From the Guidelines
No, aortic valve leaflet flutter during systole is not a normal finding on Transthoracic Echocardiogram (TTE). This finding is typically pathological and suggests aortic valve disease. Normal aortic valve leaflets should open widely during systole and remain relatively stationary in their open position, allowing smooth laminar blood flow from the left ventricle into the aorta. Course flutter or vibration of the leaflets during systole often indicates turbulent blood flow across the valve, which may be caused by conditions such as aortic stenosis, aortic regurgitation, or endocarditis with vegetation on the valve. The abnormal motion occurs because the diseased valve creates disturbed flow patterns that cause the leaflets to vibrate or flutter.
Clinical Implications
If this finding is observed on TTE, further evaluation is warranted to determine the underlying cause and severity of the valve dysfunction, which may include additional imaging modalities such as transesophageal echocardiography or cardiac CT/MRI depending on the clinical context. The 2021 ACC/AHA guideline for the management of patients with valvular heart disease 1 recommends the use of TTE as the first-line imaging modality in valvular regurgitation and emphasizes the importance of evaluating valve anatomy and motion, as well as the degree of valve obstruction.
Diagnostic Approach
The European Association of Cardiovascular Imaging recommends the use of 2D transthoracic echocardiography (TTE) as the first-line imaging modality in valvular regurgitation 1. In cases where TTE is insufficient or further diagnostic refinement is required, transesophageal echocardiography (TOE) or three-dimensional (3D) echocardiography may be indicated. The key measurements for clinical decision-making in patients with aortic stenosis include the maximum aortic velocity, mean pressure gradient, and valve area, as outlined in the 2021 ACC/AHA guideline 1.
Management
The management of patients with aortic valve disease depends on the underlying cause and severity of the valve dysfunction. In cases where aortic valve leaflet flutter is observed on TTE, further evaluation and management should be guided by the clinical context and the results of additional diagnostic testing. The 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1 provides recommendations for the diagnosis and management of patients with valvular heart disease, including those with aortic regurgitation and aortic stenosis.