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Apithanung L, Sethasathien S, Silvilairat S, Sittiwangkul R, Makonkawkeyoon K, Saengsin K, Woragidpoonpol S. Correlation between pressure gradient from echocardiography and peak-to-peak pressure gradient from cardiac catheterization or surgery in patients with coarctation of aorta. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024:10.1007/s10554-024-03086-y. [PMID: 38558331 DOI: 10.1007/s10554-024-03086-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
The gold standard for assessing pressure gradients (PG) across coarctation involves measurements obtained through cardiac catheterization or surgical intervention. There has been ongoing discussion regarding the accuracy of non-invasive methods for estimating these gradients. This study sought to establish the correlation and agreement between the systolic blood pressure (SBP) gradient between the upper and lower extremities, as well as, the mean and maximum PG derived from echocardiography, in comparison to the peak-to-peak pressure gradient obtained from either cardiac catheterization or surgery. We conducted a retrospective study on patients < 18 years diagnosed with coarctation at Chiang Mai University Hospital from 2011 to 2022. The study involved the measurement of the SBP gradient between the upper and lower extremities, mean and maximum PG using echocardiography, peak-to-peak pressure gradient obtained from cardiac catheterization, and pressure gradient recorded during surgical procedures. The Spearman's correlation and Bland-Altman analysis were employed to assess correlation and agreement. Fifty-four patients with aortic coarctation were enrolled. The mean PG measured by echocardiography showed a significantly moderate correlation (r = 0.78, p < 0.001) and the highest level of agreement according to Bland Altman plots, in comparison to the peak-to-peak pressure gradient measured during both cardiac catheterization and surgical procedure. The max PG demonstrated a notable overestimation compared to the gold standard (mean difference + 13.14 with a slope of biases + 0.64, p < 0.001). The mean PG obtained through echocardiography has more potential to be applied in practical application in predicting pressure gradient in patients with coarctation.
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Affiliation(s)
- Lalitpat Apithanung
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Saviga Sethasathien
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Suchaya Silvilairat
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Rekwan Sittiwangkul
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Krit Makonkawkeyoon
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kwannapas Saengsin
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Surin Woragidpoonpol
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Ghorbannia A, Ellepola CD, Woods RK, Ibrahim ESH, Maadooliat M, Ramirez HM, LaDisa JF. Clinical, Experimental, and Computational Validation of a New Doppler-Based Index for Coarctation Severity Assessment. J Am Soc Echocardiogr 2022; 35:1311-1321. [PMID: 36122791 PMCID: PMC9729418 DOI: 10.1016/j.echo.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 08/15/2022] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Long-term morbidity including hypertension often persists in coarctation patients despite current guidelines. Coarctation severity can be invasively assessed via peak-to-peak catheter pressure gradient (PPCG), which is estimated noninvasively via simplified Bernoulli equation and conventionally reported as peak instantaneous Doppler gradient (PIDG). However, underlying simplifications of the equation limit diagnostic accuracy. We studied the diagnostic performance of a new Doppler-based diastolic index called the continuous flow pressure gradient (CFPG) versus conventional indices in assessing coarctation severity. METHODS In a rabbit model mimicking human aortic coarctation, temporal blood pressure waveforms revealed the diastolic instantaneous pressure gradients and spectral Doppler features impacted by coarctation severity. We therefore hypothesized that CFPG provides superior correlation with coarctation gradients measured invasively. PIDG and CFPG were quantified using color flow echocardiography in humans and rabbits with discrete coarctations. Results were compared with PPCG in rabbits (n = 34) and arm-leg systolic gradients (n = 25) in humans via 1-way analysis of variance, Pearson's correlation, linear regression, and Bland-Altman analysis. RESULTS A threshold of CFPG ≥ 4.6 mm Hg was identified via the Youden index as representative of PPCG ≥ 20 mm Hg (the current guideline value for coarctation intervention) in rabbits, while a CFPG ≥1.0 mm Hg represented an arm-leg systolic gradient ≥20 mm Hg in humans. Accuracy measures revealed superior correlation of CFPG (R2 > 0.80) and mild receiver operating characteristic improvement (area under the receiver operating characteristic curve, 0.94-0.95) compared with PIDG (R2 < 0.63; area under the receiver operating characteristic curve, 0.89-0.95). Inter-/intraobserver variability tested by intraclass correlation coefficient revealed measurement reliability with differences ≤8.2% and 10.7%, respectively. Computational simulations of anesthetized versus conscious hemodynamics showed parameters were minimally impacted by isoflurane inherent in the data used to derive CFPG. These results confirm the potential diagnostic accuracy of CFPG in echocardiography-based coarctation severity assessment. We are optimistic that CFPG will be useful for translation of results from preclinical studies that revisit current guidelines to limit morbidity in humans with aortic coarctation.
