Comparison of the cardiac output and stroke volume response to upright exercise in children with valvular and subvalvular aortic stenosis

Cardiac output and stroke volume were evaluated in 17 children (mean age 11.5 +/- 3 years) with discrete, membranous subvalvular (Group I, n = 7) and valvular (Group II, n = 10) aortic stenosis during submaximal and maximal (greater than 75% predicted maximal oxygen consumption) upright cycle ergometry. Patients with valvular aortic stenosis were further subdivided on the basis of their aortic valve gradient at rest determined by cardiac catheterization (Group IIA, gradient less than 40 mm Hg; Group IIB, gradient greater than or equal to 40 mm Hg). These patients were matched with 17 control subjects on the basis of age, sex, height and intensity of exercise during maximal exertion. Cardiac and stroke indexes were determined by the acetylene rebreathing method at each exercise level. Stroke volume index in Group I was significantly greater at rest when compared with that in control subjects (69 +/- 13 versus 53 +/- 11 ml/m2, alpha = 0.01, p less than 0.05) and that in patients in Group II (69 +/- 13 versus 47 +/- 12 ml/m2, alpha = 0.01, p less than 0.05). Patients with subvalvular aortic stenosis were unable to increase their stroke volume index from rest to submaximal exercise and also decreased their stroke volume index at maximal exercise levels. In contrast, patients with mild valvular aortic stenosis (Group IIA) displayed a normal exercise response. Patients with severe valvular aortic stenosis (Group IIB) had a blunted stroke volume response at rest and at each level of exercise, as well as signs of myocardial ischemia (ST segment depression) during maximal exercise.(ABSTRACT TRUNCATED AT 250 WORDS)     

Doppler measurement of transvalvular gradients. Simultaneous Doppler-catheterization recordings on 78 patients

Several studies have demonstrated the value of Doppler ultrasound as a means of measuring gradients across cardiac valves. However, in view of sudden variations in cardiac output gradients should be measured simultaneously by Doppler and catheterization in order to validate the former method and determine its accuracy. We conducted a prospective study with simultaneous recordings in 78 patients with aortic valve stenosis (33) or mitral valve stenosis (19) or cardiac valve prosthesis (26). Mean age of the patients was 55 +/- 14 years, and 50% of them were male. Subjects with pure or predominant regurgitation were excluded from the study. In the whole of the population studied, correlation between Doppler ultrasound and haemodynamics was very good with r = 0.98, p less than 0.001 for maximum gradient and r = 0.96, p less than 0.001 for mean gradient. The perfect simultaneity of the haemodynamic and ultrasonic recordings was confirmed by comparing the duration of gradients measured by the two methods (r = 0.996, p less than 0.001). There also was very close correlation between ultrasounds and catheter in patients with mitral stenosis (maximum gradient r = 0.98, p less than 0.001; mean gradient r = 0.97, p less than 0.001). Mean Doppler-catheter differences were not significant, and no underestimation by Doppler reached or exceeded 5 mmHg. Correlations were also satisfactory in patients with aortic stenosis (maximum gradient r = 0.97, p less than 0.01; mean gradient r = 0.90, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous transluminal aortic valvuloplasty using a balloon catheter. A new therapeutic option in aortic stenosis in the elderly

