Key diagnostic steps in aortic stenosis (AS) echocardiography

With an average survival rate of 50% at two years and 20% at five years, the timely and accurate diagnosis of AS is essential¹
An integrated and stepwise approach to echocardiography assessment of AS is a key diagnostic tool for confirming the diagnosis and severity of AS²
However, it is important to understand the limitations of echocardiography to avoid the underestimation of AS severity^3,5

Optimising assessments with echocardiography

Echocardiography is a key diagnostic tool for:²

Confirming the diagnosis and severity of AS
Assessing valve calcification, left-ventricle (LV) function and wall thickness
Detecting other valve disease or aortic pathology
Providing prognostic information

Current international recommendations for the echocardiographic evaluation of patients with AS rely upon measurement of mean pressure gradient (the most robust parameter), peak transvalvular velocity (V_max) and valve area²
Both the EACVI and ESC/EACTS VHD guidelines recommend a stepwise approach to assessing AS severity using echocardiography:^2,5

* High flow may be reversible in patients with anaemia, hyperthyroidism or arterio-venous fistulae, and may also be present in patients with hypertrophic obstructive cardiomyopathy. Upper limit of normal flow using pulsed Doppler echocardiography: cardiac index 4.1 L/min/m² in men and women, stroke volume index (SVi) 54 mL/m² in men, 51 mL/m² in women).

† Consider also: typical symptoms (with no other explanation), LV hypertrophy (in the absence of coexistent hypertension) or reduced LV longitudinal function (with no other cause).

‡ DSE flow reserve= >20% increase in stroke volume in response to low-dose dobutamine.

§ Pseudo-severe aortic stenosis= AVA >1.0 cm² with increased flow.

¶ Thresholds for severe aortic stenosis assessed by means of CT measurement of aortic valve calcification (Agatston units): men >3000, women >1600= highly likely; men >2000, women >1200= likely; men <1600, women <800= unlikely.

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References

AS, aortic stenosis; AVA, aortic valve area; AVR, aortic valve replacement; EACVI, European society of cardiovascular imaging; EACTS, European association for cadio-thoracic surgery; ESC, European society of cardiology; LV, left ventricle; LVEF, left ventricular ejection fraction; Pm, mean pressure gradient; sAS, severe aortic stenosis; Vmax, peak jet velocity.

* Adverse features according to clinical, imaging (echocardiography or CT scanning) and/or assessment of biomarkers.⁶

† A positive result following exercise testing is the development of symptoms or a sustained blood pressure fall below the patient’s baseline.⁶

1Otto CM. Heart 2000;84:211–218.
2Vahanian A, et al. Eur Heart J. 2021; ehab395.doi:10.1093/eurheartj/ ehab395.
3Raddatz MA, et al. Open Heart 2020;7:e001331.
4Delgado V, et al. J Am Coll Cardiol Img. 2019;12:267–282.
5Baumgartner H, et al. Eur Heart J Cardiovasc Imaging 2017;18(3):254-275.

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Key diagnostic steps in aortic stenosis (AS) echocardiography

Optimising assessments with echocardiography

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