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You are on page 1of 10

Physiology—What Do the

Numbers Really Mean?

Arthur E. Weyman, MD, Marielle Scherrer-Crosbie, MD, PhD

Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA

Cardiac catheterization and Doppler echocardiography are two methods used to meas-

ure transvalvular gradients and valve area in the assessment of aortic stenosis severity.

Although both approaches are based on the same hemodynamic concepts and report

data using the same units of measure, each method measures pressure drop or gradient

at a different place; hence they produce fundamentally different quantities. Likewise,

cardiac catheterization formulas for valve area attempt to obtain the anatomic area

whereas the Doppler continuity equation reports the area to which flow is constricted.

To use these two methods appropriately, it is necessary to understand the underlying

hemodynamic principles and the effects of the methods of measurement on the values

obtained. This article examines these variables and shows how they affect the reported

gradients and valve areas and how differences can affect clinical application.

[Rev Cardiovasc Med. 2005;6(1)23-32]

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© 2005 MedReviews, LLC POWERPOINT FIGURES @

www.medreviews.com

• Pressure gradients • Valve area

A

ssessment of the severity of aortic stenosis depends on measurement of

the transvalvular gradients and valve area. Historically these parameters

were determined by cardiac catheterization based on direct measurement

of pressures in the left ventricle and aorta and estimation of transvalvular flow

using the Fick, dye dilution, or thermodilution method. At present, however, gra-

dients and valve areas are generally determined using noninvasive Doppler

echocardiographic methods. Although both of these approaches derive from

Aortic Stenosis continued

report their results in the same units

of measure, the catheter and Doppler

measurements of pressure drop or

gradient are not made at the same Cc = Effective orifice area

place and therefore are fundamen- Anatomic area

tally different quantities. Likewise,

catheterization formulas for valve

area attempt to derive the anatomic Flow

area whereas the Doppler continuity

equation reports the area to which Ao LV

flow is constricted or the effective

valve area. The effect of these differ-

ences is exaggerated because impor- Effective Area

tant changes in the classification of

Anatomic Area

severity are based on differences in

valve areas of only tenths of a square

centimeter. This is further complicat-

ed by the fact that although clinical Figure 1. The convergence of flow distal to a stenotic valve orifice produces an effective orifice or area to which

flow is constricted. The ratio of the effective area to the anatomic area is the coefficient of contraction (Cc). The

decisions are now commonly made

Cc is determined by the valve shape and the orifice size and shape. Ao, aorta; LV, left ventricle. Reproduced with

based on Doppler echocardiographic permission from Gilon et al.16 www.medreviews.com

data, criteria for severity are based on

more traditional catheterization data

in which outcomes have been more of gradients and valve areas, it is first called the coefficient of contraction

extensively studied.1 The appropriate necessary to appreciate the hydrody- (Figure 1). This ratio is affected by

use of these frequently differing data namic pattern of flow through a the size and shape of the orifice and

therefore depends on an understand- stenosis. In any closed system, the by the inlet geometry. To determine

ing of the underlying hemodynamic law of conservation of mass requires the anatomic orifice size, some cor-

principles and effects of the methods the volume flow to be constant at rection must be introduced to

of measurement on the resulting val- all points. Because flow equals the account for this coefficient of con-

ues. The purpose of this review is to product of mean velocity and vessel traction, which is unknown in most

examine these variables and to show area, as the area of the flow stream cases. Such calculations are facilita-

how they affect the reported gradi- decreases as blood approaches a ted by a term used in engineering,

ents and valve areas and how differ- stenosis, the velocity must increase the coefficient of discharge, which

ences can affect clinical application. proportionately in order to maintain compares the actual flow through

Although differences between constant flow. As flow exits the the valve with the predicted flow if

Doppler echocardiographic and stenotic orifice, the streamlines con- no contraction or viscous losses

catheterization data are often a result tinue to converge for a short dis- occur.2 The coefficient of discharge is

of technical errors in data acquisition, tance (the vena contracta effect) specific for an individual valve shape

inherent errors in the component because inertia prevents the periph- and size and converts the effective

methods, or simply differences in the eral streamlines entering the steno- area to the anatomic area.

parameter measured (eg, the differ- tic orifice from the side from Distal to the stenosis, there is an

ence between peak instantaneous and changing directions instantly. By the abrupt separation of the jet from the

peak-to-peak gradients), for the pur- time the flow lines have again vessel wall, resulting in the jet shear-

poses of this review, we assume that become parallel, the cross-sectional ing against the stagnant blood in the

all the data are appropriately recorded area of the jet will be smaller than sinuses of Valsalva, causing vortex

and instantaneously compared. the orifice area and the velocity of formation and a zone of recirculation

the jet will be proportionately higher. (Figure 2). The abrupt change in ves-

Characteristics of Flow The ratio of the jet area at the vena sel diameter (orifice diameter to aor-

