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AS/AR Flashcards

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1
Q
A

Bicuspid aortic valve (fused right and left coronary cusps)

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2
Q

Name three nonvalvular types of LVOTO

A
  • hypertrophic obstructive cardiomyopathy (HOCM)
  • membranous subaortic stenosis (subAS)
  • supravalvular stenosis

***all occur less frequently than valvular AS

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3
Q

What percentage of the population has BAV?

What is the pathophysiology that leads to accelerated AS?

A
  • 1% of the general population
    • more common in men
  • congenitally malformed leaflets –> turbulent flow –> accelerated progression of fibrosis –> stenosis
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4
Q

What are signs/symptoms of advanced stages of AS?

A
  • reduced CO
  • right-sided heart failure
  • A-fib
  • pulmonary congestion
  • pulmonary hypertension
  • peripheral edema
  • cachexia
  • hepatomegaly
  • functional TR
  • fatigue
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5
Q

What is an early finding on Echo of AS prior to calcification of the valve?

A
  • M-mode
    • eccentric line of diastolic closure
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6
Q

What is the current recommendation for monitoring in:

  • severe, asymptomatic AS
A

TTE every 6-12 months

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7
Q

What percentage of patients with BAV will have first degree family members with BAV?

A

9%

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8
Q

What is the pathophysiology of AS?

A
  • increased LVOTO
  • LV hypertrophy
    • attempts to normalize wall stress
  • increasing afterload mismatch leads to:
    • diastolic dysfunction
    • decreased diastolic filling time
    • increased LV filling pressures (leads to dyspnea)
  • increasing LV hypertrophy can lead to a reduced cavity size –> reduced stroke volume
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9
Q

What are common associations with unicuspid aortic valve (leading to early AS)?

A
  • ascending aortic abnormalities
  • coarctation of aorta
  • coronary anomalies
  • PDA
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10
Q

What is the next best step in an asymptomatic patient with severe AS (AVA 0.47cm2, PV 4.8 m/s)?

A
  • O2 consumption treadmill testing (Cardiopulmonary exercise testing - CPET)
    • evolution of completely asymptomatic AS is not benign
    • useful in clinical decision making for asymptomatic AS
    • development of symptoms or decrease in BP at peak exercise would suggest a more advanced disease state
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11
Q

What percentage of patients > 75 years of age have AS?

Aortic sclerosis?

A
  • 2.6%
  • 33%
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12
Q

In Aortic Stenosis:

  • What is the average reduction in aortic valve area (AVA) per year?
  • What is the average increase in aortic valve gradient (AVG) per year?
A
  • 0.1 cm2
  • 7-10 mmHg
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13
Q

What is the mortality risk associated with severe, symptomatic AS?

A

50% at 2-3 years (if valve replacement not done)

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14
Q

What is one mutation that predisposes to rapid progression of AS in BAV’s?

A

mutation in the NOTCH 1 genome

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15
Q

What are risk factors in the rate of progression of AS?

A
  • hyperlipidemia
  • DM (possibly)
  • metabolic syndrome
  • smoking
  • hypertension
  • renal dysfunction
  • increasing age
  • male gender
  • Pagets disease
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16
Q

What are the three most common causes of AS?

A
  • Calcification of a trileaflet valve
  • Secondary calcificaiton of a congenital bicuspid aortic valve
  • Rheumatic valve disease
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17
Q

What abnormality is always associated with rheumatic AS? Why?

A

mitral valve abnormalities

  • because mitral valve is the initial site of rheumatic involvement in nearly all patients
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18
Q

What are causes of supravalvular AS? (rare in adults)

A
  • Homozygous type II hyperlipoproteinemia
  • Ochronosis with alkaptonuria
  • Radiation therapy
  • Renal failure (accelerated leaflet calcification)
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19
Q

What is the most common initial symptom in adults with severe AS?

What is the best way to determine if this is present?

A
  • decreased exercise capacity
  • ask patient’s to compare his/her current exercise capacity with a specific time point (typically 1 year prior)
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20
Q

What is the key physical examination finding in adults with AS?

A
  • systolic ejection-type murmur
    • loudest at the cardiac base
    • radiates either to the carotids or to the LV apex
  • PE is critical for detection of disease but not determination of severity
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21
Q

What are common auscultation findings in severe AS?

A
  • Grade 3-4 murmur (with a thrill)
  • Single or paradoxically split second heart sound
  • “Pulsus parvus et tardus”
    • Carotid pulse that is decreased in amplitute and delayed in occurrence
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22
Q

What is the anatomical valve abnormality of Congenital bicuspid aortic valves (in order)?

A
  • Left-Right fusion (70-80%)
  • Right-NCC fusion (20-30%)
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23
Q

With CAVD, this is a strong predictor of disease progression and clinical outcome?

A

severity of leaflet calcification

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24
Q

What are the key measures of AS severity?

