Limitations of Doppler ultrasound in the diagnosis of neonatal coarctation of the aorta

doi:10.1016/0167-5273(89)90333-1

International Journal of Cardiology

Volume 23, Issue 1, April 1989, Pages 87-89

https://doi.org/10.1016/0167-5273(89)90333-1 Get rights and content

Abstract

Blood flow velocities were recorded using Doppler ultrasound in 40 babies aged between 1 day and 4 weeks who had coarctation of the aorta or interruption of the aortic arch. High velocity jets of 3 m/sec or more in the descending aorta were detected in only 3 patients, two of whom had interruption of the aortic arch. There was very poor agreement between upper and lower limb blood pressure difference and Doppler derived peak pressure drop. Doppler ultrasound may provide useful information on coexisting intracardiac abnormalities, but in the presence of ductal patency is of little value in the diagnosis of coarctation itself.

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Cited by (19)

Noninvasive diagnosis of aortic coarctation in neonates with patent ductus arteriosus
2006, Journal of Pediatrics
To find a noninvasive method to detect coarctation of the aorta (CoA) in the presence of a patent ductus arteriosus (PDA) in neonates.
From 1994 to 1998, 36 neonates with CoA and PDA confirmed by surgery or cardiac catheterization were studied; another 19 neonates with isolated PDA served as control patients. The prospective study was conducted from 2001 to 2002 on 162 neonates.
Among the 36 neonates in the CoA group, 14 patients (39%) had blood pressure discrepancy, 26 patients (72%) had a visualized posterior shelf by echocardiogram, and the ratio of isthmus/descending aorta diameters (I/D ratio) was below 0.64 in 32 patients (89%). None of the control patients had these features. A diagnostic approach was subsequently proposed, according to which a neonate with PDA who fulfilled any of the above features was diagnosed as CoA plus PDA. In the prospective study, the sensitivity and positive predictive values of this method were both 91.7%, whereas the specificity and negative predictive values were both 99.3%.
Echocardiographic measurements of I/D ratio along with the delineation of posterior shelf and a BP discrepancy can satisfactorily identify CoA in the presence of PDA in neonates.
Carotid-subclavian artery index: New echocardiographic index to detect coarctation in neonates and infants - Invited commentary
2005, Annals of Thoracic Surgery
Large ductal flow may cause high velocity in the descending aorta without coarctation: Improved diagnosis using the continuity equation
2001, American Journal of Cardiology
Effect of aortic compliance on Doppler diastolic flow pattern in coarctation of the aorta
1999, Journal of the American Society of Echocardiography
The spectral Doppler pattern at the site of an aortic coarctation (CoA) generally displays increased maximal velocity (Vmax) during systole with a slow velocity decay, resulting in the characteristic “sawtooth” pattern. If there is rapid velocity decay, the obstruction is often judged to be mild. The purpose of this study was to investigate if velocity decay is affected by proximal aortic compliance (C_p ). The relation between the velocity decay measured from the Doppler pattern and C_p was studied with the use of an in vitro pulsatile flow model. The time (τ) between Vmax and 33% Vmax was the measure of velocity decay. The C_p was varied from 0.7 to 2.6 mL/mm Hg for each of 4 levels of CoA severity. The various obstructions produced a Vmax range of 2.7 to 5.5 m/s. There was a positive linear relation between τ and C_p (r² = 0.76). For a low C_p (compliance = 0.7 mL/mm Hg), velocity decay was rapid (τ = 0.2 to 0.3 seconds) with no diastolic gradient. For equivalent obstructions, a high C_p (2.6 mL/mm Hg) produced a persistent diastolic gradient and slow velocity decay (τ = 0.5 to 0.6 seconds). The Doppler pattern across a CoA is affected by C_p. Therefore, the absence of a sawtooth pattern should not exclude the diagnosis of significant CoA obstruction. (J Am Soc Echocardiogr 1999;12:636-42.)
Accuracy of Doppler methods for estimating peak-to-peak and peak instantaneous gradients across coarctation of the aorta: An in vitro study
1999, Journal of the American Society of Echocardiography
Although data exist that address the attempt to correlate noninvasive Doppler-derived pressure gradients with invasive catheter pressure gradients in patients with coarctation of the aorta, few data exist about stiffness of the proximal descending aorta (precoarctation) and its relation to these pressure measurements. In this study, an in vitro flow model of a simulated neonatal aorta with a coarctation was developed. Three proximal descending aortas of different stiffnesses were used. The stiffness index of the proximal descending aorta was calculated as β = ln [systolic pressure/diastolic pressure/(systolic diameter – diastolic diameter)]. We evaluated pressure gradients obtained by continuous wave Doppler and standard catheter methods and looked at acceleration of flow velocity determined by pulsed wave Doppler in the 3 precoarctation segments of differing stiffnesses. Pressures in the proximal descending aorta (precoarctation) increased with increasing stiffness, ranging from 105 mm Hg (soft) to greater than 300 mm Hg (stiff). Continuous wave Doppler