3D Vena Contracta Area Research Articles

Novel 3-dimensional effective regurgitation orifice area quantification serves as a reliable tool to identify severe mitral valve regurgitation.

A precise quantification of mitral regurgitation (MR) severity is essential for treatment and outcome of patients with MR. 3D echocardiography facilitates estimation of MR but selection of patients with necessity of invasive treatment remains challenging. We investigate effective regurgitation orifice area (EROA) quantification by 3D compared to 2D echocardiography in patients with MR and highlight the improved discrimination of MR severity. We consecutively enrolled fifty patients with primary or secondary and at least moderate MR undergoing 2D and 3D colour Doppler echocardiography prior to transcatheter edge-to-edge repair (TEER). Improved accuracy of MR grading using 3D vena contracta area (VCA) as an estimate of EROA was compared to 2D proximal isovelocity surface area (PISA) quantification method and a multiparameter reference standard. Quantification of EROA remarkably varies between 2D and 3D echocardiography and the discrimination between moderate and severe MR was significantly (p = 0.001) different using 2D PISA or 3D VCA, respectively. 3D VCA correlated significantly (r = 0.501, p < 0.001) better with the pre-defined MR severity. We detected crucial differences in the correct identification of severe MR between 2D and 3D techniques, thus 2D PISA significantly (p < 0.0001) underestimates EROA due to clinical and morphological parameters. The assessment of 3D VCA resulted in improved diagnostic accuracy.

Quantification of Mitral Regurgitation in Mitral Valve Prolapse by Three-Dimensional Vena Contracta Area: Derived Cutoff Values and Comparison With Two-Dimensional Multiparametric Approach

Echocardiographic grading of mitral regurgitation (MR) in mitral valve prolapse (MVP) is challenging. Three-dimensional (3D) vena contracta area (VCA) has been proposed as a valuable method. However, data defining the cutoff values of severity and validation in the subset of patients with MVP are scarce. The aim of this study was to validate the 3D VCA by 3D color-Doppler transesophageal echocardiography (TEE) in patients with MVP and to define the cutoff values of severity grading. The secondary aim was to compare 3D VCA to the effective regurgitant orifice area estimation by proximal isovelocity surface area (EROA-PISA) method. A total of 1,138 patients with at least moderate MR who underwent TEE were included. Three-dimensional VCA was measured, and the cutoff value and area under the curve (AUC) for the prediction of severe MR were estimated by receiver operating characteristic curve using a guideline-suggested multiparametric approach as the reference standard. In a subgroup of patients, 3D regurgitant volume (RV) and 3D fraction were calculated from mitral and left ventricular outflow tract stroke volumes to further validate 3D VCA against a 3D volumetric reference standard. The optimal 3D VCA cutoff value for predicting severe MR was 0.45cm2 (specificity, 0.87; sensitivity, 0.90) with an AUC of 0.95 using a multiparametric approach as reference. Three-dimensional VCA had a good linear correlation with EROA-PISA (r=0.62, P<.05) with larger values compared to EROA-PISA (0.63cm2 vs 0.44cm2, P<.05). A cutoff of 0.50cm2 (AUC of 0.84; sensitivity, 0.78; specificity, 0.78) predicts an EROA-PISA of 0.40cm2. Three-dimensional VCA had a good linear correlation with 3D RV (r=0.56, P<.01), with an AUC of 0.86 to predict a 3D fraction>50%. The present study suggests 0.45cm2 as the best cutoff value of 3D VCA to define severe MR in patients with MVP, showing an optimal agreement with the reference standard multiparametric approach and 3D RV.

Secondary leaflet tethering in patients with severe degenerative mitral regurgitation and its association with the severity of mitral regurgitation.

The purpose of the study was to determine the association between vena contracta area (VCA) and secondary leaflet tethering among mitral valve prolapse (MVP) patients, and thus to further identify and characterize an MVP with pathological leaflet tethering (MVPt+) phenotype. We prospectively evaluated 94 consecutive MVP patients with significant mitral regurgitation (MR) and 21 healthy controls. MVPt+ group was defined as tenting volume index (TVi)>.7mL/m2 . The three-dimensional (3D) geometry of mitral valve apparatus and VCA was measured with dedicated quantification software. Of the 94 patients with MVP and significant MR, 31 patients showed a TVi>.7mL/m2 and entered the MVP with leaflet tethering (MVPt+) group. In stepwise multivariate analysis, only prolapse volume index and TVi were independently associated with 3D VCA. 3D VCA, annular area index, and plasma levels of NT-proBNP were independently correlated with the severity of leaflet tethering. ROC curve revealed that a 3D VCA ≥ .55 cm2 is the optimal cutoff point to predict MVPt+ phenotype. Secondary leaflet tethering is a significant mechanism behind severe degenerative MR, resulting in an MVPt+ phenotype featuring more advanced morphological and hemodynamical characteristics.

