Vena Contracta Width Research Articles

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<0,05), tenting volume fraction (32,5±14,8% versus 56,2±16,8% in mild IMR; p<0,05), and annulus area fraction (4,7±2,7% versus 6,6±4,5% in mild IMR; р<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 >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 >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.

P1554 Assessment of functional mitral regurgitation with leg lift and exercise echocardiography using the average pixel intensity method

Abstract Background Dynamic changes in functional mitral regurgitation (FMR) during exercise echocardiography were shown to be of prognostic value. However grading of FMR is challenging, especially during exercise echocardiography and therefore questioning its applicability in clinical practice. We recently introduced and validated the Average Pixel Intensity (API) for grading MR based on the pixel intensity of the continuous wave Doppler signal. In the current study we investigate the use of the API method using leg lift and exercise echocardiography in FMR. Methods We prospectively included 50 heart failure patients (mean ejection fraction 36%) in sinus rhythm with different grades of pure, FMR. After assessment of FMR severity at rest, the same acquisitions were repeated during leg lift and exercise echocardiography. FMR was assessed using the API method, color Doppler and quantitative grading methods (proximal isovelocity surface area (PISA) and vena contracta width (VCW)). Results The API method could be performed in all patients (100%) with leg lift (n = 50) and in 94% of the patients undergoing exercise echocardiography (n = 44), which was more than PISA and VCW (p < 0.001). During leg lift, there was a small but significant increase on visual color Doppler grading (grade 1.93 to 2.11 (p = 0.004); increase of FMR in 35% of patients, and no difference in 65%). For API, we found the same significant increase (93 to 101 au), however, API values showed increase of MR in 62% and decrease of FMR in 20%. During exercise echocardiography, we found no differences in color Doppler grade and API in the overall cohort (p 0.252 and p 0.832, respectively), despite 62% of patients showing some degree of increase in API during leg lift. On multivariate analysis, no specific echo parameter could be identified as independent predictor of API increase. Conclusions The novel API method is highly feasible for assessing dynamic FMR and may be of added value for in this setting, allowing the detection of even small increments of FMR severity. In the current study, we found only mild increases of FMR during exercise echocardiography. Leg lift testing however proved to be a simple and quick loading approach that induced a significant rise in FMR compared to exercise echocardiography. The prognostic relevance of the findings during leg lift remains to be determined.

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 < 0,0001 for RV, Rs = 0,50, p < 0,0001 for RF) and 3D-VCA (Rs = 0,48 for RV, p < 0,0001 , Rs = 0,38 for RF, p < 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 < 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.

P1796 Three dimensional echocardiograhy navigation of mitral valve in patients with left ventricular dysfunction and functional mitral regurgiation

Abstract OnBehalf cairo university Background Mitral valve MV apparatus is a dynamic three-dimensional system that allows a unidirectional heart pump function. Functional mitral regurgitation (FMR) is a common complication that adversely affects the prognosis in patients with congestive heart failure. Accurate assessment of the interaction of the LV and MV apparatus is crucial for surgical correction of FMR. Purpose Evaluation of MV deformity indices in patients with Left ventricle (LV) dysfunction and varying severity FMR using 3D transoesophageal echocardiography and MV navigation (MVN) software Methods 96 patients were selected with echocardiographic evidence of dilated LV dimensions, EF ≤ 45%,and at least mild MR . A standard comprehensive transthoracic echocardiographic assessment of : 1. LV diameters and volumes with calculation of LVEF , LV shape, sphericity index, 2. Mitral leaflets morphology including anterior mitral leaflet length ,Mitral annular (MA) diameter , mid-systolic mitral annular area (MAA) , The coaptation height (CH) or distance , MV tenting area, leaflet-tethering distance for anterolateral papillary muscle (Tethering-AL) and posteromedial papillary muscle (Tethering-PM), 3.Quantification of MR : MR jet area , vena contracta (VC) width, effective regurgitant orifice area (EROA), , regurgitant volume, 4. 2D speckle-tracking imaging for LV strain analysis,5.MV morphology and dynamics were analysed using MVN for assessment of : Annular geometry including diameters, circumference ,height , annular ellipticity . Results MV deformation (AML and PML tethering distance) was negatively correlated with GLS (r= -0.408, p = 0.009),and (r= -0.428, p = 0.006) as well as 2D and 3D MAA were negatively correlated with the GLS (r= -0.469, p = 0.002) and (r= -0.477, p = 0.002). MR severity parameters as MR volume and EROA were associated with increased MAA (r = 0.38, p = 0.015), (r = 0.469, p = 0.002) respectively. Severity of MR was strongly correlated with MVA indices including AP diameter, 3D MA circumference, MAA, MV tenting height and volume and annular ellipsicity. Conclusion Mitral annular enlargement appears to be more closely linked to occurrence of FMR in patients with LV dysfunction. 3D imaging modalities will help assessment of complicated, dynamic, three-dimensional and non-planar mitral annulus

