Aortic Stenosis Flashcards
Label the image
What is the valve ring?
Point of attachment of the cusps to the root wall
What is the sinus of valsalva?
Aorta cusps Rees’s into the sinus during systole
What is the sino-tubular junction?
Where the sinus of Valsalva becomes the tubular portion of the aorta
How do we get the measurement of the aortic root?
Measure from leading ledge to leading edge.
When is it common to see during aortic stenosis?
Post stenotic dilation
In terms of aortic commissaries, most age related calcification starts where? and how doe sit move?
At the the commissures and it works its way along the free edge to the valve orifice
Label the image
- Star: Aortic commissures
- Arrows: Free edge to the cusps
- Circle: Valve orifice
What is aortic stenosis?
Incomplete opening of the aortic valve during systole leading to a high velocity jet
What do we normally see during aortic stenosis in terms of the leaflets?
Thickened and tethered leaflets
What does the thickened and tethered leaflets cause?
Obstruction to flow from the LV to the Ao
What are signs/symptoms of AS?
- Mild- mod AS is rarely felt when it is isolated
- Symptoms are related to the pathophysiological responses to AS
In terms of AS what are symptoms related to the pathophysiological resonates to AS? 5
- exertional dyspnea/ SOB
- Fatigue
- Angina
- Signs of CHF
- Systolic thrill
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What is seen with a harsh ejection murmur? Where is it seen? 3
- Crescendo- decresendo
- RUSB
- May radiate to the carotid arteris
What is seen with auscultation? 4
- Harsh ejection murmur
- Systolic ejection click
- S4
- Ao regurgitation murmur
What are the manifestations of severe AS? (Signs) 3
- Angina
- Syncope
- CHF
What happens with Angina pectorals (chest pain/ CP)? 3
- Exacerbated by LVH (most muscle = more O2 demand)
- Compressions of intramyocardial arteries from high LV cavity pressure e
- Reduced coronary artery perfusion pressure withAS
What is syncope or presyncope (fainting)?
Reduced ability of the heart to maintain cerebral perfusion pressure through the stenotic valve
What does syncope or presyncope happen with?
Usually with exertion
What are CHF symptoms? 4
- Dyspnea
- Fatigue
- Cough
- Weight gain (fluid retention)
What is the role of echo is AS? 6
- Assess AV in 2D
- Determine etiology of the stenosis
- Exclude other sources of LVOT obstruction
- Assess LV size, systolic/ diastolic function
- Estimate severity of stenosis
- Identify associated valve lesions
In terms of Aortic valve assessment in 2D what do we look for? 5
- Equal opening/ coapt action of cusps
- Number of commissures when open
- Coronary implantation
- Degree of movement
- Morphological changes
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What are some examples of morphological changes? 4
- Artheroslerosis
- Calcium (shadow)
- Commissures fusion
- Post stenosis dilation
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What are some 2D calcific changes we need to take note of when we scan the aortic valve? 3
- Bright echoes at cusp commissures
- How many cusps
- The more stenotic the AV is, the harder it is to tell # of cusps
In terms of determining etiology of the stenosis what are the three categories we will look for? 3
- Congenital
- Degenerative
- Rheumatic
What is the order of incidence for aortic stenosis etiology? 3
- Calcific AS
- Congenital (Bicuspid)
- Rheumatic
For those under the age of 70 with the most common etiology for AS?
Bicuspid and it occurs 50% of the time with AS
For those over the age of 70, what is the most common etiology of AS?
Degenerative which occurs 48% of the time
What is the epidemiology of calcific/ degenerative etiology? How many of these will develop aortic stenosis?
- Above 25% of all adults over 65 will have some degree of aortic sclerosis
- 10-15%
M- mode often is ______ but handy when 2D is limited looking for AS
Overlooked
Label the M mod for 2 stenosis
- Leaflet excursion ~2.0cm
- Diastolic closure line - normally at middle of aortic annulus
What does this image demonstrate?
M- Mode with severe AS
What do we see with AV sclerosis? 4
- Some thickening and calcification (brightening of the cusps)
- Slight reduction of cusp excursion may be present
- CW doppler velocity through AV normal or slightly elevated
- <2.5 m/s
What do we see with AV stenosis? 4
- Most obvious thickening and calcification of cusps
- Obvious visual reduction of cusp excursion
- CW doppler velocity elevated through the AV
- >2.5 m/s
What is the ratio of Male to female having bicuspid AV?
3:1
What is a bicuspid AV? What does it look like? And how do we get it? 3
- Only 2 leaflets, or fused leaflets
- Football shaped
- May be inherited
Bicuspid AV is most common type of AS in patients in what demographic?
Under 50 years old
How often do we see Bicuspid AV?
1-2% of the general population
What is the structure of the Bicuspid AV? 3
- Multiple configurations possible
- Bicuspid with raphe or with raphe
- raphe: seam that joins two cusps together
What is the Cuspal fusion rates for the bicuspid valve? 2
- 85% RCC and LCC
- 15% RCC and NCC
What does this image demonstrate?
Raphe
What are some AV findings in a bicuspid AV? 4
- Thickened Leaflets
- Eccentric closure (M-mode)
- Normal valve excursion
- Systolic doming of the larger cusps (PLAX)
What view is best for viewing bicuspid AV?