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Affiliation(s)
- Arash Ghorbannia
- Department of Biomedical Engineering, Medical College of Wisconsin, and Marquette University, Milwaukee, Wisconsin; Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Chalani D Ellepola
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - El-Sayed H Ibrahim
- Department of Biomedical Engineering, Medical College of Wisconsin, and Marquette University, Milwaukee, Wisconsin; Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mehdi Maadooliat
- Department of Mathematics and Statistical Sciences, Marquette University, Milwaukee, Wisconsin
| | - Hilda Martinez Ramirez
- Department of Biomedical Engineering, Medical College of Wisconsin, and Marquette University, Milwaukee, Wisconsin
| | - John F LaDisa
- Department of Biomedical Engineering, Medical College of Wisconsin, and Marquette University, Milwaukee, Wisconsin; Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Medicine, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Abstract
Aortic coarctation is a discrete narrowing of the thoracic aorta. In addition to anatomic obstruction, it can be considered an aortopathy with abnormal vascular properties characterized by stiffness and impaired relaxation. There are surgical and transcatheter techniques to address the obstruction but, despite relief, patients with aortic coarctation are at risk for hypertension, aortic complications, and abnormalities with left ventricular performance. This review covers the etiology, pathophysiology, diagnosis, and management of adults with aortic coarctation, with emphasis on multimodality imaging characteristics and lifelong surveillance to identify long-term complications.
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Affiliation(s)
- Yuli Y Kim
- Philadelphia Adult Congenital Heart Center, Perelman School of Medicine at the University of Pennsylvania, Penn Medicine and Children's Hospital of Philadelphia, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Lauren Andrade
- Philadelphia Adult Congenital Heart Center, Perelman School of Medicine at the University of Pennsylvania, Penn Medicine and Children's Hospital of Philadelphia, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Stephen C Cook
- Adult Congenital Heart Disease Program, Congenital Heart Center, Helen DeVos Children's Hospital, Frederik Meijer Heart & Vascular Institute, Pediatrics and Human Development, Michigan State University, 25 Michigan Street NE Suite 4200, Grand Rapids, MI 49503, USA
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Krieger EV, Stout KK, Grosse-Wortmann L. How to Image Congenital Left Heart Obstruction in Adults. Circ Cardiovasc Imaging 2019; 10:CIRCIMAGING.116.004271. [PMID: 28495822 DOI: 10.1161/circimaging.116.004271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Eric V Krieger
- From the Seattle Adult Congenital Heart Service, University of Washington Medical Center (E.V.K., K.K.S.); Seattle Children's Hospital, Washington (E.V.K., K.K.S.); Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle (E.V.K., K.K.S.); and Labatt Family Heart Centre, Department of Pediatrics, and Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, ON, Canada (L.G.-W.)
| | - Karen K Stout
- From the Seattle Adult Congenital Heart Service, University of Washington Medical Center (E.V.K., K.K.S.); Seattle Children's Hospital, Washington (E.V.K., K.K.S.); Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle (E.V.K., K.K.S.); and Labatt Family Heart Centre, Department of Pediatrics, and Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, ON, Canada (L.G.-W.)
| | - Lars Grosse-Wortmann
- From the Seattle Adult Congenital Heart Service, University of Washington Medical Center (E.V.K., K.K.S.); Seattle Children's Hospital, Washington (E.V.K., K.K.S.); Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle (E.V.K., K.K.S.); and Labatt Family Heart Centre, Department of Pediatrics, and Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, ON, Canada (L.G.-W.).