Aortic valvular dilatation with a balloon catheter was performed in 44 patients, 20 men and 24 women, most of whom were very elderly (average age 77 years). The indication for valvular replacement had not been retained in these cases because of surgical contra-indications or a very high operative risk and in 3 cases because of patient refusal. Twenty-nine patients were in functional classes III or IV of the NYHA classification; 12 had syncopal episodes and 18 had invalidating angina. The dilatation was performed by a femoral arterial approach in 34 cases, and by a brachial arterial approach in 10 cases. MEDI-TECH catheters with 15, 18 or 20 mm diameters when inflated were used in the majority of cases. Several inflations lasting 10 to 240 seconds were performed in each case with balloons of increasing size. This was well tolerated in all but one patients who had a sharp syncope. The immediate results confirmed valvular dilatation. The average transvalvular pressure gradient fell from 76 +/- 25 mmHg to 30 +/- 13 mmHg (p less than 0.001). The aortic valve surface area calculated by the Gorlin formula increased from 0.5 +/- 0.18 cm2 to 1 +/- 0.42 cm2 (p less than 0.01). After dilatation the gradient was less than or equal to 40 mmHg in 37 cases; aortic valve surface area was greater than or equal to 1 cm2 in 14 cases and less than or equal to 0.7 cm2 in only 5 cases. The left ventricular ejection fraction increased immediately after valvuloplasty from 44 +/- 16 p. 100 to 49 +/- 15 p. 100 (p less than 0.01). In the 18 cases in which it was less than 40 p. 100 before valvuloplasty, it increased from 30 +/- 6 p. 100 to 36 +/- 9 p. 100 (p less than 0.02). Residual aortic regurgitation was only observed in one case. Two patients died in the hospital period (4.6 p. 100). There were no other serious complications. During an average follow-up period of 60 days (3 weeks to 6 months) there was a big improvement in symptoms in the great majority of cases and, in particular, syncopal and anginal attacks disappeared. Only 4 patients remained in functional classes III or IV after valvuloplasty. Percutaneous aortic valvuloplasty is a new, relatively simple, low risk, economic and very effective therapeutic procedure in all cases in which aortic valve replacement is contra-indicated or refused by the patient.(ABSTRACT TRUNCATED AT 400 WORDS)     

Methodologic issues in clinical evaluation of stenosis severity in adults undergoing aortic or mitral balloon valvuloplasty. The NHLBI Balloon Valvuloplasty Registry.

Although both catheterization and Doppler measures of valvular stenosis severity have been validated, each has specific advantages and limitations, particularly in the setting of balloon valvuloplasty. Invasive valve area and mean pressure gradient recorded immediately before and after aortic (n = 589) or mitral (n = 608) catheter balloon valvuloplasty were compared with Doppler valve area and mean pressure gradient recorded less than 30 days before and 24 to 72 hours after the procedure. For aortic stenosis, Doppler valve area ranged from 0.1 to 1.4 cm2 before and 0.2 to 2.3 cm2 after catheter balloon valvuloplasty. Doppler and invasive aortic valve areas differed by less than or equal to 0.5 cm2 in 99% and by less than 0.2 cm2 in 92% of patients. Linear correlation was higher before versus after catheter balloon valvuloplasty, for both valve area (r = 0.49 vs r = 0.35, p = 0.01) and mean pressure gradient (r = 0.64 vs r = 0.50, p = 0.01). Group mean invasive valve area was slightly smaller before (0.50 vs 0.59 cm2, p less than 0.0001) but was not different after (0.80 vs 0.78 cm2, p = 0.16) catheter balloon valvuloplasty. Variables affecting the valve area differences were cardiac output, aortic regurgitation, heart rate and blood pressure. Mean pressure gradient differences were related to echo quality, blood pressure and mitral regurgitation. For mitral stenosis, 2-dimensional echocardiographic valve area ranged from 0.4 to 2.8 cm2 before and 0.7 to 3.8 cm2 after catheter balloon valvuloplasty. Two-dimensional echocardiography and invasive mitral valve areas differed by less than or equal to 0.5 cm2 in 96% and by less than 0.2 cm2 in 81% of cases. Linear correlation was not different before versus after catheter balloon valvuloplasty for two-dimensional echocardiographic valve area (r = 0.40 vs 0.36), pressure halftime valve area (r = 0.31 vs 0.32) or mean pressure gradient (r = 0.55 vs r = 0.46). Group mean 2-dimensional echocardiography and pressure halftime valve areas were larger than invasive valve areas before (1.09 vs 1.02 cm2, p = 0.001) and smaller after (1.71 vs 2.02 cm2, p less than 0.0001) catheter balloon valvuloplasty. Important variables affecting the differences were mitral regurgitation, interatrial shunt, cardiac output and heart rate. Nonsimultaneous studies, differing volume flow measurements, and the underlying accuracy of each technique largely account for discrepancies between these methods. The clinical use of each will depend on its ability to predict long-term patient outcome.     

