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ECHOCARDIOGRAPHIC EVALUATION OF VALVULAR
STENOSISMELISSA R. CUNDANGAN, MD, FPCP, FPCC, FPSE
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AORTIC STENOSIS
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AORTIC STENOSIS
• Obstruction to LV outflow• Decrease in aortic valve area
• Normal: 3.0 – 4.0 cm2
• Mild : 1.5-2.0 cm2
• Moderate : 1.0 – 1.5 cm2
• Severe: < 1.0 cm2
Valvular Hear Disease, Chapter 63, Braunwarld’s Heart Disease 10th Edition 2014
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AORTIC STENOSISCauses:• Congenital (unicuspal, bicuspal, quadricuspal)• Rheumatic• Calcific/ Degenerative
EAE/ASE recommendations for Echocardiographic assessment of valve stenosis, European Journal of Echocardiography 2009
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A. Evaluate the anatomy of the AV
EAE/ASE recommendations for Echocardiographic assessment of valve stenosis, European Journal of Echocardiography 2009
ECHO EVALUATION OF AORTIC STENOSIS
RCC
LCCNCCDIASTOLE
SYSTOLE
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fusion of RCC and NCC fusion of RCC
and LCC
ECHO EVALUATION OF AORTIC STENOSIS
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ECHO EVALUATION OF AORTIC STENOSIS
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ECHO EVALUATION OF AORTIC STENOSIS
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ECHO EVALUATION OF AORTIC STENOSIS
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ECHO EVALUATION OF AORTIC STENOSIS
B. Determine the aortic valve area by Continuity Equation
EAE/ASE recommendations for Echocardiographic assessment of valve stenosis, European Journal of Echocardiography 2009
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ECHO EVALUATION OF AORTIC STENOSIS
C. Determine the transaortic jet velocity• measured using continuous-wave (CW) Doppler
Valvular Hear Disease, Chapter 63, Braunwarld’s Heart Disease 10th Edition 2014
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ECHO EVALUATION OF AORTIC STENOSIS
D. Determine the transaortic gradient
EAE/ASE recommendations for Echocardiographic assessment of valve stenosis, European Journal of Echocardiography 2009
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ECHO EVALUATION OF AORTIC STENOSIS
EAE/ASE recommendations for Echocardiographic assessment of valve stenosis, European Journal of Echocardiography 2009
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• LOW FLOW LOW GRADIENT AORTIC STENOSIS
• PARADOXICAL LOW FLOW LOW GRADIENT AORTIC STENOSIS
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Baseline echoAVA: 0.96 cm2PIG: 57mmHg MG: 38 mmHg EF 31%
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PSEUDOSEVERE AORTIC STENOSISwill exhibit an increase in the AVA little change in transvalvular gradient in response to the
increase in transvalvular flow rate
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TRUE SEVERE AORTIC STENOSIS• will have no or minimal increase in AVA• marked increase in gradient when flow is increased
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REST AVA: 0.96cm2 MG 38 PIG: 57 EF: 31%
LOW DOSE DOBUAVA: 0.99cm2MG: 51PIG: 76EF: 41% ( 32% inc)
TRUE SEVERE AORTIC STENOSIS
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Paradoxical Low flow Low gradient AS• Elderly female• Associated with HTN, DMEcho Characteristics• 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
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ECHO EVALUATION OF AORTIC STENOSIS
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 Heart Disease 10th Edition 2014
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MITRAL STENOSIS
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MITRAL STENOSIS
• most frequent valvular complication of rheumatic fever
Other causes:• Congenital• Obstruction of LV inflow by LA tumor/mass (myxoma,
thrombus, vegetation)• extensive mitral annular calcification
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A. Appearance of the MV and the mobility of its leaflets
ECHO EVALUATION OF MITRAL STENOSIS
EAE/ASE recommendations for Echocardiographic assessment of valve stenosis, European Journal of Echocardiography 2009
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B. Determine the valve area1. Planimetry
2. Pressure Half TimeMVA = 220/PHT
3. Continuity Equation
4. PISA
EAE/ASE recommendations for Echocardiographic assessment of valve stenosis, European Journal of Echocardiography 2009
ECHO EVALUATION OF MITRAL STENOSIS
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B. Determine the valve area1. Planimetry
2. Pressure Half TimeMVA = 220/PHT
3. Continuity Equation
4. PISA
EAE/ASE recommendations for Echocardiographic assessment of valve stenosis, European Journal of Echocardiography 2009
ECHO EVALUATION OF MITRAL STENOSIS
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PHT = 211MVA = 1.04cm2
PHT = 159MVA = 1.38cm2
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C. Determine the Mean Valve gradient
ECHO EVALUATION OF MITRAL STENOSIS
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ECHO EVALUATION OF MITRAL STENOSIS
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ASSOCIATED FINDINGS:• Left atrial enlargement• LA/ LAA thrombus• RV dilatation and dysfunction• Pulmonary hypertension
ECHO EVALUATION OF MITRAL STENOSIS
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TRICUSPID STENOSIS
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TRICUSPID STENOSIS
• Uncommon• Almost always due to RHD• Other causes:• Congenital tricuspid atresia• RA tumor/mass (myxoma,
thrombus, vegetation)• Carcinoid Syndrome
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A. Determine valve morphology and mobility of the leaflets
ECHO EVALUATION OF TRICUSPID STENOSIS
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B. Measure the valve areaTVA = 190 ÷ PHT
C. Measure the mean gradient
ECHO EVALUATION OF TRICUSPID STENOSIS
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ECHO EVALUATION OF TRICUSPID STENOSIS
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PULMONIC STENOSIS
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PULMONIC STENOSIS
Causes:• Congenital• Rheumatic• Carcinoid Syndrome
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A. Determine valve morphology and mobility of the leaflets
ECHO EVALUATION OF PULMONIC STENOSIS
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B. Measure the peak velocity and gradient across the valve
ECHO EVALUATION OF PULMONIC STENOSIS
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ECHO EVALUATION OF PULMONIC STENOSIS
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SUMMARY
• Echocardiography is the primary non invasive imagingtool for the assessment of valve stenosis
• Echocardiographic evaluation should includedetermination of valve morphology, measurement ofvalve area, transvalvular gradient and velocity as wellas to look for other associated abnormalities
• It is essential to combine all 2D and Doppler data ingrading the severity of stenosis and not relying only inone specific parameter.