balloon mitral valvotomy is the treatment of choice to 2. McKay RG, Lock JE. Safian RD. Come PC, Diver DJ, Bairn DS, Berman AD,

achieve optimal mitral valve areas. Warren SE, Mandell VE, Royal HD, Grossman W. Balloon dilation of mitral stenosis in adult oatients: wstmortem and percutaneous mitral valvuloplastv studies. J.4CC /9k7.9;723-‘731. 3. Ribeiro PA, Al Zaibag M. Rajendran V, Ashmeg A, Al Kasab S, Al Faraidi Y.

1. Al Kasab S, Ribeiro PA, Shahed M. Al Zaibag M, Al Bitar I, Idris MT, Halim M, ldris M, Al Fagih MR. Mechanism of achieving mitral valve area Sawyer W. Comparison of results of percutaneous balloon mitral valvotomy using increase by single and double balloon mitral valvotomy. Am J Cordid 1988, single and double balloon technique. Am J Cardid /989.63:/35-136. 62.264-269

Color Flow Doppler Evaluation of St. Jude Medical Prosthetic Valves Mohsin Alam, MD, Howard S. Rosman, MD, Darleen McBroom, RDMS, Lois Graham, ccvf, Donald J. Magilligan, Jr., MD, Fareed Khaja, MD, and Paul D. Stein, MD

T ransthoracic color flow Doppler imaging has shown promise in evaluating Bjork Shiley mechanical pros-

thetic heart valves in a limited number of patients.’ We present our color flow Doppler, pulsed and continuous wave Doppler findings in evaluating St. Jude Medical mitral and aortic valves.

Colorfrow Doppler, pulsed, continuous flow Doppler and echocardiographic studies were performed in 48 normal and in 6 patients with severely regurgitant St. Jude Medical mitral and aortic valves. The studies were performed from parasternal, apical, suprasternal and subcostal windows using commercially available equip- ment (Hewlett Packard, Sonas 500). All valves were evaluated by color flow Doppler for the presence or ab- sence of valve regurgitation. The maximal regurgitant jet obtainedfrom parasternal, apical and subcostal win- dows was then graded as mild, moderate or severe de- pending on the extent of the jet in the receiving cham- bers.2q3

The following definitions were used. MILD MITRAL RE-

GURGITATION = the colorflow jet occupied <20% of the left atria1 chamber. MODERATE MITRAL REGURGITATION =

the color flow jet occupied 20 to 40% of the left atria1 chamber. SEVERE MITRAL REGURGITATION = the color flow jet occupied >40% of the left atria1 chamber. MILD

AORTIC REGURGITATION = the width/height of the proxi- mal regurgitant jet was less than half the width/height of the left ventricular outflow tract. MODERATE AORTIC RE-

GURGITATION = the width/height of the proximal regur- gitant jet was half to two thirds of the left ventricular outflow tract. SEVERE AORTIC REGURGITATION = the width/height of the regurgitant jet was more than two thirds of the left ventricular outflow tract and the length of jet extended beyond the papillary muscles.

Peak transvalvular jlow 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 flow when obtaining peak transvalvular ji’ow velocities, From the peak flow, the peak and mean mitral and aortic valve gradients were calculated by an on-line computer using the modified Bernoulli equation, where gradient = 4 beak velocity)2.

From the Heart and Vascular Institute, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, Michigan 48202. Manuscript received August 3, 1989; revised manuscript received and accepted August I I, 1989.

The prosthetic mitral valve area was similarly deter- mined from the maximal transmitraljlow velocities us- ing the pressure half-time method.4

There were 48 normal mitral, 20 normal aortic, 3 regurgitant mitral and 3 regurgitant aortic valves (Table 0.

In all 6 patients with dysfunctioning valves, cardiac catheterization and angiography were performed within 12 days (mean 4) of ultrasound studies. The color flow Doppler features of valve regurgitation were correlated

FtGUREl.Co&rfbwDopplerstudyofspatiemtdemomtratt- ingmildmgu@donofaSt.JudeMe&almitr~vdve.lhis @iQmthadsovoroangkgr~vatvo~.LA=loft atrh~;LV=leftventkkqMR=mitralregmgitantjet,RV= right ventride; S = intervmtrialer septum.

THE AMERICAN JOURNAL OF CARDIOLOGY DECEMBER 1, 1989 1387

EmEFREPGRTs

TABLE I Doppler Features of St. Jude Valves I

I Peak Velocity Mean Gradient Valve Area Regurgitation Valve Function (n) (m/s) (mm W (cd Severity (%) I

Normal mitral (28) Regurgitant mitral (3) Normal aortic (20) Regurgitant aortic (3)

1.8f0.4 2.1 f 0.5 2.4 f 0.4 3.1 f 1.1

4f2 9fO

13f5 20f12

2.9 f 0.6 2.7 f 0.2

- -

Mild (6) Mild-moderate (100) Mild (18) Moderate-severe (100)

with angiography in all dysfunctioning valves. The angi- ographic valve regurgitation was graded by conventional angiographic criteria based on the degree of opacifi- cation of the receiving chambers and number of cardiac cycles required for maximal opacification. Replacement of dysfunctioning prosthetic valves was subsequently performed in all 6 patients.

Color flow Doppler detected only mild to moderate mitral regurgitation in all 3 patients who had severe angiographic evidence of St. Jude Medical mitral regur- gitation (Figure I). In 2 patients the underestimation was of a severe degree (Figure 2). All these patients presented with clinical findings of decompensated heart failure.

Color flow Doppler agreed with angiography for the severity of aortic regurgitation in 2 of 3 regurgitant St. Jude Medical aortic valves (Figure 2).

The normal values of Doppler-derived peak valve velocities, mean valve gradients and valve area of St. Jude Medical valves are listed in Table I. Note that color flow Doppler demonstrated mild mitral and aortic re- gurgitation in 6% and 18% of mitral and aortic St. Jude Medical valves, respectively. These patients had no aus- cultatory findings of valve regurgitation.

The results of the current study indicate that the color flow Doppler criteria used for quantitating native mitral2 and aortic valve regurgitation3 can accurately diagnose the presence of valve regurgitation with St. Jude Medical prosthesis but may underestimate its severity in 1 of 3 aortic valves and all 3 mitral valves. With mechanical St. Jude Medical mitral valves this underestimation of regur- gitation may be a result of masking of the left atrium behind the valve due to the highly echo-reflective metallic disc. This phenomenon was demonstrated in vitro by Sprecher et al4 with mitral ball and cage, tilting disc and St. Jude Medical valves and, to a lesser extent, with bioprosthetic valves. Transesophageal color flow Dopp ler, where transducer location averts atrial masking, is more sensitive than transthoracic color flow Doppler in diagnosing mechanical prosthetic mitral valves regurgita- tion.516

Thus, in symptomatic patients with suspected St. Jude Medical mitral valve regurgitation, the current criteria for regurgitant severity are inadequate and other means should be used for quantitating regurgitation. Trans- thoracic color flow Doppler, however, was useful in eval- uating regurgitant St. Jude Medical aortic valves because there is no masking of the left ventricular outflow tract

Doppler regurgitation Angiographic regurgitation

2 I ---- --- severe

- - + Aortic valves

- Mitral valves

T

i ---w-w

2 Severe I

FlGUGE2.CobrGowDoppkrmd~ gr&kqlmlmdhofst.JudeMedcal mlldmdaomlkvdve~.

1388 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 64

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@oU~ abkeviatimsasinFigve1.

THE AMERICAN JOURNAL OF CARDIOLOGY DECEMBER 1, 1989 1389