Congenital valvular aortic stenosis: clinical detection of small pressure gradient. Prepared for the joint study on the joint study on the natural history of congenital heart defects.

Clinical variables (from the history, physical examination, electrocardiogram and chest radiograph) were related to the pressure gradient measured between the left ventricle and the aorta in 434 young patients with congenital valvular aortic stenosis admitted to a national collaborative study. The aim was to devise a composite clinical criterion for the recognition of patients with a small pressure gradient, so as to expand the opportunity for avoiding cardiac catheterization in such patients. Flattened or inverted T waves in lead V6 were found to be inconsistent with mild disease. Therefore, a composite criterion, providing an estimate of pressure gradient, was developed for patients without T wave changes. The final criterion, based on multivariate analysis, involved only the intensity of the systolic murmor, the presence or absence of an early diastolic murmur, and voltages of the Q and R waves in lead V6. Patients with a low estimate by this procedure rarely had a large measured gradient. Only 3.7 percent (6 of 161) with an estimated gradient of less than 45 mm Hg had a gradient at cardiac catheterization of 80 or more mm Hg; none (0 of 32) with an estimated gradient of less than 30 mm Hg had a gradient of 50 or more mm Hg. This criterion should be helpful in avoiding unnecessary catheterization by identifying some patients with valvular aortic stenosis who have a small pressure gradient.     

Percutaneous transluminal valvuloplasty of pulmonary stenoses. Apropos of 35 cases

Thirty-five patients with moderate or severe valvular pulmonary stenosis underwent percutaneous transluminal valvuloplasty (PTV). The average age of the patients was 12 years (range 4 to 34 years). Sixty per cent were under the age of 10, 20 p. 100 were between 10 and 17 years old and 20 p. 100 between 18 and 34 years old. Systolic right ventricular pressures were greater than the pressures in the systemic circulation in 22 cases. The right ventricular-pulmonary artery pressure gradient was greater than 50 mmHg in 29 patients and less than or equal to 50 mmHg in the other 6 patients. The diameter of the balloon of the dilation catheter varied from 12 to 20 mm in 31 PTV; in the other 4 cases two dilating catheters were used simultaneously to dilate the pulmonary valves. The tolerance of PTV was generally good and the results were satisfactory: right ventricular pressures (RVP) fell from 140 +/- 45 to 77 +/- 25 mmHg (p less than 0.001); the RV-PA pressure gradient fell from 82 +/- 40 to 32.4 +/- 15 mmHg (p less than 0.001) and the ratio of RVP to systemic pressure from 1.2 +/- 0.4 to 0.65 +/- 0.2 (p less than 0.01). Clinical and haemodynamic reevaluation in 19 patients 4 to 16 months after PTV (mean 8.5 +/- 2 months) showed that RVP, RV-PA pressure gradients and RVP/systemic pressure ratios had significantly decreased respectively from 78 +/- 30 to 52 +/- 14 mmHg (p less than 0.001), from 27.7 +/- 7.7 to 21.8 +/- 7.3 mmHg (p less than 0.02) and from 0.6 +/- 0.2 to 0.4 +/- 0.1 (p less than 0.001). Pulmonary valvuloplasty is well tolerated, safe and may reduce the number of patients requiring surgical valvotomy.     

Pulmonary valvuloplasty in adolescents and adults: 2 year follow-up by continuous Doppler

The purpose of this study is the long term follow-up of the first pulmonary valvuloplasties performed by our group. From september 1984 to march 1988, 10 patients (4 men and 6 women) aged 8 to 58 (mean: 21) with severe or moderate pulmonary valve stenosis underwent pulmonary valvotomy. In all cases the balloon diameter was equal to or 1 mm smaller than the valvular annulus. The results were satisfactory with a significant mean gradient reduction of 51.7%. A follow-up gradient estimation by Doppler echocardiogram was obtained 10 to 37 months after valvuloplasty (mean: 23 months). The mean follow-up gradient by Doppler (31.3 +/- 9.9 mmHg) was not significantly different from the mean hemodynamic post-dilatation gradient (35.6 +/- 14.7 mmHg). A linear correlation was found between the post-dilatation hemodynamic mean gradient and the mean gradient by Doppler follow-up (r = 0.66, p less than 0.05, SEE = 4.1 mmHg). No restenosis were observed. These results suggest that the benefits of valvuloplasty are long lasting. Continuous Doppler is an excellent technique for the follow-up of these patients.     