Through Stenotic Valves contracta (the area to which flow is tic diameter) suddenly increases the

To understand the differences in constricted or effective orifice area ratio of kinetic to viscous forces, rep-

catheter and Doppler measurements [Aeff]) to the anatomic area (Aanat) is resented by the Reynolds number, up

Aortic Stenosis

pressure) must decrease to maintain

total energy constant. In pulsatile

systems, additional energy may be

required to overcome inertia and

accelerate blood to its peak velocity.

Energy may also be lost as heat as a

result of viscous friction. These rela-

tionships can be expressed mathe-

matically using the Bernoulli

equation,

P = 1 (22 – 21) + ∫ 2

1

dv ds + R(, )

2 dt

Eq.1

pressures proximal and distal to the

stenosis, 1 and 2 are the velocities

proximal to the stenosis and at the

vena contracta, s is the distance over

which flow accelerates, R is viscous

resistance, is the mass density of

blood, and is the viscosity. The

first term in the equation accounts

for convective acceleration of flow

through the stenosis, the second

Orifice Flow term for flow acceleration, and the

third for viscous friction. In the clin-

ical situation, viscous friction has

been shown to be negligible for dis-

crete orifices ≥ 0.25 cm2, because

blood velocity is approximately con-

stant across the orifice, and as a

result, there is no frictional loss

Laminar core

between adjacent fluid layers. In

Turbulent eddies

addition, although the need for flow

Figure 2. Flow visualization study illustrating the pattern of flow distal to a stenosis. Immediately beyond the to accelerate from zero delays the

orifice, the jet shears against the stagnant blood in the parajet region, causing turbulent eddies that erode the velocity waveform slightly relative

laminar core, resulting in the loss of energy as heat. Reproduced with permission from Levine et al.7

to the pressure waveform, it does not

www.medreviews.com

significantly alter the calculation of

the peak gradient (because at peak

to fivefold. The Reynolds number valvular pressure drop or gradient is velocity, dv/dt [acceleration] = 0).

(Re = blood density velocity x vessel based on the law of conservation of The mean gradient is also unaffected

diameter/blood viscosity) is a meas- energy, which states that for flow in because the lag in velocity is rough-

ure of the tendency of the blood to a closed system, the total energy at ly symmetric during acceleration

become turbulent, and this abrupt all points must remain constant. and deceleration. At other points in

increase is associated with flow insta- Because the linear velocity in cen- the cardiac cycle, the acceleration

bility and turbulence. In this turbu- timeters per second through a term produces small discrepancies

lent zone, kinetic energy is lost as stenotic valve must increase as the between pressure gradient and

heat that is nonrecoverable. valve area decreases (law of conser- velocity, but these are not clinically

vation of mass), its kinetic energy, important. Because the viscous fric-

Pressure Gradients which is proportional to the square tion and flow acceleration terms are

Doppler measurement of the trans- of the linear velocity, increases. As a negligible,3,4 they can be ignored,

Aortic Stenosis continued

and equation 1 simplifies to kinetic energy is reconverted to pres- Doppler and catheter measurements

P = 1 (22 – 21) sure. It is this downstream loss of of pressure occur at different places,

2

Eq. 2 energy that is the important effect of they measure fundamentally differ-

the stenosis, because if velocity were ent quantities and may report signifi-

In addition, in most stenotic simply reconverted to pressure (pres- cantly different results when pressure

lesions, 22 >> 12, so that v1 can be sure recovery), there would be no recovery is present.

ignored, and the pressure gradient energy loss to the system and the

after correction for different units stenosis would have no significant Pressure Recovery

= 1.06/981 g s2/mL x 1/1.36 (to con- hemodynamic effect. This lack of Although clinical studies comparing

vert dyne centimeters to millimeters effect would occur despite the fact Doppler and catheter gradients gen-

of mercury [mm Hg]) x 1/2 , which that Doppler would record an erally show excellent correlations,

after appropriate conversion of increase in velocity at the stenosis the slopes of the regression lines

measurement units (x 104) = 3.972, and pressure taps proximal to the often differ significantly, with the

or roughly 4, so that stenosis and at the vena contracta Doppler gradients frequently over-

