Angle of incidence does not affect accuracy of mitral stenosis area calculation by pressure half-time: Application to Doppler transesophageal echocardiography

Continuous wave Doppler transesophageal echocardiography (TEE) may allow the estimation of stenotic mitral valve area. Intuitively the posterolateral position of the transducer appears to limit the application of TEE for this purpose because of the excessive angle of incidence to mitral valve inflow. However, algebraic equations can be used to predict that the angle of incidence should not affect mitral valve area derived by using pressure half-time. To test the validity of this prediction and the potential application of Doppler TEE to estimate mitral valve area, 28 patients (21 women, 7 men) with a mean age of 59 ± 14 years with mitral stenosis were studied by continuous wave transthoracic echocardiography (TTE) and TEE guided color flow Doppler. TTE was performed from the apical four-chamber (TEE-0) and a modified parasternal four-chamber (TTE-MAL) plane as a means of intentionally increasing the angle of incidence. TEE was done by using the horizontal (TEE-HAX) and vertical (TEE-VAX) planes. Mitral valve area was calculated by pressure half-time method. Mean mitral valve area did not differ ( p = not significant [NS]) between TTE-0 (1.26 ± 0.84 cm 2), TTE-MAL (1.37 ± 0.94 cm 2), TEE-HAX (1.39 ± 0.92 cm 2), and TEE-VAX (1.35 ± 0.89 cm 2). The estimated mean angle of incidence during TTE-MAL was 45 ± 12 degrees (range 21 to 68 degrees). Six (21%) of 28 and 9 (32%) of 28 patients had an underestimation of transmitral peak velocities with TEE from the horizontal or vertical planes, respectively. However, excellent correlations were found between mitral valve area derived by using TEE-0 versus TTE-MAL ( r = 0.97; SEE = 0.25 cm 2; intercept = 0.02 cm 2; slope = 1.08; and p = 0.0001), TEE-HAX ( r = 0.91; SEE = 0.39 cm 2; intercept = 0.14 cm 2; slope = 1.00; and p = 0.0001) and TEE-VAX ( r = 0.92; SEE = 0.36 cm 2; intercept = 0.13 cm 2; slope = 0.97; and p = 0.0001). These results are directly applicable to Doppler TEE in the determination of mitral stenosis area by pressure half-time, whereby 21% to 32% of patients using the horizontal or vertical transesophageal planes may have a significant angle of incidence leading to underestimation of transmitral valve velocities. Future studies comparing Doppler TEE with cardiac catheterization are of interest. However, the present study suggests that Doppler TEE will play an important role in the hemodynamic assessment of the severity of mitral valve stenosis.