Aortic Stenosis Gradient - Circulationcirc.ahajournals.org/content/circulationaha/23/4/509.full.pdf · AORTIC STENOSIS Table 1 Correlations between the Pressure Gradient in Millimeters

Aortic StenosisCorrelations between Pressure Gradient and Left

Ventricular Angiocardiography

By VIKING OLov BJiRK, M.D., INGEMAR CULLHED, M.D.,AND HERMAN LODIN, M.D.

IN THE STUDY of hemodynamics in aorticstenosis until the last decade more or

less indirect methods were used, such as elec-trocardiography and phonocardiography, anddirect and indirect pulse tracings. At bestthe results would confirm a clinical diagnosisbut often were of little help in the surgicalevaluation of the valvular defect.

Only after the introduction of left-sidedheart catheterization with pressure measure-ments in the left ventricle, by the trans-thoracic or transbronchial left atrial routes1 2or percutaneous left ventricular puncture3can the aortic stenosis be evaluated with re-spect to the systolic pressure gradient.

Thoracic aortography call give valuable in-formation in aortic stenosis concerning themobility of the aortic cusps and the degreeof post-stenotic aortic dilatation4 but does notreveal subaortic stenosis. Thoracic aortog-raphy is the routine method in assessingaortic regurgitation.5

Aortic catheterization may be extended tothe left ventricle,6' 7where contrast injectionmay be done.8 This method carries the dangerof damaging an aortic cusp or obstructing acoronary ostium.6' 9 Further, the roentgeno-logic study of the mobility of the aorticleaflets is disturbed by the presence of thecatheter, and in tight stenosis the catheteradds to the obstruction and artificially exag-gerates the systolic pressure in the ventricle.We have in the last years performed percu-

taneous puncture of the left ventricle withcontrast injection in more than 120 cases.

From the Department of Thoracic Surgery (Head:V. 0. Bjbrk, M.D.), the Department of Medicine(Head: E. Ask-Upmark, M.D.), and the Departmentof Diagnostic Radiology (Head: F. Knutsson, M.D.),University Hospital, Uppsala, Sweden.

Circulation, Volume XXIII, April 1961

The value of left ventricular angiocardiog-raphy in the diagnosis of valvular heart dis-ease was shown early.'0' 11 It is the aim ofthis paper to discuss the correlations betweenthe pressure measurements and the findingsat the left ventricular angiocardiography inaortic stenosis.

Material and MethodsThe material consists of 36 patients with aortic

stenosis of whom 21 had a pressure gradient overthe aortic orifice. The patient lies supine, andwith the caudal part of the thorax at some dis-tance from the lateral film (see below). A thinpolythene catheter, 10 to 15 em. long, was intro-duced percutaneously into a peripheral artery,usually the left femoral artery. The left ventriclewas punctured under local anesthesia as suggestedby Brock.3 The catheter and the puncture needlewere connected each to a strain-gage electro-manometer,* with the anterior axillary line asreference level. The pressure curves were recordedon a direct-writing four-channel oscillograph,'together with a standard limb-lead electrocardio-gram and the x-ray exposures. On a single-beamcathode-ray oscilloscope,' the electrocardiogram ora pressure curve was continually observed.On undamped curves the systolic pressures were

determined in the ventricle and the artery. Fromthese values the gradient between the peak sys-tolic pressures was calculated. After the positionof the needle in the ventricle was controlled byobservation of the ventricular pressure curve whenthe direction of the needle was altered, 1 ml. of76 per eent "Urografin" per Kg. of body weightwas injected, an electrocardiogram being run atthe same time. Six frames per second (maximumexposure time 0.03 second) were exposed in twoplanes during inspiration. During and immediatelyafter the injection the carotid arteries were com-pressed in order to reduce the flow of contrastmaterial to the brain.

After the withdrawal of the needle an electro-cardiogram and a chest x-ray were taken to lookfor signs of cardiac tamponade or pneumothorax.

*Manufactured by Elema, Inc., Stockholm, Sweden.

