Aortic StenosisCase-Based Diagnosis and Therapy
Copyright â Springer-2015
1: General Considerations and Etiologies of Aortic Stenosis
The Aortic Valve and Root Apparatus
Prevalance and Epidemiology of Aortic Stenosis
Causes of Aortic Stenosis
Calcific Aortic Valve Stenosis
Congenital Aortic Valve Stenosis
Para-valvular Aortic Stenosis
Supra Valvular Aortic Stenosis
Sub Valvular Aortic Stenosis
Rheumatic Aortic Valve Stenosis
Natural History of Aortic Valve Stenosis
2: Clinical Assessment of the Severity of Aortic Stenosis
Increased Afterload: Effects on LV Compliance and Contractility
Outflow Obstruction: Effects on Cardiac Output
Prolonged LV Ejection Time: Compensation and Insight into Severity of Obstruction
Historical Features of Aortic Stenosis
Gastrointestinal Bleeding
Differentiating Aortic Stenosis from Other Murmurs
Specific Clinical Scenarios
Low Flow, Low Gradient AS
3: Physiological Basis for Area and Gradient Assessment: Hemodynamic Principles of Aortic Stenosis
Physiological Considerations of Transvalvular Pressure Gradient (∆P) and Aortic Valve Area (AVA) in Aortic Stenosis
Assessing the Severity of Aortic Stenosis
Aortic Valve Gradient Calculations
Maximum Achievable Pressure Gradient (∆Pmax)
Determinants of Transvalvular Gradients (∆P) and Prec
Para Valvular Determinants
Determinants of Pressure Recovery and Concordance Between Doppler and Catheter Measures of Gradient
Net Pressure Gradient (∆Pnet)
Aortic Valve Area Calculations
Coefficient of Orifice Contraction and Its Determinants
Effective Versus Geometric Orifice Area
Effect of Flow on Aortic Valve Area
Measurements of Aortic Valve Area
Doppler versus Catheter-Derived Measures of Aortic Valve Area
Other Measures to Assess Aortic Stenosis Severity
Energy Loss Coefficient and Index
AV Calcification and AV Calcium Score
Projected Aortic Valve Area
Measures of Left Ventricular Hemodynamic Burden
Brain Natriuretic Peptide (BNP)
Effect on the Right Ventricle
4: Different Classifications of Aortic Stenosis
Stages of Aortic Stenosis
Stage C, Asymptomatic Severe Aortic Stenosis
Stage D, Symptomatic Severe AS
Area/Gradient Match or Concordance
Area/Gradient Match or Concordance
Area/Gradient Mismatch or Discordance
Reverse Area/Gradient Mismatch or Discordance
Ejection Fraction and Flow
Low Ejection Fraction, Low Flow/Low Gradient Severe Aortic Stenosis
Normal Ejection Fraction Severe Aortic Stenosis
5: Invasive Evaluation of Aortic Stenosis
Invasive Measures of Trans-aortic Valve Gradients
General Considerations in Invasive Pressure Gradient Assessment
Invasive Measures of Aortic Valve Areas
General Considerations in Invasive Aortic Valve Area Assessment
Invasive Pharmacological Challenges for Assessment and Stratification of Severe Aortic Stenosis
Invasive Evaluation of Dynamic Outflow Tract Obstruction
General Considerations in Patients with HOCM
Combined Aortic Stenosis and Aortic Regurgitation
6: Echocardiographic Evaluation of Aortic Valve Stenosis
Transthoracic Echocardiography (TTE)
Echocardiography and the Normal Aortic Valve
Pathophysiology of Aortic Stenosis and Echocardiography
Echocardiography and the Stenotic Aortic Valve
Two-Dimensional Echocardiographic Evaluation of Aortic Stenosis
Left Ventricular Outflow Tract
Doppler Assessment of Aortic Stenosis
Proper Doppler Flow Measurement
Continuity Equation and Effective Orifice Area
Additional Echocardiographic Measurements of Aortic Stenosis Severity
Three-Dimensional Imaging and Aortic Stenosis
7: Complimentary Role of CT/MRI in the Assessment of Aortic Stenosis
Cardiac Magnetic Resonance Imaging in Aortic Stenosis
MRI Modalities Utilized in Patients with Aortic Stenosis (Tables 7.1a and 7.1b)
Discrepant Diagnostic Data on Severity of Aortic Stenosis and Morphology of the Aortic Valve
Assessment of Paravalvular Obstruction, Associated Aortic Regurgitation, and Congenital Anomalies
Assessment of Ventricular Function
Cardiac Computed Tomography in Aortic Stenosis
Assessment of Coronary Anatomy and Coronary Artery Disease
Pre SAVR and Pre-TAVR Evaluation by CT Aortography
Assessment of Paravalvular Obstruction and Congenital Anomalies
Assessment of Ventricular Function
Discrepant Diagnostic Data on Severity of Aortic Stenosis and Aortic Valve Morphology
Multimodality Imaging for Aortic Stenosis: Clinical Application and Case Examples
Normal Flow-High Gradient (NF/HG) Severe AS, Normal Ejection Fraction Symptomatic Severe AS
Area/Gradient Mismatch: Low Flow/Low Gradient Severe Aortic Stenosis with Reduced Ejection Fraction