Benefit of 3D Vena Contracta Area over 2D-Based Echocardiographic Methods in Quantification of Functional Mitral Valve Regurgitation

The two-dimensional proximal isovelocity surface area (2D PISA) method in the quantification of an effective regurgitation orifice area (EROA) has limitations in functional mitral valve regurgitation (FMR), particularly in non-circular coaptation defects. We aimed to validate a three-dimensional vena contracta area (3D VCA) against a conventional EROA using a 2D PISA method and anatomic regurgitation orifice area (AROA) in patients with FMR. Both 2D and 3D full-volume color Doppler data were acquired during consecutive transoesophageal echocardiography (TEE) examinations. The EROA 2D PISA was calculated as recommended by current guidelines. Multiplanar reconstruction was used for offline analysis of the 3D VCA (with a color Doppler) and AROA (without a color Doppler). Receiver operating characteristic (ROC) analysis was used to calculate a cut-off value for the 3D VCA to discriminate between moderate and severe FMR as classified by the EROA 2D PISA. From 2015 to 2018, 105 consecutive patients with complete and adequate imaging data were included. The 3D VCA correlated strongly with the 2D PISA EROA and AROA (r = 0.93 and 0.94). In the presence of eccentric or multiple regurgitant jets, there was no significant difference in correlations with the 3D VCA. We found a 3D VCA cut-off of 0.43 cm2 to discriminate between moderate and severe FMR (area under curve = 0.98). The 3D VCA showed a higher interobserver agreement than the EROA 2D PISA (interclass correlation coefficient: 0.94 vs. 0.81). The 3D VCA has excellent validity and lower variability than the conventional 2D PISA in FMR. Compared to the 2D PISA, the 3D VCA was not affected by the presence of eccentric or multiple regurgitation jets or non-circular regurgitation orifices. With a threshold of 0.43 cm2 for the 3D VCA, we demonstrated reliable discrimination between moderate and severe FMR.

Acute impact of transcatheter edge-to-edge repair for mitral regurgitation on left ventricular function

Abstract Introduction Transcatheter Edge-to-Edge repair (TEER) for the therapy of mitral valve regurgitation (MR) is an alternative to surgery for high risk patients. It is a minimal invasive procedure but the acute impact of the pre- and afterload decrease, due to the reduction of both MR and mitral valve area (MVA), on the left ventricle (LV) systolic function was never formally evaluated. Method Fifty patients with mixed MR etiologies from our TEER register with complete 3D datasets of the LV before and after TEER were included in this study. LV volumes and function, as evaluate by ejection fraction (LVEF), global longitudinal strain (LV-GLS) and global circumferential strain (LV-GCS), and the MR (3D vena contracta area, 3D VCA) were evaluated before and at the end of the therapy. Results The majority of patients suffered from secondary MR (54%), one TEER device was implanted in 64% and two in 36% of the population. TEER leads to a significant reduction of all the LV volume and function parameters excepted for the end-diastolic volume which increased non-significantly (Table 1). The decrease of the LVEF was linked to a decrease of both GLS and GCS in a multivariate analysis (r 0.85), the decrease of GCS having a higher influence (beta −0.606 vs −0.435). In the univariate linear analysis, the reduction of LVEF, GLS and GCS were inverse proportional to the LVEF before TEER and direct proportional to the reduction of the 3D VCA. LVEF decrease was also directly linked to MVA percental reduction. After multivariate evaluation, LVEF reduction kept linked to LVEF before TEER and VCA 3D reduction (r=0.51, p=0.001), GCS decrease only to VCA 3D reduction (r=0.371, P=0.08) and GLS diminution only to LVEF before TEER (r=0.313, p=0.027). Conclusion After TEER, left ventricular function reduction seems principally linked to the afterload increase (i.e. the MR reduction); the circumferential function and the left ventricles with the highest ejection fractions being apparently maximally impacted. Funding Acknowledgement Type of funding sources: None.

The value of 3D vena contracta area in a patient with degenerative mitral regurgitation and multiple jets

Quantification of degenerative mitral regurgitation with multiple jets in atrial fibrillation is challenging with two dimensional techniques and may underestimate the severity. We report the feasibility and advantages of vena contracta area in three dimensional transesophageal echocardiography in evaluation of such a patient.

Quantification of mitral regurgitation after transcatheter edge-to-edge repair: Comparison of echocardiography and patient-specific in silico models

