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)

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Summary

Introduction

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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