1. ECHOCARDIOGRAPHIC ASSESSMENT OF STENOTIC VALVULAR LESIONS
DEEPAK NANDAN

2. AORTIC VALVE Area-2.6-3.5 cm². Structure
ANATOMY
Area cm².
Structure
3 cusps,3 commissures supported by fibrous annulus
Arantius nodule
3 sinuses

4. 2D-IMAGE Qualitative diagnosis Thin and delicate
Plax-opening and closing
Basal short axis view-Y-inverted Mercedes Benz sign

9. Doppler assessment Maximum jet velocity BERNOULLI’s equation
Multiple windows
Parallel alignment
Colour doppler
Angle correction

11. Pressure gradients-Instantaneous vMean
MIPG=4 xV²(maximal jet velocity)m/s
MPG=4x(∑V1²+V2²+…Vn²)/n
MPG=∆P(max)/
MPG=2.4(Vmax)²

14. Bernoulli's VS invasive
Discrepancies
Tech poor doppler recording
Non parallel interrogation angle
Pressure grad depends on flow rate & valve narrowing –AR/LV dysfunction

15. Aortic valve area Continuity equation:- SV (lvot)= SV (Ao) SV=CSAxTVI
CSA (lvot) xTVI (lvot)=CSA (Ao) x TVI (Ao)
AVA=CSA x TVI (lvot) / TVI (Ao)

18. Correlates well with invasive data (GORLINS)
Adv compared to Berrnoulli
co-existing AR
Left ventricular dysfunction

19. AVA-Direct planimetry
Rarely are all 3 leaflets imaged perpendicular
Triangular shape- measurement error
Deformities n irregularities- further exacerb
AV- superior-inferior rapid moments
0.25 cm2 margin

20. DOBUTAMINE ECHO Ao valve area≈Ao flow rate
Dist- true severe valvular stenosis (vs) mild to mod stenosis with LV dysfn
Stepwise infusion of dobutamine(5— 30µg/kg/min)

21. Flexible valves:- AVA ↑ when SV ↑
True stenotis:- AVA↔ when SV ↑
Flexible valves:-Vmax(lvot)/jet ↑
True stenosis:-Vmax(lvot)/jet↔
Safe& clinically useful, limitation- non response to dobutamine

23. Stress findings of severe stenosis
AVA<1cm²
jet velocity>40m/s
mean gradient>40mm of Hg
Lack of contractile reserve-
failure of LVEF to ↑ by 20% is a poor prognostic sign

24. M- mode Maximal aortic cusp separation (MACS) Limitations
Vertical distance between right CC and non CC during systole
Stenotic AV → decreased MACS
Limitations
Single dimension
Asymmetrical AV involvement
Calcification / thickness
↓ LV systolic function
↓ CO status

25. AVA
MACS
N > 2cm2
N > 15 mm
< cm2
< 8 mm
> 1 cm2
> 12 mm
gray area
8 – 12 mm

26. OTHER APPROACHES Ao valve resistance-
flow independent measure of stenosis severity
Resistance=(∆P/∆Q)mean x1333
Resistance=28√gradient( mean)/AVA

27. Left ventricular stroke work loss(SWL)
SWL (%) = (100 ×∆ P mean) / (∆P mean + SBP)
Principle-LV expends work during systole to keep the AV open and to eject blood into the aorta
Depends on the stiffness of AV
Less dependent on the flow
>25%--- poor outcome

28. LVOT TVI recorded too close to valve Hgh transAo flow rate mod-sev AR
Discrepencies in AS severity assessment Severe AS by gradient Severe by area
LVOT overestimated
LVOT TVI recorded too close to valve
Hgh transAo flow rate
mod-sev AR
Hgh output state
Large body size
LVOT underestimated
LVOT TVI-too far frm val
Small body size
Lw transAo flw rate
low EF
small vent chamber
mod-sev MR
mod-sev MS

