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The purpose of this study was to evaluate whether the underlying mechanism of mitral regurgitation influences the reliability of the proximal flow con- vergence method to assess the regurgitant volume. Furthermore, the mode of imaging the flow convergence region and different correction algorithms for calculation of the regurgitant volume were compared. Regurgitant volume was assessed in 45 patients (age 61±13 years) with organic (n=19) and functional (n=26) mitral regurgitation by the proximal flow convergence method for aliasing velocities between 14 and 64 cm/s using two-dimensional color Doppler imaging. Different correction and calculation algorithms were compared. In addition, regurgitant volume was determined using color Doppler M-mode for an aliasing velocity of 28 cm/s. The quantitative Doppler method was used as reference. In organic mitral regurgitation correlation coefficients (mean differences) between the proximal flow convergence method and the reference method were 0.25–0.43/ 0.58–0.67 (46–111 ml/15–17 ml) before/after geometric correction of the regurgitant volume for the aliasing velocities investigated. The correlation coefficient (mean difference) using color Doppler M-mode imaging was 0.68 (85 ml). The corresponding values in functional mitral regurgitation were 0.74–0.88/0.74–0.88 (–5–8 ml/–7–5 ml) for two-dimensional color Doppler and 0.88 (–1 ml) for M-mode imaging. The regurgitant volume was overestimated by the proximal flow convergence method in organic mitral regurgitation irrespective of the application of different correction algorithms or the use of color Doppler M-mode. A sufficiently reliable determination of the regurgitant volume by the proximal flow convergence method was possible in functional mitral regurgitation. In that case a simplified calculation of the regurgitant volume based on the proximal flow convergence method was feasible.

Resume L’insuffisance mitrale est secondaire a la perte d’etancheite de la valve mitrale par dysfonctionnement d’un ou plusieurs elements de l’appareil valvulaire mitral. On differencie les insuffisances mitrales aigues, d’installation brutale, des insuffisances mitrales chroniques dont l’evolution est plus progressive. La physiopathologie de l’insuffisance mitrale est complexe. Elle peut etre abordee par l’etude des facteurs influencant le volume regurgite et l’evaluation du retentissement hemodynamique d’aval (etude de la fonction ventriculaire gauche) et d’amont (degre de compliance de l’oreillette gauche et pression pulmonaire). Le volume regurgite est plus important quand la duree de regurgitation est plus longue, la taille de l’orifice regurgitant plus grande et l’amplitude du gradient systolique ventriculo-atrial plus elevee. L’etude de la fonction ventriculaire gauche est difficile, tout particulierement dans les insuffisances mitrales chroniques ou la normalite apparente des indices de fonction ventriculaire gauche peut masquer une alteration significative des capacites contractiles des fibres myocardiques. Enfin, la difference de compliance atriale gauche dans la regurgitation aigue et chronique explique, a volumes regurgites identiques, certaines differences hemodynamiques. Avec l’augmentation de l’esperance de vie et la diminution d’incidence du rhumatisme articulaire aigu, les etiologies des insuffisances mitrales ont evolue sur les 30 dernieres annees. Elles sont maintenant dominees par les insuffisances mitrales dystrophiques, et par l’endocardite infectieuse alors que les atteintes rhumatismales sont devenues plus rares.

Aortic valve replacement for isolated aortic regurgitation (AR) is usually not indicated unless the regurgitation is severe. However, not all patients with severe AR require aortic valve replacement. This review focuses on the causes of AR and the pathophysiology of acute versus chronic AR, and the attendant adaptive mechanisms of the left ventricle that ultimately determine their different natural histories. Aortic valve surgery must be performed in a timely manner to prevent cardiac death, ameliorate symptoms, and limit late postoperative excess mortality.

Volumetric quantification of regurgitant volume in asymptomatic severe degenerative mitral regurgitation by echocardiography and cardiac mri with independent validation of forward stroke volume by positron emission tomography

The natural history of chronic aortic regurgitation (AR) is characterized by a series of left ventricular (LV) compensatory mechanisms. Initially, the regurgitant volume is accommodated by increases in LV end-diastolic volume and compliance and associated LV hypertrophy. However, the concomitant

The emerging role of stress and particularly exercise echocardiography in secondary mitral regurgitation (SMR) has been recently emphasized. In fact, the evaluation of SMR only under resting conditions might underestimate the full impact of the lesion and its clinical effects.

Many hypotheses regarding the mechanism of secondary mitral regurgitation (SMR) have been made from 2D echocardiographic observations. Some have been confirmed and further developed with the help of 3D echocardiography (Otsuji et al., Circulation 96:1999–2008; Otsuji et al., J Am Coll Cardiol 37:641–8, 2001). 3D echocardiography, and especially 3D transesophageal echocardiography (TEE), has much to offer in the evaluation of SMR, in addition to 2D echocardiography. First, it offers important information regarding MV geometry, giving insights into the mechanisms involved in the genesis of SMR in each patient. Second, it can improve the accuracy of MR quantification (Chandra et al., Am J Physiol Heart Circ Physiol 301:H1015–24, 2011; Hyodo et al., J Am Coll Cardiol Img 5:669–76, 2012). Third, it can play an important role in the planning of surgery or percutaneous intervention.

