ECHOCARDIOGRAPHIC

ASSESSMENT OF AORTIC
VALVE STENOSIS

Dr Ranjith MP
 Normal Aortic valve
Three cusps, crescent shaped
3 commissures
3 sinuses
supported by fibrous annulus

3.0 to 4.0 cm2

Node of Arantius
2D Echo-Long axis view
Diastole Systole
 2D Echo-Short axis view
Diastole Systole

Y or inverted Mercedes-Benz sign

2D - Apical five chamber view
2D Suprasternal view
M Mode- Normal aortic valve
CAUSES AND ANATOMIC
PRESENTATION
 Aortic stenosis- Causes
Most common :-
Bicuspid aortic valve with calcification
Senile or Degenerative calcific AS
Rheumatic AS

Less common:-
Congenital
Type 2 Hyperlipoproteinemia
Onchronosis
 Anatomic evaluation

Combination of short and long axis images to

identify
Number of leaflets
Describe leaf mobility, thickness, calcification

Combination of imaging and doppler allows

the determination of the level of obstruction;
subvalvular, valvular, or supravalvular.

Transesophageal echocardiography may be

helpful when image quality is suboptimal.
 Calcific Aortic Stenosis
Nodular calcific masses on aortic side of cusps
No commissural fusion
Free edges of cusps are not involved
stellate-shaped systolic orifice
 Calcific Aortic Stenosis
Parasternal long axis
view showing
echogenic and
immobile aortic valve
 Calcific Aortic Stenosis
Parasternal short-axis
view showing calcified
aortic valve leaflets.
Immobility of the cusps
results in only a slit like
aortic valve orifice in
systole
 Bicuspid Aortic valve
Fusion of the right and left coronary cusps (80%)
Fusion of the right and non-coronary cusps(20%)
Schaefer BM et al. Am J Cardiol 2007;99:68690
Schaefer BM et al.Heart 2008;94:16341638.
 Bicuspid Aortic valve
Two cusps are seen in systole with only two
commissures framing an elliptical systolic
orifice(the fish mouth appearance).
Diastolic images may mimic a tricuspid valve
when a raphe is present.
 Bicuspid Aortic valve
Parasternal long-axis echocardiogram may show
an asymmetric closure line
systolic doming
diastolic prolapse of the cusps

In children, valve may be stenotic

without extensive calcification.

In adults, stenosis typically is due to calcific changes,

which often obscures the number of cusps, making
determination of bicuspid vs. tricuspid valve difficult
 Calcific Aortic Stenosis
Calcification of a bicuspid or tricuspid valve, the severity
can be graded semi-quantitatively as

0 1+ 2+ 3+ 4+
Schaefer BM et al.Heart 2008;94:16341638.
The degree of valve calcification is a predictor of clinical
outcome. Rosenhek R et al. N Engl J Med 2000;343:6117.
 Aortic sclerosis
Thickened calcified cusps with preserved
mobility

Typically associated with peak doppler

velocity of less than 2.5 m/sec
 Rheumatic aortic stenosis
Characterized by
Commissural fusion
Triangular systolic orifice
thickening & calcification

Accompanied by rheumatic mitral valve

changes.
 Rheumatic aortic stenosis
Parasternal short axis view showing commissural
fusion, leaflet thickening and calcification, small
triangular systolic orifice
Subvalvular aortic stenosis
(1) Thin discrete membrane consisting of
endocardial fold and fibrous tissue
(2) A fibromuscular ridge
(3) Diffuse tunnel-like narrowing of the LVOT
(4) accessory or anomalous mitral valve tissue.
 Supravalvular Aortic stenosis
Type I - Thick, fibrous ring above the aortic
valve with less mobility and has the easily
identifiable 'hourglass' appearance of the aorta.
 Supravalvular Aortic stenosis
Type II - Thin, discrete fibrous membrane
located above the aortic valve
The membrane usually mobile and may
demonstrate doming during systole
Type III- Diffuse narrowing
HOW TO ASSESS AORTIC
STENOSIS
 Doppler assessment of AS
The primary haemodynamic parameters
recommended (EAE/ASE Recommendations for
Clinical Practice 2008)

Peak transvalvular velocity

Mean transvalvular gradient

Valve area by continuity equation.