Assessment of mitral regurgitation and mitral complex geometry in patients after transcatheter aortic valve implantation.

IntroductionMitral regurgitation (MR) of varying degrees and mechanisms is a common finding in patients with aortic stenosis with different improvement after transcatheter aortic valve implantation (TAVI).AimTo evaluate the impact of TAVI on mitral complex geometry and the degree of MR.Material and methodsA total of 31 patients (29.0% males) with severe aortic stenosis and moderate or severe MR at the baseline who underwent TAVI were included in this study. Clinical and echocardiographic characteristics were determined at baseline and at 6 and 12 months.ResultsAfter TAVI, decrease of MR vena contracta width (p = 0.00002, p = 0.00004), aorto-mural mitral annulus diameter (p = 0.00008, p = 0.02), increase of mitral annular plane systolic excursion (p = 0.0004, p = 0.0003), left ventricular stroke volume (p = 0.0003, p = 0.0004), ejection fraction (p = 0.0004, p = 0.01) and decrease of major dimension of left ventricle in three chamber view (p = 0.05, p = 0.002) were observed in patients at both time points. Additionally, we observed a decrease of distance between the head of the papillary muscles (p = 0.003) at 6 months and a decrease of left atrium volume index (p = 0.01) and systolic pulmonary artery pressure (p = 0.01) at 12 months.ConclusionsPatients with moderate or severe MR undergoing TAVI achieved significant improvement of mitral valve complex function resulting in the reduction of MR degree.

P3372Prediction of outcome in functional mitral regurgitation using the average pixel intensity method

Abstract Background Functional mitral regurgitation (FMR) is a frequent finding in patients with systolic heart failure. However, the echocardiographic grading of MR is challenging and different severity cut-offs are recommended by international guidelines. We developed and validated a novel echocardiographic parameter to grade MR, the average pixel intensity (API) method, based on pixel intensity analysis of the continuous wave Doppler signal. Purpose In this study, we assessed the long-term predictive value of the API method on clinical endpoints in FMR. Methods Transthoracic echocardiography was performed in consecutive heart failure patients with reduced EF (HF-REF) (n=221). MR was assessed using the API method, vena contracta width (VCW), effective regurgitant orifice area (PISA-EROA) and regurgitant volume (PISA-RV). The primary clinical events were major adverse cardiac events (MACE: cardiovascular mortality, mitral valve surgery, percutaneous mitral intervention or heart failure hospitalization). Results The API method was feasible in 97% of all FMR patients, which was significantly higher than parameters such as VCW, PISA-EROA and PISA-RV. 84 patients (37%) had one or more clinical events during the follow-up period (cardiovascular mortality (20%), mitral valve surgery (5%), percutaneous mitral intervention (5%), heart failure hospitalization (16%) or heart transplantation (2%)). Based on ROC curves, an API cut-off of 121 au was defined as “severe” MVP-MR with an overall better sensitivity and specificity than current guideline-recommended parameters. On multivariate analysis, MR graded with API was independently predictive for clinical events, whereas PISA-based methods were not independent. In addition, pulmonary pressures and NYHA class were powerful independent predictors of clinical outcome in FMR on multivariate analysis. Conclusions The API method better predicts clinical events and outcome in FMR compared to established grading methods. Therefore, the API method may be considered for grading FMR severity in clinical practice.

