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Annette Vegas TEE Notes > Ch 10 Aortic Valve, Stenosis, and insufficiency > Flashcards

Ch 10 Aortic Valve, Stenosis, and insufficiency Flashcards

1
Q

What are the 3 components of the aortic root?

A
  1. Aortic Valve
  2. Sinus of Valsalva
  3. Interleaflet Triangles
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2
Q

What are all the names (List 4) of the 3 aortic cusps?

A

Cusps

Leaflets

Scallops

Valvules

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3
Q

What is usually the largest aortic valve cusp?

A

Non-Coronary Cusp

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4
Q

How are the aortic valve cusp named?

A

Corresponding sinus of Valsalva

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5
Q

What % of people have bicuspid aortic cusp?

A

2.5%

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6
Q

What is the most common configuration of bicuspid aortic valve?

A

Left and Right Fusion

***

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7
Q

What are Lambl’s Excrescences?

A

Degenerative Filamentous straings on the ventricular free margin

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8
Q

What is the lunula?

A

The rim of each valve cusp is slightly thicker than the cusp body and is known as the lunula.

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9
Q

What is the nodule of Arantius?

A

During diastole, the normal leaflets form a three pointed star with a slight thickening or prominence at the central closing point formed by the aortic leaflet nodules, known as the nodules of Arantius

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10
Q

What is the sinus of valsalva?

A

Expanded parts of the ascending aorta enclosed superiorily by the STJ and inferiorly by attachment of the valve cusps

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11
Q

What is the role of the sinus of valsalva?

A
  1. Important role in AV cusp motion
  2. Distribution of stress in the cusps
  3. Act as reservoirs during diastole to perfuse the coronaries
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12
Q

If the sinotubular junction exceeds free margin cusp length, what will happen?

A

STJ diltation >> Free margin length = Cusp Mal-coaptation and Central AI

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13
Q

If you have isolated annular dilation excluding the STJ

1. What does this do to the commissural height?

2. Cause AI?

A

Reduces commissural height

Does not cause AI

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14
Q

What two structures make up the free margin of the aortic valve?

A

Lunula + Nodule of Arantius

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15
Q

The aortic cusp base is what relative length to the free margin length?

A

The aortic cusp base is 1.5x longer than the free margin length

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16
Q

What is the composition of the aortic valve cusp base at the hing-points?

A

55% fibrous

45% muscular

(Green in picture)

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17
Q

What aspect of the aortic valve architecture make the valve vulnerable to anuerysm formation?

A

Crown peaks (Interleaflet triangles) - Red in photo

  • Composed of thin fibrous sinus of valsalva walls (Not LV myocardium)
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18
Q

What are the 3 rings that describe the aortic root?

A

1. Aortic Annulus

- Basal cusp attachments in the LV)

2. Anatomic VA (Ventriculoarterial juntion)

  • Ventricular structures changes to fibroelastic aortic wall
    3. STJ
  • Give Structural support
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19
Q

The aortic root forms the transformation of what two structures?

A

Muscular LV to the Elastic Aorta

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20
Q

What defines the hemodynamic jucntion between the LV and the Aorta?

A

Cusp Attachment

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21
Q

What pressures are seen by the cusps proximally and distally?

A

Proximally = Ventricular pressures

Distally = Aortic Pressures

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22
Q

From the ME AV SAX view, how would you manipulate the probe to view the coronary ostia?

A

Withdraw the Probe

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23
Q

From the ME AV SAX view, how would you manipulate the probe to view the LVOT?

A

Advance the Probe

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24
Q

In the ME AV LAX view, the RCC is always anterior or posterior?

A

Anterior

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25
Q

For the ME AV LAX, when in the cardiac cycle do you measure the LVOT, AV, STJ and Ascending Aorta?

A

Mid-Systole

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26
Q

From what Transgastric view is it best to acquire TG LAX views?

A

TG Basal Short Axis

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27
Q

In the TG views of the Aortic Valve, which cusp signifies the RCC?

A

It is always located on the left of the screen

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28
Q

What are the normal aortic root measurements of:

Annulus?

A

20 - 31 mm

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29
Q

What are the normal aortic root measurements of:

Sinuses of Valsalva?

A

29 - 45 mm

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30
Q

What are the normal aortic root measurements of:

Sinotubular Junction?

A

22 - 36 mm

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31
Q

What are the normal aortic root measurements of:

Ascending Aorta?

A

22 - 36 mm

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32
Q

What is the root height?

What is the typical root height?

A

Horizontal Distance between STJ - Annulus

< 22 mm

*** Insert Photo here ***

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33
Q

What are the three levels of aortic stenosis?

A
  1. Subvalvular
  2. Valvular
  3. Supravalvular
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34
Q

What are the 3 most common etiologies of Aortic Stenosis in America?

A
  1. Bicuspid (38%)
  2. Degenerative Calcification (33%)
  3. Rheumatic (24%)
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35
Q

Symptoms of AS are not seen usually until the valve area is what size?

A

< 1.0 cm2

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36
Q

How much does the incidence of death rise each year with critical aortic stenosis?