29. APPROACH Valve anatomy, etiology Exclude other LVOTO
Stenosis severity – jet velocity
mean pressure gradient
AVA – continuity eq
LV – dimensions/hypertrophy/EF/diastolic fn
Aorta- aortic diameter/ assess COA
AR – quantification if more than mild
MR- mechanism & severity
Pulmonary pressure

30. NATURAL HISTORY mean 7mm Hg AVA ↓ by 0.1 to ∓ 0.19cm²
Av ↑in MPG per yr = 0 to 10mm/yr
mean 7mm Hg
AVA ↓ by 0.1 to ∓ 0.19cm²
Jet vel < 3m/s – rate of symptom onset needing MVR is 8 % /yr
3-4m/s – 17%/yr
>4m/s – 40% /yr

31. MITRAL STENOSIS

32. Mitral valve-anatomy Mitral annulus The leaflets
Chordae tendinae-papillary muscle
Underlying ventricular wall

34. Annulus

35. Leaflets Anterior- three scallops Posterior- three scallops
Scallop 1-lateral most
Scallop 3-medial most

36. LEAFLETS & SCALLOPS

38. Chordae and papillary muscles
Antero lateral PM- chordae to AL half of both leaflets
Dual blood supply
Postero medial PM- chordae to PM half both leaflets
RCA blood supply

40. 2d echo-features
Maximal excursion of leaflet tips
Tubular channel

41. RHEUMATIC MS Commissural fusion⇒doming/bowing
Chordal thickening ⇒ abnormal motion
Progressive fibrosis⇒stiffening
⇒calcification

43. Mitral stenosis 2D Doming of the mitral valve (hockey stick AML)
Funnel shaped opening of mitral valves
Focal thickening and beading of leaflets
calcification

44. early diastolic doming motion of the AML, restriction of tip motion
early diastolic doming motion of the AML, restriction of tip motion. Pliable, little fibrosis, calcification, or thickening. Dilated LA

49. 2D-Planimetry

50. 2D short axis imaging of diastolic orifice
-planimetry
Smallest orifice at the leaflet tips
Inner edge of the black/white interface traced
Correlates well with hemodynamic assessment

51. Technical factors Funnel-shaped Actual limiting orifice at the tip
Instrumentation setting
‘’blooming” of the echoes due to increased gain

53. M-mode assessment

55. Increased echogenicity of leaflets
Decreased E-F slope
>80mm/s⇒MVA =4-6cm²
<15mm/s⇒MVA <1.3cm²
Paradoxical anterior motion of PML

57. Doppler assessment Volume status Heart rate
Trans mitral pressure gradient
single most imp factor in determining the severity & relation to symptoms & functional status
Depends on
Volume status
Heart rate

58. Early trans mitral flow volume
Cardiac output
High output states
Mitral reguritation
Mean pressure gradient
Average MVA
Peak pressure gradient

61. Pressure half time Measure of rate of decay of mitral valve gradient
Time in ms at which initial instant pr gradient declines to one half
Time interval from V max to the point where velocity has fallen to Vmax/√2

62. PHT=½ Peak=V½
V½=Vmax/√2
V½=V max/1.414
V½=Vmax x .707
MVA=220/PHT

64. Limitation Post BMV- accuracy ↓
Aortic regurgitation- over estimates MVA
Severe LVH- ↓LV compliance
Prosthetic mitral valve- not validated

65. PHT
Independent of
Cardiac output
Mitral regurgitation

66. Deceleration time Pressure half time=29% of Deceleration time
MVA=220 ÷ (0.29 × DT)
MVA=759 ÷ DT

67. Secondary features of MS
Left atrial dilation
Atrial fibrillation
Spontaneous echo contrast
LA thrombus
Secondary pulm htn-TR

69. Echo approach to MS Valve morphology
Exclude other causes of clinical presentation
MS severity
Mean transmitral pr gradient
2D valve area
PHT valve area
Assos MR
LA enlargement
Pulmonary art pressure
Co-existing TR severity
TEE for LA clot

72. Individuals with score≤8 –excellent for BMV
Those with score≧12-less satisfactory results

73. THANK YOU