Gender Effects on Left Ventricular Responses and Survival in Patients with Severe Aortic Regurgitation: Results from a Cohort of 756 Patients with up to 22 Years of Follow-Up.

OBJECTIVES: We sought to evaluate the effect of gender on biology, therapeutic decisions, and survival in patients with severe aortic regurgitation (AR). BACKGROUND: Gender affects adaptive response to the presence of valvular heart diseases and therapeutic decisions. The impact of these on survival in severe AR patients is not known. METHODS: This observational study was compiled from our echocardiographic database which was screened (1993-2007) for patients with severe AR. Detailed chart reviews were performed. Mortality data were obtained from the Social Security Death Index and analyzed as a function of gender. RESULTS: Of the 756 patients with severe AR, 308 (41%) were women. Over a follow-up of up to 22 years, there were 434 deaths. Women compared to men were older (64 ± 18 vs. 59 ± 17 years, p = 0.0002). Women also had smaller left ventricular (LV) end diastolic dimension (5.2 ± 1.1 vs. 6.0 ± 1.0 cm, p < 0.0001), higher EF (56% ± 17% vs. 52% ± 18%, p = 0.003), higher prevalence of diabetes mellitus (18% vs. 11%, p = 0.006), and higher prevalence of ≥2+ mitral regurgitation (52% vs. 40%, p = 0.0008) despite a smaller LV size. Women were also less likely to receive aortic valve replacement (AVR) (24% vs. 48%, p < 0.0001) compared to men and had a lower survival on univariate analysis (p = 0.001). However, after adjusting for group differences including AVR rates, gender was not an independent predictor of survival. However, the survival benefit associated with AVR was similar in both women and men. CONCLUSIONS: This study strongly suggests that female gender is associated with different biological responses to AR compared to men. There is also a lower AVR rate in women, but women derive similar survival benefit as men with AVR. Gender does not seem to affect survival in an independent fashion in patients with severe AR after adjusting for group differences and AVR rates.

Transcatheter vs Surgical Aortic Valve Replacement in Pure Native Aortic Regurgitation.

BACKGROUND: Patients with pure native aortic regurgitation (AR) have been excluded from transcatheter aortic valve replacement (TAVR) trials. We sought to examine midterm outcomes with TAVR in AR compared with surgical AVR (SAVR) in a contemporary cohort. METHODS: Medicare beneficiaries who underwent elective TAVR or SAVR for pure AR from 2016 to 2019 were identified. Patients with concomitant aortic stenosis and who underwent a valve-in-valve intervention or concomitant mitral valve or ascending aorta operation were excluded. The primary outcome was all-cause mortality in the longest follow-up. Secondary outcomes included stroke, endocarditis, and redo AVR. Overlap propensity score weighting was used to adjust for confounders. RESULTS: During the study period, 11,027 patients with pure AR underwent elective AVR (TAVR, n = 1147; SAVR, n = 9880). SAVR patients were younger, with fewer comorbidities and less frailty compared with TAVR patients. TAVR was associated with adjusted 30-day mortality comparable to SAVR. After a median follow-up of 31 months (interquartile range, 18-44 months), TAVR was associated with higher adjusted risk of death (hazard ratio [HR], 1.41; 95% CI, 1.03-1.93; P = .02) and need for redo-AVR (HR, 2.13; 95% CI, 1.05-4.34; P = .03) compared with SAVR. The risk of stroke (HR, 1.65; 95% CI, 0.95-2.87; P = .07) and endocarditis (HR, 2.60; 95% CI, 0.92-7.36; P = .07) was numerically higher with TAVR. CONCLUSIONS: In Medicare patients with pure native AR, TAVR with the current commercially available transcatheter valves has comparable short-term outcomes. Although long-term outcomes were inferior to SAVR, the possibility of residual confounding, biasing long-term outcomes, given older and frailer TAVR patients, cannot be excluded.

Transthoracic echocardiographic assessment of cardiac valves in patients with Behçet's disease.

