This document discusses the echocardiographic assessment of aortic stenosis and regurgitation. It begins by describing normal aortic valve anatomy and various echocardiographic views used to visualize the aortic valve. It then covers the causes, anatomical presentations, and echocardiographic findings of various types of aortic valve disease including calcific stenosis, bicuspid aortic valve, rheumatic stenosis, and others. The document focuses on Doppler assessment of aortic stenosis, including peak velocity, mean gradient, valve area calculation using the continuity equation, and limitations. It also discusses low-flow low-gradient aortic stenosis and the role of dobutamine stress echocardiography.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASEPraveen Nagula
MITRAL VALVE ANATOMY , M MODE FINDINGS IN MITRAL STENOSIS,EVALUATION OF THE SEVERITY OF LESION,CALCIFIC MS,CCMA,CONGENITAL LESIONS,GUIDELINES ALL IN DETAIL....
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
Speckle tracking echocardiography (STE) is an echocardiographic imaging technique that analyzes the motion of tissues in the heart by using the naturally occurring speckle pattern in the myocardium or blood when imaged by ultrasound.
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASEPraveen Nagula
MITRAL VALVE ANATOMY , M MODE FINDINGS IN MITRAL STENOSIS,EVALUATION OF THE SEVERITY OF LESION,CALCIFIC MS,CCMA,CONGENITAL LESIONS,GUIDELINES ALL IN DETAIL....
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
Speckle tracking echocardiography (STE) is an echocardiographic imaging technique that analyzes the motion of tissues in the heart by using the naturally occurring speckle pattern in the myocardium or blood when imaged by ultrasound.
Echo assesment of Aortic Stenosis and Regurgitationdrpraveen1986
A simple ppt presentation on echo assesment of AS and AR. Don forget to leave a comment if u find this ppt useful. - Dr. Praveen Babu, Vijaya HOspital, Chennai
BCC4: Sharon Kay on Cardiac Crises Revealed in EchoSMACC Conference
Enrich your knowledge of cardiac ultrasound with the help from experienced sonographer, Sharon Kay. Sharon covers a focused cardiac ultrasound of the heart, and gives examples of emergency cardiac conditions that can be detected with this versatile modality. This talk was recorded at Bedside Critical Care Conference 4. For the full post and other BCC4 posts, head over to www.intensivecarenetwork.com
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
9. Aortic stenosis- Causes
Most common :-
Bicuspid aortic valve with calcification
Senile or Degenerative calcific AS
Rheumatic AS
Less common:-
Congenital
Type 2 Hyperlipoproteinemia
Ochronosis
10. Anatomic evaluation
Combination of short and long axis images to
identify
Number of leaflets
Describe leaf mobility, thickness, calcification
Combination of imaging and doppler allows
the determination of the level of obstruction;
subvalvular, valvular, or supravalvular.
Transesophageal echocardiography may be
helpful when image quality is suboptimal.
11. Calcific Aortic Stenosis
Nodular calcific masses on aortic side of cusps
No commissural fusion
Free edges of cusps are not involved
stellate-shaped systolic orifice
12. Calcific Aortic Stenosis
Parasternal long axis
view showing
echogenic and
immobile aortic valve
13. 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
14. Bicuspid Aortic valve
Fusion of the right and left coronary cusps (80%)
Fusion of the right and non-coronary cusps(20%)
Schaefer BM et al. Am J Cardiol 2007;99:686–90
Schaefer BM et al.Heart 2008;94:1634–1638.
15. Bicuspid Aortic valve
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.
16. Bicuspid Aortic valve
Parasternal long-axis echocardiogram may show
an asymmetric closure line
systolic doming
diastolic prolapse of the cusps
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 difficult
17. Calcific Aortic Stenosis
Calcification of a bicuspid or tricuspid valve, the severity
can be graded semi-quantitatively as
0 1+ 2+ 3+ 4+
Schaefer BM et al.Heart 2008;94:1634–1638.
The degree of valve calcification is a predictor of clinical
outcome. Rosenhek R et al. N Engl J Med 2000;343:611–7.
18. Aortic sclerosis
Thickened calcified cusps with preserved
mobility
Typically associated with peak doppler
velocity of less than 2.5 m/sec
19. Rheumatic aortic stenosis
Characterized by
Commissural fusion
Triangular systolic orifice
thickening & calcification
Accompanied by rheumatic mitral valve
changes.
20. Rheumatic aortic stenosis
Parasternal short axis view showing commissural
fusion, leaflet thickening and calcification, small
triangular systolic orifice
21. 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.
22. 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.
