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1 Different Variants Amr E Abbas, MD, FACC, FSCAI, FASE, FSVM Director, Interventional Cardiology Research Beaumont Health Associate Professor of Medicine, OU/WB School of Medicine ASCeXAM/ReASCeXAM 2018 Boston, MA Relevant Financial Relationship(s) None Off Label Usage None 1
2 Area Gradient Match Mean Gradient (mmhg) Valve Area (cm 2 ) Valve Velocity (m/sec) Mild <25 > Moderate Severe >40 <1.0 > 4.0 iava < 0.6 cm/m 2 Nishimura, et al. Circulation, 2014 Bonow RO, et al. Circulation,
3 Area Gradient Mismatch Mean Valve Gradient Area (mmhg) (cm 2 ) Valve Velocity (m/sec) Mild <20 > Moderate Severe >40 <1.0 > 4.0 iava < 0.6 cm/m 2 Bonow RO, et al. Circulation, 2008 Nishimura, et al. Circulation, 2014 Reverse Area Gradient Mismatch Mean Valve Gradient Area (mmhg) (cm 2 ) Valve Velocity (cm/sec) Mild <20 > Moderate Severe >40 < 1.0 > 4.0 Nishimura, et al., Circulation 2014 Bonow RO, et al. Circulation,
4 Determining the True Severity Area (cm 2 Gradient Global LV ) After (mmhg) Load Measurement Errors Clinical Presentation Aortic Valve Aortic Regurgitation Doppler Flow Amount/Direction (l/min) Catheterization Must be Excluded Pressure Recovery GOA Vs. EOA Doppler Vs. Catheter Factors affecting Gradient Area/Gradient Mismatch Reverse Area Gradient Mismatch 4
5 Cath Aorta Vena Contracta Aortic Valve Left Ventricle EOA EOA GOA LVOT B 5
6 Evangelista Torricelli Georg Simon Ohm Aortic Stenosis V 1 Q AS V 3 R V 2 A1 P 1 A 3 P 2 A 2 V 1,2&3 A 1,2&3 Q R P 1,2&3 D Velocity Area Flow Resistance Pressure Distance P 3 D 6
7 Daniel Bernoulli Bernoulli Equation P 2 V 2 P1-P2 = 1/2ρ(V 22 -V 12 ) Short Tube Non-Laminar Acceleration V 1 P 1 Convective acceleration + ρ max (dv/dt) * ds Flow acceleration + R(μ) Viscous Friction P1&V1= proximal to obstruction P2&V2= distal to obstruction ρ=mass density of blood R=viscous resistance μ = viscosity 7
8 Pressure Recovery Turbulence & Vortices Pressure Energy In Ventricle Kinetic Energy Heat & Doppler Gradient: Aortic Valve ΔP Friction max Doppler/Catheter Concordance Pressure Energy Catheter Gradient: Aorta ΔP Lost net Pressure Gradient Catheter Gradient GOA EOA Doppler Catheter Doppler Gradient 8
9 Upcoming Concepts For a given AV GOA The Gradient can be variable The EOA can be variable (Derived from gradient) The Area and Gradient may not match The Doppler and Catheter measures may not match 1985 Described in 30 subjects; 14 had significant AR Compared only to Fick and single plane CO angiography 9
10 Described in 10 subjects Extrapolated to aortic valve Doppler MIG = 4V 2 2-4V 2 1 MIG = 4V 2 2 Use MIG = 4V 2 2-4V 2 1 V 1 > 1.5 m/second V 2 < 3 m/second B 10
11 Catheterization Peak to Peak P mean Catheter Doppler MIG (4V 2 2-4V 12 ) P mean Doppler MIG always > PPG P mean Doppler -P mean Catheter = P rec B Not Pressure Recovery LV Pressure: Peak 200 mmhg Aortic Pressure: Peak 150 mmhg Cath Peak to Peak: 50 mmhg Doppler Velocity: 4.5 m/second Doppler Maximum Instantaneous Gradient: Peak: 81 11
