This document provides information about aortic stenosis, including its definition, location, morphology, etiology, types, stages, symptoms, complications, risk factors, diagnostic testing, and management. Aortic stenosis is a narrowing of the aortic valve that reduces or blocks blood flow from the heart to the rest of the body. It is most commonly caused by calcification of the aortic valve and affects older adults. Diagnosis involves echocardiography to evaluate valve anatomy and hemodynamics. Treatment depends on symptom severity and may include medications, lifestyle changes, surgical valve replacement, or transcatheter aortic valve replacement.

1. AORTIC STENOSIS
NAME – SOUHARDYA SAHA
YEAR - 3rd YEAR
COURSE – CARDIAC CARE TECHNOLOGY

3. DEFINITION - THE NARROWING OF
AORTIC VALVE. IMPROPER OPENING OF
THE VALVE , WHICH REDUCES OR
BLOCKS BLOOD FROM THE HEART TO
THE REST OF THE BODY.
LOCATION - THE AORTIC VALVE IS
LOCATED BETWEEN LEFT VENTRICLE
AND THE AORTA.
MORPHOLOGY – AORTIC VALVE IS
COMPOSED OF THREE CUSPS WHICH
ARE SEPERATED BY COMMISSURES

4.  THE THREE CUSPS ARE NAMELY RIGHT CORONARY
CUSP , LEFT CORONARY CUSP , NON CORONARY CUSP.
 THEY ARE CRESCENT SHAPED AND THE COMMISSURES
FORM A SLIGHT THICKENING AT THE TIP CALLED THE
NODE OF ARANTIUS.
 THE RESPECTIVE CUSPS HAVE SINUSES NAMELY RIGHT
CORONARY SINUS , LEFT CORONARY SINUS AND NON
CORONARY SINUS .
 THE LCA AND RCA ARISES FROM LEFT AND RIGHT
CORONARY SINUS RESPECTIVELY

12. MID ESOPHAGEAL AORTIC SHORT AXIS VIEW

13. SCLEROSED AORTIC VALVE (SAV)

14. APICAL 3 CHAMBER VIEW(THICKENED AV)

15. 3D ECHOCARDIOGRAPHY – SIGNIFICANT AS

16. ETIOLOGY – AORTIC STENOSIS
THE MOST COMMON CAUSE OF AORTIC STENOSIS IN A PERSON OVER
AGE 70 YREARS IS CALCIFICATION OF NORMAL TRI-LEAFLET AORTIC
VALVE ; THE PROCESS IS SOMETIMES REFFERED TO AS SENILE
DEGENERATION.
THE MOST COMMON CAUSE OF AS IN A PERSON UNDER AGE 70 IS A
CONGENITAL BICUSPID AORTIC VALVE.
 MOST COMMON –
CONGENITAL – CALCIFIC BICUSPID AORTIC VALVE
ACQUIRED – i.) SENILE OR DEGENERATIVE CALCIFIC AS
ii.) RHD

17. RARE – i.) TYPE 2 HYPERLIPOPROTEINEMIA
ii.) CARDIAC OCHRONOSIS (alkaptonuria complication)
iii.) PAGET’S DISEASE(osteitis deformans)
iv.) UNICUSPID / QUADRICUSPD VALVE
v.) SUPRAVALVULAR STENOSIS
UNCOMMON – i.) INFECTIVE VEGETATIONS
ii.) SLE(Libman-Sacks endocarditis)
iii.) RADIATION
iv.) DRUGS(anorexigens,MDMA)
v.) SUBAORTIC MEMBRANE

19. TYPES OF AS –
ON THE BASIS OF AREA
OF STENOSIS
-VALVULAR
-SUB VALVUAR
-SUPRA VALVULAR

20. STAGES OF AS
STAGE A – AT RISK OF AS
STAGE B – PROGRESSIVE AS
STAGE C1 – ASYMPTOMATIC SEVERE AS
STAGE C2 – ASYMPTOMATIC SEVERE AS WITH LV SYSTOLIC
DYSFUNCTION
STAGE D1 – SYMPTOMATIC SEVERE HIGH GRADIENT AS
STAGE D2 – SYMTOMATIC SEVERE LOW-FLOW LOW GRADIENT AS
WITH REDUCED LVEF
STAGE D3 – SYMTOMATIC SEVERE LOW-FLOW LOW GRADIENT AS
WITH NORMAL LVEF

