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The history is the most important diagnostic test for making the correct diagnosis. Effort syncope can occur in patients with valvular aortic stenosis or hypertrophie cardiomyopathy. Cough can be a symptom of pulmonary congestion or heart failure. 5 grams/dL or more of unsaturated hemoglobin in the circulation allows the clinician to recognize cynanosis. The physician should know the potential economic or personal cost of a particular diagnostic test and the likelihood that the test will be definitive in making the correct diagnosis.

Aim: A newborn with valvular aortic stenosis and a 5 mm atrial septal defect (ASD) underwent emergency aortic valvotomy. The small left ventricle of the newborn with signs of fibroelastosis showed good function but a reduced compliance and caused a large left to right shunt at atrial level. Methods and Results: As the patient became respirator-dependant the ASD was interventionally closed with an 18 mm Amplatzer® PFO occluder. The patient could be weaned from the ventilator within two days and had an uneventful recovery. Conclusion: Interventional closure of an ASD is possible even in the newborn period and should be considered as an alternative to surgery.

The anatomy of the coronary arteries was outlined angiographically in 2 190 adult patients in order to determine the proportion of left predominance. Of 253 patients with valvular aortic stenosis 14.3 per cent were found to have left predominance, while the frequency of left predominance in the rest of the patients (1 937) was 8.5 per cent. Furthermore, this rate increases with the severity (gradient > 50 mmHg) of the aortic stenosis in the absence of aortic valve incompetence. These findings support the current concept of a relationship between adult aortic stenosis and congenital valvular malformation.

Independent risk factors for new coronary events were prior myocardial infarction, valvular aortic stenosis, male gender, and increasing age in patients with aortic stenosis. In older persons with moderate or severe valvular aortic stenosis, congestive heart failure, syncope, or angina pectoris was present in 101 of 114 persons (89%) with new coronary events and in 1 of 22 persons (5%) without new coronary events (p

Objectives. The aim of this study was to evaluate the reliability of transthoracic two-dimensional echocardiography in measuring aortic valve area (AVA) by planimetry. Background. Planimetry of AVA using two-dimensional transesophageal echocardiographic images has been reported to be a reliable method for measuring AVA in patients with aortic stenosis. Recent advances in resolution of two-dimensional echocardiography permit direct visualization of an aortic valve orifice from the transthoracic approach more easily than before. Methods. Forty-two adult patients with valvular aortic stenosis were examined. A parasternal short-axis view of the aortic valve was obtained with transthoracic two-dimensional echocardiography. AVA was measured directly by planimetry of the inner leaflet edges at the time of maximal opening in early systole. AVA was also measured by planimetry using transesophageal echocardiography, by the continuity equation and by cardiac catheterization (Gorlin formula). Results. In 32 (76%) of the 42 study patients, AVA could be detected by using the transthoracic planimetry method. There were good correlations between results of transthoracic two-dimensional echocardiographic planimetry and the continuity equation (y = 0.90x + 0.09, r = 0.90, p < 0.001, SEE = 0.09 cm2), transesophageal echocardiographic planimetry (y = 1.05x − 0.02, r = 0.98, p < 0.001, SEE = 0.04 cm2) and the Gorlin formula (y = 1.02x + 0.05, r = 0.89, p < 0.001, SEE = 0.10 cm2). Conclusions. Transthoracic two-dimensional echocardiography provides a feasible and reliable method in measuring AVA in patients with aortic stenosis.

Summary: We studied a new Doppler echocardiographic ap- proach in 56 patients with valvular aortic stenosis from the right Ventricular apex (AS-RV) and compared the transvalvu- lar gradients with the results of the standard view from the left ventricular apex (AS-LV). AS-RV resulted in good or accept- able velocity curves in 59% of patients. The correlation be- tween the two apical views for the peamean gradients were close (r = 0.9Y0.96). Using all typical positions for Doppler investigation of aortic stenosis, highest peak gradients were best recorded in five cases by AS-RV. In one woman with a narrow left ventricular cavum and severe aortic stenosis, only AS-RV yielded a technically good spectral curve. Thus, in se- lected patients-probably those with a small left ventricular cavity or an enlarged right ventricle-AS-RV may be the best window or even the only possibility in Doppler investigation of aortic valve stenosis. Key words: Doppler echocardiography, aortic stenosis Introduction

