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Doppler Ultrasonography Br Heart J: first published as 10.1136/hrt.55.3.283 on 1 March 1986. Downloaded from Br Heart J 1986; 55: 283-5 Non-invasive grading of aortic regurgitation by Doppler ultrasonography ANDREAS HOFFMANN, MATTHIAS PFISTERER, PETER STULZ, HANS E SCHMITT, FELIX BURKART, DIETER BURCKHARDT From the Division of Cardiology, University Hospital, Basle, Switzerland SUMMARY Doppler ultrasound without concomitant echocardiographic imaging was used to grade isolated aortic regurgitation in 21 patients. The severity of aortic regurgitation was sub- sequently graded (from 0 to IV) angiographically. A 2 MHz continuous wave Doppler transducer was placed over the apex of the heart and the beam was aimed parallel to the mitral flow by means of acoustic guidance. Mitral pressure half time was calculated from the analogue maximum velocity tracing and it was (60 ms in 10 controls; 50-120 ms in five patients with grade II, 120-160 ms in nine patients with grade III, and > 160 ms in seven patients with grade IV aortic regurgitation. These results indicate that a semi-quantitative grading of aortic regurgitation may be; obtained non-invasively with non-imaging Doppler ultrasonography in patients without concomitant mitral valve disease. In patients with severe aortic regurgitation the pre- entire left ventricle). We also studied 10 controls systolic murmur described by Austin Flint in 1862 without valvar heart disease. presumably results from impairment of mitral flow http://heart.bmj.com/ by the aortic regurgitant jet impinging on the mitral valve.' Because intracardiac blood flow can be mea- DOPPLER TECHNIQUE sured non-invasively by Doppler ultrasonography,2 A 2 MHz continuous wave ultrasound transducer we investigated the possibility of predicting the without imaging capability was placed over the apex severity of aortic regurgitation on the basis of mitral ofthe heart, with the ultrasonic beam aimed towards flow measured by the Doppler method. the mitral orifice and kept parallel with the mitral blood flow by means of acoustic guidance. The Doppler instrument (Pedof, Vingmed, Oslo) is Patients and methods on September 26, 2021 by guest. Protected copyright. equipped with frequency estimators, providing ana- PATIENTS logue outputs of non-directional maximum flow We studied 21 patients with aortic regurgitation (15 velocity (Vmx) and directional mean velocity men, 6 women, aged 27-74 years). Patients with (Vie5.). When the typical diastolic audiosignal of rheumatic mitral valve disease were excluded by mitral flow was heard, simultaneous recordings of echocardiography. All patients underwent sub- electrocardiogram, Vmean, and V,X were made at 50 sequent left heart catheterisation and biplane aor- mm/s paper speed. The mitral pressure half time tography for visual grading of aortic regurgitation (t/2) was determined from the VM,x recordings-that by an independent observer (grade 0, no regur- is the time required for Vmax at its peak diastolic gitation; grade I, faint regurgitation; grade II, frank value (A) to reach the point B = A/,fi (Fig. 1). regurgitation without accumulation of contrast t/2 has been shown to correlate inversely with the material within the left ventricle; grade III, regur- area of the mitral valve orifice in patients in whom gitation and accumulation of contrast; grade IV, free mitral flow is impaired by mitral stenosis.23 regurgitation with immediate opacification of the STATISTICAL ANALYSIS Requests for reprints to Dr Andreas Hoffmann, Division of Cardi- Doppler and angiographic data were compared by ology, University Hospital, 4031 Basle, Switzerland. the non-parametric rank correlation method of Accepted for publication 22 October 1985 Kendall.4 283 Br Heart J: first published as 10.1136/hrt.55.3.283 on 1 March 1986. Downloaded from 284 Hoffmann, Pflsterer, Stulz, Schmitt, Burkart, Burckhardt Electrocardiogram 1 m/s A A B r / 1 1 t/2 < 60ms t/2 > 60ms Normal B- A Prolonged Fig. 1 Schematic representation of normal mitralflow (left) andprolongation of mitralpressure half time (t/2) (right). Vmax, maximumflow velocity. Results Discussion Mitral pressure halftime was < 60 ms in all controls, Non-invasive grading of aortic regurgitation has whereas it was 50-120 ms in the five patients with been unrewarding in the past. Because the aortic grade II aortic regurgitation; 120-160 ms in the nine regurgitant jet can be detected directly by Doppler patients with grade III aortic regurgitation; and > 160 ms in the seven patients with grade IV aortic regurgitation (Figs. 2 and 3). There was a highly 300 - significant correlation between the angiographic and http://heart.bmj.com/ Doppler grading (Kendall's rank correlation test, p<0 001). Left ventricular end diastolic pressures 250] ranged from 8 mm Hg to 44 mm Hg. There was no correlation. between t/2 and left ventricular end diastolic pressure. An Austin Flint murmur was detected clinically in eight of 16 patients with grade Ai 200. III or IV aortic regurgitation. ._ on September 26, 2021 by guest. Protected copyright. 