0506-245-abbas-different variants of aortic stenosis · amr e abbas, md, facc, fscai, fase, fsvm...
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Different VariantsDifferent VariantsAmr E Abbas, MD, FACC, FSCAI, FASE, FSVMDirector, Interventional Cardiology Research
Beaumont Health Associate Professor of Medicine,
OU/WB School of MedicineASCeXAM/ReASCeXAM 2018
Boston, MA
Amr E Abbas, MD, FACC, FSCAI, FASE, FSVMDirector, Interventional Cardiology Research
Beaumont Health Associate Professor of Medicine,
OU/WB School of MedicineASCeXAM/ReASCeXAM 2018
Boston, MA
Relevant Financial Relationship(s)
NoneOff Label Usage
None
Relevant Financial Relationship(s)
NoneOff Label Usage
None
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Mean Gradient (mmHg)
Valve Area (cm2)
Valve Velocity (m/sec)
Mild <25 >1.5 2-2.9
Moderate 25- 40 1.0-1.5 3-3.9
Severe >40 <1.0 > 4.0Bonow RO, et al. Circulation, 2008
Area Gradient MatchArea Gradient Match
iAVA < 0.6 cm/m2 Nishimura, et al. Circulation, 2014
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Mean Gradient (mmHg)
Valve Area (cm2)
Valve Velocity (m/sec)
Mild <20 >1.5 2 - 2.9
Moderate 20- 39 1.0-1.5 3 - 3.9
Severe >40 <1.0 > 4.0 Nishimura, et al. Circulation, 2014
Area Gradient MismatchArea Gradient Mismatch
iAVA < 0.6 cm/m2Bonow RO, et al. Circulation, 2008
Mean Gradient (mmHg)
Valve Area (cm2)
Valve Velocity (cm/sec)
Mild <20 >1.5 2 – 2.9
Moderate 20-39 1.0-1.5 3 – 3.9
Severe >40 < 1.0 > 4.0Nishimura, et al., Circulation 2014
Reverse Area Gradient MismatchReverse Area Gradient Mismatch
Bonow RO, et al. Circulation, 2008
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Determining the “True” SeverityDetermining the “True” Severity
Area (cm2)Gradient(mmHg)
Flow Amount/Direction
(l/min)
Pressure Recovery
Doppler Catheterization
Global LV After LoadClinical Presentation
Aortic ValveAortic Regurgitation
Measurement ErrorsMust be Excluded
•GOA Vs. EOA•Doppler Vs. Catheter•Factors affecting Gradient•Area/Gradient Mismatch•Reverse Area Gradient
Mismatch
•GOA Vs. EOA•Doppler Vs. Catheter•Factors affecting Gradient•Area/Gradient Mismatch•Reverse Area Gradient
Mismatch
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Left Ventricle
GOA
EOA
Aorta
Vena Contracta
Aortic Valve
LVOT
EOACath
B
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Evangelista Torricelli
1608-1647
Evangelista Torricelli
1608-1647
Georg Simon Ohm
1789-1854
Georg Simon Ohm
1789-1854
Q
RV2V1
A1A2A3
V3
V 1,2&3 VelocityA 1,2&3 AreaQ FlowR ResistanceP1,2&3 PressureD Distance
P2P1
D
P3
Aortic StenosisAS
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Daniel Bernoulli1700-1782
Daniel Bernoulli1700-1782
P1-P2 = 1/2ρ(V22-V1
2)
P1&V1= proximal to obstructionP2&V2= distal to obstructionρ=mass density of bloodR=viscous resistanceμ = viscosity
Convective acceleration+
ρ ∫max (dv/dt) * ds Flow acceleration+R(μ) Viscous Friction
V1 P1
V2P2
Bernoulli EquationBernoulli Equation
Short TubeNon-LaminarAcceleration
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Pressure Energy In Ventricle
Pressure Energy In Ventricle
Kinetic Energy
Aortic Valve
Kinetic Energy
Aortic Valve
Pressure Energy
Aorta
Pressure Energy
Aorta
Heat & Friction
Turbulence& Vortices
Lost
Doppler Gradient: ΔPmax
Catheter Gradient: ΔPnet
