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Stress Doppler Echocardiography in Valvular Heart Disease

  • Jean-Louis J. Vanoverschelde
  • Agnès Pasquet

Abstract

In adults with valvular heart disease, valve replacement and repair are the only therapeutic options that consistently improve symptoms and increase life expectancy. The assessment of the severity of a valvular lesion traditionally relies on the evaluation of valvular anatomy and on the demonstration of resting hemodynamic disturbances, attributable to the valve problem. In patients with stenotic lesions, this is usually achieved by measuring the transstenotic pressure difference and by calculating the surface of the stenotic orifice. In patients with regurgitant lesions, assessment of lesion severity requires that the degree of volume overload imposed on the heart chambers be determined. In many instances, however, discrepancies are found between the severity of the valvular lesion and either the symptoms or the hemodynamic impairment. A provocative maneuver to unmask the true severity of the valvular lesion may then be useful.

Keywords

Aortic Valve Aortic Stenosis Mitral Regurgitation Aortic Valve Replacement Aortic Regurgitation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Yoganathan AP, Cape EG, Sung HW, et al (1988) Review of hydrodynamic principles for the cardiologist: applications to the study of blood flow and jets by imaging techniques. J Am Coll Cardiol 12:1344–1352PubMedCrossRefGoogle Scholar
  2. 2.
    Gorlin R, Gorlin SG (1951) Hydraulic formula for calculation of the area of the stenotic mitral valve, other cardiac valves, and central circulatory shunts. Am Heart J 41:1–29PubMedCrossRefGoogle Scholar
  3. 3.
    Otto CM, Pearlman AS, Comess KA, et al (1986) Determination of stenotic aortic valve area in adults using Doppler echocardiography. J Am Coll Cardiol 7:509–517PubMedCrossRefGoogle Scholar
  4. 4.
    Bache RJ, Wang Y, Jorgensen CR (1971) Hemodynamic effects of exercise in isolated valvular aortic stenosis. Circulation 44:1003–1013PubMedCrossRefGoogle Scholar
  5. 5.
    Buckberg G, Eber L, Herman M et al (1975) Ischemia in aortic stenosis: hemodynamic prediction. Am J Cardiol 35:778–84PubMedCrossRefGoogle Scholar
  6. 6.
    Paulus W, Sys SU, Heyndrickx GR, et al (1991) Orifice variability of the stenotic aortic valve: evaluation before and after balloon aortic valvuloplasty. J Am Coll Cardiol 17:1263–1269PubMedCrossRefGoogle Scholar
  7. 7.
    Casale PN, Palacios IF, Abascal VM, et al (1992) Effects of dobutamine on Gorlin and continuity equation valve areas and valve resistance in valvular aortic stenosis. Am J Cardiol 70:1175–1179PubMedCrossRefGoogle Scholar
  8. 8.
    Burwash IG, Pearlman AS, Kraft CD, et al (1994) Flow dependence of measures of aortic stenosis severity during exercise. J Am Coll Cardiol 24:1342–1350PubMedCrossRefGoogle Scholar
  9. 9.
    Richards KL (1991) Assessment of aortic and pulmonic stenosis by echocardiography. Circulation 84:1182–7Google Scholar
  10. 10.
    Montarello JK, Perakis AC, Rosenthal E, et al (1990) Normal and stenotic human aortic valve opening: in vitro assessment of orifice area changes with flow. Eur Heart J 11:484–491PubMedGoogle Scholar
  11. 11.
    Chambers JB, Sprigings DC, Cochrane T, et al (1992) Continuity equation and Gorlin formula compared with directly observed orifice area in native and prosthetic aortic valves. Br Heart J 67:193–199PubMedCrossRefGoogle Scholar
  12. 12.