23. Supravalvular Aortic stenosis
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
25. Doppler assessment of AS
The primary haemodynamic parameters
recommended (EAE/ASE Recommendations for
Clinical Practice 2008)
Peak transvalvular velocity
Mean transvalvular gradient
Valve area by continuity equation.
26. Peak transvalvular velocity
Continuous-wave Doppler ultrasound
Multiple acoustic windows
Apical and suprasternal or right parasternal
most frequently yield the highest velocity
rarely subcostal or supraclavicular windows
may be required
Three or more beats are averaged in sinus
rhythm, with irregular rhythms at least 5
consecutive beats
27. Peak transvalvular velocity
AS jet velocity is defined as the highest velocity signal
obtained from any window after a careful examination
Any deviation from a parallel intercept angle results in
velocity underestimation
The degree of underestimation is 5% or less if the
intercept angle is within 15⁰ of parallel.
‘Angle correction’ should not be used because it is likely
to introduce more error given the unpredictable jet
direction.
28. Peak transvalvular velocity
The velocity scale adjusted so the spectral doppler signal
fills on the vertical axis, and with a time scale on the x-axis
of 100 mm/s
Wall filters are set at a high level and gain is decreased to
optimize identification of the velocity curve.
Grey scale is used
A smooth velocity curve with a dense outer edge and clear
maximum velocity should be recorded
29. Peak transvalvular velocity
The shape of the CW Doppler velocity curve is helpful
in distinguishing the level and severity of obstruction.
With severe obstruction, maximum
velocity occurs later in systole and the
curve is more rounded in shape
With mild obstruction, the peak
is in early systole with a triangular
shape of the velocity curve
30. Peak transvalvular velocity
The shape of the CWD velocity curve also can be
helpful in determining whether the obstruction is
fixed or dynamic
Dynamic sub aortic obstruction
shows a characteristic late-peaking
velocity curve, often with
a concave upward curve in
early systole
31. Mean transvalvular gradient
The difference in pressure between the left
ventricle and aorta in systole
Gradients are calculated from velocity
information
The relationship between peak and mean
gradient depends on the shape of the velocity
curve.
32. Mean transvalvular gradient
Bernoulli equations
ΔP =4v²
The maximum gradient is calculated from
maximum velocity
ΔP max =4v² max
The mean gradient is calculated by averaging
the instantaneous gradients over the ejection
period
33. Mean transvalvular gradient
The simplified Bernoulli equation assumes
that the proximal velocity can be ignored
When the proximal velocity is over 1.5 m/s or
the aortic velocity is ,3.0 m/s, the proximal
velocity should be included in the Bernoulli
equation ΔP max =4 (v² max- v2
proximal)
34. Sources of error for pressure
gradient calculations
Malalignment of jet and ultrasound beam.
Recording of MR jet
35. Sources of error for pressure
gradient calculations
Neglect of an elevated proximal velocity.
Any underestimation of aortic velocity results in
an even greater underestimation in gradients,
due to the squared relationship between velocity
and pressure difference
The accuracy of the Bernoulli equation to
quantify AS pressure gradients is well established
36. Pressure recovery
The conversion of potential energy to kinetic
energy across a narrowed valve results in a
high velocity and a drop in pressure.
Distal to the orifice, flow decelerates again.
Kinetic energy will be reconverted into
potential energy with a corresponding
increase in pressure, the so-called PR
37. Pressure recovery
Pressure recovery is greatest in stenosis with
gradual distal widening
Aortic stenosis with its abrupt widening from
the small orifice to the larger aorta has an
unfavorable geometry for pressure recovery
PR= 4v²× 2EOA/AoA (1-EOA/AoA)
38. Comparing pressure gradients calculated from
doppler velocities to pressures measured at cardiac
catheterization.
39. Comparing pressure gradients calculated from
doppler velocities to pressures measured at cardiac
catheterization.
Currie PJ et al. Circulation 1985;71:1162-1169
41. Aortic valve area
Aortic valve area
Continuity equation concept that the stroke
volume ejected through the LV outflow tract all
passes through the stenotic orifice
AVA= CSALVOT×VTILVOT / VTIAV
Calculation of continuity-equation valve area
requires three measurements
AS jet velocity by CWD
LVOT diameter for calculation of a circular CSA
LVOT velocity recorded with pulsed Doppler.
42. Aortic valve area
Continuity equation
LVOT diameter and velocity should be measured at the
same distance from the aortic valve.
When the PW sample volume is optimally positioned,
the recording shows a smooth velocity curve with a
well-defined peak.
43. Aortic valve area
Continuity equation
The VTI is measured by tracing the dense modal
velocity throughout systole
LVOT diameter is measured from the inner edge to
inner edge of the septal endocardium, and the
anterior mitral leaflet in mid-systole
44. Aortic valve area-Continuity equation
Level of Evidence
Well validated - clinical & experimental studies.
