Pulmonary Stenosis
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Pathophysiology

Anatomy

Aetiology & Mechanisms

Assessment Approach

How should aortic stenosis (AS) be assessed using echo?

Screening & Qualitative Assessment
Screening & Qualitative Assessment
Valve Morphology
Assessment of calcification, cusps and opening

(2D visualisation)

M-mode screening
Cusp separation and closure timing
CW Dopppler screening
Height,shape and density of aortic CW trace
Quantitative Assessment & Grading
Quantitative Assessment & Grading
Pressure & Velocity Based Severity
Peak jet velocity

(CW Doppler)

Pressure & Velocity Based Severity
Mean gradient

(VTI aortic)

Pressure & Velocity Based Severity
Doppler velocity ratio

(LVOT Peak using PW Doppler vs. Aortic Peak using PW Doppler)

Area Based Severity
AVA using continuity equation

(Continuity Equation using 2D, PW and CW Doppler)

Area Based Severity
Indexed AVA using continuity equation

(Continuity Equation using 2D, PW and CW Doppler)

Area Based Severity
AVA using planimetry

(2D or 3D visualisation)

Assessment of Aetiology
Assessment of Aetiology
Valve Morphology
Assessment of calcification, cusps and opening

(2D visualisation)

Causes of sub-valvular stenosis
Assessment of subaortic membrane or dynamic outflow obstruction

(2D visualisation)

Assessment of Secondary or Associated Pathology
Assessment of Secondary or Associated Pathology
Coexisting aortic regurgitation
Qualitative evaluation of severity
Coexisting mitral stenosis
Qualitative evaluation of severity
LV response
Assessment of hypertrophy, dimensions or volumes, systolic function (global and regional) and diastolic function
Aortic Dilatation
Assessment of aortic root diameters

Assessments of Severity

  • Leaflet thickening
  • Morphology (rolled edged)
  • Mobility (restriction) open fully, with central closure, or are doming in appearance and  with an eccentric closure lin
  • Thickening
  • Calcification (severity location and extent)
  • LVOT and annulus
  • Doppler echocardiography is now the standard method to evaluate severity of AS.
  • Parameters recommended for grading severity of AS are:
    • Maximum Aortic Jet Velocity
    • Mean transaortic pressure gradient
    • Velocity Ratio
    • Aortic valve area (AVA) using continuity equation
    • Indexed aortic valve area (AVA) using continuity equation

Overview of Severity Grading

Which echo features are used to grade aortic Stenosis severity?

  • The difference in proximal-distal pressure is a reflection of the degree of obstruction.
  • Doppler echocardiography is now the standard method to evaluate severity of AS
  • Parameters recommended for grading severity of AS are:
    • Maximum Aortic Jet Velocity
    • Mean transaortic pressure gradient
    • Velocity Ratio
    • Aortic valve area (AVA) using continuity equation
    • Indexed aortic valve area (AVA) using continuity equation

Which values are used to grade the severity of aortic stenosis?

Parameter
Mild
Moderate
Severe
Very Severe
Peak Velocity
2.5-2.9 m/s
3.0-3.9 m/s
4.0-4.9 m/s
≥5.0 m/s
Mean Gradient
<20 mmHg
20-39 mmHg
40-59 mmHg
≥60 mmHg
Vave Area (AVA)
>1.5 cm2
1.0-1.5 cm2
<1.0 cm2
≤0.6 cm2
Indexed Valve Area (AVA/BSA)
>0.85 cm2/m2
0.60-0.85 cm2/m2
<0.60 cm2/m2
-
Velocity Ratio
>0.5
0.25-0.5
<0.25
-

Peak Velocity

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How is vena contracta width measured in the assessment of MR?

Mild

Moderate

Severe

Very Severe

2.5-2.9 m/s
3.0-3.9 m/s
4.0-4.9 m/s
≥5.0 m/s

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Mean Gradient

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How is vena contracta width measured in the assessment of MR?

Mild

Moderate

Severe

Very Severe

<20 mmHg
20-39 mmHg
40-59 mmHg
≥60 mmHg

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Valve Area (Continuity Equation)

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Which values of aortic valve area (AVA) are used to grade the severity of aortic stenosis?

Mild

Moderate

Severe

Very Severe

>1.5 cm2
1.5-1.0 cm2
<1.0 cm2
≤0.6 cm2

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Valve Area (Plannimetry)

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Which values of aortic valve area (AVA) are used to grade the severity of aortic stenosis?

Mild

Moderate

Severe

Very Severe

>1.5 cm2
1.5-1.0 cm2
<1.0 cm2
≤0.6 cm2

What are the advantages of using ….. in the assessment of ….?

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What are the limitations of using ….. in the assessment of ….?

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Velocity Ratio

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Which views are used to assess ….. in ….?

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How is ….. measured in the assessment of ….?

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Which values of velocity ratio are used to grade the severity of aortic stenosis?

Mild

Moderate

Severe

>0.5
0.25-0.5
<0.25

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