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BJORK, CULLHED, LODIN

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Figure 1Schematic drawings illustrating the inclination of the valvular plane: Left, in thefrontal, center and right, in the lateral projection. F, front; B, back; R, right; L, left.The direction of the beam: (--) The needle:

B

We have encountered two fatal complicationsamong our first 120 left ventricular punctures.12In a 55-year-old man cardiac tamponade occurredand in a 9-month-old boy the contrast was in-jected into the myocardium. A detailed reportof our minor and major complications is underpreparation.

Roentgenologic AspectsIn the ideal roentgen visualization of the

aortic orifice the beams should be parallelwith the valve plane. In true frontal andlateral projections, however, the incidentbeam generally forms an angle with thatplane (fig. 1). This disadvantage can, how-ever, to some extent be reduced by adjustingthe position of the patient or the tubes tobring the beams more parallel to the valveplane.

The position of the lateral tube or thepatient should be arranged so that the beamfalls in a somewhat caudo-cranial direction;the more so, the more transverse is the posi-tion of the heart. Adjustment of the frontaltube, however, has little effect, since the anglebetween the valve plane and the vertical beam(fig. 1) generally is small and since the valveplane may be inclined either cranially orcaudally. The orientation of the valve planethus cannot be exactly predicted.

In assessing the thickness and mobility ofthe individual cusps, it is essential that thebeam be directed along the cusp and its base"tangentially" (fig. 2). It is impossible toget more than one of the three cusps in anideal position with use of two planes at

right angles to each other. In a true lateralprojection a "tangential" picture is obtainedof the right coronary cusp, whereas in purefrontal and lateral projections a more obliqueview is obtained of the other two cusps.

Accordingly we have been using truefrontal and lateral projections, the inferiorpart of the thorax being at a slight distancefrom the vertical film plane.Owing to this arrangement it may be nec-

essary to tolerate projections that are attimes highly unsatisfactory, rendering diffi-cult the assessment of the morphology of theaortic orifice and the mobility of the cusps.Thus two or even all of the cusps may beshown in some degree of "oblique" projec-tion, and it may be incorrectly assumed thatthe mobility of the cusps and ealiber of theaortic orifice are reduced. Further, the valveplane may be completely masked in the lateralprojection by an enlarged left ventricle whenthere is transverse position of the heart. Withuse of two planes at right angles to eachother, however, some of the difficulties areeliminated, the assessment of the orifice beingbased on a comparison between the twoplanes.The normal orifice is characterized by thin

scarcely visible cusps, which open fully insystole and close tightly in diastole.The diagnosis of aortic stenosis is made on

the grounds of the thickness and mobilityof the cusps, the ealiber of the orifice, therate of contrast flow through the orifice, theappearance of the ascending aorta, and the


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Table 1Correlations between the Pressure Gradient in Millimeters of MercuryOrifice and the Electrocardiographic Changes in leads V5 to V,6

Diagnes's

ASASAS MIAS MS TSAS MS MI ATAI ASASAS MSAS AI 'MIAS MI MS AIMS AS MI AIMS AS AIASASASAS MSASAI ASAI ASMS ASMS AS AI

Femoralartery

pressure

120/75100 /65140/60105/80188 /84*150/73115/49110/62142/64190/72118/70125/95125/72140/84137/59185/93135/64~210/84185/80130/55159/86

over the Aortic

Systolic andend-diastolicleft ventricu-lar pressure

248/15205/10242/20200/0277/20230/13195/6185/15194/32240/20158/0165/0157/15170/14164/0210/15156/4230/7200/5142/0167/8

*Brachial artery pressure.tIn this case no angiocardiogram was obtained. The patient died

puncture and was reported recently.'(AS = aortic stenosis, AI = aortic insufficiency, etc.)

emptying capacity of the left ventricle andthe thickness of its wall.

In estimating the thickness of the cusps,care must be taken to measure only cuspsthat are seen in "tangential" view, or mis-leading figures will be obtained.The mobility of the cusps is estimated by

observing their position during differentphases of the cardiac cycle, regard being paidto any disturbances of rhythm and the rateof flow. The rate of flow may be so slow,for example in marked mitral stenosis andmitral incompetence, that it is insufficient toopen the valves fully, especially if the aorticcusps are thickened. If the rate of flow isneglected, therefore, a "morphologic" steno-sis may be diagnosed when in fact the cuspsare normal or thickened but not fused.

