Proximal Isovelocity Surface Area Radius Research Articles

Quantification of Mitral Valve Regurgitation in Cavalier King Charles Spaniels and Chihuahuas Using Radius of Proximal Isovelocity Surface Area

Mitral regurgitation (MR) resulting from myxomatous mitral valve disease (MMVD) is a prevalent condition in dogs, particularly smaller breeds like Cavalier King Charles Spaniels (CKCSs) and Chihuahuas (CHHs). An accurate assessment of MR severity is essential for effective treatment and disease monitoring, yet a standardized method has yet to be established. In this retrospective study, we evaluated 124 client-owned dogs diagnosed with MMVD, including 64 CKCSs and 60 CHHs. Dogs were categorized into three stages: asymptomatic (B1), remodeled (B2), and congestive heart failure (CHF, C). The MR severity was quantified using the proximal isovelocity surface area (PISA) method, specifically focusing on the PISA radius (PISA-r). The PISA-r measurements exhibited significant increases across disease stages and demonstrated strong correlations with echocardiographic parameters (ranging from 0.83 to 0.94), including the left atrial size and left ventricular internal diameter. The receiver operating characteristic (ROC) curve analysis revealed the high sensitivity and specificity of PISA-r in classifying disease stages, establishing optimal cut-off values. The method displayed excellent repeatability (interobserver variability: 0.95) and reproducibility (intraobserver variability: 0.97). In conclusion, the PISA method, specifically PISA-r, was reliable for assessing MR severity in dogs with MMVD. By simplifying the diagnosis and management of MR, this research can potentially improve the life and management of MMVD-affected dogs.

Initial experience of transcatheter edge-to-edge repair guided by only transesophageal echocardiography in the treatment of tricuspid insufficiency

Objective: To evaluate the feasibility and safety of transcatheter tricuspid valve edge-to-edge repair guided by only transesophageal echocardiography (TEE). Methods: Patients with severe tricuspid regurgitation in Fuwai Yunnan Cardiovascular Hospital who met the inclusion criteria based on clinical and echocardiographic evaluationand underwent transcatheter tricuspid valve edge-to-edge repair between January 2022 and May 2023 were prospectively enrolled. The procedure was performed under general anesthesia with endotracheal intubation and solely guided by TEE. The patients underwent clinical evaluation, electrocardiogram and transthoracic echocardiography one month after the procedure. Results: A total of 22 patients (12 males and 10 females) were included, with an average age of (71.3±6.7) years. All 22 patients successfully underwent the transcatheter tricuspid valve edge-to-edge repair under TEE guidance, with an average of (1.5±0.6) clips implanted. Immediately after procedure, six patients had no or trace regurgitation, 15 patients had mild regurgitation, and one patient had moderate regurgitation. All 22 patients completed 30-day follow-up, with four patients having trace regurgitation, 17 patients having mild regurgitation, and one patient having moderate regurgitation. Echocardiographic measurements revealed that effective regurgitant orifice area, regurgitant volume, vena contracta width, and proximal isovelocity surface area radius significantly decreased after the procedure (all P<0.05). In addition, inferior vena cava width, right atrial volume, tricuspid annular diameter, and right ventricular end-diastolic diameter significantly improved (all P<0.05), but tricuspid annular plane systolic excursion and right ventricular fractional area change did not show significant differences compared with those before the procedure (both P>0.05). Conclusion: It has been preliminarily confirmed that transcatheter tricuspid valve edge-to-edge repair solely guided by TEE is feasible and safe, but requires more large-scale studies for further validation.

M-mode proximal iso-velocity surface area-based dynamics of instantaneous flow rate and its implications for degenerative mitral regurgitation quantification

Abstract Background Instantaneous flow rate of degenerative mitral regurgitation (DMR) showed dynamic changes. However, inconsistencies exist across literatures about the timing of measurements for flow convergence in proximal iso-velocity surface area (PISA) calculation. While the 2017 ASE guideline suggested measurement of PISA radius and velocity should be performed at simultaneous moments of the regurgitant phase (PISApair), a few studies used max PISA radius (PISAmax) to calculate regurgitant volume and showed poor agreement with cardiac magnetic resonance (CMR) results. Purpose This study aimed to compare the above methods with M-mode PISA, thus to investigate the effect of instantaneous flow rate on the agreement of the diagnosis of severe mitral regurgitation (sMR). Methods We prospectively enrolled 75 DMR patients with a) at least mild MR, b) single and non- eccentric MR jet. Regurgitant volume (RVol) was calculated using three PISA methods, respectively. In 25 patients who received CMR, RVol was calculated using volumetric method. The correlation and agreement of RVol among three PISA methods and CMR were compared. The agreements of the diagnosis of sMR between PISA methods and ASE multi-parameter algorithm were analyzed using Cohen’s kappa analyses. Results The curve of instantaneous flow rate of DMR displayed unimodal pattern with at the mid-late systolic phase. The correlation of RVol between PISA methods and CMR were moderate for PISAmax (r = 0.77) and strong for PISApair and M-mode PISA ( r = 0.80 and 0.87, respectively). PISAmax derived RVol was larger than that of CMR (69.1 ± 37.1 mL versus. 49.0 ± 29.0 mL, P = 0.002). Compared to the ASE algorithm, only PISAmax significantly overestimated the percentages of sMR (74.7% versus 54.7%, P =0.010), but both PISAmax and PISApair showed moderate consistency (Kappa coefficient (k): 0.496 and 0.525, respectively). A strong agreement was found between M-mode PISA and the ASE algorithm with regard to the diagnosis of sMR (k = 0.867, P &amp;lt;0.05). Conclusion Based on the unimodal pattern of instantaneous flow rate in DMR patients, PISAmax significantly overestimated RVol and may expose a significant proportion of DMR patients to MR surgery.

