when apical or parasternal windows are used. The peak Doppler flow velocity across the St. Jude Medical aortic valve can be underestimated (due to flow masking) when apical windows are used. This problem can be minimized if suprasternal and right parasternal windows are used to obtain peak aortic flow velocities. Because contin- uous wave Doppler capabilities are lacking in the trans- esophageal probes that are now available commercially, this approach will have limited value (due to aliasing) in obtaining peak aortic mechanical valve flow veloc- ities.

In conclusion, color flow Doppler is of value in diag- nosing St. Jude Medical aortic valve regurgitation, but may sometimes underestimate its severity. Color flow Doppler as used in this study has severe limitations in estimating St. Jude Medical mitral valve regurgitation. The color flow Doppler finding of severe St. Jude Medical

valve regurgitation is an excellent predictor of severity of valve dysfunction.

1. Dittrich H, Nicod P, Hoit B, Dalton N, Sahn D. Evaluation of Bjork-Shiley prosthetic valves by real time two-dimensional Doppler echocardiographic flow mapping. Am Heart J 1988;115:133-138. 2. Helmcke F, Nanda NC, Hsiung MC, Soto B, Adey CK, Goyal RG, Gatewood RP. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation 1987:75:175-183. 3. Perry GJ, Helmcke F, Nanda NC, Byard C, Soto B. Evaluation of aortic insufliciency by Doppler color flow mapping. JACC 1987,9:952-959. 4. Sprecher DL, Adamick A, Adams D, Kisslo J. In vitro color flow. pulsed and continuous wave Doppler ultrasound masking of flow by prosthetic valves. JACC 1987,9:1306-1310. 5. Daniel WG, Hanrath P, Mugge A, Langenstein B, Engel H, Grate J. Assess- ment of mitral prosthetic valve dysfunction by transesophageal color coded Dopp ler echocardiography (abstr). Circularion 1988:78(suppl 11):II-607. 6. Nellessen U, Schnittger I, Appleton CP, Masuyama T, Bolger A, Fischell TA, Tye T, Popp RL. Transesophageal two-dimensional echocardiography and color flow Doppler flow velocity mapping in the evaluation of cardiac valve prostheses. Circulation 1988:78:848-855.

Color Flow Doppler Evaluation of Cardiac Bioprosthetic Valves Mohsin Alam, MD, Howard S. Rosman, MD, Kathryn Hautamaki, RN, RDMS, Lois Graham, ccvr, Donald J. Magilligan, Jr., MD, Fareed Khaja, MD, and Paul D. Stein, MD

T ransthoracic color flow Doppler has shown promise in evaluating bioprosthetic heart valves in a limited

number of patients.’ We present our color flow Doppler, pulsed and continuous wave Doppler findings in evaluat- ing bioprostheses in the mitral and aortic valve positions.

Color flow Doppler, pulsed, continuous flow Doppler and echocardiographic studies were performed in 150 patients with bioprosthetic valves implanted in mitral and aortic positions. The studies were performed from parasternal, apical, suprasternal and subcostal windows using commercially available equipment (Hewlett Pack-

From the Heart and Vascular Institute, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, Michigan 48202. Manuscript received June 8, 1989; revised manuscript received and accepted August 11, 1989.

RGUREl.Cd6r8owDoppk6faKwraly~ bio- pRxmudc~vahf6.LA=M~Lv=left~ MR=d&al~RA=rigMattimqRV=ri&l

. MS=--.

ard, Sonas 500). All valves were evaluated by colorjlow Doppler for the presence or absence of valve regurgita- tion.