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Doppler Flow Pattern and Arterial Stiffness in Patients with Aortic Coarctation. Pediatr Cardiol 2016; 37:1465-1468. [PMID: 27558551 DOI: 10.1007/s00246-016-1458-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022]
Abstract
Patients with aortic coarctation (CoAo) often have a diastolic flow in the descending aorta. The effect of arterial stiffness on CoAo flow pattern was described in vitro and with computer models. Study of Doppler flow patterns and arterial stiffness may provide helpful data to support the decision of CoAo treatment. Fifty studies were obtained in 31 patients (14 women, 21.5 ± 15.5 years). In 19 patients, studies were performed before and after percutaneous intervention. Systolic invasive gradients were measured (Sgrad). Doppler parameters included Doppler corrected gradient (Dgrad), diastolic velocity at end of T wave (DVT), end diastolic velocity (DVQ), systolic and diastolic half pressure times (SHPTc and DHPTc) and velocity runoff (VRc). In 19 patients, before intervention, arterial stiffness was assessed by measuring pulsed wave velocity (PWV) between right carotid and radial arteries. Sgrad showed correlation with Dgrad, DVT, DVQ, SHPTc, DHPTc and VRc (p < 0.01). Using multiple regression models, Sgrad variability was best explained by combining the variables Dgrad and DHPTc (R 2 = 0.766). A variable named DTail was obtained with DTail = 1 if DHPTc > 0. In the group with Sgrad below 30 mmHg, a negative correlation was found between DTail and PWV (p = 0.024), suggesting that low aortic stiffness contributes to persistent diastolic flow in the descending aorta. Doppler systolic and diastolic parameters correlated well with severity of CoAo. In mild to moderate CoAo, Doppler diastolic flow in the descending aorta was more likely in patients with lower arterial stiffness.
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6
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Abstract
BACKGROUND Aortic arch obstruction can be evaluated by catheter peak-to-peak gradient or by Doppler peak instantaneous pressure gradient. Previous studies have shown moderate correlation in discrete coarctation, but few have assessed correlation in patients with more complex aortic reconstruction. METHODS We carried out retrospective comparison of cardiac catheterisations and pre- and post-catheterisation echocardiograms in 60 patients with native/recurrent coarctation or aortic reconstruction. Aortic arch obstruction was defined as peak-to-peak gradient ⩾25 mmHg in patients with native/recurrent coarctation and ⩾10 mmHg in aortic reconstruction. RESULTS Diastolic continuation of flow was not associated with aortic arch obstruction in either group. Doppler peak instantaneous pressure gradient, with and without the expanded Bernoulli equation, weakly correlated with peak-to-peak gradient even in patients with a normal cardiac index (r=0.36, p=0.016, and r=0.49, p=0.001, respectively). Receiver operating characteristic curve analysis identified an area under the curve of 0.61 for patients with all types of obstruction, with a cut-off point of 45 mmHg correctly classifying 64% of patients with arch obstruction (sensitivity 39%, specificity 89%). In patients with aortic arch reconstruction who had a cardiac index ⩾3 L/min/m², a cut-off point of 23 mmHg correctly classified 69% of patients (71% sensitivity, 50% specificity) with an area under the curve of 0.82. CONCLUSION The non-invasive assessment of aortic obstruction remains challenging. The greatest correlation of Doppler indices was noted in patients with aortic reconstruction and a normal cardiac index.
