Thread by @iamritu

Tweetorial on Challenges in Quantification of Aortic stenosis before tonight’s #ASEchoJC on @PPibarot & @E_Guzzetti 📝 bit.ly/2NNIJgC

~1/3 pts have DISCORDANT indices: AVA is severe <1 cm2 yet mean gradient is low <40 mmHG bit.ly/3dWmJuy

Low Gradient types👇

2/low gradient severe AS
types:

1.Classic:both flow SVI EF⬇️(classical Low flow CLF)

2. Paradoxical: EF nl BUT low flow SVI (Paradoxical Low flow PLF )

3. Both EF and flow are nl (Normal Flow NF)

Low flow⬆️💀mortality
Paradoxical Low flow &
Classical Low flow #ASEchoJC

3/ low gradient represents more advanced cardiac disease stage
D2: classical low flow low EF low gradient
D3: paradoxical low flow nl EF low gradient
D? normal flow nl EF low gradient
#ASEchoJC

4/since ⬆️mortality w low flow,calculating flow is🔑

low flow defined as
Stroke volume index (SVI) <35 ml/m2
1. 2D doppler: SV= cross-sectional area LVOT X LVOT VTI by PWDoppler
*potential for error in measuring LVOT diameter*
2. 2D Simpson's biplane or 3D #ASEchoJC

5/ Where to measure the LVOT?
controversy to be discussed in our #ASEchoJC paper tonight but first thing: use the plane that bisects right coronary cusp hinge point anteriorly & interleaflet triangle b/w left & noncoronary cusps posteriorly bit.ly/382XxPe #ASEchoJC

6/ Get Highest AV Velocity remember only 30-50% of pts will have highest AV velocity in 3 or 5 chamber apical views #ASEchoJC
Use Pedoff & Right parasternal window #ASEchoJC bit.ly/2NO80Y2

7/ If Low flow SVI<35 & EF>50% Do #Yescct to quantitate calcium, gated ID which calcium is in valve🆚LVOT 🆚mitral annulus;Don’t use en face view will underestimate calcium,use axial, AV calcification score >1,300 AU in🙋🏻‍♀️or 2,000 AU🙋‍♂️is severe #ASechoJC bit.ly/3kDv9bk

8/for calcific aortic valves, women have less calcification &more fibrosis than men, regardless of hemodynamic AS severity or age of the patient, esp younger women with BAVs had less valve calcification (young women bicuspid more false negatives) #ASEchoJC bit.ly/2MLAq4o

9/Flow rate =SV ➗LVET
For given SV, the longer LVET, the lower FR & shorter the LVET,the higher FR.sex-specific thresholds of low FR <40 ml/m2 for🙋‍♂️&<32 ml/m2 for 🙋🏻‍♀️ outperform guidelines’ threshold of 35 ml/m2 in risk stratification after AVR #ASEchoJC
bit.ly/2Pwhacd

10/ Flow Q=SV/Ejection Time 🆚 SVI=SV/BSA
🙋🏻‍♀️more commonly have discordant metrics of severity,Q was < median in 65% of 🙋🏻‍♀️, compared with 40% of 🙋‍♂️p < 0.001 bit.ly/308jIyY #ASEChoJC
Join us at 8p tonight to discuss @PPibarot @E_Guzzetti 📝 challenges on AS quantification