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 severity3,5

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 (Vmax) 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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