Peak transvalvular velocity
Continuous-wave Doppler ultrasound

Multiple acoustic windows

Apical and suprasternal or right parasternal
most frequently yield the highest velocity
rarely subcostal or supraclavicular windows
may be required

Three or more beats are averaged in sinus

rhythm, with irregular rhythms at least 5
consecutive beats
 Peak transvalvular velocity
AS jet velocity is defined as the highest velocity signal
obtained from any window after a careful examination

Any deviation from a parallel intercept angle results in

velocity underestimation

The degree of underestimation is 5% or less if the

intercept angle is within 15 of parallel.

Angle correction should not be used because it is likely

to introduce more error given the unpredictable jet
direction.
 Peak transvalvular velocity
The velocity scale adjusted so the spectral doppler signal
fills on the vertical axis, and with a time scale on the x-axis
of 100 mm/s

Wall filters are set at a high level and gain is decreased to

optimize identification of the velocity curve.

Grey scale is used

A smooth velocity curve with a dense outer edge and clear

maximum velocity should be recorded
 Peak transvalvular velocity
The shape of the CW Doppler velocity curve is helpful
in distinguishing the level and severity of obstruction.

With severe obstruction, maximum

velocity occurs later in systole and the
curve is more rounded in shape

With mild obstruction, the peak

is in early systole with a triangular
shape of the velocity curve
Peak transvalvular velocity
The shape of the CWD velocity curve also can be
helpful in determining whether the obstruction is
fixed or dynamic

Dynamic sub aortic obstruction

shows a characteristic late-
peaking velocity curve, often with
a concave upward curve in
early systole
 Mean transvalvular gradient

The difference in pressure between the left

ventricle and aorta in systole

Gradients are calculated from velocity

information

The relationship between peak and mean

gradient depends on the shape of the velocity
curve.
Mean transvalvular gradient

Bernoulli equations
P =4v
The maximum gradient is calculated from
maximum velocity
P max =4v max
The mean gradient is calculated by averaging
the instantaneous gradients over the ejection
period
 Mean transvalvular gradient

The simplified Bernoulli equation assumes

that the proximal velocity can be ignored

When the proximal velocity is over 1.5 m/s or

the aortic velocity is ,3.0 m/s, the proximal
velocity should be included in the Bernoulli
equation P max =4 (v max- v2proximal)
 Sources of error for pressure
gradient calculations
Malalignment of jet and ultrasound beam.
Recording of MR jet
 Sources of error for pressure
gradient calculations
Neglect of an elevated proximal velocity.

Any underestimation of aortic velocity results in

an even greater underestimation in gradients,
due to the squared relationship between velocity
and pressure difference

The accuracy of the Bernoulli equation to

quantify AS pressure gradients is well established
 Pressure recovery
The conversion of potential energy to kinetic
energy across a narrowed valve results in a
high velocity and a drop in pressure.

Distal to the orifice, flow decelerates again.

Kinetic energy will be reconverted into
potential energy with a corresponding
increase in pressure, the so-called PR
 Pressure recovery
Pressure recovery is greatest in stenosis with
gradual distal widening

Aortic stenosis with its abrupt widening from

the small orifice to the larger aorta has an
unfavorable geometry for pressure recovery

PR= 4v 2EOA/AoA (1-EOA/AoA)

Comparing pressure gradients calculated from
doppler velocities to pressures measured at
cardiac catheterization.
Comparing pressure gradients calculated from
doppler velocities to pressures measured at
cardiac catheterization.

