Evaluation Of Mitral Regurgitation Research Articles

Deep Learning for Echo Analysis, Tracking, and Evaluation of Mitral Regurgitation (DELINEATE-MR).

Artificial intelligence, particularly deep learning (DL), has immense potential to improve the interpretation of transthoracic echocardiography (TTE). Mitral regurgitation (MR) is the most common valvular heart disease and presents unique challenges for DL, including the integration of multiple video-level assessments into a final study-level classification. A novel DL system was developed to intake complete TTEs, identify color MR Doppler videos, and determine MR severity on a 4-step ordinal scale (none/trace, mild, moderate, and severe) using the reading cardiologist as a reference standard. This DL system was tested in internal and external test sets with performance assessed by agreement with the reading cardiologist, weighted κ, and area under the receiver-operating characteristic curve for binary classification of both moderate or greater and severe MR. In addition to the primary 4-step model, a 6-step MR assessment model was studied with the addition of the intermediate MR classes of mild-moderate and moderate-severe with performance assessed by both exact agreement and ±1 step agreement with the clinical MR interpretation. A total of 61 689 TTEs were split into train (n=43 811), validation (n=8891), and internal test (n=8987) sets with an additional external test set of 8208 TTEs. The model had high performance in MR classification in internal (exact accuracy, 82%; κ=0.84; area under the receiver-operating characteristic curve, 0.98 for moderate/severe MR) and external test sets (exact accuracy, 79%; κ=0.80; area under the receiver-operating characteristic curve, 0.98 for moderate or greater MR). Most (63% internal and 66% external) misclassification disagreements were between none/trace and mild MR. MR classification accuracy was slightly higher using multiple TTE views (accuracy, 82%) than with only apical 4-chamber views (accuracy, 80%). In subset analyses, the model was accurate in the classification of both primary and secondary MR with slightly lower performance in cases of eccentric MR. In the analysis of the 6-step classification system, the exact accuracy was 80% and 76% with a ±1 step agreement of 99% and 98% in the internal and external test set, respectively. This end-to-end DL system can intake entire echocardiogram studies to accurately classify MR severity and may be useful in helping clinicians refine MR assessments.

Prognostic impact of vasopressor test in transcatheter edge-to-edge repair of secondary mitral regurgitation: The PETIT study.

Vasopressor test (VPT) might be useful in patients with functional mitral regurgitation (MR) and left ventricular dysfunction (MITRA-FR-like patients) during transcatheter edge-to-edge repair (TEER). We aimed to evaluate the prognostic impact of VPT. MR treated with TEER were included in a multicenter prospective registry. VPT was used intraprocedurally in patients with left ventricular dysfunction and/or hypotension. The 1-year echocardiographic and clinical outcomes were compared according to the use of VPT. The primary endpoint was a combination of mortality + heart failure (HF) readmission at 1-year. A total of 1115 patients were included, mean age was 72.8 ± 10.5 years and 30.4% were women. VPT was performed in 128 subjects (11.5%), more often in critically ill patients with biventricular dysfunction. Postprocedurally the VPT group had greater rate of MR ≥ 2+ (46.9% vs. 31.7%, p = 0.003) despite greater number of devices (≥2 clips, 52% vs. 40.6 p = 0.008) and device repositioning or new clip in 12.5%. At 1-year, the primary endpoint occurred more often in the VPT group (27.3% vs. 16.9%, p = 0.002) as well as all-cause mortality (21.9% vs. 8.1%, p ≤ 0.001) but no differences existed in HF readmission rate (14.8% vs. 13.2%, p = 0.610), cardiovascular mortality (4.4% vs. 3.9%, p = 0.713) or residual MR ≥ 2+ (51.1% vs 51.7%, p = 0.371). Dynamic evaluation of MR during TEER procedure through VPT was performed in patients with worse baseline risk who also presented higher all-cause mortality at 1-year follow-up. However, 1-year residual MR, cardiovascular mortality and HF readmission rate remained comparable suggesting that VPT might help in the management of MITRA-FR-like patients.

European Association of Cardiovascular Imaging survey on the evaluation of mitral regurgitation.

