Aortic Valve Disease Normal Aortic Valve Parasternal long

Aortic Valve Disease

Normal Aortic Valve Parasternal long axis view Three cusps (right, left and non-coronary) Valve area: 3-4 cm2 Separation: 2cm

Parasternal short axis view Three cusps (right, left and non-coronary) Valve area: 3-4 cm2 Separation: 2cm Normal Aortic Valve

Apical five chamber view Three cusps (right, left and non-coronary) Valve area: 3-4 cm2 Separation: 2cm Normal Aortic Valve

M-Mode Separation: 2 cm Maximal Velocity (LVOT): 0.7-1.1 m/s Maximal Velocity (Aorta): 1.0-1.7 m/s CW Doppler Normal Aortic Valve

Congenital Anomaly Unicuspid valve Bicuspid valve Quadricuspid valve

Bicuspid Aortic Valve Most common congenital anomaly (population 1-2%) Systolic doming: PLAX Fish mouth appearance : PSAX

commissure raphe Combined aortic aneurysm or AS Normal (15%), stenosis(72%), regurgitation (4%), endocarditis (9%) Doppler is important Bicuspid Aortic Valve

Quadricuspid Aortic Valve

Aortic Stenosis

2D Echocardiography Normal Aortic Stenosis Cusp calcification and thickening Cusp motion limitation and doming Left ventricular hypertrophy

Normal Aortic Stenosis Cusp calcification and thickening Cusp motion limitation Commissural fusion (in rheumatic AS) 2D Echocardiography

Etiology of Aortic Stenosis Eur Heart J 2003;24:1231 Degenerative-calcific 81.9% Rheumatic 11.2% Congenital (ex. Bicuspid etc) 5.6% Post endocarditis 1.3% Euro Heart Survey on Valvular Heart Disease

Morphologic Characteristics Degenerative-Calcific Rheumatic Thick, stiff leaflets No commissural fusion Multivalvular involvement Commissural fusion

Degenerative vs. Rheumatic AS Thick, stiff leaflets No commissural fusion Degenerative Rheumatic Multivalvular involvement Commissural fusion

Thick, stiff leaflets No commissural fusion Multivalvular involvement Commissural fusion Degenerative Rheumatic Degenerative vs. Rheumatic AS

Membraneous Subaortic Stenosis

Doppler Examination Time (s) Pressure (mm Hg) Maximum gradient by Doppler exam Peak-to-peak gradient by Catheter exam Mean gradient LV and Aortic Pressures measured with catheter in a patient with severe AS

Peak pressure gradient Mean pressure gradient Modified Bernoulli Equation Pressure Gradient = 4 x Vmax2 4 x 4.622 = 85.3 mmHg Tracing of Velocity Curve Mean Pressure Gradient 60.9 mmHg Doppler Examination

Angle Dependency Doppler Examination

Differential Diagnosis of LVOT Obstruction Valvular Aortic Stenosis Subaortic Membrane Hypertrophic Cardiomyopathy

Other High Velocity Systolic Jets that May Be Mistaken for Aortic Stenosis Mitral regurgitation Tricuspid regurgitation Supravalvular stenosis Ventricular septal defect Pulmonic or branch pulmonary artery stenosis Peripheral vascular stenosis (e.q., subclavian artery) Aortic Stenosis Mitral Regurgitation

Calculation of Valve Area 2D Planimetry Continuity equation

2D Planimetry Severe calcification: difficult to measure AVA (should trace 80% of AVA)

Should measure oritice tip of AV Subvalvular Area 1.30 cm2 Orifice Tip 0.76 cm2 2D Planimetry

Continuity Equation LVOT Stroke Volume = AS-Jet Stroke Volume LVOT CSA x LVOT TVI = AVA x AS-Jet TVI AVA = (LVOT CSA x LVOT TVI) / AS-Jet TVI

LVOT 2D Measure Continuity Equation

Continuity Equation

Severity of Aortic Stenosis Mild Moderate Severe

Quantification of Stenosis Severity

AS with Low Pressure Gradient Low Output with Low Pressure Gradient (AVA < 1.0 cm2 and PG < 30 mmHg)