In many cases of stenosis a typical domeis seen. The caliber of the orifice is assessed


in connection with the

with greatest accuracy if there is a jet. Inmany cases, however, the caliber may be meas-

urable in only one plane, or not at all, becausethe orifice is eccentric on the dome and theincident beam therefore does not meet ittangentially.The degree of stenosis when the orifice can-

not be measured exactly may to a certainextent be assessed by estimating the rate ofthe flow and the degree of post-stenotic dila-tation of the ascending aorta. If other causes

of delayed flow can be excluded, incompletemixture of contrast medium and blood in theascending aorta indicates grave stenosis. Incases of pure stenosis conclusions can even

be drawn from the thickness of the ventricu-lar wall which is measured in diastole abovethe apex. The emptying time of the ventricleafter the completion of the injection, in rela-tion to the number of ventricular contrac-

S-T depres-sion andnegativeT waves

±

Pressuregradient

in mm. Hg

128105102100898080t755250404032302725202015128

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Figure 2Schematic drawing illustrating the relations be-tween the cusps and the incidence of the beam.In the lateral projection the right coronary cuspmeets the beam ideally. An oblique view is ob-tained of the two other cusps in both projections.RCC, right coronary cusp; R, right; L, left.The direction of the beam (->)

tions, will, in the absence of a mitral lesionand aortic insufficiency, give an idea of theresidual blood.

ResultsUndamped pressure curves were obtained

in all cases but two. These patients (casesno. 6 and 31) suffered from obliterating,probably thromboembolic aortic disease. Thefemoral pulses were absent in one and weakin the other patient. This source or error inthe determination of the pressure gradientshould be considered in the elder patients.The pressure gradient in four cases was

again measured during operation, prior tovalvulotomy. A reasonable correlation wasfound with the preoperative values, the dif-ference being -10, +13, +11, and -58 mm.Hg. The significant lower value in the lastcase (no. 100) may be due to altered hemo-dynamics, as the operation was performedin hypothermia and extracorporeal circula-tion. The remaining gradient, 70 mm., wasreduced to 0 mm. through the operation.Other authors, too, have found a good corre-lation between the pressure gradients beforeand during surgery.3 13, 14

In normal cases as well as in aortic stenosisthere is usually a higher systolic pressure inthe femoral arteries than in the centralaorta.'5-'7 Even a small positive systolic pres-


Table 2Correlations between the Gradient and the Inci-dence of Calcifications

Mean agePressure Number Number with without withgradient of calcifica- calcifica- calcifica-in mm. Hg cases tions tions tions

128-52 8 7 29 4950-25 7 4 32 4220- 8 4 1 42 460 1 0 1 41 48

Table 3The Pressure Gradient Correlated with the LeftVentricular Wall Thickness

Pressure Numbergradient of Thickness of ventricle in mm.in mm. Hg cases mean range

128-52 8 1 6 12-2050-25 7 14 9-2520- 8 5 11 8-150 15 12 6-25

sure gradient between the left ventricle andthe femoral artery will thus probably be dueto some degree of stenosis. Because of thejet effect pressure measurements just distalto the aortic valve will differ considerablyaccording to the situation of the tip of thecatheter.18-20 It should thus be safer to meas-ure the pressure in the femoral artery.

In the following our search for differentcorrelations with the pressure gradient isrelated. We wish to emphasize once more that"pressure gradient" mean.s the gradient be-tween the left ventricular and the peripheralartery pressures.Correlations between the Gradient and the Electro-cardiographic ChangesThe material was grouped according to the

pressure gradient, (table 1). All cases butone, with a gradient of at least 80 mm. Hgshow S-T depression and T-wave negativityin at least two of leads V4, V,, and V6. Thisis in general agreement with Fleming et al.,2'although the exceptional case with a gradientof 128 mm. Hg (the diagnosis was verifiedat open-heart surgery) shows the possibilityof severe aortic stenosis with an essentiallynormal electrocardiogram. This point was alsomade by Matthews et al.22 The same electro-


