Presentation
Syncopal episode, background of progressively worsening dyspnea.
Patient Data
Apical 5-chamber view: diffusely echogenic and distorted aortic valvular apparatus apparent. Visible interventricular septum hypertrophied with preserved thickening and inward excursion (within the limits of this view).
Color flow Doppler demonstrates aliasing throughout left ventricular outflow tract, area of flow convergence extends through most of visible left ventricle.
Continuous wave Doppler gate directed through outflow tract based on color flow profile; peak velocity (red arrow) 5.4 m/s
Parasternal short axis view is zoomed to aortic valve, which is trileaflet, calcification with subtle shadowing extends along annulus and valve commissures, impression of severe aortic stenosis.
Parasternal long axis zoomed to aortic valve, notable for severe calcification of right coronary cusp, noncoronary cusp out of plane. No dilation of aortic root, no flaps within lumen.
Impression: thickened, echogenic aortic valve cusps with restricted mobility and distortion of the valvular apparatus, suspicious for senile calcific aortic valve stenosis.
Case Discussion
From the continuous wave Doppler envelope of the left ventricular outflow tract, one can directly measure the peak velocity (5.4 m/s) and derive the peak pressure gradient from the modified Bernoulli equation, ΔP = 4V2, yielding a maximum pressure gradient of 117 mmHg.
Apical 5-chamber and 3-chamber (also known as apical long axis) views allow for an appropriate angle of insonation for this measurement 3.
Peak velocities over 4 m/s and peak gradients exceeding 60 mmHg are indicative of severe aortic stenosis 2.
The mean gradient and aortic valve area were not calculated in this limited bedside study, but were consistent with severe aortic stenosis in a subsequent formal echocardiogram.
Quantification of valvular pathology is beyond the scope of focused bedside echocardiography. However, severe aortic stenosis is recognized by trained physicians with good specificity, and may allow for earlier detection if noticed at the point of care and referred to an appropriate expert 1.
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