    Segal J, Lerner DJ, Miller DC, et al (1987) When should Doppler-determined valve area be better than the Gorlin formula? Variations in hydraulic constants in low flow states. J Am Coll Cardiol 9:1294–1305PubMedCrossRefGoogle Scholar
  13. 13.
    Voelker W, Peul H, Nienhaus G, et al (1995) Comparison of valvular resistance, stroke work loss, and Gorlin valve area for quantification of aortic stenosis. An in vitro study in a pulsatile aortic flow model. Circulation 91:1196–1204PubMedCrossRefGoogle Scholar
  14. 14.
    Cannon SR, Richards KL, Crawford M (1985) Hydraulic estimation of stenotic orifice area: a correction of the Gorlin formula. Circulation 71:1170–1178PubMedCrossRefGoogle Scholar
  15. 15.
    Cannon JD, Zile MR, Crawford FA, et al (1992) Aortic valve resistance as an adjunct to the Gorlin formula in assessing the severity of aortic stenosis in symptomatic patients. J Am Coll Cardiol 20:1517–1523PubMedCrossRefGoogle Scholar
  16. 16.
    Ford LE, Feldman T, Chiu YC, et al (1990) Hemodynamic resistance as a measure of functional impairment in valvular aortic stenosis. Circ Res 66:1–7PubMedCrossRefGoogle Scholar
  17. 17.
    Bermejo J, Garcia Fernandez MA, Torrecilla EG, et al (1996) Effects of dobutamine on echo-Doppler indexes of aortic stenosis. The usefulness of aortic valve resistance. J Am Coll Cardiol 28:1206–1213PubMedCrossRefGoogle Scholar
  18. 18.
    Vanoverschelde J-L, D’Hondt A-M, De Kock M (1995) Flow-dependence of aortic stenosis severity during dobutamine infusion: comparison of the Gorlin and continuity equations with measurements of aortic valve resistance (abstract). Circulation 92 [Suppl I]:466CrossRefGoogle Scholar
  19. 19.
    Vanoverschelde J-L, Pasquet A, D’Hondt A-M, et al (1997) Flow-dependence of aortic stenosis severity during dobutamine infusion: Comparison of the Gorlin and continuity equations with direct planimetry of the anatomical orifice during transesophageal echocardiography (abstract). J Am Coll Cardiol. 29:137AGoogle Scholar
  20. 20.
    Shively BK, Charlton GA, Crawford MH, et al (1998) Flow dependence of valve area in aortic stenosis: Relation to valve morphology. J Am Coll Cardiol 31:654–660PubMedCrossRefGoogle Scholar
  21. 21.
    Tardif J-C, Miller DS, Pandian NG, et al (1995) Effects of variations in flow on aortic valve area in aortic stenosis based on in vivo planimetry of aortic valve area by multiplane transesophageal echocardiography. Am J Cardiol 76:193–198PubMedCrossRefGoogle Scholar
  22. 22.
    Tardif JC, Rodrigues AG, Hardy JF, et al (1997) Simultaneous determination of aortic valve area by the Gorlin formula and by transesophageal echocardiography under different trans-valvular flow conditions. Evidence that anatomic aortic valve area does not change with variations in flow in aortic stenosis. J Am Coll Cardiol 29:1296–1302PubMedCrossRefGoogle Scholar
  23. 23.
    Carabello BA, Green LH, Grossman W, et al (1980) Hemodynamic determinants of prognosis of aortic valve replacement in critical aortic stenosis and advanced congestive heart failure. Circulation 62:42–48PubMedCrossRefGoogle Scholar
  24. 24.
    Smucker ML, Manning SB, Stuckey TD, et al (1989) Preoperative left ventricular wall stress, ejection fraction, and aortic valve gradient as prognostic indicators in aortic valve stenosis. Cath Cardiovasc Diagn 17:133–143CrossRefGoogle Scholar
  25. 25.
    Brogan WC, Grayburn PA, Lange RA, et al (1993) Prognosis after valve replacement in patients with severe aortic stenosis and a low transvalvular pressure gradient. J Am Coll Cardiol 21:1657–1660PubMedCrossRefGoogle Scholar
