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AS/AR Flashcards

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USMLE® Step 1 flashcards
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
Q

How is peak aortic velocity measured in AS?

A
  • continuous-wave Doppler US examined from multiple acoustic windows
    • to ensure stenosis severity is not underestimated
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26
Q

How is mean (transaortic) gradient measured in the evaluation of AS?

A
  • Calculated by averaging instantaneous gradients over the systolic ejection period using the Bernoulli equation
  • Bernoulli equation: ΔPmax = 4vmax2
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27
Q

What is the Bernoulli Equation?

A
  • ΔPmax = 4vmax2
  • ΔPmax = 4 (vmax2 – vproximal2)
    • proximal velocity should be included in equation when > 1.0 m/s
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28
Q

In what AS setting is AVA useful?

How is AVA calculated?

A
  • low-flow states
  • continuity equation
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29
Q

Define the continuity equation.

A

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
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30
Q

What is the recommended periodic monitoring for asymptomatic AS?

A
  • Mild –> every 3-5 years
  • Moderate –> every 1-2 years
  • Severe –> every 6-12 months
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31
Q

How are valve gradients calculated in the assessment of AS?

A
  • continuous wave (CW) Doppler with Doppler beam aligned as parallel as possible to flow
  • valve gradients are calculated using the maximum valvular velocity (Vmax)
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32
Q

What are ways in which stenosis is underestimated in Echo evaluation of AS?

A

misalignment of the US beam

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33
Q

How many positions should be obtained in the doppler assessment of AS?

What positions are preferred?

A
  • at least 3 windows (to obtain highest possible velocity)
    • LV apex
    • subcostal
    • RUSB
    • suprasternal notch
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34
Q

What is the Doppler pattern in valvular AS?

A
  • high-velocity flow beginning with AV opening
  • convex outward rising shape, peaking in mid systole, ending at AV closure
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35
Q

How is subaortic velocity (LVOT) obtained?

A
  • 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
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36
Q

What PHT correlates with:

  • mild AR
  • moderate AR
  • severe AR
A
  • 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
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37
Q

What are common associations with subaortic stenosis?

A
  • PDA
  • Pulmonary stenosis
  • VSD
  • Coarctation of the aorta
    • diagonsed with pulsed doppler of abdominal aorta
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38
Q

What is the best view for VC in the evalutation of AR?

A
  • 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
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39
Q

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?

A
  • TEE with careful inspection of pulmonary valve (pulmonary stenosis) and pulmonary artery (PDA)
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40
Q

Define how the continuity equation is utilized for regurgitant lesions?

What is the equation for this?

A
  • 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
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41
Q

What is the value of the suprasternal notch window in the evaluation of AR?

A
  • Doppler evaluation of flow reversals in the descending thoracic aorta
    • holodiastolic flow reversal is suggestive of severe AR
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42
Q

What is the Bernoulli (simplified) equation?

When should it be used?

A
  • 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
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43
Q

Why may maximum instantaneous AVG (which comes from Vmax) be higher than the peak-to-peak AVG?

A
  • Because the peak of aortic pressure often occurs later than the peak of LV pressure
  • “tardus and parvus”
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44
Q
A
  • 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
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45
Q

When may you see the use of velocity to calculate gradients in patients with AS lead to overestimation of AS severity?

A
  • small aortic root size –> overestimation of AS severity
  • Pressure-Recovery Phenomenon
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46
Q

Why are nonimaging probes used in the evaluation of AS?

A
  • smaller footprint
  • allows US interrogation from a deeper position (better penetrance)
  • better alignment of Doppler signal with direction of blood flow
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47
Q

What may result in elevated aortic valve velocities in the absence of significant valvular stenosis?

How can this be clarified?

A
  • High cardiac output
    • anemia, fever, subvalvular AS, significant vavlular regurgitation
  • Dimensionless Index “DI”
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48
Q

How is LVOT measured?

A
  • PLAX on 2D Echocardiogram
  • LVOT diameter measured in mid-systole
  • perpendicular to flow
  • 3-5 mm below the hinge points of the valve
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49
Q

What are causes of reduced flow states in severe AS?

