Aortic Stenosis

Front 1

What is aortic stenosis?

Back 1

Disease of the heart valves in which the opening of the aortic valve is narrowed

Front 2

The aortic stenosis etiology is:

Back 2

1. Calcification- age related progressive

2. Congenital- bicuspid aortic valve

3. Rheumatic fever

4. Supra and sub valvular obstructions

5. Prosthetic valve dysfuction

Front 3

List the signs and symptons of AS:

Back 3

1. Angina

2. Syncope

3. CHF

4. Systolic ejection murmur- crescendo/decrescendo

5.

Front 4

List the pathophysiology of AS:

Back 4

1.Systolic pressure overload

2.Increased in LVEDP leading to increased LA pressure

3.Ventricular dysfunction

4. Increased risk for endocarditis

Front 5

What is aortic sclerosis?

Back 5

valvular thickening by no hemodynamic gradient

Front 6

What are the hemodynamics of AS?

Back 6

Increase in afterload --> LV pressure overload

---> incr filling pressure --> LVH (compensatory mechanism)

Front 7

How does decompensation work in aortic stenosis?

Back 7

LVF down --> low cardiac output --> increase filling pressure --> heart failure

*Heart failure is caused b/c of persisitent pressure overload leads to deteroration of LVF

Front 8

How does Aortic stenosis affect the LA?

Back 8

I

Increased LA pressure which causes LA enlargement.

Front 9

How does AS affect the LV?

Back 9

Causes LVH, and LV Dilation, and Decreased contractility

Front 10

What part of the heart is not affected by AS?

Back 10

Right Atrium

Front 11

2D signs of bicuspid aortic valve:

Back 11

Thickened aortic valve leaflets

Systolic doming in PLAX

(Bicuspid)Football shaped opening of aortic valve in PSAX

Coarctation of the aorta

LVH

Front 12

2D signs of Degenerative/ Rheumatic:

Back 12

increased thickness of AOV

decr AOV excursion

post-stenotic dilation of ascending aorta

LVH

increased LV mass

Decr LV systolic function (later)

LA enlargement

Front 13

List the echocardiographic approaches to AS:

Back 13

1. Valve anatomy

2. Exclude LVOT obstruction

3. Stenosis Severity

4. Degree of co-existing AI

5. LVH and systolic function

Front 14

What are the ways you calculate AS severity:

Back 14

1. LVOT diameter -PLAX

2. LVOT VTI

3. Aortic valve VTI

Front 15

Define continuity equation:

Back 15

the flow in one area must equal in the flow in a second area if there are no shunts between the two areas.

LVOT flow = (stenotic ) aortic valve flow

Front 16

What is the Continuity eq?

Back 16

AVA (cm2) = LVOT CSA x LVOT VTI/ AV VTI

Front 17

How do you calculated CSA of LVOT?

Back 17

CSA (LVOT) = 3.14 x ( LVOT diameter^2) ^2

or CSA = (LVOT diamter)^2 x 0.785

Front 18

Where is the LVOT measured for AS:

Back 18

PLAX in zoom mode, inner diameter just below the AOV

Front 19

Where do you measure LVOT VTI:

Back 19

Apical 5 with PW at same level of LVOT diameter

Front 20

How do you calculate aortic valve VTI:

Back 20

Parallel to flow

Apical 5 or 3

CW through Aortic valve

Front 21

List the aortic valve severity scales:

Back 21

Normal 3-5 cm

mild: 1.6-2.0

mild to mod: 1.3-1.6

Moderate: 1.0-1.3

Mod to severe: 0.7 -1.0

Severe: <0.7 cm

Critical: < 0.5 cm

Front 22

What is the formula for heart pressure gradients?

Back 22

Gradient = 4 x Vmax^2

Front 23

What are gradients influenced by?

Back 23

Heart rate and stroke volume

Front 24

What type of jet is indicative of severe aortic stenosis?

Back 24

symmetric and rounded-Late peaking doppler signal

Front 25

What type of patients will give you velocities that mimic AS?

Back 25

young or anxious, hyperthyroidism, fever, high cardiac output

Front 26

How do i determine between true severe and severe psuedo AS?

Back 26

Dobutamine stress echo

Front 27

What causes Paradoxical low flow AS?

Back 27

They have AS with small ventricles and CO produces low gradients with severe aortic stenosis.

Front 28

What type of jet will congenital AS have?

Back 28

Long eccentric jet

Front 29

What type of jet will a calcific aortic valve have?

Back 29

Short jet with spray

Front 30

Low gradients in severe AS/normal EF are:

Back 30

AVA < 1.0 cm

EF > 50%

Mean gradient < 40 mmHg

Front 31

How is Aortic Stenosis and Aortic Regurgitation related?

Back 31

1. Simultaneously

2. Common in bicuspid valves

3. Significant aortic regurgitation leads to higher gradients

Front 32

What does significant AR lead to AS in quantification of aortic stenosis?

Back 32

Overestimation of the severity of AS

Front 33

How do I not confuse MR with AS jet?

Back 33

MR is longer because there is no flow during IVRT/IVCT throught aortic valve

Front 34

What are the mild values for aortic stenosis?

Back 34

Jet velocity: <3 (m/s)

Mean gradient: 25 mmhg

Area: >1.5 cm

Front 35

What are the moderate valves for AS?

Back 35

Jet velocity: 3-4 (m/s)

Mean gradient: 25-40 mmhg

Area: 1-1.5 cm^2

Front 36

What are the values for severe AS?

Back 36

Jet velocity: >4

Mean gradient: 40 mmhg

Area: <1

Front 37

What are the other pathologies of aortic stenosis?

Back 37

1. Subvalvular aortic stenosis

2. Supravalvular aortic stenosis

Front 38

What is subvalvular aortic stenosis?

Back 38

congential membrane or ridge in LVOT beneath AOV

-need TEE

Front 39

2D characteristic of subvalvular membrane:

Back 39

Congential membrane

Early systolic closure of aortic leaflets

LVH

Front 40

What is supravalvular stenosis?

Back 40

Muscular ridge w/ a membrane causing obstruction is seen in LVOT

-LVH

-PLAX- (best view)

Front 41

List the three types of supravalvular stenosis:

Back 41

1. Hourglass

2. Membranous

3. Tubular

Front 42

Dopper signs for supravalvular stenosis:

Back 42

increased velocity & turbulence at level of obstruction

measure peak gradients

Use Continuity eq for valve area

Check for AR

Use PW/Color flow to locate level of obstruction

Front 43

What does subvalvular obstruction lead to?

Back 43

Aortic valve destruction

and AI

Front 44

What are the options to fix AS?

Back 44

TAVR - severe/symptomatic patients