Echocardiographic parameters recommended for assessing the severity of tricuspid regurgitation: concordance and discordance.

Current guidelines recommend integrating several echocardiographic indices to evaluate the severity of tricuspid regurgitation (TR). Discordance of indices, including qualitative and quantitative methods, commonly exists in practice. The discordance among these parameters has not yet been fully elucidated. A total of 127 patients with recognizable TR jets without pulmonary regurgitation or intracardiac shunt were prospectively enrolled. We evaluated 8 parameters by 2-dimensional (2D) echocardiography: proximal iso-velocity surface area (PISA)-derived regurgitant volume (RVol), PISA-derived effective regurgitant orifice area (EROA), PISA radius, vena contracta width (VCW), color Doppler jet area, tricuspid valve annular diameter, inferior vena cava (IVC) diameter, and peak E wave. According to current guidelines, each echocardiographic parameter was determined to represent either severe or non-severe TR. A concordance score was calculated as the number of concordant parameters divided by 8, with a higher score reflecting better concordance. Data were further categorized into 3 subgroups: complete concordance (0 discordant parameters), high concordance (1-2 discordant parameters), and low concordance (3-4 discordant parameters). The mean concordance score was 81%±17% for the entire cohort. There were 48 (38%) patients with complete concordance, including 6 patients with severe TR. In contrast, the low concordance group (n=43, 34%) mostly comprised severe TR patients (36 patients). When considering only EROA, RVol, and VCW, concordance improved, with 98 patients (77%) in complete agreement. Concordance seems limited when using echocardiographic parameters to assess TR severity. Applying only EROA, RVol, and VCW results in better concordance, as recommended by the current guidelines.

843 QUANTIFICATION OF VENTRICULAR FUNCTIONAL MITRAL REGURGITATION USING THE VOLUMETRIC METHOD BY 3D-ECHOCARDIOGRAPHY

Abstract Background ventricular functional mitral regurgitation (v-FMR) is associated with an increased risk of mortality and hospitalization for heart failure. In this setting, the echocardiographic assessment of v-FMR severity using 2D proximal isovelocity surface area (PISA) yields several limitations, potentially leading to an underestimation of v-FMR severity. An alternative approach is to derive the regurgitant volume (RegVol) and the effective regurgitant orifice area (EROA) using the three-dimensional echocardiography (3DE) to estimate left ventricular volumes (volumetric method, VM). However, a direct comparison of these methods has never been tested. Accordingly, the aims of our study are: i; to compare both 2D PISA measurements of EROA and RegVol with those obtained by VM using 3DE, ii; to test their accuracy using the 3D planimetry of vena contracta area (3D-VCA) of MR jet, as reference. Methods we retrospectively analysed 82 (mean age 75±12, 48% men, 79% sinus rhythm, 85% with ischemic cardiomyopathy, 15% with dilated cardiomyopathy) consecutive patients with v-FMR and reduced left ventricular ejection fraction (LVEF &amp;lt;50%), acquired between July 2020 and October 2021. Exclusion criteria were: age &amp;lt; 18 years, primary MR, presence of intra-cardiac shunts, greater than mild aortic regurgitation, and inadequate acoustic window. PISA EROA was calculated using the formula: 6.28 r2×Va/Vp (where: r= PISA radius, Va= aliasing velocity, Vp= MR peak velocity). FMR regurgitant volume (RegVol) by PISA was calculated as EROA×VTIMR, where VTIMR represents the time–velocity integral of the CW Doppler MR jet tracing. FMR RegVol by 3DE volumetric method (VM) was calculated as: total LV stroke volume (LV SV) – forward LV SV (Ao SV). LV SV was obtained by subtracting the respective end-systolic (ESV) from the end-diastolic (EDV) volumes measured by 3DE. Ao SV was calculated by multiplying LV outflow area by LV outflow tract velocity time integral (VTI). EROA by VM was calculated as the MR RegVol divided by VTIMR. In a group of 10 patients, the quantification of 3D-VCA was performed by multiplanar reconstruction using a dedicated software package (EchoPAC 204 GE Vingmed, Horten, Norway). Results average LV end-diastolic and end-systolic volumes, total stroke volume, LVEF and global longitudinal strain were 211±25 mL, 134±17 mL, 73±9 mL, 36±8% and, 9.4±2.7% respectively. Median Ao SV was 50±12 mL. Left atrial volume and left atrial reservoir strain were respectively 99±19 mL and 10±16%. Both EROA and RegVol by VM were larger than EROA (0.17± 0.09 cm2 vs 0.11± 0.01 cm2; p&amp;lt;0.001) and RegVol (25.7±12.1 mL vs 17.2±9.9 mL; p&amp;lt;0.001) by PISA, respectively. Compared to 3D-VCA, EROA by VM resulted more accurate than EROA by PISA (bias= -0.15 cm2, LOA ±0.24 cm2 vs bias= -0.25 cm2, LOA ±0.29 cm2). Finally, VM EROA (r= 0.778) showed a better correlation than PISA EROA (r= 0.681) with the 3D-VCA (p&amp;lt;0.001). Conclusions in patients with v-FMR, the echocardiographic assessment of EROA and RegVol using the 3DE volumetric method showed larger values compared to the conventional PISA method, and a closer correlation with the 3D VCA. Accordingly, the 3DE VM could improve the accuracy of evaluation of v-FMR severity. Larger studies with longer clinical follow-up are needed to define if it translates into improved risk stratification and may address patients’ management.

