Abstract
Three-dimensional transthoracic echocardiography (3D-TTE) provides a semi-automated proximal isovelocity surface area method (3D-PISA) to obtain quantitative parameters. Data assessing regurgitation severity in mitral valve prolapse (MVP) are scarce, so we assessed the 3D-PISA method compared with 2D-PISA and cardiovascular magnetic resonance (CMR) and the role of an eccentricity index. We evaluated the 3D-PISA method for assessing MR in 54 patients with MVP (57 ± 14 years; 42 men; 12 mild/mild-moderate; 12 moderate-severe; and 30 severe MR). Role of an asymmetric (i.e. eccentricity index ≥ 1.25) flow convergence region (FCR) and inter-modality consistency were then assessed. 3D-PISA derived regurgitant volume (RVol) showed a good correlation with 2D-PISA and CMR derived parameters (r = 0.86 and r = 0.81, respectively). The small mean differences with 2D-PISA derived RVol did not reach statistical significance in overall population (5.7 ± 23 ml, 95% CI − 0.6 to 12; p = 0.08) but differed in those with asymmetric 3D-FCR (n = 21; 2D-PISA: 72 ± 36 ml vs. 3D-PISA: 93 ± 47 ml; p = 0.001). RVol mean values were higher using PISA methods (CMR 57 ± 33 ml; 2D-PISA 73 ± 39 ml; and 3D-PISA 79 ± 45 ml) and an overestimation was observed when CMR was used as reference (2D-PISA vs. CMR: mean difference: 15.8 ml [95% CI 10–22, p < 0.001]; and 3D-PISA vs. CMR: 21.5 ml [95% CI 14–29, p < 0.001]). Intra- and inter-observer reliability was excellent (ICC 0.91–0.99), but with numerically lower coefficient of variation for 3D-PISA (8%–10% vs. 2D-PISA: 12%–16%). 3D-PISA method for assessing regurgitation in MVP may enable analogous evaluation compared to standard 2D-PISA, but with overestimation in case of asymmetric FCR or when CMR is used as reference method.
Highlights
Transthoracic echocardiography (TTE) is widely recognized as a non-invasive reference standard for quantification of organic mitral regurgitation (MR)
Patients with severe MR had higher TTE and cardiovascular magnetic resonance (CMR) derived LV end-diastolic volume and stroke volume compared with MR grade 1 + /2 + and 3 +, but similar left ventricle outflow tract (LVOT) or forward stroke volume values reflecting the progressively higher regurgitant volume and fraction values through the groups
An overestimation with TTE methods was observed when CMR was used as the reference for regurgitant volume (RVol) values (2D-TTE vs. CMR: mean difference 15.8 ml [95% CI 9.9 to 21.7, p < 0.001]; and 3D-proximal isovelocity surface area (PISA) vs. CMR: mean difference 21.5 ml [95% CI 14.2 to 28.7, p < 0.001]; Fig. 5)
Summary
Transthoracic echocardiography (TTE) is widely recognized as a non-invasive reference standard for quantification of organic mitral regurgitation (MR). Accurate assessment of the severity of regurgitation is of significant importance for appropriate patient management and clinical decision-making. Current guidelines strongly recommend an integrative approach using multiple qualitative, semi-quantitative, and quantitative measurements, proceeding when necessary toward quantification of effective regurgitant orifice area (EROA) and regurgitant volume (RVol) using the proximal isovelocity surface area (PISA) method [1, 2]. Non-gated, real-time three-dimensional (3D) color Doppler echocardiography (RT-3DE) has been introduced allowing direct automated measurement of the true PISA (3D-PISA) without geometric assumptions, showing a trend of superiority of 3D-PISA over 2D-PISA method. We sought to investigate its diagnostic usefulness for evaluation of regurgitation in MVP with direct comparison to standard 2D-echocardiography, and cardiovascular magnetic resonance (CMR), using a multi-parametric TTE approach as an independent reference method for MR severity grading
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