To evaluate the diagnosis and imaging of patients with mitral regurgitation (MR) and the management in routine clinical practice across Europe, the European Association of Cardiovascular Imaging Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of echocardiography, advanced imaging modalities, heart valve clinics, and heart valve teams was explored. A total of 61 responders, mainly from tertiary centres or university hospitals, from 26 different countries responded to the survey, which consisted of 22 questions. For most questions related to echocardiography and advanced imaging, the answers were relatively homogeneous and demonstrated good adherence to current recommendations. In particular, the centres used a multi-parametric echocardiographic approach and selected the effective regurgitant orifice and vena contracta width as their preferred assessments. 2D measurements are still the most widely used parameters to assess left ventricular structure; however, the majority use 3D trans-oesophageal echocardiography (TOE) to evaluate valve morphology in severe MR. The majority of centres reported the onsite availability and clinical use of ergometric stress echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) imaging. Heart valve clinics and heart valve teams were also widely prevalent. Consistent with current guidelines, echocardiography (transthoracic echocardiography and TOE) remains the first-line and central imaging modality for the assessment of MR although the complementary use of 3D TOE, CCT, and CMR appears to be growing. Heart valve clinics and heart valve teams are now widely prevalent.

Automatic Segmentation and Assessment of Valvular Regurgitations with Color Doppler Echocardiography Images: A VABC-UNet-Based Framework.

This study investigated the automatic segmentation and classification of mitral regurgitation (MR) and tricuspid regurgitation (TR) using a deep learning-based method, aiming to improve the efficiency and accuracy of diagnosis of valvular regurgitations. A VABC-UNet model was proposed consisting of VGG16 encoder, U-Net decoder, batch normalization, attention block and deepened convolution layer based on the U-Net backbone. Then, a VABC-UNet-based assessment framework was established for automatic segmentation, classification, and evaluation of valvular regurgitations. A total of 315 color Doppler echocardiography images of MR and/or TR in an apical four-chamber view were collected, including 35 images in the test dataset and 280 images in the training dataset. In comparison with the classic U-Net and VGG16-UNet models, the segmentation performance of the VABC-UNet model was evaluated via four metrics: Dice, Jaccard, Precision, and Recall. According to the features of regurgitation jet and atrium, the regurgitation could automatically be classified into MR or TR, and evaluated to mild, moderate, moderate-severe, or severe grade by the framework. The results show that the VABC-UNet model has a superior performance in the segmentation of valvular regurgitation jets and atria to the other two models and consequently a higher accuracy of classification and evaluation. There were fewer pseudo- and over-segmentations by the VABC-UNet model and the values of the metrics significantly improved (p < 0.05). The proposed VABC-UNet-based framework achieves automatic segmentation, classification, and evaluation of MR and TR, having potential to assist radiologists in clinical decision making of the regurgitations in valvular heart diseases.

Multidetector Computed Tomography in Patients Who Underwent Transcatheter Mitral Edge-to-Edge Repair

Multidetector computed tomography (MDCT) can provide valuable information for mitral assessment, but its role in transcatheter mitral edge-to-edge repair (TEER) planning has been poorly elucidated. We aimed to compare MDCT with 3-dimensional transesophageal echocardiography (3D-TEE) for TEER preprocedural evaluation. We analyzed the preprocedural MDCT and 3D-TEE of 108 consecutive patients with mitral regurgitation (MR) who underwent MitraClip implantation. The levels of agreement for the etiology and mechanism of MR, mitral calcification, mitral annulus, and mitral valve orifice area (MVOA) measurements were compared between MDCT and 3D-TEE data. Receiver-operating-characteristic curves were generated for mitral annulus area and MVOA using a low mean transmitral pressure gradient at discharge (<5mm Hg) as the state variable, and the primary outcome of all-cause mortality or rehospitalization for heart failure at 1 year was compared between MDCT's and 3D-TEE's MVOA <4-cm2 cutoff. Good levels of agreement between MDCT and 3D-TEE were observed for determining the etiology (κ=0.81) and mechanism (κ=0.62) of MR but not for grading mitral calcification (κ=0.31 to 0.35). The correlations between MDCT and 3D-TEE measurements were strong for mitral annulus area (r=0.90) and good for MVOA (r=0.73). Furthermore, no significant differences in the area under the receiver-operating-characteristic curve to predict low transmitral pressure gradient at discharge or the primary outcome at 1 year were detected between MDCT- and 3D-TEE-derived parameters (all p >0.05). In conclusion, in patients who underwent TEER with MitraClip, a high degree of agreement for comprehensive evaluation of MR and prediction of clinical outcomes between MDCT and 3D-TEE was observed.