To assess the effect of left ventricular dilatation on mitral valve size, this study compared the dimensions of the mitral valve in patients with aortic valve disease and hypertrophic cardiomyopathy (HC). A total of 216 valves, removed at operation or necropsy, was analyzed by quantitative morphometric methods from: (1) 2 patient groups with dilated left ventricular cavities (i.e., 17 patients with dilated valvular aortic stenosis [AS] and 31 with pure aortic regurgitation), (2) 2 patient groups without dilated left ventricular cavities (i.e., 29 patients with nondilated AS and 94 with HC), and (3) 45 control subjects without heart disease. Mean mitral leaflet areas in patients with AS with dilated left ventricular cavities (13.1 ± 3.0 cm 2 ) and aortic regurgitation (12.0 ± 3.6 cm 2 ) were significantly greater than in control subjects (8.7 ± 2.0 cm 2 ; p without dilated left ventricular cavities (9.8 ± 2.0 cm 2 ) were similar to those of normal valves (p = NS). However, mean mitral leaflet area in patients with HC, in whom left ventricular cavities were also nondilated, was significantly greater (12.8 ± 3.7 cm 2 ) than in those with nondilated AS and in normal subjects (p Therefore, increased mitral leaflet area: (1) is often present in patients with aortic valve disease with dilated left ventricles in whom it appears to be secondary to left ventricular chamber dilatation; and (2) cannot be attributed to left ventricular cavity dilatation in patients with HC, since their cavities were of normal or small size. Thus, increased mitral leaflet area in HC, which is considered to be a primary myocardial and not valvular disease, may be due to a primary effect on the mitral valve.

Clinical Summary A male neonate weighing 3100 g was referred to our hospital with cyanosis and respiratory distress. Two-dimensional echocardiography showed type B IAA, patent ductus arteriosus, subarterial VSD, and valvular aortic stenosis. The aortic valve was bicuspid and the annular diameter measured 3.0 mm. The infundibular septum was deviated posteriorly. Because aortic flow was decreased because of a left-to-right shunt through VSD, a significant pressure gradient across the aortic valve and subaortic portion was not detected by Doppler echocardiogram.

Calcific deposits in the aortic valve are common in elderly persons and may lead to valvular aortic stenosis (AS).1–3 We performed a prospective study to determine the prevalence and severity of valvular AS by Doppler echocardiography and its association with echocardiographic and electrocardiographic left ventricular (LV) hypertrophy and with physical signs of AS in unselected elderly patients in a long-term health care facility.

The use of Doppler techniques has greatly enhanced the noninvasive ultrasound technique for evaluation of valvular aortic stenosis. M-mode and two-dimensional echocardiography could not reliably distinguish patients with severe aortic stenosis from those with milder obstructions. The hemodynamic information offered by Doppler complemented echocardiographic imaging and provided an alternative modality for evaluation of patients with aortic stenosis. By application of the modified Bernoulli equation, the pressure gradient across the stenotic aortic valve could be estimated by Doppler echocardiography. Though helpful and widely used, the information provided by the pressure gradient across the valve about the severity of the obstruction was not complete. The assessment of valvular aortic stenosis therefore includes an estimation of the valve area by application of the continuity equation. This review examines the maturation of the continuity equation by Doppler techniques and discusses the implications of the procedure.

