Aortic Valve Disease

Pauline Seydak
Clinical Physiology Trainer
 Normal AV
The aortic valve controls the direction of blood flow from
the left ventricle to the aorta.
The aortic valve has three flaps, called "cusps," or
leaflets that open and close.
During ventricular systole, pressure rises in the left
ventricle. When the pressure in the left ventricle rises
above the pressure in the aorta, the aortic valve opens,
allowing blood to exit the left ventricle into the aorta.
When ventricular systole ends, pressure in the left
ventricle rapidly drops. When the pressure in the left
ventricle decreases, the aortic pressure forces the
aortic valve to close. 2
 Aortic Cusps Coronary arteries

A feature to note is the presence

of three aortic sinuses, one for
each cusp. These are indentations,
or bulges, in the aortic root which
change the fluid dynamics of the
valve significantly. It is believed
that the sinuses cause the
formation of vortices that aid in
valve closure. Two coronary
arteries branch out from two of the
sinuses, termed the left coronary
sinus and right coronary sinus. The
other sinus is called the non-
coronary or posterior sinus. The
cusps are named accordingly.
 Malfunctions
If the valve does not open fully, it
will obstruct the flow of blood.
This is called valve stenosis.
If the valve does not close
properly, it will allow blood to leak
backwards. This is called valve
incompetence or
regurgitation.
Heart valves can have both
malfunctions at the same time
(regurgitation and stenosis). Also,
more than one heart valve can be
affected at the same time.
 Cause of Heart Valve Disease
The main causes of heart valve disease
Being born with an abnormal
valve or valves (congenital heart
disease)
The effects of rheumatic fever
Ageing of the heart
Cardiomyopathy
Ischaemic heart disease or
A previous infection with
endocarditis
 Aortic Stenosis
Aortic stenosis (AS), also called
aortic valve stenosis, is a condition
in which the aortic valve has become
narrowed or constricted (stenotic)
and does not open-and-close
properly. The leaflets may be
calcified, thickened, have reduced
mobility and thus restricted opening.
A common congenital abnormality of
the heart is the bicuspid aortic valve.
In this condition, instead of three
cusps, the aortic valve has two
cusps.
 Supravalvular/Subvalvular
Occasionally the obstruction does not
involve the Aortic valve B itself but
consists of a narrowing of the
passage either above Supravalvular
A
or below Subvalvular it.
Supravalvular: The narrowing is in
the Aorta itself immediately above B C
the valve A
Subvalvular: The narrowing occurs
within the Left Ventricular Outflow
tract below the Aortic valve C
 Stenotic AV

When the aortic valve becomes stenotic, it

causes a pressure gradient between the left
ventricle (LV) and the aorta. The more
constricted the valve, the higher the gradient
between the LV and the aorta.
For instance, with a mild AS, the gradient
may be 30 mmHg. This means that, at peak An aortic valve that, due to
rheumatic heart disease, has
systole, while the LV may generate a
a severe stenosis (centre of
pressure of 140 mmHg, the pressure that is image). The pulmonary trunk
transmitted to the aorta will only be 110 is seen at the lower right (of
the image).
mmHg. a pressure difference of 30mmHg
 Assessing Aortic Stenosis
1. Appearance of valve: Look at number of cusps,
degree and distribution of thickening and cusp
mobility. These may give a clue to the etiology:
Clues to etiology Systolic Closure Associated
in Aortic Bowing Line Features
Stenosis
Calcific degeneration No Central ----------
Bicuspid Yes Eccentric Ascending aortic
dilitation; coarctation
Rheumatic Yes Central Mitral involvement

2. Assess left ventricle: look for left ventricular

hypertrophy which suggests(but does not prove)
severe stenosis
3. Doppler Measurements
 Number of AV Leaflets/Cusps
During systole, the anterior and
posterior cusps move away from each
other and open to form a box-like
opening or parallelogram shape.
During diastole the 3 cusps form a
central closure line in the aortic
lumen.The closure line is nearly
equidistant from the anterior and
posterior aortic walls
In AS, the closure line and box like
opening are replaced by multiple thick
dense echoes. Individual cusps and
their motion are hard to decipher.The
size of box-like opening is reduced
 Appearance of Valve Leaflets
A
Valve leaflets thicken due to
fibrosis with or without
calcification. This effects their
mobility and excursion.
In Rheumatic AS, the process PLAX view calcification of Leaflets
starts in the leaflets with fusion
of commissures followed by B
secondary calcification of
leaflets and annulus(Fig. A)
In Calcific AS, the process starts
with calcification of the annulus
and progresses medially to PSAX view calcification of annulus

involve the leaflets (Fig. B)

 LV Hypertrophy
The left ventricle initially
compensates for increased
resistance caused by aortic
stenosis by thickening to help
eject blood through the stenotic
aortic valve into the aorta. The
myocardium (muscle) of the LV
undergoes hypertrophy (increase
in muscle mass). The type of
hypertrophy most commonly seen
in AS is concentric hypertrophy,
meaning that all the walls of the LV
are (approximately) equally
thickened.
 Doppler Measurements
Doppler echocardiography is the
recommended initial test for patients with
classic symptoms of aortic stenosis.
It is helpful for estimating:

Maximum/peak aortic velocity: APX apical 5-chamber view

Peak and mean transvalvular gradients:

Aortic valve area.