  26. 26.
    Connolly HM, Oh JK, Schaff HV, et al (2000) Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction. Circulation 101:1940–1946PubMedCrossRefGoogle Scholar
  27. 27.
    Carabello BA, Crawford FA (1997) Valvular heart disease. N Engl J Med 337:32–41PubMedCrossRefGoogle Scholar
  28. 28.
    DeFilippi CR, Willet DL, Brickner E, et al (1995) Usefulness of dobutamine echocardiography in distinguishing severe from nonsevere valvular aortic stenosis in patients with depressed left ventricular function and low transvalvular gradients. Am J Cardiol 75:191–194PubMedCrossRefGoogle Scholar
  29. 29.
    Monin JL, Monchi M, Gest V, et al (2001) Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients. Risk stratification by low-dose dobutamine echocardiography. J Am Coll Cardiol 37:2101–2107PubMedCrossRefGoogle Scholar
  30. 30.
    Schwammenthal E, Vered Z, Moshkowitz Y, et al (2001) Dobutamine echocardiography in patients with aortic stenosis and left ventricular dysfunction: predicting outcome as a function of management strategy. Chest 119:1766–1777PubMedCrossRefGoogle Scholar
  31. 31.
    Leavitt JI, Coats MH, Falk RH (1991) Effects of exercise on transmitral gradient and pulmonary artery pressure in patients with mitral stenosis or a prosthetic mitral valve: a Doppler echocardiographic study. J Am Coll Cardiol 17:1520–1526PubMedCrossRefGoogle Scholar
  32. 32.
    Sagar KB, Wann LS, Paulson WJH, et al (1987) Role of exercise Doppler echocardiography in isolated mitral stenosis. Chest 92:27–30PubMedCrossRefGoogle Scholar
  33. 33.
    Braverman AC, Thomas JD, Lee RT (1991) Doppler echocardiographic estimation of mitral valve area during changing hemodynamic conditions. Am J Cardiol 68:1485–1490PubMedCrossRefGoogle Scholar
  34. 34.
    Dahan M, Paillole C, Martin D, et al (1993) Determinants of stroke volume response to exercise in patients with mitral stenosis: a Doppler echocardiographic study. J Am Coll Cardiol 21:384–389PubMedCrossRefGoogle Scholar
  35. 35.
    Voelker W, Berner A, Med C, et al (1993) Effect of exercise on valvular resistance in patients with mitral stenosis. J Am Coll Cardiol 22:777–782PubMedCrossRefGoogle Scholar
  36. 36.
    Okay T, Deligonul U, Sancaktar O, et al (1993) Contribution of mitral valve reserve capacity to sustained symptomatic improvement after balloon valvulotomy in mitral stenosis: implication for restenosis. J Am Coll Cardiol 22:1691–1696PubMedCrossRefGoogle Scholar
  37. 37.
    Carabello BA, Nolan SP, McGuire LB (1981) Assessment of pre-operative left ventricular function in patients with mitral regurgitation: value of the end-systolic wall stress-end-systolic volume ratio. Circulation 64:1212–1217PubMedCrossRefGoogle Scholar
  38. 38.
    Zile MR, Gaasch WH, Carroll JD, et al (1984) Chronic mitral regurgitation: predictive value of preoperative echocardiographic indexes of left ventricular function and wall stress. J Am Coll Cardiol 3:235–242PubMedCrossRefGoogle Scholar
  39. 39.
    Pai RG, Bansal RC, Shah PM (1990) Doppler-derived rate of left ventricular pressure rise: its correlation with post-operative left ventricular function in mitral regurgitation. Circulation 82:514–520PubMedCrossRefGoogle Scholar
  40. 40.
    Tischler MD, Battle RW, Ashikaga T, et al (1996) Effects of exercise on left ventricular performance determined by echocardiography in chronic, severe mitral regurgitation secondary to mitral valve prolapse. Am J Cardiol 77:397–402PubMedCrossRefGoogle Scholar