We aimed to validate a new flow convergence (FC) method that eliminated the need to locate the regurgitant orifice and that could be performed semiautomatedly.Complex and time-consuming features of previously validated color Doppler methods for determining mitral regurgitant volume (MRV) have prevented their widespread clinical use.Thirty-nine different hemodynamic conditions in 12 sheep with surgically created flail leaflets inducing chronic mitral regurgitation were studied with two-dimensional (2D) echocardiography. Color Doppler M-mode images along the centerline of the accelerating flow towards the mitral regurgitation orifice were obtained. The distance between the two first aliasing boundaries (interaliasing distance [IAD]) was measured and the FC radius was mathematically derived according to the continuity equation (R(calc) = IAD/(1 - radicalv(1)/v(2)), v(1) and v(2) being the aliasing velocities). The conventional 2D FC radius was also measured (R(meas)). Mitral regurgitant volume was then calculated according to the FC method using both R(calc) and R(meas). Aortic and mitral electromagnetic (EM) flow probes and meters were balanced against each other to determine the reference standard MRV.Mitral regurgitant volume calculated from R(calc) and R(meas) correlated well with EM-MRV (y = 0.83x + 5.17, r = 0.90 and y = 1.04x + 0.91, r = 0.91, respectively, p0.001 for both). However, both methods resulted in slight overestimation of EM-MRV (Delta was 3.3 +/- 2.1 ml for R(calc) and 1.3 +/- 2.3 ml for R(meas)).Good correlation was observed between MRV derived from R(calc) (IAD method) and EM-MRV, similar to that observed with R(meas) (conventional FC method) and EM-MRV. The R(calc) using the IAD method has an advantage over conventional R(meas) in that it does not require spatial localization of the regurgitant orifice and can be performed semiautomatedly.

The analysis software for three-dimensional (3D) echocardiographic data developed at the German Cancer Research Center (DKFZ) is described in this paper. The system includes functions for two- and three-dimensional visualization of the morphology and/or the Doppler information and quantification of cavity volumes, ejection fraction, cardiac output and regurgitant volume. The design and functionality of the system are discussed. After successful completion of the internal tests, the software will be available for multicenter evaluation.

The authors measured the aortic regurgitant orifice area (ROA) using Doppler echocar diography and attempted to clarify how important the ROA is in determining the regur gitant volume (RV) in 22 patients with chronic aortic regurgitation (AR). The RV was calculated from the difference between the left ventricular ejection flow volume and transmitral inflow volume as measured by Doppler echocardiography. The ROA was obtained by two methods: RV/time velocity integral of AR jet measured by continuous wave Doppler (calculation method) and manual tracing of minimum cross-sectional area of short-axis color Doppler. The RV ranged from 10 to 90 mL/beat and the ROA by calculation method was from 0.05 to 0.35 cm2, which showed a strong correlation ( r = 0.93, p < 0.001). The time velocity integral of aortic regurgitant jet showed a poor correlation with the RV (r = 0.45, p < 0.05). The values of ROA by the two methods showed a good correlation ( r = 0.93, p < 0.001). Thus, the authors conclude that the ROA is a basic determinant of the RV in AR and that color Doppler can be employed to precisely assess the ROA.

Background Quantitative Doppler echocardiography and proximal flow convergence methods are validated techniques for quantifying mitral regurgitation. However, the clinical interpretation of the values calculated is hindered by the absence of calibration of ranges of severity in large numbers of patients. Methods and Results In 180 consecutive patients (men, 62%; mean age±SD, 66±11 years), the results of Doppler quantification of isolated mitral regurgitation were calibrated by use of left ventricular angiographic grading performed within 3 months in routine practice and without intervening events. The thresholds of the quantitative variables corresponding to the angiographic grades were identified by maximizing the sum of sensitivity and specificity and minimizing their difference. The mitral regurgitation grade by angiography was 2.7±1.3. The mean value and correlation with angiographic grades for effective regurgitant orifice were 43±37 mm and r =.79 ( P r =.80 ( P r =.78 ( P P 2 for regurgitant volume, regurgitant fraction, and orifice, respectively. Conclusions In routine practice in large numbers of patients in a clinical laboratory, Doppler echocardiographic quantification of mitral regurgitation shows highly significant correlation with qualitative angiographic grades. Despite an expected overlap between classes, the calibration by angiography of grading ranges for the quantitative variables provides a framework for their interpretation and allows the definition in clinical practice of thresholds for severe mitral regurgitation.

Although several methods have been used clinically to evaluate the severity of aortic regurgitation, there is no purely quantitative approach for aortic regurgitant volume (ARV) measurements. Magnetic resonance phase velocity mapping can be used to quantify the ARV, with a single imaging slice in the ascending aorta, from through-slice velocity measurements. To investigate the accuracy of this technique, in vitro experiments were performed with a compliant model of the ascending aorta. Our goals were to study the effects of slice location on the reliability of the ARV measurements and to determine the location that provides the most accurate results. It was found that when the slice was placed between the aortic valve and the coronary ostia, the measurements were most accurate. Beyond the coronary ostia, aortic compliance and coronary flow negatively affected the accuracy of the measurements, introducing significant errors. This study shows that slice location is important in quantifying the ARV accurately. The higher accuracy achieved with the slice placed between the aortic valve and the coronary ostia suggests that this slice location should be considered and thoroughly examined as the preferred measurement site clinically.

The accurate quantification of mitral regurgitation (MR) using 2D imaging tools is difficult due to its structural complexity; however, it is crucially important in clinical medicine as MR severity has prognostic consequences. Novel 3-dimensional (3D) echocardiography and 3-dimensional (3D) color Doppler methods can provide quantitative and qualitative classification of MR including measurement of the vena contracta area, regurgitant volume, regurgitant fraction, and effective regurgitant orifice area (EROA). Nevertheless, with so many conventional and developing techniques it can be difficult to decide which technique to use for selected patients. We suggest using an approach that is focused not only on the techniques and measurements but also combines imaging portability, availability, clinical efficiency, and accurate and reproducible assessments. In this review we discuss the established and emerging applications of 3D color Doppler for the quantification of MR severity.