Currie PJ et al. Circulation 1985;71:1162-1169

 Aortic valve area
Continuity equation
 Aortic valve area
Aortic valve area
Continuity equation concept that the stroke
volume ejected through the LV outflow tract all
passes through the stenotic orifice

AVA= CSA LVOTVTILVOT / VTIAV

Calculation of continuity-equation valve area

requires three measurements
AS jet velocity by CWD
LVOT diameter for calculation of a circular CSA
LVOT velocity recorded with pulsed Doppler.
 Aortic valve area
Continuity equation
LVOT diameter and velocity should be measured at the
same distance from the aortic valve.

When the PW sample volume is optimally positioned,

the recording shows a smooth velocity curve with a
well-defined peak.
 Aortic valve area
Continuity equation
The VTI is measured by tracing the dense modal
velocity throughout systole
LVOT diameter is measured from the inner edge to
inner edge of the septal endocardium, and the
anterior mitral leaflet in mid-systole
 Aortic valve area-Continuity equation
Level of Evidence

Well validated - clinical & experimental studies.

Zoghbi WA et al. Circulation 1986;73:452-9.
Oh JK et al. J Am Coll Cardiol 1988;11:1227-34.

Measures the effective valve area, the weight

of the evidence now supports the concept that
effective, not anatomic, orifice area is the
primary predictor of clinical outcome.
Baumgartner et al. J Am Society Echo 2009; 22,1 , 1-23.
 Limitations of continuity-
equation valve area
Intra- and interobserver variability
AS jet and LVOT velocity 3 to4%.
LVOT diameter 5% to 8%.
When sub aortic flow velocities are abnormal
SV calculation at this site are not accurate

Sample volume placement near to septum or

anterior mitral leaflet
 Limitations of continuity-
equation valve area
Observed changes in valve area with changes
in flow rate

AS and normal LV function, the effects of flow

rate are minimal

This effect may be significant in presence

concurrent LV dysfunction.
 Left ventricular systolic
dysfunction
Low-flow low-gradient AS includes the
following conditions:

Effective orifice area < 1.0 Cm2

LV ejection fraction < 40%
Mean pressure gradient < 3040 mmHg
Severe AS and severely reduced LVEF
represent 5% of AS patients
Vahanian A et al. Eur Heart J 2007;28:23068.
 Dobutamine stress Echo
Provides information on the changes in aortic
velocity, mean gradient, and valve area as flow rate
increases.

Measure of the contractile response to dobutamine

Helpful to differentiate two clinical situations

Severe AS causing LV systolic dysfunction
Moderate AS with another cause of LV dysfunction
 Dobutamine stress Echo
A low dose starting at 2.5 or 5 g/kg/min with
an incremental increase in the infusion every 3
5 min to a maximum dose of 1020 g/kg/min

The infusion should be stopped as soon as

Positive result is obtained
Heart rate begins to rise more than 1020 bpm
over baseline or exceeds 100bpm
 Dobutamine stress Echo
Role in decision-making in adults with AS is
controversial and the findings recommend as
reliable are
Stress findings of severe stenosis
AVA<1cm
Jet velocity>4m/s
Mean gradient>40mm of Hg
Nishimura RA et al. Circulation 2002;106:809-13.
Lack of contractile reserve-
Failure of LVEF to by 20% is a poor prognostic sign
Monin JL et al. Circulation 2003;108:319-24..
 Serial measurements
During follow-up any significant changes in
results should be checked in detail:

Make sure that aortic jet velocity is recorded from

the same window with the same quality (always
report the window where highest velocities can be
recorded).
when AVA changes, look for changes in the
different components incorporated in the
equation.
LVOT size rarely changes over time in adults.
 Alternate measures of
stenosis severity

(Level 2 EAE/ASE Recommendations )

 Simplified continuity
equation.
Based on the concept that in native aortic
valve stenosis the shape of the velocity curve
in the outflow tract and aorta is similar so that
the ratio of LVOT to aortic jet VTI is nearly
identical to the ratio of the LVOT to aortic jet
maximum velocity.
AVA= CSA LVOTVLVOT / VAV
This method is less well accepted because
results are more variable than using VTIs in
the equation.
 Velocity ratio
Another approach to reducing error related to
LVOT diameter measurements is removing CSA
from the simplified continuity equation.