Clinical role of transthoracic and transesophageal echocardiography in transapical mitral valve repair

Objective To evaluate the role of transthoracic echocardiography(TTE) and transesophageal echocardiography(TEE) in the process of transapical mitral valve repair using a novel edge-to-edge device(ValveClamp) and this device′s efficacy and safety in a preliminary clinical trial. Methods Six patients with moderate to severe or severe degenerative mitral regurgitation (DMR) confirmed by TTE and TEE were enrolled. TTE was performed pre and post procedure as well as 30 days post procedures.Related cardiac structure and hemodynamic parameters, including mitral regurgitation area(MRA-max), vena contracta width(VCW), mitral valve effective orifice area(MVEOA), left ventricular end diastolic diameter(LVEDD), left ventricular end systolic diameter(LVESD), left ventricular ejection fraction(LVEF), max and mean mitral valve pressure gradient(MVPG-max and MVPG-mean) were recorded and evaluated in a central core laboratory. Results All the procedures were successfully performed.MRA-max, VCW and MVEOA decreased significantly post procedures (all P 0.05). Meanwhile, MVPG-max and MVPG-mean slightly increased (all P 0.05). Conclusions Transapical mitral valve repair using ValveClamp can be performed safely and a significant reduction in mitral regurgitation can be achieved in patients with DMR. TEE and TTE facilitate the patient selection for ValveClamp procedures as well as perioperative navigation and assessment. Key words: Echocardiography, transthoracic; Echocardiography, transesophageal; Transcatheter mitral valve repair; Mitral regurgitation

6-Month Outcomes of Tricuspid Valve Reconstruction for Patients With Severe Tricuspid Regurgitation

BackgroundSevere tricuspid regurgitation (TR) is associated with high morbidity and mortality rates with limited treatment options. ObjectivesThe authors report the 6-month safety and performance of a transcatheter tricuspid valve reconstruction system in the treatment of moderate to severe functional TR in 30 patients enrolled in the TRI-REPAIR (TrIcuspid Regurgitation RePAIr With CaRdioband Transcatheter System) study. MethodsBetween October 2016 and July 2017, 30 patients were enrolled in this single-arm, multicenter, prospective trial. Patients were diagnosed with moderate to severe, symptomatic TR in the absence of untreated left-heart disease and deemed inoperable because of unacceptable risk for open-heart surgery by the local heart team. Clinical, functional, and echocardiographic data were prospectively collected before and up to 6 months post-procedure. An independent core lab assessed all echocardiographic data, and an independent clinical event committee adjudicated the safety events. ResultsMean patient age was 75 years, 73% were female, and 23% had ischemic heart disease. At baseline, 83% were in New York Heart Association (NYHA) functional class III to IV, and mean left ventricular ejection fraction was 58%. Technical success was 100%. Through 6 months, 3 patients died. Between 6 months and baseline, echocardiography showed average reductions of annular septolateral diameter of 9% (42 mm vs. 38 mm; p < 0.01), proximal isovelocity surface area effective regurgitant orifice area of 50% (0.8 cm2 vs. 0.4 cm2; p < 0.01), and mean vena contracta width of 28% (1.2 cm vs. 0.9 cm; p < 0.01). Clinical assessment showed that 76% of patients improved by at least 1 NYHA functional class with 88% in NYHA functional class I or II. Six-minute walk distance improved by 60 m (p < 0.01), and Kansas City Cardiomyopathy Questionnaire score improved by 24 points (p < 0.01). ConclusionsSix-month outcomes show that the system performs as intended and appears to be safe in patients with symptomatic and moderate to severe functional TR. Significant reduction of TR through decrease of annular dimensions, improvements in heart failure symptoms, quality of life, and exercise capacity were observed. Further studies are warranted to validate these initial promising results. (TrIcuspid Regurgitation RePAIr With CaRdioband Transcatheter System [TRI-REPAIR]; NCT02981953)

