1. Hemodynamics of aortic stenosis
Dr Sajeer K T
Department of Cardiology,
Govt. Medical College, Kozhikode

2. Aortic stenosis Etiology based on - level of obstruction to LVOT
- Supravalvular
- Valvular
- Congenital AS
- BAV ± calcification
- Rheumatic
- Senile degenerative
- Subvalvular

3. Pressure gradient across the AV ⇈es exponentially with ⇊ing AVA
# Severe AS:
- small changes in AVA can lead to large changes in hemodynamics

4. Framework for how mechanical stress (σ) is transduced into pressure versus volume overload hypertrophy.
(Grossman W, Jones D, McLaurin LP: Wall stress and patterns of hypertrophy in the human left ventricle. J Clin Invest 1975; 53: )

5. Compensatory Mechanisms
Chronic pressure overload ➨ concentric LV hypertrophy
increased wall thickness
normal chamber size
⇈ed myocardial cell mass and ⇈ed interstitial fibrosis
- diastolic dysfunction
Women ➨ normal LV function
small, thick walled LV
concentric LVH
diastolic dysfunction
Men ➨ eccentric LV hypertrophy
excessive systolic wall stress
systolic dysfunction & chamber dilation

6. Mild AS - intracardiac pressures & CO - normal
As the valve becomes more stenotic
- unable to increase CO during exercise
Progressive narrowing of the valve
- decreased SV and CO even at rest
Moderate to severe AS
- patients may develop elevated filling pressures to
compensate for the increase in LV EDP
Minority of patients LV systolic failure
- further elevation in intracardiac pressures

7. Pulse wave

8. Valvular AS
# Slow systolic rise
# prominent anacortic notch
# late peak
HOCM
# rapid upstroke
# absence of anacortic notch
# early systolic dip
# second peak in late systole

9. Supra valvular AS - pulse disparity (Coanda effect)
- systolic pressure in the right arm > left arm.
- relate to the tendency of a jet stream to adhere to a vessel wall
selective streaming of blood into the innominate artery
Streaming of the jet
toward the innominate, RCCA, and right SCA

10. Severe >4.0 >40 <1.0 <0.6 Aortic Stenosis- severity Mild
Moderate
Severe
Jet velocity (m/sec)
<3.0
>4.0
Mean gradient (mm Hg)
<25
25-40
>40
Valve area (cm2)
>1.5
<1.0
Valve area index (cm2/m2)
<0.6

11. Clinical Spectrum of Severe AS

12. Factors involved in generation and interpretation of a pressure gradient
# PLV1 exceeds PLV2
# VC – (2)
- maximum velocity
- site of minimal pressure
# pressure recovery (3)
# pressure P1 < P2

13. - a source of error in the assessment of AS severity
Pressure recovery
- a source of error in the assessment of AS severity
Severity of AS
1. pressure gradient across the valve or
2. effective orifice area (EOA) of the valve - preferable
- less flow dependent
EOA measurement :
1. Doppler echocardiography (continuity equation)
2. Left heart catheterization ( Gorlin formula)
Discrepancies between Doppler and catheter measurements of EOA

14. Pressure recovery
phenomenon

15. Valvulo-arterial impedance
Zva = LV systolic pressure / SVI
SAP : systolic arterial pressure
▲ Pmean : mean systolic transaortic gradient
SVI : stroke volume index.
Values of Zva > 4.5 mm Hg. ml-1 .m ➲ severe AS
“ cost in mmHg for each ml of blood indexed for BSA pumped by LV”

16. Doppler : maximal pressure drop from the maximal velocity
recorded at valve (EOA) level
Catheterization : measures the net gradient between the left ventricle
and the ascending aorta
due to pressure recovery phenomenon:
: net gradient recorded at catheterization is less than the
maximum pressure gradient measured by Doppler (Ao < 3 cm)
: EOA by catheterization with Gorlin formula is higher than
measured by Doppler
Doppler method : actual area occupied by flow at the valvular level
EOA by Gorlin formula: is a coefficient of the energy lost due to the
stenosis

