Outpatient echocardiographic assessment of complex pulmonary outflow stenosis: Doppler mean gradient is superior to the maximum instantaneous gradient.

Published on Nov 1, 2005in Journal of The American Society of Echocardiography5.508
· DOI :10.1016/J.ECHO.2005.04.003
Suchaya Silvilairat5
Estimated H-index: 5
(Mayo Clinic),
Allison K. Cabalka30
Estimated H-index: 30
(Mayo Clinic)
+ 2 AuthorsPatrick W. O'Leary40
Estimated H-index: 40
(Mayo Clinic)
Evaluation of pulmonary outflow obstruction has focused on maximum instantaneous gradient (MIG). However, experience suggests that outpatient Doppler MIG often overstates the degree of stenosis. In this study of 132 patients with complex pulmonary stenosis, the mean Doppler gradient showed superior correlation and agreement with invasive peak-to-peak gradient (PPG) ( r = 0.91, bias=−6 mm Hg). Agreement between mean gradient and PPG remained excellent for patients with prosthetic conduits (bias = −4 mm Hg). When PPG was 50 mm Hg more, both mean Doppler gradient and MIG corrected for prevalve velocity provided reasonable estimates of PPG (bias = −13 and +17 mm Hg, respectively). Uncorrected MIG remained significantly greater than PPG (bias = +27 mm Hg). Outpatient MIG consistently overstated subsequent PPG. In unselected patients with conduits or with PPG of 50 mm Hg or less, mean Doppler gradient provided the best prediction of PPG. These data provide a strong argument for the routine use of mean gradients in complex pulmonary stenosis.
📖 Papers frequently viewed together
78 Citations
553 Citations
137 Citations
#1Jae K. OhH-Index: 119
#2James B. SewardH-Index: 137
Last. A. Jamil TajikH-Index: 141
view all 3 authors...
Abbreviations Commonly Used in Text, Tables, and Figures How to Obtain a Good Echocardiography Examination: Ultrasound Physics, Technique, and Medical Knowledge Transthoracic Echocardiography: M-mode, Two-Dimensional, and Three-Dimensional Transesophageal and Intracardiac Echocardiography Jae K. Oh, Donald J. Hagler, Allison Cabalka, Guy S. Reeder, Frank Cetta, Jr., and James B. Seward Doppler Echocardiography and Color Flow Imaging: Comprehensive Noninvasive Hemodynamic Assessment Tissue Dopple...
375 Citations
#1Suchaya Silvilairat (Mayo Clinic)H-Index: 5
#2Allison K. Cabalka (Mayo Clinic)H-Index: 30
Last. Patrick W. O'Leary (Mayo Clinic)H-Index: 40
view all 5 authors...
Maximum instantaneous Doppler gradient has been the primary variable used to assess severity of pulmonary valve stenosis. However, recent observations suggest that outpatient maximum Doppler gradient often overstates clinical severity, as measured by catheter peak-to-peak gradient (PPG). This study sought to determine which outpatient Doppler gradient was most predictive of subsequently measured PPG. Ninety patients were included. Outpatient mean Doppler gradient showed the best correlation and ...
32 CitationsSource
#1Catarina HolmqvistH-Index: 7
#2Gylfi ÓskarssonH-Index: 1
Last. Sven LaurinH-Index: 12
view all 6 authors...
Abstract Extracardiac ventriculopulmonary conduits tend to deteriorate over time, developing both obstruction and regurgitation. In this prospective study, magnetic resonance imaging (MRI) was compared with Doppler echocardiography to determine whether MRI improves the noninvasive evaluation of conduit patients. Twenty-five patients (median age 10 years, range 2.5 to 32) were investigated 27 times with Doppler echocardiography and an MRI protocol with spin echo sequences for morphology, velocity...
26 CitationsSource
#1Kwok Chiu Chan (MUSC: Medical University of South Carolina)H-Index: 1
#2Derek A. Fyfe (MUSC: Medical University of South Carolina)H-Index: 16
Last. Fred A. Crawford (MUSC: Medical University of South Carolina)H-Index: 54
view all 5 authors...
Objectives. This study was performed to assess by echocardiography the intermediate-term outcome of cryopreserved homografts employed in pulmonary outflow reconstruction in children and to validate the reliability of Doppler echocardiography in their evaluation. Background. Cryopreserved homografts have become the most widely used pulmonary conduits. Previous reports have shown the occurrence of homograft regurgitation in the immediate postoperative period and the propensity of regurgitation to ...
75 CitationsSource
#1Rick A. Nishimura (Mayo Clinic)H-Index: 128
#2Charanjit S. Rihal (Mayo Clinic)H-Index: 96
Last. David R. Holmes (Mayo Clinic)H-Index: 192
view all 4 authors...
