I can even remember one day when I had seven patients in a row with moderate to severe aortic stenosis. It can certainly be frustrating and time consuming for inexperienced sonographers to have to take additional images and to add on to our study time. Even experienced sonographers must sometimes take a step back and to remember that these patients need that extra time and attention to further the clinical decision making process for the treating physician and to bring answers and solutions to our patients. We are all human and it is easy to look at our schedules and our busy lives and get frustrated when something throws off our plans. However, treating every patient as though they are our own mothers, our fathers and our friends, will help to put our scanning protocols and requirements in the right perspective. This is the reason we do what we do.... patient care. Above all else, our imaging techniques, protocols and scanning skills should be sharpened and enhanced to further benefit the patients we serve.
Aortic stenosis is very common in populations over 65 years old and progression of the disease from sclerosis to critical stenosis can take less than 5 years. If you scan in an accredited echo lab, there may be many more additional protocol images to add when assessing aortic stenosis. However, with a few tips and tricks even a very new sonographer can master the art of imaging aortic stenosis and save the frustration of this very common pathology. This is the core of what we do, which is why this is included as a case study requirement for adult echocardiography accreditation through the Intersocietal Accreditation Commission.
So let's start with the basics... knowing the anatomy of the valve is important when using descriptions of aortic disease. The valve is comprised of three leaflets:
• right coronary cusp
• left coronary cusp
• non-coronary cusp
Another core basic item in evaluation aortic stenosis is the Continuity Equation. Having an understanding of the hemodynamics is really the basis for an understanding of the disease process and echo evaluation of aortic stenosis. The Continuity Equation in it's most basic explanation is conservation of mass.... what goes in MUST come out.
Also, due to the fact that the continuity equation squares the LVOT diameter, this can significantly introduce errors into the equation if that value is only slightly off or mis-measured. It is critical that the sonographer measure the LVOT very carefully and with attention to detail. According to the American Society of Echocardiography the LVOT should be measured with the following parameters and considerations:
•Inner edge to inner edge convention
•Mid-Systole with aortic valve leaflets open
•Parallel to the aortic valve plane
•Within 0.5–1.0 cm of the valve orifice
•Perpendicular to the axis of flow
Doppler angle and sample placement. What more can I say? This is critical to the mathematics. It is important to place the LVOT Doppler sample at approximately the same location as the LVOT diameter is measured from. The LVOT Doppler waveform should also not show significant valve clicks, otherwise Doppler sample placement is too far into the aortic valve.
It's important to ensure correct angle THROUGH the aortic valve orifice. In reviewing countless numbers of echo cases through the years for accreditation and quality review, I've seen many aortic valves evaluated incorrectly.
It is important to place your continuous wave Doppler sample THROUGH the valve orifice and NOT across the valve leaflets. Simple hand maneuvers and tilting the transducer can open up the LVOT and allow for correct Doppler angle through the valve.
Now that you have the basics down, there are few extra steps we can do to evaluate aortic stenosis. Protocols should always include evaluation from the suprasternal notch view, and also evaluation with the Pedoff/dedicated continuous wave transducer. Additional Doppler attempts can also be performed in the subcostal view and the high right parasternal view (always ensuring that true valve clicks are obtained on continuous wave Doppler as this ensures the angle is positioned through the valve orifice).
While the pedoff transducer might be scary for some newer sonographers, once you get the hang of it, you'll realize it's really very simple. For the apical approach, start by beginning where you were able to obtain the best apical window of the aortic valve and LVOT. While observing the CW spectral display, listen to the blood flow and isolate one of the typical valve waveform patterns of either the mitral, aortic or tricuspid valves. Remember the aortic valve is in between the two atrioventricular valves so, keep that in mind when adjusting the probe. Also, SLOW DOWN - use very slow adjustments when optimizing the transducer waveforms and trying to bring in the aortic valve.
When using the suprasternal notch approach, have the patient extend their neck and try to visualize the position of the ascending aorta and direct the face of the probe at a steep downward angle. One important thing to remember is that because there are no images, you must annotate the location on your images. This is required for accreditation and also just a good practice.
Let's not forget that high right parasternal view! The best patient positioning for this is right lateral decubitus. The patients' arm should be positioned up and out of the way.
Often it is helpful to find this view with 2D imaging and assess the valve both with the imaging and non-imaging transducers. I suggest that you practice the Pedoff transducer and additional windows on normal patients and practice often when first beginning your echo career...
Practice makes perfect! Before you know it, you'll be an AS pro!
REFERENCE: Echocardiographic assessment of valve stenosis: EAE/ASE
recommendations for clinical practice https://www.escardio.org/static_file/Escardio/Subspecialty/EACVI/position-papers/EAE-recommendations-valve-stenosis.pdf