To evaluate the impact of mitral regurgitation (MR) etiology on the accuracy of the proximal isovelocity surface area (PISA) method, we compared PISA method with conventional volumetric method in 176 patients with degenerative MR (prolapse or flail, group A) and 126 with functional MR (group B).

Quantification of mitral regurgitation (MR) by echocardiography is well established using several echo or Doppler parameters in which effective regurgitation office area (ERO) and regurgitant volume (RV) are the most commonly used. However, hemispheric assumptions allowing application of proximal isovelocity area (PISA) may be erroneous due to complex mitral valve morphology (i.e. mitral valve prolapse). We hypothesized that 3D left ventricular echocardiography associated with pulse Doppler could obtain RV with high reliability for comparison of 2 methods (3D vs PISA) in presence of mitral regurgitation. Methods: First, in 50 patients without MR, we compared LV ejection volumes (LVEj) from a full volume 3D echocardiographic acquisition and 2D Simpson method to the aortic stroke volume (ASV) obtained by Pulsed Doppler for validation of the 3D approach. Second, we analyzed 50 patients with different degree MR for comparison of the two approaches and verification of PISA RV values. Inter and intra observer variabilities were assessed for all techniques. Results: Correlations and Bland&Altman methods gave high adequacy between 3D LVEj and ASV compared to 2D and ASV (respectively 3D, r=0.96, y=0.91x+4.8, mean error (ME) and 95% confidence interval of error (CIE) [−0.84±6 ml] and 2D, r=0.81, y=0.78x+5.8, [−5.41±16 ml]. Variabilities average for 3D LVEj was 6±3% and 15+/-5% for 2D. In patients with mitral regurgitation, RV from PISA and 3D LVEj were 23.1±12 ml and 24.5±11 ml (p=0.37) and the fractional regurgitation 32±13% and 33±12% (p=0.63). However, mean error measurement was −1.37 ml and 95% confidence interval of error was 17.90 ml showing high discrepancy between the two methods. By selecting a cut-off of 5, 10, 15 ml, numbers of patients with uncorrected measurements was 48.5, 17 and 8.5%. When using ASE 4 grades classification, 25,7% of misclassified patients was obtained with PISA. Conclusion: 3D LVEj method is robust and reliable for calculation of mitral regurgitant volumes with significant differences compared than those obtained with PISA which seems to be less adequate for all types of MR.

A method for quantifying mitral and tricuspid regurgitant volume that utilizes a measure of jet orifice velocity U(0) - m/sec), a distal centerline velocity (U(m) - m/sec), and the intervening distance (X - cm) was recently developed; where jet flow rate (Q(cal) - L/min) is calculated as Q(cal) = (U(m)X)(2)/(26.46U(o)). This method, however, modeled the regurgitant jet as a free jet, whereas many atrial jets are counterflowing jets because of jet opposing intra-atrial flow fields (counterflows). This study concentrated on the feasibility of using the free jet quantification equation in the atrium where ambient flow fields may alter jet centerline velocities and reduce the accuracy of jet flow rate calculations. A 4-cm wide chamber was used to pump counterflows of 0, 4, and 22 cm/sec against jets of 2.3, 4.8, and 6.4 m/sec originating from a 2-mm diameter orifice. For each counterflow-jet combination, jet centerline velocities were measured using laser Doppler anemometry. For free jets (no counterflow), flow rate was calculated with 98% mean accuracy. For all jets in counterflow, the calculation was less accurate as: (i) the ratio of jet orifice velocity to counterflow velocity decreased (U(o)/U(c), where U(c) is counterflow velocity), i.e., the counterflow was relatively more intense, and (ii) centerline measurements were made further from the orifice. But although counterflow lowered jet centerline velocities beneath free jet values, it did so only significantly in the jet's distal portion (X/D16, i.e.,16 orifice diameters from the origin of the jet). Thus, the initial portion (X/D16) of a jet in counterflow behaved essentially as a free jet. As a result, even in significant counterflow, jet flow rate was calculated with93% accuracy and85% for jets typical of mitral and tricuspid regurgitation, respectively. Counterflow lowers jet centerline velocities beneath equivalent free jet values. This effect, however, is most significant in the distal portion of the jet. Therefore, regurgitant jets, although not classically free because of systolic atrial inflow or jet-induced intra-atrial swirling flows, will decay in their initial portions as free jets and thus are candidates for quantification with the centerline technique. (ECHOCARDIOGRAPHY, Volume 13, July 1996)

Guidelines suggest that flail leaflet and Coanda are specific signs for severe mitral regurgitation. MRI is an accurate method for determining mitral regurgitant volume (RV) and regurgitant fraction (RF). The objective of this study is to determine the association of flail or Coanda with RV and RF