The main objectives of the current study are to investigate valvular involvement in patients with cardiac Behçet's disease (BD) and find out the risk factors of valvular involvement in cardiac BD. We retrospectively assessed the clinical and echocardiographic data in the medical records of 121 patients with BD admitted to Beijing Anzhen Hospital from January 2015 to January 2022. We evaluated the valvular structure and function mainly by echocardiography. A total of 77 BD patients (77/121, 63.64%) had cardiac valvular involvement. Valvular lesions occurred more frequently in males (p = 0.022). Aortic regurgitation (AR) (62/77, 80.52%) was the most common finding and severe AR occupied 80.65% (50/62). The most common manifestations of BD patients with severe AR was aortic valve prolapse (25/50, 50%), followed by echo-free spaces within the aortic annulus (11/50, 22%), vegetation-like lesions (10/50, 20%), and aortic root aneurysm (10/50, 20%). The incidence of paravalvular leaks (PVL) in BD patients was 14.29% (7/49). The diameter of the sinus of Valsalva and proximal ascending aorta, and total cholesterol (TCHO) were the independent risk factors of moderate-severe aortic valvular regurgitation (p < 0.01). Left ventricular end-diastolic dimension (LVEDD), left ventricular ejection fraction (LVEF) and brain natriuretic peptide (BNP) were significantly associated with moderate-severe mitral valvular regurgitation (p < 0.01). The most common valvular abnormality in BD is AR. Echocardiography has great value in the comprehensive evaluation and accurate diagnosis of valvular involvement in BD patients.

Dynamic Volumetric Assessment of the Aortic Root: The Influence of Bicuspid Aortic Valve Competence.

BACKGROUND: Aortic root evaluation is conventionally based on 2-dimensional measurements at a single phase of the cardiac cycle. This work presents an image analysis method for assessing dynamic 3-dimensional changes in the aortic root of minimally calcified bicuspid aortic valves (BAVs) with and without moderate to severe aortic regurgitation. METHODS: The aortic root was segmented over the full cardiac cycle in 3-dimensional transesophageal echocardiographic images acquired from 19 patients with minimally calcified BAVs and from 16 patients with physiologically normal tricuspid aortic valves (TAVs). The size and dynamics of the aortic root were assessed using the following image-derived measurements: absolute mean root volume and mean area at the level of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction, as well as normalized root volume change and normalized area change of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction over the cardiac cycle. RESULTS: Normalized volume change over the cardiac cycle was significantly greater in BAV roots with moderate to severe regurgitation than in normal TAV roots and in BAV roots with no or mild regurgitation. Aortic root dynamics were most significantly different at the mid-level of the sinuses of Valsalva in BAVs with moderate to severe regurgitation than in competent TAVs and BAVs. CONCLUSIONS: Echocardiographic reconstruction of the aortic root demonstrates significant differences in dynamics of BAV roots with moderate to severe regurgitation relative to physiologically normal TAVs and competent BAVs. This finding may have implications for risk of future dilatation, dissection, or rupture, which warrant further investigation.

Dissection flap masquerading as double aortic valve: an acquired complication.

Aortic dissection usually presents as an acute emergency and less commonly presents as chronic dissection. Two-dimensional and transoesophageal echocardiographic features of aortic dissection generally show dissection flap, dilated aorta and aortic regurgitation. We report a very unusual and extremely rare case of a 40-year-old female patient with chronic aortic dissection presenting as functional double aortic valve.

Large-scale assessment of aortic stenosis: facing the next cardiac epidemic?

Aims: Aortic stenosis (AS) is the most frequent valvular disease in developed countries. As society grows older, the prevalence of AS increases. However, the real burden, current aetiology, severity distribution, and echocardiographic patterns of AS are not fully clear. The aim of the present study is to provide an accurate overall picture of AS, focusing on its epidemiology, aetiology, and echocardiographic features. Methods and results: A total of 29 502 consecutive echocardiograpies were prospectively included in this multicentre study. The present sample was composed of patients with advanced age (mean 75.2 years) and similar gender distribution. High proportion (7.2%) showed any grade of AS, with important number of patients (2.8%) presenting severe AS, most of them aged 75 years or more. Coexisting valvular disease appeared in almost half of the sample (49.6%), being the most frequently diagnosed aortic regurgitation (AR) (22%) followed by mitral regurgitation (MR) (15.6%). Degenerative aetiology was found in the vast majority (93.4%) of the studies whereas rheumatic is currently infrequent (3.35%). Low flow-low gradient (LFLG) appeared in 24.6% of patients with severe AS. Atrial fibrillation (23.1% vs. 11.6%; P = 0.002), MR (23.3% vs. 15.1%; P = 0.018), and right ventricle dysfunction (13.3% vs. 5.2%; P = 0.003) appeared frequently in LFLG group. Conclusions: Burden of AS is higher than previously assumed. Degenerative aetiology is the main cause of AS. Most of the patients are elder with high prevalence of significant co-existing valvular disease. LFLG severe AS is present in an important proportion of patients, showing high grade of left ventricle remodelling.