AP = 42

Eq. 3 It is this downstream loss of energy that is the important effect of the

The simplified Bernoulli equation stenosis, because if velocity were simply reconverted to pressure (pressure

permits calculation of the trans- recovery), there would be no energy loss to the system and the stenosis

valvular gradient at each instant in would have no significant hemodynamic effect.

systole; however, two measures of

transvalvular pressure gradient are would register a corresponding fall in estimating those reported at

usually reported from Doppler aor- pressure. In practice, the conversion catheterization. Some of this overes-

tic velocity profiles: the peak gradi- of kinetic energy to heat is not always timation has been attributed to fail-

ent and the mean gradient. The complete and some pressure can be ure to account for the proximal

peak gradient is determined from recovered (see below). velocity in the Bernoulli equation in

the peak velocity, whereas the mean high-flow states. However, a num-

gradient is the mean of the squared Catheter Measures of ber of experimental studies have

instantaneous velocities recorded Transvalvular Gradients demonstrated that as the stream-

during the systolic ejection period. Experimental studies comparing lines of flow reattach to a vessel wall

It is important to remember that Doppler gradients measured using downstream from a stenosis, some

continuous-wave Doppler measures the peak velocity at the vena contrac- of the momentum in the jet is

the change in velocity from a point ta with catheter values obtained by reconverted to lateral or pressure

energy, a phenomenon known as

A number of experimental studies have demonstrated that as the stream- pressure recovery.5-7 Because the

lines of flow reattach to a vessel wall downstream from a stenosis, some energy loss in aortic stenosis is the

result of flow separation and vortex

of the momentum in the jet is reconverted to lateral or pressure energy,

formation (turbulence), the extent

a phenomenon known as pressure recovery. of this phenomenon depends on

the size relationship between the

proximal to the onset of convective positioning a catheter at the level of orifice and aorta.5,6,8 The smaller the

acceleration toward the stenosis to the vena contracta have uniformly valve orifice relative to the size of

the peak velocity at the vena contrac- reported slopes close to unity. In clin- the aorta, the more turbulence will

ta. A critical but unstated assumption ical practice, however, it is very diffi- occur, and because turbulence

in using this increase in velocity as a cult to position a catheter in the vena results in the conversion of kinetic

measure of the pressure gradient contracta because it cannot be seen energy to heat that is nonrecover-

across the valve is that all of the pres- and the jet itself tends to displace the able, less energy will be available to

sure that is converted to kinetic ener- catheter. As a result, catheter pres- be recovered as pressure. Conversely,

gy (velocity) is then lost as heat in the sures are usually recorded in the the larger the valve orifice or the

turbulent eddies downstream from ascending aorta after pressure recov- smaller the aorta, the less turbulence

the stenosis and that none of the ery has occurred. Because clinical will occur and the greater the

Aortic Stenosis

distance required for maximal pres- 200 125

Peak Doppler Gradient (mm Hg)

sure recovery varies with orifice size

and aortic diameter, the majority of 100

150

the pressure is usually recovered

75

within a few centimeters (~5 cm)

100

beyond the vena contracta.5,6

Aorta 1.8 50 Aorta 1.8

When pressure recovery occurs, Aorta 2.4 Aorta 2.4

the actual pressure loss to the sys- 50 Aorta 3.0 Aorta 3.0

25

tem, termed the head loss, will be Aorta 4.0 Aorta 4.0

Aorta 5.0 Aorta 5.0

less than that reflected by the

0 0

increase in kinetic energy at the 0 50 100 150 200 0 25 50 75 100 125

vena contracta, and the pressure Peak Catheter Gradient (mm Hg) Mean Catheter Gradient (mm Hg)

gradient between the left ventricle

and aorta (the net pressure gradient) Figure 3. Effect of aortic size on the correlation between peak Doppler and catheter gradients (left) and mean

Doppler and mean catheter gradients (right) for a valve area of 1.25 cm2 with aortas 1.8, 2.4, 3.0, 4.0, and 5.0 cm

will be less than the gradient in diameter. Slopes vary from 1.1 to 1.86. Reproduced with permission from Niederberger et al.8

between the left ventricle and the www.medreviews.com

vena contracta. Figure 3 compares

the effects of aortic size on the cor- 200 150

relations between peak and mean

Peak Doppler Gradient (mm Hg)

