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What is Aortic Stenosis?
the narrowing of the valve orifice causing an obstruction of blood flowing to the aorta.
Is there a difference between stenosis and sclerosis?
Stenosis the valve is not opening well causing a obstruction/narrowing.
Sclerotic the valve is still opening well but the valve is thickened/hardened.
What cusp of the aortic valve is affected by stenosis more commonly?
the RCC- right coronary cusp and also the NCC- Non-coronary cusp
What cusp of the aortic valve is affected by stenosis less commonly?
the LCC- left coronary cusp
What are commissures?
the spaces between the cusps
Is Aortic stenosis a pressure overload or a volume overload?
Does afterload have to do with pressure overload or volume overload?
What will happen with Chronic Aortic Stenosis?
the LV will become thick and the ejection fraction will increase. (LV will be squezzing/pumping hard because the thickened walls.
What will happen when the Aortic Stenosis has been around for a long time and has not been fixed?
the LV will become dilated and the ejection fraction with decrease. (LV will not be able to pump as hard because it is dilated).
What is the formula for Cardiac Output?
CO = SV X HR
What is Cardiac Index?
CI is a measure of left cardiac output in relation to patient size.
Based on BSA, NOT weight.
CI = CO/BSA
Normal range: 2.6-4.2 L/min/m2
What will happen to the pressure in...with Aortic Stenosis?
LV will increase. 120/10 to 200/25
AO will decrease. 120/80 to 110/75
LA will increase. 10 to 25
What is the normal pressure in the LV?
What is the normal pressure in the AO?
What is normal pressure in the LA?
Review what the Aortic Stenosis pressure curve looks like!!!
What kind of murmur is Aortic Stenosis?
Harsh systolic ejection murmur and crescendo/decrescendo.
What tells the severity of Aortic Stenosis? (by the auscultation)
the longer the duration and the later the peak
What DOES NOT tell the severity of Aortic Stenosis? (by the auscultation)
the intensity of the murmur (Grades 1-6- does not matter which one)
Where can Aortic Stenosis be heard best?
right sternal border
What does crescendo/decrescendo mean?
gets louder, then gets softer
What are three main causes of Aortic Stenosis?
How each one affect it or cause it?
1. Rheumatic disease- cusps become fibrosed and the commissures become fused together.
2. Congenital bicuspid valve- can become calcified and occurs in 2% of the population.
3. Degenerative senile aortic stenosis- occurs in patients over 65, calcification of the annulus.
What is an uncommon cause of Aortic Stenosis but can still cause it?
Congenital non-calcific aortic stenosis- no calcification on the valve.
What are 5 main symptoms of Aortic Stenosis?
- 1. Dyspnea (difficulty breathing)- pulmonary congestion.
- 2. Angina (chest pain)- blood not getting to coronary arteries.
- 3. Syncope (fainting)- blood not getting to the brain.
- 4. CHF- chronic problem that decreases ejection fraction which leads to CHF
- 5. SOB
Complications of Aortic Stenosis (Results of AS)
- 1. Pulmonary edema
- 2. Myocardial/cerebral infarcts
- 3. Sudden death
- 4. Arrhythmias
- ventricular tachycardia
- ventricular fibrillation
- complete atrio-ventricular block
How do we determine between stenosis and sclerotic aortic valve? (test wise)
Would need to put CW through the aortic valve and look for high velocities = stenosis
What are 3 Indications for surgery to fix Aortic Stenosis?
- 1. if a patient is symptomatic
- 2. if a patient is asymptomatic but has significant LVH. (surgery needs to be done before irreversible failure occurs).
- 3. A max gradient 100 mmHg or greater.
4 2D Echo Findings
- 1.) Thickened and/or calcified aortic valve leaflets.
- 2.) Restrictive leaflets motion
- 3.) LVH
- 4.) Systolic doming of aortic leaflets (curving open instead of flapping open)
Is Flutter during systole on M-Mode with Aortic Valve NORMAL OR ABNORMAL?
