009 // Aortic Stenosis

Basics

Natural History of Aortic Stenosis

NOTE: Prognosis of severe aortic stenosis (in general) is good until symptoms
occur!!

Epidemiology NOTE:
Aortic stenosis
3rd most common heart disease
shares many
Increasing prevalence with older pathological
age (2-6% in the elderly) features and risk
factors with
30% AV-sclerosis (precursor of AS) atherosclerosis!

Hemodynamics in Aortic Stenosis

Patients with aortic stenosis have an increased afterload, which results in

pressure overload. Left ventricular hypertrophy is a compensatory mechanism

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Decompensation in Aortic Stenosis

Persistent pressure overload leads to deterioration of left ventricular function

and eventual heart failure

Causes of Aortic Stenosis

Congenital abnormalities of the aortic valve are frequent causes of aortic

stenosis. In some patients stenosis is present at birth in others congenital
abnormal valves predispose for the development of aortic stenosis

NOTE: The cause of severe aortic stenosis in patients < 50 years is almost
always congenital!!

Rheumatic Aortic Stenosis

Usually mild/moderate NOTE:

The aortic valve is the
Combined with AR second most common
valve involved in
Secondary degenerative rheumatic heart
disease!

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Congenital Abnormalities of AV

NOTE: Unicuspid, bicuspid,

To make the quadricuspid
diagnosis of a
bicuspid valve
use the short axis Syndromes (i.e. Down, Heyde)
view and observe
the opening
motion of the Aortic root involvement,
valve! ectasia, aneurysm

Echocardiographic Assessment of Aortic Valve

2D

Bicuspid valve Opening, severity

Left ventricular function

Degree of calcification
(longitudinal strain)

Atrial enlargement Left ventricular hypertrophy

MMode

Eccentric AV closure „“Box“ seperation

NOTE: Coronary artery disease is frequent in calcified aortic stenosis!

Doppler Assessment of Aortic Valve

Color Doppler

DD: sub/supra valvular

Aliasing (stenotic jet)
stenosis;

Additional LVOT obstruction?

CW/PW Doppler

Diastolic dysfunction (filling

Elevated pulmonary
pressure, indirect sign of
pressure is indicative of
severity, correlation with
beginning heart failure
symptoms

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Quantification of Aortic Stenosis

Methods

Planimetry (TEE) Pressure gradients

Aortic valve area using continuity equation

Evaluation of Gradients

Gradients are influenced

Gradient = 4 x Vmax2
by heart rate and stroke
(Bernoulli equation)
volume

Jet velocity is elevated (> 2m/s) if AVA < 2-2,5 cm2

NOTE: Late peak of the doppler signal indicates severe aortic stenosis!

Practical Considerations

Try to be parallel to the stenotic jet and optimize the

angle!

Evaluate gradients from multiple windows (apical,

suprasternal and right parasternal)

Set the focus point of the CW Doppler!

Use the pencil probe!

In the setting of atrial fibrillation average the

gradients of several beats and the PW-LVOT velocity

NOTE: Patients with bicuspid stenosis and patients with severe AS in general
have eccentric AS jets! In these patients you will usually get the highest
gradient from a right parasternal approach!

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Calculation of Aortic Valve Area (Continuity Equation)

The LVOT width is measured in the PLAX slightly proximal to the aortic valve,
exactly where you would also place the PW Doppler sample (5 ch view)

NOTE: Measurement of the LVOT width is most critical for the calculation of
the aortic valve area! Small measurement errors make large differences!!

Limitations of Continuity Equation)

Geometry of LVOT
Measurement of LVOT
(round, oval)

PW sample volume position Flow profile LVOT

Underestimation of AVpeak vel

NOTE: To find the optimal location of the PW Doppler sample volume place it
first into the AS jet and slowly move the sample volume proximal until there is
a sudden velocity drop!

Reference Values for Aortic Stenosis

Mild Moderate Severe

> 40 mmHg (USA)

Mean gradient < 25 mmHg 25—40 mmHg
> 50 mmHg (EU)

Aortic valve area < 1,5 cm2 1,0— 1,5 cm2 < 1,0 cm2

Jet velocity < 3 m/s 3—4 m/s > 4 m/s

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Special Circumstances

Low Gradient Aortic Stenosis

Mean gradient
< 30mmHg- 40mmHG

EF< 40%

AVA < 1.0 cm2

NOTE: To differentiate between true severe and pseudo severe AS, you should
perform dobutamine stress echo!

Factors in Favor of True Severe “Low Flow Low Gradient“ Aortic Stenosis

Heavily calcified valve Late peak of AS signal

LVH in absence of Previous exams with

hypertension higher gradients

NOTE: Correct classification makes a difference! Patients true aortic stenosis

are potential candidates for valve replacement!

Dobutamine Stress Test in Low Flow Low Gradient Aortic Stenosis

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“Paradoxical“ Low Flow Low Gradient Aortic Stenosis

Low gradients in severe AS / normal EF

AVA < 1.0 cm2 EF > 50 %

Mean gradient < 40mmHg

Low stroke volume (<35ml/m2)

Concentric LVH ↑ Small, restrictive LV

Calcified valve (Hypertension)

Aortic Stenosis and Aortic Regurgitation

Often combined Bicuspid valves

AS + endocarditis Annular dilatation

AR leads to higher gradients Volume overload / LV

(overestimation of AS severity) size

NOTE: Only relevant if aortic regurgitation is ≥ moderate!

Pressure Recovery

Increase of pressure downstream from the

stenosis caused by reconversion of kinetic
energy to potential energy

Where is it relevant?

Small aorta < 30mm Moderate AS

High flow rate Bileaflet prosthesis

Funnular obstruction

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Sub- and Supravalvular Aortic Stenosis

Subvalvular Aortic Stenosis (Membranous) NOTE:

Look at the
2nd most common LV outflow
origin of aliasing
obstruction
(DD: valvular/
Variable morphology subvalvular/
supravalvular
TEE study often required! AS)

Other Findings in Subvalvular Aortic Stenosis

Abnormal mitral valve Associated defects

insertion (50%)

PDA, VSD, bicuspid AV, Features of LVOT

pulmonic stenosis obstruction

Color flow aliasing at

Morphology of aorta
the site of obstruction

CW velocity despite normal AV morphology

NOTE: Subvalvular obstruction leads to aortic valve destruction (jet lesion)

and aortic regurgitation!

Types of Supravalvular Aortic Stenosis

NOTE: Use other imaging modalities (CT/MRI) and search for other congenital
abnormalites

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Indication for Aortic Stenosis Surgery/Intervention

Indications for Surgery

Symptomatic patients with severe AS (dyspnea,

syncope, angina)

Symptomatic patients with reduced LV function

Asymptomatic patients with abnormal exercise test

Moderate or severe AS if other cardiac surgery is

performed

NOTE: If the patient does not full-fill the criteria/indications for surgery,
annual follow up should be performed. Shorter intervals are necessary if AS is
severe, heavily calcified, LVF or symptoms are uncertain!

Predictors for Rapid Progression of Aortic Stenosis

Valve morphology
Non-linear and variable
(bicuspid)

Severity of AS Degree of calcification

Subclinical myocardial dysfunction

TAVI (Transcatheter Aortic Valve Implantation)

Consider interventional valve replacement in:

Symptomatic/severe aortic stenosis

High risk patients (Logistic Euroscore > 20)

Suitable anatomy (AV diameter)

Eligible anatomic access for transapical or

transfemoral valve implantation

NOTE: Indications for TAVI may change with improvements of the

methodology!