150

1.25 cm2 orifice with aortas of vary-

100

ing diameters. As illustrated, the

smallest aortic diameters were asso- 100

ciated with the greatest discrepan-

cies between the Doppler and AVA 1.25 50 AVA 1.25

50 AVA 1.0 AVA 1.0

catheter gradients. Figure 4 illus-

AVA 0.75 AVA 0.75

trates the effect of valve area on AVA 0.5

AVA 0.5

pressure recovery for a fixed aortic 0 0

0 50 100 150 0 25 50 75 100 125

size. As predicted, the larger the ori-

Peak Catheter Gradient (mm Hg) Mean Catheter Gradient (mm Hg)

fice, the greater the amount of pres-

sure recovery. In small clinical

Figure 4. Effect of orifice size on the correlations between peak Doppler and peak catheter gradients (left) and

studies, an increase in peak down- between mean Doppler and mean catheter gradients (right) for an aorta with a 1.8 cm diameter and 0.5, 0.75,

stream pressure of between 4 and 82 1.0, and 1.25 cm2 orifices. Slopes range from 1.28 to 1.86. AVA, aortic valve area. Reproduced with permission

from Niederberger et al.8 www.medreviews.com

mm Hg has been reported. In

patients with aortas larger than 3

cm, only small differences in correction factor is given as peak and mean catheter gradients in

catheter and Doppler gradients were a group of patients with valvular aor-

P = 4V (1 – C)

2

observed (peak, 7.3 ± 8.7 mm Hg; with tic stenosis. Using this correction

mean, 2.6 ± 6.1 mm Hg), whereas in decreased the slopes of the peak and

C = 2[(Aeff /AA) – Aeff2 /AA2 ],

the subgroup with aortas ≥ 3 cm, Eq. 4 mean Doppler gradients from 1.36

greater degrees of pressure recovery and 1.25, respectively, for the peak

were observed (peak, 24.8 ± 19.7 where Aeff is the vena contracta area and mean uncorrected values to 1.03

mm Hg; mean, 16.2 ± 13.2 mm Hg).9 and AA is the area of the aorta. The and 0.96 for the corrected Doppler

On the basis of fluid mechanics calculated Aeff assumes a circular ori- values when compared with catheter-

theory, the Doppler-predicted pres- fice, which is appropriate given that derived gradients.

sure drop can be corrected for the pressure recovery is not affected by For any given valve area and aortic

size of the aorta in order to derive the shape of the orifice.10 Figure 5 diameter, the orifice velocity and

the actual pressure drop (head loss) compares peak and mean Doppler therefore the gradient will depend on

or net pressure gradient after pres- gradients with the Doppler gradients the flow rate. The absolute amount

sure recovery. This area-based predicted using equation 4 with the of pressure recovery increases

Aortic Stenosis continued

200 150

immediately reattach to the vessel

Peak Catheter Gradient (mm Hg)

SEE = 6 mmHg SEE = 3 mmHg wall and the head loss is only 15%

150 r = 0.99 r = 0.99 (pressure recovery 85%).

Doppler Predicted

Doppler Predicted

100

ery occurs, the head loss (which is

the loss of energy to the system and

50 is measured at catheterization where

50 the gradient after pressure recovery is

Line of Identity Line of Identity

recorded) is the appropriate measure

0 0 of energy loss to the system and

0 50 100 150 200 0 50 100 150

determines the left ventricular pres-

Peak Catheter Gradient (mm Hg) Mean Catheter Gradient (mm Hg)

sure required to maintain a given

aortic pressure. However, the

Figure 5. Correlation between Doppler-predicted catheter gradients (Doppler gradient minus predicted pressure Doppler gradient, which measures

recovery) and observed catheter gradients for central jets (left, peak gradients; right, mean gradients). The dashed line

represents the line of identity. SEE, standard error of estimate. Reproduced with permission from Niederberger et al.8 the conversion of pressure to kinetic

www.medreviews.com energy induced by the stenosis, is the

appropriate gradient to use to calcu-

with flow rate (orifice velocity). The pressure gradient (catheter after pres-

sure recovery) may differ significant- late the effective orifice area.

percent overestimation, however,

remains approximately the same and ly and therefore affect management,

particularly when the gradients are Valve Area Determination

therefore is independent of flow.

used to calculate valve area. Because the pressure drop or gradi-

Jet eccentricity also affects pressure

In addition to the ratio of the ent across a stenotic valve varies

recovery, with more eccentric jets

stenotic orifice to the aorta, both with flow, it has become common

showing decreasing Doppler-catheter

the inlet and outlet geometry of the practice to calculate the valve area,

differences (less pressure recovery

stenosis importantly affect the which is a flow-independent meas-

because momentum is lost when the

amount of pressure recovery and thus ure of severity.