Phono-mechanographic evaluation of aortic stenoses. Contribution of the B1-maximum murmur/B1-B2 index

The diagnostic value of phonomechanography in valvular aortic stenosis was reassessed with a rarely used index, the ratio S1-maximum intensity of the systolic murmur/S1-S2, or Thiron's index, the author of which only studied the correlations with the aortic transvalvular pressure gradient. The results obtained by the author being considered inconclusive, we decided to examine its correlations with aortic valve surface area calculated with the Gorlin's formula. The study was carried out in 38 patients with pure aortic stenosis, in whom 4 phonomechanographic parameters, the corrected left ventricular ejection time (Meiners), the carotid pulse half peak time, the S1-maximum intensity of the murmur interval and Thiron's index, were compared with the transvalvular pressure gradient and the aortic valve surface area at catheterisation. The first two parameters mentioned above were of limited value (correlations with aortic valve surface area r = 0.315, p less than 0.05 and r = 0.477, p less than 0.01 respectively). On the other hand, a good correlation was obtained with Thiron's index (r = 0.624, p less than 0.001) which was better than that found with the interval between S1 and maximum intensity of the systolic murmur (r = 0.483, p less than 0.001) in a population not excluding subjects with cardiac failure. These results indicate that: when Thiron's index less than or equal to 0.45, the aortic stenosis is probably mild (aortic surface area greater than 0.8 cm2), when Thiron's index is 0.46 greater than 0.56, the aortic stenosis is likely to be moderately severe (aortic surface area 0.8 less than 0.5 cm2), when Thiron's index is greater than 0.57, the aortic stenosis is probably severe (aortic surface area less than 0.5 cm2). In our series, Thiron's index was the best phonomechanographic parameter for the assessment of pure aortic stenosis. It could not be calculated in 10 out of 48 patients; this drawback was not encountered with the corrected left ventricular ejection time or the carotid pulse half peak time.(ABSTRACT TRUNCATED AT 250 WORDS)     

Does mild valvular aortic stenosis progress during childhood?

BACKGROUND AND AIM OF THE STUDY: An increased gradient in congenital valvular aortic stenosis (AS) during follow up remains the subject of controversy, and may determine a need for treatment in pediatric patients. It is hypothesized that a valvular gradient < 40 mmHg indicates a stable tendency at follow up for congenital valvular AS. METHODS: Twenty-five cases with valvular AS, isolated but not treated, were followed for eight years (range: 0.14-18.8 years). Clinical and complementary tests (electrocardiography, X-radiography) were undertaken. The gradient anatomy and function were measured using M-mode, two-dimensional, and Doppler echocardiography. RESULTS: No significant changes were noted in symptoms or at physical examination. Signs of cardiac enlargement were decreased (p < 0.001), and the functional status and gradient remained stable during the follow up period (mean difference 2.38 mmHg; p = 0.74). The relationship between gradient and age showed a slowly increasing trend (r = 0.20). CONCLUSION: The trend in gradient confirmed the stable nature of mild AS. Patients in whom gradients were < 40 mmHg at the time of diagnosis remained stable and required no treatment. Subsequent follow up control and clinical management of these patients may be performed at intervals of two years, or more.     

Balloon valvuloplasty for pulmonary valvular stenosis: a long-term follow-up study using pulsed Doppler echocardiography

