Correspondence
Clinical Problem-Solving: Assessing Aortic Valvular Insufficiency
N Engl J Med 1994; 330:941-942March 31, 1994
- Article
To the Editor:
In “The Heart of the Matter” (Nov. 4 issue),1 Thibault comments that aortic valvular insufficiency can be underestimated if the Doppler probe is not perpendicular to the direction of the jet. In fact, the best Doppler spectral display is obtained when the angle of the probe is either parallel to or within 20 degrees of the direction of the jet of blood.
Aside from this slight technical matter, the discussion was thoroughly enjoyable.
1 ReferencesM.N. Prakash, M.D.
Cardiology Associates of Greater Hazleton, Hazleton, PA 182011
Thibault GE . The heart of the matter. N Engl J Med 1993;329:1406-1410
Full Text | Web of Science | Medline
To the Editor:
Thibault presents an excellent, methodical clinical discussion of a patient in Clinical Problem-Solving. The patient had a normal echocardiogram four years before presentation, had 2+ aortic insufficiency at presentation, and 2+ to 3+ aortic insufficiency with a dilated left ventricle and pulmonary edema six months later. The expert clinician maintained a broad differential diagnosis and relentlessly pursued a cardiac cause for the clinical problem.
In his commentary, Thibault correctly states that two-dimensional echocardiography may underestimate the degree of aortic insufficiency (or valvular insufficiency in general) if the regurgitant jet is angulated, asymmetrical, or not perpendicular to the Doppler probe. However, when the patient presented the second time, with increased aortic insufficiency, a dilated left ventricle, and congestive heart failure, it is unclear why further evaluation and possible aortic-valve replacement were not considered. Evidence of left ventricular deterioration is probably the strongest echocardiographic finding that might lead to serious consideration of aortic-valve replacement.1 Multiplane transesophageal echocardiography performed from various windows could have been used to quantify the degree of aortic insufficiency, evaluate the severity of myxomatous changes in the valves, assess the possible marfanoid feature of the ascending and descending aorta, and finally, help exclude the possibility of active endocarditis. If questions remained after the echocardiographic study, cardiac catheterization (both right-sided and left-sided) could have been performed. With this information, a plan of action could have been formed on the basis of more knowledge of the patient's condition.
Although the focus of the discussion was on the cause of the clinical problem and the valvular heart disease, the progressive ventricular dilatation, worsening aortic insufficiency, and congestive heart failure warranted serious consideration of aortic-valve replacement. If they had been considered earlier, the development of acute mitral regurgitation and subsequent double-valve replacement might have been avoidable.
1 ReferencesAndrew Burger, M.D.
Masoor Kamalesh, M.D.
Deaconess Hospital, Boston, MA 02215Author/Editor Response
Dr. Thibault replies:
To the Editor: Dr. Prakash is correct that the Doppler spectral display is optimal when the probe is parallel to the jet rather than perpendicular to it. The relevant clinical point is that for technical reasons, the Doppler technique may produce an underestimate of the degree of aortic insufficiency.
I agree with Drs. Burger and Kamalesh that earlier intervention might have altered the course of the patient in “The Heart of the Matter.” It is evident that this did not occur because the doctors caring for the patient pursued a series of different diagnostic hypotheses. They therefore did not seriously consider the possibility that progressive valvular heart disease was the cause of the patient's problem.
George E. Thibault, M.D.
Veterans Affairs Medical Center, West Roxbury, MA 02132