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The Pressureof the, Aortic

Pressuregradient

- in mm. Hg

Table 4Gradient Correlated with the SizeOrifice

Numberof

casesDiameter in mm.mean range

105-52 7 8 3-1550- 8 8 10 5-150 14 11 8-15

cardiographic findings were found in a casewith a gradient of only 52 mm., with severecombined aortic valvular disease and leftheart failure. Of the 15 cases with aorticstenosis without a pressure gradient onlyone had the same electrocardiographic pic-ture, a 40-year-old man with aortic stenosisand insufficiency and mitral insufficiency.Correlation between the Gradient and the Inci-dence of Aortic Valvular CalcificationThe presence of calcifications in the ma-

terial was investigated by means of tomog-raphy, which was performed in 29 of the36 cases. When the incidence of calcificationswas correlated to the pressure gradients (table2), a higher incidence was found in thosewith a larger gradient. In the different groupsthe cases with calcification were found inthe older patients.Correlation between the Pressure Gradient andthe Degree of Left Ventricular Hypertrophy

On the angiocardiograms the thickness ofthe left ventricle in diastole was measuredas an index of the degree of hypertrophy(table 3).Since the groups are small, very limited

conclusions can be drawn. There seems to bea positive correlation, however, between thegradient and the degree of left ventricularhypertrophy, as would be anticipated.Correlation between the Pressure Gradient and theLeft Ventricular End-Systolic Volume

The volume of the contrast-filled ventricularcavity at the end of systole was assessed onthe angiocardiograms. No correlation wasfound between the gradient and this volume.Nor was any correlation found between thisvolume and the total heart volume, expressedin milliliters per square meter of body sur-Circulation, Volume XXIII, April 1961

Figure 3(G. K.) Aortic valvular stenosis. Angiocairdiogramafter ventricular puncture. Ventricular systole.Lateral plane. Typical aortic stenosis with thick-ened cusps. The enlarged left ventricle superim-poses partly the orifice. Great dilatation of theascending aorta.

face area. The degree of arrhythmia inducedby the contrast injection could not be shownto influence the magnitude of the residualvolume.Correlation between the Gradient and the Degreeof Stenosis

The normal aortic orifice has a diameterof about 2.6 cm.14 The diameter in vivo canbe estimated indirectly in pure aortic steno-sis according to the formulas introduced byGorlin.23 More directly the diameter can bedetermined during open-heart surgery, thoughpalpation may overestimate the width of theostium.24 With due regard to the limitationsdiscussed earlier in this paper we have triedto measure the diameter of the aortic orificeon the angiocardiograms. This was possiblein 29 cases, and these were grouped accordingto the pressure gradient (table 4). The orificeis smaller in the cases with the largest gra-

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Figure 4(M. J.) Aortic ralitiar stenosis + mitral stenosis. Angiocardiograms after ventricularpunctifre. Ventricular systole, (left, center) lateral plane, ventricular diastole, (right)lateral plane. Typical aortic stenosis with a 3-mm. broad jet through the orifice. Thejet is eccentric, the contrast stream directed against the anterior aortic wall (left).The cusps are rery thick (center) and practically Without any mobility (right). Slightdilatation of the middle part of the ascending aorta. Typical mitral dome26 (right):mitral stenosis.

dients: in this group only one ease had adiameter of over 10 mm. That ease had agradient of 102 mm. with a ventricular pres-sure of 240/20 mm. Hg in the absence ofany clinically significant aortic incompetence.

There was no correlation between the gra-dient and the thickness of the aortic cusps,which in all cases measured 2 to 4 mm. Themobility of the cusps was good in only fourof 20 cases with a pressure gradient, con-trasted with the good mobility in eight of15 cases without gradient.No correlations were found between the

gradient and the heart volume, the left ven-tricular emptying time or the physical work-ing capacity, as measured on an ergometercycle in kilograms per meter per minute.The findings in four cases of aortic stenosis

are presented as representative examples.

