Abstract
Although the echocardiographic effective orifice area (EOA) calculated using the continuity equation is widely used for the assessment of severity in aortic stenosis (AS), the existence of high flow velocity at the left ventricular outflow tract (LVOT) potentially causes its overestimation. The proximal isovelocity surface area (PISA) method could be an alternative tool for the estimation of EOA that limits the influence of upstream flow velocity. EOA was calculated using the continuity equation (EOACont) and PISA method (EOAPISA), respectively, in 114 patients with at least moderate AS. The geometric orifice area (GOA) was also measured using the planimetry method in 51 patients who also underwent three-dimensional transesophageal echocardiography. Patients were divided into two groups according to the median LVOT flow velocity. EOAPISA could be obtained in 108 of the 114 patients (95%). Although there was a strong correlation between EOACont and EOAPISA (r = 0.78, P < 0.001), EOACont was statistically significantly larger than EOAPISA (0.86 ± 0.33 vs 0.75 ± 0.29 cm2, P < 0.001). Both EOACont and EOAPISA similarly correlated with GOA (r = 0.70, P < 0.001 and r = 0.77, P < 0.001, respectively). However, a fixed bias, which is hydrodynamically supposed to exist between EOA and GOA, was not observed between EOACont and GOA. In contrast, there was a negative fixed bias between EOAPISA and GOA with smaller EOAPISA than GOA. The difference between EOACont and GOA was significantly greater with a larger EOACont relative to GOA in patients with high LVOT flow velocity than in those without (0.16 ± 0.25 vs − 0.07 ± 0.10 cm2, P < 0.001). In contrast, the difference between EOAPISA and GOA was consistent regardless of the LVOT flow velocity (− 0.07 ± 0.12 vs − 0.07 ± 0.15 cm2, P = 0.936). The PISA method was applied to estimate EOA in patients with AS. EOAPISA could be an alternative parameter for AS severity grading in patients with high LVOT flow velocity in whom EOACont would potentially overestimate the orifice area.
Similar content being viewed by others
References
Carabello BA, Paulus WJ (2009) Aortic stenosis. The Lancet 373:956–966
Carabello BA (2002) Clinical practice. Aortic stenosis. N Engl J Med 346:677–682
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
Koto D, Izumo M, Machida T, Suzuki K, Yoneyama K, Suzuki T, Kamijima R, Kobayashi Y, Harada T, Akashi YJ (2018) Geometry of the left ventricular outflow tract assessed by 3D TEE in patients with aortic stenosis: impact of upper septal hypertrophy on measurements of Doppler-derived left ventricular stroke volume. J Echocardiogr 16:162–172
Garcia J, Kadem L, Larose E, Clavel MA, Pibarot P (2011) Comparison between cardiovascular magnetic resonance and transthoracic Doppler echocardiography for the estimation of effective orifice area in aortic stenosis. J Cardiovasc Magn Reson 13:25
Diaz T, Pencina MJ, Benjamin EJ, Aragam J, Fuller DL, Pencina KM, Levy D, Vasan RS (2009) Prevalence, clinical correlates, and prognosis of discrete upper septal thickening on echocardiography: the Framingham Heart Study. Echocardiography 26:247–253
Xie GY, Berk MR, Hixson CS, Smith AC, DeMaria AN, Smith MD (1995) Quantification of mitral regurgitant volume by the color Doppler proximal isovelocity surface area method: a clinical study. J Am Soc Echocardiogr 8:48–54
Rifkin RD, Harper K, Tighe D (1995) Comparison of proximal isovelocity surface area method with pressure half-time and planimetry in evaluation of mitral stenosis. J Am Coll Cardiol 26:458–465
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28:1-39 e14
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD (2014) 2014 AHA/ACC guideline 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. J Am Coll Cardiol 63:e57-185
Bargiggia GS, Tronconi L, Sahn DJ, Recusani F, Raisaro A, De Servi S, Valdes-Cruz LM, Montemartini C (1991) A new method for quantitation of mitral regurgitation based on color flow Doppler imaging of flow convergence proximal to regurgitant orifice. Circulation 84:1481–1489
Shiota T, Jones M, Agler DA, McDonald RW, Marcella CP, Qin JX, Zetts AD, Greenberg NL, Cardon LA, Sun JP, Sahn DJ, Thomas JD (1999) New echocardiographic windows for quantitative determination of aortic regurgitation volume using color Doppler flow convergence and vena contracta. Am J Cardiol 83:1064–1068
