Degree of reversibility of left ventricular systolic dysfunction after aortic valve replacement for isolated aortic valve stenosis

To determine whether a low preoperative left ventricular (LV) ejection fraction (EF) returns to normal late after aortic valve replacement for aortic stenosis, 42 patients with critical aortic stenosis (valve area 0.7 cm2 or less), LV systolic dysfunction (EF 0.45 or less), angiographically normal coronary arteries, and no other significant valvular disease were studied at 10 to 84 months (mean 41 +/- 21) postoperatively. All patients survived aortic valve replacement and were discharged clinically improved. There were 4 late deaths; these patients were older (79 +/- 6 vs 64 +/- 13 years, p = 0.007) and had lower preoperative mean valve gradients (51 +/- 6 vs 68 +/- 23 mm Hg, p = 0.003) than late survivors. Of 23 survivors who returned for follow-up radionuclide angiography and Doppler echocardiography, 21 were asymptomatic. EF returned to normal (0.50 or more) in 14 patients (group 1) and remained low in 9 patients (group 2). Doppler peak prosthetic valve gradient was 24 +/- 8 mm Hg in group 1 and 25 +/- 10 mm Hg in group 2 (difference not significant). Six of the 9 patients in group 2 underwent early postoperative radionuclide imaging, and LVEF was normal in 4 (0.65 +/- 0.14 early vs 0.41 +/- 0.06 late, p = 0.02). Of 77 preoperative and intraoperative variables analyzed, only paroxysmal nocturnal dyspnea (0 of 14 vs 4 of 9, p = 0.01) distinguished group 1 from group 2. Thus, LVEF does not always normalize after aortic valve replacement for AS, implying impaired myocardial contractility.(ABSTRACT TRUNCATED AT 250 WORDS)     

Determination of the stenotic aortic valve area in adults using Doppler echocardiography

The severity of aortic stenosis was evaluated by Doppler echocardiography in 48 adults (mean age 67 years) undergoing cardiac catheterization. Maximal Doppler systolic gradient correlated with peak to peak pressure gradient (r = 0.79, y = 0.63x + 25.2 mm Hg) and mean Doppler gradient correlated with mean pressure gradient (r = 0.77, y = 0.59x + 10.0 mm Hg) by manometry. The transvalvular pressure gradient is flow dependent, however, and associated left ventricular dysfunction was common in our patients (33%). Thus, of the 32 patients with an aortic valve area less than or equal to 1.0 cm2 at catheterization, 6 (19%) had a peak Doppler gradient less than 50 mm Hg. To take into account the influence of volume flow, aortic valve area was calculated as stroke volume, measured simultaneously by thermodilution, divided by the Doppler systolic velocity integral in the aortic jet. Aortic valve areas calculated by this method were compared with results at catheterization in the total group (r = 0.71). Significant aortic insufficiency was present in 71% of the population. In the subgroup without significant coexisting aortic insufficiency, closer agreement of valve area with catheterization was noted (n = 14, r = 0.91, y = 0.83x + 0.24 cm2). Transaortic stroke volume can be determined noninvasively by Doppler echocardiographic measures in the left ventricular outflow tract, just proximal to the stenotic valve. Aortic valve area can then be calculated as left ventricular outflow tract cross-sectional area times the systolic velocity integral of outflow tract flow, divided by the systolic velocity integral in the aortic jet.(ABSTRACT TRUNCATED AT 250 WORDS)     

Progression of aortic valve dysfunction in 51 adult patients with congenital bicuspid aortic valve: assessment and follow up by Doppler echocardiography.

