterolateral –
posteromedial
closure line
Larger anterior
leaflet.
RIGHT AND
NONCORONARY
20-30% Anterior –posterior
closure line
Larger
rightward leaflet
LEFT AND
NONCORONARY
1-2% Medial – lateral
closure line
Many bicuspid aortic valves have a raphe in the larger leaflet.
Clear identification of number of leaflets is possible only in systole.
Schaefer et al ,Am J Cardiol 99(5);686-90.2007

37. Unicuspid aortic valve
 Single eccentric orifice
 Prominent systolic doming.
 Acommisural
 unicommisural

39. Quadricuspid aortic valve
 RAKESH 40Y20150128153142738.avi

41. Subvalvular aortic stenosis
(1) Thin discrete membrane consisting of endocardial fold and fibrous
tissue.
(2) A fibromuscular ridge
(3) Diffuse tunnel-like narrowing of the LVOT
(4) Accessory or anomalous mitral valve tissue.
Young adults Valve not stenotic
But high gradients think of subvalvular
AS. TEE – confirmation.

42. Supravalvular Aortic stenosis
Type I - Thick, fibrous ring above the aortic valve with less
mobility and has the easily identifiable 'hourglass' appearance
of the aorta.

43.  Type II - Thin, discrete fibrous membrane located above the aortic
valve
The membrane usually mobile and may demonstrate doming during
systole.
 Type III - Diffuse narrowing
Supravalvular Aortic stenosis

44. Rheumatic Aortic Stenosis
 Characterized by
 Commissural fusion
 Triangular systolic orifice
 Thickening & calcification
 Accompanied by rheumatic mitral valve changes.
 30% of patients with MS,aortic valve is also affected in
RHD.

45. Rheumatic aortic stenosis
Parasternal short axis view showing commissural
fusion, leaflet thickening and calcification, small
triangular systolic orifice

46. Differentiation of
Rheumatic vs Calcified AS
RHEUMATIC
AS
CALCIFIC AS
COMMISSURES FUSED FREE
LEAFLETS TIPS TO BASE BASE TO TIPS
ORIFICE TRIANGULAR STELLATE
SHAPEDAGE OF
PATIENT
NO
PARTICULAR
USUALLY
ELDERLYMITRAL
VALVE
30% OF MS CASES MAC +
OTHERS TIPS THICKENED,
CALCIFIED (INEXTREME)
TIPS ARE FREE (CALCIFIC
NODULES CAN BE
PRESENT not at TIPS)

48. M Mode- Normal aortic valve

50.  Maximal aortic cusp separation (MACS)
Vertical distance between right CC and non CC during systole
M Mode- Aortic Stenosis
Aortic valve area MACS Measurement Predictive value
Normal AVA >2Cm2 Normal MACS >15mm 100%
AVA>1.
0
> 12mm 96%
AVA<
0.75
< 8mm 97%
Gray area 8-12 mm …..
DeMaria A N et al. Circulation.Suppl II.

51. M Mode- Aortic Stenosis

52. Limitations
 Single dimension
 Asymmetrical AV involvement
 Calcification / thickness
↓ LV systolic function
 ↓ CO status
M Mode- Aortic Stenosis

53. M mode of Aortic valve in
LV dysfunction

54. HOCM

55. Sub aortic membrane

56. BAV

57. Calcific AS

58. Qualitative information of stenosis
by 2D echo
 Thickened calcified cusps that display preserved mobility define
aortic sclerosis (peak doppler velocity of ≤ 2.5 m/sec).
 Heavily calcified cusps with little or no mobility suggest severe
aortic
stenosis.
 If one cusp is seen to move normally, critical aortic stenosis has
been excluded. Can lead to overestimation of
severity.
To be combined with doppler assessment.

59. A. Evaluate the anatomy of the
AV
EAE/ASE recommendations for Echocardiographic assessment of valve
stenosis, European Journal of Echocardiography 2009
ECHO EVALUATION OF AORTIC
STENOSIS
RCC
LCCNCC
DIASTOLE
SYSTOL
E

60. fusion of RCC
and NCC
fusion of
RCC and
LCC
ECHO EVALUATION OF AORTIC
STENOSIS

61. ECHO EVALUATION OF AORTIC
STENOSIS

62. ECHO EVALUATION OF AORTIC
STENOSIS

63. ECHO EVALUATION OF AORTIC
STENOSISB. Determine the aortic valve area by
Continuity Equation
EAE/ASE recommendations for Echocardiographic assessment of valve
stenosis, European Journal of Echocardiography 2009

64. ECHO EVALUATION OF AORTIC
STENOSISC. Determine the transaortic jet velocity
•measured using continuous-wave (CW) Doppler
Valvular Hear Disease, Chapter 63, Braunwarld’s Heart Disease 10th Edition
2014

65. ECHO EVALUATION OF AORTIC
STENOSIS
EAE/ASE recommendations for Echocardiographic assessment of valve
stenosis, European Journal of Echocardiography 2009

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87. Baseline echo
AVA: 0.96 cm2
PIG: 57mmHg
MG: 38 mmHg
EF 31%

88. PSEUDOSEVERE AORTIC STENOSIS
will exhibit an increase in the AVA
little change in transvalvular gradient in
response to the increase in transvalvular flow
rate

89. TRUE SEVERE AORTIC STENOSIS
•will have no or minimal increase in
AVA

90. REST
 AVA: 0.96cm2
MG 38
PIG: 57
 EF: 31%
TRUE SEVERE AORTIC STENOSIS
LOW DOSE DOBU
AVA: 0.99cm2
MG: 51
PIG: 76
EF: 41% ( 32% inc)

91. Paradoxical Low flow Low gradient
AS• Elderly female
• Associated with HTN,
DM
Echo Characteristics• Severely thickened and calcified
AV
• AVA < 1.0; MVG <40mmHg
• EF ≥ 50%
• Small LV cavity size (LVEDD
<47mm, LVEDV <55mL
• RWT of >0.5
• Impaired global longitudinal strain
<15% ASE’s Comprehensive Echocardiography 2nd ed ,
2016

93. ECHO EVALUATION OF AORTIC
STENOSISHemodynamic Progression
•annual decrease in valve area : 0.12 cm2/year
•annual increase in jet velocity of 0.32 m/sec/year
Follow-up Echo
•every year: severe AS
•every 1 to 2 years for moderate AS
•every 3 to 5 years for mild AS.
Valvular Hear Disease, Chapter 63, Braunwarld’s Heart Disease 10th Edition
2014

94. THANK
YOU..