Assessment and management of aortic valve disease in patients with left ventricular dysfunction.

The onset of symptoms or left ventricular systolic dysfunction heralds a poor prognosis for patients with either aortic stenosis or aortic regurgitation. Echocardiography is the primary imaging modality for assessment of aortic valvular lesions. Cardiac catheterization is indicated to determine the severity of the aortic valve lesion when there is a discrepancy between the clinical findings and the results of echocardiography in patients with either symptoms or left ventricular dysfunction. For patients with low-gradient, low-output aortic stenosis, dobutamine provocation should be used to differentiate truly severe aortic stenosis from patients with a primary cardiomyopathy and low aortic valve area due to low forward flow. Aortic valve surgery improves myocardial performance by relief of ventricular afterload in both patients with severe stenosis and those with severe regurgitation. Surgery should be pursued in both patients with severe aortic stenosis and those with severe regurgitation regardless of the degree of left ventricular dysfunction.

MRI-based multiparametric strain analysis predicts contractile recovery after aortic valve replacement for aortic insufficiency.

BACKGROUND: Guidelines for referral of chronic aortic insufficiency (AI) patients for aortic valve replacement (AVR) suggest that surgery can be delayed until symptoms or reduction in left ventricular (LV) contractile function occur. The frequent occurrence of reduced LV contractile function after AVR for chronic AI suggests that new contractile metrics for surgical referral are needed. METHODS: In 16 chronic AI patients, cardiac MRI tagged images were analyzed before and 21.5 ± 13.8 months after AVR to calculate LV systolic strain. Average measurements of three strain parameters were obtained for each of 72 LV regions, normalized using a normal human strain database (n = 63), and combined into a composite index (multiparametric strain z score [MSZ]) representing standard deviation from the normal regional average. RESULTS: Preoperative global MSZ (72-region average) correlated with post-AVR global MSZ (R(2) = 0.825, p < 0.001). Preoperative global MSZ also predicts improvement of impaired regions (N = 271 regions from 14 AI patients, R(2) = 0.392, p < 0.001). Preoperative MRI-based LV ejection fraction (LVEF) is also predictive (r = 0.410, p < 0.001). Although global preoperative MSZ had a significantly higher correlation than preoperative LVEF with improvement of injured regions (p < 0.001), both measures convey the same phenomenon. CONCLUSIONS: Global preoperative MRI-based multiparametric strain predicts global strain postoperatively, as well as improvement of regions (n = 72 per LV) with impaired contractile function. Global contractile function is an important correlate with improvement in regionally impaired contractile function, perhaps reflecting total AI volume-overload burden (severity/duration of AI).

The preoperative assessment of patients with valvular heart disease as a comorbidity.

In patients with valvular heart disease planned for any type of surgery preoperative evaluation and preparation are especially important for a successfull outcome of the surgery. Preoperative preparation and intraoperative treatment of patients with valvular heart disease are different de-Spending on the type of valvular disease: aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation or mitral valve prolapse. In this paper we have outlined the criteria for evaluating the severity of valvular disease, given that the risk in surgery is proportional to the degree of valvular disease. Also, given that the risk in surgery is also directly proportional to the type and extent of non cardiac surgery, it will be presented recommendations for intraoperative monitoring, with the purpose of evaluating patient's hemodynamic state, as well as recommendations for perioperative treatment of hypotension, tachycardia, and other hemodynamic disturbances. In the paper we will separately discuss bacterial endocarditis profilaxys which can occur after the surgery of patients with valvular disease. Since the patients with valvular disease, and especially the ones with implanted prosthetic valve or heart arrhythmia, are usually on oral anticoagulation therapy, it will be given recommendations for treatment of patients on oral anticoagulation therapy as part of preoperative preparations.

Strain value in the assessment of left ventricular function and prediction of heart failure markers in aortic regurgitation.

