Limitations of Doppler Echocardiography in the Evaluation of Serial Stenoses

Abstract

A 71-year-old man with a history of coronary artery disease with multiple previous interventions, atrial fibrillation, and moderate aortic stenosis presented with progressive angina. Physical examination revealed decreased peripheral pulses and a 2 to 3/6 mid- to-late peaking systolic ejection murmur at the upper right sternal border, unchanged with squat-to-stand maneuver. Coronary angiography ruled out significant obstructive coronary disease. Echocardiography revealed a septal thickness of 19 mm (Figure 1A). Doppler interrogation of the left ventricular (LV) outflow tract revealed a late peaking systolic velocity of 4.2 m/s (Figure 1B) and an early peaking systolic velocity of 3.8 m/s with a mean gradient of 40 mm Hg (Figure 1C), with 2 discrete levels of color aliasing noted on 2-dimensional (2D) Doppler color imaging (Movies I and II in the online-only Data Supplement). Because of patient reluctance to undergo surgery based on noninvasive evaluation, hemodynamic catheterization was performed to characterize the degree of obstruction accurately at each level. Figure 1. Hemodynamic assessment of tandem stenoses. A , Transthoracic echocardiography via a parasternal window revealed thickening of the intraventricular septum, measuring 19 mm. B , Doppler interrogation of the left ventricular outflow tract revealed a late peaking systolic velocity of 4.2 m/s. C , In addition, Doppler interrogation of the left ventricular outflow tract demonstrated a distinct early peaking …