17. Energy loss coefficient (ELCo)
adjusts the Doppler EOA for the size of the aorta (AA)
ELCo = (EOA×AA) / (AA-EOA)
AA : CSA of the aorta measured at 1 cm downstream of the STJ
excellent agreement between catheter EOA and ELCo by Doppler
pressure recovery is a clinically relevant in patients with
- moderate to severe AS (Doppler EOA between cm2)
- small aortas (diameter at the sinotubular junction < 30 mm)

18. Energy loss index Energy loss index (ELI) = [EOA x AA / AA- EOA] BSA
Cut-off value for severe AS using the energy loss index < 0.55 cm2/ m2
Less flow dependent than gradient or peak velocity
Takes into account pressure recovery
Equivalent to EOA measured by catheter
Reflects true LV energy loss caused by stenosis
Measured in patients with small aortas

19. Low-Flow, Low-Gradient Aortic Stenosis With Normal and Depressed LVEF
# Decreased EF (<40%) - Low Flow –Low Gradient AS
# Normal EF ( ≥ 50%) Paradoxical Low Flow –Low Gradient AS
⇊ in gradient ➨ ⇊ in trans-valvular flow.

20. Low-flow, Low-Gradient severe AS with decreased LVEF
# valve area <1 cm2
# mean aortic valve gradient < 40 mm Hg
# ejection fraction <40%
# pseudo aortic stenosis ➨ medications that increase cardiac output
will usually increase the calculated AVA
# Intravenous dobutamine μg/kg/min ➔➔ 20 μg/kg/min

21. Effects of dobutamine infusion in patients with and without valvular AS
# Pseudo severe As
Peak stress
- MG < 30 mm Hg
- EOA > cm2
- ab. in EOA> 0.3 cm2
# true severe aortic stenosis
(1) a mean aortic valve gradient greater than 30 mm Hg
(2) an aortic valve area ≤ 1.2 cm2

22. Contractile reserve or flow reserve
# Definition: Increase in stroke volume of ≥ 20% above baseline
# Post AVR : lower peri-operative mortality (5% v/s 32%) ( n=136)
# Post AVR: mean improvement in In LVEF
Improvement in NYHA class : similar in CR <20 or >20%

25. Paradoxical Low flow –low Gradient Severe AS:
- indexed AVA < 0.6 cm2/m2
- Gradient < 40 mmHg
- EF > 50%
- Stroke volume index (SVi) : < 35 mL/m2

26. Paradoxical Low Flow –Low Gradient AS
Features :
Increased global LV hemodynamic load -⇈ed Zva
Smaller and relatively thicker LV
⇊ed LV mid-wall radius shortening (pronounced intrinsic myocardial dysfunction)
lower LVEF
Poor prognosis if treated medically rather than treated surgically

27. Physiopathology : paradoxical LF- AS despite preserved EF
Pronounced concentric LV remodelling and smaller LV cavity size
≈ restrictive physiology
# Decrease in SV is due to deficient ventricular filling
# smaller LV cavity size
# deficient ventricular emptying
# Intrinsic myocardial dysfunction causing EF lower than expected (50-60%)
# Prevalence increases with
- older age
- female gender
- concomitant systemic HTN

28. Impact of AVR on Survival in Patients With Paradoxical LF-LG AS
Tarantini G, Covolo E, Razzolini R, et al. Valve replacement for severe aortic stenosis with low transvalvular gradient and left ventricular ejection fraction exceeding The Annals of Thoracic Surgery, Volume 91(6), 1808–1815, 2011

29. Role of cardiac catheterization AS
Cardinal indications:
- left ventricular failure, angina pectoris, or syncope.
Discrepancy between echo findings and patient symptoms
What information can be obtained in AS ?
- estimation of gradient
- estimation of valve area
- level of stenosis
- valve resistance

30. Methods of measuring a transvalvular gradient in AS
LV via transseptal, AO catheter retrograde above AO valve
LV retrograde with pressure wire, AO catheter retrograde above AO valve
3. LV retrograde with pigtail, AO catheter retrograde above AO valve
4. LV and AO retrograde with dual lumen pigtail
5. LV retrograde with pigtail, AO pressure from side arm of long sheath
6. LV retrograde with pigtail, AO pressure from side is of femoral sheath
7. LV retrograde with pigtail and ‘‘pullback’’ pressure from LV to AO

