Vena Contracta Width Research Articles

Overestimation by echocardiography of the peak systolic pressure gradient between the right ventricle and right atrium due to tricuspid regurgitation and the usefulness of the early diastolic transpulmonary valve pressure gradient for estimating pulmonary artery pressure.

We investigated the influence of tricuspid regurgitation (TR) severity on the echocardiographic peak systolic transtricuspid pressure gradient (TRPG) and evaluated the usefulness of the peak early diastolic transpulmonary valve pressure gradient (PRPG) for estimating pulmonary artery (PA) pressure. In 55 consecutive right heart-catheterized patients, we measured the peak systolic right ventricular (RV)-right atrial (RA) pressure gradient (RV-RACATH), peak early diastolic PA-RV pressure gradient (PA-RVCATH), and mean PA pressure (MPAPCATH). Using echocardiography, we obtained the TRPG, PRPG, and an estimate of the mean PA pressure (EMPAP) as the sum of PRPG and the estimated RA pressure, and measured the vena contracta width of TR (VCTR). The difference between the TRPG and RV-RACATH was significantly greater in the very severe TR group (VCTR>11mm) than in the mild, moderate, and severe TR groups, and significantly greater in the severe TR group (7<VCTR≤11mm) than in the mild TR group. The overestimation of the pressure gradient >10mmHg by TRPG was not seen in the mild or moderate TR groups, but was observed in the severe and very severe TR groups (22 and 83%, respectively). In the ROC analysis, EMPAP could distinguish patients with MPAPCATH≥25mmHg with the area under the curve of 0.93, 100% sensitivity, and 87% specificity. In conclusion, TRPG frequently overestimated RV-RACATH when VCTR was >11mm and sometimes did when VCTR was >7mm, where EMPAP using PRPG was useful for estimating PA pressure.

Grading of mitral regurgitation based on intensity analysis of the continuous wave Doppler signal

ObjectivesEchocardiographic methods are used to quantify mitral regurgitation (MR) severity; however, their applicability, accuracy and reproducibility have been debated. We aimed to develop and validate a novel custom-made transthoracic echocardiographic...

Mesenchymal stem cells preserve neonatal right ventricular function in a porcine model of pressure overload.

Limited therapies exist for patients with congenital heart disease (CHD) who develop right ventricular (RV) dysfunction. Bone marrow-derived mesenchymal stem cells (MSCs) have not been evaluated in a preclinical model of pressure overload, which simulates the pathophysiology relevant to many forms of CHD. A neonatal swine model of RV pressure overload was utilized to test the hypothesis that MSCs preserve RV function and attenuate ventricular remodeling. Immunosuppressed Yorkshire swine underwent pulmonary artery banding to induce RV dysfunction. After 30 min, human MSCs (1 million cells, n = 5) or placebo (n = 5) were injected intramyocardially into the RV free wall. Serial transthoracic echocardiography monitored RV functional indices including 2D myocardial strain analysis. Four weeks postinjection, the MSC-treated myocardium had a smaller increase in RV end-diastolic area, end-systolic area, and tricuspid vena contracta width (P < 0.01), increased RV fractional area of change, and improved myocardial strain mechanics relative to placebo (P < 0.01). The MSC-treated myocardium demonstrated enhanced neovessel formation (P < 0.0001), superior recruitment of endogenous c-kit+ cardiac stem cells to the RV (P < 0.0001) and increased proliferation of cardiomyocytes (P = 0.0009) and endothelial cells (P < 0.0001). Hypertrophic changes in the RV were more pronounced in the placebo group, as evidenced by greater wall thickness by echocardiography (P = 0.008), increased cardiomyocyte cross-sectional area (P = 0.001), and increased expression of hypertrophy-related genes, including brain natriuretic peptide, β-myosin heavy chain and myosin light chain. Additionally, MSC-treated myocardium demonstrated increased expression of the antihypertrophy secreted factor, growth differentiation factor 15 (GDF15), and its downstream effector, SMAD 2/3, in cultured neonatal rat cardiomyocytes and in the porcine RV myocardium. This is the first report of the use of MSCs as a therapeutic strategy to preserve RV function and attenuate remodeling in the setting of pressure overload. Mechanistically, transplanted MSCs possibly stimulated GDF15 and its downstream SMAD proteins to antagonize the hypertrophy response of pressure overload. These encouraging results have implications in congenital cardiac pressure overload lesions.

