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ECHO 325 > Aortic Stenosis > Flashcards

Aortic Stenosis Flashcards

1
Q

What are the levels of AS obstruction and their causes?

A
  1. Supravalvular - membrane, shelf in AO
  2. Valvular - calcific, congenital, rheumatic
  3. Subvalvular - Membrane, muscular IVS
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2
Q

What are the 3 ways to calculate pressure gradients?

A
  1. Instantaneous - single point in time
  2. Peak to peak - two points in time
  3. Mean - Average
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3
Q

What is the formula for Mean/Average pressure gradient?

A

Pmean = 2.4 x (Vmax)^2

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4
Q

Describe the effect of AS effect on the LV? (4 steps)

A
  1. AS obstruction increases afterload
  2. LV systolic pressure increases
  3. Force of contraction increases
  4. LV concentric hypertrophy due to pressure overload
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5
Q

What does AS lead to?

A

CHF

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6
Q

How does AS lead to CHF? (7 steps)

A
  1. SV decreases
  2. Afterload increases
  3. LV stiffness and compliance increase
  4. LV filling pressures increase
  5. LA size and pressure increase
  6. Pulmonary congestion
  7. RV failure
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7
Q

What are the inter-leaflet triangles and what are the names?

A

Extensions of the LVOT that extend up to the STJ and provide a smooth surface for blood flow.

  1. R/L coronary interleaflet triangle
  2. R/Non coronary interleaflet triangle
  3. Non/L coronary interleaflet triangle
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8
Q

How does ASE recommend measuring the aorta?

A

Leading to leading at the sinus, STJ and ascending aorta

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9
Q

How can you find the change in pressure between the LV and AO with Bernoulli?

A

Change in P = 4(V2^2 - V1^2)

Or

Change in P = 4V^2

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10
Q

What are the symptoms of AS? (6)

A
  • SOBOE
  • Fatigue
  • Chest pain/Palpitations
  • Arrhythmias
  • Dizziness/Syncope
  • Signs of CHF (edema etc.)
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11
Q

What are the clinical signs of AS? (4)

A
  1. Auscultation
  2. Angina Pectoris
  3. Presyncope/Syncope
  4. CHF
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12
Q

What auscultation may be heard with AS and where?

A
  1. Harsh ejection murmur
  2. AO regurgitation murmur (if regurg is present)

Heard in right upper sternal border

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13
Q

Why does AS cause Angina Pectoris? (3)

A
  1. Reduced coronary artery profusion
  2. LV hypertrophy (more muscle = more O2 demand and more pressure)
  3. Increased contraction and decreased relaxation causes compression of the intramyocardial arteries
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14
Q

Why does AS cause Presyncope/Syncope?

A

Reduced cerebral perfusion with exertion.

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15
Q

What is the most common order of AS etiology in patients > 70 years?

A
  1. Calcific/Degenerative
  2. Congenital/Bicuspid
  3. Rheumatic
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16
Q

Where does thickening start with calcific AS?

A

Underside of cusps/commissures

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17
Q

Where does thickening start with rheumatic AS?

A

Free edges/tips of the cusps

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18
Q

What are 3 types of congenital AS?

A

Bicuspid, Unicuspid, Quadricuspid

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19
Q

What is the most common order of AS etiology in patients < 70 years?

A
  1. Congenital/Bicuspid
  2. Rheumatic
  3. Calcific/Degenerative
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20
Q

How often does aortic sclerosis develop into AS?

A

10-15%

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21
Q

What causes calcific/degenerative AS?

A

Atherosclerotic process (lipid deposits, smoking, stress, obesity, lack of exercise).

22
Q

What are the steps in the development of calcific AS? (4)

A
  1. Endothelial damage (force, BP increase, reduced function with age)
  2. Cells stop producing gasses that prevent clotting and inflammation
  3. Foam cells infiltrate tissue (fatty macrophages)
  4. Inflamm/necrosis/calcification/narrowing occurs
23
Q

How do you assess the AV in m-mode?

A
  1. Look for diastolic closure line between boxes (valve opening)
  2. Measure leaflets at least 2 cm apart during systole (box height)
24
Q

How do you assess the AV in 2D? (6)

A
  1. PLAX LV/LA/AO measurements
  2. Calc LV mass index
  3. Calc EF
  4. Observe valve opening/coaptation
  5. 3 cusps
  6. Observe walls/cavity
25
Q

What is the difference between AV sclerosis and stenosis?