Case ReportsCase 1

G. K., a 39-year-old mnan (201024/59). Norheumatic fever. For 2 or 3 years dyspnea anddizziness on work. Clinically he was classifiedas isolated aortie stenosis. Right heart catheteriza-tion: normal pressure values in rest and at work.Electrocardiogramn: no definite signs of hyper-trophy. Chest radiogram revealed a normal-sizedheart (340 ml./M.2 BSA), on tomography rather

extensive intracardiac calcifications were seen inthe aortic valvular region. On left ventricularpuncture a pressure gradient over the aortieorifice of 12S mmin. Hgr was detected. Left ven-tricular aniioeardiogram: see figure 3. The patientwas operated upon with the aid of deep hypother-miiia (24 C.) and extracorporeal circulation. Thenoncoronary and the fused right and left coronarycusps were found heavily calcified, leaving a longhut narrow passage for the blood stream. Bycurettage the noncoronary cusp could be decalcifiedand mnobilized, resulting in elimination of thepressure gradient, as measured during surgery.No attempt at valvulotomv was regarded as pos-sible because the mobility would not be influenced.When the patient left the hospital 5 weeks afterthe operation he was subjectively better and hadless calcifications on tomography. The patientdied 2 months later of a brain embolism froman incisional aortic aneurysm.Case 2

Ml. J., a 45-yeaer-old woman (140921/58). Rheu-illatie fever when 19 years old. For the last 5years decomiipensated-grade III (New YorkHeart Association). She was admitted for thefirst time in 19.57. A tricuspid and mitral stenosiswas diagnosed and later was operated upon.25For the first half year she felt better but thenhier sylmiptoms came back and she was againadmitted in 1958. The elinical diagnosis now be-came aortic, mnitral, and tricuspid stenosis, pos-sibly mitral regurgitation. Right heart catheteri-zation revealed moderate pulmonary hypertension


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and a diastolic gradient between the right atriumand ventricle. Electrocardiogram: right axis devi-ation, no ventricular hypertrophy. Chest radio-gram: heart size 1080 ml./M.2 BSA. Tomography:mitral and aortic calcifications. On left ventricularpuncture a systolic pressure gradient of 100 mlm.Hg was found. The angioeardiogramn (fig. 4)visualized a valvular aortie stenosis. Onl reopera-tion a transventricular dilatation of the aorticand mitral valves was done. However, a ruptureof the aortic valve occurred, resulting in severeaortic regurgitation, which overburdened the heart.The autopsy confirmed the preoperative diagnosis.

Case 3R. E., a 20-year-old man (390321/59). No

rheumatic fever. A murmur heard since the earlyschool years. Slight symptoms on exercise (gradeI). Clinical diagnosis: isolated aortic stenosis.Electrocardiogram: normal. Chest radiogram:heart size 400 ml.AI.2 BSA. Toniography: nocalcifications. Left ventricular puncture: valvularaortie stenosis (fig. 5) with a pressure gradientof 32 mm. Hg. So far operation has not beenadvised.Case 4

R. J., a 40-year-old woman (180613/58). Rheu-matic fever when 34 years old, since that increas-ingly decompensated, functionally grade III. Theclinical diagnosis was aortic and mitral stenosis.Right heart catheterization revealed definite pul-monary hypertension, Electrocardiogram: leftatrial enlargement, but no signs of ventricularhypertrophy. Chest radiogram: heart size 495ml./M.2 BSA. Tomography: no ealeifications. Leftventricular puncture was performed. There was nopressure gradient but the angiocardiograams (fig.6) showed a valvular aortic stenosis with fusedbut mobile cusps. At operation the mitral stenosiswas very tight, open only for the tip of the finger.A transventricular dilatation was performed, firstof the mitral valve to about 11/2 fingerbreadths,and then of the aortic valve, which offered a hardresistance to the instrument. With some force thevalve could be dilated to about 2 fingerbreadths.After the first postoperative week in a respiratorthe patient made a good recovery and left thehospital after 7 weeks.