12 Pressure Recovery Catheterization Gradient = Mean 40 mmhg Doppler Mean Gradient = 50 mmhg Pressure Recovery = 10 mmhg Area Flow Jet Eccentricity Aortic root diameter Global LV afterload 12
13 There is an inverse quadratic relationship: Area & MG P = Q 2 /(K x EOA 2 ) ml/sec Direct quadratic relationship: Flow & MG Low Flow: SVI < 35ml/m 2 Low Flow rate < ml/s ml/sec 250 ml/sec AVA 0.7 cm ml/s 40 mmhg 250 ml/s AVA 1.0 cm 2 AVA 1.5 cm 2 13
14 Aorta Gradient: 40 mmhg Vena Contracta Aortic Valve Left Ventricle EOA GOA LVOT Aorta Gradient: 24 mmhg Vena Contracta Aortic Valve Left Ventricle EOA GOA LVOT 14
15 A: EDV = 115, ESV = 45, SV= = 70 ml BSA = 1.79 EF = 70/115 = 60% SVI = 39 ml/m 2 B: EDV = 85, ESV = 35, SV= 85-35= 50 ml BSA = 1.79 EF = 50/85 = 60% SVI = 28 ml/m 2 A EDV A ESV B B Moderate AS will have a lower SEP and a higher flow rate than a patient with severe AS despite similar stroke volume Echo = Stroke volume Cath = Flow rate Systole TVI = 20cm Similar SV with different flow rates due to different SEP Diastole Systole TVI = 20cm Flow Rate Diastole = Stroke Volume Systolic Ejection Period 15
16 Eccentric Jet Up to 30 Higher Gradient. Jet squeezed against aorta. More pressure loss & less pressure recovery, Bicuspid valves/radiation Vel 0.7 m/s, MG 23 mmhg, EOA 0.2 Color Jet occupies the entire aorta indicating a central jet emanating across the AV Color Jet occupies only ½ of the aorta indicating an eccentric jet emanating across the AV The smaller the aortic root, the less energy loss, the more the pressure recovery, the lower the catheter gradient. This effect plateaus at a diameter of STJ 30 mm (area 7 cm 2 ) 16
17 AS High BP AS BP Low BP Moderate AS and low compliance = Severe AS and normal compliance Z SBP + Mean Gradient = (xx) VA = 150 mmhg + 26 mmhg = 5.5mmHg/mlm -2 Stroke 32 ml/m Volume 2 Index 17
18 Area Gradient Match Normal Ejection Fraction Normal SV & Flow Rate AVA<1cm 2 ΔP mean >40mmHg Courtesy Heidi Connolly Area/Gradient Mismatch 18
19 Area Gradient Mismatch Measurement Error Assumption Error Low Flow/Low Gradient/Low EF area/gradient mismatch Low Flow/Low Gradient/Normal EF area/gradient mismatch Measurement Errors: LVOT D Error Proportional to AVA 19
20 Measurement Errors: LVOT D Error Proportional to AVA LVOT diam 2.0cm LVOT TVI 25 cm AV TVI 98cm Area 1 x TVI 1 = Area 2 x TVI ( ) 2 x = AVA x AVA = 78.8 / 98 If LVOT diameter 1.8 cm 2 = 0.8 cm 2 = 0.65 cm 2 19% 20
21 Measurement Errors: LVOT TVI Error Proportional to AVA Measurement Errors: AV VTI Error Inversely Proportional to AVA 21
22 Measurement Errors Catheterization and Doppler MG 25 mmhg MG 31 mmhg 84 Y/O NYHA III, 3/6 SEM, no S2 Measurement Errors Catheterization and Doppler 22
23 Measurement Errors Catheterization and Doppler MG 44 mmhg MG 52 mmhg Carabello BA. NEJM 2002;346: Aortic Valve Area Mean Gradient Flow (cm = Area x Velocity x Cc 2 ) (mmhg) Velocity 3.0 = Cv 2g 2.6 ΔP 2.0 Flow 2 = Area x ΔP ΔP = Flow Area 2 = = Cc=coefficient 0.7 of orifice contraction Cv = coefficient of velocity *Note 2g =