21. SYMPTOMS
THE CLASSICAL TRIAD OF SYMPTOMS OF AS OCCUR ON EXERTION
AND INCLUDE –
i.) ANGINA
ii.) DYSPNEA
iii.) SYNCOPE
HOWEVER THESE “CLASSIC”SYMPTOMS REFLECT END STAGE DISEASE.
. HEART MURMUR
. FAINTING WITH ACTIVITY / DECREASED EXERCISE TOLERANCE
. FATIGUE
. NOT GAINING ENOUGH WEIGHT
AND ALSO OTHER SYMTOMS OF HEART FAILURE

22. COMPLICATIONS
LV SYSTOLIC OVERLOAD ARRHYTHMIAS
LV DILATATION HEART FAILURE
LVH BLOOD CLOTS
INCREASED LVEDP STROKE
PULMONARY HTN ENDOCARDITIS

23. RISK FACTORS
. OLDER AGE
. CHD SUCH AS BVD
. HISTORY OF INFECTIONS THAT AFFECT HEART
. CVS RISK FACTORS LIKE DIABETES , HYPERTENSION ,
HIGH CHOLESTROL
. CKD
. HISTORY OF RADIATION THERAPY TO TEST

25. HEART SOUNDS
. S2: SOFT AND SINGLE A2 IS DELAYED AND TENDS TO OCCUR
SIMANTANEOUSLY WITH P2.
. S2 MAY BECOME PARADOXICALLY SPLIT WHEN THE STENOSIS IS
SEVERE OR ASSOCIATED WITH LV DYSFUNCTION
. THE PRESENCE OF A NORMALLY SPLIT S2 IS MOST RELAIABLE
FINDING OF AS IN ADULTS

26. • THE TYPICAL MURMUR OF AORTIC STENOSIS IS A HIGH
PITCHED , ‘DIAMOND SHAPED’ CRESENDO AND
DECRESENDO , MID SYSTOLIC EJECTION MURMUR
HEARD BEST AT THE RIGHT UPPER STERNAL BORDER
RADIATING TO NECK AND CORONARY ARTERIES .
• IN MILD AS , THE MURMUR PEAKS IN EARLY SYSTOLE.
• IN SEVERE AS THE A2 COMPONENT MAY NOT BE
AUDIBLE AT ALL.

28. • Dilated
ascending
aorta
• Left
ventricular
hypertroph
y

31. ECG IN AS
• LV SYSTOLIC OVERLOAD – LVH, OFTEN WITH
REPOLARISATION ABNORMALITIES
• INCOMPLETE LBBB – DISAPPEARENCE OF SMALL INITIAL q
WAVES IN LEFT ORIANTED LEADS
• LAE – USUALLY MODERATE
• A NORMAL FRONTAL PLANE QRS AXIS – USUALLY DIRECTED
TO THE REGION OF +40 ° TO +50 °
• INVERTED U WAVES – SENSITIVE SIGN OF COMPROMISED LV
.

32. ECHO IN AS
1.) ANATOMY – SHORT AND LONG AXIS VIEWS
(OCASIONALLY TEE/3D).
2.) LVOT DIAMETER – MIDSYSTOLE ; AT THE SITE OF MEASUREMENT
OF LVOT VELOCITY MEASUREMENT PARALLEL TO AV.
3.) LVOT VELOCITY – APICAL 4C/ 5C ; Vmax / VTI
4.) AS JET VELOCITY (CW) – V max; PEAK AND MEAN grd; VTI
5.) LVOT SVI – (CSA × VTI) / BSA
6.) DSE

33. VALVE ANATOMY
RECORDING –
• PARASTERNAL LONG AND SHORT AXIS (PLAX)
• ZOOM MODE
MEASUREMENT –
• IDENTIFY NUMBER OF CUSPS IN SYSTOLE, RAPHE IF PRESENT
• ASSESS CUSP MOBILITY AND COMMISURAL FUSION
• ASSESS VALVE CALCIFICATION

38. PLAX
VIEW-
CALCIFIC
AORTIC
VALVE

39. PLAX
VIEW-
THICKENED
AORTIC
VALVE

44. RHEUMATIC
AORTIC
STENOSIS

45. RHEUMATIC HEART DISEASE

46. AORTIC STENOSIS SEVERITY MEASURES
AORTIC JET VELOCITY (m/s)
MEAN GRADIENT (mmHg)
AORTIC VALVE AREA (cm²)

47.  THE FORMAL CRITERIA FOR EACH STAGE CONSIDER VALVE
ANATOMY, HEMODYNAMICS, CHANGES IN LV AND
VASCULATURE AND THE PRESENCE AND ABSENCE OF
SYMPTOMS
 THE MOST IMPORTANT PARAMETERS FOR STAGING AS
ARE –
• MAXIMUM TRANSAORTIC VELOCITY (Vmax)
• MEAN PRESSURE GRADIENT (∆P)
• AORTIC VALVE AREA (AVA)