Background The two-dimensional (2D) proximal isovelocity surface area (PISA) method has some technical limitations, mainly the geometric assumptions of PISA shape required to calculate effective regurgitant orifice area (EROA). Recently developed single-beat, real-time three-dimensional (3D) color Doppler imaging allows direct measurement of PISA without geometric assumptions. The aim of this study was to validate this novel method in patients with chronic mitral regurgitation (MR). Methods Thirty-three patients were included, 25 (75.7%) with degenerative MR and eight (24.2%) with functional MR. EROA and regurgitant volume were assessed using transthoracic 2D and 3D PISA methods. The quantitative Doppler method and 3D transesophageal echocardiographic planimetry of EROA were used as reference methods. Results Both EROA and regurgitant volume assessed using the 3D PISA method had better correlations with the reference methods than conventional 2D PISA. A consistent significant underestimation of EROA and regurgitant volume using 2D PISA was observed, particularly in the assessment of eccentric jets. On the basis of 3D transesophageal echocardiographic planimetry of EROA, 14 patients had severe MR (EROA ≥ 0.4 cm 2 ). Of these 14 patients, 42.8% (6 of 14) were underestimated as having nonsevere MR (EROA ≤ 0.4 cm 2 ) by the 2D PISA method. In contrast, the 3D PISA method had 92.9% (13 of 14) agreement with 3D transesophageal planimetry in classifying severe MR. Good intraobserver and interobserver agreement for 3D PISA measurements was observed, with intraclass correlation coefficients of 0.96 and 0.92, respectively. Conclusions Direct measurement of PISA without geometric assumptions using single-beat, real-time 3D color Doppler echocardiography is feasible in the clinical setting. MR quantification using this methodology is more accurate than the conventional 2D PISA method.

Quantitative assessment of the severity of mitral regurgitation (MR) is based on the calculation of the effective regurgitant orifice (ERO), a measure of lesion severity, and of the regurgitant volume (RVol), a measure of left ventricular volume overload. We aimed at evaluating the determinants of RVol in both organic (OMR) and functional mitral regurgitation (FMR).MR severity was quantitatively assessed using the proximal isovelocity surface area (PISA) method in 240 patients, 142 with OMR and 98 patients with FMR. By definition, ERO and RVol were strongly correlated both in patients with OMR and FMR (both R = 0.90, P0.0001) but the slopes of the regression lines were significantly different (P0.0001). This difference remained significant in patients with elevated systolic pulmonary artery pressure (SPAP40 mmHg, P0.0001) but not in patients with normal SPAP (≤40 mmHg, P = 0.09). In multivariate analysis, independent determinants of RVol were ERO (P0.0001), MR mechanism (FMR/OMR) (P = 0.0003) and SPAP (P = 0.03). In patients with elevated SPAP, ERO (P0.0001), left ventricular ejection fraction (LVEF) (P = 0.03), and MR mechanism (P = 0.03) were independently associated with RVol, whereas in patients with normal SPAP, ERO (P0.0001) was the only independent determinant of RVol.In the present study, we evaluated the contrasting effect of similar lesion severity in OMR and FMR and showed that similar ERO were associated with lower RVol in FMR compared with OMR. The regurgitant volume is the result of complex interactions of anatomic lesions, LVEF, and SPAP and our results highlight the importance of taking into account these parameters when interpreting RVol values in clinical practice, especially in FMR.

To assess the utility of holodiastolic flow reversal (HDR) in the descending aorta on velocity-encoded cardiac magnetic resonance (MR) images in the stratification of aortic regurgitation (AR) severity.This study was approved by the institutional review board, with waiver of informed consent. A total of 80 patients (overall mean age, 49 years ± 18 [standard deviation]; 22 women and 58 men) with clinical indication for cardiac MR imaging of the aorta were analyzed retrospectively. Velocity-encoded MR imaging was used to quantify AR and assess for HDR at the level of the middescending aorta. These indexes were compared with a qualitative integrated echocardiographic evaluation of AR severity. Sensitivity and specificity for HDR in the prediction of substantial AR were determined, and logistic regression analysis (with associated odds ratios and C statistics) was performed, with HDR and regurgitant fraction as independent predictors. An additional 42 patients (overall mean age, 48 years ± 21; 12 female and 30 male) were then prospectively evaluated in similar fashion to evaluate a decision model derived from analysis of the first group.HDR predicted severe AR (echo grade, 4) with high sensitivity (100%) and specificity (93%). HDR was highly specific (100%) but had lower sensitivity (61%) for moderate to severe AR (echo grade, 3-4). Integration of HDR and direct AR quantification into a combined stratification model based on analysis of the primary group showed good predictive results in the validation group, with a C statistic of 0.94 for moderate to severe AR and 0.93 for severe AR.HDR in the middescending thoracic aorta observed at cardiac MR is indicative of severe AR and can be used in conjunction with quantified regurgitant values obtained from velocity-encoded MR imaging to stratify AR severity.

Many echocardiographic signs of severe MR are clearly demonstrated, particularly when both TEE and TTE are used. When these signs are assiduously sought, the recognition of severe MR should pose little problem. Part of the confusion concerning MR and the grading of its severity comes from the fact that the hemodynamic consequences of a given degree of MR vary widely from one individual to another. A regurgitant volume of 50 mL might prove incapacitating to one patient while seeming inconsequential in a second patient. A regurgitant fraction of 50% is poorly tolerated in some patients and asymptomatic in others. Similarly, a regurgitant orifice 0.5 cm2 has unpredictable consequences to the organism, and, in fact, this orifice may vary considerably in size depending on hemodynamic conditions. Thus, a universal definition of the severity of MR is lacking, and there is no agreement on the units with which to quantitate it. The net effect of this confusion is not an inability to recognize severe MR but frustration in differentiating moderate MR from severe MR. We believe that precise quantitation of MR will occur when comprehensive pharmacologic interventions with either TEE or surface echocardiographic monitoring are performed to define the severity of MR by its range of responses to these agents. We have had some success with Doppler measurement of the response of pulmonary artery pressure to dynamic exercise. Patients with normal pulmonary artery pressure at rest tend to show exaggerated rises in pulmonary pressure when MR is clinically important and has resulted in left ventricular dysfunction. Anticipated progress notwithstanding, competently performed TEE is the method of choice for recognizing severe MR.