Abstract Objectives . This study compared the accuracy of Doppler echocardiography with that of conventional cardiac catheterization in the measurement of transmitral gradients in patients with mitral stenosis. Background . Simultaneous measurement of left atrial and left ventricular pressures is the most accurate method for determination of the mean mitral valve gradient in patients with mitral stenosis. Because of the inherent risks of transseptal catheterization, pulmonary capillary wedge pre...
107 CitationsSource
#1Barry Marcus (SC: University of Southern California)H-Index: 1
#2Alan B. Lewis (SC: University of Southern California)H-Index: 1
To assess the utility of Doppler echocardiography in evaluation of aortic homograft valved conduit function, 10 consecutive pediatric patients had Doppler examination of aortic homograft valved conduits associated with follow-up cardiac catheterization. General correlation was found between the Doppler-derived peak systolic pressure gradient across the aortic homograft valved conduit and cardiac catheterization (r = 0.65, P < 0.05, SEE = 20.5). One patient with multilevel obstruction had signifi...
1 CitationsSource
#1Mohamed Eid FawzyH-Index: 19
#2E. N. MercerH-Index: 1
Last. W. AndayaH-Index: 1
view all 5 authors...
Seventeen patients (12 with native and five with prosthetic tricuspid valves) with tricuspid stenosis were studied by Doppler echocardiography followed by cardiac catheterization within 24 h. The mean tricuspid diastolic pressure gradient was calculated using the modified Bernoulli equation. Tricuspid valve area (TVA) was calculated by the pressure half-time method (TVA = 190 divided by pressure half-time). Data from Doppler echocardiography and cardiac catheterization were compared. The Doppler...
31 CitationsSource
#1A.Resai Bengur (UM: University of Michigan)H-Index: 13
#2A. Rebecca Snider (UM: University of Michigan)H-Index: 23
Last. Amnon Rosenthal (UM: University of Michigan)H-Index: 29
view all 5 authors...
Abstract To assess the usefulness of the Doppler mean gradient as a noninvasive indicator of the need for intervention, 33 children (ages 3 months to 20 years) with valvular aortic stenosis (AS) underwent a 2-dimensional and Doppler echocardiographic examination a median of 1 day before cardiac catheterization. The clinical decision for intervention was based on finding a catheterization peak-to-peak pressure gradient of >75 mm Hg or from 50 to 75 mm Hg in the presence of symptoms or an abnormal...
37 CitationsSource
#1Abdul W. Aldousany (UTHSC: University of Tennessee Health Science Center)H-Index: 1
#2Thomas G. DiSessa (UTHSC: University of Tennessee Health Science Center)H-Index: 8
Last. Stuart E. Birnbaum (UTHSC: University of Tennessee Health Science Center)H-Index: 3
view all 6 authors...
We undertook a study to identify the hemodynamic significance of a Doppler-derived gradient across a stenotic pulmonary valve. Furthermore, we attempted to define the optimal plane for velocity data acquisition. A total of 17 children with valvar pulmonary stenosis were evaluated using Doppler echocardiography. Flow-velocity profiles were obtained from both the parasternal and subxiphoid windows. Ten of 17 patients were studied before and after balloon valvotomy. Therefore, 27 different transval...
13 CitationsSource
#1Paulo A. RibeiroH-Index: 11
#2Muayed Al ZaibagH-Index: 10
Last. Moheeb AbdullahH-Index: 7
view all 7 authors...
Abstract A low cardiac output and high compliance of the systemic venous system may mask a resting tricuspid diastolic gradient in patients with significant rheumatic tricuspid stenosis. Thirty-three patients (mean age 28 ± 10 years) with rheumatic tricuspid stenosis evidenced by 2-dimensional echocardiography (doming and restricted motion of all 3 tricuspid valve leaflets) were studied to expose occult and to amplify borderline and basal tricuspid valve gradients. At cardiac catheterization, th...
13 CitationsSource
Cited By13
#1William R. Miranda (Mayo Clinic)H-Index: 14
#2Alexander C. Egbe (Mayo Clinic)H-Index: 20
Last. Heidi M. Connolly (Mayo Clinic)H-Index: 75
view all 4 authors...
Abstract Background Data on the features of double-chambered right ventricular (DCRV) in adults are limited. It is also unclear how invasive and Doppler-derived assessments of right ventricular (RV) obstruction in DCRV correlate. Methods Retrospective review of 17 adults (age ≥18 years) diagnosed with DCRV who underwent right heart catheterization at Mayo Clinic, MN between 1990 and 2021. Clinical, echocardiographic, and invasive hemodynamics were abstracted from the medical charts. Results Mean...
