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© 2009 by the American Institute of Ultrasound in Medicine
J Ultrasound Med 28:1167-1174 • 0278-4297

Ejection Fraction/Velocity Ratio Identifies Prosthesis-Patient Mismatches in Patients With Aortic Bioprosthetic Valves and Left Ventricular Dysfunction

Paolo Cattaneo, MD, Massimo Baravelli, MD, Andrea Rossi, MD, Giovanni Mariscalco, MD, PhD, Melania Romano, MD, Daniela Imperiale, MD, Alda Bregasi, MD and Claudio Anzà, MD

Department of Cardiology and Intensive Cardiac Rehabilitation, Istituto Di Ricovero e Cura a Carattere Scientifico Multimedica Holding, Castellanza, Italy (P.C., M.B., A.R., M.R., D.I., A.B., C.A.); and Department of Surgical Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria, Varese, Italy (G.M.).

Address correspondence to Paolo Cattaneo, MD, Department of Cardiology and Intensive Cardiac Rehabilitation, Istituto Di Ricovero e Cura a Carattere Scientifico Multimedica Holding, Viale Piemonte 70, 21053 Castellanza VA, Italy. E-mail: p.cattaneo{at}tin.it

Objectives. Recently, a new echocardiographic nonflow corrected index (ejection fraction/velocity ratio [EFVR] = percent left ventricular ejection fraction [EF]/maximum aortic gradient) has been introduced and has shown excellent accuracy in quantifying the effective orifice area (EOA) in native aortic valves and bio-prostheses. The objective of this study was to assess the utility of the EFVR to quantify the indexed EOA in patients with an aortic bioprosthesis and left ventricular dysfunction considering an indexed EOA value of 0.85 cm2/m2 or less to be indicative of a prosthesis-patient mismatch (PPM), defined as an EOA of the inserted prosthetic valve of less than that of the normal human valve. Methods. We studied 100 patients (62 men and 38 women; mean age ± SD, 71 ± 8.6 years) with an aortic bioprosthesis and left ventricular dysfunction (EF ≤49%), and we evaluated the indexed EOA by both the continuity equation (CE) and EFVR. Results. We found a significant linear correlation between the CE and EFVR (r = 0.85; P < .0001) and good agreement between the two methods in identifying patients with an indexed EOA of 0.85 cm2/m2 or less; the correlation began to become nonlinear for patients with an indexed EOA of greater than 1.2 cm2/m2, which was not clinically relevant. Notably, all 11 patients with a discrepancy between the indexed EOA and EFVR (ie, EFVR ≤1.0 and indexed EOA >0.85 cm2/m2) also showed an indexed EOA of greater than 0.85 but less than or equal to 1.0 cm2/m2 (meaning the presence of a mild PPM). Conclusions. The EFVR can be considered a reliable echocardiographic alternative to the CE, especially in conditions in which that is technically difficult, allowing identification of a PPM (indexed EOA ≤0.85 cm2/m2) with excellent sensitivity and specificity.

Key Words: aortic stenosis • ejection fraction/velocity ratio • prosthesis-patient mismatch

Abbreviations: AV, aortic valve • CE, continuity equation • CSA, cross-sectional area • EFVR, ejection fraction/velocity ratio • EOA, effective orifice area • 4V2, maximum aortic gradient • LVEF, left ventricular ejection fraction • LVOT, left ventricular outflow tract • PPM, prosthesis-patient mismatch • SV, stroke volume • TVI, time-velocity integral

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