Effects of Cardiac Contractility Modulation Electrodes on Tricuspid Regurgitation in Patients with Heart Failure with Reduced Ejection Fraction: A Pilot Study.

Cardiac contractility modulation (CCM) is an innovative therapy for heart failure with reduced ejection fraction delivered by a cardiac implantable device (Optimizer Smart®). One of the most prominent periprocedural complications common to all cardiac implantable devices (CIDs) is tricuspid regurgitation (TR) due to the placement of the right ventricular endocardial leads. To date, no published studies have assessed the changes in the TR degree in patients with heart failure with reduced ejection fraction (HFrEF) who received an implantable cardioverter-defibrillator (ICD) after the implantation of cardiac contractility modulation therapy devices. This study aimed to evaluate the effect of the implantation of the trans-tricuspid leads required to deliver CCM therapy on the severity of TR in patients with HFrEF who previously underwent ICD implantation. We enrolled 30 HFrEF patients who underwent CCM therapy between November 2020 and October 2021. For all the patients, echocardiographic evaluations of TR were performed according to current guidelines 24 h before and six months after the Optimizer Smart® implant was applied. At the 6-month follow-up, the grade of TR remained unchanged compared to the preimplant grade. The value of the vena contracta (VC) of TR was 0.40 ± 0.19 cm in the preimplant period and 0.45 ± 0.21 cm at the 6-month follow-up (p = 0.33). Similarly, the TR proximal isovelocity surface area (PISA) radius value was unchanged at follow-up (0.54 ± 0.22 cm vs. 0.62 ± 0.20 cm; p = 0.18). No statistically significant difference existed between the preimplant VC and PISA radius values, irrespective of the device type. The implantation of right ventricular electrodes for the delivery of CCM therapy did not worsen tricuspid regurgitation in patients with HFrEF and ICD.

Interobserver Variation in Echocardiographic Measurements and Grading of Tricuspid Regurgitation Based on a Novel Web-Based Assessment Environment

The primary aim of this study was to assess interobserver variability in grading tricuspid regurgitation (TR) severity. The authors' secondary goals were to delineate which transesophageal echocardiographic (TEE) parameters best correlate with severity and how consistent the participants were at grading severity. This was a prospective cohort study of how clinicians evaluated previously acquired TEE images and videos. The 19 TEE studies of patients with TR were recorded by 4 senior echocardiographers across 4 US academic institutions. The participants evaluated these cases on a novel, web-based, assessment environment designed specifically for this study. Twenty-nine fellowship-trained and board-certified cardiologists and cardiothoracic anesthesiologists volunteered to participate in the study as observers from 19 different institutions. No interventions were performed on the participants. For each case, participants measured the vena contracta (VC), proximal isovelocity surface area (PISA), and jet area before giving a final classification on the severity of TR. Variation was highest for effective regurgitant orifice area and lowest for VC and PISA. The coefficient of variation, defined as the standard deviation from the mean divided by the mean, for all cases of trace, mild, moderate and severe TR were as follows: Jet Area-111%, 46%, 48%, 76%; VC-67%, 44%, 43%, 36%; PISA-52%, 48%, 31%, 35%; and effective regurgitant orifice area-127%, 95%, 66%, 58%. The interobserver variation in quantifying TEE parameters for TR is high, suggesting these may be difficult to measure reliably in a busy perioperative setting. Of the parameters assessed, VC and PISA radius had the highest interobserver agreement and the highest correlation with severity.

