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Song H, Yang Y, Li M, Tan T, Wang L, Zhang J, Chen J, Zhou Q. Enhancing precision in effective regurgitant orifice area estimation by transthoracic echocardiography for functional mitral regurgitation using computational fluid dynamics. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:1995-2006. [PMID: 39136802 DOI: 10.1007/s10554-024-03219-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 08/05/2024] [Indexed: 10/15/2024]
Abstract
Computational fluid dynamics (CFD) was used to identify factors influencing the accuracy of the hemispherical proximal isovelocity surface area (PISA) method in calculating the effective regurgitant orifice area (EROA) for patients with functional mitral regurgitation (FMR). Ninety-nine CFD models were constructed to investigate the impact of regurgitant orifice shape and leaflet tethering on the EROA calculation using the PISA method. The correction factors for regurgitation orifice shape (CFs) and for leaflet tethering (CFt) were derived by comparing the 2D PISA method and the actual orifice area. The correction formula was then tested in vivo via 2D transthoracic echocardiography with 3D transesophageal echocardiography of the vena contracta area (VCA) as a reference method in 62 patients with FMR. Based on the CFD simulation results, the two major factors for correcting the EROA calculation were vena contracta length (VCL) and coaptation depth (CD). The correction formula for the EROA was corrected effective regurgitant orifice area (CEROA) = EROA*CFs*CFt, where CFs = 0.59 × VCL(cm) + 0.6 × MR Vmax(cm/s)-0.63 × PISA R(cm)-1.51 and CFt = 0.4 × CD (cm) + 0.96. The correction formula was applied to FMR patients, and the bias and LOA between the CEROA and VCA (0.01 ± 0.13 cm2) were much smaller than those between the EROA and VCA (0.26 ± 0.32 cm2). The CFD-based correction formula improves the accuracy of the EROA calculation based on the hemispheric PISA method, possibly leading to more accurate and reliable data for treatment decision-making in FMR patients.
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Affiliation(s)
- Hongning Song
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, China
| | - Yuanting Yang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, China
| | - Mingqi Li
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, China
| | - Tuantuan Tan
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, China
| | - Liuqing Wang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, China
| | - Ji Zhang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, China
| | - Jinling Chen
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, China
| | - Qing Zhou
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, China.
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Wifstad SV, Kildahl HA, Holte E, Berg EAR, Grenne B, Salvesen Ø, Dalen H, Lovstakken L. EasyPISA: Automatic Integrated PISA Measurements of Mitral Regurgitation From 2-D Color-Doppler Using Deep Learning. ULTRASOUND IN MEDICINE & BIOLOGY 2024:S0301-5629(24)00254-0. [PMID: 39122609 DOI: 10.1016/j.ultrasmedbio.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/14/2024] [Accepted: 06/18/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE The proximal isovelocity surface area (PISA) method is a well-established approach for mitral regurgitation (MR) quantification. However, it exhibits high inter-observer variability and inaccuracies in cases of non-hemispherical flow convergence and non-holosystolic MR. To address this, we present EasyPISA, a framework for automated integrated PISA measurements taken directly from 2-D color-Doppler sequences. METHODS We trained convolutional neural networks (UNet/Attention UNet) on 1171 images from 196 recordings (54 patients) to detect and segment flow convergence zones in 2-D color-Doppler images. Different preprocessing schemes and model architectures were compared. Flow convergence surface areas were estimated, accounting for non-hemispherical convergence, and regurgitant volume (RVol) was computed by integrating the flow rate over time. EasyPISA was retrospectively applied to 26 MR patient examinations, comparing results with reference PISA RVol measurements, severity grades, and cMRI RVol measurements for 13 patients. RESULTS The UNet trained on duplex images achieved the best results (precision: 0.63, recall: 0.95, dice: 0.58, flow rate error: 10.4 ml/s). Mitigation of false-positive segmentation on the atrial side of the mitral valve was achieved through integration with a mitral valve segmentation network. The intraclass correlation coefficient was 0.83 between EasyPISA and PISA, and 0.66 between EasyPISA and cMRI. Relative standard deviations were 46% and 53%, respectively. Receiver operator characteristics demonstrated a mean area under the curve between 0.90 and 0.97 for EasyPISA RVol estimates and reference severity grades. CONCLUSION EasyPISA demonstrates promising results for fully automated integrated PISA measurements in MR, offering potential benefits in workload reduction and mitigating inter-observer variability in MR assessment.