The following definitions were used to grade the se- verity of bioprosthetic valve regurgitation.2q3 MILD REGUR-

GITATION IN THE MITRAL POSITION: the colorflowjet occu- pied <20% of the left atria1 chamber. MODERATE REGUR-

GITATION IN THE MITRAL POSITION: the color flow jet occupied 20 to 40% of the left atria1 chamber. SEVERE

REGURGITATION IN THE MITRAL POSITION: the colorflowjet occupied >40% of the left atria1 chamber (Figure 1). MILD REGURGITATION IN THE AORTIC VALVE POSITION: the width/height of the proximal regurgitant jet was less than half the width/height of the left ventricular outflow tract. MODERATE REGURGITATION IN THE AORTIC VALVE PO-

SITION: the width/height of the proximal regurgitant jet was half to two thirds of the left ventricular outflow

FlGURE2.ColortkwDopplerofaseverelyremmRmtbio- pmshticaorticvabe.AR=aadicrtevgitartje@o%er abkeviatimsasinFigve1.

THE AMERICAN JOURNAL OF CARDIOLOGY DECEMBER 1, 1989 1389

BRIEF REPORTS

t?‘UCt. SEVERE REGURGITATION IN THE AORTIC VALVE POSI-

TION: the width/height of the regurgitant jet was greater than two thirds of the left ventricular outflow tract and the length of jet extended beyond the papillary muscles (Figure 2).

Peak transvalvular flow velocities were obtained in all prosthetic valves using both pulsed and continuous wave Doppler. The transducer alignment was kept as close as possible parallel to jlow when obtaining peak transvalvular flow velocities. From the peak jlow, the peak and mean mitral and aortic valve gradients were calculated by an on-line computer using the modified Bernoulli equation, where gradient = 4 (peak velocity)2. The prosthetic mitral valve area was similarly deter- mined from the maximal transmitralflow velocities us- ing the pressure half-time method.’ In the stenotic aortic

valve the orifice area was determined using continuity equati0n.j

Patient characteristics are summarized in Table I. In all 48 patients with dysfunctioning valves and in 12 of 102 with normal bioprostheses, cardiac catheterization and angiography were performed within 26 days (mean 6) of ultrasound studies. The color flow Doppler fea- tures of valve regurgitation were correlated with angiog- raphy in all dysfunctioning valves. The angiographic valve regurgitation was graded by conventional angiog- raphy criteria based on the degree of opacification of the receiving chambers and number of cardiac cycles re- quired for maximal opacification. In all patients with predominantly stenotic bioprostheses the valve area was calculated from cardiac catheterization by modified Gorlin equation. Replacement of dysfunctioning pros-

Doppler regurgitation Angiographlc regurgitation

Absent Absent

Mild

Doppler regurgitation Angiographic regurgitation 1

Absent 2

Absent -2

Mild Mild

Moderate

FlGURE3.CobrflowDopp&randa1&0. graphictEamaenoftileseveIGyof . lmpmdee*dvhm.

muw4.co&rllowDo#lkrmld~ graphktEommbnofthvswerityof b@WO&dkUWtkVdWi~.

1390 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 64

TABLE I Doppler Features of Bioprosthetic Valves

Valve Functron (n)

Normal mitral (61) Regurgrtant mitral (28) Pararegurgitant mitral (4) Stenotic mitral (7) Normal aortic (41) Regurgitant aortrc (8) Stenotic aortic (1)

* p <O.OOl vs normal mitral valves. NP = not performed.

Peak Velocrty Mean Gradient

(m/s) (mm W

1.9 f 0.3 7f2 2.3 f 0.3 9f4 2.2 f 0.4 7f2 2.5 f 0.3’ 15f6’ 2.4 f 0.4 13i5 2.7 f 0.4 17 f 5 4.5 49

Valve Area

O-6

3.3 f 0.5 1.9 f 0.4 2.3 f 0.6 0.9 f 0.3’ NP NP 0.6

Regurgitation Seventy (%)

Mild (5) Mild-severe (100) Moderate-severe (100) Mild-moderate (28) Mild (9) Moderate-severe (100) 0

thetic valves was subsequently performed in 41 of 48 valves.

Figure 3 shows the presence or absence of colorflow bioprosthetic mitral regurgitation and its correlation with angiography. Qualitatively, Doppler findings agreed with angiography for the presence of valvular regurgitation in 27 of 28 patients (96%) and its absence in 10 of 11 patients (91%). Quantitatively, the Doppler method correctly defined mitral regurgitation in only 19 of 28 patients (68%). It underestimated mitral regurgi- tation by 1 grade in 7 patients and by 2 grades in 2 patients (Figure 3). Figure 1 shows colorjlow Doppler of a severely regurgitant bioprosthetic mitral valve.