Early impairment of left ventricular longitudinal and radial deformation in primary mitral regurgitation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant TE 137/2020 Background. In primary mitral regurgitation (PMR) left ventricular (LV) remodeling is an adaptive process with prognostic significance. Aim. To characterize LV deformation parameters related to PMR severity for a better understanding of LV pathophysiology, in patients with mild to severe PMR and preserved LV ejection fraction (EF). Methods. 48 patients (56 ± 14 years, 42% men) with PMR (mild - 12 patients, moderate - 12 patients, severe - 24 patients) and 50 age and sex matched-controls (56 ± 12 years, 48% men) were analyzed by 2-dimensional speckle-tracking echocardiography (2D STE) for LV endo, mid, and epicardial longitudinal strain (LS); endo, mid, and epicardial circumferential strain (CS); and radial strain (RS). LV volumes and EF, and LA volumes and emptying fraction (EmF) were measured by 3D echocardiography. MR severity was quantified by vena contracta (VC), PISA radius, MR regurgitant volume, and EROA measurements, according to the 2021 ESC guidelines. Results. 3D LVEF had no significant difference between PMR patients and controls (p= 0.11). From control subjects to mild, moderate, and severe PMR, there was a progressive reduction of LS and RS (Figures 1 and 2), but not of CS. By 2D STE multilayer analysis, when compared to controls, PMR patients had decreased endo-, mid-, and epi-LS (p &amp;lt; 0.04), with a compensatory increase of endo-LS in mild PMR (Figure 2). Basal, middle, and apical segments LS decreased similarly and progressively from control subjects to PMR patients (p &amp;lt; 0.01). In addition, in patients with PMR only LS, but not RS or CS, correlated with MR severity (PISA radius, VC, and MR regurgitant volume: r= -0.43, r= -0.32, r= -0.38, all p &amp;lt; 0.01), and LA function (EmF: r = -0.41, p &amp;lt; 0.01). Conclusion. When compared to normal subjects, patients with PMR and preserved LVEF have altered LV longitudinal and radial deformation, with preserved circumferential strain. All longitudinal layers and all LV segments were similarly affected. Only longitudinal strain correlates with MR severity and atrial function. Our study suggests that a comprehensive evaluation of the LV deformation should be included in the assessment of patients with PMR, in order to identify early stages of LV dysfunction, starting even from mild MR. Abstract Figure. LV deformation - PMR vs controls Abstract Figure. Multilayer LS in PMR patients

Impact of leaflet-tethering angle correction on the assessment of tricuspid regurgitation severity using the PISA method

Abstract Funding Acknowledgements Type of funding sources: None. Background Severe tricuspid regurgitation (TR) is associated with excess mortality and morbidity. Therefore, assessment of TR severity is pivotal. Calculation of the effective regurgitant orifice area (EROA) and the regurgitant volume (RVol) using flow convergence method (PISA) by echocardiography are still the recommended parameters to define TR severity. However, the distortion of the proximal convergence zone related to the extent of valve leaflet tethering may result in smaller PISA radius and in underestimation of TR severity. Correcting for the angle of the leaflet tethering could reduce errors due to geometric assumption of a flat valvular plane and improve the accuracy of the calculations. Purpose: The aims of our study were (1) to evaluate whether taking into account the extent of leaflet tethering by applying the angle correction (AC) in the PISA formula improves the accuracy of the quantitative assessment of TR severity; (2) to assess the potential clinical impact of AC. Methods Forty-one patients with functional TR (73.5 ± 11.8 years,51% men,36% sinus rhythm,17% severe), underwent 2D and 3D echocardiography. We compared the RVol obtained by volumetric method (as reference) with the RVol by PISA with and without AC. TR RVol by volumetric method was calculated as: total RV stroke volume (RVSV) – left ventricular forward SV (LVSV), where RVSV was obtained by subtracting the end-systolic from end-diastolic RV volume measured by 3D echocardiography and LV SV was calculated by multiplying LV outflow area by velocity time integral (VTI) (Fig. 1). TR RVol by PISA was calculated as EROA x VTITR. Uncorrected EROA was calculated using the formula: 6.28 r2 xVa/ PeakVTR (r - PISA radius, Va, aliasing velocity, PeakVTR – TR peak velocity). The corrected EROA accounting for the PISA geometric distortion by leaflet tethering angle (α) was calculated as: 6.28 r2 x Va (α/180)/ PeakV TR (PISAac), where α was measured using a protractor generated by dedicated software. Results Application of AC to PISA method resulted in larger EROA and RVol (0.34± 0.38 cm2 vs 0.24± 0.24cm2 and, 25.2± 19.3 mL vs 18.6 ± 13.1mL, respectively). The percentage change in EROAac was over 40%. When compared to the volumetric method, RVol by corrected PISA method was significantly closer and correlated (bias -3.95mL, LOA ± 6.41 mL, r= .987; p&amp;lt; .001) than the conventional PISA without AC (bias -10.5 mL, LOA ± 15 mL, r= .975). Angle correction resulted in a change of TR severity in 32% of cases (Fig. 2) and in a greater concordance of TR severity grade with the volumetric method (75%, 31/41 with AC vs 52%, 22/41 without AC). Conclusions Angle-corrected PISA method that accounts for the extent of the leaflet tethering in TR provided significantly larger TR RVol that were closely correlated with the volumetric RVol by 3D echocardiography. A simple geometric angle correction of the proximal flow with PISA method reclassified up to 1/3 of patients with functional TR. Abstract Figure. Representation of study method Abstract Figure. Reclassification of TR severity

Real-world outcomes for tricuspid edge-to-edge repair: initial echocardiographic results from the TriClip bRIGHT study