Aortic Regurgitation

Etiology of Aortic Regurgitation Cusp pathology Aortic wall pathology including aortitis Congenital

Cusp Pathology (Including congenital) Rheumatic Degenerative Infective endocarditis Congenitally bicuspid valve Ass. with membraneous subaortic aortic stenosis Ass. with ventricular septal defect Aortic valve prolapse (Myxomatous or congenitally abnormal) Less common - Unicommissural and quadricuspid valve - Rupture of a fenestrated valve - SLE, RA, Ankylosing spondylitis, Takayasu disease, Whipple disease, Crohn disease etc

Rheumatic AR

Degenerative AR

Infective Endocarditis

Bicuspid Aortic Valve

Quadricuspid Aortic Valve

Ventricular Septal Defect

Ventricular Septal Defect

Aortic Valve Prolapse Best seen in parasternal long axis view Disruption of commissural support - Dissection - Dilatation - Ass. with VSD - Myxomatous or congenitally abnormality

Aortic Valve Prolapse (TTE)

Aortic Valve Prolapse (TEE)

Aortic Root Disease Aortic dilatation related with - Hypertension - Age-related (degenerative) - Bicuspid AV Aortic dissection Cystic medial necrosis (Marfan syndrome) Takayasu arteritis Behcet’s disease Ankylosing spondylitis Less common - Syphilitic aortitis, psoriatic arthritis, UC, giant cell arteritis - relapsing polychondritis, Reiter syndrome

Effacement of the Sinotubular Junction Hypertension, Degeneration, Bicuspid AV

Aortic Dissection

Marfan Syndrome-I

Marfan Syndrome-II

Behcet’s Disease

Behcet’s Disease vs. Takayasu’s Arteritis JASE 2003;16:850

M-Mode AMVL fluttering in diastole Premature closure of MV and Diastolic opening of AV in severe AR

Estimating the Severity of AR Color Flow - Jet area/height - Vena contracta width - Flow convergence or PISA Continuous Wave Doppler - Signal density - Pressure half time (P½t) or Slope Pulsed Wave Doppler - Regurgitant volume/fraction - Descending aortic flow reversal 2D Echocardiography - LV end-diastolic dimension - LV end-systolic dimension

Color Flow Jet Area/Jet Height

Jet Area/Jet Height Instrument (gain) dependent, Eccentric Jet, Temporal variability Multiple jets or Jets with irregular shapes Color Flow

Vena Contracta Width (Semiquantification Method) Most narrow point : just below flow convergence  reflect regurgitant orifice area Measure at zooming parasternal long axis view Vertical to AR jet : measure vena contracta width Color Flow

Vena Contracta Width (Semiquantification Method) Color Flow

Color Flow Flow Convergence or PISA Multiple measurements, Technically challenging AV calcification, Multiple jets, Aortic aneurysm, Limited experience

Continuous Wave Doppler CW Doppler Signal Density Qualitative Overlap between moderate and severe AR Aortic compliance, Blood pressure, LV size and compliance, etc An indicator of acuity rather than severity

Continuous Wave Doppler Mild Severe Diastolic Jet Deceleration

Pulsed Wave Doppler Descending Thoracic Aorta Abdominal Aorta Descending Aorta Holodiastolic Flow Reversal Aortic compliance Sample volume location

Pulsed Wave Doppler Regurgitation Volume and Fraction Aortic Regurgitant Volume = SVAV - SVMV Regurtitant Fraction = (Aortic regurgitant volume / SVAV) x 100

Pulsed Wave Doppler Regurgitation Volume and Fraction Require multiple measurements Assumes no regurgitation at reference valve Different stroke volume when atrial fibrillation exists

Quantification of AR Severity

Mild Moderate Severe Regurgitant jet width/LVOT diameter Regurgitant jet area/LVOT area PHT of CW Doppler signal Quantification of AR Severity

Acute versus Chronic AR

Acuity of AR Shape of AR on CW Doppler Premature Closure of MV Diastolic MR

Thank You !