OBJECTIVE--To assess the pattern and progression of aortic valve dysfunction by serial Doppler echocardiographic examinations in ambulatory adult patients with congenital bicuspid aortic valve. DESIGN AND SETTING--Retrospective analysis of patients referred for Doppler echocardiography over a four year period. SUBJECTS--Fifty one adult patients with echocardiographic diagnosis of congenital bicuspid aortic valve had serial Doppler echocardiographic studies at least six months apart. There were 40 men and 11 women with a mean age of 36 years. MAIN OUTCOME MEASURE--Doppler echocardiographic values of aortic valve dysfunction. Cardiac events including endocarditis and aortic valve replacement were also evaluated. RESULT--Coarctation was present in five patients. 31 (61%) patients had a functionally normal bicuspid aortic valve defined as a mean gradient < 25 mm Hg and mild regurgitation. Significant aortic regurgitation was present in 15 patients (moderate in 12 and severe in three). Three patients had isolated aortic stenosis and two patients had combined aortic valve dysfunction. At a median follow up of 21 months (range six to 46 months), six patients had aortic valve surgery (one for aortic stenosis, three for aortic regurgitation, and two for endocarditis). Only 22 patients (43%) continued to have a functionally normal aortic valve. CONCLUSION--In this cohort of fairly young patients, aortic regurgitation is more common than aortic stenosis. Progression of aortic valve dysfunction occurs in patients with pre-existing valve dysfunction and even in those with normal aortic valve function at the initial echocardiographic examination.     

Doppler echocardiography diagnosis and classification of the degree of aortic valve insufficiency in patients with aortic stenoses and mitral valve diseases

To test the capacity of pulsed Doppler echocardiography in the detection and quantification of aortic regurgitation, 64 consecutive patients with aortic and mitral valve disease were examined clinically and by echocardiography before cardiac catheterization. The severity of aortic regurgitation was determined angiographically (I-IV) and compared with the extent of the regurgitant jet in the left ventricle measured by pulsed Doppler echocardiography. In 15 of 64 patients neither angiography nor pulsed Doppler echocardiography showed aortic regurgitation (specificity 100%). Apart from 3 patients with poor echo quality pulsed Doppler echocardiography correctly detected aortic regurgitation in 46 of 49 patients (sensitivity 94%). Clinical examination (63%) and M-mode echocardiography (63%) were significantly less sensitive than Doppler echocardiography (p less than 0.001). The pulsed Doppler echocardiographic degree of aortic regurgitation correlated strongly with angiography (corrected contingency coefficient 0.91). In patients with severe aortic stenosis (systolic gradient greater than 50 mm Hg) aortic regurgitation I was slightly overestimated by pulsed Doppler echocardiography (p less than 0.003). Differentiation of aortic regurgitation III and IV was not possible. Mitral valve disease did not affect quantification of aortic regurgitation (n = 23).     

Effects of exercise on transmitral gradient and pulmonary artery pressure in patients with mitral stenosis or a prosthetic mitral valve: a Doppler echocardiographic study

Doppler echocardiography was used to determine changes in transmitral gradient and pulmonary artery pressure after exercise in 12 patients with mitral stenosis and 11 patients with a prosthetic mitral valve. The mean transmitral gradient in the mitral stenosis group was 9 +/- 7 mm Hg at rest and increased to 17 +/- 8 mm Hg after exercise. In patients with a prosthetic mitral valve, exercise resulted in an increase in mean transmitral gradient from 5 +/- 2 to 8 +/- 3 mm Hg. Calculated pulmonary artery systolic pressure increased with exercise from 41 +/- 19 to 70 +/- 32 mm Hg in the mitral stenosis group and from 28 +/- 8 to 39 +/- 15 mm Hg in patients with a prosthetic valve. Exercise Doppler echocardiographic evaluation of changes in transmitral gradient and pulmonary artery systolic pressure was found to be technically simple and an important addition to the noninvasive evaluation of patients with mitral valve disease.     