PSAX
What are associated anomalies with Bicuspid valve? 3
- Post stenotic aortic root dilatation/ aneurysm/ Dissection Typically asc dilatation
- LVH
- Congenital (coarctation, other supravalvular narrowing, VSD)
What is an eccentric closure line?
When there is a bicuspid AV valve and it pulls the leaflets down and it closes way closer to one side of the LVOT
Rheumatic AS is caused by what?
Scarring form rheumatic fever
In terms of excluding other sources of LVOT obstruction, what are the three things we look for? 3
- Subvalvular
- Supravalvular
- HOCM
What is the possible location of supra- valvular? 2
- Membrane shelf in Ao
- Narrowing in ASC/Arch/ Desc Ao
What are possible valvular obstructions? 3
- Calcific
- Congenital
- Rheumatic
Where are subvalvular obstructions found? 2
- Membrane
- Muscular IVS (Hypertrophic cardiomyopathy)
What does Subaortic- LVOT obstructions consist of? 3
- Associated with Hypertrophic cardiomyopathy (HCM)
- Asymmetric septal hypertrophy (ASH)
- Systolic anterior motion (SAM) of AMVL
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When we assess LV size, systolic diastolic function what do we look for? 4
- Walls
- LV chamber
- LV systolic function
- LV diastolic function
When we do a LV assessment what do we look for in terms of the Wall? 3
- Is there LVH due to high afterload?
- Measure IVS/ LVPW
- LV trace PSAX
In terms of LV assessment, what do we look for? 2
- Dilated LV as disease progresses
- Measure LVID
What do we look for in terms of LV systolic function in terms of LV assessment? 2
- Decreases EF as disease progresses
- Measure Simpsons EF
What do we look for in terms of LV diastolic function in terms of LV assessment?
- Measurement of diastolic functions
What is the AS afterload effect on LV? 4
- Outflow obstruction»_space;» increasing afterload
- LV Systolic pressure rises
- To keep SV normal»_space;»> increase force of contraction
- LVH develops (concentric) due to pressure overload
What are the hemodynamics parameters for AS severity? 5
- Peak velocity
- Mean pressure gradient
- Aortic valve area
- Indexed aortic valve area
- Dimensionless velocity ratio
When would we use planimetry?
May be used if doppler parameters are difficult
What is a reason why we tend to look away from planimetry? 2
- Not very accurate
- Tends to overestimate AVA
What do we trace during planimetry?
The orifice in mid systole
What is hard to do with planimetry?
Trace calcified valves
What does planimetry helps us do?
Produces a valve area
What are AV spectral assessment locations? 5
- Apical
- RT suprasternal
- SSN
- RT parasternal
- +/- subcoastal
When getting a AV spectral assessment what happens if AV velocity is >2.0 m/s? 5
Always use the Pedro probe (CW) to assess velocities of at least two of the list.
- Apical
- RT suprasternal
- SSN
- RT parasternal
- +/- Subcoastal
What probe is a blind probe?
Pedoff probe
Why would we use a pedoff probe? 3
- Higher signal to noise ratio
- Better access to small intercostal spaces
- Does not bias operator to 2D windows
Pedoff is all about getting what degree angle? If we want higher velocities what do we need to do? 2
- 0 degree angle
- To get higher, more accurate velocities
What is the best window for pedoff?
A5C
What is the process for Pedoff probe?
Find the idea view with normal probe, then switch to pedoff
When using a pedoff probe what window do we utilize?
A blind window
What are some of the blind windows for pedoff probes? Why are these better locations? 3
- RT parasternal
- RT clavicular
- SSN
The highest velocities may be found from any of these locations
When using the blind windows which valves do we use for calculations?
The highest velocities and VTI for calcs
In terms of AV spectral assessment locations, how many sample sites and what velocity are we looking for? 2
- High velocity for multiple views on the same patient
- Need to sample from multiple views on every AS patient
Where does AS and Mitral regurgitation appear on the baseline?
They both appear below the baseline in the approximate region in the apical view
Subaortic stenosis will be picked up in which what? How does it look?
- Picked up in A5C CW
- Much different spectral profile
What does a subarctic stenosis present like? (Velocity wise) 2
- Late peaking profile
- Very high velocity
What does a severe AS present like spectrally? 2
- Acceleration = Deceleration time
- Symmetrical waveform
What is the timing like in terms of AS? When is it seen? 4
- No flow displayed during either isovolumic period
- Only seen when AV is open
- Starts later and ends earlier than MR
- Typically a more pointed profile (V shape) than MR
What is the MR timing present like? When is it seen?3
- Flow seen during both IVCT and IVRT
- Only seen when MV is closed
- Typically has a more rounded peak (parabolic) and higher velocity
What happens with AS with low EF?
Low EF cannot generate enough force to push the blood out through AV with high gradient/ velocity
Gradients will be artificially low with what diseases? 2
- Ischemia heart disease
- Coronary arterial disease
What does AS with high EF present like?
Higher than normal EF increases force of contraction
What are somethings we see with High EF? 5
- Fever
- Hyperbole is
- Pregnancy
- LV overload due to Mod-sev AI
- Gradients will be artificially high