24 Area Gradient Mismatch Low flow (normal or reduced LVEF) Mean Gradient <30-40mmHg AVA <1.0cm 2 True, Severe AS Mild-Mod AS Low Flow (pseudo AS) MIG: 100 mmhg MIG: 36 mmhg Normal COP Low COP Area/Gradient Match AVA<1cm 2 ΔP mean >40mmHg Area/Gradient Mismatch AVA<1cm 2 ΔP mean <40mmHg 24
25 Low Flow/Low Gradient/Low EF Dobutamine Stress Projected AVA AV Calcium Score Strain Imaging Dobutamine Stress 25
26 Baseline Doppler hemodynamics Vmax Mean > 4.0m/sec gradient AVA < 1.0cm AV Area 2 True Severe AS (D2) IIa Mean gradient AV Area Pseudo Severe AS True Severe AS (D2) IIa SVI AVA cm2 AV mean gradient mmhg 26
27 LVOT v = 1 m/sec LVOT TVI = 16.5 cm LVOT v = 1.5 m/sec LVOT TVI = 28.7 cm Pseudo Severe AS SVI ml/m2 AVA cm 2 AV mean gradient mmhg 62 y/o male STEMI and subsequent CABG five years ago Recurrent heart failure x 3 months 27
28 2.2cm TVI = 14cm Stroke Volume = CSA x TVI = ( ) 2 X 28
29 Vel= TVI= 3.2m/sec 57cm Vel= TVI= 0.8m/sec 14cm Area AV ( 2.2cm) 2 x ( ) = LVOT Velocity=0.8m/s TVI=14cm LVOT Velocity=1.3m/s TVI=24cm SV= 53ml AVA=0.9cm 2 SV= 91ml AVA=1.0cm 2 Aortic Valve Velocity=3.2m/s TVI=57cm Aortic Valve Velocity=5.0m/s TVI=90cm 29
30 LV Stroke Volume 53 91ml Mean AV Gradient 24 52mmHg Valve Area 0.9cm 2 1.0cm 2 Projected AVA 30
31 = AVA rest + VC x (250- Q rest ) Valve Compliance (VC) = AVA peak - AVA rest Q peak - Q rest Q mean = Stroke Volume LV ejection time LVOT LVOT Velocity=0.8m/s TVI=14cm Aortic Valve Velocity=3.0m/s TVI=56cm ET=0.31 SV= 53ml AVA=0.9cm 2 Q mean =171ml.s -1 AVA proj = 0.96cm 2 SV= 91ml AVA=1.0cm 2 Q mean =325ml.s -1 Velocity=1.3m/s TVI=24cm Aortic Valve ET=0.28 Velocity=5.0m/s TVI=90cm 31
32 Stroke Flow Rate LVOT LVOT Velocity=0.8m/s TVI=14cm SV= 53ml AVA=0.9cm 2 ET=0.31 Q mean = 53/0.31 = 171ml.s -1 Velocity=1.3m/s TVI=24cm SV= 91ml AVA=0.9cm 2 ET=0.28 Q mean = 91/0.28 = 325ml.s -1 32
33 n Rest AVA, cm 2 Stress AVA, cm 2 p value Q < 200 ml/s <0.001 Q > 200 ml/s Interpretation: If normal resting flow rate, the corresponding AVA is likely to be represent the true hemodynamic severity of the stenosis and further flow correction with SECHO is not likely required. J Am Coll Cardiol Img 2015 Low Flow/Low Gradient/Low EF AV Calcium Score 33
34 Impact of Aortic Valve Calcification, as Measured by MDCT, on Survival in Patients with Aortic Stenosis Aortic Valve Calcium Burden AU previous study 2.>1200 (1600) AU (W), >2000 (3000)AU (M) AU/cm 2 (W), 500 AU/cm 2 (M) 4.Less Likely: <800 AU (W), <1600 AU (M) J Am Coll Cardiol 2014;64: Low Flow/Low Gradient/Low EF Strain Imaging 34
35 J Am Coll Cardiol Img 2014;7: Case 75 year old male Presents with dyspnea and syncope HTN (treated BP 150/75) Grade III/VI mid peaking systolic murmur LSB 35
36 Normal EF Area Gradient Mismatch LVEF 55% AV Mean G26mmHg AVA 0.8cm 2 AVA index 0.45cm 2 /m 2 LVEDV 88ml SVi 32 ml/m 2 36
37 So why is the Flow Low? Preload: Small LV volume (LVH) Contractility: Despite EF normal, contractility (&EF) impaired for degree of LVH Afterload: Global LV afterload (Valve and Vascular) Normal EF Area Gradient Mismatch 1. Is the patient symptomatic? (exercise testing) 2. Is the stenosis severe? 3. Is the patient hypertensive? 4. GLS/contractility & Diastolic Function/RWT? 5. Other Causes of Low Flow? Mitral regurgitation 37
