Diagnostic Contexts of Echocardiographic Nonapical Window

The long-established utility of multiwindow interrogation in echocardiography (suprasternal notch, right and left sternal border, apex, and subxiphoid) is sometimes not systematically implemented in routine practice. This case series emphasizes the pivotal importance of such practice for the systematic assessment of aortic valve stenosis and in the evaluation of left ventricular outflow tract and the aorta.

T he cornerstone of the hemodynamic evalua- tion in patients with calcified or prosthetic aortic valve relies on the Doppler continuity equation, which is profoundly affected by the proper alignment of the ultrasound beam parallel with the transvalvular blood flow jet.Improper alignment could result in underestimation of the peak jet velocity and mean gradient and in overestimation of the aortic valve area.
Hatle et al 1 established the utility of routine Doppler interrogation from multiple acoustic windows (suprasternal notch, right and left sternalborder, apex, and subxiphoid) to detect the maximal aortic flow velocity in aortic stenosis (AS).Accordingly, Stamm et al 2 reported the suprasternal/supraclavicular area as the most common approach to detect the maximum aortic velocity.Subsequent studies examining the frequency with which the peak aortic velocity is obtained from the standard imaging windows found that the apical window was the most common location of the highest jet velocity. 3,4However, these studies involved patients younger than those in contemporary AS cohorts.

LEARNING OBJECTIVES
To understand that multiple-window interrogation is usually required but not systematically implemented in routine practice.Moreover, its role has been rarely described for contexts other than the Doppler evaluation of aortic valve stenosis.To identify settings in which the oftenforgotten non-apical echocardiographic approach can help in the diagnosis.To improve the diagnostic accuracy of echocardiography for the evaluation of the aortic valve, left ventricular outflow tract flow acceleration, and the ascending-aorta by routinely implementing the non-apical windows interrogation.
ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2024.102287 In elderly patients, acute angulation of the aortic root has been described. 5,6This altered spatial orientation of the aortic root could generate a more anteriorly directed stenotic jet in AS, making it difficult to sample from the apical position.
Disappointingly, the multiple-imaging window approach is not widely implemented in contemporary routine practice, favoring the convenient shortcut of the sole apical view. 710] There are other clinical contexts aside from AS in In other patients, the best alignment can be obtained by the subcostal approach (as shown for a different case in Figure 1C).

CASE 2: MANAGEMENT IMPLICATIONS OF SEVERE AORTIC STENOSIS
A 76-year-old asymptomatic male was referred to the laboratory by the general practitioner after first evidence of a 4/6 high-pitched systolic murmur.4A).However, Doppler evaluation from the RPA identified even higher velocities and gradients through the bioprosthesis that was consistent with prosthesis degeneration (Figure 4B).
Despite a slightly reduced feasibility of the RPA after AVR, Doppler evaluation can improve the hemodynamic assessment of prosthetic valves.The RPA is the best acoustic imaging approach in patients with The right parasternal approach identified a very severe stenosis (B) vs the apical view (A).

FIGURE 3 Apparent Low-Flow Low-Gradient Aortic Stenosis
The right parasternal approach (B) solved the aortic valve area (AVA)/gradient inconsistencies (A).5A).However, the RPA showed more pronounced obstruction with a higher peak gradient and velocity with a similar Valsalva maneuver (60 mm Hg, 3.8 m/s) (Figure 5B).This may have profound implications in risk stratification for The right parasternal approach (B) revealed higher gradients through the bioprosthesis vs the apical view (A).

CASE 1 :
which multiwindow interrogation might help to perform a more refined evaluation, including left ventricular outflow tract (LVOT) flow acceleration and the ascending aorta.This case series aims to emphasize the pivotal importance of multiwindow interrogation for the assessment of the aortic valve, LVOT level, and the aorta.Written consent and ethical oversight were obtained.TAILORING THE FOLLOW-UP FOR MODERATE AS A 68-year-old asymptomatic female without cardiovascular risk factors and a previous diagnosis of mild AS during a transthoracic echocardiography performed 4 years before was studied for her scheduled follow-up from the apical 5-chamber view; velocities and gradients were consistent with mild AS (Figure 1A).Conversely, Doppler measurements obtained from the right parasternal approach (RPA) revealed moderate AS (Figure 1B) which required closer-follow-up.

FiguresFIGURE 1 4 Diagnostic
Figures 2A and 2B show the continuous-wave Doppler tracings obtained from the apical 5-chamber view and RPA, respectively.By sampling the jet velocity from the RPA, the diagnosis shifted from moderate to verysevere AS with immediate clinical consequences.An evaluation for aortic valve replacement (AVR) should be considered in asymptomatic patients with very severe AS (ie, transaortic peak velocity >5 m/s or mean transaortic gradient $60 mm Hg) with low procedural risk.CASE 3: AVOID MISCLASSIFICATION OF LOW-GRADIENT AS

CASE 4 :
EXPLAINING SYMPTOMS OF AORTIC BIOPROSTHESIS DEGENERATION A 56-year-old male underwent a prior AVR procedure (PERIMOUNT Magna 27 mm), for the stenotic bicuspid aortic valve.At follow-up, the patient had worsening dyspnea (NYHA functional class III) and a 3/6 systolic murmur.Echocardiography revealed abnormal hemodynamic parameters of prosthesis from the apical 5-chamber view (Figure

FIGURE 2
FIGURE 2 Severe Aortic Valve Stenosis

JDiagnostic 12 CASE 5 :
A C C : C A S E R E P O R T S , V O L . 2 Contexts of Echocardiographic Nonapical Window severe AS, and it generally remains so even after valve replacement.HYPERTROPHIC CARDIOMYOPATHY: LVOT OBSTRUCTION In a 45-year-old female with signs of chest congestion, echocardiography revealed septal thickness of 18 mm and systolic anterior motion of the mitral valve which allowed determination of moderate regurgitation.Doppler assessment from the apical 5-chamber view detected a maximum gradient of 28 mm Hg and a maximum velocity of 2.7 m/s during the Valsalva maneuver (Figure

FIGURE 5 4 Diagnostic
FIGURE 5 Left Ventricular Outflow Tract Obstruction

FIGURE 7
FIGURE 7 Ascending Aorta and Aortic Root Dilation

J 4 CASE 8 :
A C C : C A S E R E P O R T S , V O L . 2 9 , 2 0 2 ASSESS THE FLOW FOR THE LEFT VENTRICULAR ASSIST DEVICE A 72-year-old male with end-stage heart failure secondary to ischemic cardiomyopathy underwent implantation of a left ventricular assist device (LVAD) (HeartMate, Abbott).Post-procedural echocardiographic examinations were performed to guarantee the pump optimal settings and exclude adverse events.One key step is the interrogation of the outflow graft in the ascending aorta which usually requires RPA with color Doppler and spectral Doppler interrogations (Figure 8).14FUNDINGSUPPORT AND AUTHOR DISCLOSURES The authors have reported that they have no relationships relevant to the contents of this paper to disclose.ADDRESS FOR CORRESPONDENCE: Dr Giovanni Benfari, Department of Medicine, Division of Cardiology, University of Verona, Piazzale Stefani 1, 37126 Verona (VR), Italy.E-mail: giovanni.befari@univr.it.

FIGURE 8
FIGURE 8 Left Ventricular Assist Device