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Affiliation(s)
- Sigurd Vangen Wifstad
- University of Science and Technology (NTNU), Prinsesse Kristinas Gate 3, 7030, Trondheim, Norway.
| | - Henrik Agerup Kildahl
- University of Science and Technology (NTNU), Prinsesse Kristinas Gate 3, 7030, Trondheim, Norway; Clinic of Thoracic Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Espen Holte
- University of Science and Technology (NTNU), Prinsesse Kristinas Gate 3, 7030, Trondheim, Norway; Clinic of Cardiology, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Erik Andreas Rye Berg
- University of Science and Technology (NTNU), Prinsesse Kristinas Gate 3, 7030, Trondheim, Norway; Clinic of Cardiology, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Bjørnar Grenne
- University of Science and Technology (NTNU), Prinsesse Kristinas Gate 3, 7030, Trondheim, Norway; Clinic of Cardiology, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Øyvind Salvesen
- University of Science and Technology (NTNU), Prinsesse Kristinas Gate 3, 7030, Trondheim, Norway
| | - Håvard Dalen
- University of Science and Technology (NTNU), Prinsesse Kristinas Gate 3, 7030, Trondheim, Norway; Clinic of Cardiology, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Lasse Lovstakken
- University of Science and Technology (NTNU), Prinsesse Kristinas Gate 3, 7030, Trondheim, Norway
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Caballero A, Qin T, Hahn RT, McKay R, Sun W. Quantification of mitral regurgitation after transcatheter edge-to-edge repair: Comparison of echocardiography and patient-specific in silico models. Comput Biol Med 2022; 148:105855. [PMID: 35872413 DOI: 10.1016/j.compbiomed.2022.105855] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/26/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Doppler echocardiographic (echo) assessment of residual mitral regurgitation (MR) after transcatheter edge-to-edge repair (TEER) is challenging and often subjective. This study aimed to evaluate the accuracy and feasibility of standardized quantitative echo methods for assessment of MR severity after MitraClip repair by comparing measurements against a reference MR severity obtained from patient-specific in silico models. METHODS Post-procedure hemodynamics were simulated under five different MitraClip configurations in previously validated patient-specific in silico models for the treatment of functional MR. The residual regurgitant volume was calculated as in clinical practice using four quantitative virtual echo methods: pulsed Doppler, volumetric, proximal isovelocity surface area (PISA) and vena contracta area (VCA). Multiple permutations were performed for each method. Virtual echo MR results were evaluated against reference MR values directly extracted from the 5 patient-specific in silico models. RESULTS The echo methods with the greatest accuracy were the three-dimensional (3D) volumetric method (r = 0.957, bias -0.8 ± 1.2 ml, p = 0.01), the 3D VCA method wherein velocity time integrals were evaluated for each jet assessed (r = 0.919, bias -1.5 ± 1.7 ml, p = 0.03), and the 3D PISA method integrating surface areas throughout systole (r = 0.98, bias -2.0 ± 0.9 ml, p = 0.003). The pulsed Doppler and 2D volumetric methods had technical limitations that may result in a high underestimation or overestimation of the MR severity after TEER. In the case of multiple regurgitant jets, a more accurate MR assessment was obtained when all significant jets were evaluated. CONCLUSIONS Clinically, the 3D volumetric, 3D VCA and 3D PISA methods gave the most accurate MR quantification after TEER. Three-dimensional echo technologies harbor the potential of becoming the non-invasive imaging tool of choice for MR quantification after complex transcatheter mitral interventions.
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Affiliation(s)
- Andrés Caballero
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA; PAI+ Research Group, Energetics and Mechanics Department, Universidad Autónoma de Occidente, Cali, Colombia
| | - Tongran Qin
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Rebecca T Hahn
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Raymond McKay
- Cardiology Department, The Hartford Hospital, Hartford, CT, USA
| | - Wei Sun
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.
