J Thorac Cardiovasc Surg 1994;107:319-320
© 1994 Mosby, Inc.
Assessment of number of cusps in aortic lesions by Doppler imaging: Surgical correlations*
Colette Veyrat, MD, CNRS,
Iradj Gandjbakhch, MD,
Christian Cabrol, MD,
Daniel Kalmanson, MD
Department of Cardiology
Fondation Rothschild
Department of Cardiovascular and Thoracic Surgery
Groupe Hospitalier Universitaire La Pitié-Salpétrière
Paris, France
To the Editor:
In adults with aortic lesions, recognition of bicuspid versus tricuspid aortic orifices is usually only achieved invasively
1 or at operation. Developments in reconstructive surgery for regurgitant valves 2,3 and management of patients with bicuspid orifices of unfavorable prognosis, however, necessitate a preoperative assessment of the number of cusps. We propose a new noninvasive detection method for both types of orifices by Doppler imaging of jet origin. 4,5 Our hypothesis was that the flow areas imaged at Doppler echocardiography might show specific features in connection with either the normal or the abnormal commissural lines.
Surgical and Doppler data were reviewed for a group of adult patients (mean age 56 ± 18 years) with aortic valve disease (58 stenoses and 56 regurgitations). Three main causes were found: degenerative with calcium (56.1%), rheumatic (26.3%), and dystrophic (11.4%); the other origins were miscellaneous. For Doppler data, a review of sequential or triggered images of jet origin areas examined in the short-axis aortic view 4,5 was conducted by two observers on a video frame-by-frame basis independently of surgical reports. This review showed no discrepancy for both site and spreading of areas. Major axes of flow areas and peripheral locations were referred to by a clockwise notation, assigning the 10, 2, and 6 o'clock sites for normal commissures. At operation, the number of aortic cusps was checked and correlated with Doppler data. The diagnostic value of Doppler findings for the assessment of tricuspid and bicuspid orifices was studied according to the method described by Yerushalmy. 6
At operation, there were 85.08% tricuspid and 14.91% congenital bicuspid orifices. Among the tricuspid orifices, there were five acquired bicuspid valves with calcifications bridging free commissures in degenerative calcified stenoses. In congenital bicuspid valves, the conjoined leaflet was larger than the free one, with a low raphé (Fig. 1). Table I lists the correlations between surgical and Doppler data. Regardless of origin, both Doppler stenotic and regurgitant jet areas on tricuspid orifices were schematically central. When eccentricity was present, it was the result of an eccentric spreading from the center toward one or more normal commissural sites. Fig. 2, A shows an example of stenosis. In four of five cases of "acquired bicuspid" orifice the main part of the jet remained central, with restricted eccentricity. When shaped like a slit, the major axis of the areas was aligned with an axis running from 10 to 2 o'clock. Bicuspid valves showed transecting slitlike areas aligned with the 10 to 4 o'clock axis (or 9 to 3, Fig. 2, B), with an eccentric onset at 10 o'clock in 11 cases. In three cases the onset was at 6 o'clock, running centripetally toward the opposite site in two patients. One error for an eccentric area at 10 o'clock on a tricuspid valve led to a 100% sensitivity and 98% specificity of these findings for diagnosis of bicuspid valve. Correlations with the anatomic type of bicuspid valve (14 detailed cases) showed that areas aligned with the 10 to 4 o'clock axis were related to a conjoined right-left coronary cusp (Fig. 2, B, 12 cases) and those at 6 o'clock to a conjoined right coronary–noncoronary cusp (two cases).
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Fig. 1. Example of congenital bicuspid aortic valve removed at operation (conjoined right-left coronary cusp): The conjoined leaflet is larger and shows a low raphé. There are calcifications on the leaflets, particularly around the raphé. Jet area of this orifice is shown in Fig. 2, B.
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Fig. 2. Jet origin Doppler imaging in aortic degenerative calcified stenosis. A, Tricuspid aortic valve: From the center, flow spread toward the 10, 2, and 6 normal commissural sites (small white arrows) and delineated the three commissural lines (70mm2 stenosis, triggered image at 0.16 second from the R wave of the electrocardiogram, orifice with heavy calcified leaflets at operation). When stenosis became more severe, as in most cases in this study, jet area was confined at the center. B, Congenital bicuspid aortic valve: Jet area (white arrow) did not show any connection with the normal commissural lines and was aligned with one abnormal single commissural line (conjoined right-left coronary cusp shown in fig. 1, 60 mm2 stenosis, triggered image at 0.15 second). AO, Aortic orifice; AVA, aortic valvular area; LA, left atrium; PA, pulmonary artery; RVOT, right ventricular outflow tract; SAX, short-axis aortic view; A, E, P, I, orientation of the structures.
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This study showed that the features of jet origin areas differed thoroughly according to the number of aortic cusps found at operation. Further prospective investigations to assess the reliability of our findings will require a wider range of abnormalities. Already, however, the fact that jet origin imaging featured both types of orifices regardless of the lesion enables us to systematize our findings. In tricuspid orifices, the main site of flow areas is central at the connection of the three normal commissural lines, with further peripheral expansion toward the free commissures. This held true for all but one case of acquired bicuspid valve. The resultant area depends on the anatomic lesions—rheumatic retracted leaflets or fused or calcified bridged commissures—and on the degree of pliability of leaflets. Despite free commissures in calcified cusps with a three-branch star pattern at operation, jet area was confined to the center in most severe stenoses with bonelike calcifications. To a lesser degree, Fig. 2, A suggests that flow passing through the free commissural lines could hardly move the heavy cusps. In the case of bicuspid orifices, the common feature was that jet areas were imaged along the abnormal single commissural line regardless of the lesion, delineating the anatomic slit by their abnormal axis of flow, whether or not they had an eccentric onset. The latter could be explained by a frequent prolapse of a part of the conjoined cusp. Onsets at other sites along the slit remain possible, necessitating further studies.
Two further points should also be discussed. First, there are limitations of Doppler imaging. Indeed, at this early technologic stage, present imaging technology is still rough and improvements are required. Second, comparisons between surgical visualization of controlled arrested hearts and Doppler imaging of live ones were limited in this study to sites of areas versus number of cusps. More refined correlations requiring a close cooperation between users of Doppler echocardiography and surgeons should help to extend the indications for surgical repair procedures in the future.
References
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Veyrat C, Sainte Beuve D, Gourtchiglouian C, Legeais S, Kalmanson D. Quantification of left-sided valvular stenoses by color Doppler imaging of jets. Angiology 1990;41:352-64.
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Yerushalmy J. Statistical problems in assessing methods of medical diagnosis, with special references to x-ray techniques. Public Health Rep 1947;62:1432-49.[Medline]