An in vitro technique using color flow imaging and continuous wave Doppler was developed to measure the initial regurgitant flow jet diameter and velocity integral to yield the parameters for a volume calculation. Jets were produced by volume-controlled injection through tubes of various diameters (1.3, 1.9, 2.8, and 3.5 mm) to deliver volumes from 1 to 7 ml over 100 to 300 msec at pressures from 40 to 200 mm Hg. One hundred forty-five samples were obtained. Flow jet diameter consistently overestimated tube diameter by 2 mm when injected volume was 1.5 to 7 ml and by 1.5 mm when injected volume was less than 1.5 ml. This offset was stable with various transducers (2.5, 3.5, 5.0 MHz) at normal gain setting (just under noise). Therefore, corrected flow jet diameter (FJD) = FJD - 2 mm, and Doppler volume = corrected flow jet area x velocity integral. A range of injectates from 1.1 to 7 ml generated Doppler volume of 1.0 to 8.2 ml. The relation between Doppler volume (DV) and injected volume (IV) was DV = 1.079 IV - 0.22, r2 = 0.945, p less than 0.01. This relation was not altered by tube diameter. Thus a method combining color flow imaging and continuous wave Doppler provides a reliable and accurate measure of in vitro flow volume.

UNLABELLED The aim of study was to determine the significance of the best echocardiographic parameters for assessing the severity of mitral regurgitation (MR). METHODS The study population consisted of 107 patients, mean age 52 +/- 7 y with chronic isolated non-ischaemic MR. Quantification of the MR was performed using echocardiography through the proximal isovelocity surface area method (regurgitant volume (RV) and the effective regurgitant orifice (ERO) were calculated) and the assessment of vena contracta width (VCW). RESULTS The ROC curve analysis and Peto odds used to differentiate between the significant (III-IV grade) and non-significant (I-II grade) MR groups of patients indicated thatVCW, RV and ERO were the most powerful predictors of MR.The area under the ROC curve was 0.931, 0.944, 0.927, respectively.The cut-off values defining significant MR were: VCW > or =7 mm, RV > or =45 ml, ERO > or = 0.33 cm2. CONCLUSIONS The most powerful predictors of severe MR are VCW, ERO and RV.

A method for noninvasive estimation of regurgitant orifice and volume in aortic regurgitation is proposed and tested in anaesthesized open chested pigs. The method can be used with noninvasive measurement of regurgitant jet velocity with continuous wave ultrasound Doppler measurements together with cuff measurements of systolic and diastolic systemic pressure in the arm. These measurements are then used for parameter estimation in a Windkessel-like model which include the regurgitant orifice as a parameter. The aortic volume compliance and the peripheral resistance are also included as parameters and estimated in the same process. For the test of the method, invasive measurements in the open chest pigs are used. Electromagnetic flow measurements in the ascending aorta and pulmonary artery are used for control, and a correlation between regurgitant volume obtained from parameter estimation and electromagnetic flow measurements of 0.95 over a range from 2.1 to 17.8 mL is obtained.

The aim of our study was to determine whether planimetry of the anatomic regurgitant orifice (ARO) in patients with aortic regurgitation (AR) by magnetic resonance imaging (MRI) is feasible and whether ARO by MRI correlates with the severity of AR.Planimetry of ARO by MRI was performed on a clinical magnetic resonance system (1.5 T Sonata, Siemens Medical Solutions) in 45 patients and correlated with the regurgitant fraction (RgF) and regurgitant volume (RgV) determined by MRI phase velocity mapping (PVM; MRI-RgF, MRI-RgV, n = 45) and with invasively quantified AR by supravalvular aortography (n = 32) and RgF upon cardiac catheterisation (CATH-RgF, n = 15). Determination of ARO was possible in 98% (44/45) of the patients with adequate image quality. MRI-RgF and CATH-RgF were modestly correlated (n = 15, r = 0.71, p0.01). ARO was closely correlated with MRI-RgF (n = 44, r = 0.88, p0.001) and was modestly correlated with CATH-RgF (n = 14, r = 0.66, p = 0.01). Sensitivity and specificity of ARO to detect moderately severe and severe aortic regurgitation (defined as MRI-RgFor =40%) were 96% and 95% at a threshold of 0.28 cm2 (AUC = 0.99). Of note, sensitivity and specificity of ARO to detect moderately severe and severe AR at catheterisation (defined as CATH-RgFor =40% or supravalvular aortographyor =3+) were 90% and 91% at a similar threshold of 0.28 cm2 (AUC = 0.95). Lastly, sensitivity and specificity of ARO to detect severe aortic regurgitation (defined as MRI-RgFor =50% and/or regurgitant volumeor =60 ml) were 83% and 97% at a threshold of 0.48 cm2 (AUC = 0.97).Visualisation and planimetry of the ARO in patients with AR are feasible by MRI. There is a strong correlation of ARO with RgV and RgF assessed by PVM and with invasively graded AR at catheterisation. Therefore, determination of ARO by MRI is a new non-invasive measure for assessing the severity of AR.

To investigate and verify that real-time 3-dimensional (RT-3D) color Doppler is capable of quantifying the eccentric miral regurgitation (MR) by computing regurgitant volume (RV). 34 patients (mean age 37.13 plusmn 18.28 years) with confirmed eccentric MR were undergone RT-3D echocardiography. By the spatial and temporal integration of the cross-sectional velocity distribution of regurgitant valve, the systolic RV can be evaluated. Then RV were applied to assessing the severity of eccentric MR and compared with the jet volume (JV) and the vena contracta width (VCW) immediately measured. In 34 patients, 2 patients were graded as mild, 16 patients as moderate, and 16 patients as severe. Our RV measurements have good correlation with JV(r=0.9453) and VCW(r=0.8829) respectively. RT-3D color Doppler echocardiography was capable of quantifying the RV of the eccentric MR.

