Continuous-wave Doppler velocities and gradients across fixed tunnel obstructions: studies in vitro and in vivo.

Abstract

The simplified Bernoulli relationship appears to be quite accurate for predicting gradients across discrete valvular obstructions. Controversy exists about how accurately it predicts the severity of disease in longer segment obstructions. In this study we constructed a pulsatile model of subvalvular pulmonary stensosis in vitro to study nine custom-made subvalvular tunnels 2, 4, and 7 mm in length with flow cross sections of 0.5 to 1.5 cm2 and with the stenotic segment proximal to a nonstenotic bioprosthetic valve, and a pulsatile model in vitro of a 16 mm long tunnel-like ventricular septal defect (VSD) of varying cross-sectional area (0.20 to 0.64 cm2). We also compared the observations in vitro with those in an open-chest dog preparation with a tunnel-like interventricular communication. In the subpulmonic stenosis model, for each individual tunnel, 10 instantaneous peak gradients between 15 to 105 mm Hg were available. The pressure gradients across the tunnel alone, measured in the subvalvular area, were consistently higher than the measured gradients across the tunnel plus valve, suggesting some relaminarization of flow (i.e., a decrease in velocity) and pressure recovery (i.e., an increase in pressure) distal to the obstruction. Continuous-wave Doppler velocities across the 4 and 7 mm tunnels for the highest gradients were slightly lower than for the 2 mm tunnel at the same gradients, and it was only for the 0.5 cm2 cross section, 4 and 7 mm tunnels that there was a suggestion of minor viscous energy loss. For all the subvalvular tunnels studied, the Bernoulli relationship accurately predicted the results of the pressure drop across the tunnel only, while the gradient across tunnel plus valve was consistently lower. For the VSD tunnel model in vitro, the Doppler-derived gradients were approximately 40% higher than the measured gradients. The findings for the subvalvular and VSD tunnels in vitro and similar findings in the open-chest dogs with VSD suggest that relaminarization of flow and recovery of pressure occurred distal to the tunnel orifice, whereas continous-wave Doppler findings correlate with the highest instantaneous gradients measured in the lowest pressure areas at the vena contracta of the tunnel.

MR measurement of pulsatile pressure gradients

“…Equation (6) was used to evaluate the contribution of inertial and shear derivative operations to the total pressure gradient noise. The effect of spatial averaging was assessed by evaluating Equation (7). the velocity field, errors are introduced by finite sampling of the velocity field.…”

Simplified Bernoulli's method significantly underestimates pulmonary transvalvular pressure drop

“…Alternatively, Yoganathan et al showed that the simplified Bernoulli's equation reflects the maximal drop, which overestimates the measured drop across a valve or downstream of an obstruction. 31 Overestimation or underestimation of the true pressure drop would misrepresent the conditions under which the flow circulates and consequently affect diagnoses (e.g., grading the valvular stenosis) and follow-up. Nowadays, advanced MRI systems, equipped with phase contrast technology, can provide the required information to calculate GBE, for more accurate estimations of pressure drop in a completely noninvasive way.…”

Clinical and Echocardiographic Features of Primary Infundibular Stenosis with Intact Ventricular Septum in Dogs

“…[1][2][3][4]18,19 It has been defined as a discrete fibrous or fibromuscular diaphragm below the pulmonic valve or at the os infundibulum, or a more diffuse extensive area of fibromuscular hypertrophy creating more of a tunnel or an hour-glass type of deformity of the infundibulum.…”

“…Use of the modified Bernoulli equation for the estimation of stenosis severity has been validated in both an in vitro model of subpulmonary pulmonic stenosis 26 and in children with infundibular pulmonic stenosis. 19 Because of the location of the stenotic lesion, however, it can be difficult to align the Doppler interrogation beam parallel to the poststenotic jet, resulting in underestimation of the signal velocity and severity of the stenosis. Attempts should be made to verify the intraventricular pressure gradient derived from the peak velocity of flow across the stenosis by comparing it with the peak right ventricular systolic pressure in the proximal chamber calculated from the tricuspid regurgitation velocity.…”