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ECHOCARDIOGRAPHIC ASSESSMENT OF STENOTIC VALVULAR LESIONS. DEEPAK NANDAN. AORTIC VALVE. ANATOMY Area-2.6-3.5 cm². Structure 3 cusps,3 commissures supported by fibrous annulus Arantius nodule 3 sinuses. 2D-IMAGE. Qualitative diagnosis Thin and delicate

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aortic valve
AORTIC VALVE

ANATOMY

Area-2.6-3.5 cm².

Structure

3 cusps,3 commissures supported by fibrous annulus

Arantius nodule

3 sinuses

2d image
2D-IMAGE
  • Qualitative diagnosis
  • Thin and delicate
  • Plax-opening and closing
  • Basal short axis view-Y-inverted Mercedes Benz sign
doppler assessment
Doppler assessment
  • Maximum jet velocity
    • BERNOULLI’s equation
    • Multiple windows
    • Parallel alignment
    • Colourdoppler
    • Angle correction
pressure gradients instantaneous vmean
Pressure gradients-Instantaneous vMean
  • MIPG=4 xV²(maximal jet velocity)m/s
  • MPG=4x(∑V1²+V2²+…Vn²)/n
  • MPG=∆P(max)/1.45 +2
  • MPG=2.4(Vmax)²
bernoulli s vs invasive
Bernoulli's VS invasive
  • Discrepancies
    • Tech poor doppler recording
    • Non parallel interrogation angle
    • Pressure grad depends on flow rate & valve narrowing –AR/LV dysfunction
aortic valve area
Aortic valve area
  • Continuity equation:-

SV (lvot)= SV (Ao)

SV=CSAxTVI

CSA (lvot) xTVI (lvot)=CSA (Ao) x TVI (Ao)

AVA=CSA x TVI (lvot) / TVI (Ao)

slide18

Correlates well with invasive data (GORLINS)

  • Adv compared to Berrnoulli

co-existing AR

Left ventricular dysfunction

ava direct planimetry
AVA-Direct planimetry
  • Rarely are all 3 leaflets imaged perpendicular
  • Triangular shape- measurement error
  • Deformities n irregularities- further exacerb
  • AV- superior-inferior rapid moments
  • 0.25 cm2 margin
dobutamine echo
DOBUTAMINE ECHO
  • Ao valve area≈Ao flow rate
  • Dist- true severe valvular stenosis (vs) mild to mod stenosis with LV dysfn
  • Stepwise infusion of dobutamine(5—30µg/kg/min)
slide21

Flexible valves:- AVA ↑ when SV ↑

  • True stenotis:- AVA↔ when SV ↑
  • Flexible valves:-Vmax(lvot)/jet ↑
  • True stenosis:-Vmax(lvot)/jet↔
  • Safe& clinically useful, limitation- non response to dobutamine
slide23

Stress findings of severe stenosis

AVA<1cm²

jet velocity>40m/s

mean gradient>40mm of Hg

  • Lack of contractile reserve-

failure of LVEF to ↑ by 20% is a poor prognostic sign

m mode
M- mode
  • Maximal aortic cusp separation (MACS)

Vertical distance between right CC and non CC during systole

Stenotic AV → decreased MACS

  • Limitations

Single dimension

Asymmetrical AV involvement

Calcification / thickness

↓ LV systolic function

↓ CO status

other approaches
OTHER APPROACHES
  • Ao valve resistance-

flow independent measure of stenosis severity

Resistance=(∆P/∆Q)mean x1333

Resistance=28√gradient( mean)/AVA

slide27

Left ventricular stroke work loss(SWL)

  • SWL (%) = (100 ×∆ P mean) / (∆P mean + SBP)

Principle-LV expends work during systole to keep the AV open and to eject blood into the aorta

