Key Words Blood pressure pressure recovery Aortic valve stenosis subaortic stenosis Echocardiography, transesophageal, transthoracic
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1 J Cardiol 2005 Nov; 465: Discrete 1 Discrete Subaortic Stenosis With Pressure Recovery: A Case Report Eri Yoshihisa Makoto Nobuhiko Naohito Hiroaki Takashi Jun Yoshinori HOSHIKAWA, MD MATSUMURA, MD, FJCC OKAWA, MD HITOMI, MD YAMASAKI, MD KITAOKA, MD, FJCC FURUNO, MD TAKATA, MD, FJCC DOI, MD, FJCC Abstract A 54-year-old woman with subvalvular aortic stenosis was admitted to our hospital. The pressure gradient across the left ventricular outflow tract was estimated as 88 mmhgpeakand 45mmHgmeanby Doppler echocardiography, but only 14 mmhgpeak to peakand 31mmHgmeanby cardiac catheterization. We considered this discrepancy attributable to the presence of moderate aortic regurgitation and the pressure recovery phenomenon. Pressure recovery has clinical relevance particularly in a patient with tunnel-like stenosis, with gradual lumen re-expansion beyond the limiting orifice. Therefore, if Doppler echocardiography shows significant left ventricular outflow tract gradient, precise evaluation of the stenosis geometry is required to investigate the effect of pressure recovery. J Cardiol 2005 Nov ; 465: Key Words Blood pressure pressure recovery Aortic valve stenosis subaortic stenosis Echocardiography, transesophageal, transthoracic peak to peak 1 2, : : : 30 : Department of Medicine and Geriatrics, Kochi Medical School, Kochi Address for correspondence : DOI Y, MD, FJCC, Department of Medicine and Geriatrics, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi ; ydoimed.kochi-u.ac.jp Manuscript received January 5, 2005 ; revised June 1, 2005; accepted July 15,
2 202 Fig. 2 Transthoracic Doppler echocardiogram Continuous-wave Doppler echocardiography revealed peak flow velocity across the left ventricular outflow tract of 4.7 m/sec. Peak pressure gradient was estimated as 88mmHg with mean pressure gradient of 45 mmhg. Fig. 1 Electrocardiogram on admission : 150cm55kg 136/60 mmhg 60/min 2 // : Fig. 1 X : 50% : Na 77.0pg/ml : / 47/26 mm /9/10mm 88mmHg 45 mmhgfig. 2 Fig. 3A 12 mm Fig. 3 B J Cardiol 2005 Nov; 465:
3 203 Fig. 3 Transesophageal echocardiograms A : Long-axis view showing tunnel-like stenosis from the left ventricular outflow tract to the ascending aorta. LVleft ventricle ; LAleft atrium. B : Short-axis view showing the most stenotic site in the subaortic space with a membranous ridge arrows. The aortic root was hypoplastic, but the aortic valve itself showed good opening. Left: subaorta, Middle: aortic valve, Right: ascending aorta. 4 : 14mmHg Fig mmhg 8 peak to peak 31 mmhg 45 mmhg J Cardiol 2005 Nov; 465:
4 204 Fig. 4 Pull-back pressure recording from the left ventricle to the ascending aorta Peak to peak pressure gradient was only 14 mmhg, and pressure recovery was observed. LVOTleft ventricular outflow tract. Other abbreviation as in Fig ,91 2 m/sec 2 31 mmhg 45mmHg 41 mmhg 10 mmhg Fig. 5A Fig. 5B 2,3 2,12,14 Baumgartner 4V cw2 2AVA c /AoA1AVA c /AoA; V cw, AVA c, AoA 14,15 J Cardiol 2005 Nov; 465:
5 205 Fig. 5 Diagrams showing pressure recovery A : Model of the orifice-like stenosis. The pressure gradient by Doppler echocardiographyp LVOT P stenosis is equal to that by catheterizationp LVOT P aorta. Pressure recovery is limited by turbulence distal to the stenosis. B : Model of tunnel-like stenosis. P LVOT P stenosis is higher than P LVOT P aorta because of pressure recoveryp aorta P stenosis. Abbreviation as in Fig cm cm cm 2 21 mmhg mmhg 45 mmhg peak to peak 14mmHg31 mmhg J Cardiol 2005 Nov; 465: Currie PJ, Seward JB, Reeder GS, Vlietstra RE, Bresnahan DR, Bresnahan JF, Smith HC, Hagler DJ, Tajik AJ : Continuous-wave Doppler echocardiographic assessment of severity of calcific aortic stenosis : A simultaneous Doppler-catheter correlative study in 100 adult patients. Circulation 1985; 71: Nakajima T, Arakaki Y, Kamiya T, Ogawa M, Sano T, Yabuuchi H, Sato I, Yamada O, Miyatake K, Tomiya H : Doppler echocardiographic estimates of pressure gradients in various type stenosis : Usefulness and limitations. J Cardiol 1989; 19 : Levine RA, Jimoh A, Cape EG, McMillan S, Yoganathan AP, Weyman AE : Pressure recovery distal to a stenosis : J Cardiol 2005 Nov; 465:
6 ; 13 : el Habbal MH, Suliman RF : The aortic root in subaortic stenosis. Am Heart J 1989; 117: Schlant R C, Alexander RW: Subvalvular aortic stenosis. in Hursts The Heart : Arteries and Veinsed by Schlant R C, Alexander RW, 8th Ed. McGraw-Hill, New York, 1994; pp Braunwald E, Zipes DP, Libby P : Subvalvular aortic stenosis. in Heart Disease : A Textbook of Cardiovascular Medicineed by Braunwald E, Zipes DP, Libby P, 7th Ed. WB Saunders, Philadelphia, 2005 ; pp Movsowitz C, Jacobs LE, Eisenberg S, Movsowitz HD, Kotler MN: Discrete subaortic valvular stenosis: The clinical utility and limitations of transesophageal echocardiography. Echocardiography 1993; 10 : Connelly MS, Webb GD, Somerville J, Warnes CA, Perloff JK, Liberthson RR, Puga FJ, Collins-Nakai RL, Williams WG, Mercier LA, Huckell VF, Finley JP, McKay R : Canadian Consensus Conference on Adult Congenital Heart Disease Can J Cardiol 1998; 14 : Oliver JM, Gonzalez A, Gallego P, Sanchez-Recalde A, Benito F, Mesa JM : Discrete subaortic stenosis in adults : Increased prevalence and slow rate of progression of the obstruction and aortic regurgitation. J Am Coll Cardiol 2001; 38 : Baumgartner H, Schima H, Tulzer G, Kuhn P : Effect of stenosis geometry on the Doppler-catheter gradient relation in vitro: A manifestation of pressure recovery. J Am Coll Cardiol 1993; 21 : Gjertsson P, Caidahl K, Svensson G, Wallentin I, Bech- Hanssen O : Important pressure recovery in patients with aortic stenosis and high Doppler gradients. Am J Cardiol 2001; 88 : Levine RA, Schwammenthal E : Stenosis is in the eye of the observer: Impact of pressure recovery on assessing aortic valve area. J Am Coll Cardiol 2003; 41 : Vandervoort PM, Greenberg NL, Pu M, Powell KA, Cosgrove DM, Thomas JD : Pressure recovery in bileaflet heart valve prostheses: Localized high velocities and gradients in central and side orifices with implications for Doppler-catheter gradient relation in aortic and mitral position. Circulation 1995; 92: Neiderberger J, Schima H, Maurer G, Baumgartner H : Importance of pressure recovery for the assessment of aortic stenosis by Doppler ultrasound: Role of aortic size, aortic valve area, and direction of the stenotic jet in vitro. Circulation 1996; 94 : Baumgartner H, Stefenelli T, Niederberger J, Schima H, Maurer G : is: A predictable manifestation of pressure recovery. J Am Coll Cardiol 1999; 33 : J Cardiol 2005 Nov; 465:
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