DiscussionLeonardo da Vinci, as quoted by MeMil-

lan,24 has shown the triangular form of thenormal aortic orifice. The internal diameterof this orifice averages 2.6 em., which makesan area of about 3 cm.2 No hemodynamicchanges occur until the orifice is reduced toat least one quarter,'8 corresponding to a


Figure 5(R?. E.) Aortic calvular stenosis. Angiocardiogramnafter ventricular puncture. Ventricular systole.Lateral plane. Typical aortic stenosis with domeformation of the thicketned aortic cusps. The orificeis about 1.5 cmn. in this plane. The ascendingaorta, especially the middle part of it, is extremelydilated. Mediowecrosis cystica?

diameter of about 10 mm. In isolated aorticstenosis the valve area may be estimated whenthe rate and magnitude of flow across thevalve are known. This is possible if thepressures on both sides of the valve are de-termined at the same time as the cardiacoutput. In coexisting aortic regurgitation thetotal left ventricular stroke volume cannotbe determined and thus the valve area duringsystole cannot be assessed either. In spite ofinsignificant stenosis a large systolic pres-sure gradient will occur in aortic regurgita-tion,27 due to the large systolic flow. However,in acute dog experiments AMoscovitz et al.28obtained no systolic pressure gradient inaortic regurgitation.On the other hand, in mitral stenosis and

insufficiency the aortic flow will be dimin-ished, as in left ventricular failure. When

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Figure 6(R. J.) Aortic valvular stenosis + mitral stenosis. Angiocardiograms after ventricularpuncture. Ventricular systole: (left) lateral plane, (center) frontal -plane. Ventriculardiatstole: (right) frontal plane. Typical aortic stenosis with thick cusps and dome for-mation in both planes. The orifice is about 1.5 cm. in diameter. The aortic cusps havea good mobility. Slight dilatation of the middle part of the ascending aorta. The freeborders of the mitral leaflets acre thickened (left) and in ventricular diastole a typicalmitral dome is seen (right), causing a defect in the ventricular contrast: mitral stenosis.

significant aortic stenosis exists, the dimin-ished flow will give only a small gradient.From a practical point of view Brock29

and Wood14 stated that a pressure gradientover the aortic orifice of at least 50 mm.points to a significant aortic stenosis. In co-existing mitral stenosis or aortic regurgita-tion the gradient should exceed 25 or 100 mm.respectively.The combination in left ventricular punc-

ture of pressure measurement and left ven-tricular angiocardiography has not been re-ported earlier in the study of aortic stenosis.Cregg et al.30 mentioned "the excellent vis-ualization of the aortic mitral valves," butreported no case of aortic stenosis. RecentlyConnolly31 performed pressure measurementsin aortic stenosis and mentioned contrast in-jection. No results were given, however.Our material of 36 cases is rather heteroge-

neous, with six cases of isolated aortic stenosisand 30 cases of different combinations ofvalvular diseases. In this report we havechosen to present the whole material together,grouped according to the pressure gradient,since the different diagnostic subgroups wouldotherwise be very small.

With one exception the gradient was foundto correlate well with the T-wave negativityover the left ventricle. The same applies tothe degree of aortie valvular calcificationsand, though less marked, to the size of theorifice and to the ventricular wall thickness.In estimations of the size of the orifice dueattention must be paid to the risk of over-diagnosis by underestimating the width, ifdue to low stroke volume (e.g., in mitralinsufficiency or stenosis) or to unsatisfactory,oblique projections.

Probably hemodynamic changes may occureven before the aortic ostium is reduced toone fourth of the normal area, i.e., to a diam-eter of about 10 mm. Our two cases withisolated aortic stenosis and gradients, re-spectively 20 and 27 mm. Jig, had ostiumwidths of 15 and 12 to 13 mm., respectively,and these are minimum measurements. How-ever, these cases were young men with onlyslight symptoms and have so far not beenoperated upon.On the other hand a tight aortic stenosis

may exist without any pressure gradient, ifcombined with mitral valvular disease or inleft ventricular failure. In this material two


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cases with mitral and aortic stenosis withoutgradient had aortic ostium widths of 8 and10 mm. Both cases were operated upon withclosed transventricular dilatation of bothvalves. The aortic valves made a tough re-sistance to the instrument in both cases, buta successful dilatation was performed. Sofar no case without a gradient has beenoperated upon with open technic.