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Hajsadeghi S, Fereshtehnejad SM, Ojaghi M, Bassiri HA, Keramati MR, Chitsazan M, Gholami S. Doppler echocardiographic indices in aortic coarctation: a comparison of profiles before and after stenting. Cardiovasc J Afr 2013; 23:483-90. [PMID: 23108515 PMCID: PMC3721869 DOI: 10.5830/cvja-2012-044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Accepted: 05/11/2012] [Indexed: 12/01/2022] Open
Abstract
Background Diagnosis of aortic coarctation is important as it is a difficult condition to evaluate, especially in adults. A Doppler echocardiographic index could provide a simple tool to evaluate coarctation. This study was performed to compare Doppler echocardiographic profiles before and after stenting and to assess the diagnostic value of a complete list of echocardiographic indices for detecting aortic coarctation. Methods This prospective study was conducted on 23 patients with a diagnosis of aortic coarctation based on angiography. Echocardiographic assessment was done twice for all patients before and after stenting. Each time, two-dimensional and Doppler echocardiographic imaging modalities were performed and complete lists of indices were recorded for each case. After comparing the values of indices before and after stenting, diagnostic values of each index were calculated in order to diagnose significant coarctation. Results Twenty-three patients, including 16 males and seven females with a mean age of 26.14 ± 10.17 years, were enrolled in this study. Except for the mean velocity and mean pressure gradient of the abdominal aorta, the values of the other indices of the abdominal/descending aorta showed enough change after stenting to indicate significant diagnostic accuracy for detecting aortic coarctation. The velocity–time integral and the pressure half-time were among the indices with the highest accuracy rates for this purpose (all p < 0.001). Conclusion Post-stenting echocardiographic profiles could provide a reliable reference value of the normal aortic haemodynamics as a unique identification of each patient and it is presumed that these indices could be used as reliable indicators of response to treatment.
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Affiliation(s)
- Shokoufeh Hajsadeghi
- Department of Cardiology, Rasoul-e-Akram Hospital, Tehran University of Medical Sciences, Iran
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Keshavarz-Motamed Z, Garcia J, Maftoon N, Bedard E, Chetaille P, Kadem L. A new approach for the evaluation of the severity of coarctation of the aorta using Doppler velocity index and effective orifice area: In vitro validation and clinical implications. J Biomech 2012; 45:1239-45. [DOI: 10.1016/j.jbiomech.2012.01.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 01/21/2012] [Accepted: 01/29/2012] [Indexed: 11/16/2022]
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Tang L, Forbes TJ, Du W, Zilberman MV. Echocardiographic evaluation of pressure gradient across the stent in patients treated for coarctation of the aorta. CONGENIT HEART DIS 2009; 4:269-72. [PMID: 19664030 DOI: 10.1111/j.1747-0803.2009.00300.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Stent placement has become a widely used method of treatment for coarctation of the aorta (COA). Our goal was to find echocardiographic indices that would correlate best with directly measured gradients across the coarctation stent. MATERIAL AND METHODS Pediatric patients with COA who underwent intra-aortic stent placement were evaluated. Patients with more than mild aortic insufficiency were excluded. Aortic pressures above and below the coarctation site were directly measured in the catheterization laboratory. Echocardiography was performed the next morning. Continuous and Pulse Doppler systolic velocity profiles proximal and distal to the stent were recorded. Statistical analysis included Pearson's correlation coefficients and linear regression between the directly measured pressure gradient and strongest correlated factor. RESULT Thirty-four patients (F : M = 15 : 19) were included in the study. The directly measured gradients (DPG) had only weak positive correlations with Doppler peak velocities (r = 0.38, P= .027) or pressure gradients (r = 0.37, P= .03) across the stent. However, there was a strong positive correlation of the directly measured gradients with the continuous wave peak systolic velocity half-time indexed to heart rate (T) (r = 0.62, P= .03), and with the squared early diastolic velocity (V(d) (2)) (r = 0.073, P < .0001). When these two parameters were combined, a linear regression equation DPG = 0.06T + 1.58 V(d) (2)- 8.05 showed very strong relations (r = 0.81, P < .0001). A simplified equation DPG = 1.98V(d) (2)+ 0.77 also accurately described the relations between the directly measured gradients and squared Doppler-measured early diastolic velocity (r = 0.71, P= .0002). CONCLUSIONS A simple echocardiographic index DPG = 1.98V(d) (2)+ 0.77, where DPG is the pressure gradient across the stent, and V(d) is the early Doppler diastolic velocity, accurately describes relations between the gradient across the stent and echocardiographic data and should be used for evaluation of patients with stent-corrected COA.