From June 1984 to March 1987, percutaneous balloon valvuloplasty (PBV) was performed for 22 patients with congenital pulmonary valvular stenosis. It was successful for 20 patients, and there were significant decreases of transvalvular pressure gradients; 72 +/- 30 mmHg before PBV, and 30 +/- 12 mmHg immediately after PBV (p less than 0.001). In a follow-up study, pulsed Doppler echocardiography and cardiac catheterization were used to examine changes in long-term hemodynamic findings after PBV. One year follow-up evaluation was performed for 14 patients, and two year follow-ups for seven patients. One year after PBV the transvalvular pressure gradients were evaluated during cardiac catheterization in 11 patients, and using pulsed Doppler echocardiography in the remaining three patients. The gradients of the seven patients at two year intervals after PBV were evaluated using pulsed Doppler echocardiography. The pressure gradients of two patients improved further one year later due to the anatomical degradation in the right ventricular outflow tracts. For seven patients, two year follow-up evaluations were performed, and the transvalvular pressure gradient reduced from 84 +/- 23 to 33 +/- 15 mmHg (p less than 0.001) immediately afterwards; to 27 +/- 22 mmHg (p less than 0.01) one year later; and further to 12 +/- 5 mmHg (p less than 0.001) two years after PBV. Second PBV was performed for three patients in whom a residual gradient was recognized, with the good results. On auscultation, a pulmonary regurgitant murmur was recognized in 28% of 18 patients immediately after PBV, but 80% of this resolved one year later. Two patients had pulmonary regurgitation with pulmonary valvular stenosis before PBV.(ABSTRACT TRUNCATED AT 250 WORDS)     

Value of the continuous Doppler in the evaluation of gradients of aortic valvular stenosis in the adult

The purpose of this study, performed in 80 patients with aortic valve stenosis, was to find out whether continuous wave doppler ultrasound was reliable in assessing the severity of the stenosis. Maximum mean and instantaneous transaortic pressure gradients obtained by continuous wave doppler were compared with maximum mean instantaneous and peak to peak gradients simultaneously obtained by cardiac catheterization. 35 patients who underwent aortic valve dilation were explored beforehand and afterwards, which brings up to 115 the total number of gradient comparisons. There was a correlation between maximum instantaneous gradient at doppler and peak to peak gradient (r = 0.62, n = 115, e = 22.5 mmHg, p less than 0.001). A similar correlation was found between maximum instantaneous gradients at doppler and haemodynamics (r = 0.64, n = 80, e = 24.5 mmHg), but correlation between mean gradients was weaker (r = 0.57, n = 80, e = 17.7 mmHg). Maximum and mean instantaneous gradients are underestimated by the doppler method. After exclusion of imperfect doppler curves, correlations were better, notably as regards mean gradients (r = 0.80, n = 18, e = 11.9 mmHg). There was a closer correlation between doppler maximum instantaneous gradients and haemodynamic peak to peak gradients in patients without aortic regurgitation (r = 0.71, n = 45, e = 17.2 mmHg) than in patients with aortic regurgitation (r = 0.54, n = 70, e = 24.3 mmHg).(ABSTRACT TRUNCATED AT 250 WORDS)     

In vitro measurement of stenotic human aortic valve orifice area in a pulsatile flow model. Validation of the continuity equation

Aortic valve orifice area estimation in patients with aortic stenosis may be obtained non-invasively using several Doppler echocardiographic methods. Their validity has been established by correlation with catheterization data using the Gorlin formula, with its inherent limitations, and small discrepancies between the methods are present. To evaluate these differences further, 15 patients with severe aortic stenosis (mean transvalvular gradient 70, range 40-130 mmHg) had aortic valve area estimations by Doppler echocardiography using two variations of the continuity equation. The intact valves removed at valve replacement surgery were then mounted in a pulsatile model and the anatomical area was measured (mean 0.67 +/- 0.17 cm-2) from video recordings during flow at 5.4 l min-1. Aortic valve area calculated using the integrals of the velocity-time curves measured at the left ventricular outflow tract and aortic jet (mean 0.65 +/- 0.17 cm2) correlated best with the anatomical area (r = 0.87, P less than 0.001). The area derived by using the ratio of maximum velocities from the left ventricular outflow tract and aortic jet (mean 0.69 +/- 0.18 cm2) also correlated well with the anatomical area (r = 0.79, P less than 0.001). The index between the left ventricular outflow tract and aortic jet maximum velocities was less than or equal to 0.25 in all. In patients with severe aortic stenosis the aortic valve area can be reliably estimated using Doppler echocardiography.     