jet strikes the vessel wall). In this

case, the correction factor described the relationship between the catheter-

Doppler Echocardiographic Estimation

above is no longer applicable. and Doppler-measured gradients.

of Valve Area: the Effective Valve Area

Clinically, pressure recovery is Valvular stenoses are usually discrete,

The calculation of the aortic valve

most relevant in patients with mod- with abrupt narrowing and expan-

area from Doppler recordings is

erate aortic stenosis, small aortas, sion, and although pressure recovery

based on the law of conservation

and high flow rates. In these cases, is present, it is usually not great. For

of mass, which states that for an

the maximal pressure drop at the more tapering stenoses—such as

incompressible fluid in a closed sys-

vena contracta (Doppler) and net those that often characterize sub-

tem, flow (Q) at all points must

valvular7 and supravalvular obstruc-

Figure 6. Pressure recovery-flow through a Venturi tube. remain constant. As illustrated in

The solid line gives the pressure distribution along the tion and coarctation—the shape of

center line; the dashed curve gives the pressure distribu- the outlet becomes more important

tion along the wall. A, tube area upstream from the Figure 7. Calculation of aortic valve area using the

stenosis; a, stenosis area at the vena contracta; po , pres- than the simple orifice diameter to continuity principle. Aortic outflow is calculated as

the product of the subvalvular area A1 and velocity

sure proximal to the stenosis; p, pressure at the vena downstream vessel diameter ratio,

contracta. Reproduced with permission from Prandt V1. The stenotic valve area is then equal to A1 x V1

and Teitjens.17

and pressure recovery may cause a divided by the peak transvalvular velocity V2. LA, left

greater disparity between Doppler- atrium; Ao, aorta; LV, left ventricle.

and catheter-measured gradients than

would be predicted simply for the ori-

A a

fice aortic ratio. Figure 6 illustrates A2•V2

Ao

p this effect for a Venturi tube with a

Po A1•V1

gradually tapering outlet, which per- LV

po – p 0.15 (po – p) mits almost immediate reattachment LA

of the flow streamlines to the vessel

wall. In this example, although there

www.medreviews.com is a significant pressure loss at the www.medreviews.com

Aortic Stenosis

Figure 7, the flow through the out- and V2 are used, it can be assumed Thus, substituting (1 mm Hg = 1333

flow tract must be the same as the that the maximal A2 is calculated dyne/cm2) and = 1.05 g/mL gives

flow through the valve (Q1 = Q2) at because the gradient is greatest at

V = (2*1.333P/1.05)1/2 =

any point in time. In addition, this point, forcing the valve to open

(2,539P)1/2 = 50.4 P

because flow equals mean velocity maximally. Conversely, using the

Eq. 7

times area at any point, mean velocity will give the average

area occurring throughout systole. and

Q1 = Q2 = A1 *V1 = A2 V2

Eq. 5 One may also use the instantaneous Aeff = Q

velocities throughout systole to cal- 50.4 P

If flow through the valve is Eq. 8

culate the instantaneous valve areas

known or can be determined from and thereby detect any flow-related This equation calculates the effective

the product of area and velocity at a changes. orifice area and yields the same result

reference level, and the velocity at Because the peak Doppler velocity as the Doppler continuity equation.

the stenosis can be recorded, then is the velocity at the vena contracta, Because the effective orifice area, or

the area at the point of stenosis can the calculated valve area will be the the area to which flow is constricted,

be calculated as follows: smallest area to which the flow is related to the anatomic area of the

A2 = A1 *V1 stream is reduced, which will be valve by the coefficient of discharge:

V2 equal to the anatomic area reduced

Eq. 6 Aeff = Aanat •CD

by the coefficient of discharge. The

or

where V2 is the velocity and A2 the effective area is the appropriate

Aanat = Aeff

area at the vena contracta and V1 hydrodynamic area, but should be CD

Eq. 9

The impact of a stenosis on pressure and flow depends not only on the The Gorlin Equation

cross-sectional area of the orifice but also on the three-dimensional The first clinical application of these

geometry of the leaflets proximal to the orifice. concepts was by Gorlin and Gorlin

in 1951.11 In their original formula,

and A1 are the velocity in the out- smaller than the area calculated at they included a constant to account

flow tract proximal to the onset of catheterization using the Gorlin for- for the coefficient of contraction

convective acceleration. Because mula, which includes a constant to and thereby attempted to correct

both V1 and V2 increase proportion- account for the coefficient of dis- the flow area to the anatomic area,