In adults with severe symptomatic valvular aortic stenosis (AS), some degree of coexisting mitral regurgitation (MR) is common. 1 Given that afterload reduction can alter hemodynamics favorably in patients with isolated MR, 2 it has been suggested that, in patients with AS, the afterload reduction resulting from aortic valve replacement or catheter balloon valvuloplasty may lead to a decrease in the severity of coexisting MR. 3,4 This might lead in turn to a decrease in heart failure symptoms and might even obviate the need for double valve replacement in some patients.

s S55 Eur J Echocardiography Abstracts Supplement, December 2006 analysed by 2 separate observers. TOE and RT-3DE images were acquired digitally on the Phillips IE33 ultrasound machine and stored for off line analysis. The RT-3DE datasets were analysed with Phillips Qlab software (version 4.0). Leaflet segments and commissures were displayed in short axis en-face and long axis views. Echocardiographic results were validated intraoperatively. Results: Five patients did not have image quality suitable for analysis with RT-3DE and were excluded from analysis. This left a sample size of 39 patients (mean age 52±11 years, 19 male). Twenty five patients had mitral valve repair and 9 mitral valve replacement. In total, 54 out of 334 analysed mitral valve segments were diseased. Prolapse of a single mitral valve segment was present in 25 patients. 14 patients had complex disease involving 2 or more segments. Sensitivity, specificity and accuracy for TOE in identification of diseased segments were 94%, 100% and 96% respectively. The same values for RT-3DE were 91%, 100%, 94%. The differences were not statistically significant. Accuracies were not significantly different according to segment location. Ruptured chordae was confirmed at surgery in 20 patients. Sensitivity for the diagnosis of ruptured chordae was 90% for TOE and 72% for RT-3DE (p=0.03). Specificity was comparable by both techniques (89% TOE vs 83% RT-3DE). Interobserver agreement was 92% (for TOE (k=0.85) and 86% for RT-3DE (k=0.83, p=non significant). The mean procedure time for TOE was 27±6 minutes. This was significantly longer than the procedure time for RT-3DE (7±3 minutes, p=0.03). The mean 3D reconstruction time was 15±8 minutes. Conclusions: RT-3DE is feasible with comparative accuracy to TOE for precise anatomical localisation of prolapsing mitral valve segments. However, the technique is limited by poor image quality in a small proportion of patients. TOE remains superior for diagnosis and localisation of chordal rupture.

Aortic dissection occurred after aortic valve replacement in two patients with valvular aortic stenosis. Clinical and necropsy findings are described.

Preoperative chest films of 100 consecutive patients with valvular aortic stenosis, referred to surgery, were evaluated. Aortic valve calcifications were the most common radiologic indicator of the disease, visible on the lateral chest film in 91 per cent of the cases notwithstanding high kV technique (170 kV). Poststenotic dilatation of the aorta appeared in only 36 per cent, unquestionable left ventricular enlargement in 52 per cent. It is concluded that, by paying attention to valve calcifications also when the aortic stenosis is not yet suggested clinically, the radiologist may contribute to timely diagnosis which may prevent unnecessary suffering or death. Difficulties in detection and possible confusion of aortic valve calcification with normal structures are discussed.

Congenital aortic stenosis presenting within the first 6 months of life is a highly lethal anomaly. Although aortic valvotomy has offered excellent palliation in many instances, the operative risk remains substantial. To better understand the factors associated with a poor operative result, the records of all patients less than 6 months of age undergoing aortic valvotomy at our institution from 1972 through 1986 were analyzed. Nineteen patients (58%) (Group I) survived operation; 14 (42%) (Group II) died. The following variables were analyzed in an attempt to define those with prognostic significance: mean pulmonary artery pressure (PAP), left ventricular (LV) peak systolic pressure, LV end-diastolic pressure, peak systolic aortic valve gradient, LV end-diastolic volume (LVEDV), LV ejection fraction, and age at operation. The only variables that were significantly different in the two groups were mean PA (Group I, 29 +/- 3 mm Hg, and Group II, 54 +/- 3 mm Hg; p less than 0.001) and LVEDV (Group I, 50 +/- 8 ml/m2, and Group II, 20 +/- 4 ml/m2; p less than 0.05). No patient with an LVEDV of 20 ml/m2 or less survived operation. We conclude that small LV dimension and elevation of PAP may be predictive of a poor surgical result in patients with severe aortic stenosis presenting in infancy.