Rivera JM, Vandervoort PM, Mele D, Siu S, Morris E, Weyman AE, Thomas JD (1994) Quantification of tricuspid regurgitation by means of the proximal flow convergence method: a clinical study. Am Heart J 127:1354–1362
Messika-Zeitoun D (2003) Sequential assessment of mitral valve area during diastole using colour M-mode flow convergence analysis: new insights into mitral stenosis physiology. Eur Heart J 24:1244–1253
Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, Hahn RT, Han Y, Hung J, Lang RM, Little SH, Shah DJ, Shernan S, Thavendiranathan P, Thomas JD, Weissman NJ (2017) Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American society of echocardiography developed in collaboration with the society for cardiovascular magnetic resonance. J Am Soc Echocardiogr 30:303–371
Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, Iung B, Otto CM, Pellikka PA, Quinones M, American Society of E, European Association of E (2009) Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 22:1–23
deFilippi CR, Willett DL, Brickner ME, Appleton CP, Yancy CW, Eichhorn EJ, Grayburn PA (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 75:191–194
Haugen BO, Berg S, Brecke KM, Torp H, Slordahl SA, Skaerpe T, Samstad SO (2002) Blood flow velocity profiles in the aortic annulus: a 3-dimensional freehand color flow Doppler imaging study. J Am Soc Echocardiogr 15:328–333
Jainandunsing JS, Mahmood F, Matyal R, Shakil O, Hess PE, Lee J, Panzica PJ, Khabbaz KR (2013) Impact of three-dimensional echocardiography on classification of the severity of aortic stenosis. Ann Thorac Surg 96:1343–1348
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
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
Saitoh T, Shiota M, Izumo M, Gurudevan SV, Tolstrup K, Siegel RJ, Shiota T (2012) Comparison of left ventricular outflow geometry and aortic valve area in patients with aortic stenosis by 2-dimensional versus 3-dimensional echocardiography. Am J Cardiol 109:1626–1631
Kamperidis V, van Rosendael PJ, Katsanos S, van der Kley F, Regeer M, Al Amri I, Sianos G, Marsan NA, Delgado V, Bax JJ (2015) Low gradient severe aortic stenosis with preserved ejection fraction: reclassification of severity by fusion of Doppler and computed tomographic data. Eur Heart J 36:2087–2096
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 Imaging 8:248–257
Zhou YQ, Abassi I, Faerestrand S (1996) Flow velocity distributions in the left ventricular outflow tract and in the aortic annulus in patients with localized basal septal hypertrophy. Eur Heart J 17:1404–1412
Pibarot P, Clavel MA (2015) Left ventricular outflow tract geometry and dynamics in aortic stenosis: implications for the echocardiographic assessment of aortic valve area. J Am Soc Echocardiogr 28:1267–1269
Nabeshima Y, Nagata Y, Negishi K, Seo Y, Ishizu T, Sato K, Aonuma K, Koto D, Izumo M, Akashi YJ, Yamashita E, Oshima S, Otsuji Y, Takeuchi M (2018) Direct comparison of severity grading assessed by two-dimensional, three-dimensional, and Doppler echocardiography for predicting prognosis in asymptomatic aortic stenosis. J Am Soc Echocardiogr 31:1080-1090 e1083
Sato K, Seo Y, Ishizu T, Nakajima H, Takeuchi M, Izumo M, Suzuki K, Akashi YJ, Otsuji Y, Aonuma K (2016) Reliability of aortic stenosis severity classified by 3-dimensional echocardiography in the prediction of cardiovascular events. Am J Cardiol 118:410–417
Gilon D, Cape EG, Handschumacher MD, Song J-K, Solheim J, VanAuker M, King MEE, Levine RA (2002) Effect of three-dimensional valve shape on the hemodynamics of aortic stenosis. J Am Coll Cardiol 40:1479–1486
Acknowledgements
None.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
None of the authors have any conflicts of interest associated with this study.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Nakabachi, M., Iwano, H., Murayama, M. et al. Application of the proximal isovelocity surface area method for estimation of the effective orifice area in aortic stenosis. Heart Vessels 37, 638–646 (2022). https://doi.org/10.1007/s00380-021-01945-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00380-021-01945-5