A
  • Peak aortic velocity
  • Mean transaortic gradient
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25
How is peak aortic velocity measured in AS?
* continuous-wave Doppler US examined from multiple acoustic windows * to ensure stenosis severity is not underestimated
26
How is mean (transaortic) gradient measured in the evaluation of AS?
* Calculated by averaging instantaneous gradients over the systolic ejection period using the Bernoulli equation * Bernoulli equation: **Δ****Pmax = 4vmax2**
27
What is the Bernoulli Equation?
* ΔPmax = 4vmax2 * ΔPmax = 4 (vmax2 – vproximal2) * proximal velocity should be included in equation when \> 1.0 m/s
28
In what AS setting is AVA useful? How is AVA calculated?
* low-flow states * continuity equation
29
Define the continuity equation.
**AVA = (CSALVOT x VTILVOT) / VTIAS** **AVA = (CSALVOT x VLVOT) / VMAX** * **simplifed version utilizing maximum velocities instead of VTI's** * **CSALVOT = 3.14 (D/2)2 = 0.785 x D2** * **​D is measured at the basal insertion of the aortic leaflets from inner edge to inner edge of the aortic annulus**
30
What is the recommended periodic monitoring for asymptomatic AS?
* Mild --\> every 3-5 years * Moderate --\> every 1-2 years * Severe --\> every 6-12 months
31
How are valve gradients calculated in the assessment of AS?
* continuous wave (CW) Doppler with Doppler beam aligned as parallel as possible to flow * valve gradients are calculated using the maximum valvular velocity (Vmax)
32
What are ways in which stenosis is underestimated in Echo evaluation of AS?
misalignment of the US beam
33
How many positions should be obtained in the doppler assessment of AS? What positions are preferred?
* at least 3 windows (to obtain highest possible velocity) * LV apex * subcostal * RUSB * suprasternal notch
34
What is the Doppler pattern in valvular AS?
* high-velocity flow beginning with AV opening * convex outward rising shape, peaking in mid systole, ending at AV closure
35
How is subaortic velocity (LVOT) obtained?
* PW doppler from the LV apex * recording should be traced during systole using the modal (highest amplitude) velocities on spectral display * View should be obtained from: * anteriorly angulated four-chamber view (five-chamber view) * apical long-axis view
36
What PHT correlates with: * mild AR * moderate AR * severe AR
* Mild AR --\> **PHT \> 500 ms** * Moderate AR --\> **PHT 200-500 ms** * Severe AR --\> **PHT \< 200 ms** * in some cases as the LV remodels and LV diastolic pressure decreases, a patient may have a PHT \> 200 ms despite having severe chronic AR
37
What are common associations with subaortic stenosis?
* PDA * Pulmonary stenosis * VSD * Coarctation of the aorta * diagonsed with pulsed doppler of abdominal aorta
38
What is the best view for VC in the evalutation of AR?
* Parasternal long axis view * best axial resolution * Not Apical long axis view * VC will be typically parallel to the US beam, reducing the spatial resolution
39
What is the next step in management of a 30 year old female with newly diagnosed subaortic stenosis (PG 44 mmHg) and concomitant moderate aortic regurgitation, non-calcified aortic valve, LVEF 57%, asymptomatic?
* TEE with careful inspection of pulmonary valve (pulmonary stenosis) and pulmonary artery (PDA)
40
# Define how the continuity equation is utilized for regurgitant lesions? What is the equation for this?
* According to the continuity equation, the flow converging to the valve must be equal to the flow through the valve * As blood acclerates toward a narrowing orifice (in this case the regurgitant orifice), the spatial distribution of points in which the fluid has the same velocity (Isovelocity surface) is approximated by a hemisphere = Proximal isovelocity surface area (PISA) * Isovelocity flow = regurgitant flow * Isovelocity area x aliasing velocity = EROA x Regurgitant velocity * EROA = PISA area x aliasing velocity / regurgitant velocity
41
What is the value of the suprasternal notch window in the evaluation of AR?
* Doppler evaluation of flow reversals in the descending thoracic aorta * holodiastolic flow reversal is suggestive of severe AR
42
What is the Bernoulli (simplified) equation? When should it be used?
* AV pressure gradient (in mmHg) = 4Vmax2 (m/sec) * Equation should only be used when the maximum valve velocity is much greater than **( \> 2.5 or more times)** the peak subaortic velocity
43
Why may maximum instantaneous AVG (which comes from Vmax) be higher than the peak-to-peak AVG?
* Because the peak of aortic pressure often occurs later than the peak of LV pressure * **"tardus and parvus"**
44
* Holodiastolic flow reversal in the descending aorta suggestive of severe AR * PW doppler from the suprasternal notch window * can also be taken from the subcostal view of the abdominal aorta
45
When may you see the use of velocity to calculate gradients in patients with AS lead to overestimation of AS severity?
