Aortic Stenosis: LVOT Obstruction

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1 Aortic Stenosis: LVOT Obstruction Raymond Stainback, MD 7 th annual Houston Echo Review 2016: Boot Camp for the Echo Board

2 Murmur: Additional heart or vascular sound due to normal or abnormal turbulent blood flow heard during auscultation Innocent murmur: most innocent murmurs are soft (less than or equal to grade 2/6), heard in early systole, characterized as crescendo-decrescendo type, and may vary with position consistent with normal blood flow including but not limited to: Still s murmur pulmonary flow murmur physiologic peripheral pulmonary stenosis (peds) supraclavicular arterial bruit venous hum Pathologic murmur: suggestive of a cardiovascular abnormality (not clearly innocent including but not limited to: diastolic holosystolic late systolic > grade 3/6 systolic continuous (other than venous hums) harsh provoked or become louder with changes in position (e.g., squatting to standing) or strain phase of Valsalva maneuver

3 Normal Aortic Valve TTE Anterior TEE IAS Posterior LA TV RA RVOT R N L PV RA TV N L R RVOT PV IAS LA Posterior Anterior TEE TTE TEE

4 Aortic Stenosis Valvular Subvalvular Supravalvular

5 Aortic Stenosis Valvular Subvalvular Supravalvular

6 Valvular Aortic Stenosis Recognition by 2D exam Morphological Clues to Etiology Doppler Severity Assessment Gradient Valve Area Technical Considerations

7 Common Valvular AS Acquired Congenital Rheumatic

8 Congenital AS Bicommissural Notice patient s age < 15 yrs 60% unicuspid yrs60% bicuspid >65 yrs 90% tricuspid Weyman Principals & practice of echo pg 511 Acquired, not congenital

9 M-mode, Aortic Valve

10 Calcific AS

11 Bicuspid Aortic Valve

12 Bicuspid Aortic Valve 1-2 % of pop. males 4:1 (isolated defect) assoc. PDA, Coarct.Ao (20%) AS, AI, AoRoot aneurysm, SBE

13

14 Rheumatic Aortic Stenosis

15 Rheumatic Aortic Valve

16 AS Severity Spectral Doppler analysis CW Doppler Peak Velocity Timing of Peak Velocity (shape of envelope) Peak Gradient Mean Gradient Pulsed Doppler Dimensionless Index Valve Area by Continuity Equation Valve Area by Planimetry (2D)

17 Weyman Principals & practice of echo pg 521

18 Severity By Doppler Alone Mean Grad > 50 mmhg Severe Mean Grad mmhg Uncertain Use Continuity Equation! Peak Grad. < mm Hg (normal LV) mild Peak Vel. > 4 m/sec likely Severe

19 Weyman Principals & practice of echo pg 516 Early Peak Mid peak 2.4 m/s 4.0 m/s 5.0 m/s 5.8 m/s Nl - mild Mod Severe

20 Prospective study of asymptomatic AS: clinical echo & exercise predictors of outcome. Otto, et al Circ 1997:95

21 Aortic Gradient Peak Gradient varies dramatically with: HR Blood Pressure Stroke volume Inotropic state Therefore, Aortic Valve Area calculation is the most reliable echocardiographic indicator of Severity

22 AS Severity 2006 Area, cm2 Mean grad. mm Hg Peak Vel. m/s Mild 1.5 <25 3 Mod Severe <1.0 >40 > 4 ACC/AHA Practice Guidelines JACC, Aug 1, 2006

23

24 2014 AHA / ACC Guideline for Valvular Heart disease

25 Weyman Principals & practice of echo pg 525

26 Continuity Equation AVA = CSA LVOT x (VTI LVOT / VTI AoV ) п 3.14 circle = п r 2 AVA = п(d/2) 2 x (VTI LVOT / VTI AoV ) OR AVA = (D 2 x 0.785) x (VTI LVOT / VTI AoV ) OR Either V or VTI is valid AVA = (D 2 x 0.785) x (V LVOT / V AoV )

27 LVOT diameter Diameter 2 ~Error 2

28

29 AoV Continuous Doppler, Apical

30 Pulsed Doppler: Good Sample Volume Placement Near valve, but still laminar Weyman Principals & practice of echo pg 501

31 Steerable CW, Imaging transducer Blind CW, Pedoff transducer

32 Potential Pitfall: not coaxial to flow Also: Use nonimaging CW probe The Echo Manual, 1 st Edition

33 Pitfall of Continuous Doppler: AoV Systolic velocities besides AS. which is which? MV Weyman Principals & practice of echo pg 522

34 AoV Peak Gradient? 81mm Hg 37mm Hg

35 Rhythm: Sequential regular beats! AoV Peak Gradient? 81mm Hg 37mm Hg 70mm Hg? Post PVC? PVC Regular Sinus Rhythm Irregular rhythm (Afib): Acquire 5-10 representative cycles.