BackgroundDoppler echocardiographic (echo) assessment of residual mitral regurgitation (MR) after transcatheter edge-to-edge repair (TEER) is challenging and often subjective. This study aimed to evaluate the accuracy and feasibility of standardized quantitative echo methods for assessment of MR severity after MitraClip repair by comparing measurements against a reference MR severity obtained from patient-specific in silico models. MethodsPost-procedure hemodynamics were simulated under five different MitraClip configurations in previously validated patient-specific in silico models for the treatment of functional MR. The residual regurgitant volume was calculated as in clinical practice using four quantitative virtual echo methods: pulsed Doppler, volumetric, proximal isovelocity surface area (PISA) and vena contracta area (VCA). Multiple permutations were performed for each method. Virtual echo MR results were evaluated against reference MR values directly extracted from the 5 patient-specific in silico models. ResultsThe echo methods with the greatest accuracy were the three-dimensional (3D) volumetric method (r = 0.957, bias −0.8 ± 1.2 ml, p = 0.01), the 3D VCA method wherein velocity time integrals were evaluated for each jet assessed (r = 0.919, bias −1.5 ± 1.7 ml, p = 0.03), and the 3D PISA method integrating surface areas throughout systole (r = 0.98, bias −2.0 ± 0.9 ml, p = 0.003). The pulsed Doppler and 2D volumetric methods had technical limitations that may result in a high underestimation or overestimation of the MR severity after TEER. In the case of multiple regurgitant jets, a more accurate MR assessment was obtained when all significant jets were evaluated. ConclusionsClinically, the 3D volumetric, 3D VCA and 3D PISA methods gave the most accurate MR quantification after TEER. Three-dimensional echo technologies harbor the potential of becoming the non-invasive imaging tool of choice for MR quantification after complex transcatheter mitral interventions.

Transcatheter Mitral Valve Repair Technique in Specific Severe Mitral Regurgitation: Tips, Tricks, and Outcomes

BackgroundIn specific patients with severe mitral regurgitation (MR), mitral valve (MV) pathology is unique and requires creative transcatheter repair techniques. This study aimed to evaluate the feasibility and safety of a new transcatheter MV repair technique, using occluder devices in symptomatic high-surgical-risk patients with severe MR, either due to MV leaflet (MVL) perforations or due to post-clips residual MR, and to report on their 6-month outcomes. MethodsThe study enrolled all high-risk patients with severe MR due to MVL perforations and post-clips residual MR who underwent transcatheter MV repair using occluder devices, from November 2016 to August 2019. ResultsThe study enrolled 16 patients; 9 (56.25%) with MVL perforations and 7 (43.75%) with post-MitraClip (Abbott Laboratories, Abbott Park, Illinois) residual MR, with a mean age of 55.75 ± 16.69 years. Mean perforation/jet diameters were 5.75 ± 1.67 and 6.5 ± 1.93 mm, and the mean 3D-vena contracta area was 0.54 ± 0.14 cm2. Perforations were crossed retrograde (transaortic in 7 [43.75%] patients and transapical in 2 [12.5%] patients), and post-MitraClip devices residual jets were crossed antegrade (transvenous/transseptal). Six (37.5%) patients required arteriovenous loop formation for device deployment, that was antegrade transvenous/transseptal in 13 (81.25%) patients and retrograde transapical in 3 (18.75%) patients. Devices used were Amplatzer-ASO in 10 (62.5%) patients and Amplatzer-VP-II in 6 (37.5%) patients. Mean procedural and fluoroscopy times were 55.13 ± 16.24 and 16.25 ± 4.03 ​minutes, respectively. Patients passed successfully, without MV gradient change or device-related complications. ConclusionsTranscatheter MV repair of MVL perforations/post-clips residual MR is a new, feasible, and safe technique for high-surgical-risk patients.

Magnetic resonance derived regurgitant fraction, 3D vena contracta area, and B-natriuretic peptide: the most accurate prognostic markers in patients with chronic asymptomatic aortic regurgitation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health of the Czech Republic 17-28265A. Background The optimal timing of surgical treatment is challenging in asymptomatic patients with severe aortic regurgitation (AR). A significant number of patients undergoing aortic valve surgery as per current guidelines have irreversible left ventricular (LV) myocardial damage with a negative impact on their long-term postoperative outcome. Purpose We aimed to determine the value of magnetic resonance-, advanced echocardiography–derived indices and serum B-natriuretic peptide level (BNP) to identify patients with chronic asymptomatic AR who are at risk of early disease progression. Methods We prospectively enrolled a group of asymptomatic patients with pure chronic severe AR, without an indication for surgical treatment as per the current guidelines, in a multicenter study. Baseline examination consisted of serum BNP level analysis, comprehensive echocardiography including 3D vena contracta area (VCA) and 2D global longitudinal strain (GLS), and a comprehensive MRI including regurgitant fraction (RF) measurement; all imaging data were analyzed in Corelab. Patient follow-up was every 6 months. The primary endpoint was a new guideline-directed indication for surgical treatment. Results In total, 129 patients were enrolled between 2015 and 2019, the endpoint occurred in 43 patients during a median follow-up of 1375 (IQR 1041-1783) days. Baseline clinical data did not differ between patients with the endpoint (surgical group) and stable patients (medical group). Baseline BNP levels were significantly higher in the surgical group (55 vs. 21 ng/L, P = 0.008). MRI-derived LV ejection fraction was not different (61 vs 61 %, P = 0.815) at baseline while both CMR-derived end-systolic and end-diastolic LV volumes were significantly higher in the surgical group (all P &amp;lt; 0.01). Both baseline 3D VCA and 2D GLS were different between the surgical and medical groups (33 vs. 25 mm2, P = 0.006 and 18 vs 19 %, P = 0.07). Magnetic resonance derived RF was significantly higher in the surgical group (46 vs 32 %) with P &amp;lt; 0.01. A combined model including independent markers such as BNP (cut-off &amp;gt; 31 ng/L), MRI RF (cut-off value &amp;gt; 34 %), 3D VCA (cut-off value 36 mm2) or 2D GLS (cut-off value &amp;lt; 17 %) showed the highest predictive accuracy (P = 0.002) to predict the primary endpoint. (Figure 1). Conclusion A combination of baseline parameters of AR severity (3D VCA, MRI-derived RF) and myocardial impairment (2D GLS, serum BNP level) present an accurate tool for the identification of patients with chronic asymptomatic AR who are at risk of early disease progression. Abstract Figure 1