51. AORTIC JET VELOCITY
AORTIC SCLEROSIS ≤ 2.5 m/s
MILD 2.6 – 2.9 m/s
MODERATE 3.0 – 4.0 m/s
SEVERE >4.0 m/s
JET VELOCITY – IT IS DEFINED AS THE HIGHEST VELOCITY SIGNAL
OBTAINED FROM ANY WINDOW
– BY USING CW IN APICAL 5C

53. A HIGHER GRADIENT IS OBTAINED FROM RIGHT
PARASTERNAL (RPS) WINDOW

54. TRANSAORTIC PRESSURE GRADIENT (∆P)
- IT IS CALCULATED FROM VELOCITY (V) USING
BERNOULLI’S EQUATION AS - (∆Pmax) = 4Vmax²
PEAK PG
MILD 16-35 mmHg
MILD-MODERATE 35-50 mmHg
MODERATE 50-75 mmHg
SEVERE >75 mmHg
MEAN PG
MILD <20 mmHg
MODERATE 20-40 mmHg
SEVERE >40 mmHg

56. AORTIC VALVE AREA (BY CONTINUITY EQUATION)
THE STROKE VOLUME EJECTED THROUGH THE LVOT ALSO
PASSES THROUGH STENOTIC ORIFICE OF AV AND THUS SV IS
EQUAL AT BOTH SIDES.
MEASUREMETS RECQUIRED –
• LVOT DIAMETER (IN PLAX MID SYSTOLIC VIEW)
• LVOT VELOCITY (PW DOPPLER IN APICAL 5C OR 3C VIEW)
• AS JET VELOCITY (CW DOPPLER IN APICAL 5C VIEW)

57. CONTINUITY EQUATION
SVAV = SVLVOT (SV = CSA × VTI)
AVA × VTIAV = CSALVOT × VTILVOT
AVA = CSALVOT × VTILVOT
VTIAV

59. SEVERITY AORTIC VALVE AREA
NORMAL 3.0 – 4.0 cm²
MILD >1.5 cm²
MODERATE 1.0 – 1.5 cm²
SEVERE < 1.0 cm²
THE RELATIONSHIP BETWEEN VALVE AREA AND SEVERITY IS FURTHER INFLUNCED BY PATIENT SIZE –
FOR EXAMPLE, AN AORTIC VALVE AREA OF 0.9cm² MAY BE “SEVERE” IN LARGE PATEINT BUT ONLY
“MODERATE” IN A SMALLER SIZE PATIENT.

60. Fig-Patient with severe left ventricular dysfunction and decreased stroke
volume . A minimal degree of cusps opening is the result of decreased
flow through valve . The valve is not stenotic , but the relative immobility is
the result of a reduced stroke volume

61. LOW FLOW LOW GRADIENT AS
• IN PATIENTS WITH A VERY LOW FLOW RATE , VALVE OPENING
MAY BE INHIBITED , LEADING TO AN UNDERESTIMATION OF
AVA.
• WHEN AORTIC VELOCITY IS (< 4.0 m/s) AND VALVE AREA LESS
THEN (1.0cmsq), THE POSSIBILITY OF “LOW GRADIENT , LOW
OUTPUT” AORTIC STENOSIS MUST BE CONSIDERED.
• WHEN LV SYSTOLIC DYSFUNCTION IS PRESENT (EF<50%),
AORTIC VALVE OPENING MAY BE REDUCED DUE TO THE LOW
FLOW RATE ACROSS THE VALVE WITH ONLY MILD TO MODERATE
VALVE DISEASE.

62. LOW FLOW LOW GRADIENT AS
VALVE AREA < 1.0cm²
MEAN GRADIENT < 40mm Hg
SVI < 35 ml / m²
POSSIBILITIES –
EF < 50 % - SEVERE AS WITH REVERSIBLE LV DYSFUNCTION
- AS WITH SEVERE MYOCARDIAL FAILURE
- PSEUDO SEVERE AS
EF > 50 % - PARADOXICAL LOW FLOW SEVERE AS

