Changes in effective aortic valve area during ejection in adults with aortic stenosis

Measurements of valve orifice area in aortic stenosis are based on the assumption that orifice area remains constant throughout ejection and is independent of transvalvular gradients and flow. Recent studies, however, have suggested that the calculated valve area of calcific aortic stenosis may change in different flow conditions. Therefore, we tested the hypothesis that in vivo effective orifice area of a stenotic aortic valve changes continuously during ejection, which would make a single area measurement a potentially inadequate indicator of the severity of the stenosis. Doppler measurements of flow velocity in the ascending aorta and in the left ventricular outflow tract at peak velocity, at half-peak velocity during acceleration (midacceleration), and at half-peak velocity during deceleration (mid-deceleration) were obtained in 26 patients with aortic stenosis (mean gradient 50 ± 19 mm Hg and effective aortic orifice area 0.7 ±0.3 cm2) and in 14 normal subjects of similar age and gender, to calculate instantaneous effective aortic orifice area at midacceleration, at peak velocity and at middeceleration. In the 26 patients with aortic stenosis, aortic valve area at midacceleration was 84 ± 15% of valve area at peak velocity (p < 0.0001), and valve area at mid-deceleration was 113 ± 17% of that measured at peak velocity (p < 0.01). Conversely, in normal subjects, aortic valve area remained constant during ejection and was 97 ± 5% and 99 ± 6% of valve area at peak velocity, respectively, at midacceleration and mid-deceleration (p > 0.05). In addition, in patients with aortic stenosis the percentage of change in effective aortic valve area from midacceleration to mid-deceleration varied widely, from −17% to +49% (mean change +26 ± 14%). There was no relation between percentage of change in effective valve area and mean transaortic gradient (r = 0.05; p = 0.30) or effective valve area at peak velocity (r = −0.11; p = 0.14). Our results indicate that effective aortic valve area continues to change during ejection in patients with aortic stenosis, and that the magnitude of this change is independent of the usual indexes of severity of the stenosis. Conversely, effective aortic valve area remains constant during ejection in normal subjects.