Depends on the stiffness of AV

Less dependent on the flow

>25%--- poor outcome

discrepencies in as severity assessment severe as by gradient severe by area
Discrepencies in AS severity assessmentSevere AS by gradientSevere by area
  • LVOT underestimated
  • LVOT TVI-too far frmval
  • Small body size
  • LwtransAoflw rate

low EF

small vent chamber

mod-sev MR

mod-sev MS

  • LVOT overestimated
  • LVOT TVI recorded too close to valve
  • HghtransAo flow rate

mod-sev AR

Hgh output state

Large body size

approach
APPROACH
  • Valve anatomy, etiology
  • Exclude other LVOTO
  • Stenosis severity – jet velocity

mean pressure gradient

AVA – continuity eq

  • LV – dimensions/hypertrophy/EF/diastolic fn
  • Aorta- aortic diameter/ assess COA
  • AR – quantification if more than mild
  • MR- mechanism & severity
  • Pulmonary pressure
natural history
NATURAL HISTORY
  • Av ↑in MPG per yr = 0 to 10mm/yr

mean 7mm Hg

  • AVA ↓ by 0.1 to ∓ 0.19cm²
  • Jet vel < 3m/s – rate of symptom onset needing MVR is 8 % /yr
  • 3-4m/s – 17%/yr
  • >4m/s – 40% /yr
mitral valve anatomy
Mitral valve-anatomy
  • Mitral annulus
  • The leaflets
  • Chordaetendinae-papillary muscle
  • Underlying ventricular wall
leaflets
Leaflets
  • Anterior- three scallops
  • Posterior- three scallops
  • Scallop 1-lateral most
  • Scallop 3-medial most
chordae and papillary muscles
Chordae and papillary muscles
  • Antero lateral PM- chordae to AL half of both leaflets
  • Dual blood supply
  • Postero medial PM- chordae to PM half both leaflets
  • RCA blood supply
2d echo features
2d echo-features
  • Maximal excursion of leaflet tips
  • Tubular channel
rheumatic ms
RHEUMATIC MS
  • Commissural fusion⇒doming/bowing
  • Chordal thickening ⇒ abnormal motion
  • Progressive fibrosis⇒stiffening

⇒calcification

mitral stenosis 2d
Mitral stenosis 2D
  • Doming of the mitral valve (hockey stick AML)
  • Funnel shaped opening of mitral valves
  • Focal thickening and beading of leaflets
  • calcification
slide44

early diastolic doming motion of the AML, restriction of tip motion. Pliable, little fibrosis, calcification, or thickening. Dilated LA

slide50

2D short axis imaging of diastolic orifice

-planimetry

  • Smallest orifice at the leaflet tips
  • Inner edge of the black/white interface traced
  • Correlates well with hemodynamic assessment
technical factors
Technical factors
  • Funnel-shaped

Actual limiting orifice at the tip

  • Instrumentation setting

‘’blooming” of the echoes due to increased gain

slide55

Increased echogenicity of leaflets

  • Decreased E-F slope

>80mm/s⇒MVA =4-6cm²

<15mm/s⇒MVA <1.3cm²

  • Paradoxical anterior motion of PML
doppler assessment1
Doppler assessment
  • Trans mitral pressure gradient

single most imp factor in determining the severity & relation to symptoms & functional status

Depends on

Volume status

Heart rate

slide58

Peak pressure gradient

Early trans mitral flow volume

Cardiac output

High output states

Mitral reguritation

Mean pressure gradient

Average MVA

Cardiac output

pressure half time
Pressure half time
  • Measure of rate of decay of mitral valve gradient
  • Time in ms at which initial instant pr gradient declines to one half
  • Time interval from V max to the point where velocity has fallen to Vmax/√2
slide62

PHT=½ Peak=V½

  • V½=Vmax/√2
  • V½=V max/1.414
  • V½=Vmax x .707
  • MVA=220/PHT
limitation
Limitation
  • Post BMV- accuracy ↓
  • Aortic regurgitation- over estimates MVA
  • Severe LVH- ↓LV compliance
  • Prosthetic mitral valve- not validated
slide65
PHT
  • Independent of

Cardiac output

Mitral regurgitation

deceleration time
Deceleration time
  • Pressure half time=29% of Deceleration time
  • MVA=220 ÷ (0.29 × DT)
  • MVA=759 ÷ DT
secondary features of ms
Secondary features of MS
  • Left atrial dilation
  • Atrial fibrillation
  • Spontaneous echo contrast
  • LA thrombus
  • Secondary pulmhtn-TR
echo approach to ms
Echo approach to MS
  • Valve morphology
  • Exclude other causes of clinical presentation
  • MS severity

Mean transmitral pr gradient

2D valve area

PHT valve area

  • Assos MR
  • LA enlargement
  • Pulmonary art pressure
  • Co-existing TR severity
  • TEE for LA clot
slide72

Individuals with score≤8 –excellent for BMV

  • Those with score≧12-less satisfactory results