Pressure Recovery
Pressure Gradient
Doppler/Catheter Concordance
GOA
Doppler Catheter
Catheter Gradient
Doppler Gradient
EOA
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Upcoming ConceptsUpcoming Concepts• For a given AV GOA
The Gradient can be variableThe EOA can be variable(Derived from gradient)The Area and Gradient may not matchThe Doppler and Catheter measures may
not match
• For a given AV GOAThe Gradient can be variableThe EOA can be variable(Derived from gradient)The Area and Gradient may not matchThe Doppler and Catheter measures may
not match
• Described in 30 subjects; 14 had significant AR• Compared only to Fick and single plane CO
angiography
• Described in 30 subjects; 14 had significant AR• Compared only to Fick and single plane CO
angiography
1985
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•Described in 10 subjects•Extrapolated to aortic valve•Described in 10 subjects•Extrapolated to aortic valve
• Doppler
•MIG = 4V22 -4V1
2
•MIG= 4V22
• Use MIG = 4V22 -4V1
2
•V1 > 1.5 m/second
•V2 < 3 m/second
• Doppler
•MIG = 4V22 -4V1
2
•MIG= 4V22
• Use MIG = 4V22 -4V1
2
•V1 > 1.5 m/second
•V2 < 3 m/second
B
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• Catheterization
• Peak to Peak
• Pmean Catheter
• Doppler
• MIG (4V22 -4V1
2)
• Pmean Doppler
• MIG always > PPG
• Pmean Doppler -Pmean Catheter = Prec
• Catheterization
• Peak to Peak
• Pmean Catheter
• Doppler
• MIG (4V22 -4V1
2)
• Pmean Doppler
• MIG always > PPG
• Pmean Doppler -Pmean Catheter = Prec
B
Not Pressure RecoveryNot Pressure Recovery
•LV Pressure: Peak 200 mmHg•Aortic Pressure: Peak 150 mmHg•Cath Peak to Peak: 50 mmHg•Doppler Velocity: 4.5 m/second•Doppler Maximum Instantaneous
Gradient: Peak: 81
•LV Pressure: Peak 200 mmHg•Aortic Pressure: Peak 150 mmHg•Cath Peak to Peak: 50 mmHg•Doppler Velocity: 4.5 m/second•Doppler Maximum Instantaneous
Gradient: Peak: 81
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Pressure RecoveryPressure Recovery
•Catheterization Gradient = Mean 40 mmHg
•Doppler Mean Gradient = 50 mmHg
•Pressure Recovery = 10 mmHg
•Catheterization Gradient = Mean 40 mmHg
•Doppler Mean Gradient = 50 mmHg
•Pressure Recovery = 10 mmHg
•Area•Flow•Jet Eccentricity•Aortic root diameter•Global LV afterload
•Area•Flow•Jet Eccentricity•Aortic root diameter•Global LV afterload
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• There is an inverse quadratic relationship: Area & MG
• ∆P = Q2/(K x EOA2)
• There is an inverse quadratic relationship: Area & MG
• ∆P = Q2/(K x EOA2)160
140
120
100
80
60
40
20
250 ml/sec
• Direct quadratic relationship: Flow & MG• Low Flow: SVI < 35ml/m2
• Low Flow rate < 200-250 ml/s
• Direct quadratic relationship: Flow & MG• Low Flow: SVI < 35ml/m2
• Low Flow rate < 200-250 ml/s
160
140
120
100
80
60
40
20
250 ml/sec125 ml/sec
40 mmHg
AVA 0.7 cm2
AVA 1.0 cm2
AVA 1.5 cm2
250 ml/s125 ml/s
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Left Ventricle
GOA
EOA
Aorta
Vena Contracta
Aortic Valve
LVOT
Gradient: 40 mmHg
Left Ventricle
GOA
EOA
Aorta
Vena Contracta
Aortic Valve
LVOT
Gradient: 24 mmHg
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A: EDV = 115, ESV = 45, SV= 115-45 = 70 mlBSA = 1.79EF = 70/115 = 60%SVI = 39 ml/m2
B: EDV = 85, ESV = 35, SV= 85- 35= 50 mlBSA = 1.79EF = 50/85 = 60%SVI = 28 ml/m2