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Affiliation(s)
- Liwen Tang
- Cardiology Division, Department of Pediatrics, Wayne State University School of Medicine, Detroit, Mich 48201, USA
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10
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Silvilairat S, Cetta F, Biliciler-Denktas G, Ammash NM, Cabalka AK, Hagler DJ, O'Leary PW. Abdominal aortic pulsed wave Doppler patterns reliably reflect clinical severity in patients with coarctation of the aorta. CONGENIT HEART DIS 2009; 3:422-30. [PMID: 19037983 DOI: 10.1111/j.1747-0803.2008.00224.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE There are situations in which standard echocardiography does not adequately define the aortic arch. We sought to determine what additional information could be gained by analyzing abdominal aortic Doppler flows in coarctation. DESIGN Previously recorded echocardiographic data were reviewed in 70 controls and 248 patients with coarctation, including abdominal aortic values for pulsatility indices, pulse delay, and presence of early diastolic reversal. Ability of these variables to distinguish controls from coarctation patients and to assess coarctation severity was assessed. RESULTS Corrected maximum instantaneous gradient and all abdominal aortic flow variables were associated with severity of obstruction. Early diastolic reversal was universally absent in significant coarctation. Threshold values for other parameters associated with significant obstruction were: corrected pulse delay >or=3.4 msec(1/2), pulsatility index <2.0, and systolic to diastolic velocity ratio <3.6. A combined abdominal aortic "variable" (absence of early diastolic reversal and corrected pulse delay >or=2.8 msec(1/2)) was found to be the best predictor of clinical coarctation status (positive predictive value = 93%, negative predictive value = 88%). CONCLUSIONS In the absence of a ductus arteriosus, abdominal aortic Doppler parameters can reliably predict the presence of significant coarctation. When early diastolic reversal was present, obstruction was always absent. Lack of early diastolic reversal with a prolonged pulse delay was the best predictor of significant obstruction. Abdominal aortic Doppler evaluation should become a routine part of the evaluation of patients with known or suspected coarctation.
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Affiliation(s)
- Suchaya Silvilairat
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Konings TC, Bouma BJ, de Winter RJ, Groenink M, Mulder BJ. Protruding Stent in Thoracic Descending Aorta after Stent Implantation for Recoarctation. Echocardiography 2009; 26:230-1. [DOI: 10.1111/j.1540-8175.2008.00830.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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12
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Carvalho JS. Half peak systolic velocity deceleration time: a new index for umbilical artery Doppler, but not a new Doppler parameter for waveform quantification. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 31:716-717. [PMID: 18425983 DOI: 10.1002/uog.5312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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13
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DeGroff C. Doppler Echocardiographic Profile and Indexes. J Am Coll Cardiol 2006; 48:419; author reply 419-20. [PMID: 16843207 DOI: 10.1016/j.jacc.2006.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Tan JL, Babu-Narayan SV, Henein MY, Mullen M, Li W. Doppler echocardiographic profile and indexes in the evaluation of aortic coarctation in patients before and after stenting. J Am Coll Cardiol 2005; 46:1045-53. [PMID: 16168290 DOI: 10.1016/j.jacc.2005.05.076] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2005] [Revised: 05/17/2005] [Accepted: 05/31/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES We sought to assess the effect of successful stenting on the Doppler profile of aortic coarctation and to identify echocardiographic indexes that could be used for follow-up of such patients. BACKGROUND Doppler echocardiography demonstrates characteristic flow patterns in significant aortic coarctation. METHODS We undertook retrospective echocardiographic analyses before and at six to nine months after coarctation stenting in consecutive patients from 2002 to 2003. Peak systolic pressure gradient (SPG), diastolic velocity (DV), end-diastolic tail velocity (EDTV), systolic velocity half-time index (SVHTi) and diastolic velocity half-time index (DVHTi), and systolic pressure half-time index (SPHTi) and diastolic pressure half-time index (DPHTi) were measured. The severity of aortic coarctation was compared with cardiovascular magnetic resonance (CMR) imaging using the coarctation index (CoAi). RESULTS The patient cohort was divided into two groups: group 1 (13 patients; age 30 +/- 8 years), which consisted of patients with significant aortic coarctation treated with stenting, and group 2 (11 patients; age 39 +/- 16 years), which consisted of patients with previous surgical repair of aortic coarctation without evidence of re-coarctation. After stenting, there was significant reduction in SPG (p = 0.001), DV (p = 0.001), EDTV (p = 0.005), DVHTi (p = 0.001), and DPHTi (p = 0.001) values. In the patient group as a whole, there was a significant correlation between SPG and DV (r = 0.86; p < 0.001), EDTV (r = 0.80; p < 0.001), DVHTi (r = 0.56; p < 0.001), and DPHTi (r = 0.50; p = 0.002). In addition, DV >193 cm/s (100% sensitivity, 100% specificity) and diastolic/systolic velocity ratio >0.53 (100% sensitivity, 96% specificity) had high predictive values for severe aortic coarctation (CoAi <0.25). CONCLUSIONS After stenting, peak SPG, DV, and pressure half-time indexes (i.e., DVHTi and DPHTi) decreased significantly. These findings can confidently be used in the follow-up of coarctation patients after stenting, particularly in those with limited two-dimensional images.
