SPECIALIZED UNIVERSITY OF THE AMERICAS

Faculty of Medical Sciences

Bachelor's Degree in Radiology and Medical Imaging

Subject: English

Aortic Stenosis Imaging

Presented by:

Pineda Kathiuska 8-798-873

Gálvez Marjorie 8-973-1923

Vergara Kenneth 8-992-994

Profesor:

Arturo Britton

Panamá, October 17, 2023

FUNDAMENTALS OF PRACTICE
Aortic stenosis (AS) is obstruction of blood flow through the aortic valve. It is the most common
type of valve disease in Europe and North America. It mainly presents as calcified AS in older
adults (2-7% of the population over 65 years of age). Symptoms of aortic stenosis usually develop
gradually after an asymptomatic latent period of 10 to 20 years. In symptomatic patients with
medically treated moderate to severe aortic stenosis, death usually occurs within 5 years.

Degenerative or fibro calcifying AS is the most common native valvular disease encountered by
cardiologists. Transthoracic echocardiography is the imaging modality of choice for noninvasive
evaluation due to its wide availability, its superior assessment of flow hemodynamics, and the
extensive research data available. The diagnosis of severe AS is currently based on 3 hemodynamic
parameters: peak jet velocity, mean pressure gradient across the aortic valve, and aortic valve
area.

Antegrade systolic velocity across the narrowed aortic valve, or aortic jet velocity, is measured
using continuous wave Doppler ultrasound. The mean transvalvular pressure gradient is calculated
by averaging the instantaneous gradients over the ejection period, a feature included in clinical
instrument measurement packages that use the plotted velocity curve. Aortic valve area by
calculation of the continuity equation has been validated in clinical and experimental studies and
has been described as a valuable parameter for the prediction of clinical outcome and clinical
decision making.

Imaging of the aortic valve is essential to establish a diagnosis, classify severity, and inform the
timing of valve intervention. According to the American College of Radiology (ACR) in its
Appropriateness Criteria for Preinterventional Planning for Transcatheter Aortic Valve
Displacement (TAVI), preinterventional imaging with echocardiography and CT is essential for
procedure planning and selection. of the device, with MR angiography playing a complementary
role. Three-dimensional cross-sectional imaging has been shown to help reduce procedural
complications such as vascular access injury, paravalvular regurgitation, and coronary obstruction.

ECHOCARDIOGRAPHY
Echocardiography is the preferred imaging test for aortic stenosis. Transthoracic echocardiography
is the main imaging technique used to diagnose AS. Echocardiography is essential to evaluate the
degree of LV hypertrophy, systolic ejection performance, and aortic valve anatomy (see image
below).

A complete echocardiographic report should contain information on aortic valve morphology and
mobility (bicuspid versus tricuspid), the cause and severity of AS (including aortic valve area, mean
gradient, and peak aortic jet velocity).) and its consequences on left ventricular function (i.e.,
stroke volume, left ventricular ejection fraction, and diastolic function), left atrial pressure,
valvular artery impedance, and pulmonary artery pressure.
Doppler interrogation of the aortic valve uses the modified Bernoulli equation to assess the
severity of stenosis. As blood flows from the body of the LV through the stenotic valve, the flow
rate must be accelerated so that the volume remains constant. Doppler interrogation of the valve
detects this increase in velocity and helps estimate the valve gradient. In summary,
echocardiography can demonstrate the following findings:

 Concentric LV hypertrophy

 Reduced aortic valve cusp separation

 Mean gradients greater than 50 mm Hg in patients with severe aortic stenosis on Doppler
echocardiography

CHEST X-RAY
Chest x-rays may show several significant findings consistent with aortic stenosis. The aortic valve
may appear calcified. With simple imaging, calcification is best detected in the lateral view. Aortic
valve calcification is found in almost all adults with hemodynamically significant aortic stenosis.

The VI may be slightly enlarged, with a rounded apex; This is a nonspecific finding. The left atrium
may also be enlarged. Calcification visible on plain chest radiographs usually indicates a gradient of
50 mm Hg or more across the valve, which is severe enough to require surgery.

CT SCAN
CT scans may show enlargement of the aortic valve cavity and calcification. This calcification is a
reliable indicator of severe stenosis, especially when present in a young patient.

MAGNETIC RESONANCE IMAGING

The application of cardiovascular MRI in the evaluation of AS includes anatomical evaluation of the
aorta and aortic valve, quantification of LV volumes, mass, and function, and calculation of
stenotic jet velocity. The 3 standard measurements used to establish the severity of AS are valve
area, peak velocity, and pressure gradient.

Cine-MRI can be used to depict the signal gap caused by high-velocity jet flow through a narrow
valve orifice associated with the open valve in aortic stenosis. The signal void is projected onto the
ascending aorta in systole. Despite the good anatomical detail that can be obtained with MRI,
echocardiography has replaced MRI due to its greater portability.