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LETTER TO THE EDITOR

Ghost-Boostering Phantom Gradients

Anesthesia and Critical Care, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil, lfmbns{at}superig.com.br

To the Editor:

Popescu et al. (1) reported a common and expensive situation: preoperative conflicting data. Transthoracic echocardiography is a cheap, noninvasive, and reproducible tool with tremendous impact on management. It aggregates different physical principles to obtain information that parallels cardiac catheterization but depends highly on clinical experience and manual dexterity skills. When cardiac output is normal, left ventricle outflow tract obstacles present distinct auscultatory findings usually related to aortic stenosis, massive septal hypertrophy, or membranes. Resulting gradients are measurable by continuous wave Doppler but their exact origin must be confirmed at least by M-mode imaging. Blind interrogation of the left ventricle outflow tract using a Pedoff transducer allows unbiased evaluation of high-speed jets and would have identified mitral regurgitation as the phantom gradient. Figure 2A depicts a normal pulse-wave Doppler envelope. Figure 2B shows a mitral valve inflow envelope suggesting that the sonic beam was not exactly at the left ventricle outflow tract. Finally, a 2.35 cm² aortic valve area would result assuming reductions of 15% in cardiac output by mitral disease and of 4 mm Hg in gradient as a result of respiratory variation. Preoperative expert consultation to consider available clinical and complimentary information is certainly a helpful strategy allowing better preoperative patient information and surgical planning (2).

References

1. Popescu WM, Prokop E, Elefteriades JA, et al. Phantom aortic valve pressure gradient: discrepancies between cardiac catheterization and Doppler echocardiography. Anesth Analg 2005;100:1259-62.[Abstract/Free Full Text]
2. Park KW Preoperative cardiology consultation. Anesthesiology 2003;98:754-62.[Medline]

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