Multimodality Echocardiographic Imaging for a Novel Transcatheter Native Mitral Valve Replacement Procedure

ABSTRACT Transcatheter native mitral valve replacement (TMVR) is a novel procedure that has the potential to overcome some of the current limitations associated with the transcatheter edge-to-edge mitral valve (MV) repair technique. The aim of this study was to describe the key steps in periprocedural echocardiographic guidance of TMVR with the Tendyne system, emphasizing potential caveats and areas of difficulty. The imaging pathway can be schematized in four fundamental steps: baseline evaluation of mitral regurgitation (MR), preprocedural screening and planning, intraprocedural guidance, and follow-up. Baseline evaluation of MR in TMVR includes the guidelines-recommended imaging pathway of MR assessment. A dedicated preprocedure cardiac multimodality imaging screening and planning for TMVR is able to determine patient eligibility according to the anatomic characteristics and measurements, provide information for appropriate valve sizing, and detect features that can predispose to potential hazard or complications. Cardiac computed tomography and two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) are the main actors in this phase. The road map for intraprocedural TMVR guidance includes the following: (1) apical access assessment: 2D TEE assessment of the site for optimal left ventricular apical access as planned by the preprocedural computed tomography; (2) support for catheter and sheath localization, trajectory, and positioning; and (3) valve positioning and radial orientation. Thereafter, the prosthesis is withdrawn toward the left ventricle and deployed intra-annularly. Post-deployment includes assessment for correct clocking and hemodynamics, perivalvular leakage, and left ventricular outflow tract obstruction. Two-dimensional and 3D TEE and fluoroscopy provide intraprocedural guidance. The follow-up of the Tendyne device includes the guidelines-recommended imaging pathway of bioprosthesis. Knowledge of multimodality imaging use is key for the interventional imagers and crucial in the success of the procedure.

Mitral and aortic valve regurgitation following surgical and transcatheter perimembranous ventricular septal defect closure in children and adolescents: midterm outcomes

BackgroundClosure of perimembranous ventricular septal defects (pmVSD), either surgical or percutaneous, might improve or cause new-onset mitral regurgitation (MR) and aortic regurgitation (AR). We aimed to evaluate the changes in MR and AR after pmVSD closure by these two methods.Material and methodWe performed a comparative retrospective data review of all pediatric patients with pmVSDs treated at our institution with surgical or antegrade percutaneous methods from 2014 to 2019 and 146 consecutive patients under 18 years were enrolled. We closely looked at the mitral and aortic valve function after repair. Included patients had no or lower than moderate aortic valve prolapse and baseline normal mitral or aortic valve function or less than moderate MR or AR.ResultsOut of 146 patients, 83 (57%) pmVSDs were closed percutaneously, and 63 (43%) pmVSDs were closed surgically. 80 and 62 patients were included for MR evaluation, and 81 and 62 patients for AR evaluation in percutaneous and surgical groups. The mean follow-up time was 40.48 ± 21.59 months in the surgery group and 20.44 ± 18.66 months in the transcatheter group. Mild to moderate degrees of MR and AR did not change or decreased in most patients. In detail, MR of 70% and AR of 50% of the valves were resolved or decreased in both groups. 13% of patients with no MR developed trivial to mild MR, and 10% of patients with no AR showed mild to moderate AR after pmVSD closure in both methods. There was no significant difference between the two methods regarding emerging new regurgitation or change in the severity of the previous regurgitation.ConclusionpmVSD closure usually improves mild to moderate MR and AR to a nearly similar extent in both percutaneous and surgical methods among children and adolescents. It might lead to the onset of new MR or AR in cases with no regurgitation.

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.

