Echo cardiographic

evaluation of aortic valve

Dr. S.R.Sruthi Meenaxshi MBBS,MD,PDF
Psax view aortic level
Parasternal short axis view – aortic level
Mercedes benz sign
PLAX view – visualisation of rcc and ncc
• Two-dimensional imaging of the normal aortic valve in the parasternal long
axis view demonstrates two leaflets (right and noncoronary)
•
• while the parasternal short axis demonstrates a symmetrical structure
with three uniformly thin leaflets that open equally, forming a circular
orifice during most of systole

• During diastole, the normal leaflets form a three pointed star with a slight
thickening or prominence at the central closing point formed by the aortic
leaflet nodules, known as the nodules of Arantius.

• The three aortic valve cusps may also be visualized in a subcostal view.
• The aortic valve is composed of three cusps: the left, right, and
noncoronary cusps.
• The left cusp guards the left sinus of Valsalva, with the left main
coronary artery arising superior to and midway between the
commissures of this cusp.
• The right cusp guards the right sinus of Valsalva, with the right
coronary artery arising anteriorly and superiorly.
• It is the most anterior cusp and is positioned immediately just
posterior to the right ventricular outflow tract. Its most rightward
commissure is adjacent to the attachment of the anterior or septal
leaflet of the tricuspid valve.
• The noncoronary cusp is located posteromedially, guards the
noncoronary sinus of Valsalva, and is adjacent to the interatrial
septum.
Sclerotic aortic valve
M mode of aortic valve
• The M-mode image of a normal aortic valve and root includes a number of
distinctive features:
●In the parasternal long axis orientation, the aortic leaflets open and close
at the midpoint of the space bounded by the anterior and posterior walls of
the aortic root
●After the opening motion, the leaflets are parallel to the aortic root and
nearly appose its wall, where they remain until the end of systole. The net
effect of these features is a "box-like" appearance of the M-mode wave
form.
•Failure of the leaflets to open widely may be seen with aortic stenosis; a
decreased stroke volume is suggested if they open widely but drift shut just
after achieving maximum separation.
M mode in aortic stenosis
• Maximal aortic cusp separation MACS
• Vertical distance between RCC and NCC during systole

AVA MACS MEASUREMENT PREDICTIVE VALUE

NORMAL VALVE < 2 CM2 NORMAL MACS MORE 100 PERCENT

THAN 15 MM

AVA >1 >12 96 PERCENT

AVA <0.75 <8 97PERCENT

GRAY AREA 8-12

Quadricuspid aortic valve
Bicuspid aortic valve
Bicuspid aortic valve
Bicuspid aortic valve
• The most common congenital cardiac abnormality is bicuspid aortic
valve
• Overtime 1/3 rd to ½ of such valve becomes stenotic

• Significant narrowing of the aortic valve orifice – typically develops in

5 th to 6 th decade of life

• Fusion of right and left coronary cusp (70-80 percent)

• Fusion of right and non coronary cusp (20-30 percent )
• Patterns of leaflet motion are helpful, and when leaflets demonstrate a
systolic "doming" pattern, the possibility of significant obstruction (or
bicuspid valve) is much greater.

• This is usually only present when the leaflets remain flexible and the
pathology is related predominantly to commissural fusion.
• Two-dimensional imaging can display the aorta distal to the valve.
• Dilatation may be present due to associated aortic disease in acquired
aortic valve disease
• Bicuspid aortic valves are associated with aortopathy and the extent of
aortic dilation is not proportional to the severity of stenosis.
M mode of bicuspid aortic valve
• Fusion of the right and left cusps is most common and may be
associated with coarctation of the aorta

• Clues to the true nature of these valves include

• apparent inequality in the size of the leaflets

• ovoid opening shape of the orifice
• and eccentricity in its position
• evere narrowing or obstruction of the aortic valve accompanied by
dyspnea, angina, or syncope has a poor prognosis. Surgical (or
percutaneous) relief by prosthetic valve implantation dramatically
improves survival in such patients.
Systolic doming seen in bicuspid aortic valve
AORTIC VALVE STENOSIS
Pathophysiology of aortic stenosis
Degenerative aortic valve
Classification based on location
1. Valvular (most common type)
2. Subvalvular
3. Supravalvular
Valvular aortic stenosis
1. calcific aortic valve disease congenital bicuspid aortic valve with
superimposed calcification
2.Age related calcific AS of normal trileaflet valve
3.Rheumatic AS

