Evaluation of severity of as
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This document discusses the evaluation of severity of aortic stenosis. It covers clinical evaluation including symptoms and signs of severity. Echocardiographic assessment including Doppler assessment of peak transvalvular velocity and mean gradient is discussed. Classification of severity is described based on guidelines. The continuity equation for calculating aortic valve area is explained. Low-flow low-gradient aortic stenosis is addressed. The roles of cardiac catheterization, CT, and MRI in further evaluating severity are also summarized.
Evaluation of severity of as
- 1. EVALUATION OF SEVERITY OFAORTIC STENOSIS
- 2. Aortic stenosis- brief Introduction..
- 3. Aortic stenosis: Classification based on location Valvular- most common type. Subvalvular. Supravalvular.
- 4. Valvular Aortic Stenosis: Etiology
- 8. Calcific Aortic Stenosis of trileaflet valve
- 13. Clinical evaluation of severity
- 14. Symptoms of severe AS
- 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
- 29. Aortic valve area Continuity equation
- 30. Aortic valve area Continuity equation
- 31. Aortic valve area Continuity equation • LVOT diameter is measured in the PLAX view in mid-systole from the white–black interface of the septal endocardium to the anterior mitral leaflet, parallel to the aortic valve plane and within 0.5–1.0 cm of the valve orifice.
- 32. Aortic valve area Continuity equation • LVOT velocity is measured from the apical approach either in an apical long-axis view or an anteriorly angulated four-chamber view • An optimal signal shows a smooth velocity curve with a narrow velocity range at each time point. • The VTI is measured by tracing the modal velocity (middle of the dense signal)
- 33. Advantage of the Continuity Equation over Peak velocity Pressure gradient
- 34. Pitfalls of the Continuity Equation
- 35. Pitfalls of the Continuity Equation
- 37. Low Dose Dobutamine Stress Echo
- 38. Low Dose Dobutamine Stress Echo- Protocol
- 39. Low Dose Dobutamine Stress Echo
- 40. Low Dose Dobutamine Stress Echo
- 41. Effects of concurrent conditions on assessment of severity
- 42. Effect of LVH
- 43. Effect of LVH
- 45. Effect of Aortic Regurgitation
- 46. Effect of Mitral valve disease
- 47. M Mode- Aortic Stenosis DeMaria A N et al. Circulation.Suppl II. 58:232,1978
- 48. Cardiac Catheterization to assess severity
- 49. When to do Cath Study in AS
- 50. Comparing pressure gradients calculated from doppler velocities to pressures measured at cardiac catheterization
- 51. Transvalvular gradient Measurement - techniques
- 52. AO & peripheral artery (femoral sheath) showing peripheral amplification of 20 mmHg
- 53. Left ventricular (LV) and right femoral artery (RFA) pressure tracings in a patient who presented with exertional syncope owing to aortic stenosis demonstrating the significant time delay for the pressure waveform to reach the RFA.
- 54. Carabello Sign…
- 55. Sources of error for pressure gradient calculations
- 56. Sources of error for pressure gradient calculations Gradient derived by cath is lower than doppler derived gradient
- 57. Sources of error for pressure gradient calculations
- 58. Sources of error for pressure gradient calculations
- 59. Aortic Valve area Calculation by cath
- 60. Low Gradient low flow AS- Cath Study
- 61. Role of CT……..
- 62. Role of CT……..
- 63. Role of MRI……..
- 64. Role of MRI……..
- 66. THANK YOU..
Editor's Notes
- #6: even in the absence of valve obstruction, is associated with a 50% increased risk of CV death and MI.
- #8: 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.
- #9: Stellate- resembling a star.
- #15: Angina in 2/3rdpt of severe AS.Another clinical finding seen in patients with aortic stenosis is an increased bleeding tendency; this is thought to be due to acquired platelet dysfunction resulting from mechanical disruption of von Willebrandmultimers, with turbulent blood flow through the narrowed valve and triggered platelet clearance.
- #16: PulsusParvus e Tardus specific for severe AS , however presence of concurrent condition like AR or HTN may alter pulse character so normal carotid impulse cannot rule out severe AS.A systolic thrill is also specific but not sensitive for AS.
- #19: TTE for reevaluation of asymptomatic patients with AS with normal LV systolicfunction who have no change in signs or symptoms is performed at intervals of 6 months to 1 year when aorticvelocity 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 mper second (stage B), and 3 to 5 years when aortic velocity is 2.0 m per second to 2.9 m/s (stage B)
- #22: Angle correction’ should not be used because it is likely to introduce more error given the unpredictable jet direction.
- #27: 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.
- #29: Any underestimation of aortic velocity results in an even greater underestimation in gradients. due to the squared relationship between velocity and pressure difference
- #33: A PLAX view provides the most accurate measurement because it depends on axial rather than lateral resolution of the ultrasound beam.
- #38: 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.
- #42: Absence of contractile reserve (failure to increase SV or EF by 20%) predictor of a high surgical mortality,poor long-term outcome although valve replacement may improve LV function and outcome even in this subgroup.
- #46: 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.
- #64: Agatson volume score: it is derived by measuring the area of each calcified lesion and multiplying it by a coefficient of 1 to 4 depending on the maximum CT attenuation within that lesion. 1 for 130–199 HU, 2 for 200–299 HU, 3 for 300–399 HU, 4 for 400 HU and greater.