Pediatric Cardiology

, Volume 29, Issue 3, pp 507–514

Clinical Utility of Doppler Echocardiography in Assessing Aortic Stenosis Severity and Predicting Need for Intervention in Children

  • Antonios P. Vlahos
  • Gerald R. Marx
  • Doff McElhinney
  • Stephen Oneill
  • Ioannis Goudevenos
  • Steven D. Colan
Original Article

Abstract

The optimal echocardiographic methodology for predicting need for intervention in children with valvar aortic stenosis (VAS) is not known. We reviewed echocardiograms and catheterization reports of 79 children (aged 9.5 ± 5.9 years) with isolated VAS. The maximum and mean Doppler-predicted gradients from the apical (MIGAP, MEGAP) and the suprasternal or right parasternal (MIGHP, MEGHP) windows were measured. The peak-to-peak catheterization gradient and the intervention (if any) were recorded. All sites and methods of Doppler estimation of VAS gradient correlated in a linear fashion with the invasive gradient (R= 0.34–0.50) and with one another (R= 0.48–0.86). MIGAP and MIGHP overestimated the invasive gradient in 60% and 86% of patients, whereas MEGAP and MEGHP underestimated the invasive gradient in 94% and 83% of patients, respectively. Age and diameter of the ascending aorta had small but significant effects on the level of agreement. A MIGHP ≤ 55 mm Hg predicted no intervention with 100% accuracy, whereas the specificities of a MIGHP > 90 mm Hg, a MEGAP > 50 mm Hg, and a (MIGAP + MIGHP)/2 > 70 mm Hg for intervention were 94%, 100%, and 92%, respectively. The magnitude of overestimation was significantly lower from the apical window. In children with VAS, the best prediction of the catheterization gradient could be based on the average of MIGAP and MIGHP.