63. DSE
• DSE MAY BE USEFUL FOR PROPER ESTIMATION OF
SEVERITY OF AS.
• IF SEVERE STENOSIS REMAINS A CONCERN , THE NEXT STEP
IS LOW DOSE DOBUTAMINE STRESS ECHOCARDIOGRAPHY.
• AORTIC VELOCITY , MEAN GRADIENT, AND CONTINUITY
EQUATION VALVE AREA ARE MEASURED AT BASE LINE AND
WITH GARDUALLY INCREASING DOSE OF DOBUTAMINE , UP
TO A MAXIMUM DOSE

64. BASELINE LOW DOSE MID DOSE
LVOT VELOCITY 0.6 0.8 1.0
JET VELOCITY 3.0 4.0 5.0
MAX GRADIENT 36 mmHg 64mmHg 100mmHg
BASELINE LOW DOSE MID DOSE
LVOT VELOCITY 0.6 0.8 1.0
JET VELOCITY 3.0 3.2 3.4
MAX GRADIENT 36mmHg 41mmHg 46mmHg
BASELINE LOW DOSE MID DOSE
LVOT VELOCITY 0.6 0.6 0.6
JET VELOCITY 3.0 3.0 3.0
MAX GRADIENT 36mmHg 36mmHg 36mmHg
AS WITH LV
DYSFUNCTIO
N AND NO
EVIDENCE OF
MYOCARDIAL
VIABILITY
MODERATE AS
WITH LV
DYSFUNCTIO
N
SEVERE AS
WITH LV
DYSFUNCTIO

65. RECORDINGS OF AORTIC JET VELOCITY - DSE

66. RECORDINGS OF LVOT VELOCITY -DSE

67. TRUE SEVERE AS MILD TO MODERATE AS
FIXED VALVE AREA THAT WILL NOT
CHANGE WITH DOBUTAMINE INFUSION
LEAFLETS ARE RELATIVELY FLEXIBLE AND
VALVE AREA WILL INCREASE IN
RESPONSE TO INCREASE IN SV .
THUS AN INCREASE IN VALVE AREA
DURING INFUSION TO >1.0 cm²
IS CONSISTENT WITH MILD TO
MODERATE AS.
DOBUTAMINE INFUSION INCREASES
MAXIMAL VELOCITY OF BOTH LVOT AND
THE JET PROPORTIONALLY.
THUS THE RATIO OF PEAK VELOCITY IN
LVOT AND JET WILL REMAIN SAME
INCREASE IN VELOCITY OF LVOT IS MUCH
GREATER THAN THAT OF JET
(DUE TO FUNCTIONAL INCREASE IN
VALVE AREA )
RATIO OF LVOT TO JET VELOCITY WILL
INCREASE COMPARED TO BASE LINE

69. ALTERNATIVE MEASURES OF STENOSIS SEVERITY
1) AORTIC VALVE INDEX (AVA / BMI) IN cm²/ m²
2) VELOCITY RATIO = VLVOT / VAV
3) AORTIC VALVE AREA PLANIMETRY – TTE, TEE, 3D
ECHO
MILD >0.85
MODERATE 0.60 - 0.85
SEVERE <0.6
MILD >0.50
MODERATE 0.25=0.50
SEVERE <0.25

72. MANAGEMENT
MEDICATIONS
HEALTHY LIFESTYLE CHANGES AND MEDICATIONS TO TREAT
SYMPTOMS OR REDUCE THE RISK OF COMPLICATIONS
• IN PATIENTS WITH RISK OF DEVELOPING AS (STAGE A) AND IN
PATIENTS WITH ASYMPTOMATIC AS (STAGES B AND C),
HYPERTENSION SHOULD BE TREATED ACCORDING TO
STANDARD GDMT(GUIDELINE DIRECTED MEDICAL THERAPY),
STARTED AT A LOW DOSE , AND GRADUALLY TITRATED
UPWARDS AS NEEDED, WITH APPROPRIATE CLINICAL
MONITORING .

73. • IN ALL PATIENTS WITH CALCIFIC AS, STATIN THEREAPY IS
INDICATED FOR PRIMARY AND SECONDARY PREVENTION OF
ATHEROSCLEROSIS .
• IN PATIENTS WHO HAVE UNDERGONE TAVI , RENIN-
ANGIOTENSIN SYSTEM BLOCKER THERAPY (ACE INHIBITORS
OR ARB) MAY BE COSIDERED TO REDUCE THE LONG-TERM
RISK OF ALL CAUSE MORTALITY.
• IN PATIENTS WITH CALCIFIC AS (STAGES B AND C), STATIN
THERAPY IS NOT INDICATED FOR PREVENTION OF
HEAMODYNAMIC PROGRESSION OF AS – NO BENIFIT

