2. Epidemiology -
1-2 % age 65 yr or older & 12 % age 75 yr or older
Aortic valve sclerosis without stenosis –irregular
thickening or calcification - 9 % at mean age 54 yr to
42% at mean age 81 yr
Rate of progression from sclerosis to stenosis – 1.8%/yr
18. Quantitation of aortic stenosis severity
Standard evaluation of stenosis severity includes-
(EAE/ASE Recommendations for Clinical Practice 2009).
1. Maximum aortic jet velocity ( Vmax)
2. Mean transaortic pressure gradient
3. Continuity equation valve area ( EOA)
37. Other indicies of severity of AS
Simplified continuity equation
AVA = LVOT area X LVOT velocity / AS velocity
Dimentionless index = LVOT VTI / AS VTI
< 25 % of the normal i.e o.75 – 1.0 cm2 - severe AS ( NORMAL 3-4 sq cm )
Planimetry of Aortic anatomicvalve area – difficult in
severe calcified valve – 3D > 2D , TEE>TTE
Projected Ao Valve area at normal flow-
AVAPROJ = AVAREST - VC (250 - Qbasal ) @ DSE
Valvoarterial impedence (Zva) =mmHg/ml/sq m
Zva = Pmean + SBP / SV index
38. Used in special condition -
LV STROKE WORK LOSS
RECOVERED PRESSURE GRADIENT
ENERGY LOSS INDEX
AORTIC VALVE RESISTANCE
39. 3 variants of severe AS-
1. NORMALFLOW–HIGH GRADIENT SEVERE AS WITH NORMAL EF (
stage c & d1)
2. CLASSIC– LOWFLOW–LOWGRADIENT SEVERE AS WITH REDUCED
EF ( <50%) ( stage d2)
(A) TRUE
(B) PSEUDO
3. PARADOXICALLOWFLOW–LOWGRADIENT SEVERE AS WITH
NORMAL EF(stage d3)
40.
41.
42.
43.
44. Classic LG-LF severe AS with low EF
(STAGE D2 ) -
EOA < 1.0 cm2
iEOA < 0.6 cm2 /m2
Low mean trans valvular gradient < 40 mmHg
Low EF < 40 %
Low flow – Cardiac index < 3 L/min/m2
stroke volume index < 35ml /m2
2 types – TRUE & PSEUDO (20-30%)
45. TRUE severe AS – LG/LF- 1’ Culprit valve ds
LV dysfunction -2’ or concomitant
benefits from AVR
PSEUDO severe AS – LG/LF – 1’ Myocardial ds
AS severity is overestimated d/t incomplete
opening of Ao valve in relation to LF state
may NOT benefit from AVR
46. LV Flow reserve –
Percentage increase in stroke volume > 20% during
DSE or catheterization k/a flow reserve & carries
better prognosis & lesser operative mortality than No
flow reserve ( <20%) which has higher prevalence of
multivessel CAD
Imp predictor of operative risk & survival after AVR
47. DOBUTAMINE STRESS ECHO -
To differentiate b/w true & pseudo ( ACC/AHA-
ESC/EACTS Class II a (LOE-B )
To assess LV flow reserve
pseudo AS- peak stress mean gradient <30 or 40
mmHg , peak stress EOA >1.0 or 1.2 cm2 &/or absolute
incr EOA >0.3 cm2, Vmax < 4 m/sec
Results – EOA <1 cm2 , Vmax >4 m/sec , any flow-true
EOA <1 cm2 , Vmax < 4 m/sec –persistant
area – gradient mismatch
48.
49. NEWER parameter
PROJECTED EOA – ambiguous response of DSE d/t
unpredictability of flow augmentation
TOPAS study ( true or pseudosevere AS )
At standard flow rate of 250ml/sec ESP severe AS with
no contractile reserve
Mutislice CT
>1650 Agatston
Unit
50.
51.
52. NEWER CLASS-
Paradoxical LF-LG Severe AS ( stage D3) -
Normal EF ( >50%)
Pronounced LV concentric remodelling
Small LV cavity size
Restricted physiology leading to impaired LV filling
Altered myocardial function
Low flow with normal EF –Under estimation of AS
Worse prognosis
53. Parameters :- EOA < 1.0 cm2 , i EOA <0.6 cm2/m2 ,
restrictive physiology resulting into low CO ( <3
l/min/m2 or indexed SV < 35 ml/m2 ) & lower than
expected tranvalvular gradients (<40mm Hg) despite
the presence of preserved LVEF (>50%) -
LG/LF-AS-pEF - PARADOXICAL AS
54. Pathophysiology & clinical presentation of paradoxical
LG-LF AS -
Many similarities with HFpEF = older age , female
gender , concomitant syst HTN , restrictive physiology
therefore LV pump function & stroke vol markedly
reduced despite preserved LVEF
Distinctive feature – (1) more pronounced LV conc
remodelling & myocardial fibrosis- dec LV size ,
compliance & filling
(2)marked reduction of intrinsic LV function NOT
evident by LVEF but by more sensitive parameters like
GLS d/t advanced fibrosis in sub endocardial layers
So paradoxical AS represent advanced stage of both
valvular & ventricular ds despite normal LVEF
55.
56. Pseudo normalization of BP – d/t LF inspite of redu
systemic arterial compliance &/or incr vascular
resistance
High Valvulo-Arterial impedence ( Zva )- global LV
hemodynamic load
Severe ,normal flow , high gradient ,AS with normal
EF vs Paradoxical LG/LF severe AS with normal EF –
AVR ( Best Vs worst outcome ) , medical Vs surgical
Class II a ( LOE –C) recently inspite of High Operative
mortality & increased chances of pt prosthesis
mismatch d/t small Lv cavity
57.
58. TAKE HOME MASSAGE.....
LF-LG AS with normal or reduced LVEF – most challenging
situation in valvular heart disease
DSE greatly aid in risk stratification & clinical decision
Valve calcium score- MD CT & plasma BNP helpful esp in
NO flow reserve pt with non dx DSE
GLS has definite role in sub clinical systolic dysfunction &
early treatment in AS
Paradoxical LG-LF Severe AS with Normal EF – recently
described entity with advanced ds & worse prognosis
Role of TAVR – in LG/LG AS to be determined in future