Factors determining early improvement in mitral regurgitation after aortic valve replacement for aortic valve stenosis: a transthoracic and transesophageal prospective study

BACKGROUND: Mitral regurgitation (MR) is frequently associated with aortic stenosis. Previous reports have shown that coexisting mitral insufficiency can potentially regress after aortic valve replacement. HYPOTHESIS: This study sought to assess the frequency and severity of MR before and after aortic valve replacement for aortic stenosis and to define the determinants of its postoperative evolution. METHODS: For this purpose, 30 adult patients referred for aortic valve surgery underwent pre- and postoperative transthoracic and transesophageal echocardiography and color Doppler examination. RESULTS: Mean preoperative left ventricular ejection fraction was 57 +/- 16% and remained unchanged postoperatively. Preoperative MR was usually mild to moderate and correlated with aortic stenosis severity and left ventricular systolic dysfunction. The color Doppler mitral regurgitant jet area significantly decreased during the postoperative period (p = 0.016) as left ventricular loading conditions returned to normal, suggesting an early decrease of the functional part of MR. On the other hand, the mitral regurgitant jet width at the origin remained unchanged. Statistical analysis found pulmonary artery pressure (p = 0.02) an d indexed left ventricular mass (p = 0.009) to be preoperative predictive factors of postoperative MR improvement. Predictive factors of postoperative MR severity were left atrial diameter (p = 0.02), pulmonary artery pressure (p = 0.003), and the presence of mitral calcifications (p = 0.004). CONCLUSION: In our cohort of patients with normal left venticular ejection fraction, the majority of moderate MR, associated with severe aortic stenosis, regresses early after aortic valve replacement. Mitral calcifications and/or left atrial dilation seem to be predictive factors of fixed MR.     

Profiles of coronary blood flow velocity in patients with aortic stenosis and the effect of valve replacement: a transthoracic echocardiographic study.

OBJECTIVE--To report the first non-invasive assessment by transthoracic Doppler echocardiography of coronary blood flow in patients with aortic stenosis and of the effects of valve replacement. DESIGN--High frequency transthoracic Doppler echocardiography was used to examine resting phasic flow in the left anterior descending coronary artery before and after replacement of the aortic valve in awake, unsedated patients with pure aortic stenosis and normal coronary arteries. SETTING--A tertiary referral cardiothoracic centre. METHODS--Eleven patients with pure aortic stenosis and normal coronary arteries (six men, five women, mean (range) age 69 (50-82) years), were studied the day before and 1 week after replacement of the aortic valve. These patients were selected from a cohort of 15 due to ease of imaging of the left anterior descending coronary artery. Seven had a history of angina. Haemodynamics, peak transvalvar aortic gradient, left ventricular mass index, ventricular dimensions, and profiles of coronary flow velocity were measured. Profiles of coronary flow velocity were also measured in a control population of 10 normal subjects (five men, five women, mean (range) age 58 (34-66) years). RESULTS--The control population showed forward flow throughout systole, but reversed early systolic flow (mean velocity 20.6 (3.6) cm/s) was seen in six patients with aortic stenosis. Only three of these patients had a clinical history of angina. Peak and mean systolic and diastolic forward flow velocities were not significantly different in the control group and in patients with aortic stenosis. The time from the start of systole to the onset of forward systolic flow was significantly longer in patients with aortic stenosis than in the control population (185 (8.5) v 85 (10) ms, p < 0.01). The time from the onset of diastolic flow to peak diastolic velocity was also significantly longer in the aortic stenosis group (146 (16) v 74 (13) ms, p < 0.01). These abnormalities in profiles of coronary flow were reversed by replacement of the aortic valve. There was no correlation between changes in flow profiles in patients with aortic stenosis and preoperative clinical history, transvalvar gradient, left ventricular mass index, or ventricular dimensions. CONCLUSIONS--Coronary flow profiles in patients with aortic stenosis were characterised by reversed early systolic flow and delayed forward systolic flow and attainment of peak diastolic velocity. Reversal of these abnormalities by replacement of the aortic valve may reflect altered left ventricular and aortic haemodynamics and contribute to the relief of angina when left ventricular hypertrophy persists. Further studies may correlate abnormalities of coronary flow with preoperative clinical and haemodynamic state.     

