Case-of-the-Week

Case of the Week

Please use up your CME credits by June 30, 2022.

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AMA Category 1 Credit for Physicians Only.
ASRT CME is not available.

Case-of-the-Week Information

The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

You can change the size and the format of the image or video loops by using the links below the image or video loop.

= MP4 Video	= Ogg Video
= WebM Video	= GIF Image
Image/Video Sizes	= JPG Image
1X = 200x150 pixels 2X = 400x300 pixels	3X = 600x450 pixels 4X = 800x600 pixels

Loop Text Key
Preop	Preop TEE or TTE
Intraop	An Intraop TEE
IntraopPreOp	Intraop TEE or TTE before Operation
IntraopPostOp	Intraop TEE or TTE after Operation
IntraopEnd	Intraop TEE or TTE at End of Anesthesia
Post Op	Postop TEE or TTE

Case of the Month Information Table

IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE

Aortic Stenosis with Mitral Stenosis - What is the true MV Area?

Case#: 49

AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits

Presentation:

74 y.o. female with a history of SOB, DOE, and CHF.

What is the severity of the AS?
What is the severity of the MS?
Which MVA is correct (PHT or PISA) and why?
What is your recommendation for this patient?

Loops:

Case Discussion/CME Questions

The following where found on the echo exam:

AV Vmax 375 cm/sec, VTI 70.5, pAVG 56 mmHg, mAVG 31 mmHg
LVOT Vmax 98.3 cm/sec, VTI 19.5 cm
LVOTd 1.7 cm

AVA by VTI 0.64 cm2, AVA by Vmax 0.60 cm2
SV 44 mls
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AV Vmax 329 cm/sec, pAVG 43, mAVG 24 mmHg, VTI 54.9 cm
LVOT Vmax 73.2 cm/sec, VTI 13.1 cm
AVA by VTI 0.54 cm2, AVA by Vmax 0.51 cm2
SV 30 mls

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AVA by 2D 0.890 cm2
AVA by 3D 0.505 cm2

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MVd 3.78cm

MV VTI 55.9 cm
MV Vmax 170 cm/sec, mMVG 4 mmHg

MV PHT 122 msec, MVA by PHT 1.80 cm2, Vmax 126 cm/sec

MVA by VTI 0.53 cm2

MVA by PISA 0.57 cm2, PISA 0.778 cm, Va 38.5 cm/sec, Vmax 170 cm/sec

TVD 3.13 cm, 3.28 cm

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This case represents a case that is seen from time to time where there is mixed valvular stenosis and calculating valve areas can have a major impact on the person's outcome. On the first video of the LV basal SAX view, the LV is hypovolemic which should tip you off that the patient has hypovolemia, MS, or is vasodilated. The severe AS, which is confirmed by 2D and Continuity Equation should rule out vasodilation. SV is small (30-40 mls) so the mAVG and pAVG are falsely decreased despite a normal ejection fraction.

The MVA by PISA is 0.57 cm2 but by PHT it is 1.8 cm2. PHT can be influence by LV compliance and atrial compliance factors and aortic regurgitation. AR will equilibrate the LA-LV pressure more quickly and falsely decrease the PHT. Decreased LV compliance due to LVH/AS will do a similar effect. Also, the low flow state wil falsely lower the mMVG. The PISA method is independent of flow, so, it should be more accurate in this case.

An article from Circulation (1988) compared continuity and PHT measurements for MVA and found that MVA was over estimated in AR whereas the continuity equation was more accurate. Other articles have confirmed that the PISA method is more accurate in the setting of AR. WIthout AR, the PHT should be fairly accurate (R=0.9) but that is with a normal AV.WIth severe AS and LVH, the PISA method should be more accurate in this case. The cross sectional area by 3D would have been helpful in this case to confirm the MVA calculation.

Please answer the following questions correctly to obtain your CME.

Web Links/References

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice

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This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of University of Nebraska Medical Center, Center for Continuing Education and JLS Interactive, LLC.

The University of Nebraska Medical Center, Center for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

This activity is approved by the American Society of Radiologic Technologists (ASRT) as sonography-related continuing education (CE). Credit(s) issued for successful completion of ASRT-approved CE activities are accepted by the American Registry of Diagnostic Medical Sonography, American Registry of Radiological Technologists, Cardiovascular Credentialing International and Canadian Association of Registered Diagnostic Ultrasound Professionals. Contact the applicable registry for additional information / restrictions on their acceptance of ASRT CE credit.