• Less common
• Congenital
• Type 2 hyperlipoproteinemia
• Ochronosis
Aortic sclerosis
• Irregular thickening of valve leaflets seen on echo but without
significant obstruction

• Preserved mobility of cusps

• Typically associated with peak doppler velocity less than 2.6 m/sec
Criteria for aortic sclerosis
• irregular nonuniform thickening of portion of the aortic valve leaflets or commissure, or
both

• thickened portions of the aortic valve with an appearance (highly echogenic) suggesting
calcification

• nonrestricted or minimally restricted aortic cusp opening

• transvalvular peak continuous wave Doppler velocity <2 m/sec

• Tissue harmonic imaging and high gain settings should be avoided when evaluating for
aortic sclerosis since these enhancements can accentuate the appearance of leaflet
thickening.
Calcific aortic stenosis of trileaflet valve
• Nodular calcific masses on the aortic side of cusps , most prominent
in the central part

• No commissural fusion

• Free edges of the cusps are not involved

• Stellate shaped systolic orifice
• Valve calcification – predictor of clinical outcome
Calcific aortic stenosis
Aortic sclerosis
RHEUMATIC AORTIC STENOSIS
• Characterised by
1. Commisural fusion’
2. Triangular systolic orifice
3. Thickening / calcification

Accompanied by rheumatic mitral valve changes

Commisural fusion hallmark of rheumatic
aortic stenosis
Subvalvular aortic stenosis
• Thin discrete membrane consisting of endocardial fold and fibrous
tissue

• A fibromuscular ridge

• Diffuse tunnel like narrowing of the LVOT

• Accessory or anomalous mitral valve

•If the leaflets close immediately and abruptly after achieving full opening,
fixed subvalvular stenosis should be considered.
If the leaflets close and reopen in the first third to one half of systole,
dynamic subvalvular obstruction should be suspected.
●While in their open systolic position, it is normal for the leaflets to exhibit
fine vibrations. The vibrations on the valve have the same timing and
frequency of an early systolic low intensity ("functional") murmur.
●During diastole, the coapted leaflets move parallel to the aortic root.
•Vibrations during diastole are highly abnormal and are characteristic of
rupture or disruption of the aortic valve.
SUPRAVALVULAR AORTIC STENOSIS
• TYPE 1 Thick fibrous ring above the aortic valve with less mobility and
has the easily identifiable HOUR GLASS APPEARANCE OF AORTA

• TYPE 2 Thin discrete fibrous membrane located above the aortic valve
• Membrane usually mobile and demonstrate doming during systole

• Type 3 Diffuse narrowing

Supravalvular aortic stenosis hour glass
appearance
Type 3 supravalvular aortic stenosis
Supravalvular aortic stenosis
Supravalvular aortic stenosis is rarely seen in adults.
• It is rarely present in isolation and is most frequently found with
Williams syndrome or homozygous familial hypercholesterolemia.
• When encountered, there is a narrowing directly above and usually
affixed to the valve leaflets.
• Features include aortic regurgitation, enlarged coronary arteries,
which are sometimes obstructed, and severe hypertrophy
• Doppler measurement of the aortic gradient may be useful to
distinguish those patients who are candidates for surgical correction
Doppler assessment of AS
• The primary hemodynamic parameters are recommended

1 peak transvalvular velocity

2 mean transvalvular pressure gradient
3 valve area by continuity equation
Peak transvalvular velocity measurements
• CW doppler
• Defined as the highest velocity signal obtained from any window after
careful examination

• Multiple acoustic window

• Apical
• Suprasternal
• Right parasternal

• More than 3 are averaged in sinus rhythm

• 5 consecutive beats with irregular rhythm
Peak transvalvular velocity
• The shape of the CW doppler velocity curve helps distinguishing the
level and severity of stenosis

• With severe stenosis maximum velocity occurs later in the systole and
the curve is more rounded in shape

• With mild stenosis – peak velocity is early in the systole triangular

in shape
Shape of the CWD velocity curve also helps in
determining whether the obstruction is fixed or
dynamic

• DYNAMIC SUBAORTIC OBSTRUCTION

• Late peaking velocity curve often with a concave upward curve in

early systole
Aortic stenosis in right parasternal and
suprasternal notch view
MEAN TRANSVALVULAR PRESSURE GRADIENT
• Gradient calculated from velocity
• Simplified Bernoulli equation

• P= 4v2
OBSTRUCTION OF LEFT VENTRICULAR
OUTFLOW
• Valvular aortic stenosis — The normal aortic valve area in adults is 3
to 4 cm2.

