Aortic transvalvular gradient mis-quantification

Aortic transvalvular gradient mis-quantification | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 9 January 2025 V1 Latest version Share on Aortic transvalvular gradient mis-quantification Authors : Marco Modestini 0000-0001-8630-992X [email protected] , Jan A. Krikken , Geertje Jansma , Wobbe Bouma , and Jayant S. Jainandunsing Authors Info & Affiliations https://doi.org/10.22541/au.173641509.97606339/v1 Published Annals of Cardiac Anaesthesia Version of record Peer review timeline 199 views 107 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Mitral regurgitation (MR) can occasionally mimic aortic stenosis (AS) on echocardiographic Doppler imaging, leading to diagnostic challenges. We present the case of a 55-year-old male undergoing minimally invasive mitral valve surgery for severe MR caused by posterior mitral valve leaflet prolapse. Preoperative transthoracic echocardiography revealed severe MR with no significant aortic valve abnormalities. Intraoperative transesophageal echocardiography (TEE) initially showed a high transvalvular aortic gradient (3 m/s) in the transgastric long-axis view, suggestive of mild-to-moderate AS. However, detailed Doppler analysis revealed a double envelope signal, representing both eccentric MR and true aortic valve flow. Closer evaluation showed the MR signal occurred earlier in the cardiac cycle, aligning with its hemodynamic timing, while the true aortic flow followed isovolumetric contraction. Subsequent three-dimensional TEE confirmed normal aortic valve morphology and function. This case highlights the importance of correlating preoperative findings, Doppler signal timing, and imaging data to avoid misdiagnosis. Systematic echocardiographic evaluation, including signal timing analysis, can differentiate between MR and AS, ensuring accurate intraoperative decision-making and preventing unnecessary interventions. Aortic transvalvular gradient mis-quantification Marco Modestini MD 1 *, Jan A. Krikken MD PhD 2 , Geertje Jansma MD 1 , Wobbe Bouma MD PhD 3 , Jayant S. Jainandunsing MD 1 1 Department of Anesthesiology, University Medical Center Groningen, Groningen, the Netherlands 2 Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands 3 Department of Cardiothoracic Surgery, University Medical Center Groningen, Groningen the Netherlands *Corresponding author: Marco Modestini, email: [email protected] , address: University of Groningen, Universitair Medisch Centrum Groningen, Department of Anesthesiology, EB32, Hanzeplein 1, 9713GZ Groningen, The Netherlands. Telephone: +31503612781 Abstract Mitral regurgitation (MR) can occasionally mimic aortic stenosis (AS) on echocardiographic Doppler imaging, leading to diagnostic challenges. We present the case of a 55-year-old male undergoing minimally invasive mitral valve surgery for severe MR caused by posterior mitral valve leaflet prolapse. Preoperative transthoracic echocardiography revealed severe MR with no significant aortic valve abnormalities. Intraoperative transesophageal echocardiography (TEE) initially showed a high transvalvular aortic gradient (3 m/s) in the transgastric long-axis view, suggestive of mild-to-moderate AS. However, detailed Doppler analysis revealed a double envelope signal, representing both eccentric MR and true aortic valve flow. Closer evaluation showed the MR signal occurred earlier in the cardiac cycle, aligning with its hemodynamic timing, while the true aortic flow followed isovolumetric contraction. Subsequent three-dimensional TEE confirmed normal aortic valve morphology and function. This case highlights the importance of correlating preoperative findings, Doppler signal timing, and imaging data to avoid misdiagnosis. Systematic echocardiographic evaluation, including signal timing analysis, can differentiate between MR and AS, ensuring accurate intraoperative decision-making and preventing unnecessary interventions. Keywords: Trans esophageal echocardiography, Trans thoracic echocardiography, Mitral regurgitation, Doppler signal misinterpretation. A 55-year-old male (weight 63 kg; height 175 cm), with no history of cardiovascular disease, presented with progressive dyspnea on exertion. Physical examination revealed a systolic murmur at the apex of the heart, suggestive of mitral regurgitation (MR). The electrocardiogram showed sinus rhythm at 62 beats per minute with signs of left ventricular hypertrophy. Transthoracic echocardiography (TTE) revealed severe MR due to a prolapse of the posterior mitral valve leaflet (PMVL) with no other valvular abnormalities. A thoracic computed tomography scan, performed as part of the workup for minimally invasive mitral valve surgery (MIMVS), showed no aortic or other abnormalities. The patient was scheduled for MIMVS. After induction of anesthesia, a transesophageal echocardiographic (TEE) examination was performed, revealing a prolapse of the P2 segment of the PMVL (Video 1a - b). Due to suboptimal imaging quality in the deep transgastric view, which is tipacally used for transvalvular aortic flow assessment, an alternative approach was employed. A transgastric long axis view with continuous wave doppler (CWD) of the aortic valve (AoV) revealed a high transvalvular gradient of 3 m/s, suggestive of mild to moderate aortic valve stenosis (Video 2a). However, three-dimensional imaging of the AoV showed no abnormalities and normal aortic valve opening (Video 2b). The decision to use the transgastric long-axis view was prompted by the inability to obtain adequate images from the conventional deep transgastric aortic valve view initially. Diagnosis: Mitral regurgitation mimicking aortic stenosis The