Quantitative, Noninvasive Assessment of Patent Ductus Arteriosus Shunt Flow by Measuring Proximal Isovelocity Surface Area on Color Doppler Mapping in Very Low-Birth-Weight Infants.

Background Our goal was to evaluate the hemodynamic status of very low-birth-weight infants (VLBWIs) with patent ductus arteriosus (PDA) by measuring the vena contracta width (VCW) and effective shunt orifice area (ESOA) using the proximal isovelocity surface area (PISA) on color Doppler imaging. Method and Results In this study, 34 VLBWIs with PDA (median weight: 949 g) were studied. We measured VCW and ESOA using the PISA on echocardiography. PDA-VCW was measured at the narrowest PDA flow region. ESOA determined using PISA (PDA-ESOA) was defined as the hemispheric area of laminar flow with aliased velocities on color Doppler flow imaging: PDA-ESOA = 2π (PDA radius) 2 × aligning velocity/PDA velocity. Of the 34 VLBWIs, 26 received indomethacin (IND) for symptomatic PDA. Comparing echocardiographic parameters between infants who did versus did not receive IND, significant differences were seen in the left atrial-to-aortic root ratio (LA/AO), PDA-VCW, and PDA-ESOA. Receiver operating characteristic curve analysis to differentiate between IND usage status produced statistically significant results for PDA-VCW (area under the curve [AUC] = 0.880), PDA-ESOA (AUC = 0.813), and LA/AO (AUC = 0.769). Conclusion PDA-VCW and PDA-ESOA may allow noninvasive assessment of PDA severity, and are useful when determining the timing of clinical decision making for IND administration.

Abstract 17072: A Novel Algorithm for Quantification of Mitral Valve Regurgitation Based on Pixel Density Analysis of Continuous Wave Doppler Imaging

Introduction: Echocardiography is important for the assessment of mitral valve regurgitation (MR) and to guide clinical decision making. Echocardiographic methods are being used to quantify MR severity but their applicability, accuracy, and reproducibility have been debated. Hypothesis: To test the feasibility and in vitro validation of a novel custom-made transthoracic echocardiographic method for the assessment of MR severity based on pixel density analysis (PDA) of the continuous wave (CW) envelope in digital images. Methods: MR was prospectively assessed in 290 patients on a VIVID E9 echo machine (GE) with fixed settings. MR severity was evaluated according to international guidelines using color doppler, vena contracta (VC) width, proximal iso-velocity surface area (PISA) method, and PDA. The applicability, inter-observer, and intra-observer variability of all methods were compared. For validation of the PDA algorithm, a pulsatile in vitro cardiac phantom was used with prosthetic mitral valves with different regurgitant orifices (13.2, 27.2, 54.7, and 86.5 mm2). Regurgitant volume (RV) was calculated by multiplying the regurgitant orifice with the time velocity integral. Results: The PDA method showed a linear correlation with color doppler (r=0.82), VC width (r=0.67), PISA-effective regurgitant orifice area (EROA, r=0.72), and PISA-RV (r=0.67); p&lt;0.001 for all. The PDA was significantly more applicable than VC width (n= 275/290, 95% vs. 218/290, 75% p&lt;0.001) and PISA-based methods (n=191/290, 65% p&lt;0.001). Additionally, PDA showed a stronger intra- and inter-observer agreement compared to the VC, PISA-EROA, and PISA-RV (intra-observer ICC = 0.96 vs. 0.79, 0.87, and 0.82 respectively; inter-observer ICC = 0.96 vs. 0.46, 0.89, and 0.85 respectively). In the in vitro validation, PDA showed a strong linear correlation with regurgitant volumes (r=0.92, p&lt;0.001). Conclusions: We showed the clinical feasibility and in vitro validation of a novel digital quantitative echocardiographic method to assess MR severity. This method is more applicable and has less inter- and intra-observer variability compared to current quantitative methods. Patient follow-up is ongoing to validate the novel methods against clinical endpoints in MR.