Three cases are reported of valvular aortic stenosis in which artifactual subvalvular chambers were recorded on pressure tracings. The pressure tracings were obtained during withdrawal of multiholed catheters from the left ventricle to the aortic root. Several recent reports have described the coexistence of valvular and subvalvular aortic stenosis. The cases reported here re-emphasize that a multiholed catheter, which is the type commonly used for retrograde left ventricular entry in a patient with valvular aortic stenosis, is unsatisfactory for the detection of coexisting subvalvular obstruction.

18 patients with valvular aortic stenosis were given an i.v. glucose tolerance test and an i.v. insulin tolerance test before and 4-36 months after valve replacement. Insulin and C-peptide response to the glucose challenge was smaller preoperatively whereas the glucose response was the same pre- and postoperatively. The effect on blood glucose of the i.v. insulin challenge was more pronounced preoperatively. It is concluded that insulin sensitivity was increased preoperatively and it is suggested that this was a metabolic adaptation to the haemodynamic situation in aortic stenosis, which may have implications for preoperative glucose-insulin-potassium treatment.

Growth patterns of the cranium measured directly as head circumference have been well documented. With the availability of computed tomography (CT), cranial dimensions can be obtained easily. The objective of this project was to establish the mean values and their normal variance of CT cranial area of subjects at different ages. Cranial areas and its long and short axes were measured on CT scans for 215 neurologic patients of a wide age range who presented no evidence of abnormal growth of head size. Growth patterns of the cranial area as well as the numeric product of its linear dimensions were determined via a curve fitting process. The patterns resemble that of the head circumference growth chart, with the most rapid growth observed in the first 12 months of age and reaching full size during adolescence. It is believed that the availability of such reference, in addition to the head circumference measurement, will be valuable to the CT reviewer in determining the growth status of head size.

Real-time, cross-sectional echocardiograms were recorded in 28 consecutive adult patients with valvular aortic stenosis using a high resolution, mechanical sector scanner. Using the cross-sectional technique, the aortic valve orifice diameter was recorded in each of the 28 patients. With M-mode echocardiographic examination of these same patients, this value could be estimated in only 21 of these 28 patients (75%). The maximum aortic valve diameter recorded during the cross-sectional study averaged 7.9 +/- 1.8 mm (range 4-11 mm) in 15 patients with severe aortic stenosis; 11.6 +/- 2.3 mm (range 9-15 mm) in five patients with moderate aortic stenosis; 16.9 +/- 2.0 mm (range 14-20 mm) in eight patients with mild aortic stenosis; and 20.5 +/- 2.8 mm (range 15-26 mm) in 25 patients with no evidence of aortic valve disease. Comparing the means of these groups yielded the following: severe vs moderate P less than 0.005; moderate vs mild P less than 0.001; and mild vs normal P less than 0.001. Although there was some overlap between the individual groups, a clear separation existed between patients with severe and mild aortic stenosis. In addition, the group of patients in whom surgical intervention was recommended was also separated from the other subjects. When the aortic valve orifice was recorded using the M-mode technique, there was also a good correlation with the severity of the stenosis; however, the tendency of the M-mode study to overestimate severity in individual patients with calcific aortic stenosis and to underestimate severity in congenital aortic stenosis was again demonstrated. This study suggests that real-time, high resolution, cross-sectional echocardiography should be valuable in the noninvasive assessment of patients with aortic stenosis.

Two-dimensional echocardiographic studies have shown that maximum long-axis systolic aortic cusp separation (MACS) represents a useful, noninvasive method for estimating severity of valvular aortic stenosis in adults. Although mean values for patients with mild, moderate, and severe aortic stenosis have been clearly separated by this method, overlap occurs among individual patients. In this study, 81 adults with aortic stenosis were studied by two-dimensional echocardiography in the long-axis view. Long-axis assessment of aortic stenosis was obtainable in 93 percent of the patients. Less than 8-mm separation was 97 percent predictive of severe stenosis and 100 percent predictive of moderate or severe stenosis. Eight- to 12-mm had a low predictive value for the severity of stenosis. Greater than 12-mm separation was 96 percent predictive of mild aortic stenosis. Short-axis scans were attempted in 61 of the 81 subjects. Short axis assessment of aortic stenosis based on patterns of leaflet motion was obtainable in 46 of the 61 patients (73 percent) and provided a valuable index of severity. When short-axis scans were included in the assessment of severity in the subgroup of patients with 8- to 12-mm MACS, the predictive value improved greatly (86 percent vs 46 percent). Direct recording of aortic valve area in short-axis was successful in only 13 percent of the subjects. The echo aortic valve area compared with the hemodynamic calculated aortic valve area yielded an r = 0.87.

