Diastolic velocity half time is associated with aortic coarctation gradient at catheterization independent of echocardiographic and clinical blood pressure gradients

Abstract

Objective: The most accurate non-invasive parameter to predict whether a patient with aortic coarctation will meet interventional criteria at catheterization remains elusive. We aim to determine the best independent echocardiographic predictors of a coarctation peak-to-peak pressure gradient ≥ 20 mmHg at catheterization, the accepted threshold for intervention. Design: Retrospective query of our catheterization database from 1/2007 – 7/2016 for the diagnostic code of aortic coarctation was performed. Multiple echocardiographic measurements and blood pressure gradients prior to cardiac catheterization were collected. Univariate correlation of variables with the continuous catheterization peak were calculated using Spearman’s rho. Univariate association with peak-to-peak gradient at catheterization ≥ 20 mmHg was tested using Mann Whitney U Test and the Pearson Chi-Square test or Fisher’s Exact test. Multivariable logistic regression assessed the independent association of the clinically relevant metrics with gradient at catheterization ≥ 20mmHg. Results: Sixty-eight patients met study criteria (median age 9.25 y), of whom 84% underwent intervention at catheterization. Echocardiographic peak and mean coarctation velocity, indexed systolic and diastolic velocity half times (SVHTi, DVHTi), and blood pressure gradient all had moderate correlation (Spearman’s rho = 0.529–0.617, p < 0.001) with the continuous catheterization gradient and were significantly associated with the binary outcome of catheterization peak ≥ 20 mmHg (p < 0.001). Logistic regression found echocardiographic mean systolic gradient (OR 1.213 [95% CI 1.041–1.414]) and DVHTi (OR 1.039 [95% CI 1.004–1.074]) independently associate with catheterization peak ≥ 20 mmHg after controlling for blood pressure gradient (OR 1.066 [0.987–1.150]). Conclusions: Most echocardiographic estimates show moderate correlation with arch gradient at catheterization. Noninvasive four extremity blood pressure gradient is significantly associated with peak-to-peak gradient ≥ 20 mmHg. DVHTi may provide a unique independently associated echocardiographic estimate of coarctation severity. Further study of these variables with larger cohorts may allow for development of predictive models to direct catheterization.

A percutaneous treatment strategy of an adult patient with a bicuspid aortic valve, coarctation of the aorta, and an exceptionally large aneurysm of a collateral artery: Case report and literature overview

“…The patient’s ECG was suggestive of left ventricular hypertrophy, a consequence of the chronically increased afterload and systemic arterial hypertension. Transthoracic echocardiography revealed typical antegrade diastolic flow in the descending thoracic aorta with a “saw tooth” pattern ( 2 , 26 ). In adults, the location opposite the ductus/ligamentum arteriosus is the most commonly encountered location of CoA ( 5 , 6 , 27 ).…”

Outcomes of Arch Reintervention for Recurrent Coarctation in Young Children

“…4 In practice, the pressure gradient across the isthmus as measured by TTE is commonly considered an indication for re-CoA intervention. 18 The cutoff peak gradient across the stenotic area indicative of arch reintervention has been reported to be 20 to 30 mm Hg. 5,7,9 However, because of the poor correlation between the gradient determined by echocardiography and the peak-to-peak gradient at catheterization, the definition of re-CoA varies among centers and clinicians.…”

“…5,7,9 However, because of the poor correlation between the gradient determined by echocardiography and the peak-to-peak gradient at catheterization, the definition of re-CoA varies among centers and clinicians. 18 In our clinical practice, re-CoA is usually diagnosed when there is a peak gradient !35 mm Hg across the isthmus on TTE. For some specific re-CoA morphologies, the gradient may be overestimated or underestimated on TTE.…”

Accuracy of Current Non-invasive Methods in Estimating Aortic Coarctation Gradients

“…Most peak Doppler obtained gradients showed moderate correlation (r = 0.503-0.617, p<0.001) with gradients obtained at catheterization. It was found that noninvasive four extremity blood pressure gradients correlated significantly only if peak gradient was ≥ 20 mmHg [15]. Wisotzkey with 34 (57%) native coarctation and 26 (43%) aortic re-coarctation.…”

“…According to Christopher et al [15] retrospective study with 68 patients of whom 84% underwent intervention during catheterization. Most peak Doppler obtained gradients showed moderate correlation (r = 0.503-0.617, p<0.001) with gradients obtained at catheterization.…”