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Echo assesment of Aortic Stenosis and Regurgitation
- 1. ECHOCARDIOGRAPHIC ASSESMENT OF AORTIC VALVE DISEASES
- 2. Aortic stenosis: Classification based on location Valvular- most common type. Subvalvular. Supravalvular.
- 3. Valvular Aortic Stenosis: Etiology
- 7. Congenital Anomalies Of AV valve
- 8. Calcific Aortic Stenosis of trileaflet valve
- 15. Echocardiographic assessment of severity
- 17. Doppler assessment of AS (EAE/ASE Recommendations for Clinical Practice 2009).
- 18. Classification of AS severity (based on 2014 AHA/ACC Valvular heart disease guideline)
- 19. Peak transvalvular velocity measurement
- 26. Sources of error for pressure gradient calculations
- 27. Sources of error for pressure gradient calculations
- 28. Aortic valve area Continuity equation
- 30. Aortic valve area Continuity equation
- 32. Advantage of the Continuity Equation over Peak velocity Pressure gradient
- 33. Pitfalls of the Continuity Equation
- 34. Pitfalls of the Continuity Equation
- 36. Low Dose Dobutamine Stress Echo- Protocol
- 37. Low Dose Dobutamine Stress Echo
- 39. Effects of concurrent conditions on assessment of severity
- 40. Effect of LVH
- 41. Effect of LVH
- 43. Effect of Aortic Regurgitation
- 44. Effect of Mitral valve disease
- 45. M Mode- Aortic Stenosis DeMaria A N et al. Circulation.Suppl II. 58:232,1978
- 46. ECHOCARDIOGRAPHIC ASSESSMENT OF AORTIC REGURGITATION
- 47. MILD MODERATE SEVERE Jet width/LVOT diameter <25% >/=65% Vena contracta <3mm >/=6mm Jet area/LVOT area <5% >60% PHT >500 ms </= 250ms Holodiastolic flow reversal present
- 48. MILD MODERATE SEVERE Reg vol < 30 ml >/= 60 ml Reg fraction < 30 % >/= 50% ERO < 0.1 cm2 >/= 0.3 cm2 Mitral inflow restriction Present
- 49. AR – VC, Jet width / Lvot width
- 50. • Regurgitant jet height measured as maximal diameter of regurgitant jet just below AV,PLAX view • LVOT diameter in end diastole
- 51. Regurgitant jet width/LVOT diameter ratio greater than or equal to 60 percent
- 52. Vena contracta greater than 6 mm
- 53. AR – Jet area / Lvot area
- 54. • Regurgitant jet area measured from PSAX view at level of LVOT • LVOA measured at end diastole at same site • Ratio calculated
- 56. AR – Pressure Half Time
- 57. • Regurgitant doppler signal is a function of pressure gradient between aorta and LV • Mild AR –small increase in LVEDP-gradual decline and flat deceleration slope • Severe AR –LVEDP rises rapidly-rapid decline
- 60. • Suprasternal window-descending aortic flow profile • Short period of low velocity flow reversal-normal • Pan diastolic flow reversal with end diastolic velocity>20cm/s
- 63. Calculation of R.Volume and R.fraction • SV=CSAxVTI • R.Volume=SV[lvot]-SV[mv] • RF=R.Volume/SV[lvot] • ERO=R.Volume/VTI[ARjet] • R.V>60ml,RF>50%,ERO>0.3cm² indicate severe AR
- 65. Restrictive mitral flow pattern
- 69. Extent of jet
- 70. Signal intensity
- 71. Classification of AS severity (based on 2014 AHA/ACC Valvular heart disease guideline)
- 72. SEVERITY • 1. Regurgitant jet width/LVOT diameter ratio greater than or equal to 60 percent • 2. Vena contracta greater than 6 mm • 3. Regurgitant jet area/LVOT area ratio greater than or equal to 60 percent • 4. Aortic regurgitation pressure half-time less than or equal to 250 ms • 5. Holodiastolic flow reversal in the descending thoracic or abdominal aorta • 6. Regurgitant volume greater than or equal to 60 mL • 7. Regurgitant fraction greater than or equal to 50 percent • 8. Effective regurgitant orifice greater than or equal to 0.30cm2 • 9. Restrictive mitral flow pattern (usually in acute setting)
- 73. THANK YOU..
Editor's Notes
- even in the absence of valve obstruction, is associated with a 50% increased risk of CV death and MI.
- In adults, stenosis in BAV is d/t calcific changes, which often obscures the number of cusps, making determination of bicuspid vs. tricuspid valve difficult.
- Stellate- resembling a star.
- TTE for reevaluation of asymptomatic patients with AS with normal LV systolic function who have no change in signs or symptoms is performed at intervals of 6 months to 1 year when aortic velocity is ³4.0 m per second (stage C), 1 to 2 years when aortic velocity is between 3.0 m per second and 3.9 m per second (stage B), and 3 to 5 years when aortic velocity is 2.0 m per second to 2.9 m/s (stage B)
- the simplified Bernoulli equation assumes that the proximal velocity can be ignored, a reasonable assumption when prox velocity is less than 1 m/s, because squaring a number less than 1 makes it even smaller. When the proximal velocity is over 1.5 m/s or the aortic velocity is less than 3.0 m/s, the proximal velocity should be included in the Bernoulli equation so that DP ¼ 4 v2 max v2 proximal when calculating maximum gradients. It is more problematic to include proximal velocity in mean gradient calculations as each point on the ejection curve for the proximal and jet velocities would need to be matched and this approach is not used clinically. In this situation maximum vel and gradient should be used to grade stenosis severity.
- Any underestimation of aortic velocity results in an even greater underestimation in gradients. due to the squared relationship between velocity and pressure difference
- Severe AS causing LV systolic dysfunction. An inverse correlation between wall stress and ejection fraction has been described in patients with AS. This suggests that the depressed ejection fraction and velocity of fiber shortening that occur in some patients are a consequence of inadequate wall thickening, resulting in afterload mismatch. In others, the lower ejection fraction is secondary to a true depression of contractility. In this situation, aortic valve replacement will relieve afterload and may allow the LV ejection fraction to increase towards normal. Moderate AS with another cause of LV dysfunction (e.g. myocardial infarct or a primary cardiomyopathy). The effective orifice area is then low because the LV does not generate sufficient energy to overcome the inertia required to open the aortic valve to its maximum possible extent. In this situation, aortic valve replacement may not lead to a significant improvement in LV systolic function.
- The echocardiographic report should always include a blood pressure measurement recorded at the time of the examination to allow comparison between serial echocardiographic studies and with other clinical data.
- TTE for reevaluation of asymptomatic patients with AS with normal LV systolic function who have no change in signs or symptoms is performed at intervals of 6 months to 1 year when aortic velocity is ³4.0 m per second (stage C), 1 to 2 years when aortic velocity is between 3.0 m per second and 3.9 m per second (stage B), and 3 to 5 years when aortic velocity is 2.0 m per second to 2.9 m/s (stage B)