Prediction of the severity of aortic stenosis by Doppler aortic valve area determination: prospective Doppler-catheterization correlation in 100 patients

Two-dimensional and Doppler echocardiography was performed prospectively in 100 patients with aortic stenosis who were undergoing clinically indicated cardiac catheterization. The purpose of this study procedure was to determine various Doppler variables predictive of the severity of aortic stenosis and to compare Doppler- and catheterization-derived aortic valve areas. Doppler-derived mean gradient correlated well with corresponding gradient by catheterization (r = 0.86). Peak Doppler aortic flow velocity greater than or equal to 4.5 m/s and Doppler-derived mean aortic gradient greater than or equal to 50 mm Hg were specific (93 and 94%, respectively) for severe aortic stenosis (defined as catheterization-derived aortic valve area less than or equal to 0.75 cm2) but were not sensitive (44 and 48%, respectively). Doppler-derived aortic valve area calculated by the continuity equation correlated well with catheterization-derived aortic valve area calculated by the Gorlin equation when either the time-velocity integral ratio (r = 0.83) or the peak flow velocity ratio (r = 0.80) between the left ventricular outflow tract and the aortic valve was used in the continuity equation. A velocity ratio of less than or equal to 0.25 alone was sensitive (92%) in detecting severe aortic stenosis. Therefore, use of various Doppler-derived values allows reliable noninvasive estimation of the severity of aortic stenosis.     

Diagnostic accuracy of continuous wave Doppler echocardiography in severe aortic stenosis in the elderly

Forty-four male patients (mean age 63.6 years) with aortic stenosis (AS) were evaluated by conventional hemodynamic methods and continuous wave (CW) Doppler echocardiography. The relationship between Doppler mean gradients and direct mean pressure gradients in all patients was significant, with an r value of 0.88. Sixteen of 17 patients with a mean Doppler gradient greater than or equal to 40 mmHg had severe AS (AVA less than or equal to 1.0 cm2). Twenty-seven patients had a Doppler gradient less than 40 mmHg, and 8 of these patients had severe AS (AVA less than or equal to 1.0 cm2). The sensitivity and specificity of a Doppler gradient greater than or equal to 40 mmHg in detecting severe AS were, therefore, 67% and 95%, respectively. Thirty-three percent (8/24) of patients with severe AS and low Doppler gradients (less than 40 mmHg) had evidence of poor left ventricular function, evidenced by a lower cardiac output, a higher heart rate and an abnormal PEP/LVET ratio compared to the other patients. Thus, the presence of a low stroke volume less than or equal to 60 ml/beat and PEP/LVET x HR greater than 26 is of value in identifying patients where the Doppler is likely to significantly underestimate the degree of aortic stenosis.     

Doppler echocardiographic estimates of pressure gradients in various types of stenoses: usefulness and limitations

In the present study, the accuracy of Doppler estimates of pressure gradients in various types of stenoses was clinically and experimentally evaluated. Fifty-seven patients, including 23 with ventricular septal defect, 15 with aortic or pulmonary valvular stenosis, four with infundibular stenosis, and five with supravalvular aortic or pulmonary stenosis were observed. The peak systolic pressure gradient (dP (C] was obtained at the time of catheterization in all patients. Before catheterization, the maximum velocity was measured by pulsed or continuous Doppler echocardiography and the estimated systolic pressure gradient according to Doppler (dP (D] was calculated by the simplified Bernoulli equation. The experimental model was designed to create pulsatile flow through a stenosis model. Nine different stenotic model types were used, including three orifice-like stenoses and six truncated cones with heights of 10 mm and 20 mm distal to the stenosis. The orifices in their stenoses were 3, 4 and 5 mm, respectively. Glycerin solution containing Sephadex with a viscosity similar to that of blood was used as the circulation medium. Its specific gravity was 1.16 g/cm3. In each stenotic model, the maximum velocity and instantaneous systolic peak pressure gradient were measured at various water flow rates. Clinical results: In patients with ventricular septal defect or valvular stenosis, dP (D) correlated very well to dP (C), with the regression equation, y = 0.87x + 2.79 (r = 0.92) or y = 0.96x + 1.02 (r = 0.99). In the other patients except for three with patent ductus arteriosus, dP (D) overestimated dP (C) by 11 to 71 mmHg, and their post-stenotic areas had gradually widened according to angiographic findings.(ABSTRACT TRUNCATED AT 250 WORDS)     

