Doppler Imaging in Aortic Stenosis: The Importance of the Nonapical Imaging Windows to Determine Severity in a Contemporary Cohort

Thaden, Jeremy J.; Nkomo, Vuyisile T.; Lee, Kwang Je; Oh, Jae K.

doi:10.1016/j.echo.2015.02.016

Cited by 77 publications

(36 citation statements)

References 22 publications

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“…De Monchy (7) utiliza únicamente el AV como criterio de severidad y describe un error de clasificación entre ápex y PED de 21% (17% de leve a moderada y 4% de moderada a severa). Thaden (8) , que también utiliza criterios de severidad por AV, describe una factibilidad del PED de 81% con obtención de los valores más altos en el 50%. Si solo se utiliza el enfoque apical hay 23% de error.…”

Section: Discussionunclassified

“…La EA debe ser valorada desde diferentes enfoques (4)(5)(6) , pero son muy escasos los trabajos diseñados para cuantificar su impacto (7,8) . Las Sociedades Europeas de Ecocardiografía y de Imagen Cardiovascular y la Sociedad Americana de Ecocardiografía aconsejan, para la valoración de la estenosis aórtica (9,10) , la utilización del transductor Pedof cuando se interroga el enfoque PED.…”

Section: Introductionunclassified

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Reclasificación de la severidad de la estenosis aórtica con la utilización del enfoque paraesternal derecho con transductor ciego

2017

Rev. Urug. Cardiol.

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La severidad de la estenosis aórtica (EA) es uno de los pilares que decide la sustitución valvular. El ecocardiograma Doppler (ED) es de elección para el diagnóstico y cuantificación mediante la determinación de la velocidad máxima (VMáx), gradiente medio (GM) y área valvular (AV). VMáx y GM se obtienen desde múltiples enfoques, pero la utilización del enfoque paraesternal derecho (PED) es poco frecuente. Objetivo: determinar la magnitud de la reclasificación de la EA con la utilización del enfoque PED con transductor ciego. Método: se estudian prospectivamente pacientes con EA moderada o severa por ED desde cualquier enfoque. Se considera EA moderada: VMáx 3 a 3,9 m/s, GM 20 a 39 mmHg o AV 1,1 a 1,5 cm 2. EA severa: VMáx ³4 m/s, GM ³40 mmHg o AV £1 cm 2. Criterios de exclusión: fracción de eyección de ventrículo izquierdo (FEVI) <50%, insuficiencia valvular aórtica o mitral ³ moderada, hemoglobina (Hb) <11 g/dl. Se utilizan enfoques apical (ÁPEX), PED y subxifoideo con transductores convencional y ciego. Resultado: se incluyen 100 pacientes de 74,0 ±12 años, sexo femenino 49%, FEVI 69,1±8,4%. Por ÁPEX EA severa 56% y no severa 44%. Enfoque con gradiente más alto: ÁPEX 33/100, PED 48/100, más de un enfoque 19/100; las EA moderadas por ÁPEX son severas por PED: 18/33 (54,6%, IC 95% 36,4-71,9); leves por ÁPEX son severas por PED: 3/11 (27,3% IC 95% 6,0-61,0). PED reclasifica como severas 21 de las 44 consideradas moderadas o leves por ÁPEX (47,7% IC 95% 32,5-63,3). Conclusión: el enfoque PED obtiene los valores de gradiente más altos en 48% de los casos. En EA no severa por ÁPEX, el PED reclasifica como severa una de cada dos.

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Section: Discussionunclassified

Section: Introductionunclassified

Reclasificación de la severidad de la estenosis aórtica con la utilización del enfoque paraesternal derecho con transductor ciego

2017

Rev. Urug. Cardiol.