This dimensionless velocity ratio expresses the size

of the valvular effective area as a proportion of the
CSA of the LVOT.

Velocity ratio= VLVOT/VAV

In the absence of valve stenosis, the velocity ratio

approaches 1, with smaller numbers indicating
more severe stenosis.
 Aortic valve area -Planimetry
Planimetry may be an acceptable alternative
when Doppler estimation of flow velocities is
unreliable

Planimetry may be inaccurate when valve

calcification causes shadows or reverberations
limiting identification of the orifice

Doppler-derived mean-valve area correlated

better with maximal anatomic area than with
mean-anatomic area.
Marie Arsenault, et al. J. Am. Coll. Cardiol. 1998;32;1931-1937
Aortic valve area - Planimetry
 Experimental descriptors
of stenosis severity

(Level 3 EAE/ASE Recommendations -not

recommended for routine clinical use)
 Valve resistance
Relatively flow-independent measure of stenosis
severity
Depends on the ratio of mean pressure gradient
and mean flow rate

Resistance = (Pmean /Qmean) 1333

There is a close relationship between aortic valve

resistance and valve area
The advantage over continuity equation not
established
Left ventricular stroke work loss
Left ventricle expends work during systole to
keep the aortic valve open and to eject blood
into the aorta
SWL(%) = (100Pmean)/ Pmean+SBP

A cutoff value more than 25% effectively

discriminated between patients experiencing
a good and poor outcome.
Kristian Wachtell. Euro Heart J.Suppl. (2008) 10 ( E), E16E22
 Energy loss index
Damien Garcia.et al. Circulation. 2000;101:765-771.

Fluid energy loss across stenotic aortic valves is

influenced by factors other than the valve effective
orifice area .
An experimental model was designed to measure
EOA and energy loss in 2 fixed stenoses and 7
bioprosthetic valves for different flow rates and 2
different aortic sizes (25 and 38 mm).
EOA and energy loss is influenced by both flow rate
and AA and that the energy loss is systematically
higher (152%) in the large aorta.
Damien Garcia.et al. Circulation. 2000;101:765-771.
 Energy loss index
Damien Garcia.et al. Circulation. 2000;101:765-771.

Energy loss coefficient (EOA AA)/(AA - EOA) accurately

predicted the energy loss in all situations .
It is more closely related to the increase in left ventricular
workload than EOA.
To account for varying flow rates, the coefficient was indexed for
body surface area in a retrospective study of 138 patients with
moderate or severe aortic stenosis.
The energy loss index measured by Doppler echocardiography
was superior to the EOA in predicting the end points
An energy loss index #0.52 cm2/m2 was the best predictor of
diverse outcomes (positive predictive value of 67%).
 Classification of AS severity
(a ESC & bAHA/ACC Guidelines)

Aortic Sclerosis Mild Moderate Severe

Aortic jet velocity (m/s) 2.5 m/s 2.6 -2.9 3.0 - 4 >4

Mean gradient (mm Hg) < 20b(<30a) 20 40b (30 -50a) > 40

AVA (cm) > 1.5 1.0 - 1.5 < 1.0

Indexed AVA (cm/m) > 0.85 0.60 0.85 < 0.6

Velocity ratio > 0.50 0.25 0.50 < 0.25

 Effects of concurrent
conditions on assessment
of severity
 Effect of concurrent conditions

Left ventricular systolic dysfunction

Left ventricular hypertrophy

Small ventricular cavity & small LV ejects a
small SV so that, even in severe AS the AS
velocity and mean gradient may be lower than
expected.
Continuity-equation valve area is accurate in
this situation
 Effect of concurrent conditions contd