74. INTERVENTION
- SURGICAL AORTIC VALVE
REPLACEMENT (SAVR)
- TRANSCATHETER AORTIC VALVE
REPLACEEMENT (TAVR)
- BALLOON VALVULOPLASTY IN YOUNG
PATEIENTS OR POOR SURGICAL
CANDIDATES

76. AORTIC VALVE REPLACEMENT
• Aortic valve replacement is often needed to treat aortic
valve stenosis. In aortic valve replacement, the damaged
valve replaced with a mechanical valve or a valve made
from cow, pig or human heart tissue (biological tissue valve).
• Biological tissue valves break down over time and may
eventually need to be replaced.
• People with mechanical valves will need to take blood-
thinning medications for life to prevent blood clots.

77. S/P AVR
PRESSURE
GRADIENT
REMAINS HIGH
UNLIKE S/P
MVR PRESSURE
GRADIENT
DECREASES

78. FAVORS SURGICAL AORTIC VALVE REPLACEMENT
(SAVR)
 YOUNGER AGE/LONGER LIFE EXPECTANCY
 BAV(SUBAORTIC)/ CALCIFICATION/RHEUMATIC VALVE
DISEASE/SMALL OR LARGE AORTIC ANNULUS
 MECHANICAL OR SURGICAL BIOPROSTHETIC VALVE PREFFERED
 AORTIC DILATION/SEVERE PRIMARY AR/ SEVERE CAD RECQUIRING
BYPASS GRAFTING /SEPTAL HYPERTROPHY RECQUIRING MYECTOMY
 NOT FRAIL OR FEW FRAILITY MEASURES

79. FAVOURS TRANSCATHETER AORTIC VALVE
IMPLANTATION (TAVI)
 OLDER AGE/ FEWER EXPECTED REMAINING YEARS OF LIFE
 CLASIFIC AS OF TRILEAFLET VALVE
 BIOPROSTHETIC VALVE PREFFERED
 FAVORABLE RATIO OF LIFE EXPECTANCY TO VALVE DURABILITY
TAVI PROVIDES LARGE VALVE AREA THAN SAME SIZE SAVR
 SEVERE CALCIFICATION OF ASCENDING AORTA (PROCELAIN
AORTA)
 FRAILITY LIKELY TO IMPROVE AFTER TAVI

80. BOTH TYPES OF VALVES ARE TISSUE VALVES , BUT THE
SAVR VALVE IS A FIXED STENT WITH AN
APPROXIMATE LIFE SPAN OF 15 YEARS , WHILE THE
TAVR VALVE , WHICH EXPANDS AND CONTRACTS ,
HAS AN UNCERTAIN LIFE SPAN.
TAVI WAS ASSOSIATED WITH LESS ONSET ATRIAL
FIBRILLATION ,MAJOR BLEEDING AND AKD
WHEREAS SAVR RESULTED IN A LOWER RATE OF
MAJOR VASCULATURE COMPLICATIONS

81. AORTIC VALVE REPAIR
• To repair an aortic valve, valve flaps (cusps) are
separated that have fused.
• However, surgeons rarely repair an aortic valve to
treat aortic valve stenosis.
• Generally aortic valve stenosis requires aortic valve
replacement.

82. BALLOON VALVULOPLASTY
• In this procedure, a long catheter with a balloon on the
tip is inserted into the artery in arm or groin and guides
it to the aortic valve.
• Once in place, the balloon is inflated, which widens the
valve opening.
• The balloon is then deflated, and the catheter and
balloon are removed.

84. BALLOON AORTIC
VALVULOPLASTY IN A 3
MONTH OLD INFANT WITH
SEVERE CONGENITAL AORTIC
VALVE STENOSIS.
• A NEGATIVE WASHOUT
CAN BE SEEN FROM THE
JET EGRESSING THROUGH
VALVE LEAFLETS .
• BOTTOM RIGHT –
AORTOGRAM AFTER
BALLOON VALVULOPLASTY
DOCUMENTING ABSENSE
OF AORTIC INSUFFICIENCY

85. TRANSCATHETER AORTIC VALVE
REPLACEMENT(TAVR)
• In TAVR, catheter is inserted through leg or arm
and guided to the heart.
• A replacement valve is then inserted through the
catheter and guided to the heart.
• The balloon will expand the valve, or some valves
can self-expand.
• Also a catheter procedure may be performed to
insert a replacement valve into a biological tissue
valve that is no longer working properly.

86. TYPES OF APPROACH FOR TAVR

88. THANK YOU