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 < 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 < 0.001), weaker with ERO (R2 0.46, p < 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.

Background Indirect quantification of mitral regurgitation (MR) by cardiovascular magnetic resonance (CMR), currently used as a second-line diagnostic tool after echocardiography, can be achieved by three methods. Each method has its advantages and disadvantages due to the limitations of the underlying techniques used to determine ventricular volumes and/or flow information. The aim of the study was to compare all three indirect CMR methods to determine their agreement in grading MR severity. Methods This prospective study comprised 29 patients (mean age 60 ± 11 (standard deviation (SD)), 97% males) with severe chronic MR who underwent an echocardiographic and CMR exam prior to surgery. Steady-state free precession sequences were used to obtain a short-axis data set to evaluate left and right ventricular stroke volumes (LV/ RVSV) and phase-contrast velocity sequences were applied to obtain aortic forward flow (AoFF) and mitral inflow (MiIF). The mitral regurgitant volume (MRV) was determined by the ‘standard’ (MRV = LVSV - AoFF), ‘volumetric’ (can only be used in the absence of multivalvular disease and intra-cardiac shunt; MRV = LVSV RVSV) and ‘flow’ method (MRV = MiIF - AoFF). The mitral regurgitant fraction (MRF) was calculated as follows: MRV/LVSV x 100% (‘standard’/‘volumetric’ method) or MRV/MiIF x 100% (‘flow’ method). Agreement between the techniques was evaluated using the Bland-Altman method.

Objective We sought to describe our initial experience with real-time 3-dimensional echocardiographic (RT3DE) imaging of atrioventricular valve (AVV) anomalies in pediatric patients to resolve a specific morphologic or dynamic detail, which, although suggested, could not be well resolved during the conventional 2-dimensional (2D)/Doppler examination. Methods In all, 41 patients (age range 1 day-24 years) with different AVV anomalies underwent RT3DE as part of their comprehensive echocardiographic assessment. Matrix-array transducers with a frequency range of 1 to 4 MHz were used. The first 27 patients were not consecutive, and the RT3DE findings interpreted by one examiner were compared directly with the 2D findings interpreted by a different examiner. In the following consecutive 14 patients, the RT3DE findings were compared with the surgical findings and with the interpretations of their corresponding 2D examinations by 3 examiners who were blinded to the findings of RT3DE for more objective comparison. Results RT3DE imaging was successful in resolving the raised question in all patients. The morphology of the valve leaflets and their chordal attachments, the mechanism and origin of regurgitation, and the geometry of the regurgitant volume were well delineated by RT3DE imaging. In the second group of patients, there was agreement between the morphologic details delineated by RT3DE (a total of 21 specific questions raised) and the surgical findings in those patients who had immediate surgery. On the other hand, RT3DE showed prominent AVV chordal attachments in the left ventricular outflow tract in one patient, which was not considered surgically relevant during the repair. Conclusions Although RT3DE is still in its initial phase, has some technical limitations, and does not change the basic diagnosis made by 2D imaging, echocardiographic examination using the matrix-array transducer is a useful adjunct in delineating specific morphologic and dynamic details of the AVV in congenital heart disease.

Intraoperative transesophageal echocardiography may underestimate ischemic mitral regurgitation (MR) as a result of the unloading effect of general anesthesia on the left ventricle (LV). An intraoperative loading test could prove useful to avoid underestimation of ischemic MR.We prospectively studied 30 patients with ischemic MR referred for coronary artery bypass, mitral valve surgery, or both. Transthoracic echocardiography was performed 1.6 +/- 1.6 days preoperatively, and intraoperative transesophageal echocardiography after induction of general anesthesia before and after LV loading. Preload was adjusted using fluids (if pulmonary occlusion pressure15 mm Hg), and the afterload increased using intravenous phenylephrine aiming at systolic blood pressure of 160 mm Hg. MR severity was estimated using color Doppler, pulmonary venous flow, and the proximal isovelocity surface area method.Preoperative median MR grade was 2 (interquartile range 1-3), effective regurgitant orifice area was 0.16 +/- 0.17 cm2, and regurgitant volume was 23 +/- 23 mL. Intraoperative MR grade decreased to 1.5 (1-2.25), effective regurgitant orifice area to 0.13 +/- 0.16 cm2, and regurgitant volume to 21 +/- 26 mL (P = .02, P = .06, and P = .18). After LV loading, MR grade increased to 3 (1-4), effective regurgitant orifice area to 0.21 +/- 0.24 cm2, and regurgitant volume to 39 +/- 38 mL (Por = .005). All patients with preoperative +3 MR or greater had +3 MR or greater after loading whereas most patients with +1 MR had +1 MR. Of the 11 patients with preoperative +2 MR, 6 had +3 and 2 had +4 MR.A quantitative loading test with fluids and phenylephrine is useful to avoid underestimation of ischemic MR by intraoperative transesophageal echocardiography, and may detect significant MR in some patients who had unloaded LVs and nonsignificant MR during their preoperative assessment.