Is Flutter during diastole on M-Mode with Aortic Valve NORMAL OR ABNORMAL?
How will the M-Mode appear with Aortic Stenosis? (2)
- 1. May have diastolic flutter.
- 2. May be brighter and thicker
What are going to be the 2D findings of chronic aortic stenosis if the LV has already failed? (3)
- 1.) Dilated aortic root
- 2.) Dilated, hypokinetic LV
- 3.) Dilated LA due to long standing LV pressure
What will the pressure and velocity be like in the LV with Aortic Stenosis?
What will the pressure and velocity be like in the AO with Aortic Stenosis?
What can be calculated using the Bernoulli Equation related to Aortic Stenosis?
the maximum instantaeous pressure gradient.
(the max velocity at a certain specific time)
Using the pedoff probe, what will the flow direction be when in the apical 5 chamber?
below the baseline
Using the pedoff probe, what will the flow direction be when in the suprasternal notch?
above the baseline
Using the pedoff probe, what will the flow direction be when in the right parasternal?
above the baseline
What is the normal flow through the AV? (3)
- 1.) Has an early peak during systole.
- 2.) Starts 100 msec after the Q wave.
- 3.) Normal velocities range from 1-1.9 m/s.
Overestimation of the severity of AS is caused by what kind of cardiac states?
high cardiac output states
What are 3 things that cause an high cardiac output state?
Which then may cause?
- 1.) Anemia
- 2.) Pregnancy
- 3.) Aortic insufficiency
Overestimation of the severity of AS
What two test results may happen that may cause an overestimation of the severity of AS?
- 1. Low AVA (AV area) when really is LARGER.
- 2. High velocities when really Lower velocities
Underestimation of the severity of AS is caused by what kind of cardiac states?
low cardiac output states
What are 3 things that cause an low cardiac output state?
Which then may cause?
- 1.) LV failure
- 2.) Arrhythmias
- 3.) > 20 degress off of parallel to flow
What two test results may happen that may cause an underestimation of the severity of AS?
- 1. High AVA (AV area) when really is SMALLER.
- 2. Low velocities when really Higher velocities.
What is the reason that MR has a higher velocity than AS?
Because the pressure difference between the LA and LV is a bigger difference than the pressure between the LV and AO.
What are two other types of AV stenosis?
What to remember about these?
1.) Subvalvular aortic stenosis
2.) Supravalvular aortic stenosis
Not true AV stenosis but will cause increased velocities like AV stenosis.
What is Subvalvular aortic stenosis?
Located before the valve or after the valve?
- Obstruction in the LVOT area.
- Before the valve.
- 1.) Sigmoid septum
- 2.) Discrete membranous
- 3.) Diffuse fibromuscular
- 4.) Struts from a prosthetic valve
What is Supravalvular aortic stenosis?
One main cause? 3 other causes?
above the valve
- 1.) Membrane supravalvular
- 2.) Hourglass deformity
- 3.) Hypoplasia of aorta
What is considered to be the gold standard for AVA?
Can get accurate pressures.
How is TEE used with Aortic Stenosis?
Used to assess the severity of AS.
Tracing the valve area (AVA) in SAX- Planimetry
What is also done in Cath Lab when they are assessing the severity of AS?
Check the Coronary Arteries to see if they need work in case surgery for AV stenosis so can do both at the same time.
What is the negative about TEE and AV stenosis?
TEE don't get really accurate, on axis velocity measurements.
What TEE angle is used for TEE SAX?
What is usually smaller, Peak to Peak or Peak Instantaneous?
Peak to Peak
What is normal LVOT measurement?
1.8 - 2.4 cm
What is VTI a measurement of?
a measure of stroke volume or How much blood is passing through one area in one beat.
What is important to remember about getting the highest velocity with AS?
be as parallel as possible
What should you do when a patient has afib and you are checking for AS?
Take many spectral profiles and average them.