Question for the cards guys

[amyl]

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How reliable are TTEs? How operator dependent are they? From last year to this year my valve area went from 0.7 to 1.2 at different hospitals as I moved. What gives ? I’m pretty sure my bicuspid AV didn’t “open” up. Very frustrating as I’m trying to understand how bad it is- thanks

 

[maxxor]

I'm a radiologist, so a slightly different tack:

Phase contrast cardiac MR can be done to more directly calculate the aortic valve area from velocities. We would do this when the diagnosis was in question. cvi42 software can calculate this (which is what I've used for cardiac MR wherever I've performed it in the past. I currently don't do it much anymore.)

I will leave the scan to scan variability of TTEs to the other experts.

 

[Gern Blansten]

My brother was told his son had a bicuspid aortic valve at age ten and stated that he would eventually need a surgical replacement. . A couple of years later, another scan was done for follow up and a different cardiologist said, “I have no idea why they told you that. He does NOT have a bicuspid aortic valve.” Further follow up showed no bicuspid valve. This was years ago. I’m pretty sure he still doesn’t have a bicuspid aortic valve at age 29. So, I think the point is, sometimes they heal. Or maybe it’s that echocardiographer skill level and the skill of who interprets it can vary. One of those two things…probably.

 

[pgg]

How reliable are TTEs? How operator dependent are they? From last year to this year my valve area went from 0.7 to 1.2 at different hospitals as I moved. What gives ? I’m pretty sure my bicuspid AV didn’t “open” up. Very frustrating as I’m trying to understand how bad it is- thanks

Assessment of AS is not always straightforward.

Small errors and variations in measurement of LVOT diameter can produce larger errors in LVOT area (the measurement is squared). The LVOT isn't exactly round either, but the equation assumes it is. So area in cm^2 is rather error prone when calculated by continuity, and is just one factor in assessing the severity of aortic stenosis. Area measured by planimetry is also quite operator dependent.

Velocity and gradient measured by doppler may have more inter-operator consistency. Usually getting the doppler lined up within 10-20 deg of straight across the valve is easy enough, but not always.

If the patient isn't in sinus, or has a lot of ectopy, all of the measurements get harder and typically we'll average things over multiple beats.

If a patient has impaired LV function, assessment of AS gets a little more tricky. The gradient/velocity may not get as high as you'd expect for a severely stenotic valve. Even if EF is "normal", if the LV is small and indexed stroke volume is small (under 35 ml/m^2) the LV isn't really normal. Severe AS is often accompanied by a hypertrophied LV which may or may not result in a smaller LV size.

When the data doesn't clearly point at classic severe AS, teasing out whether or not the valve only looks bad because the LV sucks, or that the valve really is bad and the LV also sucks, can be difficult.

Correlating with symptoms, and progression, or lack thereof, is important. Often hard because so many of these patients also have respiratory comborbidities, obesity, frailty, or other confounders.

If there is conflicting data, a dobutamine echo to assess how an impaired LV is actually impacting the measurements, or TEE for better image quality, or cardiac MRI, may be reasonable.

We discuss our potential TAVR vs SAVR vs wait-and-see cases every week at our advanced valve conference, and even with multiple cardiologists and surgeons looking at multiple studies, it's sometimes rather fuzzy. And to be honest - AVA measured by continuity isn't given much attention.

 

[pgg]

My brother was told his son had a bicuspid aortic valve at age ten and stated that he would eventually need a surgical replacement. . A couple of years later, another scan was done for follow up and a different cardiologist said, “I have no idea why they told you that. He does NOT have a bicuspid aortic valve.” Further follow up showed no bicuspid valve. This was years ago. I’m pretty sure he still doesn’t have a bicuspid aortic valve at age 29. So, I think the point is, sometimes they heal. Or maybe it’s that echocardiographer skill level and the skill of who interprets it can vary. One of those two things…probably.

Bicuspid valves come in different flavors. Rarely (<10%) they're truly bicuspid, exactly two leaflets. Usually they're sorta tricuspid but two leaflets are partially or completely fused. This morphology can make it hard to tell on TTE. Throw in some calcium in older patients or a wiggly kid and/or a chubby body with small windows ...