A
  • LV dysfunction
  • RV dysfunction
  • Small LV cavity size (from increased LV hypertrophy)
  • MR
  • TR
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50
Q

What does a dobutamine echo help to distinguish in AS patients?

A
  • Pseudo-severe AS
  • Truly severe AS
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51
Q

Define “low-flow, low-gradient severe AS” effects with Dobutamine Echo?

A
  • Increase in flow –> gradients rise
  • AVA index remains low because the LVOT and valve velocities increase proportionally.
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52
Q

Describe “pseudo-severe” AS and the changes that take place during Dobutamine Echo.

A
  • 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
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53
Q

What is the grading scale for AS: Indexed AVA (cm2/m2)

A
  • Mild > 0.85 cm2/m2
  • Moderate 0.60-0.85 cm2/m2
  • Severe < 0.60 cm2/m2
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54
Q

What is the largest potential error in derivation of orifice size?

A
  • errors in measuring LVOT diameter
    • because it is squared in the calculation
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55
Q

What test is not indicated in paradoxical LF-LG severe AS?

What is the pathophysiology in these patients?

A
  • Dobutamine Echo
  • Normal LVEF but small cavity size –> low stroke volume
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56
Q

What can be done to avoid the error created with the assumption that the LVOT is circular (and not elliptical)?

A
  • Direct planimetry of the LVOT
    • 3D TEE
    • MSCT
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57
Q

What is one major limitation of the standard continuity equation in the evaluation of AS?

A
  • 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
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58
Q

What is the preferred site for LVOT measurement?

What may occur, preventing this measurement or location?

How can you fix this problem?

A
  • 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
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59
Q

What etiologies lead to LF-LG severe AS?

A
  • Low LVEF
  • Normal LVEF (paradoxical LF-LG severe AS)
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60
Q

What are some limitations to indexing AVA in LF-LG AS evaluations?

A
  • Obesity
    • current algorithms for defining body size (BSA) don’t reflect normal AVA in obese patients
    • AVA does not increase with excess body weight
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61
Q

What are positive results of Dobutamine Echo in LF-LG AS evaluation?

A
  • 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
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62
Q

What percentage of patients with BAV will have an abnormally dilated aortic root?

A

50%

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63
Q

What is one subgroup of patients with LF-LG AS who carries a very high mortality risk?

A
  • 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
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64
Q

This can influence peak velocity/mean gradients in AS evaluation and should be measured/recorded in every examination?

A

BP / Hypertension

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65
Q

What is valvuloarterial impedance (Zva)?

A
  • 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
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66
Q

What are factors that may influence SV during DSE evaluation of AS?

A
  • severity of AS
  • afterload mismatch
  • concomitant change in MR
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67
Q

What is useful in patients with low LVEF, low-flow, low-gradient AS?

A
  • Low-dose (up to 20 microgram/kg/min) DSE
    • class II recommendation
    • to assess AS severity and evaluate contractile reserve
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68
Q

When should contrast be utilized in evaluation of Low LVEF, LF-LG, severe AS patients?

A

two consecutive segments

or

< 80% myocardium is visible

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69
Q

What is a major factor that may result in decreased gradients in AS evaluation?

A
  • Hypertension
    • increase in LV afterload –> decrease in LV outflow and transvalvular gradients
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70
Q

What is the formula for projected AVA?

A

Q = SV/LV ejection time

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71
Q

Describe the algorithm for Classical LF-LG AS

A
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72
Q

Describe the algorithm for Paradoxical LFLG AS

A
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73
Q

Define Paradoxical LFLG AS

A
  • LVEF > 50%
  • AVA < 1.0 cm2
  • AVAI < 0.6 cm2/m2
  • MG < 40 mmHg
  • SVI < 35 ml/m2
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74
Q

Define Clasical LFLG AS

A
  • LVEF < 50%
  • AVA < 1.0 cm2
  • AVAI < 0.6 cm2/m2
  • MG < 40 mmHg
  • SVI < 35 ml/m2
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75
Q

What differentiates Classical and Pardoxical LFLG AS?