Color Doppler echocardiographic evaluation of valve regurgitation could be improved using a quantitative approach. While techniques have been proposed and utilized in research, their limitations restrict widespread clinical utilization. We have developed an approach to address several of these limitations and have tested the methodology in an in vitro model with flow through restrictive orifices under a wide range of operating conditions. Doppler images of flow velocities along the centerline path through the orifice were digitally acquired and processed to extract the distance (IAD) between aliasing boundaries proximal to the orifice. Flow rate and effective orifice area were computed from each IAD and compared to reference measurements. Calculated e (y=1.07x-22.8, r=0.97) and EOA (y=1.09x-0.03, r=0.98) demonstrated strong agreement with reference measurements. The IAD technique may improve the estimation of regurgitant volume and effective orifice area.

BACKGROUND Total stroke work (TSW) is used for the estimation of cardiac efficiency in mitral regurgitation (MR). We should be cautious about the interpretation of this parameter, especially when it is assessed by non-invasive methods such as echocardiography. METHODS AND RESULTS For the calculation of regurgitant stroke work, regurgitant volume is usually multiplied by left atrial (LA) pressure. However, by considering the left ventricular (LV) pressure-volume loop, it would be more appropriate to multiply regurgitant volume and the LV pressure, not the atrial one. CONCLUSIONS We might underestimate TSW when we use LA pressure for the estimation of regurgitant stroke work.

A new procedure for 3D reconstruction of color Doppler flow signals and for segmentation of regurgitant jets has been developed at our institution. We studied 55 patients with mitral regurgitation who underwent transesophageal echocardiography (TEE). A new parameter, the volume of regurgitant jets (JV), obtained by an automated procedure for segmenting the turbulent portions of the jets, has been compared to the jet area (JA), measured by conventional color Doppler. Mitral regurgitation was assessed by angiography; regurgitant volume (RV) was measured by pulsed Doppler. Jet areas did not show any correlation to angiography or to RV. Jet volumes showed significant correlations to RV(r=0.90; p

BACKGROUND: Although 2D-transthoracic echocardiography (TTE) proximal isovelocity surface area (PISA) is the first-line method to quantify mitral regurgitation (MR), recent studies have shown poor agreement with phase contrast velocity mapping by cardiac magnetic resonance (CMR), which is increasingly accepted as an accurate method to assess regurgitant volume (RV). Angle correction for wall constraint when using the PISA method is recommanded in eccentric jets but its added value in the assessment of MR severity has not been compared to CMR-derived data yet. METHODS AND RESULTS: A total of 47 patients (78% male, age 58 12 years) with at least moderate degenerative MR who underwent CMR and 2D TTE prior to mitral valve repair were included in this study. Effective regurgitant orifice (ERO) and RV by the PISA method with and without correction for wall constraint angle were calculated from TTE exams and compared to RV obtained from phase contrast velocity mapping CMR. Severe MR (RV 60ml) was present in 32 patients according to uncorrected PISA, as compared to 17 according to CMR (p1⁄4 0,004). Angle correction was needed in 40 patients. Mean RV at CMR was 63 30 ml, compared to 76 32ml at uncorrected PISA (p

The objective of this study was to determine the effect of oral losartan on the degree of mitral regurgitation (MR). The regurgitant volume and effective regurgitant orifice were quantified using 3 methods (flow convergence, quantitative Doppler, and quantitative 2-dimensional echocardiography) in 32 patients (26 men, mean age 67 +/- 14 years) with MR, both at baseline and 4 hours after losartan (50 mg orally). Twenty-eight patients were also reevaluated after 1 month of continued treatment with losartan (50 mg/day). With treatment, systolic blood pressure decreased from 143 +/- 16 to 130 +/- 18 mm Hg and left ventricular end-systolic wall stress from 173 +/- 46 to 156 +/- 44 g/cm2 (both p0.001). With treatment, regurgitant volume decreased (from 77 +/- 28 to 64 +/- 26 ml, - 18 +/- 10%; p0.001) in direct relation to the effective regurgitant orifice change (from 43 +/- 16 to 37 +/- 15 mm2, -17 +/- 10%; p0.001) but without significant change in regurgitant gradient or duration. Wide individual variability in response was observed unrelated to the magnitude of blood pressure changes. Larger reduction in regurgitant volume was observed in patients with a marked decrease in wall stress (r = 0.47, p = 0.01) and higher baseline end-diastolic volume index (r = -0.38, p = 0.03) and regurgitant volume (r = -0.45, p = 0.01). Acute improvements were sustained and unchanged at 1 month (all p0.15). Treatment of MR using the angiotensin receptor antagonist losartan produces a significant and sustained decrease in the degree of MR, with decreases in regurgitant volume and effective regurgitant orifice. However, the changes are of modest and variable magnitude.