Multiparametric assessment of the intraprocedural result after transcatheter mitral valve edge-to-edge repair proceduret

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Research grant OnBehalf n/a Background. Quantification of residual mitral regurgitation (MR) after transcatheter edge-to-edge mitral valve repair (TMVr) is challenging. Objectives. To evaluate the feasibility and the performance of an intraprocedural multiparametric approach based on echocardiographic and invasive hemodynamic parameters and to develop a multiparametric scoring system for MR grading after TMVr, and to compare this approach against currently recommended methods. Methods. Ninety-three consecutive patients treated with MitraClip (April 2019-July 2020) were enrolled. The protocol of MR evaluation included: 2D and 3D color-Doppler (3D-vena contracta area- 3D-VCA), pulsed-wave Doppler (pulmonary vein- PV flow, stroke volume), continuous-wave Doppler (jet density), morphological parameters (spontaneous echocontrast) and invasive hemodynamic (mean left atrial pressure-LAP, V-wave) at baseline and after clip implantation. A multiparametric score (M-score) was calculated by including the significant predictors (3D-VCA, dense jet on CWD, final LAP, final V wave) of primary endpoint (CV death or HF related hospitalization) at one year follow-up, weighted according to the corresponding odds ratio, to predict the clinical outcome at one-month and one-year follow-up. Results. The final study population included 86 pts (mean age 78.3 +8.9yrs, 54.6% primary MR). Procedural success was achieved in 78 pts (90.7%). 3D-VCA (AUC 0.808) and current method for MR grading (AUC 0.801) were comparable predictors of lack of symptom improvement (&amp;lt;5 point change in KCCQ-OS score) at one-month (p = 0.398, DeLong’s test). The M-score performed similarly as predictor of one-month follow-up but was a better predictor of primary endpoint at 1-year (AUC 0.919) compared to single parameters (p = 0.005 vs 3D-VCA DeLong"s test) and currently recommended methods for MR grading (p = 0.006 DeLong"s test). The optimal cut-off was 2 points with 86.7% sensitivity and 83.1% specificity. Conclusion. We evaluated intraprocedural TMVr result in a multiparametric approach showing that 3D-VCA alone is comparable to current recommended method for MR grading. However, the integration of echocardiographic and invasive hemodynamic parameters into a multiparametric score provided a further added value for predicting clinical outcome at one-year compared to currently recommended methods for MR grading and to 3D-VCA.

Prediction of procedural success of transcatheter mitral valve repair with normal and extended clip arms

TMVR using different clip sizes is a treatment option for selected patients with mitral regurgitation (MR). This study sought to identify predictors of successful transcatheter mitral valve repair (TMVR) by 3-dimensional (3D) echocardiography and to compare different effects of the larger XTR and the smaller NT/NTR devices. 3D transesophageal echocardiography was performed on 54 patients with secondary MR undergoing TMVR with one clip (55.6% NT/NTR, 44.4% XTR). All NT/NTR and 96% of XTR patients had MR reduction ≤ 2+. Despite more severe baseline MR (3D vena contracta area (VCA): 0.67 ± 0.34 cm2 vs. 0.43 ± 0.19 cm2, p = 0.004) and greater mitral valve area (MVA) (6.8 ± 2.1 cm2 vs. 5.1 ± 1.6 cm2, p = 0.001) in the XTR group, MR severity after TMVR was not different between XTR and NT/NTR patients (3D VCA: 0.19 ± 0.14 vs. 0.17 ± 0.10, p = 0.51). Baseline 3D VCA > 0.45 cm2 in NT/NTR (AUC = 0.802, 95% CI 0.602 to 1.000) and 3D VCA > 0.54 cm2 in XTR devices (AUC = 0.868, 95% CI 0.719 to 1.000) were associated with ineffective MR reduction defined as residual VCA ≤ 0.2 cm2. Baseline MVA ≤ 4.2 cm2 in NT/NTR (AUC = 0.920, 95% CI 0.809 to 1.000) and MVA ≤ 6.0 cm2 in XTR devices (AUC = 0.865, 95% CI 0.664 to 1.000) were associated with postprocedural transmitral pressure gradient (TMPG) ≥ 5 mmHg. TMVR using the XTR device resulted in an equally effective reduction of MR despite of a greater baseline MR. Distinct cut-off values of baseline 3D VCA and MVA for prediction of successful MR reduction and postprocedural increase of TMPG were identified for the different devices.