31. Simultaneous LV and central Aortic pressures in severe AS
Ideal method

32. METHOD
EASE OF USE
DISADVANTAGE
PULLBACK
+++++
LEAST ACCURATE
FEMORAL SHEATH
PRESSURE AMPLIFICATION
ILIAC ARTERY STENOSIS
DOUBLE ARTERIAL PUNCTURE
+++
EXTRA VASCULAR ACCESS RISK
PIG TAIL- DOUBLE LUMEN
DAMPING
TRANSEPTAL ++
RISK

33. Artifacts can result when a multiple-side-hole pigtail catheter is incompletely advanced into the LV chamber

34. Peripheral amplification
# increase in peak systolic pressure and pulse pressure in peripheral
arteries as compared to the central aorta
Simultaneous measurement of aortic and FA pressure demonstrating peripheral amplification

35. The tracings demonstrating the significant time delay for the pressure waveform to reach the RFA.
B. Realignment using tracing paper.

36. Peak aortic pressure and LV pressures are temporarily separated
Gradient described as
# Peak-peak
# Peak instantaneous
# Mean gradient
Peak-peak gradient:
- absolute difference between peak Ao systolic pressure
and peak LVSP
Peak instantaneous gradient:
- max. gradient between Ao and LV at single point in time
Mean Gradient :
- area b/n LV & Ao hemodynamic tracing
- best quantify severity of AS

37. peak-to-peak gradient measured by catheterization is lower than the peak instantaneous gradient measured by echo
Doppler data
# Peak instantaneous gradient over time
Cath data
# Peak to peak data
calculated mean pressure Gradients are comparable

38. Carabello Sign
rise in arterial blood pressure during left heart catheter pullback in
patients with severe aortic stenosis
Mechanism : related to partial obstruction of an already narrowed
aortic orifice by the retrograde catheter & relief of this
obstruction when the catheter is withdrawn
AVA<0.6cm2

39. Aorta pull back tracing- level of stenosis
Supra Valvular AS
Valvular AS
Sub valvular AS

40. Calculation of stenotic valve area
GORLIN FORMULA:
A = F
VCC
Torricelli's law:
flow across a round orifice F = AV CC
F = flow rate A = orifice area
V = velocity of flow CC = coefficient of orifice contraction
2. relates pressure gradient and velocity of flow - Torricelli's law
V = velocity of flow
Cv = coefficient of velocity - correcting for energy loss as pressure energy is converted to
kinetic or velocity energy
h = pressure gradient in cm H2O
g = gravitational constant (980 cm/sec2) for converting cm H2O to units of pressure

41. GORLIN FORMULA: C = empirical constant accounting for CV and CC
h = mm Hg (rather than cm H2O)
C - empirical constant ( 0.85 for mitral valve, 1.0 for Aortic valve)

42. Flow (F) = is the total cardiac output expressed in terms of the seconds per minute during which there is actually forward flow across the valve.
F= CO (ml or cm3/min)
SEP (sec/min) x HR
cm3 x min
Min x Sec
cm3 /sec

43. Heart rate x SEP or DFP x constant ≈1
Hakki formula
Heart rate x SEP or DFP x constant ≈1

45. Automated computerized analysis
Mean GD
Automated computerized analysis

46. Hypertension + aortic stenosis
Concomitant hypertension mask the signs of AS severity
Evaluation of AS severity - performed when BP control is optimal
Progression of valvulo-arterial disease
- pseudo-normalization of BP due to a reduction in SV
LV : faces a double pressure overload
- develop symptoms at an earlier age

47. Conclusion # Pressure recovery : Catheterization v/s Doppler gradient
# Newer parameters for severity of AS
- Energy loss index
- Valvulo-arterial impedance
# diagnosis of severe AS should be based on results for AVA and indexed
AVA rather than on gradients
# Paradoxical low flow-low gradient AS : better prognosis if treated
surgically than medically

48. References
Braunwald's Heart Disease: A Textbook Of Cardiovascular Medicine 9th Edition
Grossman's Cardiac Catheterization, Angiography, & Intervention, 7th Edition
Otto And Bonow : Valvular Heart Diseases
Kern- Hemodynamics
George A. Stouffer Cardiovascular Hemodynamics For The Clinician
Yang-hemodynamics
Morton G Kern-cardiac Catherization
Kanu-chaterjee-text Book Of Cardiovascular Medicine
Hemodynamic Rounds –Kern
Regosta- Hemodynamics
Uptodate – aortic stenosis
Journals
Jaac
Circulation
Can J Cardiol
Europian Heart Journal
Bmj Heart
Chest Journal