36 Dimensionless Obstructive Index Vmax LVOT / Vmax AoV = DOI DOI <.25 Weyman Principals & practice of echo pg 505 suggests severe obstruction Useful: As a check High gradients in setting of high flow Unable to use continuity equation

37 Equivocal Severe AS Dobutamine stress Echo Severe AS (AoVA < 1 cm2 by Continuity Equation) Low valve gradient defilippi et al. Am J Cardiol 1995;75:191-4

38 Case: 74 yr. male Equivocal AS Baseline Dobutamine 20 ug/kg/min SV = 67 ml SV = 78 ml LVOT = 2.2 cm 2 Diagnosis: primary CM Treatment: medical mgt of HF Peak = 36 mm Hg AoV Area =.8 cm 2 Severe AS Peak = 64 mm Hg AoV Area = 1.2 cm 2 Mod AS

39 Question AoV area by continuity =.8 cm2 LVEF = 30% AoV peak gradient = 80 mm Hg Is Dobutamine stress echo needed? Yes / No

40 Question AoV area by continuity =.8 cm2 LVEF = 30% (SV = 65 ml) AoV peak gradient = 80 mm Hg Is Dobutamine stress echo needed? Despite Low LVEF, SV is normal and Peak gradient is appropriately high. Degree of AS is not equivocal. Gradient not low.

41 AoV area by continuity =.8 cm2 LVEF = 30% (stroke volume 30 ml) AoV peak gradient = 45 mm Hg Is Dobutamine stress echo needed? Yes / No

42 AoV area by continuity =.8 cm2 LVEF = 30% (stroke volume 30 ml) AoV peak gradient = 45 mm Hg Is Dobutamine stress echo needed? Yes

43 AS Severity in Doubt Everything heretofore depends upon excellent imaging What if: Discrepant Cath Data Surface echo poor Distorted LVOT One or more variables poor Valve morphology doesn t match Doppler data Irregular rhythm

44 TEE Planimetry in Calcific AS

45 AoV Planimetry by TEE Area =.9 cm 2

46 Do Not do TEE Planimetry Too calcified (edges not clear) Too High Gain settings bicuspid or congenital AS (funnel)

47 AoV area by continuity =.8 cm2 LVEF = 30% (stroke volume 30 ml) AoV peak gradient = 45 mm Hg Would TEE for AoV area (planimetry) be helpful? Yes / No

48 AoV area by continuity =.8 cm2 LVEF = 30% (stroke volume 30 ml) AoV peak gradient = 45 mm Hg Would TEE for AoV area (planimetry) be helpful? No

49 Aortic Stenosis Valvular Subvalvular Supravalvular

50

51 LV Outflow Obstruction Valvular Subvalvular Dynamic Fixed Supravalvular

52 Dynamic LVOT obstruction (HOCM / SAM)

53 Dynamic LVOT obstruction (HOCM / SAM)

54 SAM dynamic LVOT obstuction LVOT CW Late-peaking (50 mm Hg) High Velocity MR Jet (V = 7 m/s)

55

56 Systolic Notching AoV Systolic Anterior Motion (SAM)

57 LV Outflow Obstruction (differential diagnosis) Valvular Subvalvular Dynamic Fixed Supravalvular

58 Discrete Subaortic Stenosis 10% of congenital AS Membrane, Ridge, Tunnel Shone s synd. (with Ao coarct. & congen. MS)

59 Tunnel Subaortic Stenosis

60 Subaortic Stenosis: Color Flow convergence in LVOT (well below AV)

61 Apical CW Doppler 40 mm Hg Suprasternal Notch 70 mm Hg Sub-AS AR!

62 Supravalvular Aortic Stenosis Nonfamilial, sporadic (nl IQ, nl facies) Familial (auto. Dom, nl IQ, nl facies) Williams syndrome ( elfin facies, mental retardation, branch PS, elastin gene, chrom 7q22.23) 1: 20,000 births 3 Types: Hourglass Membrane Hypoplastic

63 Associated findings Supravalvular AS Supravalvular PS (often Distal) Backer. CTS.net R.Shah. Amer.J. Roent. 2000

64 Case X, apical views

65 Case X, TEE Nonfamilial, sporadic (nl IQ, nl facies)

66 Case X, TTE apical views Peak gradient = 79 mm Hg; V = 4.5 m/s

67 Pressure Recovery Weyman Principals & practice of echo Understand this concept

68 LV Outflow Obstruction (differential diagnosis) Valvular Subvalvular Dynamic Fixed Supravalvular

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