Determination of aortic valve area by two-dimensional and Doppler echocardiography in patients with normal and stenotic bioprosthetic valves

To assess the feasibility and accuracy of determining bioprosthetic aortic valve area from two-dimensional and Doppler echocardiographic measurements, three partially overlapping groups were selected from 55 patients with such bioprosthetic valves and adequate Doppler studies. These were Group 1, 37 patients with recent aortic valve replacement surgery and no clinical or echocardiographic evidence of valve dysfunction; Group 2, 12 patients with prosthetic valve stenosis documented by cardiac catheterization; and Group 3, 22 patients with both Doppler and catheterization studies in whom noninvasive and invasive determinations of aortic valve area could be directly compared. Left ventricular outflow tract diameter was measured from two-dimensional still frame images. Flow velocity proximal to the aortic valve, transvalvular velocity and acceleration time were determined from pulsed and continuous wave Doppler spectra. Aortic valve gradient was calculated with the modified Bernoulli equation and valve area by the continuity equation. In the 37 patients with a normally functioning valve, the calculated mean gradient ranged from 5 to 25 mm Hg (average 13.6 +/- 5.2) and valve area from 1.0 to 2.3 cm2 (mean 1.6 +/- 0.31). Linear regression analysis of prosthetic aortic valve area determined by Doppler imaging and cardiac catheterization demonstrated a high correlation (r = 0.93) between the two techniques. Comparison of the patients with and without prosthetic valve stenosis revealed statistically significant differences in mean gradient (42.8 +/- 12.3 versus 13.6 +/- 5.2 mm Hg; p = 0.0001), acceleration time (116 +/- 15 versus 80 +/- 13 ms; p = 0.0001) and valve area by the continuity equation (0.80 +/- 0.16 versus 1.6 +/- 0.31 cm2; p = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Reproducibility of Doppler echocardiographic quantification of aortic and mitral valve stenoses: comparison between two echocardiography centers

Doppler echocardiography has been widely used as a noninvasive method to quantify valvular heart diseases. This study assessed the variability between 2 echocardiography centers concerning 2-dimensional and Doppler echocardiographic results in the quantification of mitral and aortic valve stenoses. Forty-two patients were studied by 2 different echocardiography centers in a blinded, independent fashion. In patients with aortic and mitral valve stenosis, mean and maximal flow velocities were measured. The aortic valve orifice area was calculated according to the continuity equation. Mitral valve orifice area was determined by direct planimetry and by pressure half-time. In patients with an aortic valve stenosis, a close relation between the 2 centers was found for the maximal and mean flow velocities (coefficient of correlation, r = 0.72 to 0.92; coefficient of variation, 3.7 to 7.7%). A close correlation and a small observer variability was found for the flow velocity ratio determined by flow velocities measured in the left ventricular outflow tract and over the stenotic valve (r = 0.88; coefficient of variation, 0.01 +/- 0.009). In contrast, there was a poor correlation between the diameter of the left ventricular outflow tract and the aortic orifice area (r = 0.36 and 0.59, respectively). In patients with a mitral valve stenosis, mean and maximal velocities were closely correlated (r = 0.85 and 0.77, respectively). Velocities were not found to be significantly different between the 2 centers. Variability between the 2 centers for the mitral valve orifice area was 9.8% (2-dimensional echocardiography) and 5.7% (pressure half-time).(ABSTRACT TRUNCATED AT 250 WORDS)     

Unusual sequelae after percutaneous mitral valvuloplasty: a Doppler echocardiographic study.

Percutaneous mitral valvuloplasty is a promising new technique for the treatment of mitral stenosis, with a relatively low complication rate reported to date. To assess the sequelae of this procedure, Doppler echocardiographic studies were prospectively performed before and after percutaneous mitral valvuloplasty in a series of 172 patients (mean age 53 +/- 17 years). After balloon dilation, mitral valve area increased from 0.9 +/- 0.3 to 2 +/- 0.8 cm2 (p less than 0.0001), mean gradient decreased from 16 +/- 6 to 6 +/- 3 mm Hg (p less than 0.0001) and mean left atrial pressure decreased from 24 +/- 7 to 14 +/- 6 mm Hg (p less than 0.0001). Although most patients were symptomatically improved, six (4%) were identified who had unusual sequelae evident on Doppler echocardiographic examination immediately after percutaneous mitral valvuloplasty. These included rupture of a posterior mitral valve leaflet, producing a flail distal leaflet portion with severe mitral regurgitation detected on Doppler color flow mapping (n = 1); asymptomatic rupture of the chordae tendineae attached to the anterior mitral valve leaflet with systolic anterior motion of the ruptured chordae into the left ventricular outflow tract (n = 1); a double-orifice mitral valve (n = 1); and evidence of a tear in the anterior mitral valve leaflet (n = 3), producing on both pulsed Doppler ultrasound and color flow mapping a second discrete jet of mitral regurgitation in addition to regurgitation through the main mitral valve orifice. All six patients made a satisfactory recovery and none has required mitral valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)     