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Computational Analysis of Virtual Echocardiographic Assessment of Functional Mitral Regurgitation for Validation of Proximal Isovelocity Surface Area Methods. J Am Soc Echocardiogr 2021; 34:1211-1223. [PMID: 34214636 DOI: 10.1016/j.echo.2021.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mitral regurgitation (MR) quantification by the proximal isovelocity surface area (PISA) method remains challenging. Using computer models, the authors evaluated the accuracy of different PISA methods and quantified their errors. METHODS Five functional MR computer models of different geometric and tethering abnormalities were created, validated, and treated as phantom models, from which the reference values were directly obtained. Virtual two-dimensional (2D) PISA and three-dimensional (3D) PISA (both peak and integrated values) were performed on these phantom models. By comparing virtual PISA results with reference values, the accuracy of different PISA methods was evaluated, and their sources of errors were quantified. RESULTS Compared with reference values of regurgitant flow rate, excellent correlations were found for true PISA (r = 0.99, bias = 32.3 ± 35.3 mL/sec), 3D PISA (r = 0.97, bias = -24.4 ± 55.5 mL/sec), followed by multiplane 2D hemicylindrical PISA (r = 0.88, bias = -24.1 ± 85.4 mL/sec) and hemiellipsoidal PISA (r = 0.91, bias = -55.7 ± 96.6 mL/sec). Weaker correlations were found for single-plane 2D hemispherical PISA (parasternal long-axis: r = 0.71, bias = -77.6 ± 124.5 mL/sec; apical two-chamber: r = 0.69, bias = -52.0 ± 122.0 mL/sec; apical four-chamber: r = 0.82, bias = -65.5 ± 107.3 mL/sec). For regurgitant volume quantification, integrated PISA was more accurate than peak PISA. The bias of 3D PISA improved from -12.7 ± 7.8 mL (peak PISA) to -2.1 ± 5.3 mL (integrated PISA). CONCLUSIONS For functional MR quantification, 2D hemispherical PISA had significant underestimation, multiplane 2D hemiellipsoidal and hemicylindrical PISA showed improved accuracy, and 3D PISA was the most accurate. The PISA method is subject to both systematic underestimation due to the Doppler angle effect and systematic overestimation when regurgitant flow is not perpendicular to PISA contour. Integrated PISA is able to capture dynamic MR and is therefore more accurate than peak PISA. The sum of regurgitant flow rates is the most feasible way to perform integrated PISA.
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Impact of Mitral Regurgitation on the Flow in a Model of a Left Ventricle. Cardiovasc Eng Technol 2020; 11:708-718. [DOI: 10.1007/s13239-020-00490-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/24/2020] [Indexed: 11/25/2022]
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Papolla C, Adda J, Rique A, Habib G, Rieu R. In Vitro Quantification of Mitral Regurgitation of Complex Geometry by the Modified Proximal Isovelocity Surface Area Method. J Am Soc Echocardiogr 2020; 33:838-847.e1. [DOI: 10.1016/j.echo.2020.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/13/2020] [Accepted: 03/13/2020] [Indexed: 12/12/2022]
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Winkel MG, Brugger N, Khalique OK, Gräni C, Huber A, Pilgrim T, Billinger M, Windecker S, Hahn RT, Praz F. Imaging and Patient Selection for Transcatheter Tricuspid Valve Interventions. Front Cardiovasc Med 2020; 7:60. [PMID: 32432125 PMCID: PMC7214677 DOI: 10.3389/fcvm.2020.00060] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/25/2020] [Indexed: 12/23/2022] Open
Abstract
With the emergence of transcatheter solutions for the treatment of tricuspid regurgitation (TR) increased attention has been directed to the once neglected tricuspid valve (TV) complex. Recent studies have highlighted new aspects of valve anatomy and TR etiology. The assessment of valve morphology along with quantification of regurgitation severity and RV function pose several challenges to cardiac imagers guiding transcatheter valve procedures. This review article aims to give an overview over the role of modern imaging modalities during assessment and treatment of the TV.
