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EDEC: Aortic Stenosis

RESOURCES

  • AORTIC STENOSIS
  • MITRAL STENOSIS

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Overview

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

Screening, Morphology & Visualisation

What views are used to evaluate the 2D morpholigical appearance of the aortic valve?
  • Should be examined using a combination of:
    • PSAX (level great vessels) zoomed AV
    • PLAX zoomed AV
What should you assess in 2D imaging to help determine the aetiology and mechanism of AS?
  • 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
Parameter
Peak Velocity
Mean Gradient
Vave Area (AVA)
Indexed Valve Area (AVA/BSA)
Velocity Ratio
Method
CW Doppler
VTI aortic
Continuity Equation (2D, PW and CW Doppler) or plannimetry
Continuity Equation (2D, PW and CW Doppler) or plannimetry
LVOT Peak (PW Doppler) vs. Aortic Peak (PW Doppler)
Mild
2.5-2.9 m/s
<20 mmHg
>1.5 cm2
>0.85 cm2/m2
>0.5
Moderate
3.0-3.9 m/s
20-39 mmHg
1.0-1.5 cm2
0.60-0.85 cm2/m2
0.25-0.5
Severe
4.0-4.9 m/s
40-59 mmHg
<1.0 cm2
<0.60 cm2/m2
<0.25
Very Severe
>5.0 m/s
≥60 mmHg
≤0.6 cm2
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Severity & Grading

Which echo features are used to grade aortic Stenosis severity?

  • 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
Parameter
Peak Velocity
Mean Gradient
Vave Area (AVA)
Indexed Valve Area (AVA/BSA)
Velocity Ratio
Method
CW Doppler
VTI aortic
Continuity Equation (2D, PW and CW Doppler) or plannimetry
Continuity Equation (2D, PW and CW Doppler) or plannimetry
LVOT Peak (PW Doppler) vs. Aortic Peak (PW Doppler)
Mild
2.5-2.9 m/s
<20 mmHg
>1.5 cm2
>0.85 cm2/m2
>0.5
Moderate
3.0-3.9 m/s
20-39 mmHg
1.0-1.5 cm2
0.60-0.85 cm2/m2
0.25-0.5
Severe
4.0-4.9 m/s
40-59 mmHg
<1.0 cm2
<0.60 cm2/m2
<0.25
Very Severe
>5.0 m/s
≥60 mmHg
≤0.6 cm2
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Parasternal Long Axis (PSAX) View

Presentation
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Complications
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Work-Up Summary
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Laboratory Investigations

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Imaging Investigations
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Severity & Prognostic Scoring
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Management Summary
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Critical Care Admission & Referral
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Supportive Management
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Specific Management
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Author

The Guidewire
Trainee in ICM & Anaesthesia

Reviewer

The Guidewire
Trainee in ICM & Anaesthesia