A
A
B
B
115 85
3545
EDV
ESV
Systole DiastoleTVI = 20cm
Systole DiastoleTVI = 20cm
Echo = Stroke volumeCath = Flow rate
Similar SV with different flow rates due to different
SEP
Moderate AS will have a lower SEP and a higher flow rate than a patient with severe AS despite similar stroke volume
Flow Rate Stroke Volume
SystolicEjection Period
=
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• Eccentric Jet Up to 30° Higher Gradient. • Jet squeezed against aorta. More pressure loss &
less pressure recovery, Bicuspid valves/radiationVel 0.7 m/s, MG 23 mmHg, EOA 0.2
• Eccentric Jet Up to 30° Higher Gradient. • Jet squeezed against aorta. More pressure loss &
less pressure recovery, Bicuspid valves/radiationVel 0.7 m/s, MG 23 mmHg, EOA 0.2
Color Jet occupies the entire aorta indicating a central jet
emanating across the AV
Color Jet occupies only ½ of the aorta indicating an eccentric jet
emanating across the AV
• The smaller the aortic root, the less energy loss, the more the pressure recovery, the lower the catheter gradient.
• This effect plateaus at a diameter of STJ 30 mm (area 7 cm2)
• The smaller the aortic root, the less energy loss, the more the pressure recovery, the lower the catheter gradient.
• This effect plateaus at a diameter of STJ 30 mm (area 7 cm2)
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AS
BPAS
High BP
Low BP
Moderate AS and low compliance = Severe AS and normal compliance
Z VA = SBP + Mean Gradient = (xx) mmHg/mlꞏm-2
Stroke Volume IndexZ VA = 150 mmHg + 26 mmHg = 5.5mmHg/mlꞏm-2
32 ml/m2
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Courtesy Heidi Connolly
Normal Ejection FractionNormal SV & Flow Rate
AVA<1cm2
ΔPmean>40mmHg
Area Gradient Match
Area/Gradient Mismatch Area/Gradient Mismatch
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Area Gradient MismatchArea Gradient Mismatch• Measurement Error• Assumption Error• Low Flow/Low Gradient/Low EF
area/gradient mismatch• Low Flow/Low Gradient/Normal
EF area/gradient mismatch
• Measurement Error• Assumption Error• Low Flow/Low Gradient/Low EF
area/gradient mismatch• Low Flow/Low Gradient/Normal
EF area/gradient mismatch
Measurement Errors: LVOT DError Proportional to AVA
Measurement Errors: LVOT DError Proportional to AVA
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Measurement Errors: LVOT DError Proportional to AVA
Measurement Errors: LVOT DError Proportional to AVA
LVOT diamLVOT TVI cm
AV TVI cm
Area 1 x TVI1 = Area 2 x TVI2.785 ( )2
2.0cm
= AVA x
98
x
25
= 0.8 cm2
= 78.8 / 98AVA
= 0.65 cm2 19%If LVOT diameter 1.8 cm2
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Measurement Errors: LVOT TVIError Proportional to AVA
Measurement Errors: LVOT TVIError Proportional to AVA
Measurement Errors: AV VTIError Inversely Proportional to AVA
Measurement Errors: AV VTIError Inversely Proportional to AVA
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Measurement ErrorsCatheterization and DopplerMeasurement ErrorsCatheterization and Doppler
MG 25 mmHg MG 31 mmHg
84 Y/O NYHA III, 3/6 SEM, no S2
Measurement ErrorsCatheterization and DopplerMeasurement ErrorsCatheterization and Doppler
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Measurement ErrorsCatheterization and DopplerMeasurement ErrorsCatheterization and Doppler