* small aortic root size --\> overestimation of AS severity * **Pressure-Recovery Phenomenon**
46
Why are nonimaging probes used in the evaluation of AS?
* smaller footprint * allows US interrogation from a deeper position (better penetrance) * better alignment of Doppler signal with direction of blood flow
47
What may result in elevated aortic valve velocities in the absence of significant valvular stenosis? How can this be clarified?
* High cardiac output * anemia, fever, subvalvular AS, significant vavlular regurgitation * Dimensionless Index "DI"
48
How is LVOT measured?
* PLAX on 2D Echocardiogram * LVOT diameter measured in mid-systole * perpendicular to flow * 3-5 mm below the hinge points of the valve
49
What are causes of reduced flow states in severe AS?
* LV dysfunction * RV dysfunction * Small LV cavity size (from increased LV hypertrophy) * MR * TR
50
What does a dobutamine echo help to distinguish in AS patients?
* Pseudo-severe AS * Truly severe AS
51
Define "low-flow, low-gradient severe AS" effects with Dobutamine Echo?
* Increase in flow --\> gradients rise * AVA index remains low because the LVOT and valve velocities increase proportionally.
52
Describe "pseudo-severe" AS and the changes that take place during Dobutamine Echo.
* Pseudo-severe stenosis * if the gradient is moderate and during infusion * and it does not increase substantially while the valve area increases * LV dysfunction may not be a result of the AS, and the AS may be less than severe
53
What is the grading scale for AS: Indexed AVA (cm2/m2)
* Mild \> 0.85 cm2/m2 * Moderate 0.60-0.85 cm2/m2 * Severe \< 0.60 cm2/m2
54
What is the largest potential error in derivation of orifice size?
* errors in measuring LVOT diameter * because it is squared in the calculation
55
What test is not indicated in paradoxical LF-LG severe AS? What is the pathophysiology in these patients?
* Dobutamine Echo * Normal LVEF but small cavity size --\> low stroke volume
56
What can be done to avoid the error created with the assumption that the LVOT is circular (and not elliptical)?
* Direct planimetry of the LVOT * 3D TEE * MSCT
57
What is one major limitation of the standard continuity equation in the evaluation of AS?
* Assumption of a circular outflow tract shape * Because LVOT is more/less elliptical, area may be underestimated and as a consequence flow and AVA will be understeimated as well
58
What is the preferred site for LVOT measurement? What may occur, preventing this measurement or location? How can you fix this problem?
* Aortic valve annulus * only when a smooth velocity curve can be obtained * Flow acceleration may occur at the annulus * Move the sample volume apically by 0.5-1.0 cm * to obtain a laminar flow curve without spectral dispersion
59
What etiologies lead to LF-LG severe AS?
* Low LVEF * Normal LVEF (paradoxical LF-LG severe AS)
60
What are some limitations to indexing AVA in LF-LG AS evaluations?
* Obesity * current algorithms for defining body size (BSA) don't reflect normal AVA in obese patients * AVA does not increase with excess body weight
61
What are positive results of Dobutamine Echo in LF-LG AS evaluation?
* Increase in effective AVA \> 1.0 cm2 --\> AS not severe * Severe stenosis suggested by: * AS velocity \> 4 m/s or MG \> 30-40 mmHg * provided AVA does not exceed 1.0 cm2 * Absence of contractile reserve (failure to increase SV by \> 20%) * predictor of high surgical mortality and poor long-term outcome * although valve replacement may improve LV function and outcome even in this subgroup
62
What percentage of patients with BAV will have an abnormally dilated aortic root?
50%
63
What is one subgroup of patients with LF-LG AS who carries a very high mortality risk?
* Absence of contractile reserve (failure to increase SV by \> 20%) with Dobutamine Echo * predictor of high surgical mortality and poor long-term outcome although valve replacement may improve LV function and outcome even in this subgroup * "Projected AVA" can be calculated * calculated AVA if SV would have increased and been in normal range
64
This can influence peak velocity/mean gradients in AS evaluation and should be measured/recorded in every examination?
BP / Hypertension
65
What is valvuloarterial impedance (Zva)?
* Ratio of the estimated LV systolic pressure (sum of arterial pressure and AVGm) to the SVI * Parameter reflects the total LV afterload * results from peripheral arterial resistance in addition to the valve stenosis * Zva is elevated in patients with uncontrolled HTN * Elevated Zva --\> adverse outcomes
66
What are factors that may influence SV during DSE evaluation of AS?
* severity of AS * afterload mismatch * concomitant change in MR
67
What is useful in patients with low LVEF, low-flow, low-gradient AS?
* Low-dose (up to 20 microgram/kg/min) DSE * class II recommendation * to assess AS severity and evaluate contractile reserve
