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CARDIOVASCULAR ANESTHESIA

An Evaluation of Prosthetic Aortic Valves Using Transesophageal Echocardiography: The Double-Envelope Technique

Andrew D. Maslow, MD^*, J. Michael Haering, MD^*, Stephanie Heindel, MD^*, John Mashikian, MD^*, Robert Levine, MD, and Pamela Douglas, MD

Departments of *Anesthesia and Cardiology, Beth Israel-Deaconess Medical Center; and Department of Cardiology, Mass General Hospital, Boston, Massachusetts

Address correspondence and reprint requests to Andrew Maslow, MD, Department of Anesthesia, Rhode Island Hospital, 593 Eddy St., Davol 129, Providence, RI 02903. Address e-mail to amaslow{at}lifespan.org

The conventional continuity equation uses nonsimultaneous measurements of blood flow velocities through the left ventricular outflow tract and across the aortic valve to calculate aortic valve area (AVA). We have noted that both velocities can be simultaneously obtained from continuous wave (CW) Doppler analysis (double-envelope [DE]). We hypothesize that prosthetic AVA can be calculated by using the DE technique, during transesophageal echocardiography (TEE). Prosthetic AVA was calculated in 41 of 45 patients immediately after aortic valve replacement by using the DE/AVA technique. Left ventricular outflow tract diameter was obtained from an esophageal view, while subvalvular (V₁) and valvular (V₂) peak velocities were simultaneously obtained from transgastric views by using CW Doppler. Prosthetic AVA and V₁/V₂ ratio (Doppler velocity index) were calculated. V₁ was also measured by using pulse wave Doppler, as is conventionally done. Twenty-three Carbomedic (CM) and 18 Carpentier-Edwards (CE) AVA were evaluated. DE/AVAs for CM and CE valves correlated and agreed with that reported by the manufacturer (CM r² = 0.91, mean bias -0.25 cm² [SD 0.18]; CE r² = 0.73, mean bias -0.02 cm² [SD 0.27]). Calculated Doppler velocity index values agree with available data (mean bias 0.03 [SD 0.05]). The V₁ obtained by using the DE method was nearly identical to the V₁ obtained by using pulse wave (r² = 0.95, mean bias 0.02 m/s [SD 0.04 m/s]). TEE assessment of prosthetic AVA using the DE technique agrees with data reported by the manufacturer. Obtaining subvalvular and valvular velocities from the same CW Doppler trace may simplify the continuity equation and help avoid errors caused by beat-to-beat changes in blood flow. Quantitative prosthetic aortic valve assessment can be performed, on-line, with TEE by using the DE technique.

Implications: Quantitative assessment of prosthetic aortic valve area can be performed on-line by using transesophageal echocardiography using the double envelope technique.

Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999