Leaflet area as a determinant of tricuspid regurgitation severity in patients with pulmonary hypertension.

Tricuspid regurgitation (TR) is a risk factor for mortality in pulmonary hypertension (PH). TR severity varies among patients with comparable degrees of PH and right ventricular remodeling. The contribution of leaflet adaptation to the pathophysiology of TR has yet to be examined. We hypothesized that tricuspid leaflet area (TLA) is increased in PH, and that the adequacy of this increase relative to right ventricular remodeling determines TR severity. A prospective cohort of 255 patients with PH from pre and postcapillary pathogeneses was assembled from 2 centers. Patients underwent a 3-dimensional echocardiogram focused on the tricuspid apparatus. TLA was measured with the Omni 4D software package. Compared with normal controls, patients with PH had a 2-fold increase in right ventricular volumes, 62% increase in annular area, and 49% increase in TLA. Those with severe TR demonstrated inadequate increase in TLA relative to the closure area, such that the ratio of TLA:closure area <1.78 was highly predictive of severe TR (odds ratio, 68.7; 95% confidence interval, 16.2-292.7). The median vena contracta width was 8.5 mm in the group with small TLA and large closure area as opposed to 4.8 mm in the group with large TLA and large closure area. TLA plays a significant role in determining which patients with PH develop severe functional TR. The ratio of TLA:closure area, reflecting the balance between leaflet adaptation versus annular dilation and tethering forces, is an indicator of TR severity that may identify which patients stand to benefit from leaflet augmentation during tricuspid valve repair.

ASSESSMENT OF MITRAL REGURGITATION THROUGH DOPPLER ECHOCARDIOGRAPHY: FEASIBILITY, PITFALLS AND DIAGNOSTIC ADVANTAGES

Background: Echodoppler quantification of mitral regurgitation (MR) is still controversial, in particular little is known about correlation between quantitative and semi-quantitative methods. Methods and Results: 95 patients (pts) aged 58 +/- 13 years, 56% male, with at least moderate organic MR were enrolled in the period between Oct 2006 and Nov 2014. The etiology of MR was flail of MV leaflet. Regurgitant volume (RV) and effective regurgitant orifice (ERO) quantified by PISA (RV 56 ± 17 mL, ERO 0.32 ± 0.09 cm2), Doppler (RV 58 ± 17 mL, ERO 0.34 ± 0.12 cm2) and Volumetric (RV 48 ± 17 mL, ERO 0.27 ± 0.1 cm2) methods, were similar, particularly by quantitative Doppler and PISA (R2 0.89, p &lt; 0.001). By semiquantitative methods jet area 4C was 9.1 ± 4.4 cm2, jet area/left atrium (LA) area 41 ± 20%, vena contracta (VC) was 5 ± 4.2 mm; pulmonary vein (PV) systolic flow reversal was present in 44% of patients. Only VC width among semiquantitative methods showed a sufficient correlation with RV (R2 0.52, p &lt; 0.001), weaker with ERO (R2 0.46, p &lt; 0.001). Conclusion: MR should be always evaluated by quantitative methods, particularly doppler and PISA RV and ERO, which showed the best correlation. Among semiquantitative methods only VC width represents a good option to RV or ERO evaluation by quantitative methods.

Significant Reduction in Mitral Regurgitation Volume Is the Main Contributor for Increase in Systolic Forward Flow in Patients with Functional Mitral Regurgitation after Transcatheter Aortic Valve Replacement: Hemodynamic Analysis Using Echocardiography.

