Stenosis hemodynamics: from physical principles to clinical indices

Clinical evaluation of patients with aortic stenosis entails hemodynamic determinations and interpretations that depend on complex blood flow patterns. Although pressure gradient and Doppler velocity are intrinsically adjusted for a wide range of species and body size, they are highly flow-dependent indices that can vary among patients with physically identical stenosis areas and within individuals between determinations. Other indices, such as the Gorlin area, are adjusted for flow. All stenosis indices derived from hemodynamic measurements, however, must exhibit some degree of flow dependence because of fundamental aspects of fluid dynamics that affect the blood velocity profile. The Gorlin effective orifice area is an index that sacrifices adjustment for body size. This hinders comparisons over a range of patient species, breed, and size because it may be problematic to determine what effective orifice area is appropriate for a given individual. One potential solution is to compare the effective area of an individual's normal tract, if one exists, to the tract in question as a ratio, the effective orifice area ratio (EOAR). The EOAR can be estimated from the ratio of flow velocity integrals (FVIs) of the 2 outflow tracts. Clinical data and experience are lacking, but theoretical advantages of the index include intrinsic adjustment for both body size and flow rate. Aortic stenosis is a complex, multifactorial disease, and selection of an optimal hemodynamic severity index may not result in adequate prognostic criteria for segregation of patient risk and treatment groups.