Aortic Insufficiency during LVAD Support: A Mock Loop Study

Purpose Aortic valve (AoV) insufficiency (AI) is a serious complication in more than 20% of Left Ventricle Assist Device (LVAD) patients within 12 months of LVAD implantation. Normal AoV have developed AI following long-term LVAD support,which has been associated with a significant reduction in LVAD patient survival. During LVAD support, the AoV pressure difference is increased, which reduces systolic opening and worsens regurgitant flow through an incompetent valve. The goal of this study was to measure the effect of LVAD support on intraventricular flow during AI. Methods The velocity field was measured in the midplane of a dilated silicone LV model attached to a rotary LVAD (Abbott Labs, Chicago IL) in a mock circulatory loop. A Pre-LVAD without AI condition (BL) of 20% ejection fraction was established, followed by testing at three LVAD speeds. AI was created with a small 3-D printed stent which was nonobstructive to forward flow but prevented the leaflets from fully closing. LV and aortic pressure, and LVAD and distal aortic flow, were recorded. Results At the Pre-LVAD BL condition, the mean aortic pressure was 63 mmHg and the cardiac output was 2.3 L/min; AI maintained a similar pressure but reduced flow to 1.8 L/min producing a 32% regurgitant fraction (mild-moderate AI). At an LVAD speed of 6400rpm, total systemic flow was 4.3 L/min and 3.1 L/min for BL and AI, respectively, and LVAD flow was 4.2 and 3.6 L/min, producing a 45% regurgitant fraction (moderate-severe AI). The reduction of systemic flow was accompanied by higher LVAD flow, confirming that a regurgitant loop was present. Net forward flow through AoV during BL decreased progressively by 23%, 12% and 0.5% for 4800, 5400, and 6400rpm respectively. AI reduced forward flow and increased backward flow, such that net forward flow was 0.5%, -14%, and -17% at 4800, 5400 and 6400rpm. The AI vena contracta width increased from 2.3 to 3.4 mm as LVAD speed increased. Conclusion Overall, the results showed that an initially mild level of AI worsened with LVAD support prior to any remodeling, simply due to the altered biomechanics of the AoV. These findings provide a foundation for new strategies that can restore AoV biomechanics and reduce the impact of AI on patients with LVAD support.

Insights into functional mitral regurgitation using the average pixel intensity method.

Previously we introduced and validated the average pixel intensity (API) method for grading mitral regurgitation (MR) in a heterogeneous MR population. We now investigated the feasibility and added value of the API method more specifically in patients with functional MR (FMR). We consecutively enrolled 283 patients with pure FMR. Transthoracic echocardiography was performed and MR was assessed using the API method and guideline-recommended parameters, including color Doppler, vena contracta width (VCW) and proximal isovelocity surface area (PISA)-based methods. The API method had an applicability of 98% in this FMR cohort, which was significantly higher than VCW (84%) and PISA-based methods (75%). Overall, the API method had significant correlations with direct parameters of FMR severity, ejection fraction, atrial and ventricular dimensions, pulmonary pressures and New York Heart Association class. Analysis of the API dynamics during MR revealed a typical pattern with early and late systolic peaks in API and a midsystolic nadir, which matched the temporal changes of the effective regurgitant orifice (ERO) during FMR. Based on ROC curves of established FMR severity cut-offs, an API value of 125 au was considered the optimal cut-off to determine severe MR. Interestingly, this API severity cut-off is similar to the API severity cut-off for MR in degenerative MR (DMR), despite different EROA/RV cut-offs in current ESC guidelines for FMR and DMR. The API method is an easy, fast and feasible parameter for grading FMR and may complement the multiparametric assessment of FMR in daily clinical practice.