 

[dchz]

Assessment of AS is not always straightforward.

Small errors and variations in measurement of LVOT diameter can produce larger errors in LVOT area (the measurement is squared). The LVOT isn't exactly round either, but the equation assumes it is. So area in cm^2 is rather error prone when calculated by continuity, and is just one factor in assessing the severity of aortic stenosis. Area measured by planimetry is also quite operator dependent.

Velocity and gradient measured by doppler may have more inter-operator consistency. Usually getting the doppler lined up within 10-20 deg of straight across the valve is easy enough, but not always.

If the patient isn't in sinus, or has a lot of ectopy, all of the measurements get harder and typically we'll average things over multiple beats.

If a patient has impaired LV function, assessment of AS gets a little more tricky. The gradient/velocity may not get as high as you'd expect for a severely stenotic valve. Even if EF is "normal", if the LV is small and indexed stroke volume is small (under 35 ml/m^2) the LV isn't really normal. Severe AS is often accompanied by a hypertrophied LV which may or may not result in a smaller LV size.

When the data doesn't clearly point at classic severe AS, teasing out whether or not the valve only looks bad because the LV sucks, or that the valve really is bad and the LV also sucks, can be difficult.

Correlating with symptoms, and progression, or lack thereof, is important. Often hard because so many of these patients also have respiratory comborbidities, obesity, frailty, or other confounders.

If there is conflicting data, a dobutamine echo to assess how an impaired LV is actually impacting the measurements, or TEE for better image quality, or cardiac MRI, may be reasonable.

We discuss our potential TAVR vs SAVR vs wait-and-see cases every week at our advanced valve conference, and even with multiple cardiologists and surgeons looking at multiple studies, it's sometimes rather fuzzy. And to be honest - AVA measured by continuity isn't given much attention.

Agree with everything above. Second to say that aortic valve area by continuity is basically a crapshoot. Mean gradient is a lot less prone to inter-operator measuring variability, but still one datapoint in a big picture.

*Retracted to curb unqualified medical advice. Consult your cardiologist.*

My brother was told his son had a bicuspid aortic valve at age ten and stated that he would eventually need a surgical replacement. . A couple of years later, another scan was done for follow up and a different cardiologist said, “I have no idea why they told you that. He does NOT have a bicuspid aortic valve.” Further follow up showed no bicuspid valve. This was years ago. I’m pretty sure he still doesn’t have a bicuspid aortic valve at age 29. So, I think the point is, sometimes they heal. Or maybe it’s that echocardiographer skill level and the skill of who interprets it can vary. One of those two things…probably.

Don't think that's ever been documented.

 

[abolt18]

I was going to add something but pgg covered it. Lots of room for error. It could be as simple as the doppler not being well-aligned and leading to a falsely low velocity -> falsely large AVA.

 

[caligas]

Probably need a TEE if symptomatic

 

[pgg]

We should keep this thread firmly in the realm of discussing medicine in general, and away from medical advice offered/taken.

🙂

 

[DrN2O]

2020 AHA guideline. AS is section 3.

https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923

I tend to believe a TTE more than TEE under sedation. While 2D measurement of annulus and LVOT may be poor, Doppler is better aligned for gradient measurement on TTE. The TTE techs are usually very experienced (1000's), probably better than the fellows who are doing TEE (100's). Discordant diagnostic data can happen. There are roles for CT and CMR. The decision to intervene can be complicated. Indication for AVR is also creeping towards moderate AS. Best talk to your own doctor.

 

[sevoflurane]

How reliable are TTEs? How operator dependent are they? From last year to this year my valve area went from 0.7 to 1.2 at different hospitals as I moved. What gives ? I’m pretty sure my bicuspid AV didn’t “open” up. Very frustrating as I’m trying to understand how bad it is- thanks

.7 to 1.2 is quite a difference IMO as it has implications for those who are in their 50s and early 60s that are asymptomatic.
That’s frustrating. Sorry you are going through this.

