Imaging Assessment of Aortic Stenosis/Aortic Regurgitation
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1 Imaging Assessment of Aortic Stenosis/Aortic Regurgitation Craig E Fleishman, MD FACC FASE The Heart Center at Arnold Palmer Hospital for Children, Orlando SCAI Fall Fellows Course 2014 Las Vegas
2 Disclosure Information Echocardiographic assessment of Aortic Stenosis/Aortic Regurgitation Craig E Fleishman MD, FACC, FASE As a faculty member for this program, I disclose the following relationships with industry: (GRS): Grant/Research Support (C): Consultant (SB): Speaker s Bureau (MSH): Major Stock Holder (AB): Advisory Board (E): Employment (O):Other Financial or Material Support None
3 Goals Aortic Valve Aortic Stenosis Aortic Regurgitation Example
4 Aortic Valve Valve extends from ventricle to sinotubular junction Leaflets attached in semilunar fashion Interdigitation of sinus and ventricle No ring-like annulus
5 Sinutubular junction Ventricular attachment Courtesy Dr. Robert Anderson
6 Semilunar hinge Sinutubular junction Arterial wall Ventricular in ventricle muscle Virtual basal in sinus ring Anatomic ventriculo-arterial junction Courtesy Dr. Robert Anderson
7 Left Ventricular Outflow Tract Obstruction Subvalvar 33% Supravalvar 17% Valvar 50%
8 Aortic Valve Morphology
9 Aortic Valve Morphology Congenital bicommissural valve (2% incidence) Most common congenital lesion Unicommissural Tricommissural dysplastic Doming Thickened leaflets with restricted mobility
10 Dysplastic Aortic Valves
11 Aortic Valve Stenosis
12 Aortic Valve Stenosis
13 3-D Echo after balloon aortic valvuloplasty
14 Aortic Valve Stenosis - Doppler Peak Doppler Mean Doppler (mmhg) (mmhg) Mild <36 (3 m/s) <25 Moderate Severe >64 (4 m/s) >40 Extremely Severe >100 >60 Critical Left ventricular dysfunction Ductal dependent Severity
15 Critical Aortic Stenosis Thickened and domed aortic leaflets Nearly immobile Post stenotic dilatation LVH Echogenicity from EFE Decreased LV function Dec cardiac output Dec Doppler grad
16 Echocardiographic Assessment of Severity Indirect signs LV mass LV mass/volume LA hypertension Doppler Peak Instant. Gradient Mean Systolic Gradient Tissue Doppler, Strain Aortic Valve area Planimetry Continuity
17 Aortic Valve Stenosis - Doppler Pre-balloon Post-balloon
18 Advantages of Doppler Mean vs Peak Instantaneous Mean grad directly comparable to cath Mean grad not dependent on a single velocity measurement Greater accuracy and reproducibility Mean grad less affected by transvalvular flow More direct relationship to valve area
19 Cath: Peak to Peak Echo: Peak Instantaneous Beekman et al AJC 1992;69:813
20 Aortic Valve Area Continuity equation SVAV=SVLVOT AVA X VTIAV =CSALVOTX VTILVOT AVA= (CSALVOTXVTILVOT ) / VTIAV Baumgartner et al. JASE 2009;22:1-23
21 Aortic Valve Area Continuity Equation Potential Error Inaccurate measurement LVOT diameter Error is squared Error in proximal velocity Doppler Area = Effective Orifice Area Planimetry Area = Anatomic Orifice Area
22 Aortic Valve Imaging - MSCT Schultz C J et al. Eur Heart J 2010;31: Published on behalf of the European Society of Cardiology. All rights reserved. The Author For permissions please journals.permissions@oxfordjournals.org.
23 Effective Aortic Valve Area 3D Echo Direct measurement Can align with eccentric orifice Change in 3D EOA correlated with acute change in aortic gradient Bharucha Tet al Echocardiography 2011;29:484-91
24 Pressure Differences (Gradients) Depends on flow of blood through a restricted orifice Interpretation: Effect of cardiac output anesthesia / sedation / agitation Effect of time Sensitive to changes in contractility anesthesia, contrast, etc Effect of intervention
25 Pressure and Flow Pressure is determined by flow and resistance Remember that both are variable and can change between echo and catheterization Vascular resistance Stenosis and Regurgitation Myocardial Contractility Volume status Hematology
26 Univentricular versus Biventricular Rhodes Score for Critical Aortic Stenosis LV to apex of heart long axis < 0.8 Indexed aortic root <3.5 cm/m2 Mitral valve area < 4.75 cm/m2 LV mass <35 g/m2 BiV Mortality 100% if 2 or more risk factors SCORE = 14.0 (BSA)+0.943(indexed Ao root) (LAR) (MVA indexed) <-0.35 predicts death with biventricular repair
27 Univentricular versus Biventricular 2006 Rhodes Score revisited/re-evaluated Revised discriminant score Ao root replaced with Ao annulus z-score MVA and LV mass removed EFE added SCORE = (BSA)+0.56 (aortic annulus z-score) (LAR) -0.79(gr 2 or 3 EFE) 6.78 <-0.65 predicts death with biventricular repair Colan SD et al.jacc;47:
28 Univentricular versus Biventricular CHSS data: 1. ascending aorta 2. Valve (at level of sinuses) 3. Length (apex to MV) in long axis. 4. Echo grade of EFE: 0-none, 1-papillary, 2pap muscles and some of the myocardium. 3 - extensive EFE. 5. Length and wt of child 6. Amount of TR 7. Prediction of management pathway that Assumesprovided that survival withbenefit single ventricle is equivalent survival to survival with biventricular circulation JTCVS 2001;121:10-27
29 Aortic Regurgiation Anatomic Variants Primary Congenital Valve Structural Ao valve abnormalities Aortico-left ventricular tunnel Absence of Ao valve cusps Associated Congenital Heart Disease VSD Subvalvar AS Truncus arteriosus Aortic Root dilation Connective Tissue disorder Genetic disorder Infection Infective Endocarditis Rheumatic Fever Ruptured aneurysm of sinus of Valsalva
30 Aortic Regurgitation Echo Severity LV Size and Function LVEDD or LVEDV, LVESD or LVESV, LV mass, EF LVESD/LVESV occurs with LV failure Indirect Doppler indicators Diastolic flow reversal in aorta AR Deceleration rate, pressure half-time Ratio of AR jet width/diameter LVOT In pediatric patients, few absolute Regurgitant Volume, Regurgitant Fraction, Effective echo predictors Regurgitant Orifice Area for intervention have been identified
31 Aortic Regurgitation Integrative Approach LV Size Aortic leaflet changes Jet width in LVOT Vena Contracta width Flow quantitation Regurg volume and fraction Effective ROA AR Jet Pressure half-time, slope Diastolic flow reversal in descending aorta
32
33 Aortic Regurgitation
34 Aortic Regurgitation - Guidelines Zoghbi et al. JASE 2003;16:
35 Aortic Regurgitation Multi-modality Cardiac MRI Cardiac CT
36 Case Example - Newborn
37 Case Example - Newborn
38 Case Example After Balloon Dilation Good News! Bad News
39 Case Example After Balloon Dilation
40 Case Example After Balloon Dilation
41 Thanks!
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