Mitral regurgitation severity assessment after percutaneous edge-to-edge mitral valve repair: guidelines-recommended integration versus volumetric assessment

Abstract Background Percutaneous edge-to edge mitral valve repair (PMVr) using the MitraClip device is a common method for treating mitral regurgitation (MR) when mitral valve operation is contra-indicated or deemed too risky. The evaluation of residual MR post PMVr is crucial for understanding the benefit and prognostic effect on patients. The common methods used today, based on color flow Doppler and the appearance of the color Doppler jet, may be misguiding because of the multiple jets created by the PMVr technique. Also, flow acceleration induced by the reduced systolic orifice may exaggerate systolic flow acceleration and thus jet area. Purpose We hypothesized that the guidelines-recommended method to assess MR may underestimate the effect of PMVr in reducing MR. Methods Patients undergoing PMVr in a large-volume PMVr centre were recruited between 2015–2019. Post procedural MR was evaluated using the integrated qualitative approach as recommended by the guidelines. In addition, MR volume for each patient was calculated by subtracting the forward stroke volume (calculated by multiplying LVOT area with the velocity time integral of LVOT systolic flow) from the total stroke volume (using the biplane method of discs), We compared the two methods for concordance. Results Overall, 112 cases were enrolled. In 59% of cases, the calculated volumetric residual MR was lower than the MR assessed by the integrated method. In 25.1% of patients the grade of MR was identical in both methods. In 16.2% the MR was more severe when calculated by the volumetric method (p&amp;lt;0.001, Kappa measure of agreement = 0.053–0.074). The reduction in residual MR degree using the volumetric approach was mostly observed in patients classified as “moderate” by the integrated qualitative approach. When considering basic characteristics and cardiac function of the patients, we did not find any sub-group of patients in whom the tendency for this mistake was higher. Conclusion Because of multiple jet origins and clip-induced flow acceleration, the integrated method to assess MR severity, based mainly on color Doppler, is not ideal in patients after PMVr. In most cases, MR severity after MitraClip is over-estimated by the integrated, guideline-recommended integrative method when compared with a volumetric method. This is especially relevant for patients classified with “moderate” MR. This study suggests that quantitative methods, not based on colour Doppler, should be used to assess MR severity after PMVr Funding Acknowledgement Type of funding sources: None.

Evaluation of functional mitral regurgitation profile in a real-world cohort of heart failure patients and the referral rate of these patients

Abstract Introduction Patients with heart failure and reduced ejection fraction (HFrEF) frequently have significant functional mitral regurgitation (FMR), which carries important prognostic impact. Randomized clinical trials on transcatheter mitral-valve repair have shown conflicting results, and their representativeness in real-world populations are unclear. Purpose This real-world study sought to identify the proportion of patients who would be eligible for mitral valve intervention and describe the current referral patterns at an academic center. Methods We conducted a single center cross-sectional study enrolling consecutive patients with HFrEF and FMR under guideline directed medical therapy from January 2010 to December 2018. Moderate FMR was defined as the presence of an effective regurgitant orifice area (EROA) of ≥20mm2 or a regurgitant volume (Regvol) of ≥30mL/beat, according to American Society of Echocardiography guidelines. Demographic, clinical, echocardiographic and treatment data were assessed. Main MITRA-FR and COAPT Trial eligibility criteria (NYHA class, left ventricular ejection fraction (LVEF), left ventricle end-systolic diameter, pulmonary artery systolic pressure, and right ventricle dysfunction) were applied according to trial protocols. Patterns of referral for mitral valve intervention were assessed by pre-procedural transesophageal echocardiography for mitral regurgitation evaluation. Results A total of 175 patients with at least moderate FMR were included in the analysis (mean age 70±12 years, 80% male, mean LVEF 32% ±9). After applying the main eligibility criteria for each study, 73.7% (n=129) of patients would have been enrolled in MITRA-FR trial, whereas only 27.4% (n=48) patients would have met criteria for COAPT trial (Figure 1). Patients with MITRA-FR profile had a mean EROA 25±8 mm2; mean Regvol 36±9 mL/beat; mean LVEDV 205±72 mL; EROA/LVEDV ratio 0.13±0.04. “COAPT-like” patients had a mean EROA 33±10 mm2; mean Regvol 48±13 mL/beat; mean LVEDV 203±65 mL; mean EROA/LVEDV ratio 0.17±0.05. Only 13.1% (n=23) were referred for transesophageal echocardiography in order to establish the criteria of feasibility for mitral intervention. A total of 16 patients (9.1%) were submitted to mitral valve intervention during follow-up. Conclusion In a real-world population of HFrEF patients with significant FMR, more than one fourth of patients had a “COAPT-like” profile and could have benefited from percutaneous mitral valve intervention. The referral rate for evaluation for a potential intervention was low, which precludes patients from benefiting from this type of treatment. Funding Acknowledgement Type of funding sources: None.

