Echo - Aortic Stenosis

Question 1

Stages of Aortic Stenosis

Answer 1

A - At risk for disease
B- Progressive disease
C - asymptomatic Disease

c1 - normal LVEF
c2 - LVEF <50%

D- symptomatic Severe disease

D1 - high gradient
D2 - low flow, low gradient with reduced LVEF
D3 - low gradient with normal LVEF or paradoxical low flow

Question 2

Can cause aortic stenosis
- 1-2% og general population
fusion of two cusps
associated with aortopathy
common in Male

Answer 2

BAV - most common is fusion of RCC and LCC

Question 2

fatal AS in children under 1 year old, rare in adults with uni- or acommisural

usually in the absence of severe calcification of valves

Answer 2

unicuspid aortic valve

usually in the absence of severe calcification of valves

Question 2

At risk to develop As

Answer 2

see pic

Question 3

Classification of BAV fused on fusion of cusps

Answer 3

see pic

Question 4

associated aortopathy of BAV?

Answer 4

• Dilatation of Sinus of valsalva
• aorta dilatation
• aortic coarctation

Question 5

Clues for coarctation of aorta in BAV

Answer 5

• associated with hypertension
• on CWD at descending aorta (suprasternal view), look for saw like pattern - persistently high velocity both in systole and diastole

Question 6

characteristics of a Quadricuspid Aortic Valve

Answer 6

see pic

Question 7

the most common cause of AS

Answer 7

Calcific Degenerative AS

Question 8

Grading severity of Aortic Stenosis

Answer 8

MILD
- AVA of >1.5 cm2,
-mean G <20mmHg,
- Vmax <3/sec

Moderate
- AVA of >1-1.5 cm2,
mean G of 20-39 mmHg,
Vmax of 3-3.9/sec

SEVERE
- AVA of <1.0 cm2 OR AVAi ≤0.6
mean G ≥40mmHg,
Vmax ≥ 4/sec

***VERY SEVERE
mean G of ≥ 60mmHg,
Vmax ≥5/sec

Question 9

Criteria for a D2 - symptomatic severe low flow, low gradient AS with reduced LVEF

Answer 9

• AVA of <1.0 cm2
• with resting mean G <40mmHg,
  -resting Vmax ≥ 4/sec
• LVEF <50%

***DSE shows AVA of <1.0 cm2 with Vmax ≥ 4/sec at any flow rate

Question 10

Criteria for a D3 - symptomatic severe low flow AS with normal LVEF or paradoxical low flow severe AS

Answer 10

• AVA of <1.0 cm2
• with resting mean G <40mmHg,
  -resting Vmax ≥ 4/sec
• Stroke volume index of <35mL/m2

*** measured when patient is normotensive (SBP <140mmHg)

Question 11

Doppler Assessment of Aortic Stenosis

Answer 11

• Stroke volume - LVOT and LVOT VTI
• AVA - Continuity equation
• Vmax across the AV
• mean PG

MEASUREMENT REQUIRED
LVOT diameter via 2D
LVOT VTI via PWD
Peak AV VTI via CWD

Question 12

Formula for AVA by continuity equation

Answer 12

see pic

Question 13

severity cut off for velocity ratio for AS?

Answer 13

0.25 for severe AS
>0.5 is normal

Dimensionless index for AS severity

Question 13

Why planimetry is unreliable in measuring AVA?

Answer 13

(1) the inability to determine whether the plane of imaging is at the leaflet tips where maximum stenosis occurs and is parallel to the orifice; and

(2) planimetry is difficult because of poor cusp definition from heavy calcium deposition, acoustic shadowing, and reverberation artifact.

Question 14

cut off AVA index for severe AS?

Answer 14

≤0.6 cm2/m2

Question 15

Discordant between AVA and MG in AS. what will you check??

Answer 15

see pic

for low gradient AS with LVEF <50%, do DSE

Question 16

Dobutamine stress echo interpretation for true and pseudo severe AS.

Answer 16

True-severe AS is generally defined by an AVA of 1.0 cm2 or less and a MG of 40 mm Hg or greater at any
stage during DSE.

