Carotid duplex sonography: bisferious pulse contour in patients with aortic valvular disease

Characteristic systolic and diastolic pulse contours occur in the carotid Doppler waveforms of patients with aortic valvular disease that have not previously been described in publications concerning carotid duplex sonography. The purpose of this study was to evaluate the presence and characterize the nature of these carotid duplex waveform abnormalities in patients with known aortic valve disease and to correlate these changes with the severity of valve dysfunction. The study group consisted of 26 patients with aortic regurgitation or combined aortic regurgitation and aortic stenosis. Duplex studies were retrospectively reviewed by two radiologists for the presence of two systolic peaks, and for the presence of diastolic reversal of flow direction. This pattern of two systolic peaks, characteristic of aortic regurgitation, is called bisferious from the Latin "twice beating." Aortic regurgitation was graded by echocardiography as mild, moderate, or severe by the cardiologists reviewing the examination. A group of 20 age-matched patients without aortic valvular disease were similarly assessed. The bisferious pattern was demonstrated in 13 (50%) of 26 patients. Five (19%) of 26 patients had significant reversal of diastolic flow. Four patients were studied both before and after aortic valve replacement. Three had bisferious wave contours preoperatively; two of these also had diastolic reversal of flow. The fourth patient had retrograde flow in diastole without systolic contour abnormality. Postoperatively, all carotid waveforms were normal. None of the duplex waveforms in the control group demonstrated characteristic systolic or diastolic abnormalities. The bisferious waveform and retrograde diastolic flow are Doppler patterns associated with aortic valvular disease. These patterns are reversible after aortic valve replacement. While echocardiography remains the study of choice in the evaluation of suspected valvular dysfunction, up to one third of patients with aortic regurgitation may not have a detectable murmur. Therefore, identifying these patterns on carotid duplex examinations may provide clinically useful information and serve as a clue to previously unsuspected cardiovascular disease.