Automatic Assessment of Mitral Regurgitation Severity Using the Mask R-CNN Algorithm with Color Doppler Echocardiography Images.

Accurate assessment of mitral regurgitation (MR) severity is critical in clinical diagnosis and treatment. No single echocardiographic method has been recommended for MR quantification thus far. We sought to define the feasibility and accuracy of the mask regions with a convolutional neural network (Mask R-CNN) algorithm in the automatic qualitative evaluation of MR using color Doppler echocardiography images. The authors collected 1132 cases of MR from hospital A and 295 cases of MR from hospital B and divided them into the following four types according to the 2017 American Society of Echocardiography (ASE) guidelines: grade I (mild), grade II (moderate), grade III (moderate), and grade IV (severe). Both grade II and grade III are moderate. After image marking with the LabelMe software, a method using the Mask R-CNN algorithm based on deep learning (DL) was used to evaluate MR severity. We used the data from hospital A to build the artificial intelligence (AI) model and conduct internal verification, and we used the data from hospital B for external verification. According to severity, the accuracy of classification was 0.90, 0.89, and 0.91 for mild, moderate, and severe MR, respectively. The Macro F1 and Micro F1 coefficients were 0.91 and 0.92, respectively. According to grading, the accuracy of classification was 0.90, 0.87, 0.81, and 0.91 for grade I, grade II, grade III, and grade IV, respectively. The Macro F1 and Micro F1 coefficients were 0.89 and 0.89, respectively. Automatic assessment of MR severity is feasible with the Mask R-CNN algorithm and color Doppler electrocardiography images collected in accordance with the 2017 ASE guidelines, and the model demonstrates reasonable performance and provides reliable qualitative results for MR severity.

Two and Three-Dimensional Echocardiography in Primary Mitral Regurgitation: Practical Hints to Optimize the Surgical Planning.

Primary mitral regurgitation (MR) is the second most common valvular disease, characterized by a high burden in terms of quality of life, morbidity, and mortality. Surgical treatment is considered the best therapeutic strategy for patients with severe MR, especially if they are symptomatic. However, pre-operative echocardiographic evaluation is an essential step not only for surgical candidate selection but also to avoid post-operative complications. Therefore, a strong collaboration between cardiologists and cardiac surgeons is fundamental in this setting. A meticulous pre-operative echocardiographic exam, both with transthoracic or transesophageal echocardiography, followed by a precise report containing anatomical information and parameters should always be performed to optimize surgical planning. Moreover, intraoperative transesophageal evaluation is often required by cardiac surgeons as it may offer additive important information with different hemodynamic conditions. Three-dimensional echocardiography has recently gained higher consideration and availability for the evaluation of MR, providing more insights into mitral valve geometry and MR mechanism. This review paper aims to realize a practical overview on the main use of basic and advanced echocardiography in MR surgical planning and to provide a precise checklist with reference parameters to follow when performing pre-operative echocardiographic exam, in order to aid cardiologists to provide a complete echocardiographic evaluation for MR operation planning from clinical and surgical point-of-view.

Effect of mitral valve replacement on left ventricular function in subjects with severe rheumatic mitral regurgitation.

This study describes the effects of mitral valve replacement (MVR) on left ventricular (LV) function in patients with severe rheumatic mitral regurgitation (MR). This was a retrospective analysis over a nine-year period (2005-2013). Clinical and echocardiographic parameters were recorded pre-operatively and at two weeks, six weeks to three months and six months following MVR. Of the 132 patients included in the study, 66% were in New York Heart Association (NYHA) class III-IV and 38% presented with clinical features of heart failure. Pre-operatively, 28% of subjects had impaired LV function [ejection fraction (EF) < 60%] and the majority had advanced chamber dilatation [left ventricular end-diastolic diameter (LVEDD) 60.7 ± 7.9 mm (n = 132), left ventricular end-systolic diameter (LVESD) 39.9 ± 7.2 mm (n = 118) and left atrial size 61.2 ± 12.6 mm (n = 128)]. Paired analysis of 83 patients revealed that the EF was > 55% in 87% (n = 72) pre-operatively, decreasing to 20% (n = 17) of patients at two weeks postoperatively (p < 0.001); thereafter an EF > 55% was recorded in 60% (n = 50) at the six-month follow-up visit (p < 0.001). On multivariate analysis, only LVESD emerged as a significant predictor of postoperative LV dysfunction. In this study, most patients with severe MR presented late with significant impairment of LV function and chamber dilatation that often did not recover fully after surgery. This study emphasises early comprehensive evaluation of severe MR followed by timeous surgery in order to preserve LV function.