MG 52 mmHgMG 44 mmHg
Flow2
Area2ΔP = 52
12= = 25
• Flow = Area x Velocity x Cc• Velocity = Cv √2g ΔP
Flow2 = Area2 x ΔP
Cv = coefficient of velocity *Note √2g = 44.3 Cc=coefficient of orifice contraction
Aortic Valve Area (cm2)
Mean Gradient(mmHg)
3.0 2.6
2.0 6.6
1.0 26
0.9 32
0.8 41
0.7 53
0.6 73
Carabello BA. NEJM 2002;346:677-682
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Area Gradient MismatchArea Gradient MismatchLow flow (normal or reduced LVEF)
Mean Gradient <30-40mmHgAVA <1.0cm2
True, Severe AS
Mild-Mod ASLow Flow
(pseudo AS)
Area/Gradient MatchAVA<1cm2
ΔPmean>40mmHg
Area/Gradient MismatchAVA<1cm2
ΔPmean<40mmHg
MIG: 100 mmHg MIG: 36 mmHg
NormalCOP
LowCOP
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Dobutamine StressProjected AVA
AV Calcium ScoreStrain Imaging
Dobutamine StressProjected AVA
AV Calcium ScoreStrain Imaging
Low Flow/Low Gradient/Low EFLow Flow/Low Gradient/Low EF
Dobutamine StressDobutamine Stress
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Baseline Dopplerhemodynamics
Mean gradient AV Area
Mean gradient AV Area
True Severe AS (D2) IIa
Pseudo Severe AS
Vmax > 4.0m/sec AVA < 1.0cm2
g g
SVI 27 - 48AVA 0.8 – 0.8 cm2
AV mean gradient 20 – 43 mmHg
True Severe AS (D2) IIa
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LVOT v = 1 m/secLVOT TVI = 16 .5 cm
LVOT v = 1.5 m/secLVOT TVI = 28.7 cm
SVI 34 – 59 ml/m2AVA 0.9 –1.5 cm2
AV mean gradient 19 – 23 mmHg
Pseudo
Severe AS
•62 y/o male•STEMI and subsequent CABG five years ago
•Recurrent heart failure x 3 months
•62 y/o male•STEMI and subsequent CABG five years ago
•Recurrent heart failure x 3 months
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2.2cm
TVI = 14cm
Stroke Volume = CSA x TVI = 0.785 ( )2 X
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Vel= TVI=
0.8m/sec
Vel= TVI=
3.2m/sec
AreaAV0.785 ( 2.2cm) 2 x ( )
=
14cm
57cm
LVOT Aortic Valve
Velocity=0.8m/sTVI=14cm
Velocity=3.2m/sTVI=57cm
LVOT Aortic Valve
Velocity=1.3m/sTVI=24cm
Velocity=5.0m/sTVI=90cm
SV= 53mlAVA=0.9cm2
SV= 91mlAVA=1.0cm2
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Mean AV Gradient24 – 52mmHg
Valve Area0.9cm2 – 1.0cm2
LV Stroke Volume 53– 91ml
Projected AVAProjected AVA
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Qmean =Stroke VolumeLV ejection time
= AVArest + VC x (250- Qrest)
Valve Compliance (VC) =AVApeak - AVArest
Qpeak - Qrest
LVOT
Aortic Valve
Velocity=0.8m/sTVI=14cm
Velocity=3.0m/sTVI=56cm
LVOT
Aortic Valve
Velocity=1.3m/sTVI=24cm
Velocity=5.0m/sTVI=90cm
ET=0.31 ET=0.28
SV= 53mlAVA=0.9cm2
Qmean=171ml.s-1
SV= 91mlAVA=1.0cm2
Qmean=325ml.s-1
AVAproj = 0.96cm2
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Stroke Flow RateStroke Flow Rate
LVOT
Velocity=0.8m/sTVI=14cm
LVOT
Velocity=1.3m/sTVI=24cm
SV= 53mlAVA=0.9cm2
ET=0.31Qmean= 53/0.31 = 171ml.s-1
SV= 91mlAVA=0.9cm2
ET=0.28Qmean= 91/0.28 = 325ml.s-1
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n Rest AVA, cm2 Stress AVA, cm2 p value
Q < 200 ml/s 48 0.74+0.12 0.89+0.25 <0.001
Q > 200 ml/s 19 0.85+0.09 0.89+0.12 0.19
Interpretation: If normal resting flow rate, the corresponding AVA is likely to be represent the true hemodynamic severity of the stenosis and further “flow correction” with SECHO is not likely required.