Hypertension
3545% of patients
primarily affect flow and gradients but less AVA
measurements
Control of blood pressure is recommended
The echocardiographic report should always
include a blood pressure measurement
 Effect of concurrent conditions contd

Aortic regurgitation

About 80% of adults with AS also have aortic

regurgitation
High transaortic volume flow rate, maximum
velocity, and mean gradient will be higher than
expected for a given valve area
In this situation, reporting accurate quantitative
data for the severity of both stenosis and
regurgitation
 Effect of concurrent conditions contd

Mitral valve disease

With severe MR, transaortic flow rate may be

low resulting in a low gradient .Valve area
calculations remain accurate in this setting

A high-velocity MR jet may be mistaken for the

AS jet. Timing of the signal is the most reliable
way to distinguish
 Effect of concurrent conditions contd

High cardiac output

Relatively high gradients in the presence of
mild or moderate AS
The shape of the CWD spectrum with a very
early peak may help to quantify the severity
correctly
Ascending aorta
Aortic root dilation
Coarctation of aorta
 M Mode- Aortic Stenosis
Maximal aortic cusp separation (MACS)
Vertical distance between right CC and non CC
during systole
Aortic valve area MACS Measurement Predictive value

Normal AVA >2Cm2 Normal MACS >15mm 100%

AVA>1.0 > 12mm 96%

AVA< 0.75 < 8mm 97%

Gray area 8-12 mm ..

DeMaria A N et al. Circulation.Suppl II. 58:232,1978

M Mode- Aortic Stenosis
 M Mode- Aortic Stenosis
Limitations
Single dimension
Asymmetrical AV involvement
Calcification / thickness
LV systolic function
CO status
 Approach
Valve anatomy, etiology
Exclude other LVOTO
Stenosis severity jet velocity
mean pressure gradient
AVA continuity equation

LV dimensions/hypertrophy/EF/diastolic fn
Aorta- aortic diameter/ assess COA
AR quantification if more than mild
MR- mechanism & severity
Pulmonary pressure
 MCQ -1
Which is false about Severe AS?

a) Aortic jet velocity > 4 m/s

b) Velocity ratio > 0.50
c) Indexed AVA < 0.6 cm/m
d) Mean gradient > 40 mm Hg
e) None of the above
 MCQ-2
By definition Low-flow low-gradient AS
includes the following conditions except

a) Anatomic orifice area < 1.0 Cm2

b) LV ejection fraction < 40%
c) Mean pressure gradient < 3040 mmHg
d) None
 MCQ-3
Characteristic feature of calcific aortic stenosis
is .

a) Nodular calcific masses on ventricular side of

cusps
b) Calcium deposition at free edges of the cusp
c) Commissural fusion
d) None of the above
 MCQ- 4
False about Maximal aortic cusp separation?
a) MACS of normal aortic valve is >15 mm
b) AVA <0.75 corresponds to MACS <8mm
c) Vertical distance between right CC and non CC
during systole
d) Gray area is 8-12mm
e) None of the above
 MCQ 5
All are true about standard dobutamine stress
echocardiography for evaluation of AS severity in setting
of LV dysfunction except?
A) Uses low dose of dobutamine starting at 2.5 or 5g/kg/min

B) Maximum dose of dobutamine used is 1020 g/kg/min

C) The infusion should be stopped when the heart rate

begins to rise more than 1020 bpm over baseline

D) Failure of LVEF to by 40% is a poor prognostic sign

e) None of the above

 MCQ 6
In a patient with aortic valve area of 0.6 sq
cm(not a low flow low gradient AS) continuous
wave Doppler velocity will be:

a) 1-2 m/sec
b) 2-3 m/sec
c) 3-4 m/sec
d) > 4 m/sec
 MCQ-7
True about doppler assessment of AS is all
except ?
a) With severe obstruction, maximum velocity
occurs later in systole
b) Angle correction is likely to reduce errors in
measuring peak transvalvular gradient
a) Apical and suprasternal windows most
frequently yield the highest velocity
c) None of the above
 MCQ-8
True a bout Bicuspid valve is?