The angiographic and color flow Doppler correlation of aortic regurgitation is summarized in Figure 4. Note that color flow Doppler correctly estimated severity of aortic regurgitation in 7 of 8 (87%) patients and under- estimated it in 1. Figure 2 shows colorjlow Doppler of a severely regurgitant bioprosthetic aortic valve.

All 4 patients with paravalvular mitral regurgitation had an eccentric color jet located outside the confines of the valve ring (Figure 5). Compared to angiography, colorjlow Doppler correctly estimated the severity of the mitral valve regurgitation in 3 of 4 (75%) patients.

The correlation between Doppler- and catheteriza- tion-derived mitral and aortic valve areas is summarized

FlGURE5.Color6owDoppbrimagedapuav~ mitral vaive. Note Ihe eccenbk

ka6o11ofthem6vgbntcolar6owjet.MR=mitral regu&mtict;otharabbre~asinFiil.

in Figure 6. Note the good correlation (r = 0.83) between the 2 methods when evaluating stenotic bioprosthetic valves.

The normal values of Doppler-derived peak valve velocities, mean valve gradients and valve area of bio- prosthetic valves are summarized in Table I.

Our results indicate that color flow Doppler can accu- rately diagnose the presence of bioprosthetic valve regur- gitation but may underestimate its severity in 13% of aortic and 32% of mitral valves. Because all patients with color flow Doppler findings of severe bioprosthetic valve regurgitation had severe angiographic regurgitation, its presence on color flow Doppler is an excellent predictor of severe valve dysfunction. Recently, transesophageal color flow Doppler has shown potential in evaluating biopros- thetic and mechanical mitral valve regurgitation.6

We were also able to differentiate paravalvular bio- prosthetic mitral regurgitation from valvular regurgita- tion by virtue of the eccentric location of the origin of

Doppler cm*

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0 0.2 0.4 0.6 0.8 1.0 1.2 1.4

Cardiac Catheterization cm*

l Mitral valve AAortic valve r= 0.83

FlGURE6.Cardiac-and--of themhlandaellic8tendk~ VdWBS.NObtha

goodltomhth(r=0.82)betweeflthe2methods.

THE AMERICAN JOURNAL OF CARDIOLOGY DECEMBER 1, 1989 1391

BBIEF BEPOBTB

color flow jet when viewed from multiple acoustic win- dows. In stenotic bioprosthetic valves the Doppler-de- rived mitral and aortic valve areas correlate fairly well with areas obtained during cardiac catheterizations.

In conclusion, color flow Doppler is of value in diag- nosing bioprosthetic mitral and aortic valve regurgita- tion, but may underestimate its severity in some in- stances. The color flow Doppler findings of severe bio- prosthetic mitral and aortic valve regurgitation are an excellent predictor of severity of valve dysfunction. Pulsed and continuous wave Doppler are of value in diag- nosing and quantitating bioprosthetic mitral and aortic valve stenosis.

1. Fan P, Kapur KK, Aggarawal KK, Jain S, Goyal R, Nanda NC. Utility of color flow acceleration in differentiating valvar from paravalvar prosthetic mitral regurgitation. Circulation 1987;76(suppI Iv):IV-448. 2. Helmcke F, Nanda NC, Hsiung MC, 8oto B, Adey CK, Goyal RG, Gatewood RP. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation 1987;75:175-183. 3. Perry GJ, Helmcke F, Nanda NC, Byard C, 8oto B. Evaluation of aortic insufficiency by Doppler color flow mapping. JACC 1987,9:952-959. 4. Holen J, Aaslid R, Landmark K, Simonsen S, Cktrem T. Determination of effective orifice area in mitral stem& from noninvasive ultrasound Doppler data and mitral flow rate. Acra Med Stand 1977:201:83-88. 5. Zoghbi WA, Farmer KL, 8oto JG, Nelson JG, Quinones MA. Accurate noninvasive quantification of stenotic aortic valve area by Doppler echocardiogra- phy. Circulation 1986;73:452-459. 6. Daniel WG, Hanrath P, Mugge A, Langemtein B, Engel H, Grote J. Assess- ment of mitral prosthetic valve dysfunction by transesophageal color coded Dopp ler echocardiography. Circulation 1988;78(suppl II):II-607.

