Critical Aortic Stenosis

 

Image Library  >> Valvular Disease >>Critical Aortic Stenosis.                                                     Author: Atif Qasim, M.D.

Parasternal Long Axis

2D view

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Note the calcified and thickened aortic valve which has very limited excursion. The aortic root and ascending aorta also are calcified. This individual also has significant mitral annular calcification, (MAC), especially along the posterior leaflet.

 

Parasternal Long Axis

M mode across the aortic valve

 

The M mode shows clearer time detail of what we saw on the 2D image. There is very limited excursion of the aortic valve. Instead of the normal square box shape opening, we see here in systole the valve barely opens. The aortic valve opening is more of a small rectangle M mode shape .

Parasternal Long Axis

Zoom in on Aortic and Mitral Valve Level, 2D view

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A closer look at these two valves shows again how calcified the aortic valve is. In this view the non coronary cusp appears to be moving, however there is minimal movement of the right coronary cusp.
This is the essential view in which to measure the LVOT diameter to calculate the aortic valve area.
 

Parasternal Long Axis

Color Doppler

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Color Doppler shows that there is just mild aortic insufficiency and trace mitral regurgitation. Note the turbulent flow in systole across the aortic valve. There is aliasing of the color flow since the velocities are very high.

Parasternal Short Axis

Zoom on Aortic Valve,
2D View

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A magnified short axis view of the aortic valve shows there are 3 cusps; they are moderately calcified with limited movement during systole. It is important to confirm there are 3 cusps, especially in individuals who are younger who may have bicuspid valves.

Parasternal Short Axis

Color Doppler

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Color Doppler here again shows turbulence in systole. There is also some trace inconsequential pulmonic valve insufficiency seen toward the top of the color window.

Apical 5 Chamber

2D View

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The 5 chamber view shows the calcified aortic valve, and overall normal LV function, which was confirmed in other views as well.
This view, along with the apical long axis/3chamber view is the main view in which to assess LVOT and aortic valve velocities.

Apical 5 Chamber

Color Doppler

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Color Doppler here illustrates the trace to mild aortic regurgitation and the increased flow from a laminar blue color to highly turbulent, multi-color at the level of the aortic valve.

Apical 5 Chamber

Pulsed Wave Doppler, LVOT

 

Place the cursor in the LVOT below the aortic valve and measure the velocity. We see the flow is largely laminar and here the VTI has been traced out, giving value calculated at 19.5cm.

Apical 5 Chamber

Continuous Wave Doppler

 

CW Doppler must be used across the aortic valve in cases of severe stenosis since the velocities will be too high for PW Doppler. Note here the peak velocity is 4.8 m/sec. The VTI was calculated to be 139 cm with a peak gradient of 93 mmHg and mean gradient of 53 mmHg. It is important to remeasure this with CW in multiple views.  The valve area here is calculated out to 0.5cm^2 by VTI. Click here to review how to calculate this.
 

Apical 3 Chamber

Color Doppler

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This view, the apical long axis or 3 chamber view is another view in which to measure with PW and CW the LVOT and aortic valve velocities respectively.  In addition the CW-only probe (Piedoff probe) can be used in the right parasternal position. The goal of measuring this multiple times is to find out what is the true, highest gradient. Lower gradients in some views suggest that you may be off axis to the direction of the turbulent jet.

Parasternal Long Axis

Summary of Findings

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This case reviewed the major findings seen in senile calcific AS and the views needed to take the appropriate measurements to calculate the aortic valve area (AVA). For more information how to calculate AVA, see the aortic stenosis section on the echo calculator page.
This individual has preserved LV function with critical AS, with a valve area of 0.5 cm, peak gradient of 93 mmHg and mean gradient of 53 mmHg.