ECHO 2013 / Aortic Stenosis Quantitation It’s Not All About the Gradient
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Measurement Errors: LVOT Velocity
Underestimation of VLVOT
Too far from the valve
Doppler beam not well aligned
Overestimation of VLVOT (>1.5)
Subvalvular flow acceleration
Too far in the valve/aorta
Aortic Stenosis in Community Medical Practice:
Determinants of Outcome and Implications for
Aortic Valve Replacement
“An AVA <1.0 cm2 is the most powerful and sensitive predictor of severe outcomes”
Malouf J. J Thorac Cardiovasc Surg 2012
Case Study #1: Asymptomatic Patient with Severe AS
65 y.o. woman with calcific AS
Asymptomatic (exercise testing)
LVEF: 60%
AS severity on echo:
Peak jet velocity: 5.1 m/s (1 Yr ago: 4.8 m/s)
Peak/mean gradient: 104/64 mmHg
AVA: 0.65 cm2
Indexed AVA: 0.35 cm2/m2
Case Study #1: Look At the Valve!
Severe Aortic Valve Calcification
Valve Calcification
(≥3/4)
Rosenhek et al N Engl J Med
2000; 343:611-7
Severe Aortic Stenosis
VPeak>4 m/s
Mean gradient >40 mm Hg AVA < 1.0 cm²
Re-evaluation Undergoing CABG or
other heart surgery?
Symptoms?
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Yes |
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Equivocal |
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No |
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Normal |
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Exercise test |
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LV ejection fraction |
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Symptoms |
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BP |
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<50% |
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Normal |
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(ESC) |
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(ACC/AHA) |
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Yes |
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Very severe AS (<0.6 cm2) |
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Severe valve calcification (≥3/4) |
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(ESC) |
(ACC/AHA) |
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Rapid progression (≥0.3 m /s/yr) |
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Class I |
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Class I |
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Class IIb |
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Class I |
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Class IIa |
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Class IIb |
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No |
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Aortic Valve Replacement |
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Clinical/ echo follow-up, |
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Wait for symptoms |
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Preoperative coronary angiography |
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Look at the Aorta And Arteries
►Accounting for Pressure Recovery
►Assessing Vascular Load
Pressure Recovery
EOA
Determinants of Pressure Recovery
LVOT
EOA
AA
AORTA
A New Doppler-Echo Parameter of AS Severity that Accounts for Pressure Recovery
EOA
EOA
AA
Garcia et al, Circulation 2000 ; 101 : 765-771
Garcia et al., JACC 2003; 41:435-42
Energy loss coefficient
EOA
EOA
Pressure Recovery: Reclassification of AS Severity
Case #1
Severe
AS
Doppler |
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Aorta Diameter (mm) |
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AVA |
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(cm2) |
20 |
25 |
30 |
35 |
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40 |
45 |
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0.4 |
0.5 |
0.4 |
0.4 |
0.4 |
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0.4 |
0.4 |
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0.5 |
0.6 |
0.6 |
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0.5 |
0.5 |
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0.5 |
0.5 |
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0.6 |
0.7 |
0.7 |
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0.7 |
0.6 |
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0.6 |
0.6 |
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0.7 |
0.9 |
0.8 |
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0.8 |
0.8 |
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0.7 |
0.7 |
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0.8 |
1.1 |
1.0 |
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0.9 |
0.9 |
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0.9 |
0.8 |
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0.9 |
1.3 |
1.1 |
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1.0 |
1.0 |
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1.0 |
1.0 |
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1.0 |
1.5 |
1.3 |
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1.2 |
1.1 |
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1.1 |
1.1 |
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1.1 |
1.7 |
1.4 |
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1.3 |
1.2 |
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1.2 |
1.2 |
1.2 |
1.9 |
1.6 |
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1.4 |
1.4 |
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1.3 |
1.3 |
1.3 |
2.2 |
1.8 |
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1.6 |
1.5 |
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1.5 |
1.4 |
1.4 |
2.5 |
2.0 |
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1.7 |
1.6 |
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1.6 |
1.5 |
1.5 |
2.9 |
2.2 |
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1.9 |
1.8 |
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1.7 |
1.7 |
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Garcia et al., JACC 2003; 41:435-42