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Abbott Background Tricuspid regurgitation (TR) is a frequent disease with a graded increase in mortality as disease severity increases. The TriClip tricuspid valve repair system (TVRS) recently gained CE mark approval in March 2020 as a transcatheter treatment option for severe TR. The bRIGHT study was initiated to evaluate real-world safety and efficacy in patients treated with the TriClip TVRS and gather data to better understand these patients and this disease. Purpose To report real-world, core lab adjudicated changes in TR severity and echocardiographic parameters from baseline through 30-day follow-up in subjects treated with tricuspid transcatheter edge-to-edge repair (TEER). Methods bRIGHT is a prospective, multi-center, single arm post-market study evaluating the safety and effectiveness of the TriClip device in symptomatic patients with severe TR. Detailed echocardiographic assessment was performed on all available echo data for the first 175 enrolled subjects by an independent echo core lab. TR was categorized using a 5-grade scale, with the traditional "severe" grade further characterized as severe, massive and torrential. Results At baseline, TR was "severe" in 98% (143/146) of subjects, which further stratifies to severe in 9% (13/146), massive in 63% (92/146) and torrential in 26% (38/146) of subjects using the 5-grade scale. At 30 days, TR was reduced by ≥1 grade in 81% of subjects, with 70% of subjects at moderate or less residual TR compared to only 1% at baseline (p &amp;lt; 0.0001, Figure 1). Vena contracta width decreased from 0.79 ± 0.56 mm at baseline to 0.41 ± 0.37 mm at 30 days. Effective regurgitant orifice (EROA) area decreased from 0.87 ± 0.57 cm2 at baseline to 0.38 ± 0.25 cm2 at 30-days. Similarly, regurgitant volume, PISA radius and jet area showed significant reductions (Table 1). RV end diastolic dimension decreased from 4.70 ± 0.85 cm at baseline to 4.22 ± 0.83 cm at 30 days. No changes were observed in right atrial volume or right ventricular function. Subjects were treated with 1.9 ± 0.7 clips on average, with less than a 1 mmHg increase in mean tricuspid valve gradient; average gradient was 1.12 ± 0.65, 1.92 ± 1.15 and 1.97 ± 1.81mm Hg at baseline, discharge and 30 days respectively. Tricuspid annular diameter was significantly higher in subjects with torrential TR at baseline compared to subjects with severe or massive TR (p &amp;lt; 0.001). Conclusions Tricuspid TEER with the TriClip device showed significant reduction in TR severity in a real-world setting. Significant reduction were seen in vena contracta width, PISA radius, EROA, regurgitant volume and jet area among others. The majority of patients had massive TR at baseline. Future studies in larger cohorts are needed to investigate the relationship between the extent of TR reduction and clinical outcomes. Abstract Figure 1 Abstract Table 1

181 Impact of leaflet-tethering angle correction on the assessment of tricuspid regurgitation severity using the PISA method

Abstract Aims Severe tricuspid regurgitation (TR) is associated with excess mortality and morbidity. Therefore, accurate assessment of TR severity is pivotal. In clinical routine, the calculation of the effective regurgitant orifice area (EROA) and the regurgitant volume (RVol) using flow convergence method (PISA) by echocardiography are among the recommended parameters to define TR severity. However, the distortion of the proximal convergence zone related to the extent of valve leaflet tethering may result in smaller PISA radius and in underestimation of TR severity. Correcting for the angle of the leaflet tethering could reduce errors due to geometric assumption of a flat valvular plane and improve the accuracy of the calculations. The aims of our study were: (1) to evaluate whether taking into account the extent of leaflet tethering by applying the angle correction (AC) in the PISA formula improves the accuracy of the quantitative assessment of TR severity; (2) to assess the potential clinical impact of AC. Methods and results Forty-one patients with functional TR (73.5 ± 11.8 years, 51% men, 36% sinus rhythm, 17% severe), underwent 2D and 3D echocardiography. We compared the RVol obtained by volumetric method (as reference) with the RVol by PISA with and without AC. TR RVol by volumetric method was calculated as: total RV stroke volume (RV SV)–left ventricular forward SV (LV SV), where RV SV was obtained by subtracting the end-systolic from end-diastolic RV volume measured by 3D echocardiography and LV SV was calculated by multiplying LV outflow area by velocity time integral (VTI). TR RVol by PISA was calculated as EROA × VTI TR. Uncorrected EROA was calculated using the formula: 6.28 r2 × Va/PeakV TR (r—PISA radius, Va, aliasing velocity, PeakV TR—TR peak velocity). The corrected EROA accounting for the PISA geometric distortion by leaflet tethering angle (α) was calculated as: 6.28 r2 × Va (α/180)/PeakV TR (PISAAC), where α was measured using a protractor generated by dedicated software. PISA radius and angle were 5.5 ± 1.97 mm and 211.2° ± 13.6°, respectively. Application of AC to PISA method resulted in larger EROA and RVol (0.34 ± 0.38 cm2 vs. 0.24 ± 0.24 cm2 and, 25.2 ± 19.3 ml vs. 18.6 ± 13.1 ml, respectively). The percentage change in EROAAC was over 40%. When compared to the volumetric method, RVol by corrected PISA method was significantly closer and correlated (bias −3.95 ml, LOA ± 6.41 ml, r = 0.987; P &amp;lt; 0.001) than the conventional PISA without AC (bias −10.5 ml, LOA ± 15 ml, r = 0.975). Angle correction resulted in a change of TR severity in 32% of cases and in a greater concordance of TR severity grade with the volumetric method (75%, 31/41 with AC vs. 52%, 22/41 without AC). Conclusions Angle-corrected PISA method that accounts for the extent of the leaflet tethering in TR provided significantly larger TR RVol that were closely correlated with the volumetric RVol by 3D echocardiography. A simple geometric angle correction of the proximal flow with PISA method reclassified up to one-third of patients with functional TR.

Prior angina reduces ıschemic mitral regurgitation in patients with ST-Elevation myocardial ınfarction, role of ıschemic preconditioning.