In Search of Quality: Echocardiographic Mitral Regurgitation Evaluation Discrepancies

Introduction: Two-dimensional (2D) transthoracic echocardiography (TTE) for mitral regurgitation (MR) evaluation plays a vital role in choosing the adequate type of treatment. Considerable undertreatment prevalence suggests a possible knowledge gap. The aim of the present study was to assess physician diagnostic adherence according to clinical echocardiographic guidelines. Methods: 438 echocardiographically confirmed MR cases evaluated by 60 beginner, intermediate, or expert level physicians were enrolled. MR eyeballing tendencies, quantitative method application accuracy, and guideline adherence were analyzed. Results: Main discrepancies were unjustified eyeballing (66.95%; p&lt;0.001), inaccurate application of methods (22.46%, p=0.002), and misinterpretation of diagnostic criteria (10.59%). Female patient gender (p=0.026) and lower physician competence levels (p&lt;0.001) were identified as predictors for eyeballing discrepancy possibility. The latter was also a predictor quantitative method discrepancy (p=0.043). Method choice had the most substantial correlation to discrepancies when determining moderate–severe MR (p&lt;0.001). Conclusions: Echocardiographic evaluation of hemodynamically significant MR discrepant in 53.88% of cases as non-quantitative evaluation of hemodynamically significant MR, methodological inaccuracies, and misinterpretation of diagnostic criteria compile the largest proportion of discrepancies. Female gender, lower physician competence, and downgraded diagnostic method application were the most substantial predictors of discrepancy occurrence.

Direct mitral regurgitation quantification in hypertrophic cardiomyopathy using 4D flow CMR jet tracking: evaluation in comparison to conventional CMR

BackgroundQuantitative evaluation of mitral regurgitation (MR) in hypertrophic cardiomyopathy (HCM) by cardiovascular magnetic resonance (CMR) relies on an indirect volumetric calculation. The aim of this study was to directly assess and quantify MR jets in patients with HCM using 4D flow CMR jet tracking in comparison to standard-of-care CMR indirect volumetric method.MethodsThis retrospective study included patients with HCM undergoing 4D flow CMR. By the indirect volumetric method from CMR, MR volume was quantified as left ventricular stroke volume minus forward aortic volume. By 4D flow CMR direct jet tracking, multiplanar reformatted planes were positioned in the peak velocity of the MR jet during systole to calculate through-plane regurgitant flow. MR severity was collected for agreement analysis from a clinical echocardiograms performed within 1 month of CMR. Inter-method and inter-observer agreement were assessed by intraclass correlation coefficient (ICC), Bland–Altman analysis, and Cohen’s kappa.ResultsThirty-seven patients with HCM were included. Direct jet tracking demonstrated good inter-method agreement of MR volume compared to the indirect volumetric method (ICC = 0.80, p = 0.004) and fair agreement of MR severity (kappa = 0.27, p = 0.03). Direct jet tracking showed higher agreement with echocardiography (kappa = 0.35, p = 0.04) than indirect volumetric method (kappa = 0.16, p = 0.35). Inter-observer reproducibility of indirect volumetric method components revealed the lowest reproducibility in end-systolic volume (ICC = 0.69, p = 0.15). Indirect volumetric method showed good agreement of MR volume (ICC = 0.80, p = 0.003) and fair agreement of MR severity (kappa = 0.38, p < 0.001). Direct jet tracking demonstrated (1) excellent inter-observer reproducibility of MR volume (ICC = 0.97, p < 0.001) and MR severity (kappa = 0.84, p < 0.001) and (2) excellent intra-observer reproducibility of MR volume (ICC = 0.98, p < 0.001) and MR severity (kappa = 0.88, p < 0.001).ConclusionsQuantifying MR and assessing MR severity by indirect volumetric method in HCM patients has limited inter-observer reproducibility. 4D flow CMR jet tracking is a potential alternative technique to directly quantify and assess MR severity with excellent inter- and intra-observer reproducibility and higher agreement with echocardiography in this population.