Hard to argue with a CWD with a mean gradient over 40 mmHg and a velocity over 4m/s along with CFD that supports this.

However, often times patient's are put into the “severe” category for reasons sighted above which are very valid.
User error does happen. I have cancelled a handful or cases due to artifact or incorrect measurements. Mitral clip with a baseline gradient of 5-6 under GA or a Type A dissection that had artifact on CT for example.

It does become more challenging with an open mitral case whose MR is moderate after induction. It’s impressive how moderate can become severe under particular loading conditions or a 200-300 mcgs of neo.

Good luck Amyl.

 

[PpfSuxTube]

These are reasonably operator dependant.

Tte for rwma, lv thrombus, stenosis lesion severity using PG are usually fairly reliable in most places I've worked. And most often as good if not better than tee.

Tte and tee can be wrong about bicuspid vs tricuspid. And both can get lvot incorrect so as said ava by vti just isn't reliable.

Tee is often better than tte for assessment of regurgitant lesions especially mitral when the plan is repair. If youre replacing it who cares the etiology

Tomor we have MVR. Outside tte done at other center. Screening tte literally says there is severe MR. Thats it... wild stuff... stethoscope level insight right there

 

[Bertelman]

How reliable are TTEs? How operator dependent are they? From last year to this year my valve area went from 0.7 to 1.2 at different hospitals as I moved. What gives ? I’m pretty sure my bicuspid AV didn’t “open” up. Very frustrating as I’m trying to understand how bad it is- thanks

Plenty of good comments above. I would emphasize that peak and mean gradients are likely a better metric to track than AVA. In my experience, AVA was how a cardiologist justified dropping a TAVR in someone with a marginal gradient. And planimetry is almost worthless in any modality. I rarely struggle to get a clean gradient envelope with TEE, but TTE is generally considered more reliable. I might argue TEE can often produce a better LVOT measurement for AVA, depending on TTE windows.

I'd talk to the cardiologists at your hospital. Ask for the best sonographer, they should know. Request a scan from them.

Different scenario, but I got a calcium scan last month. I know and trust the radiologist that read it. He called me, said "I won't report it, but your ascending aorta is around 4.1"

I'm a tall guy, so I was little concerned. Talked to the best sonographer at my hospital, curbsided a quick TTE. Not only did he assure me my AV was tricuspid, he said my Ascending was no more than 3.5.

 

[PpfSuxTube]

Plenty of good comments above. I would emphasize that peak and mean gradients are likely a better metric to track than AVA. In my experience, AVA was how a cardiologist justified dropping a TAVR in someone with a marginal gradient. And planimetry is almost worthless in any modality. I rarely struggle to get a clean gradient envelope with TEE, but TTE is generally considered more reliable. I might argue TEE can often produce a better LVOT measurement for AVA, depending on TTE windows.

I'd talk to the cardiologists at your hospital. Ask for the best sonographer, they should know. Request a scan from them.

Different scenario, but I got a calcium scan last month. I know and trust the radiologist that read it. He called me, said "I won't report it, but your ascending aorta is around 4.1"

I'm a tall guy, so I was little concerned. Talked to the best sonographer at my hospital, curbsided a quick TTE. Not only did he assure me my AV was tricuspid, he said my Ascending was no more than 3.5.

Ct is far better for ascending measurements. I definitely wouldn't trust tte for that. I dont care who is doing it. Most importantly however its tricuspid. I would definitely insure heavily stat. You could be denied going forward

 

[Bertelman]

Ct is far better for ascending measurements. I definitely wouldn't trust tte for that. I dont care who is doing it. Most importantly however its tricuspid. I would definitely insure heavily stat. You could be denied going forward

Not sure I understand the end of that statement. Something about insurance?

I had two accepted modalities to measure my ascending. There was a 0.5 cm discrepancy. That was my point.

 

[Dantrolene FC]

Not sure I understand the end of that statement. Something about insurance?

I had two accepted modalities to measure my ascending. There was a 0.5 cm discrepancy. That was my point.

He’s talking about getting life insurance.

 

[PpfSuxTube]

Not sure I understand the end of that statement. Something about insurance?