Zoghbi WA et al. Circulation 1986;73:452-9.
Oh JK et al. J Am Coll Cardiol 1988;11:1227-34.
Measures the effective valve area, the weight
of the evidence now supports the concept that
effective, not anatomic, orifice area is the
primary predictor of clinical outcome.
Baumgartner et al. J Am Society Echo 2009; 22,1 , 1-23.
45. Limitations of continuity-equation
valve area
Intra- and interobserver variability
AS jet and LVOT velocity 3 to4%.
LVOT diameter 5% to 8%.
When sub aortic flow velocities are abnormal
SV calculation at this site are not accurate
Sample volume placement near to septum or
anterior mitral leaflet
46. Limitations of continuity-equation
valve area
Observed changes in valve area with changes
in flow rate
AS and normal LV function, the effects of flow
rate are minimal
This effect may be significant in presence
concurrent LV dysfunction.
47. Left ventricular systolic
dysfunction
Low-flow low-gradient AS includes the
following conditions:
Effective orifice area < 1.0 Cm2
LV ejection fraction < 40%
Mean pressure gradient < 30–40 mmHg
Severe AS and severely reduced LVEF
represent 5% of AS patients
Vahanian A et al. Eur Heart J 2007;28:230–68.
48. Dobutamine stress Echo
Provides information on the changes in aortic
velocity, mean gradient, and valve area as flow rate
increases.
Measure of the contractile response to dobutamine
Helpful to differentiate two clinical situations
Severe AS causing LV systolic dysfunction
Moderate AS with another cause of LV dysfunction
49. Dobutamine stress Echo
A low dose starting at 2.5 or 5 ủg/kg/min with
an incremental increase in the infusion every 3–
5 min to a maximum dose of 10–20 ủg/kg/min
The infusion should be stopped as soon as
Positive result is obtained
Heart rate begins to rise more than 10–20 bpm
over baseline or exceeds 100bpm
50. Dobutamine stress Echo
Role in decision-making in adults with AS is
controversial and the findings recommend as
reliable are
Stress findings of severe stenosis
AVA<1cm²
Jet velocity>4m/s
Mean gradient>40mm of Hg
Nishimura RA et al. Circulation 2002;106:809-13.
Lack of contractile reserve-
Failure of LVEF to ↑ by 20% is a poor prognostic sign
Monin JL et al. Circulation 2003;108:319-24..
51. Serial measurements
During follow-up any significant changes in
results should be checked in detail:
Make sure that aortic jet velocity is recorded from
the same window with the same quality (always
report the window where highest velocities can be
recorded).
when AVA changes, look for changes in the
different components incorporated in the
equation.
LVOT size rarely changes over time in adults.
53. Simplified continuity equation.
Based on the concept that in native aortic
valve stenosis the shape of the velocity curve
in the outflow tract and aorta is similar so that
the ratio of LVOT to aortic jet VTI is nearly
identical to the ratio of the LVOT to aortic jet
maximum velocity.
AVA= CSALVOT×VLVOT / VAV
This method is less well accepted because
results are more variable than using VTIs in
the equation.
54. Velocity ratio
Another approach to reducing error related to
LVOT diameter measurements is removing CSA
from the simplified continuity equation.
This dimensionless velocity ratio expresses the size
of the valvular effective area as a proportion of the
CSA of the LVOT.
Velocity ratio= VLVOT/VAV
In the absence of valve stenosis, the velocity ratio
approaches 1, with smaller numbers indicating
more severe stenosis.
55. Aortic valve area -Planimetry
Planimetry may be an acceptable alternative
when Doppler estimation of flow velocities is
unreliable
Planimetry may be inaccurate when valve
calcification causes shadows or reverberations
limiting identification of the orifice
Doppler-derived mean-valve area correlated
better with maximal anatomic area than with
mean-anatomic area.
Marie Arsenault, et al. J. Am. Coll. Cardiol. 1998;32;1931-1937
57. Experimental descriptors of
stenosis severity
(Level 3 EAE/ASE Recommendations -not
recommended for routine clinical use)
58. Valve resistance
Relatively flow-independent measure of stenosis
severity
Depends on the ratio of mean pressure gradient
and mean flow rate
Resistance = (ΔPmean /Qmean) × 1333
There is a close relationship between aortic valve
resistance and valve area
The advantage over continuity equation not
established
59. Left ventricular stroke work loss
Left ventricle expends work during systole to
keep the aortic valve open and to eject blood
into the aorta
SWL(%) = (100×ΔPmean)/ ΔPmean+SBP
A cutoff value more than 25% effectively
discriminated between patients experiencing
a good and poor outcome.