Evaluation of mitral regurgitation by cardiac magnetic resonance and transthoracic echocardiography: a systematic review and meta-analysis.

Transthoracic echocardiography (TTE) and Cardiac Magnetic Resonance (CMR) have complementary roles in the severity grading of mitral regurgitation (MR). Our objective was to systematically review the correlation of MR severity as assessed by TTE and CMR. We searched MEDLINE and Cochrane Library for original series published between January 1st, 2000 and March 23rd, 2020. We used Cohen's kappa coefficient to measure agreement between modalities. We plotted a hierarchical summary receiver operator characteristic (HSROC) curve and estimated the area under the curve (AUC) to assess the concordance between the two imaging modalities for the detection of severe MR. We identified 858 studies, of which 65 underwent full-text assessment and 8 were included in the meta-analysis. A total of 718 patients were included (425 males, 59%) in the final analysis. There was significant heterogeneity in the methods used and considerable variation in kappa coefficient, ranging from 0.10 to 0.48. Seven out of eight studies provided the necessary data to plot HSROC curves and calculate the AUC. The AUC for detecting severe MR was 0.83 (95% CI 0.80 to 0.86), whereas the AUC for detecting moderate to severe MR was 0.83 (95% CI 0.79 to 0.86). The agreement between TTE and CMR in MR severity evaluation is modest across the entire spectrum of severity grading. However, when focusing on patients with at least moderate MR the concordance between TTE and CMR is very good. Further prospective studies comparing hard clinical endpoints based on the CMR and TTE assessment of MR severity are needed.

Reproducibility of transthoracic echo-doppler parameters to assess mitral regurgitation severity. Insights from a French multicentric study

The dynamic nature of MR throughout systole and the complexity of MR mechanisms may cause uncertainty among TTE readers and lead to interobserver variability. To evaluate the interobserver agreement of parameters used in daily practice to quantify mitral regurgitation (MR) severity according to the experience of the physician. Complete MR evaluation of 25 consecutive patients were assessed by transthoracic echocardiography in 8 French tertiary public and private hospitals by 16 physicians (1 junior and 1 senior in each centre). In total, 400 analyses per parameter have been obtained. The overall interobserver agreement for effective regurgitant orifice area (EROA) and regurgitant volume (RV) was only moderate, lower in secondary MR. Interobserver agreement was better in the senior group than in the junior group regarding parameters used to quantify MR severity, i.e. EROA, respectively substantial (0.61, 95% CI: 0.45–0.75) and fair (0.33, 95% CI: 0.19–0.51) and RV with the PISA method, respectively moderate (0.50, 95% CI: 0.33–0.56) and fair (0.36, 95% CI: 0.36–0.43). Finally, using a multiparametric approach, the overall interobserver agreement for grading MR severity was fair (0.30), slightly better in the senior group than the junior group (respectively 0.31 vs. 0.28) with a substantial or almost perfect agreement more frequently observed in the senior group than in the junior group (respectively 52% vs. 36%). The use of quantitative parameters to assess MR severity was moderately reliable in daily practice, even in case of multiparametric approach. The experience of the physician and the mechanism of the MR impact interobserver agreement, paving the way for a better learning of this valvular disease and for the use of multimodality imaging in case of complex or secondary MR.

Reproducibility of reading echocardiographic parameters to assess severity of mitral regurgitation. Insights from a French multicentre study

