Aortic valve anatomy:

- Symmetrical trilleaflet
- Semilunar valves
- Supported by aortic sinuses only
- Free edge slightly thickened
- Normal variant
o Central nodule (Nodes of Aranti)
o Lambl’s excrescences on the LOVT side with aging

Aetiology Aortic stenosis

- Rheumatic or Senile (due to age)

- Rheumatic

o Nodular free edge thickening with doming

o Commissural fusion
o Calcification
- Senile
o Calcification within body leaflet and annulus

Pathophysiology

- LVH- concentric
- Diastolic dysfunction – late stage
- LV dilation – late stage
- Aortic root dilation – post stenotic
- Coincide with other pathology eg. IHD, Hypertension
- Symptoms
o Chest pain (CP)
o Dyspnoea
o Syncope

Echocardiography on Aortic stenosis

- Valve morphology
o Aetiology: what caused the problem??
- Semi quantitative v.s. quantitative
o Aortic root size
o LV size and function
o Severity LVH
o Other associated disease such as coarctation with Bicuspid AV
o Mean and peak gradients, AV area
Discrepant data

- Gradient too low

o Poor CO, reduced stroke volume
o Non parallel CW interrogation
- Gradient too high
o Severe aortic regurgitation
o Confusion with mitral regurgitation
- AVA doesn’t fit with other data
o Poor LVOT diameter measurement
o Poor LVOT sample volume positioning
o Non- parallel CW interrogation

Distinguish MR and AS

- Using IVCT & IVRT (AS)

- MR is a leak through valve, after the valve is shuts, it leaks there should be no timing
before or after
- MR= change of pressure between LA and LV

Aortic regurgitation

Most common reason: leaflet coaptation

- Inflammatory
- Degenerative
- Annular dilation
- Prolapse

Pathology:

- Ventricle compensating in the early stage

o LV dilation
- LVH- eccentric (mass increase, wall stay the same thickness)
- LV dysfunction – late
o EF drops
o Diastolic abnormality
o Early rise in LVEDP
- Wide pulse pressure- flow reversal in aorta

Echocardiography for Aortic regurgitation

- 2D
o Valve (cause of the problem)
o Associated vessel
o Size of the heart
o Mitral valve leaflet motion (may get a flutter)
- Aortic root size- dissection? Marfan’s?
- LV size and function (LVEDV and EF)
- Colour doppler
- Length of the colour jet
o Extend to back of the chamber?
o Bear in mind the chamber size
o Width of the jet compare to LVOT diameter
o Jet direction (is it eccentric jet?)
o Colour flow reversal inarch or descending aorta
- PW/CW doppler
o Pressure half time: if sever AR it is short
o Regurgitant volume/ fraction
o ERO: regurgitant orifice size
o PW flow reversal in arch or descending aorta

Mock

- Briefly describe 2 cuspal abnormalities that may lead to AR.

Include in the answer the mechanism of the cuspal abnormality which leads to AR

o Endocarditis: perforation or destruction and leaflet

o Rheumatic fever changes
o Age related Calcification valves
- A simple qualitative technique useful for the identification of sever aortic
regurgitation is the vena contracta.
Define the vena contracta with respect to an AR jet

o Draw a diagram of Contacta and jet high

o Narrow part of the jet down stream from the orifice
- Briefly describe 2 potential limitation of the vena contracta method in the
assessment of AR
o Assumption that the regurgitation orifice is almost circular, however it is
often elliptic or irregular in shape
o The measure itself is usually very small, so small measurement errors may
lead to underestimation or overestimation of the AR severity
o VC cannot be used in the presence of multiple jets as the respective widths
are not additive
o Colour doppler display often overestimates regurgitant volume as RBCs
displaced by regurgitant jet are often incorporated into the colour
regurgitant volume displayed (eccentric hits the wall)
o Regurgitant jets are 3D and CFI may not be correctly delineated if poor jet
interrogation with ultrasound beam alignment
- The spectral doppler flow profiles are very useful in the semi quantitative (indirect)
assessment of the aortic regurgitation severity

Describe how pulsed wave and continuous wave doppler can be used to identify
severe aortic regurgitation
 o CW
 Alignment of the ultrasound beam has to be as parallel as it can be
to the AR jet in apical or PLAX
 Look for spectral intensity of the regurgitant signal to see if it’s the
same as the forward flow
 If severe, it’s the same intensity
 Pressure half time or the slope <200ms cut off and really short slope
o PW
 Descending aorta in the arch in the suprasternal window
 Place the sample volume 1cm distal to the original of LSA (left
subclavian artery)
 Sample volume size between 2-5mm
 Pan diastolic flow reversal
 End diastolic velocity > 20cm/s

 Abdominal Aorta in subcostal view

 Sample volume as parallel as possible to the aortic flow
 Sample size between 2-5mm
 Pan diastolic flow reversal
- If parameters are suggestive of more than mild aortic regurgitation, quantification of
regurgitation severity should be attempted by regurgitation volume and regurgitant
fraction
Using the stroke volume method, write the extended formula for calculating
o The aortic regurgitant volume
o The aortic regurgitant fraction
o Include appropriate units in our answer
- List 3 potential technical imitations associated with quantitative aortic regurgitant
volume calculations
o Assumption of stroke volume calculations
 Assumes flow occurring solid, regid, circular tube and that velocity
across the tube is uniform
o Errors in velocity time integral measurement
 Must trace nodal velocity
o MV PW must be at the level of annular dimension – not at tip of MVLs
o Non parallel alignment between doppler beam and flow
o Failure to optimise the doppler trace
o Presence of multivalvular lesions or shunts (not valid with significant MR
present)
o Significant learning curve of operator