BACKGROUND: This study aimed to examine the relationship between biochemical heart failure markers and conventional left ventricular (LV) measurements and strain assessed by speckle-tracking echocardiography in chronic aortic regurgitation (AR) patients. METHODS AND RESULTS: LV strain, rotation assessed by speckle-tracking echocardiography, LV measurements, mitral annular plane excursion measured by M-mode, and systolic annular plane velocity measured by tissue Doppler echocardiography were analyzed in 64 controls and 65 chronic AR patients. Reduced LV longitudinal strain with increased apical rotation was seen in normal plasma NT-proBNP patients. Increased NT-proBNP (>400 pg/mL) was associated with reduced longitudinal and circumferential strain, diminished mitral annular plane excursions and systolic annular plane velocity. Global systolic longitudinal strain was an indepentent predictor of NT-proBNP level. Longitudinal strain less than 16.0% was the cutoff value for NT-proBNP>400 pg/mL (P<0.05). CONCLUSIONS: LV strain analysis in conjunction with NT-proBNP evaluation is a useful tool in assessing LV function in AR patients.

Pulmonary hypertension and long-term mortality in aortic and mitral regurgitation.

BACKGROUND: Outcomes data in patients with aortic regurgitation or mitral regurgitation have been limited to small series with generally <10 years of follow-up. The quantitative impact of pulmonary artery hypertension has not been well described. The purpose of this study was to describe the 15-year mortality of aortic regurgitation and mitral regurgitation. METHODS: Our institution's electronic echocardiography database was queried to identify those patients examined in 1992 and reported to have at least mild aortic regurgitation or mitral regurgitation. Patients were classified by semi-quantitative degree of regurgitation. Pulmonary artery systolic pressure was categorized as normal, borderline, mild, or moderate or greater hypertension (pulmonary artery systolic pressure >40 mm Hg). Age-stratified Cox proportional hazards models compared survival among groups and adjusted for sex, depressed left ventricular ejection fraction, and pulmonary artery systolic pressure. Mortality data were obtained from the 2008 Social Security Death Index. RESULTS: Of 4984 echocardiograms performed in 4050 patients, 1156 patients (28%; aged 72±14 years) had at least mild aortic regurgitation and 1971 patients (49%; aged 69±16 years) had at least mild mitral regurgitation. Overall 15-year mortality in patients with aortic regurgitation was 74% and similar for all grades of aortic regurgitation. Overall 15-year mortality in patients with mitral regurgitation was 71% and got progressively worse with increasing severity grade of mitral regurgitation (63% for mild to 81% for at least moderate-to-severe). For both aortic and mitral regurgitation, moderate or greater pulmonary artery systolic hypertension was associated with increased mortality (in patients with aortic regurgitation, hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.58-2.41, and in mitral regurgitation patients, HR, 1.48; 95% CI, 1.26-1.75). CONCLUSION: Long-term (15-year) survival of patients with aortic regurgitation is poor and is independent of regurgitation severity. In contrast, long-term survival of patients with mitral regurgitation correlates with regurgitation severity. For both groups, moderate or greater pulmonary artery systolic hypertension identified those at highest risk.

Prevalence and optimal management strategy for aortic regurgitation in tetralogy of Fallot.

OBJECTIVE: Aortic regurgitation (AR) in the tetralogy of Fallot (TOF) is not frequent, but when present it impacts significantly on surgical management. Furthermore, the incidence of late AR development has been increasing, along with surgical interest in current practices. METHODS: Pre- and post-operative studies on 427 patients (TOF, 374; TOF/PA (TOF with pulmonary atresia), 53) who survived corrective operation were reviewed. AR (> or =mild) was detected in 28. RESULTS: Nine had AR preoperatively, while 25 (including six with preoperative AR) exhibited AR post-operatively. In the 19 who developed AR post-operatively, the aortic root diameter (AoRoD) and indexed AoRoD (%AoRoD) were 42+/-11 mm and 166+/-36%, increased from the preoperative values of 30+/-10mm and 149+/-24%. AR-free rate at 20 years was 95.1% of all cases studied, 84.3 vs 96.5% in TOF/PA vs classic TOF (P<0.0001), and 82.2 vs 97.0% in bulboventricular VSD vs infracristal VSD (P<0.0001). Older age at repair, and bulboventricular VSD were identified as risk factors for the progression of AR. Aortic valvuloplasty (AVP; n=5) or replacement (AVR; n=4) was performed nine times in eight patients before (n=1), during (n=4), or late after TOF repair (n=4); all showed improvement of NYHA class. Survival- and reoperation-free survival curves showed no significant difference between patients with or without AR. CONCLUSIONS: After repair of TOF, careful observation for a late progression of AR is needed for the optimal timing of surgical intervention, especially in patients who repaired at higher age with a dilated aortic root or in patients with bulboventricular VSD.