• As aortic stenosis develops with progressive thickening and

calcification of the leaflets, a minimal valve gradient is present until
the orifice area becomes less than half of normal.

• In general, symptoms in patients with aortic stenosis occur when the

valve area is <1 cm2 or the mean transvalvular gradient exceeds 40
mmHg
• severe narrowing or obstruction of the aortic valve accompanied by
dyspnea, angina, or syncope has a poor prognosis.

• Surgical (or percutaneous) relief by prosthetic valve implantation

dramatically improves survival in such patients.
Aortic valve area – continuity equation
• Calculation of continuity equation valve area requires three
measurements

• AS jet velocity by CWD

• LVOT diameter for calculation of a circular CSA
• LVOT velocity recorded with pulsed doppler
Calculation of aortic valve area
• The most effective method of quantitating the severity of aortic
stenosis is to calculate the valve area

• This calculation is performed by using the continuity principle, which

states that in a closed system the flow in one portion of the system is
equal to the flow in another
• According to the continuity equation, flow in the LV outflow tract (LVOT) is exactly
equal to the flow across the stenotic aortic valve. Simply stated, flow volume (Q)
measurements at serial sites in a closed system (such as the heart) should be
identical. Planimetry of the pulsed wave Doppler flow signal from the LVOT
derives theVTI, which is the distance the average red blood cell travels during
systole in the outflow tract:
• Q = AreaLVOT x VTILVOT = AVA x VTIAV

• where AreaLVOT = cross-sectional area of the LVOT, VTILVOT = velocity time integral
in the outflow tract, AVA = aortic valve area, and VTIAV = velocity time integral
across the aortic valve. The effective orifice area of the stenotic valve can
therefore be calculated after simple equation rearrangement:
• AVA = (AreaLVOT x VTILVOT) ÷ VTIAV
Severity of aortic stenosis
Severity of aortic stenosis
❖Mild – Valve area exceeds 1.5 cm2; transvalvular velocity 2.0 to 2.9
m/s; mean gradient <20 mmHg.

❖Moderate – Valve area of 1.0 to 1.5 cm2; transvalvular velocity 3.0 to

3.9 m/s; mean gradient 20 to 39 mmHg.

❖Severe – Valve area is less than 1.0 cm2; transvalvular velocity ≥4

m/s; mean pressure gradient ≥40 mmHg.
Dimensionless index
• The Doppler Velocity index or Dimensionless index is a
measure of the ratio of the LVOT velocity to the AV velocity
using CW Doppleracross the aortic valve
• It is normally higher than 0.28 but decreases with significant
aortic stenosis.
• An index of less than 0.25 generally correlates with severe
aortic stenosis.
Doppler velocity index
• The methods of estimating the severity of the aortic stenosis include
measurement of aortic valve resistance. Aortic valve resistance (AVR) can
be calculated using Doppler echocardiography based upon the following
equation

• AVR = [4 (PkVAV)2 ÷ (rLVOT2 x PkVLVOT)] x 1333

• where PkVAV = peak velocity across the aortic valve, PkVLVOT = peak velocity
through the LVOT, and rLVOT is the systolic radius of the LVOT. The cut-off for
severe AS is 280 dynes/s/cm5.
• While aortic valve resistance was initially believed to be less dependent on
flow, this claim turns out not to be true

• . Moreover, resistance is less predictive of prognosis than other measures

such as the peak velocity through the valve.
Low gradient aortic stenosis
• LOW GRADIENT AORTIC STENOSIS
• Patients with severe aortic stenosis (AS)
• left ventricular systolic dysfunction, and a
• low cardiac output often present with only modest transvalvular
pressure gradients (less than 30 mmHg).
• It has been suggested that aortic valve resistance might provide a better separation between
critical and noncritical AS, particularly in patients with low transvalvular pressure gradients
• Although valve resistance is less sensitive to flow than valve area, the resistance calculations
have not proven to be substantially better than valve area calculations alone.

• In patients with low-gradient AS (thought to be related to low flow), it can be useful to determine
the transvalvular pressure gradient and calculate the valve area and resistance during a baseline
state and again during exercise or other hemodynamic stress (for example, dobutamine infusion).

• This concept is based upon the observation that the valve area may increase during an increase in
the cardiac output in some patients with low gradient AS
• If dobutamine produces an increment in cardiac output, an increase in valve area, and a decrease
in resistance, it is likely that the baseline calculations produced an overestimation of the severity.
thankyou