It is thus our impression that left ven-tricular angiocardiography is a valuable addi-tion to the technic of left ventricular punc-ture, in the study of aortic stenosis. Especiallyin combined valvular disease we think it maysometimes be of vital importance in order todetect preoperatively and to grade an aorticstenosis. The absence of a gradient at rest inthese cases is probably due to lessened dias-tolic filling. Perhaps more information couldbe gained by measuring the ventricular pres-sure at rest and graded exercise.The value of left ventricular angiocardiog-

raphy in the diagnosis of subvalvular aortiestenosis was recently reported.32 The sameshould apply to the diagnosis of supraaorticstenosis and a coexistent aortic coaretation.

Post-stenotic aortic dilatation is usual invalvular aortic stenosis and can be detectedin chest radiograms. A more exact outlinemay be obtained by contrast injection, as isshown in our case 3, where the considerableaortic dilatation awoke suspicions of medio-necrosis cystica.33

SummaryIn 36 cases of valvular heart disease with a

clinical diagnosis of isolated or significantaortic stenosis we have performed percuta-neous intercostal puncture of the left ven-tricle for pressure measurements and, in allbut one case, left ventricular angiocardiog-raphy. The possible correlations between thepressure gradient and the angiocardiographicfindings are discussed.With the exception of the unsatisfactory

angiocardiograms due to oblique projectionof the valvular planes, valuable informationwas obtained regarding the degree of aorticstenosis. This was especially the case if theCirculation, Volume XXIII, April 1961

aortic stenosis was combined with mitralvalve disease, resulting in a small or no sys-tolic pressure gradient.

References1. BJURK, V. 0. AND MALMSTROM, G.: Left heart

catheterization. Circulation Research 2: 424,1954.

2. MORROW, A. G., BRAUNWALD, E., HALLER, J. A.,AND SHARP, E. H.: Left atrial pressure pulsein mitral valve disease: A correlation of pres-sures obtained by transbronchial puncturewith the valvular lesion. Circulation 16: 399,1957.

3. BROCK, R. C., MILSTEIN, B. D., AND Ross, D. N.:Percutaneous left ventricular puncture in theassessment of aortic stenosis. Thorax 11: 163,1956.

4. ODMAN, P., AND PHILIPSSON, J.: Aortic valvulardiseases studied by percutaneous thoracicaortography. Acta radiol., Suppl. 172, 1958.

5. CASTELLANOS, A., AND GARCIA, 0.: The diagnosisof aortic insufficiency in the living subjectand the cadaver by means of retrogradeaortography. Rev. cubana Pediat. 25: 455,1953 (see reference 4).

6. ZIMMERMAN, H. A., SCOTT, R. W., AND BECHER,N. 0.: Catheterization of the left heart inman. Circulation 1: 357, 1950.

/ STAMPBACH, 0., AND Joss, E.: Der Katheteris-mus des linken Herzens. Unter besondererBertieksichtigung des retrograden arteriellenWeges. Cardiologia 35: 382, 1959.

8. JOHNSON, J. B., LAWLAH, J. W., MCFADDEN,F., AND DYER, JR., J. F.: Thoracic aortog-raphy. Am. Heart J. 53: 40, 1957.

9. JOHNSON, B., AND LOGAN, A.: Coronary arterycatheterization during thoracic aortography.Brit. Heart J. 20: 411, 1958.

10. PONSDOMENECH, E. R., AND NUNEZ, V. B.:Heart puncture in man for diodrast visualiza-tion of the ventricular chambers and greatarteries. Am. Heart J. 41: 643, 1951.

1.1. NUNEZ, V. B., AND PONSDOMENECH, E. R.: Heartpuncture. II. Cardioangiography: Clinical andelectrocardiographic results. Am. Heart J.41: 855, 1951.

12. BJURK, V. 0. AND LODIN, H.: Left heart cathe-terization with selective left atrial and ven-

tricular angiocardiography in the diagnosis ofmitral and aortic valvular disease. Progr.Cardiovas. Dis. 2: 116, 1959.

13. GREENt, D. G., SHARP, J. T., GRIFFITH, G. T.,BUNELL, I. L., AND MACMANUS, J. E.: Surgicalapplications of anterior percutaneous leftheart puncture. Surgery 43: 1, 1958.