I had two accepted modalities to measure my ascending. There was a 0.5 cm discrepancy. That was my point.

I dont really agree that Tte is accepted modality.

Its probably ok for its negative predictive value but for borderline cases any place ive worked the ct is gold standard. I dont know any ct surgeon or cardiologist that relies on tte for any aortic work.


i also dont agree that 0.5cm discrepancy is negligible. 0.5cm is huge when it comes to ascending aortic decision making. The difference btwn say 4.1 and 4.6 is enormous

And my last point is to make sure you have life insurance yourself maxed before anything is put on paper. You never know how these things pan out. I dont know anything about your medical situation and im not prying but it sounds like someone is already looking for something on you. Next thing you know a chest xray or something labels wide mediastinum and thats it you insurance can fight you if heaven forbid something bad happens. They can claim pre existing for any myriad of reasons

 

[maxxor]

I dont really agree that Tte is accepted modality.

Its probably ok for its negative predictive value but for borderline cases any place ive worked the ct is gold standard. I dont know any ct surgeon or cardiologist that relies on tte for any aortic work.


i also dont agree that 0.5cm discrepancy is negligible. 0.5cm is huge when it comes to ascending aortic decision making. The difference btwn say 4.1 and 4.6 is enormous

And my last point is to make sure you have life insurance yourself maxed before anything is put on paper. You never know how these things pan out. I dont know anything about your medical situation and im not prying but it sounds like someone is already looking for something on you. Next thing you know a chest xray or something labels wide mediastinum and thats it you insurance can fight you if heaven forbid something bad happens. They can claim pre existing for any myriad of reasons

Only want to chime in that a cardiac gated CT is probably the most accurate as it takes the motion out of the equation.

Calcium scores are gated so the measurement is something I’d believe.

 

[Bertelman]

I dont really agree that Tte is accepted modality.

Its probably ok for its negative predictive value but for borderline cases any place ive worked the ct is gold standard. I dont know any ct surgeon or cardiologist that relies on tte for any aortic work.


i also dont agree that 0.5cm discrepancy is negligible. 0.5cm is huge when it comes to ascending aortic decision making. The difference btwn say 4.1 and 4.6 is enormous

And my last point is to make sure you have life insurance yourself maxed before anything is put on paper. You never know how these things pan out. I dont know anything about your medical situation and im not prying but it sounds like someone is already looking for something on you. Next thing you know a chest xray or something labels wide mediastinum and thats it you insurance can fight you if heaven forbid something bad happens. They can claim pre existing for any myriad of reasons

I appreciate your concern. I think we may be looking at my comments through a different lens. I'm at the age where adding an additional life insurance policy would not be wise.

I wanted to echo what the OP already knows, that there can be significant variation based on the sonographer performing the study, also between modalities. So don't get too attached to an isolated result, certainly not an AVA with a TTE.

I don't have any relevant personal medical history, and I'm asymptomatic. But I'm at the age where a calcium scan is useful. I was a little surprised to hear my Asc may be dilated, so I dug a little deeper. I work at a place with very good cardiac facilities, but some low performers. I'm talking cardiologists that cannot, or will not, measure an aortic gradient with a TEE because "it's a hard view to get". So they simply state aortic stenosis based on qualitative data. So I understand interoperator variability.

At no point did I state, nor do I believe, that a 0.5 cm discrepancy is negligible. But my intention, at my age and risk factors, was to predict the progression of an arguably dilated ascending. Arguable because at 4.0 cm, me standing 75 in tall, I remain low risk. See link. Either way, the question I was asking - do I have a bicuspid valve - was answered, by a fully accepted modality. Him throwing in his measurement of my Asc was nice, but not necessary.

https://www.jtcvs.org/cms/10.1016/j.jtcvs.2017.10.140/asset/49d4f4da-e076-41ac-b6b2-8714163dd04c/main.assets/fx1_lrg.jpg

Do I believe my ascending is dilated? Hard to say. But I never asked that question. It's an incidental finding, and no surgeon is interested in my 4.0 cm value. What I do know is I'm very low risk for CAD, and I'm the same risk for aneurysm/dissection as everyone else out there with a 3.5 cm aorta, per the aortic height index. I also know I don't have a bicuspid valve. At this point in my life, with my medical history and diagnostic results, I'm satisfied with my concerns.