ately with increasing flow, the calcu- charge and thus attempts to convert given that their standard of refer-

lated area should be independent of hydrodynamic area to anatomic area. ence was excised valves. Thus,

flow. When flow through the out- Aanat = Q

flow tract is used as a reference, it Calculation of Valve Area at C • 44.3 P

includes both forward and aortic Catheterization Eq. 10

regurgitant flow so that the valve Theoretical Background

areas calculated using the continuity Valve area can also be calculated where 44.3 = 2 • 981. The empiric

equation will be accurate whether using the pressure drop or gradient constant C in the original formula-

aortic regurgitation is present or not. across the valve. To do this requires tion included the coefficients of

The continuity equation is instan- use of both the continuity and contraction Cc and viscosity Cv as

taneously valid so that the velocity Bernoulli equations, where well as correction for the conversion

used in the equation may be either Q = Aeff *V of centimeters of water (cm H2O) to

the stroke velocity integral or the and mm Hg. Recognizing that blood vis-

peak velocity (assuming that the P = 1V2. cosity, turbulence, pulsatile flow,

2

valve area does not change). If the and the inconstant shape of

orifice is elastic and varies because of Solving for V gives deformed valves made it almost

changes in the gradient across the impossible to predict the discharge

V = Q/Aeff and V = (2P/)1/2.

obstruction during pulsatile flow, coefficient analytically, they deter-

the size of the valve area calculated In this equation, P is in metric mined an empiric coefficient from

by equation 6 will depend on when units (dyne/cm2), whereas clinically direct measurement of mitral valves

V1 and V2 are determined. If peak V1 it is usually expressed in mm Hg. at surgery or autopsy. For the mitral

Aortic Stenosis continued

Discharge coefficient itself should not cause these

changes, they have been attributed

to the viscosity,13 because for an

0.85 eccentric jet, the jet perimeter—

where viscous losses occur—is larger

relative to the cross-sectional area

0.80 than for a circular jet. Likewise, for a

small jet, the perimeter-to-area ratio

is greater than for a large jet.

0.75 The shape of the valve inlet also

affects the coefficient of discharge.13

Figure 9 illustrates the relationship of

0.70 valve shape to coefficient of contrac-

1:1 tion as a function of valve area

2:1

3:1 derived from three-dimensional mod-

0.65 5:1 ECC els of clinical echocardiographically

0.3 0.5 1 1.5 2 2.5

imaged aortic valves. As illustrated,

Area [cm2] the impact of a stenosis on pressure

and flow depends not only on the

Figure 8. Influence of valve area and eccentricity (ECC) on discharge coefficients. The discharge coefficient for each

area decreases with higher eccentricity; for each eccentricity, the discharge increases as area increases. Reproduced cross-sectional area of the orifice but

with permission from Flachskampf et al.13 www.medreviews.com also on the three-dimensional geome-

try of the leaflets proximal to the ori-

valve, they concluded that the mean pressure gradient in the Gorlin fice. The geometry determines the

anatomic valve area equals formula instead of the mathemati- pattern of flow convergence and thus

cally correct mean of the square the relationship of Aeff to Aeff. Patients

Aanat = Q/31 P1 – P2 with flat valves and steeper flow con-

roots of the instantaneous gradients,

Eq. 11 which systematically underestimates vergence have smaller Aeff than those

the valve area and results in a value with more gradually tapered domed

which corresponds to a discharge valves for the same anatomic area and

closer to the physiologic area.12,13

coefficient of roughly 0.62. flow rate. Corresponding pressure

Thus the Gorlin formula actually

For the aortic valve, they used the losses may be increased by up to 40%,

calculates the flow area (Aeff) offset by

constant C = 1, which results in increasing the ventricular workload

a small constant and will correspond

Aanat = Q to the anatomic area only by chance proportionately. Theoretically, hemo-

44.3 P (ie, when the empiric coefficient of dynamic severity may increase

Eq. 12

discharge happens to be appropriate because of changes in valve shape

Use of the constant 44.3 ignores the for the valve in question). without change in orifice area, as with

conversion of cm H2O to mm Hg Does the Gorlin constant bear a the progressive calcification of a bicus-

and the mass density of blood but consistent relationship with the pid valve.

