Skip to main content
SpringerLink
Log in

Measurement errors in serial echocardiographic assessments of aortic valve stenosis severity

  • Original Paper
  • Published:
The International Journal of Cardiovascular Imaging Aims and scope Submit manuscript

Abstract

Transthoracic echocardiography (TTE) evaluation of aortic stenosis (AS) is routinely performed using the continuity equation. Inaccurate measurements of the left ventricular (LV) outflow tract (LVOT) diameter are considered the most common source of error in AS grading. We hypothesized that inconsistency in LVOT velocity time integral (VTI) is an under-recognized cause of AS assessment error. We sought to determine which parameters contribute most towards inconsistencies in AS grading by studying the prevalence of different errors in a historic cohort. We identified patients with mild to severe AS with multiple studies from our database from 1994 to 2018 (n = 988 patients, 2859 studies). Errors were defined when: (1) LVOT diameter changed by > 2 mm, (2) LVOT VTI changed by > 15% without change in LV function from the initial TTE, (3) aortic valve (AV) maximum velocity (Vmax), mean pressure gradient (ΔP) or AV VTI decreased by > 15% without change in LV function from prior study. The most common error was the LVOT VTI measurement with 22% prevalence. LVOT diameter, AV VTI, AV Vmax and AV ΔP measurement caused errors in < 7% studies. Patients with normal LV function and more severe AS were more likely to have LVOT VTI errors (P < 0.05). LVOT VTI is a frequent, under-recognized source of error in assessing AS. Greater attention should be directed toward the proper positioning of the pulsed Doppler sample volume, particularly in patients with higher grades of AS and normal systolic function, to ensure accurate and reproducible assessment of AS.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Cheitlin MD, Gertz EW, Brundage BH, Carlson CJ, Quash JA, Bode RS Jr (1979) Rate of progression of severity of valvular aortic stenosis in the adult. Am Heart J 98:689–700

    Article  CAS  Google Scholar 

  2. Davies SW, Gershlick AH, Balcon R (1991) Progression of valvar aortic stenosis: a long-term retrospective study. Eur Heart J 12:10–14

    Article  CAS  Google Scholar 

  3. Faggiano P, Aurigemma GP, Rusconi C, Gaasch WH (1996) Progression of valvular aortic stenosis in adults: literature review and clinical implications. Am Heart J 132:408–417

    Article  CAS  Google Scholar 

  4. Eveborn GW, Schirmer H, Heggelund G, Lunde P, Rasmussen K (2013) The evolving epidemiology of valvular aortic stenosis. The Tromso study. Heart 99:396–400

    Article  Google Scholar 

  5. Gorlin R, Gorlin SG (1951) Hydraulic formula for calculation of the area of the stenotic mitral valve, other cardiac valves, and central circulatory shunts. I. Am Heart J 41:1–29

    Article  CAS  Google Scholar 

  6. Hatle L, Angelsen BA, Tromsdal A (1980) Non-invasive assessment of aortic stenosis by Doppler ultrasound. Br Heart J 43:284–292

    Article  CAS  Google Scholar 

  7. Callahan MJ, Tajik AJ, Su-Fan Q, Bove AA (1985) Validation of instantaneous pressure gradients measured by continuous-wave Doppler in experimentally induced aortic stenosis. Am J Cardiol 56:989–993

    Article  CAS  Google Scholar 

  8. Smith MD, Dawson PL, Elion JL, Booth DC, Handshoe R, Kwan OL, Earle GF, DeMaria AN (1985) Correlation of continuous wave Doppler velocities with cardiac catheterization gradients: an experimental model of aortic stenosis. J Am Coll Cardiol 6:1306–1314

    Article  CAS  Google Scholar 

  9. Skjaerpe T, Hegrenaes L, Hatle L (1985) Noninvasive estimation of valve area in patients with aortic stenosis by Doppler ultrasound and two-dimensional echocardiography. Circulation 72:810–818

    Article  CAS  Google Scholar 

  10. Oh JK, Taliercio CP, Holmes DR Jr, Reeder GS, Bailey KR, Seward JB, Tajik AJ (1988) Prediction of the severity of aortic stenosis by Doppler aortic valve area determination: prospective Doppler-catheterization correlation in 100 patients. J Am Coll Cardiol 11:1227–1234

