title: Localized transvalvular pressure gradients in mitral bileaflet mechanical heart valves and impact on gradient overestimation by Doppler.
abstract: BACKGROUND
  It has been reported that localized high velocity may be recorded by continuous-wave Doppler interrogation through the smaller central orifices of bileaflet mechanical heart valves (BMHV) and that this may result in overestimation of the transvalvular pressure gradient (TPG). However, the prevalence and clinical relevance of this phenomenon remain unclear, particularly for BMHVs in the mitral position. The objective of this in vitro study was to assess the presence and magnitude of localized high velocity in mitral BMHVs as well as its impact on TPG overestimation by Doppler.
  
  
  METHODS
  Nine BMHVs were tested under nine different flow conditions (volumes and flow waveforms) in a simulator specifically designed to assess mitral valve hemodynamics. Flow velocity was measured at three different locations (leading edge, midleaflets, and trailing edge) within the central and lateral orifices of the BMHVs using pulsed-wave Doppler. TPG was measured by pulsed-wave and continuous-wave Doppler and by catheterization.
  
  
  RESULTS
  The maximum flow velocity occurred within the central orifice of the BMHV in 61% of the 81 tested conditions. This locally higher velocity within the central orifice predominantly occurred at the leading edge of the prosthesis. Doppler overestimated mean TPG by an average of 5% to 10% compared with catheterization. The magnitude of the localized high velocity and ensuing overestimation of TPG by Doppler was more important at higher mitral flow volumes (P < .0001) as well as in BMHVs with smaller internal ring diameters (P < .0001).
  
  
  CONCLUSIONS
  This study shows that the flow velocity distribution within the three orifices of mitral BMHVs is not uniform and that higher velocity occurs more frequently, but not always, within the inflow aspect of the central orifice. In most mitral BMHVs and flow conditions, this localized high-velocity phenomenon causes small overestimation of TPGs (<2 mm Hg and <10%) by Doppler and is thus not clinically relevant. However, in small mitral BMHVs exposed to high flow rates, the overestimation of TPG due to localized high velocity could become more important and overlap with the range of gradients found in patients with prosthesis dysfunction or prosthesis-patient mismatch.
authors.affiliation: Aix-Marseille Université, CNRS, ISM UMR 7287, Marseille, France.
authors.forename: Morgane
authors.initials: M
authors.lastname: Evin
authors.forename: Philippe
authors.initials: P
authors.lastname: Pibarot
authors.forename: Carine
authors.initials: C
authors.lastname: Guivier-Curien
authors.forename: David
authors.initials: D
authors.lastname: Tanné
authors.forename: Lyes
authors.initials: L
authors.lastname: Kadem
authors.forename: Regis
authors.initials: R
authors.lastname: Rieu
mesh_terms: D000704:Analysis of Variance; D001783:Blood Flow Velocity; D006328:Cardiac Catheterization; D015150:Echocardiography, Doppler; D006350:Heart Valve Prosthesis; D006439:Hemodynamics; D066298:In Vitro Techniques; D016014:Linear Models; D008943:Mitral Valve / Q000000981:diagnostic imaging* / Q000601:surgery*; D011312:Pressure; D011474:Prosthesis Design