Keywords

Aortic stenosis Doppler Echocardiography Children Gradient Intervention 

References

  1. 1.
    Barker PC, Ensing G, Ludomirsky A, Bradley DJ, Lloyd TR, Rocchini AP (2002) Comparison of simultaneous invasive and noninvasive measurements of pressure gradients in congenital aortic valve stenosis. J Am Soc Echocardiogr 15:1496–1502PubMedCrossRefGoogle Scholar
  2. 2.
    Baumgartner, Schima H, Tulzer G, Kuhn P (1993) Effect of stenosis geometry on the Doppler-catheter gradient relation in vitro: a manifestation of pressure recovery. J Am Coll Cardiol 21:1018–1025PubMedGoogle Scholar
  3. 3.
    Baumgartner H, Stefenelli T, Niederberger J, Schima H, Maurer G (1999) “Overestimation” of catheter gradients by Doppler ultrasound in patients with aortic stenosis: a predictable manifestation of pressure recovery. J Am Coll Cardiol 33:1655–1661PubMedCrossRefGoogle Scholar
  4. 4.
    Beauchesne LM, deKemp R, Chan KL, Burwash IG (2003) Temporal variations in effective orifice area during ejection in patients with valvular aortic stenosis. J Am Soc Echocardiogr 16:958–964PubMedCrossRefGoogle Scholar
  5. 5.
    Beekman RH, Rocchini AP, Gillon JH, Mancini GB (1992) Hemodynamic determinants of the peak systolic left ventricular-aortic pressure gradient in children with valvar aortic stenosis. Am J Cardiol 69:813–815PubMedCrossRefGoogle Scholar
  6. 6.
    Bengur AR, Snider AR, Serwer GA, Peters J, Rosenthal A (1989) Usefulness of the Doppler mean gradient in evaluation of children with aortic valve stenosis and comparison to gradient at catheterization. Am J Cardiol 64:756–761PubMedCrossRefGoogle Scholar
  7. 7.
    Bonow RO, Carabello B, de Leon AC Jr, et al. (1998) Guidelines for the management of patients with valvular heart disease: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). Circulation 98:1949–1984PubMedGoogle Scholar
  8. 8.
    Bonow RO, Carabello BA, Chatterjee K, et al. (2006) ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 48:e1–e148PubMedCrossRefGoogle Scholar
  9. 9.
    Cheitlin MD, Armstrong WF, Aurigemma GP, et al. (2003) ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 108:1146–1162PubMedCrossRefGoogle Scholar
  10. 10.
    Garcia D, Dumesnil JG, Durand LG, Kadem L, Pibarot P (2003) Discrepancies between catheter and Doppler estimates of valve effective orifice area can be predicted from the pressure recovery phenomenon: practical implications with regard to quantification of aortic stenosis severity. J Am Coll Cardiol 41:435–442PubMedCrossRefGoogle Scholar
  11. 11.
    Keane JF, Driscoll DJ, Gersony WM et al. (1993) Second natural history study of congenital heart defects. Results of treatment of patients with aortic valvar stenosis. Circulation 87:I16–I27PubMedGoogle Scholar
  12. 12.
    Levine RA, Jimoh A, Cape EG, McMillan S, Yoganathan AP, Weyman AE (1989) Pressure recovery distal to a stenosis: potential cause of gradient “overestimation” by Doppler echocardiography. J Am Coll Cardiol 13:706–715PubMedGoogle Scholar
  13. 13.
    Levine RA, Schwammenthal E (2003) Stenosis is in the eye of the observer: impact of pressure recovery on assessing aortic valve area. J Am Coll Cardiol 41:443–445PubMedCrossRefGoogle Scholar
  14. 14.
    Lima VC, Zahn E, Houde C, Smallhorn J, Freedom RM, Benson LN (2000) Non-invasive determination of the systolic peak-to-peak gradient in children with aortic stenosis: validation of a mathematical model. Cardiol Young 10:115–119PubMedCrossRefGoogle Scholar
  15. 15.
    Martin GR, Soifer SJ, Silverman NH. Dae MW, Stanger P (1987) Effects of activity on ascending aortic velocity in children with valvar aortic stenosis. Am J Cardiol 59:1386–1390PubMedCrossRefGoogle Scholar
  16. 16.
    Niederberger J, Schima H, Maurer G, Baumgartner H (1996) Importance of pressure recovery for the assessment of aortic stenosis by Doppler ultrasound. Role of aortic size, aortic valve area, and direction of the stenotic jet in vitro. Circulation 94:1934–1940PubMedGoogle Scholar
  17. 17.
    Richards KL (1991) Assessment of aortic and pulmonic stenosis by echocardiography. Circulation 84:I182–I187PubMedGoogle Scholar
  18. 18.
    Schobel WA, Voelker W, Haase KK, Karsch KR (1999) Occurrence of a saccular pseudoaneurysm formation two weeks after perforation of the left anterior descending coronary artery during balloon angioplasty in acute myocardial infarction. Catheter Cardiovasc Intervent 47:341–346CrossRefGoogle Scholar
  19. 19.
    Smith MD, Dawson PL, Elion JL, et al. (1985) Correlation of continuous wave Doppler velocities with cardiac catheterization gradients: an experimental model of aortic stenosis. J Am Coll Cardiol 6:1306–1314PubMedCrossRefGoogle Scholar
  20. 20.
    Smith MD, Dawson PL, Elion JL, et al. (1986). Systematic correlation of continuous-wave Doppler and hemodynamic measurements in patients with aortic stenosis. Am Heart J 111:245–252PubMedCrossRefGoogle Scholar
  21. 21.
    Villavicencio RE, Forbes TJ, Thomas RL, Humes RA (2003) Pressure recovery in pediatric aortic valve stenosis. Pediatr Cardiol 24:457–462PubMedCrossRefGoogle Scholar
  22. 22.
    Zoghbi WA, Farmer KL, Soto JG, Nelson JG, Quinones MA (1986) Accurate noninvasive quantification of stenotic aortic valve area by Doppler echocardiography. Circulation 73:452–459PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Antonios P. Vlahos
    • 1
  • Gerald R. Marx
    • 2
    • 3
  • Doff McElhinney
    • 2
    • 3
  • Stephen Oneill
    • 2
    • 3
  • Ioannis Goudevenos
    • 4
  • Steven D. Colan
    • 2
    • 3
  1. 1.Child Health Department, Pediatric Cardiology DivisionUniversity of IoanninaIoanninaGreece
  2. 2.Department of CardiologyChildren’s HospitalBostonUSA
  3. 3.Department of PediatricsHarvard Medical SchoolBostonUSA
  4. 4.University of IoanninaIoanninaGreece

Personalised recommendations