Using clinical pathways in patients undergoing cardiac valve surgery.

Clinical pathways, protocols, and standing order sets help organize patients' care and eliminate variations created by practitioners' different preferences. Much attention is being focused on providing the most cost-effective care in the shortest time. Quality of care must be maintained during this process. Clinical pathways, protocols, and standing order sets help ensure that care is consistent and quality of care is maintained with the added benefit of a shorter stay in the hospital.

Assessment of left ventricular long axis contraction can detect early myocardial dysfunction in asymptomatic patients with severe aortic regurgitation.

OBJECTIVE: To identify variables that could be applied at rest to diagnose subclinical ventricular dysfunction in asymptomatic patients with severe aortic regurgitation. DESIGN: Cross sectional study. PATIENTS: Left ventricular long axis contraction was studied using tissue Doppler and M mode echocardiography in 21 patients with no symptoms (New York Heart Association (NYHA) functional class 40%). MAIN OUTCOME MEASURES: Left ventricular ejection fraction (LVEF) at baseline and peak exercise (Weber protocol), cardiopulmonary function, and left ventricular long axis function at rest (peak systolic velocity and excursion of the mitral annulus). RESULTS: In 11 patients, ejection fraction increased or did not change (from mean (SD) 55 (5)% to 58 (4)%, p < 0.05) (group I); in 10 patients it decreased by > 5% (from 54 (4)% to 42 (5)%, p < 0.001) (group II). Exercise ejection fraction was < 50% in all patients in group II. At rest, there were no differences between the groups in ejection fraction, left ventricular diameter indices, wall stress, and short axis contraction. However, patients in group II had reduced long axis contraction compared with group I: peak systolic velocity 8.6 (0.6) v 11.9 (2.2) cm/s (p < 0.001); excursion 11 (2) v 14 (2) mm (p < 0.01). A resting velocity of < 9.5 cm/s was the best indicator of poor exercise tolerance (sensitivity 90%, specificity 100%). CONCLUSIONS: Markers of reduced long axis contraction may provide simple and reliable indices of subclinical left ventricular dysfunction in asymptomatic patients with severe aortic regurgitation.

Clinical assessment of prolonged myocardial preservation for patients with a severely dilated heart.

BACKGROUND: The purpose of this study was to compare the myocardial protective effect of histidine-tryptophan-potassium and glucose-insulin-potassium cardioplegic solutions in patients with a dilated heart (left ventricular diastolic diameter > 55 mm, left ventricular systolic diameter > 45 mm) associated with prolonged cross-clamp time (longer than 200 minutes). METHODS: We selected 20 patients with dilated hearts due to severe aortic regurgitation. Glucose-insulin-potassium cardioplegia was used in 11 patients and histidine-tryptophan-potassium cardioplegia was used in 9 patients. RESULTS: After operation, the cardiac index was significantly increased in the histidine-tryptophan-potassium group (p < 0.05). Postoperative percent fractional shortening was 13.4% +/- 3.1% in the glucose-insulin-potassium group and 23.6% +/- 2.6% in the histidine-tryptophan-potassium group (p < 0.05). Creatine kinase levels were significantly lower in the histidine-tryptophan-potassium group than that in the glucose-insulin-potassium group (p < 0.05). The incidence of ventricular arrhythmia (higher than Lown's grade 2) was lower in the histidine-tryptophan-potassium group. CONCLUSIONS: These data support the superiority of the histidine-tryptophan-potassium method over the glucose-insulin-potassium method for protection of the dilated heart during prolonged ischemia in open heart operations.

Doppler echocardiographic assessment of long-term progression of mitral stenosis in 103 patients: valve area and right heart disease.