  41. 41.
    Leung DY, Griffin BP, Stewart WJ, et al (1996) Left ventricular function after mitral valve repair for chronic mitral regurgitation: predictive value of preoperative assessment of contractile reserve by exercise echocardiography. J Am Coll Cardiol 28:1198–1205PubMedCrossRefGoogle Scholar
  42. 42.
    Tischler MD, Battle RW, Saha M, et al (1994) Observations suggesting a high incidence of exercise-induced severe mitral regurgitation in patients with mild rheumatic mitral valve disease at rest. J Am Coll Cardiol 25:128–133CrossRefGoogle Scholar
  43. 43.
    Heinle SK, Tice FD, Kisslo J (1995) Effect of dobutamine stress echocardiography on mitral regurgitation. J Am Coll Cardiol 25:122–127PubMedCrossRefGoogle Scholar
  44. 44.
    Spain MG, Smith MD, Kwan OL, et al (1990) Effect of isometric exercise on mitral and aortic regurgitation as assessed by color Doppler flow imaging. Am J Cardiol 65:78–83PubMedCrossRefGoogle Scholar
  45. 45.
    Lapu-Bula R, Robert A, De Kock M, et al (2002) Contribution of exercise-induced mitral regurgitation to exercise stroke volume and exercise capacity in patients with dilated cardiomyopathy. Circulation 106:1342–1348PubMedCrossRefGoogle Scholar
  46. 46.
    Ross J (1985) Afterload mismatch and preload reserve in aortic and mitral valve disease: implications for surgical therapy. J Am Coll Cardiol 5:811–826PubMedCrossRefGoogle Scholar
  47. 47.
    Bonow RO, Lakatos E, Maron BJ, et al (1991) Serial long-term assessment of the natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function. Circulation 84:1625–1635PubMedCrossRefGoogle Scholar
  48. 48.
    Kawanishi DT, McKay CR, Chandraratna AN, et al (1986) Cardiovascular response to dynamic exercise in patients with chronic symptomatic mild-to-moderate and severe aortic regurgitation. Circulation 73:62–72PubMedCrossRefGoogle Scholar
  49. 49.
    Steingart RW, Yee C, Weinstein L, et al (1983) Radionuclide ventriculographic study of adaptations to exercise in aortic regurgitation. Am J Cardiol 51:483–488PubMedCrossRefGoogle Scholar
  50. 50.
    Percy RF, Miller AB, Conetta DA (1993) Usefulness of left ventricular wall stress at rest and after exercise for outcome prediction in asymptomatic aortic regurgitation. Am Heart J 125:151–155PubMedCrossRefGoogle Scholar
  51. 51.
    Wahi S, Haluska B, Pasquet A, et al (2000) Exercise echocardiography predicts development of left ventricular dysfunction in medically and surgically treated patients with asymptomatic severe aortic regurgitation. Heart 84:606–614PubMedCrossRefGoogle Scholar
  52. 52.
    Smucker ML, Tedesco CL, Manning SB, et al (1988) Demonstration of an imbalance between coronary perfusion and excessive load as a mechanism of ischemia during stress in patients with aortic stenosis. Circulation 78:573–582PubMedCrossRefGoogle Scholar
  53. 53.
    Nittenberg A, Foult J-M, Antony I, et al (1988) Coronary flow and resistance reserve in patients with chronic aortic regurgitation, angina pectoris and normal coronary arteries. J Am Coll Cardiol 11:478–486CrossRefGoogle Scholar
  54. 54.
    Baroni M, Maffei S, Terrazzi M, et al (1996) Mechanisms of regional ischaemic changes during dipyridamole echocardiography in patients with severe aortic valve stenosis and normal coronary arteries. Heart 75:492–497PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2003

Authors and Affiliations

  • Jean-Louis J. Vanoverschelde
  • Agnès Pasquet

There are no affiliations available

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