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Echocardiographic evaluation of the aortic valve

Author
Elyse Foster, MD
Section Editor
Warren J Manning, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

Echocardiography is the most effective means of evaluating the aortic valve in normal and diseased states. For most conditions, transthoracic (surface) echocardiography (TTE) is sufficient. Congenital, degenerative, and inflammatory lesions are readily recognized and their severity graded. In addition, it is standard practice for TTE to be the sole method of serial evaluation of aortic stenosis and aortic regurgitation.

This topic will review echocardiography of the aortic valve. The diagnosis and management of aortic stenosis and aortic regurgitation are discussed separately in individual topic reviews including the following: (See "Clinical manifestations and diagnosis of aortic stenosis in adults" and "Indications for valve replacement in aortic stenosis in adults" and "Medical management of asymptomatic aortic stenosis in adults" and "Medical management of symptomatic aortic stenosis" and "Clinical manifestations and diagnosis of chronic aortic regurgitation in adults" and "Natural history and management of chronic aortic regurgitation in adults".)

ECHOCARDIOGRAPHY OF THE NORMAL AORTIC VALVE

Two-dimensional echocardiography — Two-dimensional imaging of the normal aortic valve in the parasternal long axis view demonstrates two leaflets (right and noncoronary) (image 1), while the parasternal short axis demonstrates a symmetrical structure with three uniformly thin leaflets that open equally, forming a circular orifice during most of systole (figure 1). During diastole, the normal leaflets form a three pointed star with a slight thickening or prominence at the central closing point formed by the aortic leaflet nodules, known as the nodules of Arantius. The three aortic valve cusps may also be visualized in a subcostal view.

The aortic valve is composed of three cusps: the left, right, and noncoronary cusps. The left cusp guards the left sinus of Valsalva, with the left main coronary artery arising superior to and midway between the commissures of this cusp. The right cusp guards the right sinus of Valsalva, with the right coronary artery arising anteriorly and superiorly. It is the most anterior cusp and is positioned immediately just posterior to the right ventricular outflow tract. Its most rightward commissure is adjacent to the septal attachment of the tricuspid valve. The noncoronary cusp is located posteromedially, guards the noncoronary sinus of Valsalva, and is adjacent to the interatrial septum.

M-mode echocardiogram — M-mode echocardiography of the aortic valve is performed in conjunction with two-dimensional imaging by targeting the M-mode beam through the aortic leaflets as displayed in the two-dimensional cross sectional view. The M-mode image of a normal aortic valve and root includes a number of distinctive features:

                                         