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Affiliation(s)
- Ju-Le Tan
- Adult Congenital Heart Disease Unit, Royal Brompton Hospital, London, United Kingdom
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15
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Giardini A, Schmitt B, Azakie A, Tacy TA. Effect of chamber capacitance on Doppler flow pattern across restrictive defects in obligatory atrial-level shunts. J Am Soc Echocardiogr 2004; 17:1286-91. [PMID: 15562268 DOI: 10.1016/j.echo.2004.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The right atrium has a significantly higher capacitance than the left atrium, and this may affect the Doppler flow pattern across an atrial septal defect (ASD) in unilateral atrioventricular (AV) valve atresia. This Doppler flow pattern is often used to assess ASD adequacy in this setting. We studied the effect of atrial capacitance and ASD size on the trans-ASD Doppler flow pattern in an in vivo flow model of alternate left or right AV valve atresia (LAVVA and RAVVA). We assessed trans-ASD Doppler flow patterns using the max/min velocity ratio and mean interatrial pressure gradients (PGs). In both models, ASD flow rate correlated with mean trans-ASD PG, but for similar flow rates the slope was higher in the LAVVA model. In LAVVA, a persistent PG was consistently observed, with low max/min ratio (median, 1.46; range, 1.03-3.13), whereas in RAVVA, phasic flow was common (median, 8.0; range, 2.8-20). Because atrial capacitance affects mean PG and Doppler flow pattern across the ASD, we propose that the assessment of ASD adequacy in RAVVA should not rely on Doppler findings.
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Affiliation(s)
- Alessandro Giardini
- Pediatric Cardiology and Adult Congenital Unit, University of Bologna, Italy
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16
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DeGroff CG, Orlando W, Shandas R. Insights into the effect of aortic compliance on Doppler diastolic flow patterns seen in coarctation of the aorta: a numeric study. J Am Soc Echocardiogr 2003; 16:162-9. [PMID: 12574743 DOI: 10.1067/mje.2003.20] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND In the echocardiographic evaluation of coarctation of the aorta, the degree of antegrade diastolic flow (diastolic runoff) noted on spectral Doppler tracings traditionally was thought to be solely dependent on lesion severity. However, recent in vitro experiments suggest the presence of this spectral Doppler pattern is as much related to the severity of coarctation as it is with changes in aortic compliance. Using state-of-the-art, multidisciplinary, numeric analysis tools, the purpose of this study was to investigate the specific fluid and wall mechanics present in coarctation of the aorta to further understand these relationships. METHODS Three computational numeric models of coarctation were developed with high, low, and no wall compliance. Flow simulations were run representing high- and low-flow states. RESULTS In both the low- and high-flow states, the degree of diastolic runoff increased with increasing vessel compliance. The high compliance model had larger changes in aortic dilatation in the precoarctation region compared with the low compliance model. CONCLUSIONS Increased aortic compliance brings about greater dilatation of the precoarctation aorta in systole, resulting in a persistence of stored upstream energy. This stored energy, released downstream in diastole as the precoarctation aortic walls contract, leads to increased degrees of diastolic runoff. Numeric methods offer a unique perspective into the mechanisms behind such clinical measures.