150* 100 W a * Electrocardiogram 50 v n=31 VMIEE Controls fI III IV Angiographic grode Fig. 3 Comparison ofmitral pressure half time (t/2) as Fig. 2 Prolonged mitral pressure half time (200 is) as measured by the non-invasive Doppler method and measured on the mitral maximum flow velocity curve in a angiographic grade ofaortic regurgitation in 21 patients with patient with severe aortic regurgiation (angiographic grade aortic regurgitation and in 10 controls (p < 0.001 by IV) (calibration = 1 mis, paper speed =SO mme s). Kendall's rank correlation test). Br Heart J: first published as 10.1136/hrt.55.3.283 on 1 March 1986. Downloaded from Non-invasive grading of aortic regurgitation by Doppler ultrasonography 285 ultrasound techniques there have been several increase in left ventricular end diastolic pressure attempts at quantitation. Boughner calculated a impedes left atrial emptying. The relation between regurgitant fraction from planimetric comparison of t/2 and end diastolic pressure in our patients, how- forward-to-reverse flow curves.5 A similar approach ever, was less obvious than that between t/2 and aor- was used by Sequeira and Watt6 and by Quinones et tic regurgitation grade, and t/2 was normal in al,7 whereas Diebold et al reported the use of a patients with raised end diastolic pressures due to forward-to-reverse velocity index.8 The usefulness congestive heart failure of non-valvar origin. of these methods is limited primarily by the consid- In conclusion, non-invasive grading of aortic erable overlap of data and by the difficulty of obtain- regurgitation by measurement of mitral flow ing adequate simultaneous tracings of systolic and impairment with a simple continuous wave Doppler diastolic flow curves. Jenni et al showed that the use ultrasound method without simultaneous imaging is ofmultiple gates (pulsed wave mode) provides a bet- feasible in patients without concomitant mitral valve ter basis for measurement of flow.9 This technique, disease. however, is experimental. Ciobanu et al reported a different technique with mapping of the left ventric- ular outflow tract to detect the presence of aortic References regurgitant flow, and the results of this method Their 1 Flint A. On cardiac murmurs. Am J Med Sci 1862; 44: accorded well with angiographic grading.'0 29-54. method needs to be confirmed. 2 Hatle L, Angelsen B. Doppler ultrasound in cardiology. We used the simple and inexpensive technique of 2nd ed. Philadelphia: Lea and Febiger, 1985. continuous wave Doppler without concomitant 3 Robson DJ, Flaxman JC. Measurement of the end di- echocardiographic imaging. The impairment of astolic pressure gradient and mitral valve area in mitral diastolic flow through the mitral orifice was used as stenosis by Doppler ultrasound. Eur Heart J 1984; 5: a measure of aortic regurgitation. Prediction of the 660-7. angiographic severity of aortic regurgitation by this 4 Kendall MG. Rank correlation methods. 4th ed. Lon- method was good (Fig. 3). Most authorities agree don: Griffin, 1970. the mitral 5 Boughner DR. Assessment of aortic insufficiency by that though there may be early closure of transcutaneous Doppler ultrasound. Circulation 1975; valve in cases of acute aortic regurgitation, this is not 52: 874-9. likely to be responsible for the Flint murmur in all 6 Sequeira RF, Watt I. Assessment of aortic regur- as cases. The Flint murmur seems to arise rather a gitation by transcutaneous aortovelography [Abstract]. http://heart.bmj.com/ result of turbulence generated between mitral and Br Heart J 1977; 39: 929. aortic flows in diastole." 7 Quinones MA, Young JB, Waggoner AD, Ostojic MC, Alteration of mitral flow can only be used as a Ribeiro LGT, Miller RR. Assessment of pulsed measure of aortic regurgitation in patients without Doppler echocardiography in detection and mitral valve disease because in mitral stenosis the quantification of aortic and mitral regurgitation. Br valve HeartJt 1980; 44: 612-20. duration of t/2 is inversely related to the mitral 8 Diebold B, Peronneau P, Blanchard D, et al. Non- area.3 Also in patients with severe aortic regur- invasive quantification of aortic regurgitation by clear recordings of mitral flow are some- gitation Doppler echocardiography. Br Heart J 1983; 49: on September 26, 2021 by guest. Protected copyright. times difficult to obtain because of excessive tur- 167-73. bulence. Indeed, mitral Vmax tracings were difficult 9 Jenni R, Hubscher W, Casty M, Anliker M, Krayen- to record in some ofour patients. Normal mitral flow biuhl HP. Quantitation of aortic regurgitation by a per- does not entirely rule out important aortic regur- cutaneous 128-channel digital Doppler ultrasound gitation because the regurgitant jet may be diverted instrument. In: Lancee CT, ed. Echocardiology. The more towards the left ventricular posterior wall and Hague: M Nijhoff, 1979: 241-3. 10 Ciobanu M, Abbasi AS, Allen M, Hermer A, Spellberg thus avoid the mitral inflow.
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