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“…Optimal alignment of the continuous wave Doppler beam with the direction of the aortic flow jet is crucial to accurately quantify aortic valve gradient, aortic valve area and thereby severity of AS. The apical window detects peak velocity in 40% of cases where as the right parasternal window picks up peak velocity in 50% of cases [23]. A multiwindow approach is recommended which includes apical, right parasternal, suprasternal and right supraclavicular windows.…”

Section: Echocardiographic Caveats In Estimating As Severitymentioning

confidence: 99%

Low Flow Low Gradient Severe Aortic Stenosis: Diagnosis and Treatment

Ali¹,

Wilson²,

Nair³

2019

Aortic Stenosis - Current Perspectives

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Approximately 40% of patients with aortic stenosis (AS) show discordant Doppler-echocardiographic parameters with aortic valve area (AVA) <1 cm 2 and/or index iAVA <0.6 cm 2 /m 2 (consistent with severe AS) and the mean gradient (MG) <40 mmHg, consistent with mild/moderate AS. Accurate diagnosis of true severe low flow low gradient AS versus pseudo-severe aortic stenosis is important for prognosis and optimal timing for intervention. Doppler echocardiography using intravenous low dose dobutamine challenge is widely used for differentiating pseudo-severe from true severe aortic stenosis. However, relying on echocardiography alone may have limitations in accurate diagnosis. Reliable diagnosis using echocardiography is dependent on multiple factors like the angle of interrogation of the aortic jet, the assumption that the LVOT area is circular in cross section, optimal echo windows, the presence of underlying subclinical coronary artery disease prior to dobutamine challenge etc. In this chapter, we describe non-invasive and invasive strategies to assess the aortic valve using dobutamine stress. Direct measurement of gradients across the aortic valve while estimating the change in cardiac output and aortic valve area with increments of dobutamine infusion dose is complementary, safe and useful when conventional echocardiography techniques are inconclusive. Finally, the chapter describes effective strategies of treatment for low gradient severe aortic stenosis, including the role for diagnostic balloon valvuloplasty, in the era of transcatheter valve replacement (TAVR).

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“…Thaden et al showed that in 100 consecutive patients with severe AS, the right parasternal window was superior for identifying maximal velocity. When sampling maximal velocity only from the apical window, nearly a quarter of patients were misclassified, of whom two-thirds were underestimated as moderate AS and one-third were misclassified from highgradient severe AS to low-gradient severe AS (14). Measurement of the LV outflow tract (LVOT) dimensions is measured in mid-systole at the same time in the cardiac cycle as the maximum LVOT velocity just below the insertion of the aortic valve leaflets (15), and it may have relatively high inter-observer variability (16).…”

Section: Severity Of Asmentioning

confidence: 99%

The role of echocardiography in transcatheter aortic valve implantation

Onishi

Sengoku

Ichibori

et al. 2018

Cardiovasc. Diagn. Ther.

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Transcatheter aortic valve implantation (TAVI) is an effective and less invasive treatment for the increasing population of individuals with severe aortic stenosis (AS). Echocardiography is crucial in the assessment of AS patients from pre- to post-procedure. Transthoracic echocardiography (TTE) may be used to assess patient suitability for TAVI, as well as evaluate the severity of AS, the aortic valve complex, aortic valve morphology, mitral regurgitation (MR), and left ventricular function. Transesophageal echocardiography (TEE) is usually used as an intra-procedural monitoring tool to provide feedback during the procedure, to assess prosthetic valve function, and to detect complications rapidly before and after balloon aortic valvuloplasty (BAV) or transcatheter heart valve (THV) deployment. In this review, the role of echocardiography in the pre-, intra-, and post-TAVI procedure periods is described in detail.

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Doppler Imaging in Aortic Stenosis: The Importance of the Nonapical Imaging Windows to Determine Severity in a Contemporary Cohort

Cited by 77 publications

References 22 publications

Reclasificación de la severidad de la estenosis aórtica con la utilización del enfoque paraesternal derecho con transductor ciego

Reclasificación de la severidad de la estenosis aórtica con la utilización del enfoque paraesternal derecho con transductor ciego

Low Flow Low Gradient Severe Aortic Stenosis: Diagnosis and Treatment

The role of echocardiography in transcatheter aortic valve implantation

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