68
When should contrast be utilized in evaluation of Low LVEF, LF-LG, severe AS patients?
two consecutive segments or \< 80% myocardium is visible
69
What is a major factor that may result in decreased gradients in AS evaluation?
* Hypertension * increase in LV afterload --\> decrease in LV outflow and transvalvular gradients
70
What is the formula for projected AVA?
Q = SV/LV ejection time
71
Describe the algorithm for Classical LF-LG AS
72
Describe the algorithm for Paradoxical LFLG AS
73
Define Paradoxical LFLG AS
* LVEF \> 50% * AVA \< 1.0 cm2 * AVAI \< 0.6 cm2/m2 * MG \< 40 mmHg * SVI \< 35 ml/m2
74
Define Clasical LFLG AS
* LVEF \< 50% * AVA \< 1.0 cm2 * AVAI \< 0.6 cm2/m2 * MG \< 40 mmHg * SVI \< 35 ml/m2
75
What differentiates Classical and Pardoxical LFLG AS?
* LVEF * Clasical LVEF \< 50% * Paradoxical LVEF \> 50%
76
What is the first step in the evaluation of Classical LFLG AS? What is considered a positive test/result?
* DSE * Increased SV (flow reserve) \> 20% * True Severe (AVA \< 1, MG \> 40) * Pseudo-severe (AVA +/- 1, MG \< 40)
77
In the evaluation of Classical LFLG AS, with DSE resulting in increased SV (flow reserve) ≥ 20% leading to indeterminant results, what is the next step?
HF therapy
78
In the evaluation of Classical LFLG AS, with DSE resulting in increased SV (flow reserve) \< 20%, what is the next step?
* MDCT Calcium score * True Severe AS if Ca score: * male \> 2000 (or Ca load \> 500) * femal \> 1200 (or Ca load \> 300)
79
In the evaluation of Classical LFLG AS, with DSE resulting in increased SV (flow reserve) \< 20% * what is the diagnosis and next step?
* Pseudo-severe AS * HF therapy
80
What is the first step in the evaluation of Paradoxical LFLG AS?
* Evaluate sources of measurement error * SV * AVA * MG
81
What is the stepwise progression in the evaluation of Paradoxical LFLG AS?
* Measurement error * Symptoms * Hypertension * Stenosis severity
82
What is the next step in the evaluation of Paradoxical LFLG AS with no measurement error?
* Symptom evaluation (exercise testing) * Close follow up
83
What is the next step in the evaluation of Paradoxical LFLG AS with no measurement error and positive symptoms on exercise testing?
* Hypertension * treat hypertension and recheck quantitative measures when well controlled
84
What is the next step in the evaluation of Paradoxical LFLG AS with: * no measurement error * positive symptoms on exercise testing * no hypertension
* True severe * measurements correlate with AS * Pseudo-severe (indeterminant severity) * MDCT calcium score * DSE
85
What are the windows that are utilized in obtaining peak aortic velocities?
* Apical 3-chamber * Apical 5-chamber * Right parasternal * Suprasternal
86
What is the grading scale for AS: Valvuloarterial impedance (Zva)
* Mild \< 3.5 * Moderate 3.5-4.5 * Severe \> 4.5
87
What is the grading scale for AS: Velocity ratio (DVI)
* Mild \> 0.50 * Moderate 0.25.050 * Severe \< 0.25
88
What can result in discordant measurements of AS: * AVA \> 1 cm2 * MG \> 40 mmHg * PV \> 4 m/s
* High flow (transvalvular) states * AR (concomitant) * MR * Fever * Anemia * Hyperthyroidism * AV shunts (dialysis)
89
What can effect the pull-back method on cardiac cath when evaluating AS severity?
* Aortic compliance * markedly reduced when compliance is low
90
In what patients does indexing AVA for LF-LG AS proven to be accurate?
* Children * Adolescents * Small adults
91
What can lead to underestimation of valvular stenosis severity with Doppler Echocardiography?
misalignment of the doppler beam * rarely overestimates velocities and gradients
92
What determines the magnitude of pressure recovery? When is pressure recovery clinically significant?
* EROAaortic valve / CSAascending aorta * Clinically significant when (leads to **overestimation of gradient**): * moderate - mod-severe AS (AVA 0.9 - 1.2) * **small ascending aorta ( \< 30mm)**
93
What is one pitfall of utilizing the right parasternal view in evaluating AS? How can you avoid this?
* Mistaking mitral or tricuspid regurgitant flow velocity for transaortic velocity * Measure the duration of the flow (continuous wave doppler) in both the apical and right parasternal views. Duration should be relatively the same
94
What is the most probable etiology of a mobile, \> 1 cm, aortic valve mass (on the LV side) in a 50 year old patient?
* Infective endocarditis * Papillary fibroelastoma usually \< 1 cm * Rhabdomyoma could occur here but usually in children \< 4 years of age * Paraganglioma could occur here but usually immobile and in younger adults * Thrombi on native valves are unlikely * Myxomas generally occur in the left atrium
95
What is an important step in patients who are larger/smaller than average?
* index the AVA to body surface area * helps to understand the magnitude of obstruction relevant to their body size
96
What is Shone Complex associated with?