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Affiliation(s)
- Mirjam G. Winkel
- Department of Cardiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Nicolas Brugger
- Department of Cardiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Omar K. Khalique
- Columbia University Medical Center/NY Presbyterian Hospital, New York, NY, United States
| | - Christoph Gräni
- Department of Cardiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Adrian Huber
- Department of Cardiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Michael Billinger
- Department of Cardiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Rebecca T. Hahn
- Columbia University Medical Center/NY Presbyterian Hospital, New York, NY, United States
| | - Fabien Praz
- Department of Cardiology, Inselspital, University Hospital Bern, Bern, Switzerland
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Mao W, Caballero A, Hahn RT, Sun W. Comparative quantification of primary mitral regurgitation by computer modeling and simulated echocardiography. Am J Physiol Heart Circ Physiol 2020; 318:H547-H557. [PMID: 31922890 DOI: 10.1152/ajpheart.00367.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Clinical investigations have demonstrated that mitral regurgitation (MR) quantification using echocardiography (echo) may significantly underestimate or overestimate the regurgitant volume, especially for two-dimensional (2D) echo. Computer modeling and simulated echo were conducted to evaluate the fundamental assumptions in the echo quantification of primary MR that is due to posterior mitral leaflet prolapse. The theoretical flaw of the proximal isovelocity surface area (PISA) method originates from the assumption that the MR flow rate is the product of the isovelocity surface area and aliasing velocity, which is only valid when the velocity vectors are perpendicular to the isovelocity surface. Other factors such as the Doppler angle effect, the view planes of 2D echo, and the single time instant of PISA were also analyzed. We find that the hemielliptic PISA method gives the smallest error for moderate and severe MR cases compared with other PISA methods. Compared with the PISA method, the volumetric technique (VT) is theoretically more robust. By considering correction factors that are caused by nonflat velocity profiles and the closing volume of the aortic valve, the accuracy of the VT method can be significantly improved. The corrected volumetric technique provides more accurate results compared with the PISA methods, especially for mild MR.NEW & NOTEWORTHY We evaluate the accuracy of common echocardiography techniques for the quantification of primary mitral regurgitations using computer modeling. The hemielliptic proximal isovelocity surface area (PISA) method gives the smallest error (within 15%) for moderate and severe mitral regurgitation cases compared with other PISA methods. The volumetric method is theoretically more robust than the PISA method. The accuracy of the volumetric method can be improved by a correction factor around 0.7 because of the nonflat velocity profiles and the closing volume of the aortic valve.
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Affiliation(s)
- Wenbin Mao
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Andrés Caballero
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Rebecca T Hahn
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Wei Sun
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
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Capoulade R, Piriou N, Serfaty JM, Le Tourneau T. Multimodality imaging assessment of mitral valve anatomy in planning for mitral valve repair in secondary mitral regurgitation. J Thorac Dis 2017; 9:S640-S660. [PMID: 28740719 PMCID: PMC5505945 DOI: 10.21037/jtd.2017.06.99] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 06/13/2017] [Indexed: 12/23/2022]
Abstract
Secondary mitral regurgitation (MR) is frequent valvular heart disease and conveys worse prognostic. Therapeutic surgical or percutaneous options are available in the context of severe symptomatic secondary MR, but the best approach to treat these patients remains unclear, given the lack of clear clinical evidence of benefit. A comprehensive evaluation of the mitral valve apparatus and the left ventricle (LV) has the ability to clearly define and characterize the disease, and thus determine the best option for the patient to improve its clinical outcomes, as well as quality of life and symptoms. The current report reviews the mitral valve (MV) anatomy, the underlying mechanisms associated with secondary MR, the related therapeutic options available, and finally the usefulness of a multimodality imaging approach for the planning of surgical or percutaneous mitral valve intervention.
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Affiliation(s)
- Romain Capoulade
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Institut du Thorax, CHU Nantes, Nantes University, Nantes, France
| | - Nicolas Piriou
- Institut du Thorax, CHU Nantes, Nantes University, Nantes, France
- Department of Nuclear Medicine, CHU Nantes, Nantes University, Nantes, France
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