Kristian Wachtell. Euro Heart J.Suppl. (2008) 10 ( E), E16–E22
60. Energy loss index
Damien Garcia.et al. Circulation. 2000;101:765-771.
Fluid energy loss across stenotic aortic valves is
influenced by factors other than the valve effective
orifice area .
An experimental model was designed to measure
EOA and energy loss in 2 fixed stenoses and 7
bioprosthetic valves for different flow rates and 2
different aortic sizes (25 and 38 mm).
EOA and energy loss is influenced by both flow rate
and AA and that the energy loss is systematically
higher (15±2%) in the large aorta.
Damien Garcia.et al. Circulation. 2000;101:765-771.
61. Energy loss index
Damien Garcia.et al. Circulation. 2000;101:765-771.
Energy loss coefficient (EOA × AA)/(AA - EOA) accurately
predicted the energy loss in all situations .
It is more closely related to the increase in left ventricular
workload than EOA.
To account for varying flow rates, the coefficient was indexed for
body surface area in a retrospective study of 138 patients with
moderate or severe aortic stenosis.
The energy loss index measured by Doppler echocardiography
was superior to the EOA in predicting the end points
An energy loss index #0.52 cm2/m2 was the best predictor of
diverse outcomes (positive predictive value of 67%).
62. Classification of AS severity
(a ESC & bAHA/ACC Guidelines)
Aortic Sclerosis Mild Moderate Severe
Aortic jet velocity (m/s) ≤ 2.5 m/s 2.6 -2.9 3.0 - 4 > 4
Mean gradient (mm Hg) < 20b(<30a) 20 – 40b (30 -50a) > 40
AVA (cm²) > 1.5 1.0 - 1.5 < 1.0
Indexed AVA (cm²/m²) > 0.85 0.60 – 0.85 < 0.6
Velocity ratio > 0.50 0.25 – 0.50 < 0.25
64. Effect of concurrent conditions ……
Left ventricular systolic dysfunction
Left ventricular hypertrophy
Small ventricular cavity & small LV ejects a
small SV so that, even in severe AS the AS
velocity and mean gradient may be lower than
expected.
Continuity-equation valve area is accurate in
this situation
65. Effect of concurrent conditions contd…
Hypertension
35–45% of patients
primarily affect flow and gradients but less AVA
measurements
Control of blood pressure is recommended
The echocardiographic report should always
include a blood pressure measurement
66. Effect of concurrent conditions contd…
Aortic regurgitation
About 80% of adults with AS also have aortic
regurgitation
High transaortic volume flow rate, maximum
velocity, and mean gradient will be higher than
expected for a given valve area
In this situation, reporting accurate quantitative
data for the severity of both stenosis and
regurgitation
67. Effect of concurrent conditions contd…
Mitral valve disease
With severe MR, transaortic flow rate may be
low resulting in a low gradient .Valve area
calculations remain accurate in this setting
A high-velocity MR jet may be mistaken for the
AS jet. Timing of the signal is the most reliable
way to distinguish
68. Effect of concurrent conditions contd…
High cardiac output
Relatively high gradients in the presence of
mild or moderate AS
The shape of the CWD spectrum with a very
early peak may help to quantify the severity
correctly
Ascending aorta
Aortic root dilation
Coarctation of aorta
69. M Mode- Aortic Stenosis
Maximal aortic cusp separation (MACS)
Vertical distance between right CC and non CC
during systole
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. 58:232,1978
74. 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)
75. • Regurgitant jet height measured as maximal
diameter of regurgitant jet just below AV,PLAX
view
• LVOT diameter in end diastole
78. • Regurgitant jet area measured from PSAX view
at level of LVOT
• LVOA measured at end diastole at same site
• Ratio calculated
79.
80.
81. • 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
82.
83.
84. • Suprasternal window-descending aortic flow
profile
• Short period of low velocity flow reversal-normal
• Pan diastolic flow reversal with end diastolic
velocity>20cm/s
85.
86.
87. 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
88.
89.
90.
91.
92. MILD MODERAT
E
SEVERE
Jet
width/LVOT
diameter
<25% >/=65%
Vena
contracta
<3mm >/=6mm
Jet
area/LVOT
area
<5% >60%
PHT >500 ms </= 250ms
Holodiastoli
c flow
reversal
present
93. MILD MODERATE SEVERE
Reg vol < 30 ml >/= 60 ml
Reg fraction < 30 % >/= 50%
ERO < 0.1 cm2 >/= 0.3 cm2
Mitral inflow
restriction
Present
96. ACUTE VS CHRONIC
• Shape of the envelope CW doppler
• Rate of deceleration of flow
• Premature mitral valve closure
• Endocarditis,dissection
• Normal lv dimensions