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Echo 2 > Module 4 : Aortic Stenosis > Flashcards

Module 4 : Aortic Stenosis Flashcards

1
Q

4 components of the aortic root

A
  • valve ring = poin t of attachment of the cusps to the root wall
  • cusps (NCC, RCC, LCC)
  • sinus of valsalva = aortic cusps recess into the sinus during systole
  • Sino-tubular junction = where the sinus valsalva becomes the tubular portion of the aorta
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2
Q

aortic commissures

A
  • most age related calcification starts at the commissures and work its way along the free edges to the orifice
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3
Q

stenosis definiton

A
  • formation of a high velocity jet through a narrowed orifice
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4
Q

aortic stenosis

A
  • incomplete opening of the aortic valve during systole leading to a high velocity jet
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5
Q

effect of aortic stenosis

A
  • causes and obstruction to flow from the LV to AO
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6
Q

three levels of obstruction

A
  • supravalvular = membrane, shelf in AO
  • valvular - valvular AS
    + calcific, congenital, rheumatic
    + MOST COMMON
  • subvalvular - membrane or muscular IVS
    + hypertrophic cardiomyopathy
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7
Q

afterlaod effect on the LV

A

outflow obstruction&raquo_space; increasing after load» LV systolic pressure rises» TO keep SV normal&raquo_space; increased force of contraction&raquo_space; LVH develops (concentric) due to pressure overload

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8
Q

clinical symptoms of aortic stenosis

A
  • exertion dyspnea/ SOB
  • fatigue
  • chest pain
  • dizziness/snycope
  • arrhythmias
  • signs CHF
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9
Q

auscultation of aortic stenosis

A
  • harsh éjection murmur
  • systolic ejection click
  • crescendo decrescendo murmur
  • right upper sternal border
  • may radiate to carotid arteries
  • +/- aortic regurge murmur
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10
Q

clinical manifestations of AS

A
  • mild and moderate rarely felt
  • symptoms are related to the pathophysiological response
  • angina pectoris
    + mini heart attacks
  • syncope or presyncope
    + exertion not enough blood flow to brain
  • congestive heart failure
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11
Q

etiology AS - in order of incidence

A 
- calcific AS (degenerative)
   \+ thickening starts at the underside of the cusps
   \+ increased incidence with age
   \+ associated with bicuspid AV
- congenital (bicuspid, uni.quad)
- rheumatic
   \+ thickening starts at cusp edges
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12
Q

calcific AS - epidemiology

A
  • about 25% over 65 have some degree of aortic sclerosis
  • 10-15% develop aortic stenosis
  • progressive thickening over many years
  • AV leaflets thicken then start to tether together at the edges
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13
Q

calcific AS - pathology

A
  • number cusps cannot be identified due to disintegration
  • calcific aortic valve is seen as extension of the atherosclerotic process
  • lipid deposition, inflammation and calcification cause leaflets to stick together
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14
Q

pathogenesis of calcific AS

A
  • endothelial damage&raquo_space; endothelial cells lose ability to produce gasses that prevent clotting inflammation» foam cells infiltrate into tissue» macrophages engulf foam cells causing inflammation» necrosis, calcification and narrowing occurs
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15
Q

6 jobs of echo in AS

A
  • determine etiology of the lesion
  • exclude other sources of LVOT obstruction
  • assess LV size systolic, diastolic function
  • assess degree of LVH
  • estimate severity of stenosis
  • identify associated valve lesion
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16
Q

AV assessment - M Mode

A
  • look for
    + diastolic closure line - normally at middle of aortic annulus
    + leaflet excursion 2.0cm
  • BOX
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17
Q

AV assessment - 2D

A 
- look for 
  \+ equal opening/coaptation of cusps
  \+ cusp number
  \+ coronary implantation 
  \+ degree of movement 
  \+ morphology changes (atherosclerosis, calcium, commissural fusion, post stenotic dilatation)
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18
Q

2D exam

A 
- assess
  \+ walls
  \+ cavities
  \+ valve morphology 
- measure
  \+ IVS, LV, LVPW
  \+ LA, AoRoot, AscAo
  \+ LVOT
- calculate
  \+ LV mass index
  \+ EF
  \+ LVOT area
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19
Q

AV sclerosis

A
  • some thickening and calcification(brightening)of cusps
  • slight reduction of cusp excursion may be present
  • CW doppler velocity through AV normal or slightly elevated
    < 2.5m/s
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20
Q

AV stenosis

A
  • more obvious thickening and calcification of cusp
  • obvious visual reduction of cusp excursion
  • CW doppler velocity elevated through the AV >2.5m/s
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21
Q

bicuspid AV is what shape when opened

A
  • football shaped orifice when open
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22
Q

bicuspid AV.

A
  • MOST COMMON TYPE OF AS IN PATIENTS UNDER 50 YEARS OLD
  • occurs in 1-2% of the general pop
  • affects more males than female
  • familial inheritance 9%
  • often occurs along with ascending aortic dilation which has 6% chance of rupture
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23
Q

bicuspid AV structure

A
  • multiple configurations possible

- bicuspid with raphe or without raphe

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24
Q

raphe defintion

A
  • seam that joins two cusps together
25
Q

bicuspid AV - cusps fusion stats

A
  • 85% RCC and LCC

- 15% RCC and NCC

26
Q

7 things to look for with bicuspid AV

A
  • thickened leaflets
  • eccentric closure
  • normal valve excursion
  • systolic doming of LARGER cusp
  • concentric LVH
  • LV dilation
  • LA enlargement
27
Q

what is best view to see bicuspid

A
  • PSAX
28
Q

anomalies associated with bicuspid AV

A 
- congenital membranes
  \+ subvalvular/supravalvular
- supravalvular narrowing
  \+ ascending AO, AO arch or junction with descending A)
- sub aortic LVOT obstruction 
  \+ associated with HCM (hypertrophic cardiomyopathy)
  \+ asymmetric septal hypertrophy
  \+ systolic anterior motion of AML
29
Q

