Elevated Prosthetic Valve Gradients: What to Consider When Determining an Etiology

DOPPLER echocardiography is a useful noninvasive tool for the assessment of cardiac hemodynamics. However, it is subject to limitations that can have important clinical implications, especially in the setting of valve prosthesis. Elevation in mean transvalvular gradient is a finding that has a variety of etiologies. One such etiology is the pressure-recovery (PR) phenomenon, a consequence of stream convergence and energy conversion across a narrowing, which is an artifact of Doppler echocardiographic calculations of valvular flow. The elevated gradient measured with Doppler echocardiography as a result of PR is not present on cardiac catheterization and does not represent true problematic valve hemodynamics. PR should be suspected with an elevated gradient on Doppler echocardiography with normal leaflet motion, especially in the setting of a small proximal aorta. Understanding and awareness of PR are important because PR can lead to overestimation of disease severity in the clinical setting.