Whoops, not quite! The long axis view always shows the right coronary cusp of the AV, along with either the non-coronary (more often) or the left coronary (sometimes.) Perhaps this x-plane image will help make that more clear. Notice how the x-plane cuts through the right coronary cusp on the bottom. It would basically be impossible to cut through the aortic valve in this view and not capture a portion of the RCC anteriorly. On the other hand, you could rotate so you saw either the NCC or the LCC. Make sense?

Come on, now, you didn’t mean that did you? You know that this is clearly a bicuspid valve with fusion of the RCC and LCC, right? Now go check this patient for an aortic coarctation.

Nope, not quite. This is the deep transgastric long axis. It looks a little bit like the apical 5 chamber (because it is a little like that, but there’s multiplane in the image.) It’s created by advancing the probe from the transgastric window deeper into the stomach and anteflexing. Hopefully your probe will be somewhere near the apex of the LV and will create an image like this. This is one of 2 views in TEE that can be used to interrogate the AV with spectral doppler. Why can’t we just do spectral doppler from the midesophageal windows?

Nope, this is a parasternal short axis of the AV. And the valve is QUADRICUSIPD, super rare. When you see this you’re almost certainly wrong.

Nope. In this parasternal AV SAX the right ventricle will be at the top of the screen. That makes 12 o’clock the RCC, then the LCC, and the NCC will be at 7 o’clock by the interatrial septum. If this isn’t intuitive because you’re used to the midesophageal RV inflow outflow that’s OK, take a sec to reorient yourself.

Nope, this is not OK. You need to bring the Doppler, this is not mildly stenotic.

Nope. I recommend you give that another try until you get it right.

Nope, not quite.  This valve is not so bad.  It would be surprising if there was more than mild stenosis, and there is certainly not severe AS.

Give that another try. Don’t feel badly, it takes practice. Take your time, show your work, and get back in the saddle.

Nope, this isn’t too bad.  File this away as “little restricted opening, but not significantly stenotic.”

OK, I know this isn’t a fair question.  I just want you to be exposed to a lot of images to build your experience.  This should trigger your “Hmm, I’m concerned about this calcification” reaction, but notice that there is some reasonable opening of this valve.  It would be totally reasonable to quantify the stenosis here, but you’d be a little surprised if you found severe stenosis.

Don’t get down, this is a little tough and probably unfair of me to ask. We see here a limitation of excursion, but probably not enough to kill someone yet. If you wanted to quantify this stenosis that is probably wise, anything you think is moderate or worse should trigger quantification.

Whoops, back to the drawing board! Go slow and show your work if you need to.

Oh darn!  Take another look at your quantification of AS if you need to, the American Society of Echo has a nice set of guidelines available on their site (http://www.asecho.org/)  In this image, continuous wave Doppler through the AV in the deep TG LAX shows us a nice double envelope (remember why that is useful?)  We see a peak velocity < 3 (consistent with mild stenosis) and a doppler velocity index of more than 0.5 (also mild.)  Both measures are barely on the mild side of moderate, though, so with more quantification you wouldn’t be surprised to find this called “mild-to-moderate.”

Well, not quite…we’re seeing pretty typical rheumatic disease here.  In the long axis view there is thickening primarily of the tips of the leaflets.  In systole you see the classic “hockey-stick” appearance, especially of the non-coronary cusp here.  This is caused by restriction of the tips of the leaflet with relative sparing of the body.

We’ll just assume your keyboard is malfunctioning. This is another classic rheumatic valve. In the long axis view there is thickening of the tips of the leaflets.  In systole you see the classic “hockey-stick” appearance, especially of the non-coronary cusp here.  This is caused by restriction of the tips of the leaflet with relative sparing of the body. You also see dilation of the ascending aorta, which you find associated with aortic stenosis.

I assume you’re joking…this is a classic rheumatic aortic valve. You can see thickening and calcification of the commisures and the tips of the leaflets. Take a moment to store this in your CPU.