Analysis of Calcium, Zinc, Magnesium, Iron and Copper Content in Myocardium and Stenotic Mitral Valves llker Durak, PhD, Ahmet Sahin, MD, Zuhal Yurtarslani, MD. and Ahmet Sonel, MD

R heumatic endocarditis produces the verrucous valvu- litis of acute rheumatic fever, which leads to serious

permanent cardiac lesions. While the initial insult to the mitral valve is rheumatic, subsequent changes may be nonspecific. They can result from trauma to the valve caused by altered flow patterns due to the initial deformi- ty or other reasons not yet known. In this respect, changes in the metabolism of some elements including calcium, zinc, magnesium, iron and copper may have unestab- lished functions in the disease process. This work intends to evaluate that hypothesis.

Although calcium has many vital functions in the body, experimentall~* and clinical3 studies have shown that high intracellular calcium levels can cause damage to muscle. Several studies have emphasized the signifi-

From the Department of Biochemistry, Faculty of Medicine, and the Department of Cardiology, Ibn-i Sina Hospital, University of Ankara, Ankara, Turkey. Manuscript received March 24, 1989; revised manu- script received August 21,1989, and accepted August 22.

cant role of hypercalcemia in cardiac valvular4~5 and mi- tral anula@ calcification. To our knowledge, no investi- gation between quantitative calcium levels of heart valve and heart muscle and valve calcification has been report- ed. We performed such a study to establish possible corre lations between the calcification process and quantitative calcium levels of heart valve and heart muscle.

We also attempted to investigate the roles, if any, of other elements such as zinc, iron, magnesium and copper because the metabolism of these elements is related to calcium metabolism. Among these elements, magnesium seems to be of particular importance. In 1 study,9 myo- cardial magnesium content was found to be lower in biopsy samples from patients with cardiomyopathic and dysplastic lesions than that in biopsy samples from con- trol subjects. Two studies have established correla- tions between magnesium deficiency and cardiac disor- ders.l”J1

Mitral valves and papillary muscle pieces removed together with chordae tendineae were obtained by surgi-

TABLE I Values of Elements in Heart Valves from 40 Patients (1) and 12 Control Subjects (2)

A 0 C p Value Element Group

p Value (n = 19) (n = 7) pn=14) BvsC CVSD

Calcium(ppm) 1 - 64f23 419f 128 6,871 f2,714 <O.ool <O.ool 2 307f 120 - - - - -

P value - <O.oDl <0.005 <O.Ol - -

Zinc (ppm) 1 13f6 8f2 13f2 20f9 <O.Ol <O.Ol 2 14f4 - - - - -

P value NS <O.Ol NS <O.Ol - - Magnesium (ppm) 1 361 f 137 189 f 47 453f 190 539 f 128 <O.ool <O.Ol

2 362f 140 - - - - -

P value NS <O.ool <O.Ol <O.Ol - -

IrOn C-m) 1 54f 13 47f13 57*9 63f14 -co.05 <0.05 2 174f37 - - - - -

P value <O.ool <O.ool <O.ool <O.ool - - Copper (ppm) 1 8f4 7f4 - llf5 - -

2 35f17 - - - - -

P value <O.ool <0.001 - <0.001 - -

All * values are mean f standard deviation. A = patient and control @OUpS in general without ck3ssifkation: B = patient group with heart valve c&ium levels <ZOO ppm; C = pat&t group with heart ~a& &jum lev& &

Lween 200 and 1.000 ppm; D = patient group with heart valve calcium levels >1.000 ppm; NS = difference not significant.

1392 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 64