Reduction in mitral regurgitation (MR) after transcatheter aortic valve replacement (TAVR) has previously been reported. However, the hemodynamic effects of TAVR in patients with MR have not been previously evaluated. We analyzed 571 patients who underwent TAVR from December 2010 to December 2013. We studied 20 patients with moderate or severe preprocedural functional mitral regurgitation (FMR) who also had a follow-up transthoracic echocardiography (TTE) examination between 90 and 360days (median 213days) after TAVR (Significant FMR Group). We also studied age- and gender-matched 20 patients with mild or lesser MR (Nonsignificant MR Group). Left ventricular functional measurements were assessed using echocardiography before and after TAVR. Left ventricular outflow tract stroke volume measurements using pulsed-wave Doppler (SVLVOT ) were calculated as a representative of systolic forward flow, and stroke volume by the Simpson's method (SVSimpson ) was calculated as a parameter of degree of LV contraction. MR grade improved in 22 of 40 patients after TAVR. In both groups, BNP level decreased, left ventricular ejection fraction increased, and SVLVOT increased after TAVR. SVSimpson increased in the Nonsignificant MR Group and remained unchanged in the Significant FMR Group. Vena contracta width of MR (MRVC) decreased in the Significant FMR Group. Using multivariable analysis in the Significant FMR Group, the increase in SVLVOT significantly correlated with the decrease in MRVC (P<0.05). SVLVOT increased significantly after TAVR in patients with FMR. In these patients, increase in SVLVOT after TAVR was associated with decrease in severity of MR.

Abstract 9480: Persistent MR Reduction With Stabilization of LV Remodeling and Following Chronic Polymer-Mesh Device on Infarcted Myocardium in a Chronic Ischemic MR Model

Background: Mitral valve repair with ring annuloplasty for ischemic mitral regurgitation (IMR) is associated with significant recurrent IMR due to continued left ventricular (LV) remodeling as it does not directly address LV and mitral valve tethering. We aimed to assess chronic implantation of novel polymer based mesh device to reduce IMR reduction and reverse LV remodeling. Methods: Five Dorset sheep underwent ligation of second and third circumflex obtuse marginal branches to produce chronic IMR after 8 weeks. Poly-mesh was attached to the infarcted myocardium underlying the papillary muscle with a further 8 weeks follow-up. In addition, chronic IMR was produced in 5 untreated control sheep. IMR severity was assessed by 2D vena contracta width (VCW) and 3D vena contracta area (VCA). LV end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF) by 2D echo and hemodynamic data were also obtained at each baseline, chronic MR, and chronic poly-mesh stages. Results: In all sheep, after poly-mesh attachment, IMR decreased and this reduction persisted over 8 weeks (VCW 0.42±0.09 to 0.08±0.12cm; VCA 0.13±0.08 to 0.05±0.08cmsq, p&lt;0.01) with significant increase in Emax (1.1±0.5 to 2.9±0.7mmHg/ml, p&lt;0.05). There were no significant changes in LVEF (45.4±6.7 vs 42.6±3.5%, p=NS). Importantly, LV EDV and ESV at chronic poly-mesh stage were reduced compared to the chronic MR stage (EDV 110±15 to 88±18ml, p&lt;0.05; ESV 61±14 to 51±12ml, p=NS) and % increases of both EDV and ESV from chronic MR to chronic poly-mesh stage were significantly lower than those of untreated control sheep (%EDV change -22±11 vs 11±10%, p&lt;0.01; %ESV change -10±14 vs 9±10%, p&lt;0.05) (FIGURE). Conclusions: Chronic follow up after polymer-mesh device attachment shows the stabilization of mitral-LV complex in a chronic IMR model, causing persistent reduction of IMR and preventing continued LV remodeling.