Rheumatic AS

A
  • caused by scarring from rheumatic fever
  • inflammatory condition
  • caused by beta-hemolytic streptococci
30
Q

acute phase of rheumatic fever

A
  • endocardial vasculitis = swelling leads to valve damage
  • myocardium
  • pericardium
  • synovial joints
  • lungs and pleura
    • all of these have swelling which may or may not lead to swelling
31
Q

rheumatic heart disease

A 
- endocardial vasculitis 
  \+ mitral MOST
  \+ aortic valve next
  \+ PV,TV
- may resolve of lead to progressive scarring
32
Q

2D parameters of estimating AS severity

A
  • AV planimetry
33
Q

how is AV planimetry assessed

A 
- using hemodynamic parameters like
   \+ peak velocity 
   \+ mean pressure gradient
   \+ aortic valve area
   \+ indexed aortic valve area
   \+ dimensionless velocity ratio
34
Q

2D AV planimetry

A
  • identify number of cusps
  • assess cusp mobility and commissural fusion
  • assess valve calcification
  • trace orifice in mid systole
35
Q

continuity principle

A
  • volume of low proximal to and in the narrowing most be equal
36
Q

continuity equation stroke volume

A

stoke volume LVOT = stroke volume AV

37
Q

continuity equation CSA and VTI

A
  • CSAlvot x VTIlvot = CSAav x VTIac
38
Q

continuity equation rearranged to determine Aortic valve area (AVA)

A

AVA = (o.785 x LVOTd^2) x VTIlovt / VTIav

39
Q

three things needed for AVA continuity equation

A
  • obtain LVOT diameter
  • obtain VTI of LVOT in PW
  • obtain VTI of aorta using CW
40
Q

continuity equation relationship = velocity and area

A
  • increase in velocity through stenotic valve is inversely proportional to the reduction in area of valve
41
Q

where to go to get good AV alignment

A
  • LATERAL
42
Q

what 4 places should you asses AV velocity is over 2.5m/s

A
  • apical
  • right suprasternal or right supraclavicular
  • right parasternal
  • +/- subcostal
43
Q

rationale behind sampling 4 please when AV velcoty high

A
  • highest velocity could be found at any of these locations
  • highest velocity and VTI are used for the calculation unless an arrhythmia is present then they are averaged over 5 beats
44
Q

continuity equation peak velocity method

A
  • uses single pint only from LVOT and AV
  • less accurate than VTI
  • unable to incorporate velocity over time
  • will overestimate stenosis if waveform is narrow with high peak velocity
45
Q

continuity equation VTI method

A
  • uses velocity -time integral which incorporates all of the velocities throughout the ejection period
  • incorporates the parabolic shape of a waveform
  • does not overestimate the degree of stenosis
46
Q

velocity ratio - relationship to degree of stenosis

A

VR = velocity LVOT / velocity AV

  • inversely related to degree of stenosis
47
Q

velocity ratio using VTI

A

VTIlvot / VTI av

48
Q

AV sclerosis - severity values

A
  • = 2.5m/s
49
Q

mild aortic stenosis - severity values

A 
av jet velocity = 2.5-2.9m/s
mean gradient = , 20mmHG
AVA cm^2 = > 1.5cm^2
indexed AVA to BSA = > 0.85
velocity ratio = > 0.50
50
Q

moderate aortic stenosis - severity values

A 
AV jet velocity = 3.0-4.0 m/s
mean gradient = 20-40mmHg
AVA cm^2 = 1.0-1.5cm^2
indexed AVA to BSA = 0.6-0.85
velocity ratio = 0.25 -0.5
51
Q

severe aortic stenosis - severity values

A 
AV jet velocity = >4.0m/s
mean gradient = > 40mmHg
AVA cm^2 = < 1 cm^2
indexed AVA to BSA = < 0.6
velocity ratio = < 0.25
52
Q

subaortic stenosis wave form characteristics

A
  • late peaking profile (dagger)
  • asymmetric
  • very high velocity
  • will cover in CMO
53
Q

severe aortic stenosis waveform characteristics

A
  • acceleration time = deceleration time

- symmetrical waveform

54
Q

which starts later and ends earlier MR or AS

A
  • AS
55
Q

aortic stenosis with LOW EF

A
  • low EF cannot generate enough force to push the blood out through the AV with high gradient/ velcoty
  • gradients will be artificially low
    + IHD
    + CAD
    +CMO
56
Q

aortic stenosis with high EF

A 
- increases force of contraction 
  \+ fever
  \+ hypervolumia 
  \+ pregnancy 
  \+ LV overload due to moderate-severe AR
  \+ gradients artificially high
57
Q

discrepancy of severity - severe velocity but not by area

A
  • TECHNICAL ERRORS
    + LVOTd overestimated
    + LVOT VTI overestimated (measured to Cloe to AV)

= remeasure and recalculate AVA

58
Q

discrepancy of severity - severe by area but not by velocity

A
  • TECHNICAL ERRORS
    + LVOTd underestimated
    + LVOT VTI underestimated (measured to far from AV)

= remeasure and recalculate AVA

Echo 2 (18 decks)

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