Echocardiographic assessment of subvalvular aortic stenosis before and after operation.

The development of two-dimensional and Doppler echocardiography has provided a noninvasive technique for the diagnosis and serial assessment of patients with subvalvular aortic stenosis. The clinical records and echocardiographic data were reviewed of all patients with subaortic stenosis diagnosed between 1983 and 1991. Of the 77 patients identified (45 male and 32 female), 28 had isolated subaortic stenosis and 49 had associated cardiac lesions. The most frequently encountered associated lesions were ventricular septal defect (n = 19) and coarctation of the aorta/interrupted aortic arch (n = 14). Serial echocardiographic studies, performed in 38 of the 77 patients, documented significant progression of the left ventricular outflow tract gradient in 25 patients (66%) and development of aortic regurgitation in 25 patients (66%). Surgical resection was performed in 36 patients. The preoperative outflow tract peak gradient was 62.9 +/- 31 mm Hg (range 0 to 153), whereas the immediate postoperative gradient was 14.4 +/- 14 mm Hg (range 0 to 67). The two patients with a significant residual gradient (37 and 67 mm Hg, respectively) in the immediate postoperative period had severe subaortic stenosis preoperatively with marked left ventricular hypertrophy and intracavitary gradient. The immediate postoperative echocardiograms demonstrated no worsening of aortic regurgitation in any patient and regression of regurgitation in one patient from mild to none. Intermediate-term follow-up studies were available for review in 13 postoperative patients at a mean of 4 years postoperatively. In 2(15%) of these 13 patients, subaortic stenosis recurred; however, the degree of aortic regurgitation did not increase in any patient.(ABSTRACT TRUNCATED AT 250 WORDS)     

Doppler echocardiographic measurement of aortic valve area in aortic stenosis: a noninvasive application of the Gorlin formula

Thirty adult patients with aortic stenosis had Doppler echocardiography within 1 day of cardiac catheterization. Noninvasive measurement of the mean transaortic pressure gradient was calculated by applying the simplified Bernoulli equation to the continuous wave Doppler transaortic velocity recording. Stroke volume was measured noninvasively by multiplying the systolic velocity integral of flow in the left ventricular outflow tract (obtained by pulsed Doppler ultrasonography) by the cross-sectional area of the left ventricular outflow tract (measured by two-dimensional echocardiography). Non-invasive measurement of aortic valve area was calculated by two methods. In method 1, the Gorlin equation was applied using Doppler-derived mean pressure gradient, cardiac output and systolic ejection period. Method 2 used the continuity equation. These noninvasive measurements were compared with invasive measurements using linear regression analysis, and mean pressure gradients correlated well (r = 0.92). Aortic valve area by either noninvasive method also correlated well with cardiac catheterization values (method 1, r = 0.87; method 2, r = 0.88). The sensitivity of Doppler detection of critical aortic stenosis was 0.86, with a specificity of 0.88 and a positive predictive value of 0.86. Cardiac output measured nonsimultaneously showed poor correlation (r = 0.51). Doppler echocardiography can distinguish critical from noncritical aortic stenosis with a high degree of accuracy. Measurement of aortic valve area aids interpretation of Doppler-derived mean pressure gradient data when the gradients are in an intermediate range (30 to 50 mm Hg).     

