Expert consensus document on the assessment of the severity of aortic valve stenosis by echocardiography to provide diagnostic conclusiveness by standardized verifiable documentation

Abstract

According to recent recommendations on echocardiographic assessment of aortic valve stenosis direct measurement of transvalvular peak jet velocity, calculation of transvalvular mean gradient from the velocities using the Bernoulli equation and calculation of the effective aortic valve area by continuity equation are the appropriate primary key instruments for grading severity of aortic valve stenosis. It is obvious that no gold standard can be declared for grading the severity of aortic stenosis. Thus, conclusions of the exclusive evaluation of aortic stenosis by Doppler echocardiography seem to be questionable due to the susceptibility to errors caused by methodological limitations, mathematical simplifications and inappropriate documentation. The present paper will address practical issues of echocardiographic documentation to satisfy the needs to analyze different scenarios of aortic stenosis due to various flow conditions and pressure gradients. Transesophageal and multidimensional echocardiography should be implemented for reliable measurement of geometric aortic valve area and of cardiac dimensions at an early stage of the diagnostic procedure to avoid misinterpretation due to inconsistent results.

“Pure” severe aortic stenosis without concomitant valvular heart diseases: echocardiographic and pathophysiological features

“…Further, LVH, DD and PAH can be induced by other diseases independently of AS. According to these circumstances it might be possible that either the pathophysiological sequelae of AS are not fully understood or that patients with hemodynamically not relevant AS will also be characterized as severe AS according to current guideline criteria [19].…”

Disproportionate mitral regurgitation: another myth? A critical appraisal of echocardiographic assessment of functional mitral regurgitation

“…These principles cannot be neglected meaning that blood flow velocities at defined orifices are proportional in a system of communicating tubes. If we assume "pure" aortic valve stenosis (AS), and if cross sectional areas are known at the level of the left ventricular outflow tract (LVOT) as well as at the level of the stenotic orifice area, LVSV tot can be measured at the level of the LVOT as well as at the level of the stenotic orifice area by Doppler echocardiography, because volume flow has to be the same at both levels [24,25]. In "pure" mitral regurgitation the same principle can be applied at the regurgitant orifice area; RegVol MV is the calculated difference LVSV tot − LVSV eff .…”

Update Klappenvitien

“…Eine hochgradige AS geht in der Regel mit linksventrikulärer Hypertrophie, diastolischer Dysfunktion und oft pulmonaler Hypertonie einher [6]. Liegen diese nicht vor, sollten alle Messungen noch einmal kritisch hinterfragt werden.…”

“…Es kann ein Circulus vitiosus entstehen, wobei die Verschlechterung der rechtsventrikulären Pumpfunktion wiederum mehr Insuffizienz erzeugt. Nicht selten wird eine isolierte funktionelle TI aber auch bei Patienten mit persistierendem Vorhofflimmern und rechtsatrialer Vergrößerung beobachtet, was zu einem Remodeling des Trikuspidalklappenanulus führen kann [5,6]. Bemerkenswerterweise tritt die Trikuspidalanulusdilatation bei Vorhofflimmern bevorzugt entlang des posterioren Anulus auf, bei Patienten mit Linksherzerkrankung und Sinusrhythmus hingegen entlang des anterolateralen Anulus [4].…”