Assessment of Asymptomatic Severe Aortic Regurgitation by Doppler-Derived Echo Indices: Comparison with Magnetic Resonance Quantification.

Reliable quantification of aortic regurgitation (AR) severity is essential for clinical management. We aimed to compare quantitative and indirect echo-Doppler indices to quantitative cardiac magnetic resonance (CMR) parameters in asymptomatic chronic severe AR. Methods and Results: We evaluated 104 consecutive patients using echocardiography and CMR. A comprehensive 2D, 3D, and Doppler echocardiography was performed. The CMR was used to quantify regurgitation fraction (RF) and volume (RV) using the phase-contrast velocity mapping technique. Concordant grading of AR severity with both techniques was observed in 77 (74%) patients. Correlation between RV and RF as assessed by echocardiography and CMR was relatively good (rs = 0.50 for RV, rs = 0.40 for RF, p < 0.0001). The best correlation between indirect echo-Doppler and CMR parameters was found for diastolic flow reversal (DFR) velocity in descending aorta (rs = 0.62 for RV, rs = 0.50 for RF, p < 0.0001) and 3D vena contracta area (VCA) (rs = 0.48 for RV, rs = 0.38 for RF, p < 0.0001). Using receiver operating characteristic analysis, the largest area under curve (AUC) to predict severe AR by CMR RV was observed for DFR velocity (AUC = 0.79). DFR velocity of 19.5 cm/s provided 78% sensitivity and 80% specificity. The AUC for 3D VCA to predict severe AR by CMR RV was 0.73, with optimal cut-off of 26 mm2 (sensitivity 80% and specificity 66%). Conclusions: Out of the indirect echo-Doppler indices of AR severity, DFR velocity in descending aorta and 3D vena contracta area showed the best correlation with CMR-derived RV and RF in patients with chronic severe AR.

Prevalence, distribution, and determinants of pulmonary venous systolic flow reversal in severe mitral regurgitation.

This study aimed to evaluate the prevalence and distribution of pulmonary venous systolic flow reversal (PVSFR) in patients with severe mitral regurgitation (MR), and to examine the relationship between PVSFR profile and cardiac parameters. A total of 125 patients with severe MR who had transoesophageal echocardiography (TOE) performed were reviewed. Of these, 121 (96.8%) patients showed all four pulmonary venous (PV) flows by TOE. They were categorized into three groups by the MR aetiology: degenerative MR (DMR) (n = 72), ventricular functional MR (V-FMR) (n = 20), and atrial functional MR (A-FMR) (n = 16). Eighteen (16.7%) patients had PVSFR in all four PVs. Twenty-nine (26.9%) had PVSFR in three PVs, 23 (21.3%) in two PVs, and 23 (21.3%) in one PV. PVSFR appeared at right PVs more frequently compared with left PVs. A high number of PVSFR was significantly correlated with higher pulmonary capillary wedge pressure (PCWP) and 3D vena contracta area (3D-VCA). With regard to MR aetiology, the number of PVSFRs was correlated with high 3D-VCA in patients with DMR and A-FMR, while it was correlated with high PCWP in patients with V-FMR. Laminar-type PVSFR appeared more frequently in FMR compared with DMR, and it had a relationship with higher PCWP and lower right ventricular fractional area change (RVFAC). All four PV were detected in 96.8%, and 16.8% patients had PVSFR in all four PVs. PCWP and 3D-VCA were correlated with the number of PVSFRs in severe MR patients. Laminar-type PVSFR was related to higher PCWP and lower RVFAC.

Dynamic Systolic Changes in Tricuspid Regurgitation Vena Contracta Size and Proximal Isovelocity Surface Area in Hypoplastic Left Heart Syndrome: A Three-Dimensional Color Doppler Echocardiographic Study

The aims of this study were to investigate the dynamic changes in the vena contracta (VC) and proximal isovelocity surface area (PISA) through systole in patients with hypoplastic left heart syndrome and tricuspid regurgitation and to identify the stage of systole (early, mid, or late) in which VC and PISA radius are optimal. Twenty-eight patients with hypoplastic left heart syndrome were prospectively studied using continuous two-dimensional (2D) and three-dimensional (3D) echocardiography. Two-dimensional VC width, 3D VC area, and PISA radii (2D and 3D) were measured frame by frame throughout systole. The maximal 2D VC width, 3D VC area, and PISA radii in the first, middle, and last thirds of systole were compared, and correlations were explored with 3D tricuspid annular areas, right atrial volumes, and right ventricular volumes. In all, 35 data sets that met inclusion criteria were analyzed. On frame-by-frame analysis, maximal 2D VC width and 3D VC area were found in the first third of systole in 17% and 20% of studies, in the second third in 34% and 31%, and in the final third in 49% and 49%. Similarly, the maximal 2D and 3D PISA radii were found in the first third of systole in 26% and 17% of studies, in the second third in 28% and 34%, and in the final third in 46% and 49%. In hypoplastic left heart syndrome, detailed temporal analysis of tricuspid regurgitation-associated VC and PISA by 2D and 3D echocardiography reveals no reliable pattern predicting when in systole these parameters peak. Frame-by-frame measurement is necessary for identification of maximal VC and PISA radius on 2D and 3D color Doppler echocardiography because the severity of tricuspid regurgitation could be underestimated because of temporal variability in VC and PISA.