Impact of Implantable Transvenous Device Lead Location on Severity of Tricuspid Regurgitation

Implantable device leads can cause tricuspid regurgitation (TR) when they interfere with leaflet motion. The aim of this study was to determine whether lead-leaflet interference is associated with TR severity, independent of other causative factors of functional TR. A total of 100 patients who underwent transthoracic two-dimensional and three-dimensional (3D) echocardiography of the tricuspid valve before and after lead placement were studied. Lead position was classified on 3D echocardiography as leaflet-interfering or noninterfering. TR severity was estimated by vena contracta (VC) width. Logistic regression analysis was used to identify factors associated with postdevice TR, including predevice VC width, right ventricular end-diastolic and end-systolic areas, fractional area change, right atrial size, tricuspid annular diameter, TR gradient, device lead age, and presence or absence of lead interference. Odds ratios were used to describe the association with moderate (VC width ≥ 0.5 cm) or severe (VC width ≥ 0.7 cm) TR, separately, using bivariate and stepwise multivariate logistic regression analysis. Forty-five of 100 patients showed device lead tricuspid valve leaflet interference. The septal leaflet was the most commonly affected (23 patients). On bivariate analysis, preimplantation VC width, right atrial size, tricuspid annular diameter, and lead-leaflet interference were significantly associated with postdevice TR. On multivariate analysis, preimplantation VC width and the presence of an interfering lead were independently associated with postdevice TR. Furthermore, the presence of an interfering lead was the only factor associated with TR worsening, increasing the likelihood of developing moderate or severe TR by 15- and 11-fold, respectively. Lead-leaflet interference as seen on 3D echocardiography is associated with TR after device lead placement, suggesting that 3D echocardiography should be used to assess for lead interference in patients with significant TR.

Imaging Challenges in Secondary Mitral Regurgitation

Chronic secondary mitral regurgitation (SMR) is a complex entity that is often clinically underappreciated.1 It complicates either ischemic heart disease or dilated cardiomyopathy; its prevalence varies among series but may reach ≤50% in patients with heart failure.2 When present, SMR may exhibit a broad range of severity and confers an adverse prognosis, which is worse with increasing severity of mitral regurgitation (MR).3,4 The management of SMR poses a unique set of challenges, based partly on the complexity of the valve disorder and the still-evolving adoption of the optimal therapeutic approach.5 Noninvasive imaging and, in particular, echocardiography, plays a critical role for the initial and longitudinal assessment, for individual risk stratification and outcome prediction, and for guiding intervention in patients with chronic SMR.6 SMR develops because of a combination of mitral leaflet tethering secondary to left ventricular (LV) dilatation/deformation with papillary displacement/discoordination, annular dilatation/dysfunction, insufficient LV-generated closing forces attributable to reduction of LV contractility, and global LV/papillary muscle dyssynchrony.1,5 Tethering of the mitral leaflets is the principal lesion of SMR and results in restriction of systolic leaflet motion, namely type IIIb of Carpentier’s classification. SMR does not typically occur in global LV dysfunction without tethering. However, once tethering occurs, leaflet closure is further impaired by LV dysfunction because there is decreased force opposing tethering.6–9 The key event in the pathogenesis of SMR is the distortion of normal LV geometry—regional and global LV remodeling—with subsequent apical and lateral displacement of papillary muscles, which, in turn, draws the chordae tendineae away from the line of coaptation.7,8 The extent of LV systolic dysfunction and dilatation is weakly correlated to the degree of SMR unless accompanied by geometric distortion in the region of the papillary muscles.1,9 …

Assessment of mitral regurgitation severity by Doppler color flow mapping of the vena contracta in dogs.