instantaneous pressure gradients overestimated the catheter instantaneous pressure gradients substantially (mean 41% ± 19%). The stiffer the precoarctation segment, the more the degree of overestimation: soft, 0% to 63% (= 3.47); medium, 13% to 54% (β = 4.42); and stiff, 43% to 66% (β = 5.91). Inclusion of the precoarctation velocity [V1] component in the Bernoulli equation did not significantly improve the correlation or the agreement. An additional observation was that pullback catheter peak-to-peak gradients were higher than simultaneous peak-to-peak gradients. In the stiff aorta, this difference could be greater than 22 mm Hg (>19%). Acceleration of flow velocity toward the coarctation was evident by pulsed wave Doppler interrogation. Increasing the stiffness of the precoarctation segment also increased the degree of acceleration within this proximal segment: soft, 0.4 to 0.8 m/s; medium, 0.5 to 1.4 m/s; and stiff, 0.7 to 1.5 m/s. These data suggest that increasing stiffness of the proximal descending aorta can alter the continuous wave detected Doppler gradient and although the gradient itself has increased, it may not predict accurately the true severity of the localized, most severely obstructed segment. (J Am Soc Echocardiogr 1999;12:744-53.)
Coarctation of the aorta: Different anatomo-clinical forms depending of the age of presentation
1998, Revista Espanola de Cardiologia
Analizar las características anatomoclínicasdiferenciales de la coartación de aorta en susdiferentes edades de presentación.
Se revisaron restrospectivamentelos datos clínicos, angiográficos, hallazgosintraoperatorios y resultados quirúrgicos de 82 casosde coartación de aorta (54 varones y 28 mujeres). La edad media fue de 16, 2 ± 13, 7 años (rango= 1 mes-63 años). Los pacientes fueron divididos entres grupos: menores de 1 año (grupo A; n = 10); de1-12 años (grupo B; n = 30) y mayores de 12 años(grupo C; n = 42).
La forma preductal se observó en el 20, 7% de los casos (el 50,0%, el 30,0% y el 7,1% en los grupos A, B y C respectivamente; p = 0,003) y las anomalías asociadas tipo shunt izquierda-dere chaen el 19,5% (el 40,0%, el 16,7% y el 16,7% enlos grupos A, B y C, respectivamente; p = NS). La insuficiencia cardíaca fue la manifestación predominante en el grupo A (70,0%), mientras que lomás frecuente en el grupo B fue el hallazgo casualen un paciente asintomático (30,0%). La hipertensión arterial o sus complicaciones fueron la presentaciónmás habitual en el grupo C (38,0%). Se observó crecimiento ventricular izquierdo en el electrocardiograma en el 0,0%, el 30,0% y el 54,7% de los pacientes de los grupos A, B y C, respectivamente(p = 0,003). Se observaron complicaciones postoperatorias, incluyendo fallecimiento, crisis hipertensivasy recoartación, respectivamente, en el 90,0%, 33,3% y 21,4% de los casos de los grupos A, B y C (p = 0,01).
La edad de presentación de la coartaciónaórtica permite establecer grupos con diferentes características anatómicas y clínicas, e incluso con diferente evolución postoperatoria.
To analyse the anatomo-clinical characteristicsof the coarctation of the aorta at differentages of presentation as well as the findings and resultsof its surgical correction at different periods.
We retrospectively studiedthe clinical and angiographic data, as well asthe intraoperative findings and surgical outcomesof 82 consecutive patients (54 M and 28 F) with coarctationof the aorta. Mean age was 16.2 ± 13.7years (1 month to 63 years). The patients were dividedinto three groups according to age: Group A(n = 10) under 1 year; Group B (n = 30) from 1 to12 years and Group C (n = 42) over 12 years.
A preductal form was found in 20.7% cases(50.0%, 30.0% and 7.1% of groups A, B, and Crespectively; p = 0.003). An associated left-to-rightshunt was present in 19.5% (40.0%, 16.7% and16.7% of groups A, B and C respectively; p = NS). The first manifestation of the disease was differentin groups A, B and C. Among group A patients, congestiveheart failure was the most frequent presentation(70.0%). In group B, the most frequent presentation(30%) was as an incidental finding in anasymptomatic patient. Finally, systemic hypertensionor its complications predominated amonggroup C patients (38.0%). Left ventricular hypertrophyon ECG was present in 0.0%, 30.0% and54.7% of patients in groups A, B and C (p = 0.003)respectively. Postoperative complications includingdeath, hypertensive crisis and re-coarctation wereobserved in 90.0%, 33.3% and 21.4% in groups A, Band C (p = 0.01) respectively.
Among patients with coarctation ofthe aorta, the age of clinical presentation allows usto define groups of patients with different anatomicalcharacteristics, clinical course and postoperativeoutcome.

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Original studyLimitations of Doppler ultrasound in the diagnosis of neonatal coarctation of the aorta

Abstract

J Am Coll Cardiol

Am J Cardiol

Use of continuous wave Doppler ultrasound velocimetry to assess the severity of coarctation of the aorta by measurement of aortic flow velocities

Br Heart J

Continuous wave Doppler velocimetry as an adjunct to cross sectional echocardiography in the diagnosis of critical left heart obstruction in neonates

Br Heart J

Original study
Limitations of Doppler ultrasound in the diagnosis of neonatal coarctation of the aorta