Typically, pseudo-severe AS shows a marked increase in AVA and little or no increase in gradients in response to increasing flow

whereas true-severe AS shows little or no increase in AVA and a marked increase in gradients which is congruent with the relative increase in flow

Question 17

Goal of DSE for AS

Answer 17

increase SV by 20%

for true severe AS - AVA ≤1.0 cm2 and MG ≥40mmHg

pseudo severe AS. - AVA >1cm2 and MG ≤40mmHG

Question 18

What are the echo parameters that is important in classifying severe AS?

Answer 18

flow (SVi), mean gradient and LVEF

Question 19

type of AS that is usually caused by discrete fibrous membrane and by muscular narrowing

Answer 19

subvalvular AS

Question 20

differential dx for Dynamic LVOT obstruction

Answer 20

a type of subvalvular AS

Question 21

type of AS that can be focal or diffuse narrowing starting at the sinotubular junction

Answer 21

supravalvular AS

*** associated with Williams-Beuren Syndrome

Williams syndrome, also known as Williams-Beuren syndrome, is a rare, neurodevelopmental, genetic condition characterized by many symptoms including unique physical features, delayed development, cognitive challenges and cardiovascular abnormalities.

Question 22

When to use CT calcium score in patient with AS?

Answer 22

low flow, low gradient AS with LVEF <50% AND - DSE is not feasible or inconclusive, or - mean flow rate at rest echo >200 mL/sec -> proceed with AV calcium scoring by MDCT cut off: ≥1,200 for female, ≥2000 for male

Question 23

in AS, anatomical and procedural factors favours TAVI over SAVR?

Answer 23

- TAVI feasible via transfemoral approach - Sequelae of chest radiation - Porcelain aorta - High likelihood of severe patient-prosthetic mismatch (AVAi <0.65cm2/m2 BSA) - severe chest deformation or scoliosis ESC guidelines on Valvular Heart Disease

Question 24

in AS, clinical characteristics that favous TAVI over SAVR?

Answer 24

- Higher surgical risk - Older age - Previous Cardiac Surgery (particularly intact CABG at risk of injury during repeat sternotomy. - Severe Frailty (>2 factors of Katz Index) ***active or suspected IE favours SAVR

Question 25

in severe AS, SAVR vs TAVI?

Answer 25

see pic

Question 26

in SYMPTOMATIC SEVERE AS, which are class I indication for intervention. (ESC)

Answer 26

- severe, high gradient AS mean G ≥ 40mmHg Vmax ≥ 4m/sec AND AVA ≤ 1cm2 or AVAi ≤0.6cm2/m2 - severe, low flow (SVi ≤35ml/m2), low gradient (< 40mmhg) AS with LVEF <50%), and evidence of flow (contractile) reserve ***flow reserve is assess after DSE. there should be ≥20% increase in SV

Question 27

in ASYMPTOMATIC SEVERE AS, which are class I indication for intervention. (ESC)

Answer 27

- severe AS with LVEF <50% without another cause - severe AS and demonstrable symptoms on exercise testing

Question 27

in SYMPTOMATIC SEVERE AS, which are class IIa indication for intervention. (ESC)

Answer 27

- severe, low flow, low gradient AS with normal LVEF -severe, low flow (SVi ≤35ml/m2), low gradient (< 40mmhg) AS with LVEF <50%), AND no evidence of flow (contractile) reserve, particularly when CTT calcium score confirms severe AS ***flow reserve is assess after DSE. there should be ≥20% increase in SV

Question 28

in ASYMPTOMATIC SEVERE AS, which are class IIa indication for intervention. (ESC)

Answer 28

-severe AS with LVEF <55% without another cause - severe As with sustained fall on BP (>20mhg) during exercise testing - severe AS, LVEF >55%, low risk procedure AND present of one of the following: 1. vere severe AS (mean G ≥ 60mmhg, Vmax of >5m/s) 2. severe valve calcification (ideally assessed by CCT) and Vmax progression of ≥0.3 m/s/yr 4. markedly elevated BNP levels (x 3 x age- and sex- corrected normal range) without any other explanation

Question 29

TAVI vs SAVR?

Answer 29

SAVR, class I indication for: - <75 yrs old and STS-PROM/EuroSCORE II <4%, or - patients who are operable and unsuitable for transfemoral TAVI TAVI, class I indication for - ≥ 75yrs old, or - STS-PROM/EuroSCORE of >8%, or - unsuitable for surgery

Question 30

For Moderate AsS patient undergoing CABG or procedure on the ascending AORTA or another valve , what is the recommendation?

Answer 30

- Class IIa for SAVR