* left heart obstructive disease * supravavluar mitral stenosis * parachute mitral valve * subvalvular aortic stenosis * valvular aortic stenosis\*\* * coarctation of the aorta * can be complete 4/4 or incomplete
97
What percentage of patients evaluted for AS, are the highest velocities obtained in windows other than the apical ( 3 or 5) chamber views?
* 30-35% * most often highest velocities are obtained from the right parasternal window
98
What is the effect of the pull-back method in cardiac catheterization on peak velocity and mean gradient (in the evaluation of AS)?
* Overestimation of severity * due to space occupied by the catheter within the aortic valve orifice during the measurementof the LV systolic pressure
99
When is exercise stress testing contraindicated in severe AS?
symptoms are present (class III)
100
What are the major differences in transvalvular pressure gradients obtained by cardiac cath and doppler echocardiography?
* Doppler echocardiography measures velocity at the VC, where pressure gradient's are highest * Cardiac cath measures a few cm downstream --\> after pressure-recovery has occurred
101
What is the cutoff to define low-flow patients with AS?
SVI = \< 35 ml/m2
102
What are alternative methods to measure LVOT SV?
* Continuity equation * subject to errors in measurement of LVOT diameter * Simpson's biplane method * tendancy to underestimate LV volumes due to frequent foreshortening * 3D Echo * provides accurate measurements of LV but is dependent on good-quality images * Teicholz formula * SV = (7 x LVEDD3 / 2.4 + LVEDD) x LVEF
103
What are limitations/problems with determining SV using the continuity equation in AS?
* subject to errors in measurement of LVOT diameter * underestimation may result in underestimation of SV and AVA --\> missclassification of flow status (low vs. normal) and stenosis severity (severe vs. moderate)
104
* Define the Teicholz formula? * When is it used? * When can this formula not be used?
* SV = (7 x LVEDD3 / 2.4 + LVEDD) x LVEF * LVEDD ust be measured below septal bulge * septal bulge common in AS patients * LF AS cases to determine SV * Moderate or greater MR is present
105
Define paradoxical LF AS
* Normal LVEF * Low flow state = MG, PV which are not severe
106
What percentage of asymptomatic, severe AS patients actually will demonstrate exercise limiting symptoms during exercise stress testing?
30%
107
How is stroke volume calculated from VTI measurements?
* SV = VTILVOT x AreaLVOT * Can be divided by BSA to obtain SV index (SVI)
108
What are indications for more frequent interval Echo monitoring in AS?
* Severe Calcification * Rapid progression * increase in aortic (peak) velocity \> 0.3 m/s/year * increase in mean gradient \> 7mmHg/year * decrease in AVA \> 0.1cm2/year * Clinical factors associated with more severe disease * renal failure * prior radiation therapy
109
What conditions may impact the hemodynamics of LVOTO? What is used as a better portrayal of AS severity?
* Variations in loading conditions --\> lower LVOT gradient * low CO * high HR * AVA or AVAI
110
What are the goals of DSE in low LVEF, LF-LG AS patients?
* differentiate true vs. pseudo severe stenosis * assess the presence of LV flow reserve * useful for operative risk stratification * 30-day mortality: * low flow reserve (\< 20%) = 8-30% * good flow reserve (\> 20%) = 5-8%
111
Why is echocardiographic evaluation of peak gradients superior to peak-to-peak gradients measured in cardiac catheterization?
* peak-to-peak gradient typically evaluated at pullback does not reflect a true event * as peak aortic pressure occurs after peak LV pressure when AS is present * Echo estimation of the peak gradient is more accurate * it reflects instantaneous pressure differences between aorta and LV
112
What is the AS Severity scale - Aortic jet velocity m/s (peak velocity)?
* Sclerosis = \< 2.5 m/s * Mild = 2.6 - 2.9 m/s * Moderate = 3.0 - 3.9 m/s * Severe = \> 4.0 m/s
113
What is the AS Severity scale - Mean Gradient mmHg?
* Mild = \< 20 mmHg * \< 30 mmHg by ESC * Moderate = 20 - 40 mmHg * 30 - 50 mmHg by ESC * Severe = \> 40 mmHg * \> 50 mmHg by ESC
114
What is the AS Severity scale - AVA cm2?
* Mild = \> 1.5 cm2 * Moderate = 1.0 - 1.5 cm2 * Severe = \< 1.0 cm2
115
What is the AS Severity scale - indexed AVA cm2/m2?
* Mild = \> 0.85 cm2/m2 * Moderate = 0.6 - 0.85 cm2/m2 * Severe = \< 0.6 cm2/m2
116
What is the diagnosis/severity of AS: * MG 45mmHg * PV 4.2m/s * AVA 1.32 cm2
severe AS
117
What is the diagnosis/severity of AS: * MG 36mmHg * PV 3.7m/s * AVA 0.9 cm2 * LVEF \< 50%
Low-flow, low-gradient AS * will need low-dose dobutamine stress echo
118
In the evaluation of AS, when discordant AVA and MG, what are possible explanations/diagnoses?