Mitral regurgitationmay develop due to left ventricular (LV) remodeling within 3months following acute myocardial infarction (AMI) and is called ischemic mitral regurgitation (IMR).Ischemic preconditioning (IPC) has been reported as the most important mechanism of the association between prior angina and the favorable outcome. The aim of this study was to investigate the effect of prior angina on the development and severity of IMR at 3rdmonth in patients with ST elevation MI (STEMI). Fourty five (45) patients admitted with STEMI and at least mild IMR, revascularized by PCI were enrolled. According topresence of prior angina within 72h before STEMI, patients were then divided into two groups as angina (+) (n:26; 58%) and angina (-) (n:19; 42%). All patients underwent 2D transthoracic echocardiography at1st, 3rddays and 3rdmonth. IMR was evaluated byproximal isovelocity surface area (PISA) method: PISA radius (PISA-r), effective regurgitant orifice area (EROA), regurgitant volume (Rvol). LV ejection fraction (EF %) was calculated by Simpson's method. High sensitive troponin T (hs-TnT), creatine phosphokinase myocardial band (CK-MB) and N-terminal pro-brain natriuretic peptid (NTpro-BNP) levels were compared between two groups. Although PISA-r, EROA and Rvol were similar in both groups at 1stand 3rddays, all were significantly decreased (p = 0.012, p = 0.007, p = 0.011, respectively) and EF was significantly increased (p< 0.001) in angina (+) group at 3rdmonth. NTpro-BNP and hs-TnT levels at 1stday and 3rdmonth were similar, however CK-MB level at 3rdmonth was found to be significantly lower in the angina (+) group (p = 0.034). At the end of the 3rdmonth, it was observed that the severity of IMR evaluated by PISA method was decreased and EF increased significantly in patients who defined angina within 72h prior to STEMI, suggesting a relation withIPC.

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.

S2642 A Novel Use of Transcatheter Aortic Valve Replacement for Aortic Regurgitation in End-Stage Liver Disease

INTRODUCTION: The combination of severe aortic regurgitation (AR), end-stage liver disease (ESLD), and end-stage renal disease (ESRD) carries significant morbidity and mortality. ESLD induces a hyperdynamic circulation characterized by peripheral vasodilation, low intravascular volume, and impaired contractility, resulting in poor cardiac reserve. As such, treatment options for valvular abnormalities such as AR in the setting of ESLD and ESRD remain challenging. While transcatheter aortic valve replacement (TAVR) for treatment of severe aortic stenosis (AS) is well established, minimally-invasive treatment options for AR are limited. We present a case of severe AR in a patient with ESLD and ESRD treated via expanded-access TAVR, hence allowing the patient to maintain transplant candidacy. CASE DESCRIPTION/METHODS: A 48 y/o male with history of alcohol-related ESLD and ESRD was referred for evaluation of simultaneous liver and kidney transplant. Initial evaluation revealed him to be Child Turcotte Pugh class C with a MELD-Na of 33. During pre-transplant evaluation, a transthoracic echocardiogram revealed a mobile hypoechoic mass near the non-coronary leaflet, with resultant severe eccentric AR. Transesophageal echocardiogram confirmed a 10 × 4.5mm mobile vegetation on the left coronary cusp (AR PISA radius: 0.81cm and AR PISA volume: 52.29ml). Upon further workup, blood cultures were found to be positive for Streptococcus, likely disseminated from his tunneled internal jugular dialysis catheter. The patient was initiated on 6 weeks of IV Cefazolin with subsequent replacement of the hemodialysis catheter. The presence of severe AR was deemed prohibitive for transplantation, and he was assessed to be too high-risk for open cardiac valve repair. However, after presentation at a multi-disciplinary structural heart disease case conference, the treating team recommended an expanded access, compassionate use TAVR, usually performed for AS. FDA and Henry Ford IRB approval was obtained with completion of TAVR via transfemoral approach and resulting reduction of his severe AR to trivial AR. This novel technique has allowed the patient to potentially be re-listed for liver and kidney transplant. DISCUSSION: Our case displays the use of a multidisciplinary approach to determining a novel and minimally-invasive approach for repair of AR in a high-risk patient. Furthermore, correction of the patient’s AR has allowed for preservation of his transplant candidacy.

Optimal Echocardiographic Approach to the Evaluation of Tricuspid Regurgitation.

To summarize the most recent literature on the optimal echocardiographic approach to the evaluation of tricuspid regurgitation (TR). Severe TR is increasingly recognized as an independent adverse prognostic marker. TR severity grading has been mainly based on qualitative and semiquantitative parameters according to the 2017 ASE guidelines, but new data emerging from 3D echocardiography and MRI will likely provide insights into more quantitative measurements of TR severity. The tricuspid valve's anatomy and physiology is complex and unique. TR can be primary or secondary to tricuspid annular dilatation. Commonly used echocardiographic parameters to define severe TR are severe valve lesions, a large color flow jet area, a vena contracta width of ≥ 7cm, a PISA radius of ≥ 0.9cm, a dense and triangular continuous wave Doppler jet shape, and hepatic vein systolic flow reversal. Complementary imaging modalities such as 3D echocardiography and MRI should be utilized if the 2D echocardiographic evaluation is suboptimal.