38 Low Flow/Low Gradient/NL EF AV Calcium Score Strain Imaging Stroke Flow Rate Novel Classification of AS with Normal EF 38
39 Reverse Area/Gradient Mismatch Elevated Gradient Despite non-critical AS Reverse Area/Gradient Mismatch AVA>1cm 2 ΔP mean >40mmHg Courtesy Heidi Connolly 39
40 Causes of Reverse A/G Mismatch Errors of Measurement High Flow Pressure recovery Eccentric Jet Para-valvular Obstruction Prosthetic-valve specific Errors of Measurements Eccentric Mitral 40
41 Mitral Regurgitant Jet Versus Aortic Stenosis Jet Mitral regurgitation occupies IVC and IVR High Flow Aortic regurgitation Hyperdynamic states (dialysis, anemia) Dimensionless Index B 41
42 Pressure Recovery Doppler Pmean = 34 mmhg EOA = 0.6 cm 2 GOA 1.1 cm 2 Catheterization Pmean = 18 mmhg EOA = 1 cm 2 APR= = 16 Energy Loss Index Energy loss Co-efficient ELCo = AVA x AAa AAa-AVA AVA = aortic valve area, AAa = aortic area Energy loss index: ELCo/BSA ELI < cm 2 has poor outcomes and severe AS More significant with increase flow and moderate aortic stenosis B 42
43 Pressure Recovery/High Flow EOA = 0.6 cm 2 AAd = 2.2 cm GOA 1.3 cm 2 AAa = 3.8 cm 2 ElCo = 3.8x0.6/ Eccentric Jet Case: 29 y/o male Carries a diagnosis of Asymptomatic severe AS Quit Law School 43
44 AVA=2.61 cm 2 P mean = 57 mmhg MIG = 91 mmhg Cardiac Catheterization P mean = 50 mmhg, AVA 1 cm 2 Eccentric Jet 44
45 Eccentric Jet: Echo Aortic Diameter = 4.0 cm Eccentric Jet Para-valvular Obstruction Sub-Aortic membrane Hypertrophic Obstructive Cardiomyopathy Supravalvular Obstruction Mitral valve Prosthesis 45
46 AV Membrane Progressive Disease Other congenital anomalies in 50% VSD/PDA/Coarctation Shone s Complex Bicuspid AV leftsided-svc Types: Membrane, fibromuscular ridge, Diffuse tunnel narrowing, mitral tissue B May Cause aortic regurgitation Treatment: Surgery No symptoms: Catheter LVOT-A peak/doppler Mean = 50 mmhg Symptoms: Catheter LVOT-A peak/doppler Mean = mmhg Adults may use Doppler Peak > 50 mmhg Resection/Konno procedure B AV max = 4.1 m/s MIG = 65 mmhg P Mean = 39 mmhg 46
47 Alcohol Septal Ablation or Surgery High Risk features ICD Non-Familial Sporadic William syndrome: Elfin Facial B Hypercalcemia Behavioral Diagnosed by CVS and fetal echo Familial Sporadic Coronary anomalies Types: Hour glass, Membrane, Diffuse narrowing: Surgery 47
48 Multimodality Approach In addition to AVA and ΔP mean Flow SVI < 35 ml/m 2, Flow rate < 200 ml/s Flow eccentricity Pressure Recovery/ AV morphology Think of global afterload in AS to the LV: Mixed AV disease/htn regardless of symptoms Area and Gradient may not match Echo/Cath/AV morphology provide complimentary NOT identical data 48
49 CONCLUSIONS For a given AV GOA The Gradient can be variable The EOA can be variable (Derived from gradient) The Area and Gradient may not match The Doppler and Catheter measures may not match 49
Usually we DON T need to go beyond the gradient
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