Cardiac magnetic resonance and B-natriuretic peptide: prognostic value in patients with asymptomatic chronic aortic regurgitation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by Ministry of Health of the Czech Republic 17-28265A. Background Indication for surgical treatment in asymptomatic patients with severe aortic regurgitation (AR) is curretly based on 2-dimensional echocardiography derived left ventricle (LV) diameter and ejection fraction. Suboptimal sensitivity of this quideline-directed approach may lead to late intervention in a substantial number of patients. Purpose We aimed to develop a new prognostic stratification scheme based on novel imaging and biochemical markers of heart failure. Methods Consecutive patients with chronic severe AR not indicated for surgery per the current guidelines were enrolled into prospective multi-center study. Baseline examination consisted of B-natriuretic peptide (BNP); comprehensive echocardiography (ECHO) including 3-dimensional (3D) vena contracta area (VCA); comprehensive cardiac magnetic resonance (CMR) including regurgitant volume and fraction measurement, and extracellular volume (ECV); all imaging data were analysed in core lab. The perioperative myocardial biopsy from basal septum was performed in all surgically treated patients for histological myocardial fibrosis quantification by Picrosirius Red staining. Patient follow-up was every 6 months. The endpoint was a disease progression (indication for surgery per the current guidelines). Results In total, 132 patients were enrolled between 2015 and 2019, the endpoint occurred in 39 patients during a median follow-up of 1217 days. Baseline clinical data did not differ between patients with endpoint (surgical group) and stable patients (medical group). Baseline BNP levels were higher in the surgical group (57 vs. 20, P &amp;lt; 0.01). Most baseline ECHO parameters did not differ, only 3D VCA, mitral inflow E-wave and flow reversal velocity in the descending aorta were significantly different between two groups (33 vs. 25 mm2, 61 vs 68 cm/s, 21 vs. 19 cm/s with P = 0.012, P = 0.019, P = 0.001). Both CMR-derived end-systolic and end-diastolic LV volumes were significantly different (all P &amp;lt; 0.01); the LV ejection fraction was similar (61 vs. 61%, P = 0.83). The ECV was similar in both groups (24.2 vs. 24%, P = 0.69) and correlated well with histologically validated diffuse myocardial fibrosis (15%). CMR-derived regurgitant volume and fraction were significantly higher in the surgical group (58 vs. 36 ml, P &amp;lt; 0.01 and 45 vs. 33%, P &amp;lt; 0.01). Based on our results, we developed a multi-factorial scoring system combining the independent predictors of disease progression (specificity 79%, sensitivity 74%). Conclusion Baseline CMR-derived LV volumes, CMR-derived regurgitant fraction, and BNP levels can predict disease progression in asymptomatic patients with chronic severe aortic regurgitation. The novel multi-factorial scoring system might identify candidates of early surgical treatment but this hypothesis will require prospective clinical testing. Abstract Figure. Cardiac magnetic resonance imaging

Cardiac magnetic resonance and B-natriuretic peptide are superior prognostic tools to guideline-based echocardiography in asymptomatic patients with chronic severe aortic regurgitation

Abstract Background The optimal timing of intervention in patients with chronic aortic regurgitation (AR) is currently based on patient symptoms and echocardiography derived parameters. The sensitivity of this approach is suboptimal and late operation often results in irreversible myocardial damage. Purpose To determine the prognostic value of novel parameters in asymptomatic patients with chronic severe AR in optimal timing of aortic valve surgery. Methods Consecutive patients with chronic severe AR not indicated for surgery per the current guidelines were studied in a prospective design in 5 centers. Baseline examination consisted of B-natriuretic peptide (BNP) measurement, comprehensive echocardiography (ECHO) including 3-dimensional (3D) study with vena contracta area (VCA), and complex magnetic resonance (MRI) including regurgitant volume (RV), regurgitant fraction (RF), global myocardial work efficiency (GWE) and extracellular volume (ECV); all analyzed in core lab. All patients were followed every 6 months and the endpoint was disease progression defined as an indication for surgery. The perioperative myocardial biopsy was performed in all surgically treated patients for histological myocardial fibrosis quantification. Results In total, 129 patients were enrolled between 2015 and 2019, the endpoint occurred in 35 patients during a mean follow-up of 1044 days. Baseline clinical data did not differ between patients with disease progression (surgical group) and stable patients. Baseline BNP levels were higher in the surgical group (63 vs. 20, P&amp;lt;0.01) and a cut-off value of 30.4 ng/L was predictive of disease progression with AUC 0.75. None of the standard ECHO parameters of left ventricular (LV) size and function was predictive of the endpoint. Novel ECHO parameter 3D VCA was higher in the surgical group (32 vs. 26 mm2, P=0.037). All MRI parameters of LV size and function were predictive of disease progression (all P&amp;lt;0.02), except LV ejection fraction. MRI-derived RV (57 vs. 37 ml, P&amp;lt;0.01) and RF (46 vs. 34%, P&amp;lt;0.01) were identified as the strongest independent predictors of surgery. There was no difference in ECV between the surgical group and stable patients (24 vs. 24, P=0.81) despite a good correlation with histological quantification of myocardial fibrosis. Conclusions Standard ECHO parameters cannot reliably predict the need for surgery in asymptomatic aortic regurgitation patients. Baseline BNP levels above 30.4 ng/L predict disease progression. Novel imaging parameters – ECHO-derived 3D VCA and MRI-derived parameters of LV size and AR severity might be useful in optimal timing determination. Imaging markers and myocardial histology Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Ministry of Health of the Czech Republic