Nope, back to the drawing board. This is a calcified trileaflet valve, consistent with “degenerative changes” meaning this is not a rheumatic valve. There is calcification throughout the entire body of the leaflet, and there’s a lot of it. You expect severe calcification.

Bzzzt! Try again! This is a heavily calcified (concerning!) aortic valve, with calcification throughout the body of the leaflets consistent with degenerative changes of aging and decrepitude.

Take another look at this and regroup. The color flow signal in the parasternal LAX suggests only mild AI, you would be surprised if it was more. The continuous wave Doppler confirms this with a pressure half time above 500 ms (the cutoff below which we call AI moderate.)

I’m sure you’re on the right track. This is holodiastolic reversal of flow in the thoracic aorta (notice the high velocity of the diastolic signal as well.) You expect this to be the descending aorta rather than the arch because of the long axis appearance in the scout image at 90 degrees. This is a specific finding for severe aortic insufficiency.

Nope, not exactly. Try again and I’m sure you’ll get it. This is a parasternal SAX of the AV with significant color flow seen in diastole. This should concern you for significant aortic insufficiency.

OK, maybe this is unfair. Reasonable people can disagree, and if you called this moderate you might not be wrong. I had called it mild-to-moderate because the pressure half-time was juuuust on the moderate side of mild (500 ms.)

Not exactly.  Take another look and regroup.  There is a large coaptation defect in the aortic valve, and you should expect significant regurgitation any time you see a 2D defect.

Rats, I was sure you had this one! The first image looks like more-than-mild aortic insufficiency, meaning you’d like to spend some more time quantifying it. When you measure the vena contracta, it falls into the moderate range (3-6 mm) confirming your suspicions. How would you improve the vena contracta measurement here? What other information would you need to shore up your quantification?

Whoops! You probably realize by now that this is a midesophageal aortic valve short axis.  We see the left atrium at the top of the screen (under the transducer), which tell us that we’re in the mid esophagus, and we’re focused on the aortic valve.  The arrow is pointing at the right coronary cusp of the aortic valve.  Remember that the noncoronary cusp is always located adjacent to the interatrial septum and the right cusp is always by the right ventricle (you could say the left cusp is “left over” I guess.)

Rats! This is a midesophageal aortic valve short axis.  We see the left atrium at the top of the screen (under the transducer), which tell us that we’re in the mid esophagus, and we’re focused on the aortic valve. The arrow in this case is showing us the left coronary cusp of the aortic valve. Remember the right cusp is by the RV and the non coronary cusp is by the interatrial septum.

Well, not exactly…remember that the non-coronary cusp is always by the interatrial septum and you’ll be on track.

Not exactly, did I fool you?  Remember that the non-coronary cusp will always be by the interatrial septum and the right coronary cusp will be by the RV and you should stay on track.

Come back and try this one again. Remember that the non-coronary cusp is by the interatrial septum and the right cusp will by the RV.

Whoops, come back and try that one again!

Not exactly. This is definitely not enough AI to worry about (mild) but you should be worried about AS here and will want to go on to quantify.

Nope, time to review cutoffs for pressure half time in AI. The better the valve works the slower blood comes in (cutoff between mild and moderate is 500 ms.)

Must have been a mouse malfunction. This continuous wave doppler shows us two characteristics of severe aortic stenosis. Mean gradient > 40 mmHg, and peak velocity > 4 m/s.

Well…no, not exactly. The color flow shows a concerning amount of AI, though you cannot quantify it easily because it is terribly eccentric.  But the holodiastolic reversal of flow in the aorta confirms severe AI.

Must have had a brief absence seizure, hope you’re better now. This is clearly a small amount of AI, you don’t really need to quantify further.

Take a second to review these images again, and check your numbers. This is mild AI by both CFD and PHT.

Nope, not this time. This is just mild AI.

Another slip of the mouse, you’d better get that thing checked. If this is all you have, you have to call it moderate AI (between 200 and 500.)

Rats, you missed it! It is tough to call moderate, and you would want to confirm with multiple other modalities. Think of 5 ways to quantify further…

Nope, take another look at methods to quantify aortic insufficiency. PHT 200-500 with no reversal of flow = moderate.