BackgroundQuantitative and semiquantitative methods have been proposed for the assessment of MR severity, and though all are associated with limitations. Measurement of vena contracta width (VCW) has been used in clinical practice.ObjectiveTo measure the VCW in dogs with different levels of MR severity.AnimalsTwo hundred and seventy‐nine dogs were classified according to 5 levels of MR severity.MethodsThis was a retrospective study. EROA and regurgitant volume calculated by the PISA method, were measured and indexed to BSA. Descriptive statistics were calculated for VCW and VCW index for all categories of MR severity. Spearman's rank correlation coefficients (ρs) were calculated to compare the results of the different methods (VCW and VCW index vs RV PISA, RV PISA index, EROA, EROA index), and between VCW and VCW index versus MR severity.ResultsAll Spearman's rank correlation coefficients were significant (P < .001). The median values of VCW resulted of 2.9 mm (IQR 3.4–2.5) and of 4.6 mm (IQR 5.4–4.1) in the groups previously classified as mild‐to‐moderate and moderate‐to‐severe, respectively. The median values of VCW index resulted of 4.4 mm/m2 (IQR = 5.5–4.2) in mild‐to‐moderate MR and of 10.8 mm/m2 (IQR = 12.8–9.4) in moderate‐to‐severe MR.Conclusion and Clinical ImportanceThis is not a validation study against any previously validated invasive gold standard, the VCW method has proved easy to employ and it might be an additional tool in quantifying disease severity that supports, rather than replace, data coming from other techniques in daily clinical practice and research.

The change in mitral regurgitation severity after trans-catheter aortic valve implantation

BackgroundMitral regurgitation (MR) is a frequent finding in patients with aortic stenosis (AS). The objective of this study is to assess the change in MR severity following transcatheter aortic valve implantation (TAVI). MethodsMR changes were assessed by comparing transthoracic echocardiography before and after the procedure. ResultsThe prosthetic aortic valve was successfully implanted in 65 patients. The number of patients with pre-procedure MR was reduced from 58 (85.3%) to 43 (63.2%) (p<0.001). Vena contracta width was decreased from 0.47±0.28 to 0.25±0.21, (p=0.043). About 59.4% (19/32) of those who had moderate to severe MR and 85.7% (12/14) of those with severe MR experienced a significant improvement in MR after the procedure (p<0.001). Improvement in MR was independent of prosthetic valve type with 54.2% in CoreValve and 43.9% in Edwards SAPIEN, p=0.424; valve sizes were 25.8±1.9 in those who improved vs. 25.0±1.9mm in those who did not improve, p=0.105; femoral approach was 51.2% and apical approach was 41.7%, p=0.457; MR etiology was 48.1% in organic and 48.6% in functional, p=0.968; and operative risk was 50.0% in EuroScore >20 and 48.6% in EuroScore <20, p=0.356. ConclusionsTAVI is associated with a significant improvement in MR, especially in severe types. The lack of influence of MR improvement by the etiology of MR, the type of valve implanted, and the operative risk need to be confirmed in a larger multi-center study.

Efficacy and durability of central oversewing for treatment of aortic insufficiency in patients with continuous-flow left ventricular assist devices

Aortic insufficiency (AI) in patients supported with continuous-flow left ventricular assist devices (CF-LVAD) results in regurgitant volume returning from the aorta to the left ventricle, increased LVAD pump volume and reduced systemic cardiac output. One common strategy to address AI during CF-LVAD support is central oversewing of the aortic valve, which allows some opening between the valve leaflets laterally. However, the long-term durability of this technique has not been extensively described. All patients who underwent central oversewing of the aortic valve during CF-LVAD support between January 2006 and March 2013 were included in this analysis. Pre- and post-procedure intra-operative transesophageal echocardiograms (TEEs) were reviewed to determine the efficacy of the surgical technique, whereas all subsequent transthoracic echocardiograms (TTEs) were reviewed to assess durability. AI severity was graded using the vena contracta (VC) width and the ratio between the VC and left ventricular outflow tract (LVOT) diameter. Nineteen patients with central aortic valve oversewing were identified. Median follow-up was 560 days (range 46 to 954 days). All but 1 patient had their aortic insufficiency reduced to "none/trace" on post-operative TEE. There was no statistically significant increase in the VC width and VC/LVOT ratio between the first and last follow-up echocardiograms, and only 2 patients developed more than mild aortic insufficiency after central oversewing. Central oversewing of the aortic valve did not adversely affect outcomes after LVAD implantation. Central oversewing of the aortic valve is an effective and durable means of addressing greater than mild AI in patients with CF-LVAD.