J Am Coll Cardiol Img 2015
AV Calcium ScoreAV Calcium Score
Low Flow/Low Gradient/Low EFLow Flow/Low Gradient/Low EF
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Impact of Aortic Valve Calcification,as Measured by MDCT, on Survivalin Patients with Aortic Stenosis
J Am Coll Cardiol 2014;64:1202-13
Aortic Valve Calcium Burden1. 1651 AU previous study2.>1200 (1600) AU (W), >2000 (3000)AU (M)3. 300 AU/cm2 (W), 500 AU/cm2 (M)4.Less Likely: <800 AU (W), <1600 AU (M)
Strain ImagingStrain Imaging
Low Flow/Low Gradient/Low EFLow Flow/Low Gradient/Low EF
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J Am Coll Cardiol Img 2014;7:1151-66
CaseCase•75 year old male
• Presents with dyspnea and syncope
• HTN (treated BP 150/75)
• Grade III/VI mid peaking systolic murmur LSB
•75 year old male
• Presents with dyspnea and syncope
• HTN (treated BP 150/75)
• Grade III/VI mid peaking systolic murmur LSB
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Normal EF Area Gradient MismatchNormal EF Area Gradient Mismatch
• LVEF 55%• AV Mean G26mmHg• AVA 0.8cm2
• AVA index 0.45cm2/m2
• LVEDV 88ml• SVi 32 ml/m2
• LVEF 55%• AV Mean G26mmHg• AVA 0.8cm2
• AVA index 0.45cm2/m2
• LVEDV 88ml• SVi 32 ml/m2
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• So why is the Flow Low?Preload: Small LV volume (LVH)Contractility: Despite EF normal, contractility (&EF) impaired for degree of LVH
Afterload: Global LV afterload (Valve and Vascular)
• So why is the Flow Low?Preload: Small LV volume (LVH)Contractility: Despite EF normal, contractility (&EF) impaired for degree of LVH
Afterload: Global LV afterload (Valve and Vascular)
Normal EF Area Gradient MismatchNormal EF Area Gradient Mismatch
1. Is the patient symptomatic?(exercise testing)
3. Is the patienthypertensive?2. Is the stenosis
severe?
4. GLS/contractility& Diastolic Function/RWT? 5. Other Causes of Low Flow?
Mitral regurgitation
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AV Calcium ScoreStrain Imaging
Stroke Flow Rate
AV Calcium ScoreStrain Imaging
Stroke Flow Rate
Low Flow/Low Gradient/NL EFLow Flow/Low Gradient/NL EF
Novel Classification of AS with Normal EF
Novel Classification of AS with Normal EF
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Reverse Area/Gradient Mismatch
Reverse Area/Gradient Mismatch
Courtesy Heidi Connolly
Elevated Gradient Despite non-critical AS
Reverse Area/Gradient MismatchAVA>1cm2
ΔPmean>40mmHg
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Causes of Reverse A/G MismatchCauses of Reverse A/G Mismatch
• Errors of Measurement• High Flow• Pressure recovery• Eccentric Jet• Para-valvular Obstruction• Prosthetic-valve specific
• Errors of Measurement• High Flow• Pressure recovery• Eccentric Jet• Para-valvular Obstruction• Prosthetic-valve specific
Errors of MeasurementsEccentric Mitral
Errors of MeasurementsEccentric Mitral
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Mitral Regurgitant Jet Versus Aortic Stenosis Jet
Mitral Regurgitant Jet Versus Aortic Stenosis Jet
• Mitral regurgitation occupies IVC and IVR• Mitral regurgitation occupies IVC and IVR
High FlowHigh Flow
• Aortic regurgitation• Hyperdynamic states (dialysis, anemia)• Dimensionless Index B
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Pressure RecoveryPressure RecoveryGOA 1.1 cm2
DopplerPmean = 34 mmHgEOA = 0.6 cm2
CatheterizationPmean = 18 mmHgEOA = 1 cm2
APR= 34-18 = 16
Energy Loss IndexEnergy Loss Index• Energy loss Co-efficient