observed transaortic gradients (video 2a) reveal a double envelop, mimicking signals from both the left ventricular outflow tract (LVOT) (small signal/blue arrow) and the transvalvular aortic signal (higher signal/red arrow). However, closer evaluation shows that the higher gradient begins earlier in the cardiac cycle which is implausible in the case of true aortic valve stenosis. In true aortic valve stenosis both signals represent the same blood flow and, therefore should have synchronized timing. Additionally, preprocedural TTE showed no signs of significant aortic valve stenosis (video 3a). Moreover the apical 5 chamber view shows a very eccentric MR jet directed towards the inter-atrial septum running parallel to the aortic flow (video 3b). Therefore the CWD signal likely captured both the MR signal (early an higher signal red arrow) and the true transvalvular aortic flow (late and low signal/ blue arrow) (video 2a). 1, 2 This interpretation aligns with the timing of these signals, as aortic flow signals typically start later in het cardiac cycle (after the isovolumetric contraction time) while the MR signals occur earlier. In conclusion, CWD is known to capture multiple velocities within the same envelope, as it records all velocities along the ultrasound beam, in contrast to the single-location recording of pulse wave Doppler. In cases presenting with apparent discrepancies, such as a high transvalvular aortic gradient despite a visually normal functioning valve, it is essential to review the pre-operative TTE. 3 In this case, the TTE showed normal gradients and a highly eccentric MR jet, which could have provided valuable insights into the observed findings. Further analysis of signal timing, as in video 2a, is a valuable tool for distinguishing between MR and AoV signals. It is worth noting the limited literature available on MR mimicking aortic stenosis, making diagnosis and differentiation in such scenarios particularly challenging. 4 When echocardiographic findings contradict prior assessments, observers should consider that the Doppler beam can capture multiple velocities, potentially leading to misinterpretation of the data. Recommendations to avoid this error: 1. In the presence of discrepancies (e.g., a high gradient with a visually normally functioning aortic valve), review the preoperative TTE for clues. Normal gradients and a highly eccentric MR jet may suggest the true underlying issue. 2. Carefully examine the Doppler signal timing, as shown in video 2a, focusing on onset and duration to differentiate MR from AoV flow. 3. For accurate timing analysis, measure the isovolumetric contraction time using tissue velocity imaging (TVI) or pulsed-wave (PW) Doppler, and relate the timing of the suspected AoV signal to this period. Typically, AoV flow begins after isovolumetric contraction, whereas MR flow may start earlier. Videos. Video 1a: 2D TEE with a mid-esophageal long-axis view showing the eccentric jet of severe MR directed over the anterior mitral valve leaflet, parallel to the aorta. Video 1b: 3D TEE of the mitral valve showing P2 mitral valve prolapse (blue arrow). Video 2a: 2D TEE with a continuous-wave Doppler transgastric long axis aortic view reveals a double signal representing both AoV and MR flows. The inner envelope corresponds to the transvalvular aortic valve flow tract (LVOT, smaller signal/blue arrow) and the outer signal reflects the MR flow (larger signal/red arrow) . Video 2b: 3D TEE view of the normal functioning aortic valve. Video 3a: 2D pre operative TTE. Apical 5 chamber view with color Doppler showing no signs of significant aortic stenosis. Video 3b: 2D pre operative TTE. Apical 4 chamber view with color Doppler showing a very excentric MR jet. References. 1. Nicoara A, Skubas N, Ad N, et al. Guidelines for the use of transesophageal echocardiography to assist with surgical decision-making in the operating room: A surgery-based approach. J Am Soc Echocardiogr. 2020;33(6):692-734. 2. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination. J Am Soc Echocardiogr. 2013;26(9):921-64. 3. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA guidelines on non-cardiac surgery: Cardiovascular assessment and management. Eur Heart J. 2014;35(35):2383-431. 4. Kumar A, Rajanikant K, Negi S, Singla A. Misdiagnosis of severe aortic stenosis instead of severe eccentric mitral regurgitation. Saudi J Anaesth. 2019;13(4):391-393. Information & Authors Information Version history V1 Version 1 09 January 2025 Peer review timeline Published Annals of Cardiac Anaesthesia Version of Record 8 Jul 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords doppler signal misinterpretation mitral regurgitation trans esophageal echocardiography trans thoracic echocardiography Authors Affiliations Marco Modestini 0000-0001-8630-992X [email protected] Universitair Medisch Centrum Groningen View all articles by this author Jan A. Krikken Universitair Medisch Centrum Groningen Afdeling Cardiologie View all articles by this author Geertje Jansma Universitair Medisch Centrum Groningen View all articles by this author Wobbe Bouma Universitair Medisch Centrum Groningen Thoraxcentrum View all articles by this author Jayant S. Jainandunsing Universitair Medisch Centrum Groningen View all articles by this author Metrics & Citations Metrics Article Usage 199 views 107 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Marco Modestini, Jan A. Krikken, Geertje Jansma, et al. Aortic transvalvular gradient mis-quantification. Authorea . 09 January 2025. DOI: https://doi.org/10.22541/au.173641509.97606339/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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