A
  • LVEF
    • Clasical LVEF < 50%
    • Paradoxical LVEF > 50%
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76
Q

What is the first step in the evaluation of Classical LFLG AS?

What is considered a positive test/result?

A
  • DSE
  • Increased SV (flow reserve) > 20%
    • True Severe (AVA < 1, MG > 40)
    • Pseudo-severe (AVA +/- 1, MG < 40)
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77
Q

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?

A

HF therapy

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78
Q

In the evaluation of Classical LFLG AS, with DSE resulting in increased SV (flow reserve) < 20%, what is the next step?

A
  • MDCT Calcium score
    • True Severe AS if Ca score:
      • male > 2000 (or Ca load > 500)
      • femal > 1200 (or Ca load > 300)
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79
Q

In the evaluation of Classical LFLG AS, with DSE resulting in increased SV (flow reserve) < 20%

  • what is the diagnosis and next step?
A
  • Pseudo-severe AS
  • HF therapy
80
Q

What is the first step in the evaluation of Paradoxical LFLG AS?

A
  • Evaluate sources of measurement error
    • SV
    • AVA
    • MG
81
Q

What is the stepwise progression in the evaluation of Paradoxical LFLG AS?

A
  • Measurement error
  • Symptoms
  • Hypertension
  • Stenosis severity
82
Q

What is the next step in the evaluation of Paradoxical LFLG AS with no measurement error?

A
  • Symptom evaluation (exercise testing)
  • Close follow up
83
Q

What is the next step in the evaluation of Paradoxical LFLG AS with no measurement error and positive symptoms on exercise testing?

A
  • Hypertension
    • treat hypertension and recheck quantitative measures when well controlled
84
Q

What is the next step in the evaluation of Paradoxical LFLG AS with:

  • no measurement error
  • positive symptoms on exercise testing
  • no hypertension
A
  • True severe
    • measurements correlate with AS
  • Pseudo-severe (indeterminant severity)
    • MDCT calcium score
    • DSE
85
Q

What are the windows that are utilized in obtaining peak aortic velocities?

A
  • Apical 3-chamber
  • Apical 5-chamber
  • Right parasternal
  • Suprasternal
86
Q

What is the grading scale for AS: Valvuloarterial impedance (Zva)

A
  • Mild < 3.5
  • Moderate 3.5-4.5
  • Severe > 4.5
87
Q

What is the grading scale for AS: Velocity ratio (DVI)

A
  • Mild > 0.50
  • Moderate 0.25.050
  • Severe < 0.25
88
Q

What can result in discordant measurements of AS:

  • AVA > 1 cm2
  • MG > 40 mmHg
  • PV > 4 m/s
A
  • High flow (transvalvular) states
    • AR (concomitant)
    • MR
    • Fever
    • Anemia
    • Hyperthyroidism
    • AV shunts (dialysis)
89
Q

What can effect the pull-back method on cardiac cath when evaluating AS severity?

A
  • Aortic compliance
    • markedly reduced when compliance is low
90
Q

In what patients does indexing AVA for LF-LG AS proven to be accurate?

A
  • Children
  • Adolescents
  • Small adults
91
Q

What can lead to underestimation of valvular stenosis severity with Doppler Echocardiography?

A

misalignment of the doppler beam

  • rarely overestimates velocities and gradients
92
Q

What determines the magnitude of pressure recovery?

When is pressure recovery clinically significant?

A
  • 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
Q

What is one pitfall of utilizing the right parasternal view in evaluating AS?

How can you avoid this?

A
  • 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
Q

What is the most probable etiology of a mobile, > 1 cm, aortic valve mass (on the LV side) in a 50 year old patient?

A
  • 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
Q

What is an important step in patients who are larger/smaller than average?

A
  • index the AVA to body surface area
    • helps to understand the magnitude of obstruction relevant to their body size
96
Q

What is Shone Complex associated with?