    Article  CAS  Google Scholar 

  11. Michelena HI, Margaryan E, Miller FA, Eleid M, Maalouf J, Suri R, Messika-Zeitoun D, Pellikka PA, Enriquez-Sarano M (2013) Inconsistent echocardiographic grading of aortic stenosis: is the left ventricular outflow tract important? Heart 99:921–931

    Article  Google Scholar 

  12. Gaspar T, Adawi S, Sachner R, Asmer I, Ganaeem M, Rubinshtein R, Shiran A (2012) Three-dimensional imaging of the left ventricular outflow tract: impact on aortic valve area estimation by the continuity equation. J Am Soc Echocardiogr 25:749–757

    Article  Google Scholar 

  13. Clavel MA, Malouf J, Messika-Zeitoun D, Araoz PA, Michelena HI, Enriquez-Sarano M (2015) Aortic valve area calculation in aortic stenosis by CT and Doppler echocardiography. JACC Cardiovasc Imag 8:248–257

    Article  Google Scholar 

  14. Baumgartner H, Hung J, Bermejo J, Chambers JB, Edvardsen T, Goldstein S, Lancellotti P, LeFevre M, Miller F Jr, Otto CM (2017) Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European association of cardiovascular imaging and the American society of echocardiography. J Am Soc Echocardiogr 30:372–392

    Article  Google Scholar 

  15. Mehrotra P, Flynn AW, Jansen K, Tan TC, Mak G, Julien HM, Zeng X, Picard MH, Passeri JJ, Hung J (2015) Differential left ventricular outflow tract remodeling and dynamics in aortic stenosis. J Am Soc Echocardiogr 28:1259–1266

    Article  Google Scholar 

  16. Caballero L, Saura D, Oliva-Sandoval MJ, Gonzalez-Carrillo J, Espinosa MD, Garcia-Navarro M, Valdes M, Lancellotti P, de la Morena G (2017) Three-dimensional morphology of the left ventricular outflow tract: impact on grading aortic stenosis severity. J Am Soc Echocardiogr 30:28–35

    Article  Google Scholar 

  17. Halpern EJ, Gupta S, Halpern DJ, Wiener DH, Owen AN (2012) Characterization and normal measurements of the left ventricular outflow tract by ECG-gated cardiac CT: implications for disorders of the outflow tract and aortic valve. Acad Radiol 19:1252–1259

    Article  Google Scholar 

  18. Otani K, Takeuchi M, Kaku K, Sugeng L, Yoshitani H, Haruki N, Ota T, Mor-Avi V, Lang RM, Otsuji Y (2010) Assessment of the aortic root using real-time 3D transesophageal echocardiography. Circ J 74:2649–2657

    Article  Google Scholar 

  19. Wiseth R, Samstad S, Rossvoll O, Torp HG, Skjaerpe T, Hatle L (1993) Cross-sectional left ventricular outflow tract velocities before and after aortic valve replacement: a comparative study with two-dimensional Doppler ultrasound. J Am Soc Echocardiogr 6:279–285

    Article  CAS  Google Scholar 

  20. Petersen JW, Liu J, Chi YY, Lingis M, Williams RS, Rhoton-Vlasak A, Segal MS, Conrad KP (2017) Comparison of multiple non-invasive methods of measuring cardiac output during pregnancy reveals marked heterogeneity in the magnitude of cardiac output change between women. Physiol Rep 5:E13223

    Article  Google Scholar 

Download references

Author information

Author notes

  1. Kalie Kebed and Deyu Sun contributed equally to this study.

Authors and Affiliations

  1. Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA

    Kalie Kebed, Karima Addetia, Victor Mor-Avi & Roberto M. Lang

  2. Philips Healthcare, Andover, MA, USA

    Deyu Sun & Natasha Markuzon

Authors
  1. Kalie Kebed
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Deyu Sun
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Karima Addetia
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Victor Mor-Avi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Natasha Markuzon
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Roberto M. Lang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Roberto M. Lang.

Ethics declarations

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

The study was approved by the Institutional Review Board.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kebed, K., Sun, D., Addetia, K. et al. Measurement errors in serial echocardiographic assessments of aortic valve stenosis severity. Int J Cardiovasc Imaging 36, 471–479 (2020). https://doi.org/10.1007/s10554-019-01745-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10554-019-01745-z

Keywords

Search

Navigation