Serial assessment of mitral regurgitation by pulsed Doppler echocardiography in patients undergoing balloon aortic valvuloplasty

Mitral regurgitation was serially assessed by pulsed Doppler echocardiography in 144 patients undergoing balloon aortic valvuloplasty for symptomatic aortic stenosis. Regurgitant scores of 0, 1, 2 and 3 were assigned to pulsed Doppler patterns corresponding to no, mild, moderate and severe mitral regurgitation, respectively. Before balloon aortic valvuloplasty, mitral regurgitant score correlated significantly (p less than 0.005) but weakly with aortic valve area (r = -0.24), left ventricular ejection fraction (r = -0.34) and left ventricular systolic pressure (r = 0.23). There was no significant correlation between mitral regurgitation and either mean catheterization or mean Doppler aortic valve gradient. Balloon aortic valvuloplasty produced significant decreases in both catheterization and Doppler mean transvalvular aortic valve gradients (56 +/- 19 to 31 +/- 12 and 60 +/- 19 to 48 +/- 16 mm Hg, respectively; both p less than 0.0001) and a significant increase (p less than 0.0001) in aortic valve area assessed by catheterization (0.6 +/- 0.2 to 0.9 +/- 0.3 cm2). Left ventricular ejection fraction did not change, but cardiac output increased (p less than 0.001) and pulmonary capillary wedge pressure decreased (p less than 0.0001). Pulsed Doppler findings of mitral regurgitation were present in 102 of the 144 patients. Eighty-eight patients had a score compatible with mild or more severe degrees of mitral regurgitation, and 49 had a score indicative of moderate or severe valvular insufficiency. In the entire group of 144 patients, mitral regurgitant score decreased significantly from 1.1 +/- 1.0 to 1.0 +/- 1.0 (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Calculation of aortic valve area by Doppler echocardiography: a direct application of the continuity equation

The continuity equation suggests that a ratio of velocities at two different cardiac valves is inversely proportional to the ratio of cross-sectional areas of the valves. To determine whether a ratio of mitral/aortic valve orifice velocities is useful in determining aortic valve area in patients with aortic stenosis, 10 control subjects and 22 patients with predominant aortic stenosis were examined by Doppler echocardiography. The ratio of (mean diastolic mitral velocity)/(mean systolic aortic velocity), (Vm)/(Va), and the ratio of (mitral diastolic velocity-time integral)/(aortic systolic velocity-time integral), (VTm)/(VTa), were determined from Doppler spectral recordings. Aortic valve area determined at catheterization by the Gorlin equation was the standard of reference. High-quality Doppler recordings were obtained in 30 of 32 subjects (94%). Catheterization documented valve areas of 0.5 to 2.6 (mean 1.1) cm2. There was good correlation between Doppler-determined (Vm)/(Va) and Gorlin valve area (r = .90, SEE = 0.23 cm2); a better correlation was noted between (VTm)/(VTa) and Gorlin valve area (r = .93, SEE = 0.18 cm2). The data demonstrate the usefulness of Doppler alone in the determination of aortic valve area in adults with absent or mild aortic or mitral regurgitation and no mitral stenosis. Although the use of mean velocity and velocity-time integral ratios requires accurate measurement of mitral and aortic velocities, it does not require squaring of these velocities or measurement of the cross-sectional area of flow.     

Clinical and Doppler echocardiographic follow-up after percutaneous balloon valvuloplasty for aortic valve stenosis

Percutaneous balloon valvuloplasty has been shown to increase the aortic orifice area and to improve clinical symptoms. However, there are only few data concerning long-term results after balloon valvuloplasty. In this study, 36 patients (11 men, 25 women, mean age 75 +/- 8 years) were followed after balloon valvuloplasty for a period of up to 18 months by means of clinical parameters and repeated Doppler echocardiographic measurements after 1, 3, 6, 12 and 18 months. Invasive measurements revealed a decrease of the systolic peak gradient from 78 +/- 24 to 38 +/- 13 mm Hg (p less than 0.001), and an increase in the aortic orifice area from 0.58 +/- 0.23 to 0.93 +/- 0.2 cm2 (p less than 0.001). The Doppler echocardiographic approach revealed that the maximal instantaneous gradient decreased from 96 +/- 26 to 67 +/- 22 mm Hg (p less than 0.001). The aortic orifice area increased from 0.49 +/- 0.16 to 0.73 +/- 0.21 cm2 (p less than 0.001). Three patients (8%) died in the hospital. After hospital discharge, 16 patients (44%) died and 8 patients (22%) underwent successful aortic valve replacement after a mean follow-up of 8 +/- 6 months. Nine patients (25%) were alive after a follow-up period of 18 months. Seven of these (19%) remained clinically improved. During follow-up, the Doppler echocardiographic results revealed a continuous trend toward the preprocedural severity of the aortic valve stenosis. Progression of restenosis assessed by Doppler echocardiographic measurements was accelerated in the group of patients who subsequently died or underwent repeat balloon valvuloplasty or aortic valve replacement.     