A
  • 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
Q

What percentage of patients evaluted for AS, are the highest velocities obtained in windows other than the apical ( 3 or 5) chamber views?

A
  • 30-35%
    • most often highest velocities are obtained from the right parasternal window
98
Q

What is the effect of the pull-back method in cardiac catheterization on peak velocity and mean gradient (in the evaluation of AS)?

A
  • Overestimation of severity
    • due to space occupied by the catheter within the aortic valve orifice during the measurementof the LV systolic pressure
99
Q

When is exercise stress testing contraindicated in severe AS?

A

symptoms are present (class III)

100
Q

What are the major differences in transvalvular pressure gradients obtained by cardiac cath and doppler echocardiography?

A
  • 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
Q

What is the cutoff to define low-flow patients with AS?

A

SVI = < 35 ml/m2

102
Q

What are alternative methods to measure LVOT SV?

A
  • 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
Q

What are limitations/problems with determining SV using the continuity equation in AS?

A
  • 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
Q
  • Define the Teicholz formula?
  • When is it used?
  • When can this formula not be used?
A
  • 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
Q

Define paradoxical LF AS

A
  • Normal LVEF
  • Low flow state = MG, PV which are not severe
106
Q

What percentage of asymptomatic, severe AS patients actually will demonstrate exercise limiting symptoms during exercise stress testing?

A

30%

107
Q

How is stroke volume calculated from VTI measurements?

A
  • SV = VTILVOT x AreaLVOT
  • Can be divided by BSA to obtain SV index (SVI)
108
Q

What are indications for more frequent interval Echo monitoring in AS?

A
  • 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
Q

What conditions may impact the hemodynamics of LVOTO?

What is used as a better portrayal of AS severity?

A
  • Variations in loading conditions –> lower LVOT gradient
    • low CO
    • high HR
  • AVA or AVAI
110
Q

What are the goals of DSE in low LVEF, LF-LG AS patients?

A
  • 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
Q

Why is echocardiographic evaluation of peak gradients superior to peak-to-peak gradients measured in cardiac catheterization?

A
  • 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
Q

What is the AS Severity scale - Aortic jet velocity m/s (peak velocity)?

A
  • 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
Q

What is the AS Severity scale - Mean Gradient mmHg?

A
  • Mild = < 20 mmHg
    • < 30 mmHg by ESC
  • Moderate = 20 - 40 mmHg
    • 30 - 50 mmHg by ESC
  • Severe = > 40 mmHg
    • > 50 mmHg by ESC
114
Q

What is the AS Severity scale - AVA cm2?

A
  • Mild = > 1.5 cm2
  • Moderate = 1.0 - 1.5 cm2
  • Severe = < 1.0 cm2
115
Q

What is the AS Severity scale - indexed AVA cm2/m2?

A
  • Mild = > 0.85 cm2/m2
  • Moderate = 0.6 - 0.85 cm2/m2
  • Severe = < 0.6 cm2/m2
116
Q

What is the diagnosis/severity of AS:

  • MG 45mmHg
  • PV 4.2m/s
  • AVA 1.32 cm2
A

severe AS

117
Q

What is the diagnosis/severity of AS:

  • MG 36mmHg
  • PV 3.7m/s
  • AVA 0.9 cm2
  • LVEF < 50%
A

Low-flow, low-gradient AS

  • will need low-dose dobutamine stress echo
118
Q

In the evaluation of AS, when discordant AVA and MG, what are possible explanations/diagnoses?

A
  • 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
Q
  • In evaluation of AS, what is the formula for diminisionless index?
  • What is the cutoff that indicates severe AS?
A
  • DI = LVOTVTI / AVVTI
  • < 0.25
120
Q

What are signs of an effective DSE when evaluating AS severity?

A

SV increase by 20%

121
Q

What is the most common cause of low gradient AS with a normal EF?

A

Hypertrophied LV with reduced LV volume

122
Q

CT calcium score that indicates severe AS?

A
  • Males = > 2,000
    • Ca load > 500
  • Females = > 1,200
    • Ca load > 300
123
Q

Patients with subvalvular aortic stenosis are often misdiagnosed as this?