Poor reproducibility in assessment of mitral regurgitation (MR) has been reported. To investigate the robustness of echocardiographic MR assessment in 2019, based on improvements in technology and the skill of echocardiographists regarding MR quantification. Reproducibility in parameters of MR severity and global rating were tested using transthoracic echocardiography in 25consecutive patients independently analysed by 16 junior and senior cardiologists specialized in echocardiography (400 analyses per parameter). Overall interobserver agreement for mechanism definition, effective regurgitant orifice area (EROA) and regurgitant volume (RVol) was moderate, and was lower in secondary MR. Interobserver agreement was substantial for EROA [0.61, 95% confidence interval (CI) 0.45-0.75] and moderate for RVol with the PISA method (0.50, 95% CI 0.33-0.56) in senior physicians and was fair in junior physicians (0.33, 95% CI 0.19-0.51 and 0.36, 95% CI 0.36-0.43, respectively). Using a multiparametric approach, overall interobserver agreement for grading MR severity was fair (0.30), was slightly better in senior than in junior physicians (0.31 vs. 0.28, respectively) with substantial or almost perfect agreement more frequently observed in senior versus junior physicians (52% vs. 36%, respectively). Reproducible transthoracic echocardiography MR quantification remains challenging in 2019, despite the expected high skills of echocardiographers regarding MR at the time of dedicated percutaneous intervention. The multiparametric approach does not entirely alleviate the substantial dispersion in measurement of MR severity parameters, whereas reader experience seems to partially address the issue. Our study emphasizes the continuing need for multimodality imaging and education in the evaluation of MR among cardiologists.

Mitral regurgitation: a contemporary review of percutaneous mitral valve repair and role of periprocedural imaging.

This article aims to review recent landmark clinical trials that have resulted in a paradigm shift in the management of patients with mitral regurgitation. This article additionally highlights the instrumental role that structural heart disease (SHD) imaging plays in evaluation of mitral regurgitation and determining candidacy for transcatheter mitral valve repair (TMVr), in addition to the procedural guidance and detection of complications. Edge-to-edge TMVr with the MitraClip device (Abbott Vascular, Santa Clara, California) was initially studied and subsequently approved by the US Food and Drug Administration (FDA) for treatment of primary mitral regurgitation in 2013. After the publication of a landmark clinical trial in 2018, the indications have been expanded and FDA has subsequently, in 2019, approved TMVr for patients with functional mitral regurgitation. This has been paralleled by advances in cardiac imaging with more emphasis on the role of SHD imagers as a part of the heart team. TMVr has revolutionized the management of mitral regurgitation and relies heavily on SHD imaging to ensure optimal outcomes.

Validation of Semiautomated Quantification of Mitral Valve Regurgitation by Three-Dimensional Color Doppler Transesophageal Echocardiography

The aim of this study was to evaluate the accuracy of mitral regurgitation (MR) volume quantified on three-dimensional (3D) color Doppler transesophageal echocardiography (TEE) using new semiautomated software compared with conventional two-dimensional (2D) proximal isovelocity surface area (PISA) transthoracic echocardiography (TTE) and TEE and cardiac magnetic resonance imaging (CMR). Fifty-one patients (mean age, 63±16years; 35 men) prospectively underwent TTE, TEE, and CMR for MR evaluation. Regurgitant volume (RVol) by 3D MR flow quantification was compared with 2D TTE, TEE, and CMR, and the accuracy of evaluation of severe MR by 3D MR flow quantification was compared against guideline criteria by TEE. Twenty-nine patients had severe MR, 16 had moderate MR, and six had mild MR. Three-dimensional MR flow quantification was feasible in all patients, including prolapse (n=37), restriction (n=9), functional MR (n=5), and eccentric or multiple jects (n=41). RVol on 3D MR flow quantification correlated well with RVol on 2D PISA TTE (interclass correlation coefficient [ICC]=0.75, P<.001), quantitatively estimated RVol (ICC=0.74, P<.001), and 2D PISA TEE (ICC=0.79, P<.001). Three-dimensional MR flow quantification agreed better with CMR (ICC=0.86, P<.001) than did RVol on 2D PISA TTE (ICC=0.66, P<.001) and 2D PISA TEE (ICC=0.69, P<.001), with narrower limits of agreement on Bland-Altman analysis. Three-dimensional MR flow quantification had high accuracy for diagnosing severe MR using TEE (area under the curve=0.85, 95% CI 0.74-0.96, P<.001) or CMR (area under the curve=0.95; 95% CI, 0.89-1.00; P<.001) as the criterion. The new software enabled semiautomated 3D MR flow quantification in complex MR with multiple and eccentric jets and showed better agreement with CMR than 2D PISA TTE or TEE, suggesting that this method is more accurate than conventional 2D PISA TTE and TEE.