Color flow imaging of the vena contracta in mitral regurgitation: technical considerations

Timing of Surgery for Asymptomatic Primary Mitral Regurgitation: Possible Value of Early, Serial Measurements of Left Ventricular Sphericity

Asymptomatic primary mitral regurgitation due to myxomatous degeneration of the mitral valve leaflets may remain so for long periods, even as left ventricular function progresses to a decompensated stage. During the early compensated stage, the ventricle's initial response to the volume overload is an asymmetric increase in the diastolic short axis dimension, accomplished by a diastolic shift of the interventricular septum into the right ventricular cavity, creating a more spherical left ventricular diastolic shape, increasing diastolic filling and stroke volume. Early valve repair is recommended to reduce postoperative left ventricular dysfunction. Early serial measurements of left ventricular sphericity index [LV-Si]. during the compensated stage of mitral regurgitation might identify subtle changes in left ventricular shape and assist in determining the optimal earliest timing for surgical intervention.

Quantification of primary mitral regurgitation by echocardiography: A practical appraisal

The accurate quantification of primary mitral regurgitation (MR) and its consequences on cardiac remodeling is of paramount importance to determine the best timing for surgery in these patients. The recommended echocardiographic grading of primary MR severity relies on an integrated multiparametric approach. It is expected that the large number of echocardiographic parameters collected would offer the possibility to check the measured values regarding their congruence in order to conclude reliably on MR severity. However, the use of multiple parameters to grade MR can result in potential discrepancies between one or more of them. Importantly, many factors beyond MR severity impact the values obtained for these parameters including technical settings, anatomic and hemodynamic considerations, patient's characteristics and echocardiographer' skills. Hence, clinicians involved in valvular diseases should be well aware of the respective strengths and pitfalls of each of MR grading methods by echocardiography. Recent literature highlighted the need for a reappraisal of the severity of primary MR from a hemodynamic perspective. The estimation of MR regurgitation fraction by indirect quantitative methods, whenever possible, should be central when grading the severity of these patients. The assessment of the MR effective regurgitant orifice area by the proximal flow convergence method should be used in a semi-quantitative manner. Furthermore, it is crucial to acknowledge specific clinical situations in MR at risk of misevaluation when grading severity such as late-systolic MR, bi-leaflet prolapse with multiple jets or extensive leak, wall-constrained eccentric jet or in older patients with complex MR mechanism. Finally, it is debatable whether the 4-grades classification of MR severity would be still relevant nowadays, since the indication for mitral valve (MV) surgery is discussed in clinical practice for patients with 3+ and 4+ primary MR based on symptoms, specific markers of adverse outcome and MV repair probability. Primary MR grading should be seen as a continuum integrating both quantification of MR and its consequences, even for patients with presumed “moderate” MR.

Additive value of 3D-echo in prediction of immediate outcome after percutaneous balloon mitral valvuloplasty

Background

Results of percutaneous balloon mitral valvuloplasty (BMV) are basically dependent on suitable patient selection. Currently used two-dimensional (2D) echocardiography (2DE) scores have many limitations. Three-dimensional (3D) echocardiography (3DE)-based scores were developed for better patient selection and outcome prediction. We aimed to compare between 3D-Anwar and 2D-Wilkins scores in mitral assessment for BMV, and investigate the additive value of 3DE in prediction of immediate post-procedural outcome. Fifty patients with rheumatic mitral stenosis and candidates for BMV were included. Patients were subjected to 2D- and real-time 3D-transthoracic echocardiography (TTE) before and immediately after BMV for assessing MV area (MVA), 2D-Wilkins and 3D-Anwar score, commissural splitting, and mitral regurgitation (MR). Transesophageal echocardiography (TEE) was also undertaken immediately before and intra-procedural. Percutaneous BMV was performed by either multi-track or Inoue balloon technique.

Results

The 2DE underestimated post-procedural MVA than 3DE (p = 0.008). Patients with post-procedural suboptimal MVA or significant MR had higher 3D-Anwar score compared to 2D-Wilkins score (p = 0.008 and p = 0.03 respectively). The 3D-Anwar score showed a negative correlation with post-procedural MVA (r = − 0.48, p = 0.001). Receiver operating characteristic (ROC) curve analysis for both scores revealed superior prediction of suboptimal results by 3D-Anwar score (p < 0.0001). The 3DE showed better post-procedural posterior-commissural splitting than 2DE (p = 0.004). Results of both multi-track and Inoue balloon were comparable except for favorable posterior-commissural splitting by multi-track balloon (p = 0.04).

Conclusion

The 3DE gave valuable additive data before BMV that may predict immediate post-procedural outcome and suboptimal results.

Electronic supplementary material

The online version of this article (10.1186/s43044-019-0019-x) contains supplementary material, which is available to authorized users.

Advanced Imaging Techniques for Mitral Regurgitation

Mitral regurgitation (MR) is one of the most commonly encountered valvular lesions in clinical practice. MR can be either primary (degenerative) or secondary (functional) depending on the etiology of MR and the pathology of the mitral valve (MV). Echocardiography is the primary diagnostic tool for MR and is key in determining this etiology as well as MR severity. While clinicians usually turn to 2 Dimensional echocardiography as first-line imaging, 3 Dimensional echocardiography (3DE) has continually shown to be superior in terms of describing MV anatomy and pathology. This review article elaborates on 3DE techniques, modalities, and advances in software. Furthermore, the article demonstrates how 3DE has reformed MR evaluation and has played a vital role in determining patient management.

