Ferdous

ECHOCARDIOGRAPHIC
EVALUATION OF AORTIC
STENOSIS
Dr. Kazi AbulFazal Ferdous
IMO, CCU, DMCH

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

2D Echo-Long axis view
Diastole Systole

2D Echo-Short axis view
Diastole Systole
Y or inverted Mercedes-Benzsign

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 assessmentof valve
stenosis, European Journal of Echocardiography 2009

CLASSIFICATION OF
AORTIC STENOSIS

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.

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.

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

 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).

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.

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 SHORTAXIS
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).

 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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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

Types of BAV
FUSION OF CUSPS FREQUENCY LEAFLET
CLOSURE LINE
REMARKS
RIGHTAND LEFT 70 -80% Anterolateral–
posteromedial closure
line
Larger anterior
leaflet.
RIGHTAND
NONCORONARY
20-30% Anterior–posterior
closure line
Larger
rightward leaflet
LEFTAND
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

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

Quadricuspid aortic valve
 RAKESH 40Y20150128153142738.avi

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 Valvenot stenotic
But high gradients think of subvalvularAS.
TEE – confirmation.

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.

 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

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.

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

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

 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
NormalAVA >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

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

M mode of Aortic valve in
LV dysfunction

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.

A. Evaluate the anatomy of the AV
ECHO EVALUATION OF AORTIC STENOSIS
RCC
LCCNCC
DIASTOLE
SYSTOLE

fusion of
RCC and
NCC
fusion of
RCC and
LCC

B. Determine the aortic valve area by
Continuity Equation

C. Determine the transaortic jet velocity
• measured using continuous-wave (CW) Doppler
Valvular Hear Disease, Chapter 63, Braunwarld’s HeartDisease10th Edition 2014

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

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

TRUE SEVERE AORTIC STENOSIS
• will have no or minimal increase in AVA
• marked increase in gradient when flow is increased

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)

ParadoxicalLow flow Low gradient AS
• Elderly female
• Associatedwith HTN, DM
EchoCharacteristics
• 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%
• SV index of <35mL/m2 ASE’s Comprehensive Echocardiography 2nd ed , 2016

Hemodynamic 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 HeartDisease10th Edition 2014

Ferdous

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