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Literature review current through: Nov 2016. | This topic last updated: Mon Mar 21 00:00:00 GMT 2016.
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References
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  1. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
  2. Chin ML, Bernstein RF, Child JS, Krivokapich J. Aortic valve systolic flutter as a screening test for severe aortic stenosis. Am J Cardiol 1983; 51:981.
  3. Godley RW, Green D, Dillon JC, et al. Reliability of two-dimensional echocardiography in assessing the severity of valvular aortic stenosis. Chest 1981; 79:657.
  4. Stoddard MF, Hammons RT, Longaker RA. Doppler transesophageal echocardiographic determination of aortic valve area in adults with aortic stenosis. Am Heart J 1996; 132:337.
  5. Teirstein P, Yeager M, Yock PG, Popp RL. Doppler echocardiographic measurement of aortic valve area in aortic stenosis: a noninvasive application of the Gorlin formula. J Am Coll Cardiol 1986; 8:1059.
  6. Yeager M, Yock PG, Popp RL. Comparison of Doppler-derived pressure gradient to that determined at cardiac catheterization in adults with aortic valve stenosis: implications for management. Am J Cardiol 1986; 57:644.
  7. Otto CM. Valvular aortic stenosis: disease severity and timing of intervention. J Am Coll Cardiol 2006; 47:2141.
  8. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 2009; 22:1.
  9. Baumgartner H, Kratzer H, Helmreich G, Kuehn P. Determination of aortic valve area by Doppler echocardiography using the continuity equation: a critical evaluation. Cardiology 1990; 77:101.
  10. Gharacholou SM, Karon BL, Shub C, Pellikka PA. Aortic valve sclerosis and clinical outcomes: moving toward a definition. Am J Med 2011; 124:103.
  11. Tani LY, Minich LL, Pagotto LT, Shaddy RE. Usefulness of doppler echocardiography to determine the timing of surgery for supravalvar aortic stenosis. Am J Cardiol 2000; 86:114.
  12. Siu SC, Silversides CK. Bicuspid aortic valve disease. J Am Coll Cardiol 2010; 55:2789.
  13. Sievers HH, Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg 2007; 133:1226.
  14. Landzberg JS, Pflugfelder PW, Cassidy MM, et al. Etiology of the Austin Flint murmur. J Am Coll Cardiol 1992; 20:408.
  15. Botvinick EH, Schiller NB, Wickramasekaran R, et al. Echocardiographic demonstration of early mitral valve closure in severe aortic insufficiency. Its clinical implications. Circulation 1975; 51:836.
  16. Blumlein S, Bouchard A, Schiller NB, et al. Quantitation of mitral regurgitation by Doppler echocardiography. Circulation 1986; 74:306.
  17. Sechtem U, Pflugfelder PW, Cassidy MM, et al. Mitral or aortic regurgitation: quantification of regurgitant volumes with cine MR imaging. Radiology 1988; 167:425.
  18. Pflugfelder PW, Landzberg JS, Cassidy MM, et al. Comparison of cine MR imaging with Doppler echocardiography for the evaluation of aortic regurgitation. AJR Am J Roentgenol 1989; 152:729.
  19. Tribouilloy CM, Enriquez-Sarano M, Fett SL, et al. Application of the proximal flow convergence method to calculate the effective regurgitant orifice area in aortic regurgitation. J Am Coll Cardiol 1998; 32:1032.
  20. Tribouilloy CM, Enriquez-Sarano M, Bailey KR, et al. Assessment of severity of aortic regurgitation using the width of the vena contracta: A clinical color Doppler imaging study. Circulation 2000; 102:558.
  21. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003; 16:777.
  22. Lancellotti P, Tribouilloy C, Hagendorff A, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease). Eur J Echocardiogr 2010; 11:223.
  23. Pouleur AC, le Polain de Waroux JB, Goffinet C, et al. Accuracy of the flow convergence method for quantification of aortic regurgitation in patients with central versus eccentric jets. Am J Cardiol 2008; 102:475.
  24. Messika-Zeitoun D, Detaint D, Leye M, et al. Comparison of semiquantitative and quantitative assessment of severity of aortic regurgitation: clinical implications. J Am Soc Echocardiogr 2011; 24:1246.
  25. Perry GJ, Helmcke F, Nanda NC, et al. Evaluation of aortic insufficiency by Doppler color flow mapping. J Am Coll Cardiol 1987; 9:952.
  26. Touche T, Prasquier R, Nitenberg A, et al. Assessment and follow-up of patients with aortic regurgitation by an updated Doppler echocardiographic measurement of the regurgitant fraction in the aortic arch. Circulation 1985; 72:819.
  27. Teague SM, Heinsimer JA, Anderson JL, et al. Quantification of aortic regurgitation utilizing continuous wave Doppler ultrasound. J Am Coll Cardiol 1986; 8:592.
  28. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation 2005; 112:125.
  29. Freed C, Schiller NB. Echocardiographic findings in Marfan's syndrome. West J Med 1977; 126:87.
  30. Foster E, Schiller NB. The role of transesophageal echocardiography in critical care: UCSF experience. J Am Soc Echocardiogr 1992; 5:368.
  31. Khandheria BK, Seward JB, Tajik AJ. Transesophageal echocardiography. Mayo Clin Proc 1994; 69:856.
  32. Pavlides GS, Hauser AM, Stewart JR, et al. Contribution of transesophageal echocardiography to patient diagnosis and treatment: a prospective analysis. Am Heart J 1990; 120:910.
  33. Grayburn PA, Handshoe R, Smith MD, et al. Quantitative assessment of the hemodynamic consequences of aortic regurgitation by means of continuous wave Doppler recordings. J Am Coll Cardiol 1987; 10:135.
  34. Piper C, Hetzer R, Körfer R, et al. The importance of secondary mitral valve involvement in primary aortic valve endocarditis; the mitral kissing vegetation. Eur Heart J 2002; 23:79.
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