Relation of Mitral Annulus and Left Atrial Dysfunction to the Severity of Functional Mitral Regurgitation in Patients with Dilated Cardiomyopathy.

Methods 56 patients (58 ± 17 years, 42 men) with DCM and FMR and 52 controls, prospectively enrolled, underwent 3DTTE dedicated for mitral valve (MV), LA, and left ventricle (LV) quantitative analysis. Results Patients with FMR vs. controls presented increased MA size and sphericity during the entire systole, whereas MA fractional area change (MAFAC) and MA displacement were decreased (15 ± 5 vs. 28 ± 5%; and 5 ± 3 vs. 10 ± 2 mm, p < 0.001). In patients with moderate/severe FMR, MA diameters correlated with PISA radius, EROA, and regurgitant volume (Rvol), as also did the MA area (with PISA radius, EROA, and Rvol: r = 0.48, r = 0.58, and r = 0.47, p < 0.05). MAFAC correlated inversely with EROA and Rvol (r = −0.32 and r = −0.35, p < 0.05), with both active and total LA emptying fractions and with LV ejection fraction as well. In a stepwise multivariate regression model, decreased MAFAC and increased LA volume independently predicted patients with severe FMR. Conclusions Patients with DCM and FMR have MA geometry remodeling and contractile dysfunction, correlated with the severity of FMR. MA contractile dysfunction correlated with both LA and left LV pumps dysfunctions and predicted patients with severe FMR. Our results provide new insights that might help with better selection of patients for MV transcatheter procedures.

In Vitro Quantification of Mitral Regurgitation of Complex Geometry by the Modified Proximal Isovelocity Surface Area Method

Doppler echocardiographic methods, such as the proximal isovelocity surface area (PISA) method, are used to quantify mitral regurgitations (MRs). However, their accuracy and reproducibility are still being discussed, especially in the case of MR of complex geometry. The aim of this study was to evaluate the accuracy of the PISA method depending on the shape and number of regurgitant flows. First, various MR shapes and severities (central, oblong, and multiple-jet MR) were mimicked in a left heart simulator. The effective regurgitant orifice area (EROA) was calculated using the standard and modified PISA methods and was compared to a reference value obtained from an electromagnetic flowmeter. Second, in order to clinically validate the invitro findings, 16 patients were examined with two-dimensional (2D) echocardiography. The results were analyzed by comparing the PISA method and the echocardiographic 2D quantitative volumetric method. Both hemicylindrical and hemiellipsoidal PISA assumptions improved the quantification of the EROA for oblong MR compared with the traditional PISA method (hemispherical PISA assumption: 11±4.6mm2, P<.01; hemicylindrical PISA assumption: 2±0.8mm2, P=.83; hemiellipsoidal PISA assumption: 6±3.7mm2, P=.05). In the case of multiple jets of different sizes, an improved EROA calculation was measured when both jets were considered (single hemispherical PISA assumption: 4.5±0.7mm2, P<.01; double hemispherical PISA assumption: 2±1.1mm2, P=.64). For a correct diagnosis of MR, the PISA geometry must be considered. A measurement of both PISA radius and PISA width is necessary for an accurate quantification of an oblong MR. In the case of a double-jet MR, a measurement of the two radii is recommended.

Ischemic Mitral Regurgitation: Echocardiographic Algorithm, the Place of Three-Dimensional Transesophageal Echocardiography

Objective Identify the diagnostic markers of the severe MV changes in patients with ischemic mitral regurgitation (IMR) and suggest a modification of the echocardiography (EchoCG) algorithm.Materials and Methods A two-stage examination of 65 patients with mild (n=22), moderate (n=22), and severe (n=21) IMR was performed using two-dimensional (2D) transthoracic EchoCG with dopplerography, 2D and three-dimensional (3D) transesophageal EchoCG (TEE). 4D MV-Assessment in off-line mode was made in TomTec Imaging Systems GmbH, Germany. Statistical analysis (SAS 9.4) included Student's t-test, Kruskal-Wallis method, Pearson correlation, multivariate regression analysis, and ROC-analysis.Results According to 3D TEE the significant changes in MV annulus, leaflets and tenting are detected. 3D parameters of MV geometry are related to IMR severity, left ventricle (LV) remodeling (global and regional), and they are different in symmetric and asymmetric variants. In symmetric variant MV reconstruction is correlated with LV dilatation and contractility decrease, in asymmetric variant it's correlated with regional remodeling parameters. Severe IMR is characterized by a decrease in MV annulus displacement (27,0±6,6 mm/s versus 32,4±10,8 mm/s in mild IMR; р&lt;0,05), tenting volume fraction (32,5±14,8% versus 56,2±16,8% in mild IMR; p&lt;0,05), and annulus area fraction (4,7±2,7% versus 6,6±4,5% in mild IMR; р&lt;0,05). Vena contracta width (VCW), Proximal Isovelocity Surface Area (PISA) radius, Effective Regurgitant Orifice Area (EROA), Regurgitant Volume (Rvol), LV end systolic dimension (LV ESD), and central large jet &gt;50% of left atrium (LA) area have a predictive value in the diagnosis of MV geometry severe changes. If thresholds are reached these 2D TTE parameters can be used as indications for the 3D TEE.Conclusion 3D TEE allows for detailed assessment of MV geometry and function depended on IMR severity and variant. To make decision of MV surgery 3D TEE is recommended if the following indicators are presented: (1) VCW ≥0,7 cm; PISA radius ≥1,0 cm; central large jet &gt;50% of LA area; LV ESD ≥4,0 cm; (2) VCW ≥0,6 cm; PISA radius = 0,6-0,99 cm; EROA ≥0,3 cm2; RVol≥45 cm; IMR eccentric jet + IMR elliptical orifice.

