Learning Radiology xray montage

Aortic Stenosis

General Considerations 

  • Most often as result of degeneration of bicuspid aortic valve
  • Less commonly rheumatic heart disease or secondary to degeneration
    of a tricuspid aortic valve in person > 65


  • Supravalvular
    • Uncommon
    • Associated with William’s Syndrome
      • Hypercalcemia
      • Elfin facies
      • Pulmonary stenoses
      • Hypoplasia of aorta
      • Stenoses in
        • Renal, celiac, superior mesenteric arteries
  • Valvular
    • Most common
    • Either congenital (from a bicuspid aortic valve) or acquired
      • Bicuspid aortic valve is the most common congenital cardiac anomaly
        • 0.5 –2%
  • Subvalvular
    • Associated with
      • Hypoplastic left heart syndrome
      • Idiopathic Hypertrophic Subaortic Stenosis
      • Hypertrophic cardiomyopathy
      • Subaortic fibrous membrane 


  • Congenital aortic stenosis (more common)
    • Most frequent congenital heart disease associated with
      intra-uterine growth retardation (IUGR)
      • Subvalvular (30%)
      • Valvular (70%)
        • Degeneration of bicuspid valve
      • Supravalvular
  • Acquired aortic stenosis
    • Rheumatic valvulitis
      • Almost invariably associated with mitral valve disease
    • Fibrocalcific senile aortic stenosis
      • Degenerative 

Clinical Findings

  • Asymptomatic for many years
  • Classical triad
    • Angina
    • Syncope
    • Shortness of breath (heart failure)
  • Systolic ejection murmur
  • Carotid pulsus parvus et tardus
  • Diminished aortic component of 2nd heart sound
  • Sudden death in severe stenosis after exercise
    • Diminished flow in coronary arteries causes ventricular dysrhythmias
      and fibrillation
    • Decompensation leads to left ventricular dilatation and pulmonary
      venous congestion

Imaging Findings 

  • In older children or young adults
    • Prominent ascending aorta
      • Poststenotic dilatation of ascending aorta
        • Due to turbulent flow
    • Left ventricular heart configuration
      • Normal-sized or enlarged left ventricle
      • Concentric hypertrophy of left ventricle produces a relatively small
        left ventricular chamber with thick walls
    • Heart size is frequently normal
  • In adults >30 years
    • Prominent ascending aorta
      • Poststenotic dilatation of ascending aorta
        • Due to turbulent flow
    • Calcification of aortic valve (best seen on RAO)
      • In females, usually indicates hemodynamically significant aortic stenosis
      • Calcification of the valve usually indicates a gradient across
        valve of > 50mm Hg
      • Calcification begins in bicuspid and rheumatic valve in 4th decade
        but not until > 65 in tricuspid
      • DDx
        • Calcification of aortic annulus in elderly
        • Calcified coronary artery ostium (thickened cusp echoes only in diastole)
    • Normal to enlarged left ventricle

Echocardiographic findings

  • Thickened and calcified aortic valve with multiple dense cusp echoes
    throughout cardiac cycle
  • Right > non-coronary > left coronary cusp
  • Decreased separation of leaflets in systole with reduced opening orifice
  • (13-14 mm = mild AS; 8-12 mm = moderate AS; <8 mm = severe AS)
  • ± Doming in systole
  • Dilated aortic root
  • Increased thickness of LV wall (= concentric LV hypertrophy)
  • Hyperdynamic contraction of LV (in compensated state)
  • Decreased mitral EF slope (reduced LV compliance)
  • LA enlargement
  • Increased aortic valve gradient (Doppler)
  • Decreased aortic valve area (unreliable)

Angiographic findings


  • Simultaneous LV and aortic pressures recordings yield valve gradients from left heart
  • Angiographic technique uses standard RAO left ventriculogram and an aortogram
    using a 40° LAO projection
  • A non-calcified, bicuspid valve reveals thickening and doming of the valve leaflets
    in systole
  • A jet of non-opacified blood is visible through stenotic valve
    • Congenitally bicuspid valves still usually have three aortic sinuses with one large
      non-coronary sinus equal in size to the other two
    • Calcification begins in the bicuspid and rheumatic valve in the 4th decade
      but not until >65 in tricuspid
    • In rheumatic disease, the aortic valve commissures usually fuse whereas they
      do not in the degenerated tricuspid valve

 Differentiating Causes of Aortic Stenosis

Etiology/Findings Calcification Other clues
Congenital Bicuspid Valve 30’s Jet effect on aortogram
Degeneration of Tricuspid Valve > 65 Coronary artery ca++
Commissures don’t fuse
Rheumatic dz in Tricuspid Valve 30’s here; teens in 3rd
world countries
MS or MR almost always present;
commissures fuse


Valve areas










Aortic Stenosis. Top: Axial CT scan through heart demonstrates a heavily
calcified aortic valve (white arrow). Bottom: Frontal chest radiograph in
another patient with aortic stenosis shows a dilated ascending
aorta (white arrow) that abnormally projects farther
to the right than the right heart border. This is caused by
post-stenotic dilatation of the aorta.

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