These are the primary measures for

SSN suprasternal notch
assessing disease severity.
Multiple windows need to be examined to
obtain parallelism between the Doppler
beam and aortic flow and thus to estimate
the true peak aortic velocity (Vmax). RPS right parasternal window
Aortic flow velocity by Doppler echo
Aortic flow is estimated by placing
the Doppler cursor just beyond the
aortic valve (subvalvular) in the
apical five chamber view.
If the velocity is high as in AS,
continuous wave (CW) Doppler has
to be used to avoid aliasing.
A good estimate requires that the
cursor and the jet has a parallel
alignment. Angle correction can be
applied using built in software in
most echocardiographic machines.
Errors will be high if the mal-
alignment is more than 20 degrees.
 Bernoulli,s Equation
Using the velocity of the blood
through the valve, the pressure
gradient across can be calculated
by use of: Bernoulli's equation
This is a complex formula that
relates the pressure drop (or
gradient) across an obstruction
to many factors. For practical use
in Doppler echocardiography a
modified formula is used in two
forms:
Short modified Bernoulli
Long modified Bernoulli
 Short modified Bernoulli equation
V1
This short form can be used
when subvalvular V1 is much less
than transvalvular V2 velocity, V2
e.g. moderate or severe AS
(v2>3.0m/s) but not mild aortic
stenosis or normal functioning
replacement valves.
The formulae is:

P = 4V2 mmHg
Gradient = 4(velocity) mmHg
The formula's are inbuilt in the
equipment software.
 Long modified Bernoulli equation
If the Vmax (peak velocity) is <
3.0m/sec either avoid estimation of
pressure drop altogether or use
the long form of the Bernoulli
equation.
This will require a pulsed Doppler
measurement in the Left Peak AV Velocity
Ventricular outflow tract (LVOT).
The formulae is : P = 4(V22-V12) Peak Velocity
Where V1 is the peak LVOT velocity
and V2 the peak transvalvular
velocity
 Continuity Equation
Transaortic pressure gradient
depends on variables including heart
rate, stroke volume, etc and may not
be a true indicator of the severity of
valve stenosis.
Calculation of the aortic valve area
(AVA), also referred to as effective
orifice area (EOA) using Continuity
equation is more accurate
The Continuity equation relies on the
simple principle that the volume of
blood leaving the LV is equal to the
volume of blood crossing the AV.
 Evaluation of Valve Area
AS severity is based on
measurement of LVOT diameter(D) *
in a parasternal long-axis view for *
calculation of a circular cross-
sectional area (CSA),
LVOT (V) from an apical approach
using pulsed Doppler , and the
maximum aortic jet from the
continuous-wave Doppler recording.
Either velocity-time integrals (VTIs)
or maximum velocities can be used
in the continuity equation for aortic
valve area (AVA).
 Velocity Time Integral (VTI)
Velocity Time Integral (VTI)
is the area measured under
the Doppler velocity
envelope for one heartbeat.
The mean gradient is
calculated from the VTI of
aortic outflow and can be
estimated by manually or
electronically sketching out
the envelope of the jet and
the computer programme
generates the mean
gradient display.
 Planimetry of Valve Area
Planimetry is the tracing out of the
opening of the aortic valve in a still image
obtained during echocardiographic
acquisition during ventricular systole,
when the valve is supposed to be open.
While this method directly measures the Valve closed
valve area, the image may be difficult to
obtain due to artifacts during
echocardiography, and the measurements
are dependent on the operator who has
to manually trace the perimeter of the
open aortic valve. Because of these
reasons, planimetry of aortic valve is not
routinely performed.
Valve open
Color Flow Doppler Characteristics
Proximal to the stenosis flow
is Laminar as is displayed by
the solid blue colour. (picture
A)
Near the point of maximum
stenosis the flow velocity
increases.
Turbulent flow is present distal
to the stenosis and is
represented by the mosaic
colours in the aorta.
 Pedoff or Stand alone transducer
A comprehensive Doppler examination for
aortic stenosis requires that Pedoff or
blindprobe is used during assessment
This stand alone transducer does not share
bandwidth with the imaging component of
the inline transducer and may detect
significantly higher gradients across the
valve
Doppler examination for aortic stenosis will
add an average of 15-30 minutes to the two-
dimensional and routine Doppler
echocardiographic examination, even with
the experienced operator.
 Classification of Aortic Stenosis
Moderate and severe stenosis can be
difficult to distinguish because of the
influence of Left ventricular function .
Report should include
LV dimensions and systolic function
Appearance of the Aortic valve
Severity of stenosis
Other valves
Right ventricular function (pulmonary
artery pressure if indicated)
Clinical findings
 Example BSE Questions
1) Severe Aortic Stenosis:
a) Always results in a ventricular diastolic septal width > 1.3cm
b) May be associated with an aortic valve area of 1cm2 if LV
function is poor
c) Is a cause of Aortic dilatation
d) Predisposes the patient to endocarditis
e) Can only be diagnosed if the continuity equation is used.

2 ) A Transaortic peak systolic Doppler velocity of 2.5m/sec is

compatible with:
a) Pure aortic regurgitation
b) Moderate aortic stenosis
c) Normal bio prosthesis function
d) Anxiety
e) Large ventricular septal defect Happy Revision