The Conundrum of Tricuspid Regurgitation Grading

Findings from early percutaneous tricuspid intervention trials have shown that the severity of tricuspid regurgitation (TR) far exceeded the current definition of severe TR. Also, the improvement in the amount of TR following tricuspid intervention is not accounted for by the current definition of TR as different degrees of severity at the severe end was grouped under the same umbrella term of “severe.” There has been a recent call to expand the TR grading system, encompassing two more grades, namely “massive” and “torrential” TR, in the order of increasing severity. This seems appropriate as the patients enrolled in tricuspid intervention trials were found to have TR severity up to 2 grades above the current severe thresholds of effective regurgitant orifice area (EROA) 40 mm2, regurgitant volume (R Vol) 45 ml and vena contracta (VC) width 7 mm. The proposed grade of “massive” is defined by EROA 60–79 mm2, R Vol 60–74 ml and VC 14–20 mm, while “torrential” is defined by EROA ≥80 mm2, R Vol ≥75 ml, and VC ≥21 mm. The grading of TR requires a comprehensive, multi-parametric approach. In particular, quantitative assessment of TR should be performed in patients who require serial monitoring and quantification of treatment effect.

Treatment of Tricuspid Regurgitation With the FORMA Repair System.

Background: Tricuspid regurgitation (TR) is common and undertreated as the risk of surgery is high in this patient population. Transcatheter devices offer treatment with a lower procedural risk. The FORMA Tricuspid Valve Therapy system (Edwards Lifesciences) will be reviewed here.Device Description: The system combines a spacer placed in the regurgitant orifice and a rail, over which the spacer is delivered, that is anchored to the endocardial surface of the RV. The spacer provides a surface for leaflet coaptation.Outcomes: Eighteen compassionate care patients and 29 patients included in the US EFS trial are reviewed. Patients were elderly (76 years) and high risk (Euroscore 2 was 9.0 and 8.1%, respectively). There were 2 procedural failures in both groups. Mortality at 30 days was 0% in the compassionate group and 7% in the EFS trial. TR was reduced in both groups; 2D/3D EROA 2.1 ± 1.8 to 1.1 ± 0.9 cm2 in the EFS trial and vena contracta width 12.1 ± 3.3 to 7.1 ± 2.2 mm. Symptomatic improvement was seen in both groups; the proportion of patients in NYHA class III/IV decreased from 84 to 28% at 30 days in the EFS group, and from 94 to 21% at 1 year, in the compassionate group.Conclusions: Reduction of TR with FORMA system is feasible and sustained. Despite residual TR post-procedure, the significant relative reduction in TR severity contributes to substantial clinical improvements in patients with a FORMA device in place.

Validation of “left ventricular early inflow-outflow index”: A novel echocardiographic method for quantification of mitral regurgitation in an Indian population with special focus on rheumatic etiology

BackgroundQuantification of mitral regurgitation (MR) has always required an “integrated approach” as there is no single gold-standard method. We investigated a new Doppler-derived parameter “left ventricular early inflow-outflow index (LVEIO)” for the quantification of MR and its likelihood to predict severe MR in correlation with already established parameters in an Indian population including a large subset of patients with rheumatic etiology. MethodsA prospective study was performed at a major tertiary care center in western India over a 5-month period. Five hundred patients diagnosed with isolated MR including 260 (52%) patients with rheumatic etiology were included in the study after applying exclusion criteria. We analyzed MR using color flow jet, effective regurgitant orifice area (EROA), and vena contracta (VC) width. LVEIO is a simplification of the regurgitant volume (RV) method, which was calculated as “E velocity divided by LV outflow velocity integrated over the systolic ejection period left ventricular outflow tract velocity time integral” and compared with the established parameters. ResultsLVEIO was 4.65 ± 1.45, 6.56 ± 1.52, and 9.91 ± 3.70 among patients diagnosed with mild, moderate, and severe MR, respectively (p < 0.001). Those with LVEIO ≥8 were the most likely to have severe MR (positive likelihood ratio: 10.42). LVEIO had specificity of 93.25% for diagnosis of severe MR with positive predictive value of 86.36%. There was positive correlation observed between LVEIO and VC width (r = 0.591), RV (r = 0.410), and EROA (r = 0.778) (all p < 0.001) in the Pearson correlation test. The specificity of LVEIO remained consistent in diagnosing severe MR in patients with rheumatic etiology. ConclusionLVEIO is a simple yet specific Doppler echocardiographic parameter for estimation of severity of MR including that of rheumatic etiology.

