Catheter estimation of

stenotic valves
Dr. DAYASAGAR RAO
KIMS
HYDERABAD

Stenotic valve orifice areaevaluation

Cardiac catheterization- gold standard?
Echo doppler
MRI based
MDCT

Clinical

Stenotic valve orifice areaevaluation

Is there role of catheter based
assessment- stenotic valves in 2009?

ACC/AHA guidelines valvular heart

disease-evaluation 2008
Discrepancy:

clinical findings
noninvasive data

.
Technically unsatisfactory non invasive data
(echo-doppler)
operator dependent
acoustic window
TEE

Low flow- low gradient: aortic stenosis

Catheter based evaluation of

stenotic orifice
Is it safe?
tight/ critical stenosis
cerebral embolism- calcific aortic stenosis

Omran et al:

LANCET 2003

152 patients aortic stenosis

randomized: CAG only
Vs
CAG + crossing of aortic valve (retrograde)

Stenotic orifice area (catheter

based)
Brain MRI: diffusion imaging
22% focal diffusion imaging abnormalities
3% clinically apparent neurodeficit
only in patients- crossing of aortic valve.

Stenotic orifice area- catheter

based
Aortic stenosis:

retrograde approach
antegrade

Mitral stenosis:

LV- PCW
LV- LA

Stenotic orifice area

AORTIC STENOSIS- (LV-AO)
METHOD

EASE OF USE

DISADVANTAGE

PULLBACK

+++++

LEAST ACCURATE

FEMORAL SHEATH

+++++

PRESSURE
AMPLIFICATION ILIAC
ARTERY STENOSIS

DOUBLE ARTERIAL
PUNCTURE

+++

EXTRA VASCULAR
ACCESS RISK

PIG TAIL- DOUBLE

LUMEN

+++

DAMPING

PIG TAIL + PRESSURE

+++

EXPENSE

TRANSEPTAL

++

RISK

STENOTIC ORIFICE AREA

MITRAL STENOSIS
LV-PCW
LV-LA TRANSEPTAL
PROPER PCW PRESSURE: MEAN WEDGE- MEAN
PA
ALIGNMENT MISMATCH- TIME DELAY 50-70
msec
REALIGNMENT- PEAK OF V WAVE BISECTED BY
LV PRESSURE DOWNSTROKE.

STENOTIC ORIFICE AREA

MILD

MODERATE

SEVERE

AORTIC

>1.5 sq cm

1-1.5 sq cm

<1 sq cm

MITRAL

>1.5 sq cm

1-1.5 sq cm

<1 sq cm

TRICUSPID

<1 sq cm

PULMONARY

Peak gradient
>60 mm hg

VALVULAR STENOSISSEVERITY
Valvular disease cause of symptoms
Timing of intervention: symptomatic
status
natural history- symptoms

Stenotic orifice area

Geometric orifice area
Effective orifice area
Critical valve area

DIAGRAM SHOWING
Geometric / effective orifice area
Contraction co efficient

Contraction coefficient

STENOTIC ORIFICE- VALVES

Hemodynamic impact influenced by
Cross sectional area
Geometry of valve flat valves have
greater contraction co-efficient (for similar
CSA and volume flow)

Stenotic orifice area

Clinical implication:
- Planimetry area
- Effective orifice area (continuity/Gorlins)
- EOA smaller than planimetered areaproportional contraction coefficient.

PRESSURE RECOVERY
Fluid energy= pressure energy+ kinetic
energy
Narrowed orifice (vena contracta) highest
velocity
Downstream - flow stream expands
Deccleration (decreased velocity- kinetic)
Conversionkinetic pressure
(pressure recovery)

PRESSURE RECOVERY

Clinical implication- pressure

recovery
Doppler derived gradients- using CW
doppler @ vena contracta
Catheter derived gradients- downstream
vena contracta- pressure recovery

GRADIENT DERIVED BY CATH IS LOWER THAN

DOPPLER DERIVED GRADIENT

PROSTHETIC VALVES
Bileaflet valves
Side orifice velocities are less than central orifice
velocities. (side orifice velocities is 85% of central
orifice)
Pressure recovery occurs much further
downstream in central orifice than side orifice.
Discrepancy measurement of gradients- over
time.

Stenotic orifice area- pressure recovery

Pressure recovery is more across aortic than at
mitral
prosthetic valve- native valve.
Pressure recovery- exaggerated in
- Smaller aorta
- Stiffer aorta
- Hypertension
Discrepancy between catheter derived and doppler derived
pressure data. (thus calculated valve area)

Stenotic orifice area- pressure recovery

(exaggeration- HTN)

Stenotic valve area

Torricellis law
F= A X V
A=F/V
A=F/V Cc
F- Flow
A- Valve area
V- Velocity of flow
Cc- coefficient of contraction

Stenotic valve area

V2 = (CV)2 X 2Gh
V= (CV) x sq root 2Gh
h = pressure gradient
G = gravitational constant (980 cm/sec2)
for conversion cmH2 to units pressure
Cv- coefficient velocity for correcting energy
loss
(pressure energy- kinetic energy)

Stenotic valve area

A= F/V
F- flow (vol flow ml/sec)
Flow rate= cardiac output/ duration of
systole or diastole (SEP/DFP X HR)

Stenotic valve area

Valve area= cardiac output (HR X SEP)
44.3 X C X sq root of pressure
gradient
C- empirical constant
calculated valve area (by Gorlin)
actual valve area (at surgery)
Mitral Valve = constant 0.7 (later changed 0.85)
Aortic valve: assumed to be 1

GORLINS FORMULA

(AHJ 1951 Gorlin R, Gorlin G)

Eleven patients
Right heart catheterization- PCWP
Assumed LV diastolic pressure- 5mmhg
Duration diastole- peripheral arterial
tracing
Calculated mitral valve area
Measured MVA at surgery

GORLIN FORMULA
Cardiac output
Pressure gradient across valve
(mitral/aortic)
Duration of flow (DFP/SEP)- pressure
tracing
Constant (calculated-measured valve
area)

GORLIN FORMULA
Empirical constant includes
Conversion of cms H2o to units of pressure
Contraction co-efficient
Velocity co-efficient
Difference-

valve area calculatedand valve area at surgery

GORLIN FORMULA
Problems
cardiac output
Fick - oxygen consumption
Thermodilution- low output state
- significant TR
Duration of flow (SEP-DFP)
Alignment mismatch
Calibration errors

GORLIN FORMULA
Modification: HAKKI
cardiac output (L/ min)
Sq root of MPG
Heart rate: 60- 100/ min

Stenotic valve orifie area

Catheterization : gold standard ?
(Grossman et al 2006)

1.Invasive procedure
2.Risk
3.Limitations measured parameters
- calibration
-valvular regurgitation
4.Expensive
ACC/AHA Guidelines