1642 Mitral annulus disjunction, a rare form of focal arrhythmogenic cardiomyopathy

Abstract Funding Acknowledgements Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary The rate of sudden cardiac death in mitral valve prolapse (MVP) patients is roughly twice that observed in the general population. Arrhythmogenic bileaflet MVP syndrome has been recently described and mitral annulus disjunction (MAD) has been found associated with papillary muscle fibrosis and ventricular arrhythmias even without severe mitral regurgitation. An underlying primary structural myocardial disease might be expected and the non-invasive imaging techniques are playing an increasingly important role in the detection of myocardial fibrosis as a focal arrhythmogenic substrate. Standard 2D-, 3D- and speckle tracking echocardiography and cardiac MRI can help to differentiate between the benign and malignant forms of MVP. A 52-year-old man with a history of hypertension was referred for evaluation of frequent palpitations and presyncope. Ambulatory Holter monitoring showed paroxysmal atrial fibrillation and non-sustained ventricular tachycardias. Dilated left ventricle (LVEDD: 65mm, LVESD: 45 mm) and left atrium (LAVi: 52mL/m2), moderately reduced left ventricular (LV) systolic function (LVEF: 42%), and reduced LV global longitudinal strain (GLS: -13.5%) with severely decreased segmental longitudinal strain in the basal inferolateral segment were measured by transthoracic echocardiography. The diastolic function was preserved, however Pickelhaube sign was noticed in the lateral mitral annulus TDI curves. MAD (17 mm) and curling motion of the inferolateral basal segment of the left ventricle was observed. Transesophageal echocardiography showed bileaflet mitral valve prolapse with the involvement of all the six scallops (mitral valve prolapse volume: 10.2 mL). Severe mitral regurgitation (3D vena contracta area: 1cm2) and extremely dilated and dyskinetic mitral annulus (diameters: 55x72x12 mm, area: 34 cm2) was measured by 3D echocardiography. MRI showed transmural late gadolinium enhancement in the underlying myocardium of both papillary muscles and midmyocardial enhancement in the basal inferior, inferolateral and anteroseptal LV segments. During electrophysiology study ventricular fibrillation was easily induced and ICD was placed for primary prevention of sudden cardiac death. The patient was referred to the heart surgeon for mitral valve replacement. This case highlights the importance of early recognition of MAD and arrhythmogenic MVP syndrome using novel non-invasive imaging techniques. The presence of MAD, the curling motion of the inferolateral basal LV segment, the Pickelhaube sign, the decreased LVEF and GLS, the characteristic segmental longitudinal strain pattern and the presence of late enhancement in the papillary muscles and the surrounding myocardium could be warning signs of the malignant form of MVP. Abstract 1642 Figure. CMR images of arrhythmogenic MAD

1051 Assessment of asymptomatic severe aortic regurgitation by doppler-derived echo indices: comparison with magnetic resonance quantification