A double fistulous communication between the aortic root and both left cardiac chambers. Its diagnosis by multiplanar transesophageal echocardiography

The case of a patient with mitral and aortic mechanical valve prostheses is presented who developed early postoperative infective endocarditis and, subsequently, a fistulous communication between the posterior aortic sinus and both the left atrium and the left ventricle. A diastolic murmur of apparent aortic prosthesis regurgitation was heard, although an abnormal aortic valve function could not be demonstrated in the transthoracic echocardiographic study. Instead, the presence of a systolic high velocity flow by continuous wave Doppler suggested prosthetic mitral leakage. The clinical presentation of progressive congestive heart failure and pulmonary hypertension by Doppler prompted a further study by means of transesophageal echocardiography with multiplanar probe showing the above mentioned double fistulous communication. The diagnosis was later confirmed by angiography and also at surgery.     

Assessment of rheumatic mitral valve disease. Value of echocardiography in patients clinically suspected of predominant stenosis.

The value of echocardiography as compared with cardiac catheterisation was evaluated prospectively in 33 consecutive patients clinically suspected of predominant mitral stenosis. Patients with clinical signs of accompanying mitral regurgitation, no matter how severe, and patients with clinical findings indicating insignificant aortic valve disease were included. Critical mitral stenosis was defined by a valve area of less than or equal to 1 cm2. Severe mitral regurgitation was diagnosed by echocardiography on the basis of left ventricular dilatation (more than 3.2 cm/m2 at end-diastole) if not explained otherwise. Significant aortic valve disease was suspected in cases with aortic valve deformity and left ventricular dilatation or hypertrophy as defined by echocardiography. Mitral valve area by echocardiography correlated well with mitral valve area calculated from catheterisation data and a good interobserver correlation was found for echocardiographic measurement. Mitral stenosis, critical or non-critical, may mask significant coexistent valve lesions; echocardiography failed to discover severe mitral regurgitation requiring valve replacement in two patients with non-critical stenosis, and significant aortic regurgitation needing valve replacement was underestimated in one patient with critical mitral stenosis. A correct echocardiographic classification with respect to surgery, however, was obtained in: (1) all patients with clinically pure mitral stenosis (nine patients), and (2) all patients with combined mitral stenosis and regurgitation when either critical stenosis or severe regurgitation was found at echocardiography (12 patients). It thus appears that two out of three patients with mitral valve disease in whom the clinical findings indicate predominant stenosis can be correctly evaluated with the echocardiogram.     

Doppler echocardiographic evaluation of aortic stenosis

Doppler echocardiography allows accurate noninvasive measurement of transaortic velocity and pressure gradient in patients with valvular aortic stenosis. Because pressure gradients vary with transaortic volume flow, calculation of aortic valve area with the continuity equation is essential for complete echocardiographic evaluation of adult patients. The physician and sonographer should be aware of potential technical and physiologic pitfalls in applying Doppler echocardiographic techniques to the evaluation of the adult with aortic stenosis. With proper training and experience, however, the needed data can be obtained reliably and reproducibly. Doppler evaluation of patients with aortic stenosis has improved our understanding of the prevalence and natural history of this disease. In addition, Doppler measures of stenosis severity can be used in a cost-effective manner for clinical decision making regarding the need for valve replacement in symptomatic adults. It now has supplanted the need for invasive measures of stenosis severity in many of these patients.     