6067Right ventricular global longitudinal strain predicts cardiovascular mortality and heart failure hospitalization in patients with functional tricuspid regurgitation

Abstract Background Functional tricuspid regurgitation (FTR) and its increasing severity are well-known factors associated with increased morbidity and mortality in patients with pulmonary artery hypertension or left heart diseases. Purpose To assess the main clinical and echocardiographic determinants of outcome in patients with various causes of FTR. Methods A total of 140 patients (pts) (72±14 years, 40% men) with FTR of diverse etiologies underwent complete 2D and additional 3D echocardiography acquisitions and were followed for a median of 5.2 years (interquartile range 2.1 - 6.7 years). Severe FTR was defined by ≥2 parameters: (1) coaptation defect; (2) vena contract ≥7; (3) PISA radius &gt;9 mm; (4) hepatic vein systolic flow reversal. The primary composite outcome was defined as death from cardiovascular causes and hospitalization due to right-sided heart failure (HF). Results 74 pts (53%) developed the primary composite outcome. Death occurred in 31 pts (22%), while hospitalization due to right-sided HF occurred in 66 pts (47%). At baseline, patients who developed the primary composite outcome, compared to those who did not, had more symptoms, more severe FTR, higher pulmonary systolic pressure (60±27 vs 43±16 mmHg), larger right atrium (69±34 vs 51±22 mL/mm2), right ventricular (RV) basal diameter (29±6 vs 24±4 mm/m2), larger RV end-diastolic (102±45 vs 76±25 mL/m2) and end-systolic (62±37 vs 43±17 mL/m2) volumes, larger tricuspid annulus area (7.7±1.8 vs 6.8±1.8 cm2/m2), lower RV systolic function (RVEF [42±11 vs 46±8%], TAPSE [18±4 vs 21±4], S' [11±3 vs 12±2], RV global longitudinal strain (RVGLS) [16±5 vs 19±4], RV free wall longitudinal strain [19±7 vs 23.5]); all p-values &lt;0.03. There were no significant differences in age, body size or comorbidities. After multivariable Cox regression analysis, FTR grade severity (hazard ratio [HR]=2.95, 95% confidence interval [CI] 2.14–4.06, p&lt;0.001) and RVGLS (HR= 0.91, 95% CI 0.86–0.95) were the only independent predictors of mortality. A cutoff of −17.5 for RVGLS had 57% sensitivity, 73% specificity and a HR of 2.34 (95% CI of 1.42–3.88, p-value=0.001). The Kaplan Meier survival curve showed that patients with an RVGLS ≥ −17.5 had a higher probability of developing the primary composite outcome, especially at an earlier phase of the follow up when compared to those with higher LS (log rank test chi-square = 13.0, p&lt;0.001) (Figure). At the end of follow up, 60% of patients with a RVGLS ≥-17.5 did not developed the primary composite outcome vs 29% in the group with a LS lower than −17.5. Kaplan-Meier curve of outcome by RVGLS Conclusions In patients with FTR, a decreased RVGLS, with a cutoff of −17.5, proved to be an independent prognostic factor for the development of HF hospitalizations and death from cardiovascular causes.

Outcome of patients with severe secondary tricuspid regurgitation treated first with diuretics

Medical treatment based on diuretics was often attempted in patients with severe secondary tricuspid regurgitation even when risk of surgery was acceptable. This strategy tends currently to be abandoned. Estimate the rate of heart failure hospitalization and cardiac mortality of patients with severe secondary tricuspid regurgitation treated first with diuretics. The study is retrospective and observational. We included patients with severe secondary tricuspid regurgitation, defined as PISA radius superior to 9 mm at a Nyquist limit of 28 cm/s. Tricuspid regurgitation was assessed by echocardiography before and after treatment with furosemide. Reduction in tricuspid regurgitation was defined by a decrease in PISA radius superior to 50%. The primary end point was heart failure hospitalization or cardiac mortality. Three hundred and fourteen patients were included, with a mean age of 69.2 ± 13.7 years and 53.2% of men. The mean left ventricular ejection fraction was 41.3 ± 11.8%. Sixty three percent of the patients had a history of left side surgery. Right ventricular dysfunction assessed by echocardiography was present in 69.4% of cases. The median started dose of furosemide was 236 ± 129 mg. After a median follow up of 90 days, improvement of the tricuspid regurgitation was observed in 18.5% ( n = 58) of the patients. Eighty three (26.4%) patients died. More than half of the patients were hospitalized for heart failure (63.4%; n = 199). Occurrence of events was associated with TAPSE ( P = 0.04), S wave on DTI ( P = 0.03), pulmonary systolic pressure ( P = 0.02), left ventricular ejection fraction ( P = 0.02), but not with decrease in tricuspid regurgitation severity. Data from our study show that medical treatment with diuretics should not delay cardiac surgery in patients with severe secondary tricuspid regurgitation.