Independent contribution of left ventricular ejection time to the mean gradient in aortic stenosis

Transvalvular mean pressure gradients (MPG) are important in the evaluation of aortic stenosis, but surprisingly they often differ in patients having similar valve effective orifice area (EOA) and stroke volume (SV). The study aim was to determine if these differences could be explained by variations in left ventricular ejection time (LVET).

A pulse duplicator system with a constant SV of 75 ml and incremental increases of LVET from 250 to 450 ms was used to measure MPG by Doppler echocardiography in three fixed stenoses (0.5, 1.0 and 1.5 cm2). The same variables were also measured at rest in 192 patients with isolated aortic stenosis (EOA <1.5 cm2) as well as during stress in a subgroup of 24 patients.

In vitro, the increase in LVET produced marked decreases of MPG ranging from -40 mmHg (-45%) for the 0.5-cm2 stenosis to -22 mmHg (-61%) for the 1.5-cm2 stenosis. In vivo, MPG measured by Doppler correlated strongly (R2 = 0.83) with the MPG predicted by the formula: MPGpred [SV/(50xEOAxLVET)]2, and on this basis the relative contributions of EOA, SV and LVET to the variance of MPG were found to be 36, 34 and 13%, respectively. During stress, the contribution of LVET to the increase in MPG was variable, but was sometimes as important as that of SV.

LVET may significantly and independently influence MPG in aortic stenosis. Clinically, variations of up to 15 mmHg in MPG may be observed uniquely on the basis of a change in duration of LVET, and hence the MPG cannot be used as a stand-alone parameter for serial evaluations or for comparisons of aortic stenosis severity between patients. A correction of MPG for LVET (in ms) such as MPGc = MPGx(LVET/300)2 might be helpful for rendering comparisons of MPG more meaningful in patients with aortic stenosis.