Quantification of pulmonary arterial hypertension by phonocardiography and M-mode echocardiography in children with congenital cardiopathies

We studied 20 children with congenital heart disease using Echo-Phonocardiographic techniques to determine the presence and magnitude of pulmonary arterial hypertension. The results were compared with those obtained by catheterization. There was a significant correlation between the pulmonary arterial systolic pressure (PSP) estimated from the right ventricular isovolumetric relaxation period and the PSP from the catheterization (r = 0.92). The ratio preejection period /right ventricular ejection time (PEP/RVET) identified the patients (PEP/RVET greater than or equal to 0.30) with a PSP mean value = 64.5 mmHg (p less than 0.01). The presence of a systolic notch on the pulmonary valve echogram distinguished the group with a PSP mean value = 60 mmHg (p less than 0.005). There was a poor correlation between the depth of the "a" wave and the E-F slope of the pulmonary valve echogram and the catheterization PSP (r = -0.50 and r = -0.40, respectively). The interval PR from the electrocardiogram minus the distance AC from the tricuspid valve echogram had a poor correlation with the right ventricular end diastolic pressure (r = 0.57). We conclude that there are some Echo-Phonocardiographic signs which are very useful in the diagnosis and measurement of pulmonary arterial hypertension in children with congenital heart disease.     

Noninvasive determination of valve area in adults with aortic stenosis using Doppler echocardiography

Doppler ultrasound has been used to determine the pressure gradient P1-P2 across the valve in patients with aortic stenosis (AS), but since the gradient varies over time and may be deceptively low in patients with impaired cardiac output, the key parameter to obtain is the orifice area (A). By calculating stroke volume (SV) from the modal flow velocity [Vmode(t)] over the systolic ejection period (sep) or diastolic filling period (dfp), wherever laminar flow exists in the heart across an area of known diameter D, (pulmonary artery or atrioventricular valves), and by substituting P1-P2 = 4Vmax2, (Vmax = peak velocity in the aortic jet), the Gorlin formula becomes: (Formula: see text) where theta = flow intercept angle at D. This approach was applied in nine adult patients with AS (age 64 +/- 8 years) in whom recent catheterization data was available for comparison. Close correlation was found between the calculated areas: A(Doppler) = 0.82 A(Cath) + 0.17 (r = 0.94, p less than 0.001). Two patients with Doppler gradients of less than 40 mmHg were shown by this Doppler method nevertheless to have severely narrowed orifice areas of less than or equal to 0.78 cm2. Although there is a tendency to overestimate slightly the valve area, Doppler ultrasound assessment using this technique adds valuable noninvasive information concerning the degree of aortic valve disease.     

Endoluminal mitral valvuloplasty in young adults and children. Apropos of 10 cases

Between April 1 and May 15, 1986, transluminal dilatation of the mitral valve was performed at the Marie-Lannelongue Hospital, near Paris, in 10 patients aged from 12 to 48 years (mean 25,3 years) suffering from rheumatic mitral stenosis with supple valve leaflets. The procedure, carried out under local anaesthesia, included trans-septal catheterization followed by installation of one, then usually two balloons opposite the mitral orifice. The total diameter of the balloons was often greater than that of the mitral annulus. No haemorrhage, embolism or arrhythmia was observed. A significant left-to-right shunt, evaluated by radioisotope exploration with technetium pyrophosphate performed on the 8th day, was present in only one patient. The LV-LA end-diastolic gradient fell from 14.4 +/- 9.8 to 4.6 +/- 3.4 mmHg (p less than 0.01). The mean pulmonary arterial pressure was reduced less significantly from 39.9 +/- 18.4 to 27.2 +/- 11.3 mmHg (p less than 0.02). The cardiac output was only moderately increased from 2.52 +/- 0.48 to 2.88 +/- 0.66 l/min/m2. The mitral valve area, measured from the smaller axis on 2-dimensional echocardiography, more than doubled, reaching a mean value of 1.99 +/- 0.56 cm2. This figure was confirmed by the reduction, at Doppler velocimetry, of the gradient half-regression time from 267 +/- 62 to 118 +/- 46 ms (p less than 0.01). Similarly, the end-systolic gradient evaluated by Doppler, fell from 17.5 +/- 8.9 to 5.3 +/- 4.7 mmHg (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnosis of tricuspid stenosis by two-dimensional and pulsed Doppler echocardiography