Adaptive Color Gain for Vena Contracta Quantification in Valvular Regurgitation

Severe valvular regurgitation can lead to pulmonary hypertension, atrial fibrillation and heart failure. Vena contracta width is used to estimate the severity of the regurgitation. Parameters affecting visualization of color Doppler have a significant impact on the measurement. We propose a data-driven method for automated adjustment of color gain based on the peak power of the color Doppler signal in the vicinity of the vena contracta. A linear regression model trained on the peak power was used to predict the orifice diameter. According to our study, the color gain should be set to about 6 dB above where color Doppler data completely disappears from the image. Based on our method, orifices with reference diameters of 4, 6.5 and 8.5 mm were estimated with relative diameter errors within 18%, 12% and 14%, respectively.

Grading of mitral regurgitation in mitral valve prolapse using the average pixel intensity method

AimsWe recently reported the feasibility of the average pixel intensity (API) method for grading mitral regurgitation (MR) in a heterogeneous MR population. Since mitral valve prolapse (MVP) is an important cause of primary MR, we more specifically investigated the feasibility of the API method and the MR flow dynamics in patients with MVP. MethodsTransthoracic echocardiography was performed by a single operator in consecutive MVP patients (n=112). MR was assessed using the API method, color Doppler, vena contracta width (VCW), effective regurgitant orifice area (PISA-EROA) and regurgitant volume (PISA-RV). ResultsThe API method was feasible in 89% of all MVP patients (68%, 71% for VCW and PISA method, respectively ;p<.001). Inter- and intra-observer correlations for API in MVP with non-holosystolic MR were 0.989 and 0.995. For the overall MVP-MR population, API had significant correlations with direct and indirect measures of MR severity. Based on ROC curves, an API cutoff value of 125 au was suggested to identify severe MR in MVP and a MR duration/systolic time ratio<100% (i.e. non-holosystolic MVP-MR) identifies patients with non-severe MR (API<125), whereas the majority of holosystolic MVP had severe MR (API>125). Finally, API analysis of the proto-, mid- and telesystolic phases of MR in MVP showed different kinetics in non-holosystolic compared to holosystolic MVP. ConclusionsThe API method is a feasible and reproducible method for grading MVP-MR. As the API method takes into account the temporal MR flow changes during the entire systolic cycle, it may be of added value in clinical practice.

Torsion Mechanics as an Indicator of More Advanced Left Ventricular Systolic Dysfunction in Secondary Mitral Regurgitation in Patients with Dilated Cardiomyopathy: A 2D Speckle-Tracking Analysis