A

hypertrophic obstructive cardiomyopathy

124
Q

What is the best test to confirm a diagnosis of subvalvular aortic stenosis (if suspected)?

A

TEE –> excellent vies of the LVOT

125
Q

Subvalvular Aortic stenosis may present as part of this complex?

A

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
Q

Supravalvular AS is a rare form of aortic valve stenosis associated with this syndrome

A

Williams Syndrome (71%)

  • supravalvular AS
  • intellectual disabilities
  • connective tissue abnormalities
  • hypercalcemia
127
Q

What are the AS quantification methods by 2-D Echo?

A
  • 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
Q

What are common aortopathy’s associated with Bicuspid aortic valve?

A
  • Sinus of valsalva
  • Ascending aorta
  • Aortic coarctation
129
Q

What are the indications for surgery in pateints with ascending aortic aneurysm and BAV?

A
  • > 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
Q

What is the common finding in patients with BAV + HTN?

What will doppler wave of descending aorta show?

A
  • Coarctation of the aorta
  • Saw tooth pattern
131
Q

In the evaluation of AS, how many acoustic windows should be sampled to ensure that the highest velocity signal is obtained?

A

at least 3 acoustic windows

132
Q

What is the additional probe utilized in evaluation of AS?

How does the probe differ?

A
  • 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
Q

What is the difference in gradients between cath and 2D echo (doppler)?

A
  • 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
Q

What are the Level 1 ASE recommendations for evaluation of AS?

A
  • Peak velocity (AS jet)
  • Mean transaortic gradient
  • Valve area by the continuity equation using VTI’s
135
Q

Define the continuity equation in calculation of AS?

A
  • 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
Q

In the evaluation of measurement error for paradoxical LFLG AS, what are several ways to corroborate SV?

A
  • Simpson’s biplane method
  • 3D Echo
  • Teicholz formula
    • measure LV cavity size below septal bulge for accurate SV
137
Q

What is one method of calculating SV that cannot be utilized with moderate or greater MR?

A

Teicholz formula

138
Q

In regards to normal-flow, low gradient AS evaluations, what are the sources of error/problems in evaluating these patients?

A
  • 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
Q

In regards to normal-flow, low gradient AS evaluations, what is the major limitation of stress echocardiography?

A

Flow is already normal

140
Q

What is the MDCT calcium scoring cutoff for severity in evaluation of AS?

A
  • Males:
    • calcium score > 2000 AU
    • calcium load > 500 AU/cm2
  • Females:
    • calcium score > 1200 AU
    • calcium load > 300 AU/cm2
141
Q

What is the VC severity scale in AR diagnosis?

A
  • Mild = < 0.3cm
  • Moderate = 0.3 - 0.6cm
  • Severe = > 0.6cm
142
Q

Describe the severity scale in diagnosis of AR:

  • jet width and cross-sectional area
A
  • Mild = < 25%
  • Moderate = 25-65%
  • Severe = > 65%
143
Q

What are the best views and velocity scale settings for diagnosis of AR?

A
  • parasternal long axis (2D) or long axis - 120 (TEE)
  • Nyquist limit 50-60cm/s
144
Q

What are the steps/parameters to evaluate AR severity?

A
  • 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
Q

In addition to severity of AR what other parameters should be assessed/obtained in the evaluation?

A
  • AS severity
    • AVA (using continuity equation)
    • Mean pressure gradient
    • Peak transvalvular velocity
146
Q

Describe the severity scale in diagnosis of AR:

  • diastolic flow reversal
A
  • 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
Q
A
  • Severe AR
    • holodiastolic flow reversal obtained from TTE PW doppler at the suprasternal notch
149
Q
A
  • Moderate AR
    • CW doppler assessing pressure-half time of the regurgitant jet
150
Q

Define AR pressure half-time?

A

measure of how quickly the aortoventricular pressure gradient equalizes during diastole

152
Q

What are two factors that may influence PHT in AR?