Indeterminate Severity Aortic Stenosis, Preserved Ejection Fraction
Reverse Area Gradient Mismatch and the Bicuspid Aortic Valve
Paravalvular Obstruction: Sub-aortic Stenosis
8: Area and Gradient Mismatch: The Discordance of a Small Valve Area and Low Gradients
Low Flow Area-Gradient Mismatch
Low Flow/Low Gradient AS with Depressed LVEF (Low LVEF Area-Gradient Mismatch)
Low Flow/Low Gradient AS with Preserved LVEF (Normal LVEF Area-Gradient Mismatch)
9: Reverse Area and Gradient Mismatch: The Discordance of a Large Valve Area and High Gradients
Reverse Area/Gradient Mismatch
Causes of Reverse Area-Gradient Mismatch in Native Valves
Errors of Measurement and/or Assumption
Causes of Reverse Area-Gradient Mismatch in Prosthetic Aortic Valves
Localized High Gradient in Central Orifice of Bileaflet Mechanical Valves
Prosthesis-Patient Mismatch (PPM)
Paravalvular Obstruction: Sub or Supra-valvular Aortic Obstruction
Hypertrophic Obstructive Cardiomyopathy
10: Prosthetic Aortic Valves and Diagnostic Challenges
Prosthetic Aortic Valves and Diagnostic Challenges
Causes of Prosthetic Valve Aortic Stenosis
Hemodynamics and Anticipated Gradients of Prosthetic Valves
Algorithmic Approach to Evaluate Prosthetic Aortic Valve Function
ASE: PV Algorithm Case Illustration
Importance of Qualitative Indices in the Assessment of Prosthetic Valve Stenosis
Valve Prosthesis: Patient Mismatch (VP-PM)
Role of Cardiac CT and Cardiac MRI for Assessment of Prosthetic Valve Complications
11: Risk Prediction Models, Guidelines, Special Populations, and Outcomes
Development and Limitations
Comparing Different Surgical Risk Models for Aortic Valve Replacement
The Heart Valve Team, Heart Valve Center of Excellence
Novel Guidelines and Aortic Valve Replacement
Special Populations with Severe Aortic Stenosis
Pregnancy and Aortic Stenosis
Management of Aortic Stenosis During Pregnancy
Perioperative Risk Assessment in Patients with Severe Aortic Stenosis Undergoing Noncardiac Surgery
Aortic Stenosis in Association with Other Valvular Diseases
Aortic Stenosis with Aortic Regurgitation
AS with Moderate or Severe Mitral Stenosis (MS)
Aortic Stenosis in Association with Basal Septal Hypertrophy
AS in Association with Mitral Regurgitation (MR)
Aortic Stenosis in Bicuspid Aortic Valve (BAV)
Evaluation of Coronary Artery Disease Prior to AVR
Appendix: VARC-2 Definitions
The Valve Academic Research Consortium (VARC) Consensus Document
12: Surgical Management of Aortic Valve Stenosis
Mechanical Aortic Valve Replacement
Auto-graft Aortic Valve Replacement (Ross Procedure)
Bioprosthetic Aortic Valve Replacement
Comparison Between Mechanical and Bioprosthetic Aortic Valve
Comparison Between Stented and Stentless Bioprosthetic Aortic Valves
Aortic Valve Decalcification
Transcatheter Aortic Valve Replacement
Historical Perspective and Background
Approaches for Surgical Aortic Valve Replacement
Traditional Full Sternotomy Approach
Minimally Invasive Aortic Valve Replacement (MIAVR)
Right Thoracotomy Approach
Robotic Aortic Valve Replacement
Sutureless Aortic Valve Replacement
Types and Choice of the Prosthetic Aortic Valve
13: Balloon Aortic Valvuloplasty
Historical Considerations
Patho-anatomic Mechanism of Balloon Aortic Valvuloplasty (BAV)
Immediate Hemodynamic Results
Mechanisms of Clinical Improvement
Miscellaneous Applications
14: Imaging for Transcatheter Aortic Valve Replacement
Two-Dimensional Transthoracic Echocardiography (2D-TTE)
Left and Right Ventricular Function
Paradoxical Low Flow Low Gradient Aortic Stenosis
Severity of Aortic Stenosis
Aorto-ilio-femoral Angiography
Two-Dimensional Transesophageal Echocardiography (2D-TEE)
Three-Dimensional Transesophageal Echocardiography (3D-TEE)
Multi-slice Computed Tomography
Aortic Apparatus Calcification
MSCT Vasculature Assessment
Optimal Fluoroscopic Projection
Fluoroscopy and Angiography
Valve-in-Valve Fluoroscopy
Transesophageal Echocardiography
Transthoracic Echocardiography
Case Presentations and Imaging Considerations
Case 1: Aortic Stenosis Echocardiography
Case 2: Dobutamine Stress Echocardiography
Case 5: THV Sizing Dilemma
Case 7: Bicuspid Aortic Valve
Case 8: Vasculature Reconstruction
Case 9: Edwards and CoreValve Fluoroscopy
15: Transcatheter Aortic Valve Replacement
Commercially Approved Transcatheter Heart Valves in the United States
Valve Function and Durability
Access Site Complications and Bleeding
Paravalvular Aortic Regurgitation
Conduction Disturbances and Atrial Fibrillation
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