The first successful surgical repair of subaortic annular aneurysm associated with discrete subaortic stenosis and valvular aortic stenosis and incompetence is reported. The literature concerning this rare malformation is reviewed, and problems of diagnosis and surgical management are discussed.

Hypertrophic cardiomyopathy (HC) is a primary cardiac disease with diverse clinical and morphologic expressions.r-l3 The asymmetric distribution of left ventricular (LV) hypertrophy has often been cited as a sine qua non of the disease, LW,6-UJ-21 although SOme investigators have described patients with HC and a symmetric pattern of hypertrophy similar to that characteristic of valvular aortic stenosis or systemic hypertension.22-28 Considerable emphasis has been placed on the value of the septal to free wall thickness ratio (calculated from the M-mode echocardiogram) in the identification and morphologic characterization of HC, although some uncertainty has also arisen regarding the precise significance or value of this ratio. Extensive experience with 2-dimensional (2-D) echocardiography in HC has, however, provided us with a certain measure of clarification of these issues. This brief review constitutes a discussion of the septal-free wall ratio and its relevance to the clinical diagnosis of HC.

Combined forms of left ventricular outflow obstruction are being recognized with increasing frequency. A patient who had coarctation of the aorta, valvular aortic stenosis, and fixed and dynamic subvalvular obstruction is described. The importance of recognizing multiple levels of obstruction in such patients is emphasized.

Moderate and severe levels of experimental valvular aortic stenosis (VAS) were produced in anesthetized, open-chest dogs to determine the effects of VAS on subepicardial (EPI) and subendocardial (ENDO) blood flow, O2 extraction, and O2 consumption (MVO2). Regional flow was determined by microspheres, and O2 saturation and extraction were analyzed by a three-wavelength absorbance microspectrophotometric method. Left ventricular pressure-volume work increased by 49% in moderate and 135% in severe VAS. The ENDO:EPI flow ratio averaged 1.21 +/- 0.09 in controls and decreased to 0.90 +/- 0.16 in moderate and 0.89 +/- 0.09 in severe VAS, and coronary flow increased by 40% and 58%, respectively. O2 extraction increased with both moderate and severe VAS, with extraction being higher in the ENDO than the EPI. MVO2 increased more in severe VAS than in moderate VAS. The ENDO:EPI MVO2 ratios fell to 1.10 (moderate) and to 0.84 (severe) from 1.44 in controls. We conclude that the O2 supply and consequently the MVO2 became limited in the ENDO relative to that in the EPI by simultaneous limitation of the O2 extraction reserve and the blood flow to this region during the increased O2 requirements imposed by experimentally induced VAS.

Cet index est le produit du temps d'ejection ventriculaire gauche (corrige par la frequence cardiaque par la somme de l'epaisseur diastolique de la paroi posterieure du ventricule gauche et de la cloison interventriculaire

Echocardiographic and hemodynamic studies were obtained in 42 consecutive patients undergoing aortic valve replacement for isolated aortic stenosis. Concentric left ventricular (LV) wall thickening, the most common preoperative abnormality, occurred in 95% of patients. LV dilation with reduced fractional shortening was noted in approximately 25% of patients but was severe in only one patient. Six months after operation, LV wall thickness had decreased on average but had not returned to normal and fractional shortening was unchanged. Repeat measurements in 13 patients an average of 37 months after operation were unchanged compared with measurements made 6 months after operation. When patients were subdivided into those with LV dilatation and those without, we found that patients with dilated ventricles preoperatively had a greater decrease in LV internal dimension and mass than those without preoperative dilatation. The patient data also were examined for possible association with mortality. One operative (2%) and five late cardiac (13%) deaths occurred. No preoperative or 6-month postoperative echocardiographic or hemodynamic measurement was strongly associated with these deaths, nor were any late deaths due to congestive heart failure. Compared with preoperative measurements in symptomatic patients who were operated for isolated aortic regurgitation, patients with aortic stenosis had smaller left ventricles with less depression of systolic function, as well as less aortic root and left atrial dilatation. Our data do not support the concept that the aortic valve should be replaced before the onset of symptoms to prevent irreversible LV damage in patients with isolated aortic stenosis.