(525) - Efficacy and Durability of Central Oversewing for Treatment of Aortic Valve Insufficiency in Patients with Continuous Flow Left Ventricular Assist Devices

(525) - Efficacy and Durability of Central Oversewing for Treatment of Aortic Valve Insufficiency in Patients with Continuous Flow Left Ventricular Assist Devices

Quantitative, noninvasive assessment of patent ductus arteriosus shunt flow by measuring proximal isovelocity surface area on color Doppler imaging.

We evaluated the hemodynamic status of patent ductus arteriosus (PDA) by measuring vena contracta width (VCW) and effective shunt orifice area (ESOA) using proximal isovelocity surface area (PISA) on color Doppler imaging. METHODS AND RESULTS: Study subjects were 21 patients with PDA (mean age, 3.6 years). We measured VCW (mm/m(2)) and ESOA (cm(2)) by the PISA method using echocardiography. Color images were obtained from parasternal long-axis views. VCW (mm/m(2)) was measured at the narrowest region of PDA flow. ESOA by PISA (PDA-ESOA) was defined on color Doppler flow imaging as a hemispheric area of laminar flow with aliased velocities [PDA-ESOA (cm(2))=2π[PDA radius (cm)]^2×aligning velocity (cm/s)/PDA peak velocity (cm/s)]. Upon examining the relationships with catheterization parameters by univariate analysis, VCW correlated with diastolic blood pressure (DBP), % left ventricular end-diastolic volume (%LVEDV), pulmonary blood flow index, pulmonary blood flow/systemic blood flow ratio (Qp/Qs), left-right (LR) shunt ratio, left atrial to aortic root ratio (LA/AO), chest-thoracic ratio and N-terminal pro-brain natriuretic peptide (NTproBNP); and PDA-ESOA correlated with DBP, Qp/Qs, average pulmonary artery pressure, pulmonary/systemic pressure ratio, %LVEDV, LR shunt ratio, LA/AO and NTproBNP. When stepwise multiple linear regression analysis was performed with the correlations that were significant on univariate analysis, significant correlations with Qp/Qs were noted (VCW; R(2)=0.836, β=0.914, P<0.001, PDA-ESOA; R(2)=0.621, β=0.788, P<0.001). Measurement of VCW and PDA-ESOA by the PISA method can noninvasively evaluate the hemodynamic status of PDA.

Development of a Consensus Algorithm to Improve Interobserver Agreement and Accuracy in the Determination of Tricuspid Regurgitation Severity

Multiparametric scoring of valvular regurgitation may compromise interobserver agreement, as readers weight parameters differently. The aims of this study were to quantify interobserver variability in the grading of chronic tricuspid regurgitation (TR), develop an algorithm for grading TR, and assess the effect of this algorithm on concordance and accuracy. On the basis of current guidelines, two experts graded the severity of TR by consensus in 40 patients with a spectrum of TR severity. A subgroup of patients (n = 18) also had TR severity assessed by cardiac magnetic resonance. Sixteen cardiologists independently graded the first 20 cases as severe or nonsevere TR. After group review, a grading algorithm to differentiate severe and nonsevere TR was devised by consensus. The same observers used the algorithm to grade the second set of cases. Baseline differentiation of severe from nonsevere TR showed modest reliability and accuracy compared with an expert read (multirater κ = 0.55; overall agreement, 78%; accuracy, 81%). The consensus algorithm for severe TR was a suggestive color jet and at least one of (1) right atrial area > 18 cm(2) and inferior vena cava diameter > 2.5 cm; (2) vena contracta width > 0.7 cm and jet area > 10 cm(2); (3) a dense, triangular TR Doppler profile; and (4) holosystolic reversal of hepatic vein flow. Application of this algorithm improved the multirater κ coefficient to 0.80, the level of agreement to 90% (P = .033), and mean reader accuracy to 92% (P = .001). Only modest baseline agreement was found between readers on the distinction of severe and nonsevere TR. An objective, structured grading algorithm improved both interrater agreement and accuracy.

