In a patient with aortic valve sclerosis documented five years ago and no indication for aortic valve calcium scoring, is a repeat transthoracic echocardiogram with focused assessment of the aortic valve reasonable?

Repeat Echocardiography for Aortic Valve Sclerosis After 5 Years

Yes, a repeat transthoracic echocardiogram with focused assessment of the aortic valve is reasonable and appropriate in this patient with documented aortic valve sclerosis from five years ago. 1

Rationale for Repeat Imaging

Aortic valve sclerosis is a progressive disease that can advance to hemodynamically significant stenosis, requiring surveillance echocardiography even in asymptomatic patients. 1 The European Heart Journal appropriateness criteria specifically support repeat echocardiography for progression assessment of valvular heart disease, including sclerotic changes. 1

Natural History and Progression Risk

• Aortic valve sclerosis represents early-stage valve disease characterized by focal thickening and calcification without outflow obstruction, but it progresses to stenosis in a substantial proportion of patients over time. 2, 3
• In patients with initial aortic jet velocities of at least 2.6 m/s, the rate of symptom development was 38% at 3 years, demonstrating the progressive nature of early valve disease. 1
• After a 5-year interval without imaging, progression from sclerosis to mild or even moderate stenosis is entirely plausible and warrants reassessment. 1

Guideline-Based Surveillance Intervals

The ACC/AHA guidelines provide clear recommendations for echocardiographic surveillance based on stenosis severity: 1

• Mild aortic stenosis: every 3 to 5 years 1
• Moderate aortic stenosis: every 1 to 2 years 1
• Severe aortic stenosis: annually 1

Since your patient's last echocardiogram showed sclerosis (not yet stenosis) five years ago, the current timing falls within the appropriate surveillance window for mild disease, assuming progression has occurred. 1

Key Parameters to Assess

The repeat echocardiogram should specifically evaluate: 1

• Aortic valve morphology: Document progression of thickening, calcification, and cusp mobility 1
• Hemodynamic severity: Measure peak aortic jet velocity, mean transvalvular gradient, and calculate aortic valve area by continuity equation 1
• Left ventricular response: Assess LV wall thickness, chamber dimensions (end-diastolic and end-systolic), and systolic function (ejection fraction) 1
• Associated valvular disease: Evaluate for any aortic regurgitation or other valve abnormalities 1

Special Considerations

Bicuspid Valve Assessment

If the patient has a bicuspid aortic valve (which accelerates progression), additional assessment is mandatory: 1, 4

• Measure aortic root and ascending aorta dimensions at multiple levels (annulus, sinuses of Valsalva, sinotubular junction, and ascending aorta 2-3 cm above the sinotubular junction) 4
• If aortic dimensions exceed 4.0 cm, annual surveillance becomes mandatory regardless of valve function 4

Risk Stratification Beyond Imaging

Aortic valve sclerosis carries prognostic significance beyond hemodynamic obstruction: 3

• The Cardiovascular Health Study demonstrated that aortic sclerosis increases cardiovascular mortality by approximately 50% (relative risk 1.52) even without hemodynamically significant stenosis 3
• This association persists after adjustment for traditional cardiovascular risk factors 3

Common Pitfalls to Avoid

• Do not assume sclerosis remains stable over 5 years. The disease is inherently progressive, and the interval since last imaging justifies reassessment. 1
• Do not rely solely on symptoms. Many patients with progressing valve disease remain asymptomatic until stenosis becomes severe, at which point event-free survival drops precipitously. 1
• Ensure complete Doppler interrogation. The most common technical error is underestimating stenosis severity due to non-parallel intercept angle between the ultrasound beam and the high-velocity jet. 1
• Do not confuse sclerosis with normal age-related changes. True sclerosis requires focal thickening and increased echogenicity of valve leaflets, not just mild thickening at the leaflet tips. 2

Clinical Decision Algorithm

Proceed with transthoracic echocardiography now if: 1

1. Five years have elapsed since last imaging (as in this case)
2. Any new symptoms have developed (dyspnea, reduced exercise tolerance, chest pain, syncope)
3. Physical examination reveals a new or changed murmur
4. The patient has risk factors for accelerated progression (bicuspid valve, chronic kidney disease, diabetes, hyperlipidemia)

After obtaining the repeat echocardiogram, establish future surveillance intervals based on findings: 1

• If progression to mild stenosis: repeat in 3-5 years
• If progression to moderate stenosis: repeat in 1-2 years
• If progression to severe stenosis: repeat every 6-12 months
• If sclerosis remains unchanged without stenosis: consider repeat in 3-5 years

The 5-year gap since the last echocardiogram, combined with the progressive nature of aortic valve sclerosis and guideline-supported surveillance intervals, makes repeat imaging both reasonable and clinically appropriate at this time. 1