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Affiliation(s)
- Curt G DeGroff
- Pediatric Cardiology, Cardiovascular Flow Dynamics Laboratory, University of Colorado, The Children's Hospital, Denver 80218, USA.
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Holmqvist C, Ståhlberg F, Hanséus K, Hochbergs P, Sandström S, Larsson EM, Laurin S. Collateral flow in coarctation of the aorta with magnetic resonance velocity mapping: correlation to morphological imaging of collateral vessels. J Magn Reson Imaging 2002; 15:39-46. [PMID: 11793455 DOI: 10.1002/jmri.10036] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To correlate quantification of collateral flow in aortic coarctation with the morphological visualization of the collateral vessels and to compare different approaches to measurement of collateral flow. MATERIALS AND METHODS Thirteen children with coarctation were examined with T1-weighted spin-echo (T1-W SE) imaging and 3D contrast-enhanced magnetic resonance angiography (MRA). MR velocity mapping was performed at four levels in the descending aorta. RESULTS The flow immediately above and below the coarctation did not differ significantly. Measuring within the coarctation resulted in flow overestimation. The increase of flow from proximal to distal aorta was 12 +/- 21% in patients with no or uncertain collaterals and 69 +/- 55% in patients with pronounced collaterals. Spin-echo images and MRA were comparable in visualizing collateral vessels. The visual estimation of collaterals correlated reasonably well with flow quantification MR velocity mapping. CONCLUSION Collateral flow assessment with MR velocity mapping is an accurate technique for evaluating the hemodynamic importance of a coarctation and is recommended if abundant collaterals are not visualized with spin echo or MRA.
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Affiliation(s)
- Catarina Holmqvist
- Diagnostic Center of Medical Imaging and Physiology, Lund University Hospital, Lund, Sweden.
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Verhaaren H, De Mey S, Coomans I, Segers P, De Wolf D, Matthys D, Verdonck P. Fixed region of nondistensibility after coarctation repair: in vitro validation of its influence on Doppler peak velocities. J Am Soc Echocardiogr 2001; 14:580-7. [PMID: 11391286 DOI: 10.1067/mje.2001.113256] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
After coarctectomy, local loss of distensibility is noted in addition to mild anatomic narrowing. We hypothesize that the increased Doppler peak velocities measured at the aortic isthmus in these patients partly reflect obstruction secondary to the stiff surgical scar. The hypothesis was studied in a pulsatile hydraulic model. Thirty-one patients (13.0 +/- 4.0 years of age), 10.5 +/- 4.7 years after coarctectomy by end-to-end anastomosis, were studied clinically and echocardiographically. Indexes of distensibility were calculated. The effect of isolated increased stiffness was studied in vitro with a stiff and a compliant 1:1 scale latex model of the aorta mounted in a pulsatile full-scale circulation loop. Local stiffening was obtained by a rigid ring mounted around the aorta, fitted to the dimension of the unloaded aorta. For different pressure and flow regimens, pressures and Doppler velocities were measured across the ring. Mean peak velocities at the surgical scar were 2.2 +/- 0.4 m/s. Mild anatomic stenosis was present. All distensibility indexes indicated locally increased stiffness (P <.001). In the stiff latex model, Doppler peak velocities increased from 1.89 +/- 0.04 m/s to 2.32 +/- 0.06 m/s (P <.03); in the compliant model, from 1.15 +/- 0.03 m/s to 1.79 +/- 0.05 m/s (P <.001). The increase of Doppler peak velocities depends on model compliance only and is independent of flow rate, length of the noncompliant segment, and viscosity of the perfusion fluid. Velocities do not change when semicircular stiffening is applied. We have demonstrated in vitro that isolated local nondistensibility leads to vessel narrowing during vascular distension. The relative contribution of local scar stiffness in the increase of Doppler peak velocities after coarctectomy was hereby assessed.
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Affiliation(s)
- H Verhaaren
- Division of Pediatric Cardiology and Department of Hydraulics, Ghent University, Belgium
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