differs from equation 6 only in the anatomic area? Recent studies have

constant (50.4 vs 44.3). Because shown that the true coefficient of

anatomic area can in theory be cal- discharge is not constant but rather Effects of Pressure Recovery

culated as varies with valve orifice size and on Valve Area Measurements

Aanat = Q/(CD50.4 P) shape, but, importantly, is inde- Pressure recovery also affects the

pendent of flow, except at very low measurement of valve area at

Eq. 13

flow rates.13 The discharge coeffi- catheterization because the net pres-

the Gorlin constant corresponds to cient increases with increasing valve sure gradient (measured between the

CD*50.4, which implies a discharge area and decreases with increasing left ventricle and aorta after pressure

coefficient of 0.879. eccentricity. Figure 8 illustrates the recovery) is smaller than the gradient

This correction is partially offset combined effects of orifice area and at the vena contracta, therefore

by the use of the square root of the eccentricity on the discharge coeffi- resulting in a larger calculated valve

Aortic Stenosis

the net gradient does not correspond

to either the effective or anatomic Domed Intermediate Flattened

valve area but rather represents the

area that would have occurred had

there been no pressure recovery: a

theoretic value, but one that reflects Anatomic Area

the hydrodynamic impact of the

stenosis. Use of the net gradient fur-

ther increases the difference between 1.0 cm2 0.9 0.85 0.76

Doppler measures of the effective

valve area and the area calculated at

catheterization.

Because the amount of pressure 0.75 cm2 0.88 0.83 0.74

recovery is determined by the ratio

of the orifice area to the aortic area,

a correction factor has been pro-

posed to correct the Doppler conti- 0.5 cm2 0.85 0.81 0.71

nuity valve area for the effect of

pressure recovery.14 Using this cor- Figure 9. Coefficients of contraction according to valve shape and orifice size. Reproduced with permission from

Gilon et al.16 www.medreviews.com

rection, Doppler Aeff is multiplied by

Aa /Aa – Aeff = 1 + Aeff /Aa – Aeff

Cardiology guidelines.1 Further, larger than that measured using

where Aa is the area of the ascending although Aeff and CD • Aanat are meas- Doppler echocardiography when

aorta. As can be appreciated from ures of the severity of stenosis, Aanat these data are accurately recorded

this equation, in patients with tight is not because the hemodynamic and simultaneously compared, even

aortic stenosis in which the Aeff is severity of stenosis may increase in the absence of pressure recovery.

much smaller than the ascending with no change in the anatomic When pressure recovery is present,

aortic area, there will be little differ- area, as a result of progressive dila- this difference will increase and may

ence between the actual and cor- tion of the aorta with a correspon- result in significant misclassification

rected Aeff. Table 1 illustrates the ding decrease in pressure recovery. of severity. Understanding these dif-

relationship between the Gorlin- ferences allows appropriate correc-

derived effective areas and the Summary tions to be introduced and the total

Doppler areas for a series of aortic The area of a stenotic aortic valve effect of the stenosis on the system to

diameters.14 Relating these changes calculated using standard hemody- be appreciated. Alternatively, more

to current criteria for severity, it can namic methods will be consistently conservative standards may be more

be shown that a patient with an

ascending aortic diameter of 2.6 cm

and a Doppler Aeff of 0.9 cm2 would Table 1

have a valve area of 1.1 cm2 after Doppler-Derived Effective Orifice Area (EOA)

correcting for pressure recovery.1,15

This effect would be greater for a

Catheter- Catheter- Aortic Aortic Aortic

patient with the same aortic diame- Derived Diameter Diameter Diameter Derived

ter and a Doppler Aeff of 1.2 cm2, in EOA (cm2) EOA (cm2) = 2.0 cm (Area = 3.0 cm (Area = 4.0 cm (Area

which the corrected area would cor- (Constant 50) (Constant 44.3) = 3.14 cm2) = 7.07 cm2) = 12.6 cm2)

respond to a recovered catheter- 1.50 1.69 1.02 1.24 1.34

derived area of 1.6 cm2.15 In both of 1.00 1.13 0.76 0.88 0.93

these cases, the change would shift 0.75 0.85 0.61 0.68 0.71

the patient to a lower grade of sever- 0.50 0.56 0.43 0.47 0.48

ity based on current American Heart Adapted from Garcia et al.14

Association/American College of

Aortic Stenosis continued

appropriate for estimating severity 5. Clark C. The fluid mechanics of aortic steno- 12. Dumesnil JG, Yoganathan AP. Theoretical and

sis—I. Theory and steady flow experiments. J practical differences between the Gorlin for-

using Doppler echocardiographic Biomech. 1976;9:521-528. mula and the continuity equation for calcu-

data than those currently recom- 6. Clark C. The fluid mechanics of aortic steno- lating aortic and mitral valve areas. Am J

sis—II. Unsteady flow experiments. J Biomech. Cardiol. 1991;67:1268-1272.