a) Fusion of the right and non-coronary cusps occurs in

80% of cases
b) Fusion of the right and non-coronary cusps is more
commonly associated with mitral vale myxomatous
disease
c) Parasternal short axis view in diastole always
demonstrate bicuspid anatomy
d) Calcification usually occurs along the edges of cusp
 MCQ -9
True about Supravalvular aortic stenosis is all?

a) Type 2 shows doming in systole

b) Type 3 hourglass appearance of aorta
c) Type 1is thin discrete fibrous membrane
d) Type 3 is localized disease just above aortic
valve
 MCQ- 10
All are true except

a) accuracy of the Bernoulli equation to quantify AS

pressure gradients is well established
b) The relationship between peak and mean gradient
depends on the shape of the velocity curve.
c) Gradients are calculated from velocity information
d) Dynamic sub aortic obstruction shows a characteristic
early peaking velocity curve
e) None
 MCQ -1
Which is false about Severe AS?

a) Aortic jet velocity > 4 m/s

b) Velocity ratio > 0.50
c) Indexed AVA < 0.6 cm/m
d) Mean gradient > 40 mm Hg
e) None of the above
 MCQ-2
By definition Low-flow low-gradient AS
includes the following conditions except

a) Anatomic orifice area < 1.0 Cm2

b) LV ejection fraction < 40%
c) Mean pressure gradient < 3040 mmHg
d) None
 MCQ-3
Characteristic feature of calcific aortic stenosis
is .

a) Nodular calcific masses on ventricular side of

cusps
b) Calcium deposition at free edges of the cusp
c) Commissural fusion is common and early
d) None of the above
 MCQ- 4
False about Maximal aortic cusp separation?
a) MACS of normal aortic valve is >15 mm
b) AVA <0.75 corresponds to MACS <8mm
c) Vertical distance between right CC and non CC
during systole
d) Gray area is 8-12mm
e) None of the above
 MCQ 5
All are true about standard dobutamine stress
echocardiography for evaluation of AS severity in setting
of LV dysfunction except?
A) Uses low dose of dobutamine starting at 2.5 or 5g/kg/min

B) Maximum dose of dobutamine used is 1020 g/kg/min

C) The infusion should be stopped when the heart rate

begins to rise more than 1020 bpm over baseline

D) Failure of LVEF to by 40% is a poor prognostic sign

e) None of the above

 MCQ 6
In a patient with aortic valve area of 0.6 sq
cm(not a low flow low gradient AS) continuous
wave Doppler velocity will be:

a) 1-2 m/sec
b) 2-3 m/sec
c) 3-4 m/sec
d) > 4 m/sec
 MCQ-7
True about doppler assessment of AS is all
except ?
a) With severe obstruction, maximum velocity
occurs later in systole
b) Angle correction is likely to reduce errors in
measuring peak transvalvular gradient
a) Apical and suprasternal windows most
frequently yield the highest velocity
c) None of the above
 MCQ-8
True a bout Bicuspid valve is?

a) Fusion of the right and non-coronary cusps occurs in

80% of cases
b) Fusion of the right and non-coronary cusps is more
commonly associated with mitral vale myxomatous
disease
c) Parasternal short axis view in diastole always
demonstrate bicuspid anatomy
d) Calcification usually starts along the edges of cusp
 MCQ -9
True about Supravalvular aortic stenosis is all?

a) Type 2 shows doming in systole

b) Type 3 shows hourglass appearance of aorta
c) Type 1 is thin discrete fibrous membrane
d) Type 3 is localized disease just above aortic
valve
 MCQ- 10
All are true except

a) accuracy of the Bernoulli equation to quantify AS

pressure gradients is well established
b) The relationship between peak and mean gradient
depends on the shape of the velocity curve.
c) Gradients are calculated from velocity information
d) Dynamic sub aortic obstruction shows a characteristic
early peaking velocity curve
e) None