Changes in Effective Regurgitant Orifice Throughout Systole in Patients With Mitral Valve Prolapse

Abstract

In patients with mitral valve prolapse, spontaneous changes of the effective regurgitant orifice during systole are not well documented. Such changes can now be analyzed by use of the proximal isovelocity surface area method, but the changes raise concern about the reliability of this method for assessing overall severity of regurgitation in these patients. In a prospective study of 42 patients with mitral valve prolapse, the effective mitral regurgitant orifice was calculated at four phases of systole (early, mid, mid-late, and late) as the ratio of regurgitant flow to regurgitant velocity by use of the proximal isovelocity surface area method. Throughout systole, the effective regurgitant orifice increased significantly, from 32 +/- 27 mm2 in early systole to 41 +/- 27 in midsystole, 55 +/- 30 in mid-late systole, and 107 +/- 66 mm2 during late systole (P < .0001). Phasic regurgitant volume increased from early to mid-late systole but decreased in late systole. For quantitation of the overall effective regurgitant orifice, four approaches using the proximal isovelocity surface area were compared with simultaneously performed quantitative Doppler echocardiography (54 +/- 30 mm2) and quantitative two-dimensional echocardiography (51 +/- 29 mm2). All correlations were good (r > .95), but overestimation was considerable when the largest flow convergence was used (70 +/- 39 mm2; both P < .0001), significant when the simple mean of the four phases was used (59 +/- 36 mm2; P = .005 and P = .0007, respectively), mild when a weighted mean of the four phases was used (55 +/- 33 mm2; P = .41 and P = .01, respectively), and no overestimation was observed when the effective regurgitant orifice calculated at maximum regurgitant velocity was used (54 +/- 30 mm2; P = .29 and P = .17, respectively). Phasic changes of mitral regurgitation are observed in patients with mitral valve prolapse. The effective regurgitant orifice increases throughout systole. Regurgitant volume also increases initially but tends to decrease in late systole. These changes can lead to overestimation of the overall degree of regurgitation, but properly timed measurements made by use of the proximal isovelocity surface area method allow an accurate estimation of the overall effective regurgitant orifice.