Abstract Funding Acknowledgements This study was supported by Ministry of Health of the Czech Republic 17-28265A Introduction Management of asymptomatic patients with chronic severe aortic regurgitation (AR) is challenging. Reliable quantification of the AR severity is essential. Transthoracic echocardiography (TTE) is a primary imaging modality. Grading of AR severity is achieved by an integrative approach. Cardiovascular magnetic resonance (CMR) can directly quantify AR severity by measuring regurgitation volume (RV) and regurgitation fraction (RF). Purpose There are few data on direct comparison between TTE and CMR for quantification of AR. Our study aimed to compare quantitative and indirect echo-Doppler indices to quantitative MRI derived parameters in asymptomatic patients with severe chronic AR. Methods In a prospective three-centre study, we evaluated patients with moderate to severe (3+) and severe (4+) chronic AR using TTE and CMR. All patients were asymptomatic, without indication for surgical treatment. The severity of AR was graded using TTE multiparametric approach. A 2-D and 3-D TTE were performed with an assessment of left ventricle size and function, valve morphology, Doppler parameters of AR including vena contracta width, diastolic flow reversal velocity in descending aorta, RV, RF using volumetric method, 3D-vena contracta area (3D-VCA). The CMR quantified left ventricle volumes and function, RF and RV using the phase-contrast velocity mapping. All imaging studies were analysed in CoreLab. Results A total of 104 patients were enrolled during 2015-2018. Mean patient age was 44 ± 13 years, 89 patients (86%) were males and 83 patients (81%) had a bicuspid or unicuspid aortic valve. Using the TTE severe (4+) AR was present in 48 (46%) and moderate to severe (3+) AR in 56 (54%) individuals. Concordant grading of AR severity with both techniques was observed in 77 (74%) patients. An integrative TTE approach showed a trend to underestimate AR severity. The best correlation between echo-Doppler indices and CMR measured RV and RF was found in two parameters: diastolic flow reversal velocity in descending aorta ( Rs = 0,62, p &amp;lt; 0,0001 for RV, Rs = 0,50, p &amp;lt; 0,0001 for RF) and 3D-VCA (Rs = 0,48 for RV, p &amp;lt; 0,0001 , Rs = 0,38 for RF, p &amp;lt; 0,0001). On the contrary vena contracta width showed poor correlation with CMR (Rs = 0,18, p = 0,07 for RV and Rs = 0,11, p = 0,29 for RF). Correlation between quantitative parameters of AR assessed by TTE volumetric method and CMR technique was modest (Rs = 0,40 for RF and Rs = 0,50 for RV, p &amp;lt; 0,0001), 95% confidence intervals were wide. Good correlation between TTE and CMR were found for LV dimensions, volumes and ejection fraction. Conclusion Out of indirect Doppler-echo indices of AR severity, diastolic flow reversal velocity in descending aorta and 3D-vena contracta area showed the best correlation with MRI derived RF and RV in patients with chronic severe AR. Quantitative parameters of AR (RF and RV) assessed by echo volumetric method had an only modest correlation to RF and RV measured using CMR.

New Imaging Markers of Clinical Outcome in Asymptomatic Patients with Severe Aortic Regurgitation.

Background: Determining the value of new imaging markers to predict aortic valve (AV) surgery in asymptomatic patients with severe aortic regurgitation (AR) in a prospective, observational, multicenter study. Methods: Consecutive patients with chronic severe AR were enrolled between 2015–2018. Baseline examination included echocardiography (ECHO) with 2- and 3-dimensional (2D and 3D) vena contracta area (VCA), and magnetic resonance imaging (MRI) with regurgitant volume (RV) and fraction (RF) analyzed in CoreLab. Results: The mean follow-up was 587 days (interquartile range (IQR) 296–901) in a total of 104 patients. Twenty patients underwent AV surgery. Baseline clinical and laboratory data did not differ between surgically and medically treated patients. Surgically treated patients had larger left ventricular (LV) dimension, end-diastolic volume (all p < 0.05), and the LV ejection fraction was similar. The surgical group showed higher prevalence of severe AR (70% vs. 40%, p = 0.02). Out of all imaging markers 3D VCA, MRI-derived RV and RF were identified as the strongest independent predictors of AV surgery (all p < 0.001). Conclusions: Parameters related to LV morphology and function showed moderate accuracy to identify patients in need of early AV surgery at the early stage of the disease. 3D ECHO-derived VCA and MRI-derived RV and RF showed high accuracy and excellent sensitivity to identify patients in need of early surgery.

Comprehensive Evaluation of Tricuspid Regurgitation Location and Severity Using Vena Contracta Analysis: A Color Doppler Three-Dimensional Transesophageal Echocardiographic Study

The clinical significance of three-dimensional (3D) vena contracta area (VCA) in tricuspid regurgitation (TR) is not fully elucidated. The aim of this study was to investigate the diagnostic accuracy of 3D VCA using 3D echocardiography-derived regurgitation volume as a reference standard. One hundred sixteen patients with at least moderate TR underwent two-dimensional transthoracic and color Doppler 3D transesophageal echocardiography. The 3D vena contracta, which was located at the narrowest neck of the TR jet just above and toward the right atrial side of the flow convergence zone, was assessed for TR location and severity. As for TR location, patients with severe functional TR had the highest prevalence of central jet location among TR subgroups, whereas patients with severe primary TR showed a greater spatial extent of TR jet location involved compared with the moderate TR group (P<.05 for both). As for TR severity, a 3D VCA cutoff value of 0.61cm2 discriminated severe TR with sensitivity of 78% and specificity of 97% in the total patient population (area under the curve=0.93, P<.001). Multivariate analysis revealed that 3D VCA, a dilated right ventricle, and hepatic vein systolic reversal were independently associated with regurgitant volume (P<.001 for all). The χ2 value for the model that incorporated clinical and two-dimensional integrative parameters and 3D VCA > 0.61cm2 to evaluate severe TR was significantly higher than that for the model that incorporated only clinical and two-dimensional integrative parameters (P=.001). Three-dimensional VCA has independent and incremental diagnostic value for evaluating severe TR. Comprehensive evaluation of TR location and severity using 3D vena contracta analysis may help in treatment selection for TR.