To determine which preoperative factors might affect the development of cardiac complications after major noncardiac operations, we prospectively studied 1001 patients over 40 years of age. By multivariate discriminant analysis, we identified nine independent significant correlates of life-threatening and fatal cardiac complications: preoperative third heart sound or jugular venous distention; myocardial infarction in the preceding six months; more than five premature ventricular contractions per minute documented at any time before operation; rhythm other than sinus or presence of premature atrial contractions on preoperative electrocardiogram; age over 70 years; intraperitoneal, intrathoracic or aortic operation; emergency operation; important valvular aortic stenosis; and poor general medical condition. Patients could be separated into four classes of significantly different risk. Ten of the 19 postoperative cardiac fatalities occurred in the 18 patients at highest risk. If validated by prospective application, the multifactorial index may allow preoperative estimation of cardiac risk independent of direct surgical risk.

Doppler echocardiography was used to study left ventricular (LV) diastolic filling in 49 adults with isolated aortic stenosis (AS), selected from 155 consecutive patients with AS by excluding coexisting mitral disease (n = 41) and/or significant aortic regurgitation (n = 80). There were no differences between patients with AS and age-matched normal subjects for early diastolic filling (E) velocity (68 +/- 17 vs 67 +/- 13 cm/s), late diastolic filling (A) velocity (79 +/- 25 vs 67 +/- 21 cm/s), E/A ratio (1.00 +/- 0.78 vs 1.06 +/- 0.32) or early diastolic deceleration slope (264 +/- 151 vs 319 +/- 137 cm/s2, differences not significant for all). There was no correlation between any LV filling parameter and AS severity, but late diastolic filling velocity was higher in patients with AS who had LV hypertrophy (n = 33) vs those who did not (n = 16) (86 +/- 23 vs 65 +/- 26 cm/s, p less than 0.01). In the patients with AS and systolic dysfunction (LV ejection fraction less than 50%) (n = 6), early diastolic filling velocity was higher (88 +/- 20 vs 65 +/- 15 cm/s, p less than 0.01), late diastolic filling velocity lower (53 +/- 23 vs 83 +/- 23 cm/s, p less than 0.01), E/A ratio higher (2.20 +/- 1.80 vs 0.84 +/- 0.28, p less than 0.01), deceleration slope steeper (439 +/- 230 vs 240 +/- 121 cm/s2, p = 0.02) and LV end-diastolic pressure higher (23 +/- 9 vs 10 +/- 6 mm Hg, p less than 0.01) than in patients with AS and normal systolic function.(ABSTRACT TRUNCATED AT 250 WORDS)

A patient is presented in whom coexisting bicuspid valvular aortic stenosis and asymmetrical septal hypertrophy were suggested by echocardiography. A focal area of hypertrophy noted at operation was excised. Subsequent histological examination did not reveal evidence to support the echographic and surgical observations. The necessity for careful intraoperative assessment of the degree and nature of subvalvular muscular hypertrophy is stressed. The absence of classic echographic findings in these patients is noted.

2. Cohen LS, Friedman WF, Braunwald E: Natural history of mild congenital aortic stenosis elucidated by serial hemodynamic studies. Am J Cardiol 30:1, 1972. 3. Bogart DB, Murphy BL, Wong BYS, Pugh DM, Dunn MI: Progression of aortic stenosis. Chest 76:391, 1979. 4. Cheitlin MD, Gertz EW, Brundage BH, Carlson CJ, Quash JA, Bode RS Jr: Rate of progression of severity of valvular aortic stenosis in the adult. AM HEART J 98:689, 1979.