Left ventricular (LV) twist serves as a compensatory mechanism in systolic dysfunction and its degree of reduction may reflect a more advanced stage of disease. Aim: The aim was to investigate twist alterations depending on the degree of functional mitral regurgitation (MR) by speckle-tracking echocardiography. Methods: Sixty-three patients with symptomatic dilated cardiomyopathy (DCM) were included. Patients were divided according to MR vena contracta width (VCW): group 1 with VCW <7 mm (mild/moderate MR) and group 2 with VCW ≥7 mm (severe MR). Results: There were no differences in LV geometry and function between groups. Group 2 showed lower endocardial basal rotation (BR) (–2.04° ± 1.83° vs. –3.23° ± 1.83°, p = 0.012); epicardial BR (–1.54° ± 1.18° vs. –2.31° ± 1.22°, p = 0.015); endocardial torsion (0.41°/cm ± 0.36°/cm vs. 0.63°/cm ± 0.44°/cm, p = 0.033) and mid-level circumferential strain (CSmid) (–6.12% ± 2.64% vs. –7.75% ± 2.90%, p = 0.028), when compared with group 1. Multivariable linear regression analysis identified endocardial BR, torsion and CSmid, as the best predictors of larger VCW. In the ROC curve analysis, endocardial BR and CSmid values greater than or equal to –3.63° and –9.35%, respectively, can differentiate patients with severe MR. Conclusions: In DCM patients, torsional profile was more altered in severe MR. Endocardial BR, endocardial torsion, and CSmid, can be used as indicators of advanced structural wall architecture damage.

The Correlation of NT-Pro BNP with Echocardiographic Indices Including 3D Vena Contracta Width in the Assessment of Severity of Mitral Regurgitation

Introduction: Mitral regurgitation (MR) is a common valvular disease that causes significant morbidity and mortality. The use of multiple echocardiographic indices and hormonal parameters in combination can provide an accurate assessment of MR severity and LV dysfunction in most cases. Aim of study: The aim of this study was to correlate the levels of serum NT-pro BNP with various echocardiographic parameters including 3D vena contracta width in patients with MR. Methods: 74 Patients diagnosed with primary mitral regurgitation in sinus rhythm with no conduction disturbance were included in the study. 2D and Doppler echocardiography indices were calculated. A full-volume 3D color Doppler acquisition was obtained and 3D vena contracta width was calculated and serum BNP levels were obtained. Results: NT-pro BNP levels were increased with symptoms in patients with mitral regurgitation (NYHAI: 4.48 ± 0.06, NYHAII: 5.54 ± 0.78, NYHAIII: 6.68 ± 1.21 pg/ml, p 0.01). NT-pro BNP plasma levels were significantly correlated with MPI (r = 0.945, p 0.01), LVESV (r = 0.706, p 0.01), LVESVI (r = 0.677, p 0.01), LAVI (r = 0.709, p 0.01), MR 2D VC (r = 0.430, p 0.01), 3D VC (r = 0.441, p 0.01), PISA (r = 0.440, p 0.01) and negative correlation with LV ejection fraction (r = 0.846, p 0.01), dp/dt (r = 0.795, p BNP plasma level and LA jet area ratio (P = 0.33). It was observed that there was a significant correlation between 3D VC and PISA levels in patients of mitral regurgitation. However correlation is better in MR with central jet compared to eccentric jet in moderate and severe MR (r = 0.807, 0.817 vs r = 0.617, 0.572). Conclusion: This study showed that NT-pro BNP measurement has the same sensitivity and specificity as echocardiographic indices. Three-dimensional VCA may provide a reliable measurement of ROA, independent of geometric and flow assumptions.

Mitral Regurgitation Grading in the Operating Room: A Systematic Review and Meta-analysis Comparing Preoperative and Intraoperative Assessments During Cardiac Surgery