mended for catheterization values. 1976;9:567-573. 13. Flachskampf FA, Weyman AE, Guerrero JL,

7. Levine RA, Jimoh A, Cape EG, et al. Pressure Thomas JD. Influence of orifice geometry

recovery distal to a stenosis: potential cause of and flow rate on effective valve area: an in

References gradient “overestimation” by Doppler echocar- vitro study. J Am Coll Cardiol. 1990;15:

1. Bonow RO, Carabello B, de Leon AC, et al. diography. J Am Coll Cardiol. 1989;13:706-715. 1173-1180.

ACC/AHA guidelines for the management of 8. Niederberger J, Schima H, Maurer G, 14. Garcia D, Dumesnil JG, Durand LG, et al.

patients with valvular heart disease. Executive Baumgartner H. Importance of pressure recov- Discrepancies between catheter and Doppler

summary. A report of the American College of ery for the assessment of aortic stenosis by estimates of valve effective orifice area can be

Cardiology/American Heart Association Task Doppler ultrasound. Role of aortic size, aortic predicted from the pressure recovery phenom-

Force on Practice Guidelines (Committee on valve area, and direction of the stenotic jet in enon: practical implications with regard

Management of Patients with Valvular Heart vitro. Circulation. 1996;94:1934-1940. to quantification of aortic stenosis severity. J

Disease). J Heart Valve Dis. 1998;7:672-707. 9. Baumgartner H, Stefenelli T, Niederberger J, et Am Coll Cardiol. 2003;41:435-442.

2. Fox RMT. Incompressible Viscous Flow. New al. “Overestimation” of catheter gradients by 15. Levine RA, Schwammenthal E. Stenosis is in

York: John Wiley and Sons; 1978. Doppler ultrasound in patients with aortic the eye of the observer: impact of pressure

3. Holen J, Waag RC, Gramiak R, et al. Doppler stenosis: a predictable manifestation of pressure recovery on assessing aortic valve area. J Am

ultrasound in orifice flow. In vitro studies of recovery. J Am Coll Cardiol. 1999;33:1655-1661. Coll Cardiol. 2003;41:443-445.

the relationship between pressure difference 10. Voelker W, Reul H, Stelzer T, et al. Pressure 16. Gilon D, Cape EG, Handschumacher MD, et

and fluid velocity. Ultrasound Med Biol. recovery in aortic stenosis: an in vitro study in al. Effect of three-dimensional valve shape on

1985;11:261-266. a pulsatile flow model. J Am Coll Cardiol. the hemodynamics of aortic stenosis: three-

4. Teirstein PS, Yock PG, Popp RL. The accuracy 1992;20:1585-1593. dimensional echocardiographic stereolithography

of Doppler ultrasound measurement of pres- 11. Gorlin R, Gorlin SG. Hydraulic formula for and patient studies. J Am Coll Cardiol. 2002;

sure gradients across irregular, dual, and tun- calculation of the area of the stenotic mitral 40:1479-1486.

nellike obstructions to blood flow. Circulation. valve, other cardiac valves, and central circu- 17. Prandt L, Teitjens OJ. Applied Hydro- and

1985;72:577-584. latory shunts. I. Am Heart J. 1951;41:1-29. Aeromechanics. New York: Dover; 1957.

Main Points

• To understand the differences in catheter and Doppler measurements of gradients and valve areas, it is first necessary

to appreciate the hydrodynamic pattern of flow through a stenosis.

• Doppler measurement of the transvalvular pressure drop or gradient is based on the law of conservation of energy,

which states that for flow in a closed system, the total energy at all points must remain constant. Catheter pressures

are usually recorded in the ascending aorta after pressure recovery has occurred. Because clinical Doppler and catheter

measurements of pressure occur at different places, they measure fundamentally different quantities and may report

significantly different results when pressure recovery is present.

• The calculation of the aortic valve area from Doppler recordings is based on the law of conservation of mass, which

states that for an incompressible fluid in a closed system, flow at all points must remain constant. Catheterization

calculates valve area by measuring the pressure drop or gradient across the valve using continuity and Bernoulli

equations.

• The area of a stenotic aortic valve calculated using standard hemodynamic methods will be consistently larger than

that measured using Doppler echocardiography when these data are accurately recorded and simultaneously com-

pared, even in the absence of pressure recovery. When pressure recovery is present, this difference will increase and

may result in significant misclassification of severity.

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