* Measurement error * suboptimal CW doppler signal across AV * LVOT issues * Falsely small LVOT * Assume circular LVOT * 2D vs. 3D TTE/TEE vs. CT * Inherently small LVOT * Low-flow, low-gradient (LVEF \< 50%) * true severe AS vs. pseudo AS * Paradoxial Low-Gradient (LVEF \> 50%) * Low stroke volume ( \< 35 cc/m2) * High afterload (SBP + MG)/SVi - valvuloarterial impedance
119
* In evaluation of AS, what is the formula for diminisionless index? * What is the cutoff that indicates severe AS?
* DI = LVOTVTI / AVVTI * \< 0.25
120
What are signs of an effective DSE when evaluating AS severity?
SV increase by 20%
121
What is the most common cause of low gradient AS with a normal EF?
Hypertrophied LV with reduced LV volume
122
CT calcium score that indicates severe AS?
* Males = \> 2,000 * Ca load \> 500 * Females = \> 1,200 * Ca load \> 300
123
Patients with subvalvular aortic stenosis are often misdiagnosed as this?
hypertrophic obstructive cardiomyopathy
124
What is the best test to confirm a diagnosis of subvalvular aortic stenosis (if suspected)?
TEE --\> excellent vies of the LVOT
125
Subvalvular Aortic stenosis may present as part of this complex?
Shone's Complex * supravalvular MS * parachute mitral valve * subvalvular AS * bicuspid aortic valve\*\* (not always present) * coarctation of the aorta \*\*\*Subvalvular AS can also be associated with PDA or VSD
126
Supravalvular AS is a rare form of aortic valve stenosis associated with this syndrome
Williams Syndrome (71%) * supravalvular AS * intellectual disabilities * connective tissue abnormalities * hypercalcemia
127
What are the AS quantification methods by 2-D Echo?
* Valvular thickening, calcification and restricted leaflet motion (commissural fusion if inflammatory) * LV hypertrophy * Poststenotic dilation of ascending aorta * AV area by planimetry using TEE
128
What are common aortopathy's associated with Bicuspid aortic valve?
* Sinus of valsalva * Ascending aorta * Aortic coarctation
129
What are the indications for surgery in pateints with ascending aortic aneurysm and BAV?
* \> 5.5cm --\> class I * \> 5.0cm --\> class IIa * FH of dissection * \> 0.5cm/yr growth rate * Low risk + experience surgical center * \> 4.5cm --\> class IIa * undergoing AVR
130
What is the common finding in patients with BAV + HTN? What will doppler wave of descending aorta show?
* Coarctation of the aorta * Saw tooth pattern
131
In the evaluation of AS, how many acoustic windows should be sampled to ensure that the highest velocity signal is obtained?
at least 3 acoustic windows
132
What is the additional probe utilized in evaluation of AS? How does the probe differ?
* Pedoff probe * Differences: * smaller footprint to allow for manipulation in between rib spaces * higher frequency (allowing for the probe to recognize and display higher velocities) * No imaging capabilities
133
What is the difference in gradients between cath and 2D echo (doppler)?
* Doppler --\> provides instantaneous gradient throughout systole * Cath --\> provide noninstaneous, peak-to-peak gradients * not a true measurement of pressure drop across the valve as these do not occur at the same time
134
What are the Level 1 ASE recommendations for evaluation of AS?
* Peak velocity (AS jet) * Mean transaortic gradient * Valve area by the continuity equation using VTI's
135
Define the continuity equation in calculation of AS?
* AV AV = AV LVOT * ​AAV = AV LVOT / VAV * ​AAV = (d2 x 0.785 x V LVOT)/ VAV * VAV = VTIAV (obtained from CW doppler through AV) * VLVOT = VTILVOT (obtained from PW doppler through LVOT)
136
In the evaluation of measurement error for paradoxical LFLG AS, what are several ways to corroborate SV?
* Simpson's biplane method * 3D Echo * Teicholz formula * measure LV cavity size below septal bulge for accurate SV
137
What is one method of calculating SV that cannot be utilized with moderate or greater MR?
Teicholz formula
138
In regards to normal-flow, low gradient AS evaluations, what are the sources of error/problems in evaluating these patients?
* moderate AS * measurement error in SV and thus AVA * small BSA * AVA is small but AVAI \> 0.6 cm2 --\> moderate AS * severe AS * discordant grading * due to inconsistencies in the AVA-gradient cut-point values used in the guidelines
139
In regards to normal-flow, low gradient AS evaluations, what is the major limitation of stress echocardiography?
Flow is already normal
140
What is the MDCT calcium scoring cutoff for severity in evaluation of AS?
* Males: * calcium score \> 2000 AU * calcium load \> 500 AU/cm2 * Females: * calcium score \> 1200 AU * calcium load \> 300 AU/cm2
141
What is the VC severity scale in AR diagnosis?
* Mild = \< 0.3cm * Moderate = 0.3 - 0.6cm * Severe = \> 0.6cm
142
Describe the severity scale in diagnosis of AR: * jet width and cross-sectional area
* Mild = \< 25% * Moderate = 25-65% * Severe = \> 65%
143
What are the best views and velocity scale settings for diagnosis of AR?
* parasternal long axis (2D) or long axis - 120 (TEE) * Nyquist limit 50-60cm/s
144
What are the steps/parameters to evaluate AR severity?
