Circulation, Vol 85, 2275-2283, Copyright © 1992 by American Heart Association
H Baumgartner, SS Khan, M DeRobertis, LS Czer and G Maurer
BACKGROUND. Although Doppler echocardiography has been shown to be accurate
in assessing stenotic orifice areas in native valves, its accuracy in
evaluating the prosthetic valve orifice area remains undetermined. METHODS
AND RESULTS. Doppler-estimated valve areas were studied for their agreement
with catheter-derived Gorlin effective orifice areas and their flow
dependence in five sizes (19/20-27 mm) of St. Jude, Medtronic-Hall, and
Hancock aortic valves using a pulsatile flow model. Doppler areas were
calculated three ways: using the standard continuity equation; using its
simplified modification (peak flow/peak velocity); and using the Gorlin
equation with Doppler pressure gradients. The results were compared with
Gorlin effective orifice areas derived from direct flow and catheter
pressure measurements. Excellent correlation between Gorlin effective
orifice areas and the three Doppler approaches was found in all three valve
types (r = 0.93-0.99, SEE = 0.07-0.11 cm2). In Medtronic-Hall and Hancock
valves, there was only slight underestimation by Doppler (mean difference,
0.003-0.25 cm2). In St. Jude valves, however, all three Doppler methods
significantly underestimated effective orifice areas derived from direct
flow and pressure measurements (mean difference, 0.40-0.57 cm2) with
differences as great as 1.6 cm2. In general, the modified continuity
equation calculated the largest Doppler areas. When orifice areas were
calculated from the valve geometry using the area determined from the inner
valve diameter reduced by the projected area of the opened leaflets, Gorlin
effective orifice areas were much closer to the geometric orifice areas
than Doppler areas (mean difference, 0.40 +/- 0.31 versus 1.04 +/- 0.20
cm2). In St. Jude and Medtronic-Hall valves, areas calculated by either
technique did not show a consistent or clinically significant flow
dependence. In Hancock valves, however, areas calculated by both the
continuity equation and the Gorlin equation decreased significantly (p less
than 0.001) with low flow rates. CONCLUSIONS. Doppler echocardiography
using either the continuity equation or Gorlin formula allows in vitro
calculation of Medtronic-Hall and Hancock effective valve orifice areas but
underestimates valve areas in St. Jude valves. This phenomenon is due to
localized high velocities in St. Jude valves, which do not reflect the mean
velocity distribution across the orifice. Valve areas are flow independent
in St. Jude and Medtronic-Hall prostheses but decrease significantly with
low flow in Hancock valves, suggesting that bioprosthetic leaflets may not
open fully at low flow rates.
ARTICLES
Doppler assessment of prosthetic valve orifice area. An in vitro study
Division of Cardiology and Cardiovascular Surgery, Cedars-Sinai Medical Center, Los Angeles.
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