Daniel W Mason MD FACC FASE

Echocardiography
Currently, TTE and occasionally TEE are
the diagnostic tools most commonly used to
evaluate the AV, with visualization of the
leaflets, evaluate the other valves, look at the
right side and estimate pressures, look at the
aorta, quantitate the degree of stenosis, and
evaluate lv function.
Imaging
Not talked about very much, but still very
important. The majority of times we can see
leaflet thickening, calcification, and restriction.
In congenital AS you may see good leaflet
mobility and still have significant AS as much of
the stenosis is just at the orifice and the leaflets
may be pliable.
But in adults if you see the leaflets moving
well, you won’t have much stenosis, ie you can
rule it out on appearance alone many times.
Quantification is more difficult, but always make a
guess just based on appearance. It is reassuring if
it matches doppler data.
Planemetry
The simplest way to get a valve area, but
you need a good window, a good short axis
view, and it helps to not have much calcium
which will give side lobe artifacts. TEE can
really help here.
Hemodynamic Evaluation
Doppler has certainly added dramatic
amounts of information to echo. I am not
going to review echo physics, CW vs. PW and
how this translates into gradients and flow,
but if anyone is not certain about this come to
me privately.
I really feel that to be comfortable with
your report on valvular lesions, you need to be
comfortable with the formulas and use them
repeatedly. There are many ways to make
significant mistakes, which could have serious
results for your patients.
FORMULAS
πR 2
= area of circle

πR 2=
π(1/2D)2 = 1/4πD2 = 0.785D2

Area of circle = 0.785D2

FORMULAS
Area x Length = Volume

L
FORMULAS
If flow through a cylinder were constant,
we can easily measure volume if we know
velocity, time, and diameter.
FORMULAS
L=VxT
V

T
FORMULAS
Then, if we know diameter, we can
calculate area of the cylinder. Multiply this
by the length and we get a volume

V = area x length.

In this case, L would be the length of the

cylinder described by flow over that time
(T), and could be referred to as stroke
distance, the distance the fluid traveled
over that period of time.
FORMULAS
But flow is not constant, it’s velocity is
constantly changing, so how can we
measure volume. What would Sir Isaac
Newton have done? Calculus? Integrate?
VTI
V

T
VTI
The integral of the curve in essence is taking
the average velocity during that time, and
multiplying it by the time of the systolic
period, giving us stroke distance.
MORE FORMULAS
AVA x TVIav = Arealvot x TVIlvot
AVA = Arealvot x (TVIlvot/ TVIav)
Using Maximal velocities of the aortic
valve and lvot gives a reasonable
approximation of the area.
Ratio’s of TVI’s or maximal velocities
(DOI) are most helpful when it is
difficult to measure a diameter
(calcium or prosthesis)
Major Sources of Error
Alignment of the transducer
Accurate measurements
Atrial fib
Positioning of the PW sampling volume.
Confusion with mitral regurgitation
Confusion with HOCM
LVOT diameter vs AVA (DOI 0.3)
1.8 cm 0.76 cm2
2.0 cm 0.94 cm2
2.2 cm 1.14 cm2
2.4 cm 1.4 cm2
 So always look to see that the numbers
make sense. Look at the LVOTd, the LVOTTVI,
and the gradient. Be familiar with normal
values. A quick check for lvot dimension is to
compare the DOI with the AVA.
Another useful check is to look at left
ventricular function and compare it to the lvot
TVI and max V.
Finally, compare your gradients and valve
areas with the appearance of the valve and be
sure you are comfortable with it.
If not sure, make it clear there is
uncertainty in the report.
LV Dysfunction
This is a risk factor but does not preclude
a surgical approach. Pseudo-stenosis is
secondary to a poor cardiac output, so that
mild to moderate stenosis may calculate to
be severe. (I think of it as a weak ventricle
that can’t open a “stiff” valve ).
Poor LV reserve suggest increased risk,
but is also not an absolute contraindication.
Dobutamine helps us define this. Good
reserve usually means the LVOTtvi will increase
at least 20% with dobutamine.