* Specific signs * Jet width/LVOT width * Vena contracta * Diastolic flow reversal in descending aorta * Quantitative parameters * Regurgitant volumes * Regurgitant fraction * EROA * Supportive signs * Pressure-half time * LV dimensions (LVEDD, EF)
145
In addition to severity of AR what other parameters should be assessed/obtained in the evaluation?
* AS severity * AVA (using continuity equation) * Mean pressure gradient * Peak transvalvular velocity
146
Describe the severity scale in diagnosis of AR: * diastolic flow reversal
* Mild = no or brief early diastolic flow reversal in the descending aorta * obtained from suprasternal view * Severe = holodiastolic flow reversal in descending thoracic/abdominal aorta * obtained in suprasternal or subcostal view * **\> 25 cm/s** consistent with severe AR
147
* Severe AR * holodiastolic flow reversal obtained from TTE PW doppler at the suprasternal notch
149
* Moderate AR * CW doppler assessing pressure-half time of the regurgitant jet
150
Define AR pressure half-time?
measure of how quickly the aortoventricular pressure gradient equalizes during diastole
152
What are two factors that may influence PHT in AR?
* Systemic vascular resistance * Ventricular compliance
153
Describe the severity scale in diagnosis of AR: * Pressure-half time
* Mild = \> 500msec * Moderate = 200-500msec * Severe = \< 200 msec * or a decay slope of \> 3 m/sec2 \*\*Obtained using CW doppler
154
What are the quantitative measures of AR severity?
* Regurgitant volume * Regurgitant fraction * EROA
155
Describe the severity scale in diagnosis of AR: * Regurgitant volume
* Mild = \< 30 mL/beat * Moderate = 30 - 44 mL/beat * Moderately severe = 45 - 59 mL/beat * Severe = \> 60 mL/beat
156
Describe the severity scale in diagnosis of AR: * Regurgitant fraction
* Mild = \< 30% * Moderate = 30 - 39% * Moderately Severe = 40 - 49% * Severe = \> 50%
157
Describe the severity scale in diagnosis of AR: * EROA
* Mild = \< 0.10 cm2 * Moderate = 0.10 - 0.19 cm2 * Moderately Severe = 0.2 - 0.29 cm2 * Severe = \> 0.30 cm2
158
What is the recommended monitoring in patients with: * Mild MR * normal LV systolic function * near normal LV end-diastolic dimension
* Clinical exam yearly * Echo every 2-3 years
159
What is the recommended monitoring in patients with: * Severe MR * normal LV systolic function * evidence of LV dilatation (LV end-diastolic dimension \> 60mm)
* Clinical exam - 6 months * Echo - 6-12 months
160
What is the recommended monitoring in patients with: * Severe MR * normal LV systolic function * advanced LV dilatation (LVEDD \> 70mm, LVESD \> 50mm)
* Clinical exam - \< 6months * Echo - \< 6 months
161
What are the Class I indications for aortic valve replacement in Severe AR?
* Symptomatic (Stage D) * Asymptomatic (Stage C) * LV systolic dysfunction (EF \< 50%) - Stage C2 * Other Cardiac Surgery
162
What is the normal diameter: aortic annulus
* Men: 26 mm (+/- 3 mm) * Women: 23 mm ( +/- 2mm) * Indexed - 1.3 (+/- 1 cm/m2)
163
What is the normal diameter: aortic root/sinus of valsalva
* Men: 34 mm (+/- 3 mm) * Women: 30 mm ( +/- 3 mm) * Indexed - 1.7 (+/- 2 cm/m2)
164
* Prolapse of the distal right coronary cusp * TEE with scalloped appearance
165
What is the normal diameter: sinotubular junction (BSA index)
* Men: 29 mm (+/- 3 mm) * Women: 26 mm ( +/- 3 mm) * Indexed - 1.5 (+/- 2 cm/m2)
166
What is the normal diameter: proximal ascending aorta (BSA index)
* Men: 30 mm (+/- 4 mm) * Women: 27 mm ( +/- 4mm) * Indexed - 1.5 (+/- 3 cm/m2)
168
Describe the algorithm to distinguish mild or severe AR
1. Is the color Doppler width \< 25% of the LVOT width? * YES = Mild AI, if CW Doppler is also faint * No (or not central jet), continue to 2 2. What is the VC? * \< 0.3 cm = mild AI * \> 0.6 cm = SEVERE AI * 0.3 - 0.6 cm (or not obtainable), continue to 3 3. Is there *abdominal* aortic flow reversal with PW? * YES = SEVERE AI * NO, continue to 4 4. PW quantification? * RV \> 60% or RF \> 50% = SEVERE AI * NO (or unobtainable): consider other imaging modality or invasive evaluation.
169
* Diastolic flow reversal in the abdominal aorta and descending thoracic aorta * Supportive signs of severe AR
170
What finding on imeediate post-procedure intraoperative TEE would be the most strongly associated with the risk of recurrence of severe AR after AV repair?
distance of the cusp coaptation to the aortic annulus
171
What are the levels of severity in the jet width/LVOT ratio or JWR (jet/width ratio) for evaluation of AR?
* Mild * \< 25% * Moderate: * 25-44% (Grade II) * 45-64% (Grade III) * Severe * \> 65%
172
What is the downside of the JWR in evaluation of AR?
* Eccentric AR may be underestimated by this method * Should not be used with eccentric or multiple jets as it can overestimate severity with rapidly expanding jets
174
In what scenario may a patient have a PHT \>200ms and still have chronic, severe AR?