49. Thank you

50. What is the calculated aortic valve area by Gorlins formula from the following parameters?
# CO-4400ml/min, # SEP- 0.5sec, # HR-50 beat/min
# Mean aortic gradient =100mmHg
0.7 cm2
0.2 cm2
0.9cm2
0.4cm2

51. 2. common pitfalls in the estimation of aortic valve area in the catheterization lab all except? a) Peripheral amplification b) Aortoiliac stenosis c) Aortic regurgitation d) Low gradient AS e) Alignment match

52. 3. True regarding Carabello’s sign except?
rise in pulse pressure by > 5 mm Hg when a catheter is removed from the LV
Phenomenon is seen in aortic valve area < 0.6cm2
Not seen when AVA> 0.7 cm2
Mechanism: additional occlusive effect of the catheter across the valve – decreasing aortic pressure

53. 4. True about paradoxical low flow-low gradient AS except?
LVEF> 50%
Indexed AVA <0.6cm2/m2
Stroke volume index< 35 ml/m2
Mean Gradient < 50 mmHg

54. 5. In Dobutamine SE- pseudo severe AS is identified by
a) Peak stress Mean gradient <30 mmHg
Peak stress EOA > 0.6 cm2
absolute increase in EOA > 0.3 cm2
d) Stroke volume < 35 ml/m2

55. 6. True about Paradoxical LF-LG severe AS except?
More in females
Prevalence decreases with age
Prevalence Increases with concomitant systemic HTN
AVR (class II a recommendation ) is better than Medical treatment

56. 7. True regarding hypertension and aortic stenosis except?
Hypertension mask AS severity
Pseudo normalization of blood pressure occurs
HTN + AS – vary late onset of AS symptoms
LV faces more global LV hemodynamic load

57. 8. True regarding contractile reserve except?
Increase in stroke volume of ≥ 30% above baseline
Lower contractile reserve –higher peri-operative mortality after AVR
mean improvement in In LVEF more in higher contractile
reserve patients with severe AS after AVR
Improvement in NYHA class- similar in high and low
contractile reserve groups with severe AS after AVR

58. 9. All are features of paradoxical low- flow , low -gradient AS except
9. All are features of paradoxical low- flow , low -gradient AS except? a) Increased global LV hemodynamic load -⇈ed Zva b) Smaller and relatively thicker LV c) intrinsic myocardial dysfunction d) Survival better after medical management than AVR

59. 10. True about Energy loss index (ELI) except?
Cut-off value for severe AS < 0.55 cm2/ m2
b) Less flow dependent than gradient or peak velocity
Takes into account pressure recovery
Equivalent to EOA measured by catheter
e) Measured in patients with large aorta ( size >35 mm)

61. Valve resistance
mean pressure gradient divided by the flow rate ratio.
UNIT = dyne-seconds cm−5
> 300 dyne-seconds cm− ➨ severe aortic stenosis

62. Hypertrophic cardiomyopathy
dynamic intraventricular pressure gradient
no systolic pressure gradient at rest
gradient - provoked with : Valsalva maneuver
: extra systole
: systemic vasodilator (amyl nitrate)
: inotropic stimulation

63. HOCM : spike-and- dome configuration of pulse wave
dynamic outflow obstruction ➨ characteristic arterial pressure
waveform “spike-and-dome configuration
early spike ➨ rapid LV ejection by the hypercontractile myocardium
pressure dip & doming ➨ reflect the dynamic outflow obstruction

64. LV and FA pressure tracings in HCM
Valsalva maneuver : produces a marked increase in the gradient
: change in the FA pressure waveform to a spike-and-
dome configuration.

65. Brokenbrough-Braunwald-Morrow sign
Post PVC potentiation in HOCM
PVC ➨⇈in intracavitary gradient ➨⇈ed contractility (⇈ed Ca2+)
# Post PVC beat is associated with a reduction in aortic systolic pressure and pulse pressure ≈ B-B-M sign