We both agree that CT is the gold standard. But TTE is an acceptable standard, in my mind, because organizations support using it as a screening tool, and guidelines/standards include it for routine exams. Looking at it a different way, if all I had ever done was get a full TTE, we wouldn't even be talking about this. Say there is a 0.2 cm variability in CAC CTs detecting asc diameter. I'd bet mine would be 3.8 before it was 4.2, based on my studies.

 

[PpfSuxTube]

I appreciate your concern. I think we may be looking at my comments through a different lens. I'm at the age where adding an additional life insurance policy would not be wise.

I wanted to echo what the OP already knows, that there can be significant variation based on the sonographer performing the study, also between modalities. So don't get too attached to an isolated result, certainly not an AVA with a TTE.

I don't have any relevant personal medical history, and I'm asymptomatic. But I'm at the age where a calcium scan is useful. I was a little surprised to hear my Asc may be dilated, so I dug a little deeper. I work at a place with very good cardiac facilities, but some low performers. I'm talking cardiologists that cannot, or will not, measure an aortic gradient with a TEE because "it's a hard view to get". So they simply state aortic stenosis based on qualitative data. So I understand interoperator variability.

At no point did I state, nor do I believe, that a 0.5 cm discrepancy is negligible. But my intention, at my age and risk factors, was to predict the progression of an arguably dilated ascending. Arguable because at 4.0 cm, me standing 75 in tall, I remain low risk. See link. Either way, the question I was asking - do I have a bicuspid valve - was answered, by a fully accepted modality. Him throwing in his measurement of my Asc was nice, but not necessary.

https://www.jtcvs.org/cms/10.1016/j.jtcvs.2017.10.140/asset/49d4f4da-e076-41ac-b6b2-8714163dd04c/main.assets/fx1_lrg.jpg

Do I believe my ascending is dilated? Hard to say. But I never asked that question. It's an incidental finding, and no surgeon is interested in my 4.0 cm value. What I do know is I'm very low risk for CAD, and I'm the same risk for aneurysm/dissection as everyone else out there with a 3.5 cm aorta, per the aortic height index. I also know I don't have a bicuspid valve. At this point in my life, with my medical history and diagnostic results, I'm satisfied with my concerns.

We both agree that CT is the gold standard. But TTE is an acceptable standard, in my mind, because organizations support using it as a screening tool, and guidelines/standards include it for routine exams. Looking at it a different way, if all I had ever done was get a full TTE, we wouldn't even be talking about this. Say there is a 0.2 cm variability in CAC CTs detecting asc diameter. I'd bet mine would be 3.8 before it was 4.2, based on my studies.

Good, happy for you and agreed as long as its tricuspid there's no worry. Apologies if I misread the 0.5 bit!

 

[pgg]

cardiologists that cannot, or will not, measure an aortic gradient with a TEE because "it's a hard view to get".

 

[greatnt249]

I'm talking cardiologists that cannot, or will not, measure an aortic gradient with a TEE because "it's a hard view to get". So they simply state aortic stenosis based on qualitative data. So I understand interoperator variability.

This would be a, quite frankly, embarrassing admission to make if they're doing TEEs with any degree of regularity, especially if they work in the OR. Yes it can be challenging, but it isn't impossible, and it's not uncommon for me to get gradients that the sonographers couldn't because the necessary angle wasn't available from a transthoracic approach.

That being said, if there's any question regarding aorta size I would favor the CT measurement over TTE, as there's less variables at play with CT when it comes to image acquisition. That, and you can only see so much of the ascending aorta with TTE, so the dilation might not be visible in the available TTE windows compared to what you can see with CT.

 

[Bertelman]

Our cardiologists never enter the OR. But yes, embarrassing to practice in such a manner.

 

[urge]

Isn’t it like everything else? Just go with the number you like.