#1Béatrice Santens (CUA: The Catholic University of America)H-Index: 1
#2Ruben De Bosscher (CUA: The Catholic University of America)
Last. Jan Bogaert (CUA: The Catholic University of America)H-Index: 10
view all 4 authors...
Background Right ventricular outflow tract obstruction in patients with congenital heart disease is usually assessed using echocardiographic peak instantaneous gradient at rest. Since right ventricular outflow tract obstruction may change during exercise (dynamic right ventricular outflow tract obstruction), we present a case emphasizing the potential use of exercise cardiac magnetic resonance imaging (CMR). Case summary We discuss a 15-year-old patient with repaired mid-ventricular sub-pulmonar...
#1Randolph L. Winter (OSU: Ohio State University)H-Index: 1
#2Jaylyn D. Rhinehart (OSU: Ohio State University)H-Index: 3
Last. Karsten E. Schober (OSU: Ohio State University)H-Index: 26
view all 10 authors...
Abstract Introduction/Objectives Pulmonary stenosis (PS) is a common congenital defect in the dog. Severe valvar PS can be treated with balloon valvuloplasty (BV) to reduce obstruction severity and improve clinical signs. Repeat BV is often unnecessary, as restenosis is uncommon. Repeated pulmonary BV in people is generally successful and safe, but outcomes in dogs with recurrent or persistent stenosis have not been reported. The objective of this study was to retrospectively evaluate outcome of...
#1Edward C. Kirkpatrick (Children's Hospital of Wisconsin)H-Index: 6
Last. Meryl S. CohenH-Index: 43
view all 2 authors...
#1Emily Ruckdeschel (Children's Hospital of Philadelphia)H-Index: 4
#2Yuli Y. Kim (Children's Hospital of Philadelphia)H-Index: 14
### Learning objectives The most common form of right ventricular outflow tract (RVOT) obstruction is pulmonary valve stenosis. Pulmonary stenosis (PS) occurs in isolation in 8%–10% of congenital heart disease but is often associated with other congenital lesions1 Subvalvar and supravalvar PS are less common but also seen in adults. PS and supravalvar PS are most often congenital and can be associated with genetic syndromes including Noonan, Alagille and Williams syndromes as well as congenital ...
7 CitationsSource
#1Marie A. ChaixH-Index: 4
#2Annie DoreH-Index: 27
#2Michael SteinmetzH-Index: 14
Last. Jan M SohnsH-Index: 18
view all 12 authors...
Abstract Aim To compare estimated pressure gradients from routine follow-up cardiovascular phase-contrast magnetic resonance (PC-MR) with those from Doppler echocardiography and invasive catheterization in patients with congenital heart disease (CHD) and pulmonary outflow tract obstruction. Methods In 75 patients with pulmonary outflow tract obstruction maximal and mean PC-MR gradients were compared to maximal and mean Doppler gradients. Additionally, in a subgroup of 31 patients maximal and mea...
2 CitationsSource
#1Wendy Whiteside (UM: University of Michigan)H-Index: 8
#1Wendy Whiteside (UM: University of Michigan)H-Index: 4
Last. Aimee K. Armstrong (UM: University of Michigan)H-Index: 10
view all 6 authors...
The aim of this study was to determine the utility of intracardiac echocardiography (ICE) in assessing Melody™ transcatheter pulmonary valve (TPV) function immediately following valve implantation. ICE is used increasingly in percutaneous cardiac interventions. At our center, ICE is routinely utilized to evaluate valve function following Melody TPV implantation, but the utility of this practice remains unclear. A retrospective review of all Melody valves placed in the right ventricular outflow t...
13 CitationsSource
#1Luke M. Wiggins (Children's Hospital Los Angeles)H-Index: 2
#2S. Ram Kumar (Children's Hospital Los Angeles)H-Index: 27
Last. Winfield J. Wells (Children's Hospital Los Angeles)H-Index: 36
view all 4 authors...
Background Right ventricular outflow tract obstruction (RVOT) is the most common late complication requiring intervention after arterial switch operation (ASO). The durability of surgical management of this complication has not been well established. Methods We retrospectively reviewed the charts of 38 consecutive patients who underwent RVOT reconstruction after ASO at our institution between 2004 and 2013. During the same time period, 223 consecutive patients underwent ASO for transposition of ...
2 CitationsSource
#1Dominique BettexH-Index: 21
#2Marco BosshartH-Index: 1
Last. Matthias GreutmannH-Index: 23
view all 3 authors...