14. WOOD, P.: Aortic stenosis. Am. J. Cardiol. 1:553, 1958.

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15. KROEKER, E. J., AND WOOD, E. H.: Comparisonof simultaneous recorded central and periph-eral arterial pulses during rest, exercisesand tilted position in man. Circulation Re-search 3: 623, 1955.

16. WRIGHT, J. L., TOSCANO-BARBOZA, E. ANDBRANDENBURG, R. 0.: Left ventricular andaortic pulses in aortic valvular disease. Proc.Staff Meet., Mayo Clin. 31: 120, 1956.

17. ROSHE, J., AND MORROW, A. G.: Central andfemoral pulses in aortic valve disease. Am.Heart J. 55: 599, 1958.

18. WIGERS, C. J.: Physiology in Health and Dis-ease. Ed. 2. London, Henry Kimpton, 1937.

19. CASTENFORS, H., PoRJI, I. G., AND RUDEWALD,B.: The hydrodynamics of aortic valve steno-sis; experiments with a special model. Car-diologia 25: 37, 1954.

20. PoaJt, I. G.: Himodynamiken vid aortastenos.Opusc. Med. 2: 62, 1957.

21. FLEMING, P., AND GIBSON, R.: Percutaneousleft ventricular puncture in the assessmentof aortic stenosis. Thorax 12: 37, 1957.

22.' MATTHEWS, M. B., MEDD, W. E., AND GORLIN,R.: Aortic stenosis: a clinical study. Brit.M. J. 2: 759, 1955.

23. GORLIN, R., AND GORLIN, S. G.: Hydraulic form-ula for calculation of the area of the stenoticmitral valve, other cardiac valves, and centralcirculatory shunts. Am. Heart J. 41: 1, 1951.

24. MCMILLAN, I. K. R.: Aortic stenosis. A post-

mortem cinephotographic study of valve action.Brit. Heart J. 17: 56, 1955.

25. CULLHED, I. AND MALERS, E.: Tricuspid-mitralstenosis. Acta Soc. med. upsalien 62: X, 1957.

26. BJMRK, V. 0., AND LODIN, H.: The evaluationof mitral stenosis with selective left ventricularangiocardiography. J. Thoracic Surg. 40: 17,1960.

27. GORLIN, R., MCMILLAN, I. K. R., MEDD, W. E.,MATTHEWS, M. B., AND DALEY, R.: Dynamicsof the circulation in aortic valvular disease.Am. J. Med. 18: 855, 1955.

28. MoscowiTz, H. L., AND WILDER, R. J.: Thepressure events of the cardiac cycle in thedog: Aortic valve lesions. Am. Heart J. 54:572, 1957.

29. BROCK, R.: Surgical treatment of aortic steno-sis. Brit. M. J. 1: 1019, 1957.

30. CREGG, H. A., SMITH, P. W., WILSON, C. W.,AND BULL, J. W.: Cardioangiography. Radi-ology 65: 369, 1955.

31. CONNOLLY, J. E.: Left ventricular puncture inthe assessment of aortic stenosis. J.A.M.A.171: 160, 1959.

32. BJ6RK, V. 0., JONSSON, B., AND NORDwNSTR.6m,B.: Subaortic stenosis. Thorax 13: 201, 1958.

33. MOKUSICK, V. A., LOGUE, R. B., AND BAHNSON,H. T.: Association of aortic valvular diseaseand cystic medial necrosis of the ascendingaorta: Report of four instances. Circulation16: 188, 1957.

To the physician particularly a scientific discipline is an incalculable gift, whichleavens his whole life, giving exactness to habits of thought and tempering the mindwith that judicious faculty of distrust, which can alone, amid the uncertainty of practice,make him wise.-SIR WILLIAM OSLER. Aphorisms from His Bedside Teachings and Writ-ings. Edited by William Bennett Bean, M.D. New York, Henry Schuman, Inc., 1950,p. 114.


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VIKING OLOV BJÖRK, INGEMAR CULLHED and HERMAN LODINAngiocardiography

Aortic Stenosis: Correlations between Pressure Gradient and Left Ventricular

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Aortic Stenosis Gradient - Circulationcirc.ahajournals.org/content/circulationaha/23/4/509.full.pdf · AORTIC STENOSIS Table 1 Correlations between the Pressure Gradient in Millimeters