A

10% per year

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37
Q

What is the survival rate after AV replacement for AS:

5 years?
10 years?

15 years?

A

5 = 75%

10 = 61%

15 = 49%

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38
Q

For Calcified aortic stenosis, what is usually calcified? (Specifics)

A

Aortic annulus and mitro-aortic fibrosa (MAIVF in picture)

Fibrocalcific changes in cusp body

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39
Q

What is a bicuspid valve associated with?

A

Coarctation of Aorta

Dilated Ascending Aorta

Interrupted Aortic Arch

VSD

ASD

PDA

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40
Q

What age is calcific aortic stenosis seen?

A

66 +/- 12 years

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41
Q

What age is bicuspid aortic stenosis seen?

A

48 +/- 6 years

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42
Q

What age is rheumatic aortic stenosis seen?

A

39 +/- 18 years

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43
Q

What is the appearance of rheumatic aortic stenosis?

A

Thick, Calcified Free Edge

Calcific nodules on both surfaces

Commissural fusion

Chordal Shortening

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44
Q

In Rheumatic AS, what is also seen almost always?

A

Mitral valve pathology (Isolated AS from Rheumatic is rare)

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45
Q

What defines reduced excursion of the valve in aortic stenosis?

A

<15 mm in both short and long axis

46
Q

For bicuspid valves, what is seen of the aortic cusp leaflets in systole in the ME AV LAX in terms of their relationship to the aorta?

A

Curve towards the aorta (Systolic doming)

47
Q

What defines aortic sclerosis?

A

Aortic valve thickening but no hemodynamic gradient

48
Q

What compensatory mechanism occurs within the LV for AS?

A

LVH (Left Ventricular Hypertrophy)

49
Q

Why does LVH occus in AS?

A

Compensatory mechanism

  • Flow restriction and systolic pressure overload that minimizes LV Systolic Wall stress (Think LaPlace Law)
50
Q

What does LVH do to:

Stroke Volume?

Diastolic Function?

A

Small SV (Stroke volume)

Diastolic Dysfunction

51
Q

Why is an AS patient at risk for subendocardial ischemia?

A

Higher myocardial oxygen demand due to Thick LV wall

CAD history may be prone to inferior wall hypokinesis

52
Q

If you have MR in setting of Aortic Stenosis, what must be evaluated?

A

Function MR = Secondary to AS

  • Why? Elevated LV systolic pressures

vs.

Primary MR = Instrinic MV disease that will require repair

53
Q

What is a normal jet velocity across AV?

A

1.2 - 2.2 meters/second

54
Q

What is a jet velocity across AV associated with Mild AS?

A

2.6 - 2.9 meters / second

55
Q

What is a jet velocity across AV associated with Moderate AS?

A

3.0 - 4.0 meters / second

56
Q

What is a jet velocity across AV associated with Severe AS?

A

> 4.0 meters /second

57
Q

What mean gradient is associated with mild AS?

(Include American and European)

A

American < 20 meters / second

European < 30 meters / second

58
Q

What mean gradient is associated with Moderate AS?

(Include American and European)

A

American 20 - 40 mmHg

European 30 - 50 mmHg

59
Q

What mean gradient is associated with Severe AS?

(Include American and European)

A

American > 40 mmHg

European > 50 mmHg

60
Q

What is a normal Aortic Valve size?

A

3 - 4 cm2

61
Q

What is a valve size of mild AS?

A

>1.5 - 2.5

62
Q

What is a valve size of moderate AS?

A

1.0 - 1.5 cm2

63
Q

What is a valve size of severe AS?

A

< 1.0 cm2

64
Q

What indexed ratio is mild AS?

A

> 0.85

65
Q

What indexed ratio is moderate AS?

A

0.6 - 0.85 cm2/m2

66
Q

What indexed ratio is severe AS?

A

< 0.6

67
Q

What is a velocity ratio of mild AS?

A

> 0.5

68
Q

What is a velocity ratio of moderate AS?

A

0.25 - 0.5

69
Q

What is a velocity ratio of severe AS?

A

< 0.25

70
Q

Does TEE measure Peak instantaneous or Peak to peak drop?

A

Peak Instantaneous pressure drop (TEE) is higher

Peak to peak (Cath) is lower

71
Q

When you trace a gradient, what are you measuring?

A

Mean transaortic gradient = Averages the instantaneous gradient over the ejection time

72
Q

What is the formula for mean pressure gradient to be estimated from peak velocity?

A

Mean PG = 2.4 (Vmax2)

73
Q

How will Cardiac output affect your AS gradients?

A

High CO = Overestimate

Low CO = Underestimate

74
Q

How will SVR affect your AS gradients?

A

Low SVR = Overestimate

High SVR = Underestimate

75
Q

How will AI affect your gradients for AS?

A

AI = Overestimate the gradients

76
Q

How will MR and MS affect your AS gradients?

A

Underestimate AS

77
Q

The anatomical aortic valve area is determined by what?

A

Planimetry

78
Q

The functional aortic valve area is determined by what?

A

Doppler

79
Q

What are the 3 doppler techniques to estimate AVA?