A

Sclerosis = Some thickening/calcification and a normal CW velocity

Stenosis = Obvious thickening/calcification and an abnormal CW velocity

26
Q

What is the NV for CW velocity of the AV?

A

< 2.5 m/s

27
Q

What is a raphe?

A

The seam that joins two cusps together in a bicuspid valve (bicupid may or may not have a raphe tho).

28
Q

What are the most common bicuspid cuspal fusions?

A

85% RCC and NCC

15% RCC and LCC

29
Q

What are 5 common signs of bicuspid valve?

A
  1. Thick cusps with doming
  2. Off centre cusp closure m-mode or PLAX
  3. Systolic doming of larger cusp
  4. Concentric LVH and LV/LA dilation
30
Q

What are the 3 most common associations of bicuspid?

A
  1. Sub/supra valvular congenital membranes
  2. Supravalvular coarctation (AO)
  3. Subvalvular LVOT obstuction (due to HCM- septal LVH or SAM)
31
Q

What causes Rheumatic AS?

A
  1. Rheumatic fever caused by beta-hemolytic streptococci

2. Endocardium swells and damages the valve

32
Q

What valves does rheumatic affect from most to least?

A

MV = 75 - 80%
AV = 20 - 25%
PV and TV = 5%

33
Q

What is the cause of acute and chronic rheumatic heart disease?

A

Acute = Caught fever travelling

Chronic = Had fever as child, effects manifest later

34
Q

What are the two methods to calculate AVA and what is more accurate?

A
  1. Planimetry
  2. Continuity equation

Continuity = more accurate

35
Q

What is the continuity of flow and what is needed to calculate?

A

The volume of flow proximal to and within the narrowing must be equal (SV LVOT = SV AV)

  1. LVOT diameter (PLAX)
  2. PW LVOT VTI trace
  3. CW AV VTI trace (highest, most parallel signal)
36
Q

What is the AVA formula?

A

AVA = ( (0.785 x LVOT d^2) x VTI LVOT ) / VTI AV

37
Q

What is the normal value for LVOT?

A

18 - 22 mm

38
Q

Where should the PW VTI be measured in the AO?

A

Same spot as LVOT measurement

39
Q

What are the two methods of AVA by the continuity equation?

A
  1. AVA by velocity only

2. AVA by VTI

40
Q

What is the diff between velocity continuity method and VTI method?

A

Velocity = Plug in velocities instead of VTI’s

41
Q

When the AV velocity is greater than 2.5 m/s what should be done? (5)

A

Assessment in ALL views:

  1. Apical
  2. Rt suprasternal
  3. Rt supraclavicular
  4. Rt parasternal
  5. +/- subcostal
42
Q

How is the velocity and VTI ratio calculated?

A

VTI ratio = LVOT VTI / AV VTI

Velocity ratio = LVOT vel / AV vel

43
Q

How can you tell if you are catching MR vs AS on continuous wave?

A

AS will not have flow during isovolumic periods and MR will.

With true AS, a small space will be seen between jet outflow below baseline and MV inflow above baseline.

44
Q

How does subaortic stenosis outflow differ from severe AS?

A

Subaortic => Late peaking profile (dagger sign wave) and high velocity

Severe AS => Acceleration time = Deceleration time (more symmetrical than normal outflow wave)

45
Q

What AV jet velocity indicates only sclerosis?

A

≤ 2.5 m/s

46
Q

What AV jet velocity indicates mild and severe AS?

A

Mild = 2.5 - 2.9 m/s

Severe = >4.0

47
Q

What mean gradient indicated mild and severe AS?

A

Mild = < 20 mmHg

Severe = > 40 mmHg

48
Q

What AVA indicates mild and severe AS?

A

Mild = >1.5 cm^2

Severe = < 1.0 cm ^2

49
Q

What is indexed AVA?

A

Comparing the AVA to height and weight

AVA/BSA

50
Q

What indexed AVA indicated mild and severe AS?

A

Mild = > 0.85 cm^2/m^2

Severe = < 0.6 cm^2/m^2

51
Q

What velocity ratio indicates mild and severe AS?

A 
Mild = > 0.5 
Severe = < 0.25

ECHO 325 (19 decks)

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