This study verified the usefulness of two-dimensional (2-D) and pulsed Doppler echocardiography (PDE) in the diagnosis of tricuspid stenosis (TS), and estimated the diastolic pressure gradient (PG) across the tricuspid valve (TV). Fifty-two patients with rheumatic mitral stenosis showing a decreased EF slope of the TV less than 40 mm/sec were studied. All patients underwent cardiac catheterization, and the mean diastolic pressure gradients (PG) across the TV were calculated with simultaneous recordings of right atrial and ventricular pressures. Based on surgical findings, all patients were categorized as the TS group consisting of 10 patients with TS (mean PG less than or equal to 5.0 mmHg; seven patients, greater than 5.0 mmHg; three patients), and the non-TS group consisting of 42 patients without TS. In three patients with PG exceeding 5 mmHg, the TV disclosed typical commissural fusions between the leaflets. 1. 2-D echocardiography The diagnosis of TS was made by recording diastolic doming and thickening of the TV in the parasternal long-axis and apical 4-chamber views. Among the 52 patients, 2-DE detected stenosis in all 10 patients with TS, for a sensitivity of 100%, while excluding TS in 40 of 42 patients without TS for a specificity of 95%. 2. Pulsed Doppler echocardiography The transtricuspid flow velocity in diastole was recorded from the apical window.(ABSTRACT TRUNCATED AT 250 WORDS)     

Echocardiographic assessment of aortic valve area in elderly patients with aortic stenosis and of changes in valve area after percutaneous balloon valvuloplasty

Echocardiographic studies, adequate for analysis of aortic valve area using the continuity equation, were obtained in 31 patients aged greater than or equal to 60 years who were undergoing catheterization for assessment of suspected aortic stenosis. Catheterization-determined aortic valve area was 0.74 +/- 0.30 cm2 (mean +/- SD) and Doppler-determined aortic valve areas were 0.68 +/- 0.27 and 0.65 +/- 0.27 cm2, depending on whether peak or mean velocities, respectively, were entered into the continuity equation. There were significant correlations between both of the Doppler-derived and the catheterization-determined aortic valve areas (r = 0.86, p less than 0.001 for both the continuity equation employing peak velocities and the continuity equation employing mean velocities) which were demonstrated to be linear by F test (catheterization area = -0.03 + 1.13 X Doppler area determined using peak velocities, SEE = 0.163 cm2, p less than 0.001; and catheterization area = -0.02 + 1.16 X Doppler area determined using mean velocities, SEE = 0.165 cm2, p less than 0.001). Both sets of correlations had linear regression parameters meeting the conditions for identity. Significant linear correlations were also noted between the non-invasive measurements of aortic valve excursion, ventricular ejection time, time to one-half carotid upstroke, maximal Doppler velocity and maximal Doppler gradient and catheterization aortic valve area, but the correlations were less tight than those between valve areas determined by catheterization and by Doppler continuity equation. Ten of the patients underwent percutaneous balloon aortic valvuloplasty. There were significant linear correlations between aortic valve areas determined by Doppler and catheterization methods both before valvuloplasty (r = 0.77, p = 0.01; p less than 0.001 by F test, SEE = 0.134 cm2) and after valvuloplasty (r = 0.85, p less than 0.01; p = 0.0001 by F test, SEE = 0.161 cm2). Linear regression parameters met the conditions for identity. There was also a significant linear correlation between catheterization and Doppler measurements of absolute change in aortic valve area (r = 0.79, p less than 0.01; p less than 0.001 by F test, SEE = 0.11 cm2). Aortic valve area can be determined reliably by continuity equation in elderly patients. In addition, results of balloon valvuloplasty, measured by changes in catheterization-determined aortic valve area, are accurately reflected by changes in aortic valve area determined using the continuity equation.