Two-dimensional echocardiography and color Doppler are useful in the qualitative assessment of aortic regurgitation. However, color Doppler planar methods are not accurate in quantifying regurgitant flow, in part because of the complex geometry of aortic regurgitant flow events. Three-dimensional echocardiographic reconstruction is a new technique that provides dynamic 3-dimensional images of intracardiac color flow jets. We sought to determine whether the measurement of aortic regurgitant jet volume by 3-dimensional echocardiography correlated with the true regurgitant volume, measured by electromagnetic flowmeter in vivo, to accurately reflect the severity of aortic regurgitation. We performed volume-rendered 3-dimensional echocardiography in 6 sheep with surgically induced chronic eccentric aortic regurgitation. We obtained a total of 22 aortic regurgitation states by altering loading conditions. Instantaneous regurgitant flow rates were obtained by aortic and pulmonary electromagnetic flowmeters. The maximum aortic regurgitant jet volume by 3-dimensional echocardiography and the maximum jet area by 2-dimensional echocardiography were measured and compared with electromagnetic flowmeter data. By electromagnetic flowmeter, aortic regurgitant flow rate varied from 0.14 to 3.1 L/min (mean 1. 25 +/- 0.78); aortic regurgitant stroke volume varied from 1 to 34 mL/beat (mean 12 +/- 8), and regurgitant fraction varied from 3% to 42% (mean 25% +/- 12%). The maximum jet volume by 3-dimensional echocardiography correlated very well with the aortic regurgitant stroke volume (r = 0.92; P.0001), with the mean regurgitant flow rate (r = 0.87; P.0001), and with the regurgitant fraction (r = 0. 87; P.0001) derived from electromagnetic flowmeter. Both intraobserver and interobserver variability on the measurement of the jet volume by 3-dimensional echocardiography were excellent (r = 0.98; P.0001 and r = 0.90; P.001, respectively). The maximum jet area by 2-dimensional echocardiography did not correlate with the aortic regurgitant stroke volume (r = 0.41; P = not significant) and related poorly with the regurgitant fraction (r = 0.52; P.05) by electromagnetic flowmeter. Dynamic 3-dimensional echocardiography can allow better determination of the geometry of the aortic regurgitant jet and may assist of quantifying the severity of aortic regurgitation.

Magnetic resonance has proven to be of considerable usefulness in the study of valvular heart disease and in the evaluation of its severity and the associated complications. Although echocardiography continues to be the method of choice in this disease, MRI represents an alternative when echocardiographic results are inconclusive or limited.

We compared quantitative Doppler echocardiography and cine magnetic resonance imaging for calculation of regurgitant volume and regurgitant fraction in mitral regurgitation. A good correlation was present between the 2 methods with some scatter in patients with severe mitral regurgitation and high regurgitant volumes.

The proximal isovelocity surface area (PISA) method is accurate for quantitating mitral regurgitation but requires recording both mitral maximal and integrated jet velocities using the same continuous-wave Doppler jet signal. In 272 consecutive patients with isolated mitral regurgitation, the mean ratio of maximal to integral of velocity had a narrow range of variation (mean +/- SD, 3.25 +/- 0.47). The estimated regurgitant volume, calculated as regurgitant flow/3.25, showed an excellent correlation with reference regurgitant volumes (r = 0.96 and r = 0.97; standard error of the estimate, 11 ml; both p < 0.0001), with limited overestimation and high sensitivity and specificity for severe mitral regurgitation. The estimated regurgitant volume is a useful measurement in patients in whom the continuous-wave Doppler signal of mitral regurgitation cannot be obtained.

The aim of the present study was to quantitate aortic regurgitant volume and regurgitant fraction in a chronic animal model with surgically created aortic regurgitation using a new semiautomated color Doppler flow calculation method.The conventional noninvasive methods for evaluating the severity of aortic regurgitation have not been accepted widely nor compared with truly quantitative reference standards.Eight to 20 weeks after aortic regurgitation was surgically induced in six sheep, a total of 22 hemodynamic states were studied. Electromagnetic flow probes and meters provided reference flow data. Epicardial color Doppler echocardiographic studies were performed to image left ventricular outflow tract forward and aortic regurgitant blood flows. The new method digitally integrated spatial and temporal color flow velocity data for left ventricular outflow tract forward flow and ascending aortic regurgitant flow. The pulsed Doppler method using the velocity-time integral was also used to obtain regurgitant volumes and regurgitant fractions.Regurgitant volumes and regurgitant fractions by the new method agreed well with those obtained electromagnetically, whereas the pulsed Doppler method overestimated these reference data (mean [+/-SD] difference 0.23 +/- 2.9 ml vs. 11 +/- 5.8 ml, p0.0001 for regurgitant volume; mean difference 1.2 +/- 7.6% vs. 19 +/- 13%, p0.0001 for regurgitant fraction).This animal study, using strictly quantified aortic regurgitant volumes, demonstrated that the digital color Doppler method provides accurate aortic regurgitant volumes and regurgitant fractions without cumbersome measurements.

Does quantitative assessment of asymptomatic mitral regurgitation predict patients' outcomes?

PurposeECG-gated Multidetector Computed Tomography (MDCT) is widely used for coronary imaging, including preoperative appraisal of patients with valvular disease. We aimed to evaluate its ability to provide additional valvular information in mitral regurgitation (MR).MethodsConsecutive MDCTs performed for coronary assessment in 29 patients with MR were reviewed. Mitral valves were analyzed in multiphase imaging using a standardized protocol. Four types of multiplanar reconstructions were tested: axial, short-axis slices, and from the three-chamber view slices positioned either parallel or rotating around the centre of the aortic valve. We defined motion as normal, prolapse or restriction, noted the most effective phase and calculated the regurgitant volume as the difference between left and right ventricular ejection volumes. Echocardiography was used as a reference for leaflet motion, functional quantification using effective regurgitant orifice (ERO) and ventricular volumes.ResultsThe severity of MR, derived from ERO, was graded 1 for 11 patients, 2 (3 patients), 3 (7) and 4 (8). The motion agreement (Kappa coefficient) for the 174 scallops studied was 0.91 (95% CI 0.83-0.97) for the three-chamber-derived views, 0.88 (0.79-0.96) for the axial slices and 0.60 (0.46-0.74) for the short-axis plane. However, the latter was efficient in prolapsed scallops (Se 0.87, Sp 0.98, PPV 0.87 and NPV 0.98). The MDCT RV differed between grades 1 and 3, 1 and 4 (p=0.001), 2 and 3, 2 and 4 (P