A
  • Systemic vascular resistance
  • Ventricular compliance
153
Q

Describe the severity scale in diagnosis of AR:

  • Pressure-half time
A
  • Mild = > 500msec
  • Moderate = 200-500msec
  • Severe = < 200 msec
    • or a decay slope of > 3 m/sec2

**Obtained using CW doppler

154
Q

What are the quantitative measures of AR severity?

A
  • Regurgitant volume
  • Regurgitant fraction
  • EROA
155
Q

Describe the severity scale in diagnosis of AR:

  • Regurgitant volume
A
  • Mild = < 30 mL/beat
  • Moderate = 30 - 44 mL/beat
  • Moderately severe = 45 - 59 mL/beat
  • Severe = > 60 mL/beat
156
Q

Describe the severity scale in diagnosis of AR:

  • Regurgitant fraction
A
  • Mild = < 30%
  • Moderate = 30 - 39%
  • Moderately Severe = 40 - 49%
  • Severe = > 50%
157
Q

Describe the severity scale in diagnosis of AR:

  • EROA
A
  • Mild = < 0.10 cm2
  • Moderate = 0.10 - 0.19 cm2
  • Moderately Severe = 0.2 - 0.29 cm2
  • Severe = > 0.30 cm2
158
Q

What is the recommended monitoring in patients with:

  • Mild MR
  • normal LV systolic function
  • near normal LV end-diastolic dimension
A
  • Clinical exam yearly
  • Echo every 2-3 years
159
Q

What is the recommended monitoring in patients with:

  • Severe MR
  • normal LV systolic function
  • evidence of LV dilatation (LV end-diastolic dimension > 60mm)
A
  • Clinical exam - 6 months
  • Echo - 6-12 months
160
Q

What is the recommended monitoring in patients with:

  • Severe MR
  • normal LV systolic function
  • advanced LV dilatation (LVEDD > 70mm, LVESD > 50mm)
A
  • Clinical exam - < 6months
  • Echo - < 6 months
161
Q

What are the Class I indications for aortic valve replacement in Severe AR?

A
  • Symptomatic (Stage D)
  • Asymptomatic (Stage C)
    • LV systolic dysfunction (EF < 50%) - Stage C2
    • Other Cardiac Surgery
162
Q

What is the normal diameter: aortic annulus

A
  • Men: 26 mm (+/- 3 mm)
  • Women: 23 mm ( +/- 2mm)
  • Indexed - 1.3 (+/- 1 cm/m2)
163
Q

What is the normal diameter: aortic root/sinus of valsalva

A
  • Men: 34 mm (+/- 3 mm)
  • Women: 30 mm ( +/- 3 mm)
  • Indexed - 1.7 (+/- 2 cm/m2)
164
Q
A
  • Prolapse of the distal right coronary cusp
  • TEE with scalloped appearance
165
Q

What is the normal diameter: sinotubular junction (BSA index)

A
  • Men: 29 mm (+/- 3 mm)
  • Women: 26 mm ( +/- 3 mm)
  • Indexed - 1.5 (+/- 2 cm/m2)
166
Q

What is the normal diameter: proximal ascending aorta (BSA index)

A
  • Men: 30 mm (+/- 4 mm)
  • Women: 27 mm ( +/- 4mm)
  • Indexed - 1.5 (+/- 3 cm/m2)
168
Q

Describe the algorithm to distinguish mild or severe AR

A
  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
Q
A
  • Diastolic flow reversal in the abdominal aorta and descending thoracic aorta
  • Supportive signs of severe AR
170
Q

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?

A

distance of the cusp coaptation to the aortic annulus

171
Q

What are the levels of severity in the jet width/LVOT ratio or JWR (jet/width ratio) for evaluation of AR?

A
  • Mild
    • < 25%
  • Moderate:
    • 25-44% (Grade II)
    • 45-64% (Grade III)
  • Severe
    • > 65%
172
Q

What is the downside of the JWR in evaluation of AR?

A
  • 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
Q

In what scenario may a patient have a PHT >200ms and still have chronic, severe AR?

A
  • 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
Q

What are two M-mode findings of AR (mainly acute)?