Comparisons between female and male patients with mitral stenosis.

OBJECTIVE--To compare Doppler, echocardiographic, and clinical variables in female and male patients with mitral stenosis. DESIGN--Observational study in consecutive patients with mitral stenosis of cross sectional and Doppler echocardiographic and clinical variables and a retrospective search for a history of systemic embolism. SETTING--A medical centre with 3000 beds, serving both urban and rural populations. PATIENTS--500 consecutive patients with an echocardiographic mitral valve area of 2 cm2 or less. 331 (66.2%) were female and 169 (33.8%) male (mean (SD) ages of 49 (13) and 48 (14) respectively). MAIN OUTCOME MEASURES--Mitral valve areas by echocardiographic planimetry and Doppler pressure half-time method, peak early diastolic mitral velocity and pressure gradient, echocardiographic score of mitral valve, left atrial end systolic diameter, frequency of left atrial thrombus and smoky echoes as well as various valve lesions detected with Doppler and echocardiography, cardiac rhythm, symptomatic functional class of heart failure, and history of systemic embolism. RESULTS--The prevalence of significant tricuspid (22% v 9%, P < 0.001) and pulmonary regurgitation (5% v 1%, P = 0.018) was higher in the female patients than in the male patients. Female patients also had a higher peak regurgitant velocity (3.2 (0.7) v 2.9 (0.7) m/s, P = 0.007) and pressure gradient (41 (21) v 36 (19) mm Hg, P = 0.010) across the tricuspid valve. However, the male patients had a higher echocardiographic score (9.7 (2.4) v 7.0 (2.3), P < 0.001) and a smaller Doppler-derived mitral valve area (0.9 (0.4) v 1.0 (0.4) cm2, P = 0.027). There were no differences between the female and the male patients in mitral valve area measured by planimetry, peak early diastolic mitral velocity and pressure gradient, and left atrial end systolic diameter or in the prevalence of atrial fibrillation, left atrial thrombus, left atrial smoky echoes, significant aortic stenosis, aortic regurgitation, or heart failure of New York Heart Association class III or IV. CONCLUSIONS--Female patients not only had a higher prevalence of mitral stenosis but also had a higher prevalence of associated tricuspid and pulmonary regurgitation along with a higher velocity and gradient of tricuspid regurgitation. The echocardiographic score was higher in male patients, however. These findings suggest that the pathophysiology of mitral stenosis is different in the two sexes and that gender should be taken into account when therapeutic strategies are formulated.     

Ultrasonic aortic valve decalcification: serial Doppler echocardiographic follow-up

Serial two-dimensional and Doppler echocardiography was performed on 61 patients who had surgical ultrasonic aortic valve decalcification for calcific aortic stenosis. The mean patient age at the time of operation was 77.4 +/- 7.0 years; 93% had moderate to severe preoperative symptomatic limitation. Compared with preoperative studies, Doppler echocardiographic evaluation before hospital discharge revealed a significant reduction in the mean aortic valve pressure gradient (45.3 +/- 16.2 to 14.4 +/- 6.5 mm Hg, p less than 0.0001) and improvement in aortic valve area (0.62 +/- 0.17 to 1.33 +/- 0.33 cm2, p less than 0.0001). There was no initial change in aortic regurgitation grade. Follow-up Doppler echocardiographic evaluation was possible in 43 patients alive at 9.3 +/- 3.9 months. A small but statistically significant trend toward aortic restenosis was found; only one patient had severe restenosis. Severe aortic regurgitation had developed in 26% of patients and moderate aortic regurgitation in 37%. Aortic valve replacement was performed in six patients (14%) with severe symptomatic aortic regurgitation. Significant deficiency in central coaptation as a result of cusp scarification and retraction appeared to be the mechanism of postdecalcification regurgitation. Attempted salvage of the native aortic valve in severe calcific stenosis by ultrasonic decalcification adequately relieves stenosis but leads to an unacceptable incidence of significant aortic regurgitation at follow-up study.