A
  1. Continuity Equation
  2. Simplified continuity equation
  3. Velocity ratio
80
Q

What is the velocity ratio (Dimensionless index) independent of?

A

Flow

81
Q

What is the continuity equation based on?

A

Conservation of mass

(Blood flow through different orifices of a continuous vascular system is equal

82
Q

What does the simplified continuity equation use?

What does it remove

A

Peak velocities

Removes LVOT diameter

83
Q

What is mild AS from mild dimensionless index?

A

> 0.5

84
Q

What is moderate AS from mild dimensionless index?

A

0.25 - 0.5

85
Q

What is moderate AS from mild dimensionless index?

A

< 0.25

86
Q

What is the formula for coninuity equation?

A

SV (LVOT) = SV (AV)

Area (LVOT) * VTI (LVOT) = Area (AV) * VTI (AV)

Solve for AVA

87
Q

What is the Simplified Continuity equation?

A

AVA = _V(Max) * CSA (LVOT)_ / V(Max) AV

88
Q

What is the formula for dimensionless index?

A

VR = V (LVOT)* / *V (AVA)

89
Q

What is the formula for CSA of the LVOT?

A

CSA = πr2

= π(d/2)2

= 0.785 d2

90
Q

When in the cardiac cycle do you measure LVOT diameter?

Where and how do we measure it?

A

Mid - systole (Just before T wave)

Inner edge to Inner Edge

91
Q

When in the cardiac cycle do you measure Aortic Root and Ascending Aorta diameter?

A

End - Diastole (Before R wave)

Leading edge to leading edge

92
Q

What two scenarios can you have Low Gradient AS?

A
  1. Low EF
  2. Normal EF with MR or low diastolic volume
93
Q

What is low gradient AS, low EF defined as?

A

Aortic stenosis (AVA <1.0 cm2)

  • Transvalvular gradient of <30 - 40 mmHg
  • LV EF < 40%
94
Q

What is the pathophysiology of low gradient AS?

A

Insufficient forward flow from LV dysfunction to fully open the stenotic valve, resulting in a low gradient and estimated AVA

95
Q

What is the key differentiation of Low Gradient AS?

A

Key Question

  1. True AS by AVA (Reduced cusp mobility)

vs.

  1. Pseudo AS which has reduced cusp opening (but normal AVA) from reduced flow
96
Q

What is the key test to differentiate Low Gradient AS?

A

Dobutamine Stress Echo

97
Q

How does a dobutamine stress echo help you differentiate true AS vs. pseudo AS in low gradient AS?

A

Alters SV and assessing changes in:

1. Aortic velocity

2. Mean gradient

3. AVA

98
Q

What is the starting dose of dobutamine in low gradient AS?

A

2.5 - 5.0 mcg/kg/min by 5.0 mcg/kg/min every 3 minutes to a maximum of 40 mcg/kg/min

99
Q

What is the cutoff for pseudo AS for dobutamine stress echo by:

AVA (Absolute or relative value)

A
  1. Increase AVA by >0.3 cm2 (Relative)
  2. Increase AVA to over 1 (Absolute)
100
Q

Why is Dobutamine Stress Echo done in terms of surgical outcomes?

A

If you identify a group with contractile reserve, those patients have better surgical outcomes after aortic valve replacement

101
Q

What phase in the cardiac cycle does not truly exist in Aortic insufficiency?

A

Isovolumetric relaxation

(As the LV relaxes), even before the MV opens, the LV volume increases from AI flow

102
Q

What happens to the pressure volume loop in AI?

A

LV filling enhanced (AI and MV inflow)

  • Increased preload
  • Higher contractile forces
  • Raises SV
103
Q

What are the two main etiologies of AI?

A
  1. Intrinsic disease of the cusps
  2. Root/Ascending disease causing secondary AI
104
Q

How do we classify etiology of AI on echo?

A

Based on cusp motion

105
Q

What is Type 1 AI?

A

Normal cusp motion but coapts at or above the annulus in the sinus of valsalva

106
Q

How do we further subclassify AI into:

Type 1A

A

Normal cusp motion but coapts at or above the annulus in the sinus of valsalva specifically dilatation of the STJ

107
Q

How do we further subclassify AI into:

Type 1B

A

Normal cusp motion but coapts at or above the annulus in the sinus of valsalva specifically dilatation of the Sinus of Valsalva

108
Q

How do we further subclassify AI into:

Type 1C

A

Normal cusp motion but coapts at or above the annulus in the sinus of valsalva specifically dilatation of the Annulus

109
Q

How do we further subclassify AI into:

Type 1D

A

Normal cusp motion but coapts at or above the annulus in the sinus of valsalva specifically dilatation of the Cusp Fenestration

110
Q

How do we further subclassify AI into:

Type 2

A

Excessive Cusp Motion occurs when the body (belly) of the cusp falls below the AV annulus as with prolapse or flail cusps

111
Q

How do we further subclassify AI into:

Type 3

A

Restricted cusp motion from calcification or rheumatic results in central malcoaptation

112
Q
A

Annette Vegas TEE Notes (20 decks)

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