* PHT typically shortens with increasing severity of AR * However, as LV remodels and LV diastolic pressure decreases over time, a subject with severe chronic AR can have a PHT \> 200ms
175
What are two M-mode findings of AR (mainly acute)?
* **fluttering of the anterior mitral valve leaflet during diastole** * due to aortic regurgitant jet hitting the anterior leaflet * **premature closure of the MV** * due to increased LV diastolic pressure * an create murmur similar to MS --\> "Austin-Flint" murmur
176
What are common differences between acute and chronic AR?
* LV usually not dilated * Murmur and color jets not impressive * Vena contracta more reliable * Diagnosis on high clinical suspicion, context
177
What is the EF cutoff for symptomatic patients with AR and low EF?
Almost no cutoff * even EF \< 25% may benefit * prognosis without surgery very poor
178
* Severe AR effecting the MV on M-mode * diastolic fluttering of MV * premature diastolic closure (yellow)
179
What is the formula for Jet width ratio (%)?
Jet Width Ratio (%) = ((AR Jet Width (cm)/(LVOT Diameter (cm)) x 100
180
What is the formul for Jet Area/LVOT Area Ratio? What are the cutoffs?
* Jet Area Ratio (%) = ((AR Jet Area (cm2 )/(LVOT Area (cm2)) x 100 * Severity: * mild \< 5% * severe \> 60%
182
What type of remodeling takes place in chronic AR? Why is this important to assess?
* LV dilatation --\> eccentric hypertrophy * in order to normalize afterload and wall stress * Excessive LV dilatation and reduced LVEF may lead to LV fibrosis that will not undergo reverse remodeling even with AVR
183
In the assessment of AR, what are the class IIa recommendations for AVR?
* Severe AR - Asymptomatic (Stage C2) * LVEF ≥ 50% and * LVESD \> 50 mm (or indexed LVESD \> 25 mm/m2) * Progressive AR * Other Cardiac Surgery
184
In the assessment of AR, what are the class IIb recommendations for AVR?
* Severe AR - Asymptomatic (Stage C1) * LVEF ≥ 50% and * LVEDD \> 65 mm and * Low surgical risk
185
What is the initial medical therapy for acute AR?
* IV vasodilators (nitroglylcerin) * Afterload reduction * IV diuretics * to reduce congestion * IV inodilators (Dobutamine) * in cardiogenic shock * LV mechanical support * IABP contraindicated in more than mild AR \*\*\*Definitive therapy --\> surgery
186
What is the medical therapy for chronic AR?
* Class I * Treat hypertension (SBP \> 140 mmHg) * Vasodilators * Non-dihydropyridine CCB's or ACE/ARB's * Class IIa * Severe AR with LV dysfunction and HTN * ACE/ARBS and Beta-blockers \*\*\*\*Definitive therapy --\> surgery
187
What is the status of the LV in patients with chronic, severe AR?
* not normal * cannot be normal in this setting
188
What are the equation's to calculate regurgitant volume?
RV = EROA x ARVTI​ or RV = SVLVOT - SVMV
189
Describe the types of AR
190
Describe the algorithm for diagnosing chronic AR
191
What are the specific criteria for severe AR? How many criteria are required to make a diagnosis of severe AR?
* Large flow convergence * Enlarged LV with normal function * Flail valve * Central Jet * Jet width / LVOT width \> 65% * VC \> 0.6cm * PHT \< 200 ms * Holodiastolic flow reversal in descending/abdominal aorta * \> 4 required for diagnosis of severe AR
192
What are the specific criteria for mild AR? How many criteria are required to make a diagnosis of severe AR?
* Small or no flow convergence * Soft or incomplete jet by CW * Normal LV size * Jet width / LVOT width \< 25% * VC \< 0.3 cm * PHT \> 500 ms * \> 4 required for diagnosis of mild AR
193
Define AR Grade I
* Mild AR * EROA \< 0.1 cm2 * RV \< 30 mL * RF \< 30%
194
Define AR Grade II
* Moderate AR * EROA 0.10-0.19 cm2 * RV 30-44 mL * RF 30-39%
195
Define Grade III AR
* Moderate AR * EROA 0.20-0.29 cm2 * RV 45-59 mL * RF 40-49% \*\*\* May be severe if meets 3 specific criteria for severe AR
196
Define Grade IV AR
* Severe AR * EROA \> 0.3 cm2 * RV \> 60 mL * RF \> 50%
197
What is the next step in indeterminant AR?
* CMR * phase-contrast * TEE
198
What are some of the key physical exam findings of chronic AR?
* Wide pulse pressure * Bounding carotid pulses * Decrescendo murmur of AI * sit forward and hold breath-expiration
199
What are the class I recommendations for AVR in AS?
* Severe AS * Symptomatic (Stage D1) * Asymptomatic (Stage C) * LVEF \< 50% (C2) * Other Cardiac Surgery
200
What are the Class IIa recommendations for AVR in Severe AS?
* Asymptomatic (Stage C) * Abnormal ETT * Vmax ≥ 5 m/s + MG ≥ 60 mmHg + Low Surgical Risk
201
What are the Class IIa recommendations for AVR in Moderate-Severe AS?
* Symptomatic * LVEF \< 50% * DSE with: * AVA ≤ 1 cm2 and Vmax ≥ 4 m/s * LVEF \> 50% * AVA ≤ 1 cm2 and AS likely cause of symptoms * Asymptomatic (Stage B) * Other Cardiac Surgery
202
What are the Class IIb recommendations for AVR in Severe AS?
* Asymptomatic (Stage C) * ΔVmax \> 0.3 m/s/y and * Low surgical risk
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