To assess differences in mitral regurgitation (MR) grade between the preoperative and the intraoperative evaluations. Systematic review and meta-analysis of 6 observational studies found from MEDLINE and EMBASE. Cardiac surgery. One hundred thirty-seven patients. Comparison between the preoperative MR assessment and the intraoperative evaluation conducted under general anesthesia (GA), with or without "hemodynamic matching" (HM) (artificial increase of afterload). The primary outcome was the difference between the preoperative and intraoperative MR grade under "GA-only" or "after-HM." Secondary analyses addressed differences according to effective regurgitant orifice area (EROA), regurgitant volume (RVol), color-jet area, and vena contracta width. Risk of MR underestimation was found under "GA-only" (SMD: 0.55; 95% confidence interval [CI], 0.31-0.79, p < 0.00001), but not "after-HM" (SMD: -0.16; 95% CI, -0.46 to 0.13, p = 0.27). Under "GA-only", EROA had a trend toward underestimation (p = 0.07), RVol was reliable (p = 0.17), while reliance on color-jet area and vena contracta width incur risk of underestimation (both p = 0.003). After HM, EROA accurately reflected preoperative MR (p = 0.68) while RVol had a trend toward overestimation (p = 0.05). The overall reported incidence of misdiagnoses was slightly more common under "GA-only" (mean 48%, 39% underestimation, 9% overestimation; range: 32%-57%) than "after-HM" (mean 41%, 12% underestimation, 29% overestimation; range: 33%-50%). Only the minority of misdiagnoses were clinically relevant: underestimation was around 10% (both approaches), but 18% had clinically significant overestimation "after-HM" as compared with 3% under GA-only. Intraoperative assessment under "GA-only" significantly underestimated MR. A more accurate intraoperative evaluation can be obtained with afterload manipulation, although HM strategy carries high risk of clinically significant overestimation.

A new and simple method for clarifying the severity of tricuspid regurgitation.

No gold standard exists for grading tricuspid regurgitation (TR) severity. We developed a simple parameter, the right ventricular (RV) early inflow-outflow (RVEIO) index, using the early diastolic filling velocity and RV outflow velocity integrated over the systolic ejection period. We hypothesized that this index would help identify severe TR in clinical practice. We obtained data from routine transthoracic echocardiograms. All records reporting moderate (n=395) or severe (n=395) TR were reanalyzed to measure vena contracta (VC) width, TR jet area, effective regurgitant orifice (EROA) derived with the proximal isovelocity surface area method, RVEIO index, and right-sided chamber volumes. Significant linear trends were demonstrated for right atrial volume index, end-diastolic volume index, E-wave velocity, RV velocity time integral, TR jet area, VC width, and EROA with increasing TR severity. Independent predictors of severe RT included RVEIO index ≥ 10, VC width ≥ 0.7cm, TR jet area>10cm2 , and EROA ≥ 0.4cm2 . RVEIO index is a useful, simple, accurate, and independent predictor of severe TR that adds incrementally to traditional methods of quantifying TR severity. Accurate quantification and classification of TR severity is critical for clinical decision-making and management; therefore, the incorporation of RVEIO index into the integrative approach to grading TR severity should be considered.

Real-Time 3-Dimensional Echocardiographic Assessment of Effective Regurgitant Orifice Area in Dogs With Myxomatous Mitral Valve Disease.

BackgroundEffective regurgitant orifice area (EROA), calculated from the vena contracta width (VCW) as the narrowest portion of the proximal regurgitant jet, might be used to estimate severity of mitral regurgitation. However, this simplified assumption only holds when the EROA is circular, which might not be true in dogs with myxomatous mitral valve disease (MMVD).HypothesisEffective regurgitant orifice area in dogs with MMVD is noncircular, and using color Doppler real‐time 3‐dimensional (RT3D) echocardiography, measured EROA in the en face view will be significantly different from calculated EROA.AnimalsHundred and fifty‐eight privately owned dogs with naturally occurring MMVD.Materials and MethodsProspective observational study comparing en face view of EROA with calculated EROA using VCW in 4‐chamber (4Ch) and 2‐chamber (2Ch) view only or combined 4Ch and 2Ch views using RT3D echocardiography.ResultsThe calculated EROA using the 2Ch view showed a systematic underestimation of 17% compared with the measured en face EROA corrected for body surface area. The calculated EROA using 4Ch and 4Ch + 2Ch views showed less agreement with the en face EROA, and the difference between methods increased with increasing EROA. The difference between calculated and measured EROA showed a systematic underestimation of the calculated EROA by 36% (4Ch) and 33% (4Ch + 2Ch), respectively, compared to measured en face EROA.Conclusion and Clinical ImportanceWhen replacing measured EROA with calculated EROA using VCW measurements, the 2Ch view is preferred in dogs with MMVD.