Interpapillary muscle distance independently affects severity of functional mitral regurgitation in patients with systolic left ventricular dysfunction

Surgical papillary muscle (PM) imbrication has been reported to be effective to relieve leaflet tethering in patients with functional mitral regurgitation (FMR). However, the mechanism that contributes to improvement of FMR by shortening the interpapillary muscle distance (IPMD) has not been well investigated. The purpose of the present study was to investigate whether IPMD can affect MR severity independently ofPMtethering distance in patients with left ventricular dysfunction (LVD) using multislice computed tomography. We analyzed volumetric multislice computed tomography images of mitral apparatus in 83 patients with LVD (ejection fraction <50%): 37 patients with FMR and 46 patients without FMR. By using the original software, we assessed the 3-dimensional geometry of mitral apparatus including IPMD, tethering distances, andmitral tenting volume at end-systole. The severity of FMR was assessed using vena contracta (VC) width by 2-dimensional echocardiography. Posterior and anterior tethering distance and IPMD were increased significantly in patients with FMR than in those without FMR. Patients with IPMD in the highest tertile had a significantly higher degrees of MR (mean ± standard error VC width, 4.5 ± 0.3 mm) compared with patients in the lowest and the middle tertiles, adjusting for PM tethering distance (mean ± standard error VC width, 3.0 ± 0.4 and 2.9 ± 0.3 mm; P<.001, respectively). Multivariate analysis showed that anteroposterior annular diameter and IPMD were the strongest determinants of FMR severity and mitral tenting volume. IPMD, which affects leaflet tethering independently of PM tethering distance, was the major determinant of mitral tenting volume and FMR severity in patients with LVD.

Utility of cystatin C as a marker for the severity of aortic regurgitation in hypertensive patients

BackgroundCystatin C, a cathepsin inhibitor, is involved in the remodeling of human aortic valve and left ventricle (LV). ObjectiveCystatin C may be related to the severity of aortic regurgitation (AR). MethodsWe measured cystatin C and CRP in hypertensive patients with mild-to-moderate AR (n=120) and in those without AR (n=128). Echocardiography was performed to assess the vena contracta width (the narrowest region of regurgitant jet, VCW) as a marker of the severity of AR, relative wall thickness as a marker of LV concentric remodeling, and the ratio of early peak mitral flow to early diastolic mitral annular velocity (E/e′) as an index of LV diastolic function. Glomerular filtration rate (GFR) was estimated using the MDRD methods. ResultsCystatin C levels were greater in hypertensive patients with AR than in those without AR. A multiple linear regression analysis indicated cystatin C levels correlated with the VCW independent of GFR, body mass index, CRP, relative wall thickness, and E/e′ in hypertensive patients with AR. ConclusionsCystatin C was associated with the severity of regurgitation independent of renal function body composition chronic inflammation LV remodeling and diastolic function in hypertensive patients with mild-to-moderate AR.

A Mathematical Evaluation of Mitral Regurgitation Severity with EROA

It is to be investigated and verified that vena contracta width (VCW) obtained from color Doppler images and effective regurgitant orifice area (EROA) obtained from the VCW is capable of quantifying the severity of mitral regurgitation (MR). A mathematical expression has been developed between VCW and EROA. Vena contracta width is an efficient method for grading the severity of MR, but it is very difficult to locate this narrowest part exactly in transthoracic echocardiography as well as in transesophageal echocardiography. So, indeed, there is a need to develop a method which is capable of finding out the vena contracta width. A comparison has also been made between the results obtained using the proposed computing method and the results obtained by the clinicians, manually. For this analysis have been done from the results obtained with automatic VCW finding method and with clinical data for severity grading.