A
  • 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
Q

What are common differences between acute and chronic AR?

A
  • LV usually not dilated
  • Murmur and color jets not impressive
  • Vena contracta more reliable
  • Diagnosis on high clinical suspicion, context
177
Q

What is the EF cutoff for symptomatic patients with AR and low EF?

A

Almost no cutoff

  • even EF < 25% may benefit
  • prognosis without surgery very poor
178
Q
A
  • Severe AR effecting the MV on M-mode
    • diastolic fluttering of MV
    • premature diastolic closure (yellow)
179
Q

What is the formula for Jet width ratio (%)?

A

Jet Width Ratio (%) = ((AR Jet Width (cm)/(LVOT Diameter (cm)) x 100

180
Q

What is the formul for Jet Area/LVOT Area Ratio?

What are the cutoffs?

A
  • Jet Area Ratio (%) = ((AR Jet Area (cm2 )/(LVOT Area (cm2)) x 100
  • Severity:
    • mild < 5%
    • severe > 60%
182
Q

What type of remodeling takes place in chronic AR?

Why is this important to assess?

A
  • 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
Q

In the assessment of AR, what are the class IIa recommendations for AVR?

A
  • Severe AR - Asymptomatic (Stage C2)
    • LVEF ≥ 50% and
    • LVESD > 50 mm (or indexed LVESD > 25 mm/m2)
  • Progressive AR
    • Other Cardiac Surgery
184
Q

In the assessment of AR, what are the class IIb recommendations for AVR?

A
  • Severe AR - Asymptomatic (Stage C1)
    • LVEF ≥ 50% and
    • LVEDD > 65 mm and
    • Low surgical risk
185
Q

What is the initial medical therapy for acute AR?

A
  • 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
Q

What is the medical therapy for chronic AR?

A
  • 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
Q

What is the status of the LV in patients with chronic, severe AR?

A
  • not normal
    • cannot be normal in this setting
188
Q

What are the equation’s to calculate regurgitant volume?

A

RV = EROA x ARVTI​

or

RV = SVLVOT - SVMV

189
Q

Describe the types of AR

A
190
Q

Describe the algorithm for diagnosing chronic AR

A
191
Q

What are the specific criteria for severe AR?

How many criteria are required to make a diagnosis of severe AR?

A
  • 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
Q

What are the specific criteria for mild AR?

How many criteria are required to make a diagnosis of severe AR?

A
  • 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
Q

Define AR Grade I

A
  • Mild AR
    • EROA < 0.1 cm2
    • RV < 30 mL
    • RF < 30%
194
Q

Define AR Grade II

A
  • Moderate AR
    • EROA 0.10-0.19 cm2
    • RV 30-44 mL
    • RF 30-39%
195
Q

Define Grade III AR

A
  • 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
Q

Define Grade IV AR

A
  • Severe AR
    • EROA > 0.3 cm2
    • RV > 60 mL
    • RF > 50%
197
Q

What is the next step in indeterminant AR?

A
  • CMR
    • phase-contrast
  • TEE
198
Q

What are some of the key physical exam findings of chronic AR?

A
  • Wide pulse pressure
  • Bounding carotid pulses
  • Decrescendo murmur of AI
    • sit forward and hold breath-expiration
199
Q

What are the class I recommendations for AVR in AS?

A
  • Severe AS
    • Symptomatic (Stage D1)
    • Asymptomatic (Stage C)
      • LVEF < 50% (C2)
      • Other Cardiac Surgery
200
Q

What are the Class IIa recommendations for AVR in Severe AS?

A
  • Asymptomatic (Stage C)
    • Abnormal ETT
    • Vmax ≥ 5 m/s + MG ≥ 60 mmHg + Low Surgical Risk
201
Q

What are the Class IIa recommendations for AVR in Moderate-Severe AS?

A
  • 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
Q

What are the Class IIb recommendations for AVR in Severe AS?

A
  • Asymptomatic (Stage C)
    • ΔVmax > 0.3 m/s/y and
    • Low surgical risk

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