ELCo = AVA x AAaAAa-AVA
• AVA = aortic valve area, AAa = aortic area• Energy loss index: ELCo/BSA• ELI < 0.52-0.76 cm2 has poor outcomes and severe
AS• More significant with increase flow and moderate
aortic stenosis
• Energy loss Co-efficientELCo = AVA x AAa
AAa-AVA• AVA = aortic valve area, AAa = aortic area• Energy loss index: ELCo/BSA• ELI < 0.52-0.76 cm2 has poor outcomes and severe
AS• More significant with increase flow and moderate
aortic stenosis B
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Pressure Recovery/High FlowPressure Recovery/High Flow
GOA 1.3 cm2
EOA = 0.6 cm2
AAd = 2.2 cm
AAa = 3.8 cm2
ElCo = 3.8x0.6/3.8-0.6
Eccentric JetEccentric Jet
•Case:•29 y/o male•Carries a diagnosis of Asymptomatic severe AS
•Quit Law School
•Case:•29 y/o male•Carries a diagnosis of Asymptomatic severe AS
•Quit Law School
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Cardiac Catheterization Pmean = 50 mmHg, AVA 1 cm2
AVA=2.61 cm2
Pmean = 57 mmHgMIG = 91 mmHg
Eccentric JetEccentric Jet
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Aortic Diameter = 4.0 cm Eccentric Jet
Eccentric Jet: EchoEccentric Jet: Echo
Para-valvular ObstructionPara-valvular Obstruction
•Sub-Aortic membrane•Hypertrophic Obstructive
Cardiomyopathy•Supravalvular Obstruction•Mitral valve Prosthesis
•Sub-Aortic membrane•Hypertrophic Obstructive
Cardiomyopathy•Supravalvular Obstruction•Mitral valve Prosthesis
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Membrane
AV
AVmax= 4.1 m/sMIG = 65 mmHgPMean= 39 mmHg
Progressive DiseaseOther congenital anomalies in 50%
VSD/PDA/CoarctationShone’s ComplexBicuspid AVleftsided-SVC
Types: Membrane, fibromuscular ridge, Diffuse tunnel narrowing, mitral tissue
May Cause aortic regurgitationTreatment: SurgeryNo symptoms: Catheter LVOT-A peak/Doppler Mean = 50 mmHgSymptoms: Catheter LVOT-A peak/Doppler Mean = 30-50 mmHgAdults may use Doppler Peak > 50 mmHgResection/Konno procedure B
B
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Alcohol Septal Ablation or SurgeryHigh Risk features
ICD
Non-Familial SporadicWilliam syndrome:
Elfin FacialHypercalcemiaBehavioralDiagnosed by CVS and fetal echo
Familial SporadicCoronary anomaliesTypes: Hour glass, Membrane, Diffuse narrowing: Surgery
B
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• In addition to AVA and ΔPmean
Flow SVI < 35 ml/m2, Flow rate < 200 ml/s
Flow eccentricity
Pressure Recovery/ AV morphology
• Think of global afterload in AS to the LV: Mixed AV disease/HTN
regardless of symptoms
• Area and Gradient may not match
• Echo/Cath/AV morphology provide complimentary NOT identical
data
• In addition to AVA and ΔPmean
Flow SVI < 35 ml/m2, Flow rate < 200 ml/s
Flow eccentricity
Pressure Recovery/ AV morphology
• Think of global afterload in AS to the LV: Mixed AV disease/HTN
regardless of symptoms
• Area and Gradient may not match
• Echo/Cath/AV morphology provide complimentary NOT identical
data
Multimodality Approach Multimodality Approach
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CONCLUSIONSCONCLUSIONS• For a given AV GOA
The Gradient can be variableThe EOA can be variable(Derived from gradient)The Area and Gradient may not matchThe Doppler and Catheter measures may
not match
• For a given AV GOAThe Gradient can be variableThe EOA can be variable(Derived from gradient)The Area and Gradient may not matchThe Doppler and Catheter measures may
not match