Echocardiography is the principal imaging method employed to assess patients with known or suspected valvular heart disease, including those with prosthetic valves. It has largely supplanted the use of invasive cardiac catheterization in the evaluation and management of these patients.1,2,3 The publications by Holen and Hatle in the late 1970s4,5 in which Doppler echocardiography was demonstrated to be a reliable noninvasive technique to accurately assess valve function resulted in more widespread acceptance and utilization of echocardiography. Important early publications also validated the use of echocardiography and the Doppler technique in the assessment of cardiovascular hemodynamics.
While other imaging techniques, such as cardiac CT and MRI, have provided additional tools to evaluate cardiac valves, they currently play a secondary role in the assessment of valve structure and function in most settings. MRI may play a larger role in the assessment of ventricular size and function in the future.
The use of echocardiography is a Class 1 indication for the evaluation of many clinical scenarios in which valvular heart disease is suspected.2 In the recently revised appropriate use criteria for echocardiography,3 echocardiography is deemed appropriate in a variety of clinical scenarios in patients with known or suspected valvular heart disease. The 2014 guideline for the management of patients with valvular heart disease provides an excellent resource for the role of echocardiography in evaluating and managing these patients.1
In this chapter, we will explore the use of echocardiography in a variety of clinical settings in patients with valvular heart disease, including native valve disease, endocarditis, and patients with prosthetic heart valves.
SECTION 1: ASYMPTOMATIC SEVERE AORTIC STENOSIS
CLINICAL CASE PRESENTATION
The patient is an 82-year-old man with a longstanding history of a heart murmur. He was initially seen in consultation at the request of his primary care physician 11 years ago for an evaluation of a heart murmur. At that time, he was completely asymptomatic and categorically denied any angina, dyspnea, heart failure symptoms, or syncope. An echocardiogram was obtained which demonstrated severe aortic stenosis. In view of his lack of symptoms, the patient was managed expectantly. Over the ensuing 11 years, he was seen frequently for follow-up and underwent periodic echocardiography (Figures 3-1-1, 3-1-2, 3-1-3, 3-1-4, 3-1-5). He continued to deny any symptoms and was quite physically active, frequently working out at his local fitness center with no limitations. His echocardiogram (Table 3-1-1) demonstrated progressive worsening of his aortic stenosis with significant increases in the calculated aortic valve gradients. His physical examination was consistent with severe aortic stenosis. He demonstrated delayed carotid upstrokes with diminished volume, a harsh, late peaking systolic ejection murmur that radiated to the carotids and across the precordium, and an absent aortic component of the second heart sound. ...