Echo valve quantitation — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 76-year-old man with breathlessness on exertion has severe leaflet calcification with severely reduced leaflet motion, LV hypertrophy and LV diastolic dysfunction.^[2] TTE shows AVA 0.85 cm², aortic Vmax 3.4 m/s, mean gradient 29 mm Hg, stroke volume index 28 mL/m² and LVEF 35%. His blood pressure is 120/72 mm Hg.^[1][2]

1. Which ESC/EACTS 2025 category of discordant AS does he fit, and which ACC/AHA 2020 Table 13 stage is suspected? (2)^[1][2]
2. Which test does ACC/AHA 2020 call reasonable to further define severity and assess contractile reserve in this stage, with COR and LOE? (2)^[3]
3. Describe the ACC/AHA 2020 findings on that test that indicate true severe AS, and those that indicate moderate AS with primary LV dysfunction. (2)^[3]
4. What does ESC/EACTS 2025 say about CT aortic valve calcium scoring in this setting, and which value indicates severe AS in a man? (2)^[1]
5. If severe AS is confirmed, give the ESC/EACTS 2025 Recommendation Table 4 row with class and level. (2)^[1]

Model answers — SAQ 1

1. ESC/EACTS 2025: low-flow, low-gradient AS with reduced LVEF (mean gradient <40 mmHg, AVA ≤1 cm², SVi ≤35 mL/m², LVEF <50%) (1 mark).^[1] ACC/AHA 2020: suspected Stage D2, symptomatic severe low-flow, low-gradient AS with reduced LVEF (1 mark).^[2]
2. Low-dose dobutamine stress testing with echocardiographic or invasive haemodynamic measurements (1 mark).^[3] COR 2a, LOE B-NR (1 mark).^[3]
3. True severe AS: a fixed valve area, with velocity rising to ≥4 m/s (mean gradient ≥40 mm Hg) at any flow rate while the valve area stays ≤1.0 cm² (1 mark).^[3] Moderate AS with primary LV dysfunction: the valve area increases as flow rises, with only a modest increase in velocity or gradient (1 mark).^[3]
4. ESC/EACTS 2025 says CCT calcium AV scoring is readily available and provides important adjunctive information in low-flow, low-gradient AS because it correlates with haemodynamic severity, progression and clinical outcomes; with reduced LVEF it gives complementary information to DSE (1 mark).^[1] Values of >2000 AU in men indicate severe AS with high sensitivity and specificity (∼85%) (1 mark).^[1]
5. Intervention is recommended in symptomatic patients with low-flow (SVi ≤35 mL/m²), low-gradient (<40 mmHg) AS with reduced LVEF (<50%) after careful confirmation that AS is severe (1 mark).^[1] Class I, Level B (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 63-year-old man with ischaemic cardiomyopathy (LVEF 30%) has moderate-to-severe secondary mitral regurgitation on a TTE done during an admission with decompensated heart failure.^[1] He is now on optimised medical therapy, euvolaemic and normotensive.^[1]

1. When does ESC/EACTS 2025 say SMR should be assessed? (1)^[1]
2. Why may lower EROA and RVol thresholds apply in SMR, according to ESC/EACTS 2025, and which values has it identified as having a significant impact on outcomes? (2)^[1]
3. How does the ACC/AHA 2020 text define severe secondary MR, and what does it say about moderate MR? (2)^[3]
4. What does the ACC/AHA 2020 Table 18 footnote say about PISA measured by 2D TTE in secondary MR, and about regurgitant volume in low-flow states? (2)^[2]
5. Name the ACC/AHA 2020 diagnostic row for TTE in chronic secondary MR, with COR and LOE. (1)^[3]
6. Which two further tests does ESC/EACTS 2025 name to confirm SMR severity or to identify severe SMR when resting values are inconclusive? (2)^[1]

Model answers — SAQ 2

1. After optimisation of medical therapy and in a euvolaemic and normotensive state (1 mark).^[1]
2. Because of the potential elliptical regurgitant orifice and/or the low-flow state (1 mark).^[1] An EROA of ≥30 mm² and/or an RVol of ≥45 mL has been identified as having a significant impact on outcomes, with prognosis improved after treatment (1 mark).^[1]
3. Severe secondary MR is defined as an ERO ≥40 mm² (1 mark).^[3] In secondary MR, outcome studies have shown poor prognosis in those with moderate MR (ERO ≥20 mm²) (1 mark).^[3]
4. The measurement of the proximal isovelocity surface area by 2D TTE in secondary MR underestimates the true ERO because of the crescentic shape of the proximal convergence (1 mark).^[2] The ‡ footnote sits on the severe regurgitant volume cell (≥60 mL, Stages C and D) and says it may be lower in low-flow states (1 mark).^[2]
5. ACC/AHA 2020: in chronic secondary MR (Stages B to D), TTE is useful to establish the aetiology and to assess the extent of regional and global LV remodelling and systolic dysfunction, severity of MR and magnitude of pulmonary hypertension (COR 1, LOE B-NR) (1 mark).^[3]
6. CMR is used to confirm SMR severity and assess cardiac chamber function and dimensions (1 mark).^[1] Exercise echocardiography may help to identify severe SMR when values at rest are inconclusive, owing to the dynamic nature of SMR (1 mark).^[1]