OBJECTIVES: The purpose of this study was to determine, in a large referral population, the rate of echocardiographic change in mitral valve area (MVA) without interim intervention, to determine which factors influence progression of narrowing and to examine associated changes in the right side of the heart. BACKGROUND: Little information is currently available on the echocardiographic progression of mitral stenosis, particularly on progressive changes in the right side of the heart and the ability of a previously proposed algorithm to predict progression. METHODS: We studied 103 patients (mean age 61 years; 74% female) with serial two-dimensional and Doppler echocardiography. The average interval between entry and most recent follow-up study was 3.3 +/- 2 years (range 1 to 11). RESULTS: During the follow-up period, MVA decreased at a mean rate of 0.09 cm2/year. In 28 patients there was no decrease, in 40 there was only relatively little change (< 0.1 cm2/year) and in 35 the rate of progression of mitral valve narrowing was more rapid (> or = 0.1 cm2/year). The rate of progression was significantly greater among patients with a larger initial MVA and milder mitral stenosis (0.12 vs. 0.06 vs. 0.03 cm2/year for mild, moderate and severe stenosis, p < 0.01). Although the rate of mitral valve narrowing was a weak function of initial MVA and echocardiographic score by multivariate analysis, no set of individual values or cutoff points of these variables or pressure gradients could predict this rate in individual patients. There was a significant increase in right ventricular diastolic area (17 to 18.7 cm2) and tricuspid regurgitation grade (2 + to 3 +; p < 0.0001 between entry and follow-up studies). Progression in right heart disease occurred even in patients with minimal or no change in MVA. Patients with associated aortic regurgitation had a higher rate of decrease in MVA than did those with trace or no aortic regurgitation (0.19 vs. 0.086 cm2/year, p < 0.05). CONCLUSIONS: The rate of mitral valve narrowing in individual patients is variable and cannot be predicted by initial MVA, mitral valve score or transmitral gradient, alone or in combination. Right heart disease can progress independent of mitral valve narrowing.

Intraoperative TEE assessment of ventricular septal defect with aortic regurgitation.

BACKGROUND: It is desirable to repair but not replace the aortic valve in patients with ventricular septal defect and acquired aortic regurgitation. Precise definition of the valvar pathology with monitoring of its repair perioperatively would enhance the surgical management of this condition. METHODS: Fourteen consecutive patients (age, 10.6 +/- 6 years; weight 29.7 +/- 5.7 kg) who underwent repair of ventricular septal defect with aortic regurgitation were studied by intraoperative transesophageal echocardiography. The severity of prolapse of each of the individual aortic cusps and its adjacent sinus was assessed and the valvar regurgitation quantified by Doppler-derived regurgitant indices. The echocardiographic and surgical findings were correlated and the preoperative and postoperative echocardiographic data were compared to assess the effectiveness of operation. RESULTS: Eight subarterial and six perimembranous defects were located accurately and their sizes (11.8 +/- 3.0 mm) correlated well (r = 0.80) with the surgical measurements. Transesophageal echocardiography detected prolapse of the aortic valve and its sinus in all 14 patients. The severity of the prolapse was severe in 10, moderate in 4, and mild in 5 leaflets. One the basis of these findings, together with the Doppler-derived mean regurgitant indices, exploration of the valve and valvuloplasty were executed appropriately in 12 of 14 patients. In all 14 patients, transesophageal echocardiography after bypass revealed no further cuspal prolapse and significant reduction of the mean regurgitant index (0.55 +/- 0.23 to 0.17 +/- 0.15, p < 0.0001). Residual ventricular septal defect was detected in 5 patients and the only patient with significant shunting who required reexploration was identified correctly. CONCLUSIONS: Intraoperative transesophageal echocardiography can assess effectively the surgical repair of ventricular septal defect with aortic regurgitation and provide information that directs and alters surgical plans to the benefit of patients.

Validity of continuous wave Doppler and colour Doppler in the assessment of aortic regurgitation.

Continuous wave Doppler, colour Doppler, and their combined use were compared for their validity in the semiquantitative evaluation of aortic regurgitation in 80 angiographically proven cases. The diastolic decay slope, as measured from the continuous wave Doppler signal of the aortic regurgitation, correlated well with angiographic data (r = 0.82) and, after classification in three grades, coincided in 78% of all patients. When rated on a three-grade scale the intensity of the aortic regurgitation signal measured by continuous wave Doppler corresponded with invasive data in 82% of patients, and a three-graded maximal width at the base of the colour Doppler regurgitant jet relative to the aortic outflow tract showed agreement in 71%. The best results were obtained by combining continuous wave and colour Doppler indices, which yielded agreement with angiography in 85% of patients. Subdivision of the patient group into those with pure aortic regurgitation and those with combined aortic lesions revealed less accurate gradings with both Doppler methods in the presence of aortic stenosis.