Left atrial dilatation in systolic heart failure: a marker of poor prognosis, not just a buffer between the left ventricle and pulmonary circulation

BACKGROUND

The relation between systolic pulmonary pressure (sPAP) and left atrium in patients with heart failure (HF) is unclear. Diastolic dysfunction, expressed as restrictive mitral filling pattern (RMP), and functional mitral regurgitation (FMR) are associated with both LA enlargement and increased sPAP. We aimed to evaluate whether atrial dilation might modulate the consequences of RMP and FMR on the pulmonary circulation of patients with HF with reduced ejection fraction (HFrEF).

METHODS

1256 HFrEF patients were retrospectively recruited in four Italian centers. Left ventricular (LVD) and atrial (LAD) diameters were measure by m-mode, and EF were measured. RMP was defined as E-wave deceleration time lower than 140 ms. FMR was quantitatively measured. sPAP was evaluated based on maximal tricuspid regurgitant velocity and estimated right atrial pressure.

RESULTS

Final study population was formed by 1005 patients because of unavailability of sPAP in 252 patients. Mean EF was 33 ± 3, 35% had RMP, 67% had mild, and 26% moderate-to-severe FMR. 69% of patients had increased sPAP. A significant association was observed between sPAP and EF, RMP, FMR, and LAD (p < 0.0001 for all). At multivariate analysis, LAD was positively associated with sPAP (p < 0.0001) independently of EF, RMP, and FMR. Analogously, LAD (p < 0.05) was associated with more severe symptoms and worse prognosis after adjustment for LV function and FMR.

CONCLUSION

LA dilation was positively associated with sPAP independently of EF, RMP, and FMR. This highlights that LA size should be considered a marker of the severity of the disease.

Controversies in quantification of mitral valve regurgitation: role of cardiac magnetic resonance imaging

PURPOSE OF REVIEW

Mitral regurgitation remains a common problem, and when severe, is associated with significant morbidity and mortality. At present, echocardiography remains the primary modality for assessing both mechanism and severity of mitral regurgitation. However, recent studies demonstrate that the echocardiographic assessment of mitral regurgitation severity may be subject to variability as a result of semiquantitative parameters, dependence upon loading conditions and significant interobserver variability.

RECENT FINDINGS

Cardiac magnetic resonance (CMR) imaging is the gold standard in the assessment of cardiac function and structure, and offers an alternative method to estimate mitral regurgitation severity. Herein, we discuss the pitfalls of echocardiography in the assessment of mitral regurgitation and describe recent data demonstrating improved accuracy of CMR in the assessment of mitral regurgitation severity. Further, CMR derived regurgitant volume of ≤55 ml is associated with freedom from surgical intervention, in contrast to traditional volumetric measures, which fail to predict the need for surgical intervention.

SUMMARY

The CMR assessment of mitral regurgitation severity is easily performed and appears to be more accurate and predictive of the need for surgery than traditional echocardiography. These promising findings require further confirmation in larger outcome trials.

Left ventricular early inflow-outflow index: a novel echocardiographic indicator of mitral regurgitation severity

BACKGROUND

No gold standard currently exists for quantification of mitral regurgitation (MR) severity. Classification by echocardiography is based on integrative criteria using color and spectral Doppler and anatomic measurements. We hypothesized that a simple Doppler left ventricular early inflow-outflow index (LVEIO), based on flow velocity into the left ventricle (LV) in diastole and ejected from the LV in systole, would add incrementally to current diagnostic criteria. LVEIO was calculated by dividing the mitral E-wave velocity by the LV outflow velocity time integral.

METHODS AND RESULTS

Transthoracic echocardiography reports from Montefiore Medical Center and its referring clinics from July 1, 2011, to December 31, 2011 (n=11 235) were reviewed. The MR severity reported by a cardiologist certified by the National Board of Echocardiography was used as a reference standard. Studies reporting moderate or severe MR (n=550) were reanalyzed to measure effective regurgitant orifice area by the proximal isovelocity surface area method, vena contracta width, MR jet area, and left-sided chamber volumes. LVEIO was 9.3±3.9, 7.0±3.2, and 4.2±1.7 among those with severe, moderate, and insignificant MR, respectively (ANOVA P<0.001). By receiver operating characteristic analysis, area under the curve for LVEIO was 0.92 for severe MR. Those with LVEIO ≥8 were likely to have severe MR (likelihood ratio 26.5), whereas those with LVEIO ≤4 were unlikely to have severe MR (likelihood ratio 0.11). LVEIO performed better in those with normal LV ejection fraction (≥50%) compared with those with reduced LV ejection fraction (<50%) (area under the curve 0.92 versus 0.80, P<0.001). By multivariate logistic regression analysis, LVEIO was independently associated with severe MR when compared with vena contracta width, MR jet area, and effective regurgitant orifice area measured by the proximal isovelocity surface area method.

CONCLUSION

LVEIO is a simple-to-use echocardiographic parameter that accurately identifies severe MR, particularly in patients with normal LV ejection fraction.

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

BACKGROUND

Quantitative 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.

OBJECTIVE

To measure the VCW in dogs with different levels of MR severity.

ANIMALS

Two hundred and seventy-nine dogs were classified according to 5 levels of MR severity.

METHODS

This 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.

RESULTS

All 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/m(2) (IQR = 5.5-4.2) in mild-to-moderate MR and of 10.8 mm/m(2) (IQR = 12.8-9.4) in moderate-to-severe MR.

CONCLUSION AND CLINICAL IMPORTANCE

This 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.

Color Doppler twinkling artifact of calcified cardiac valves in vitro: a not well known phenomenon in echocardiography

The color Doppler twinkling artifact manifests as a rapidly changing mixture of red and blue colors behind strongly reflective structures. The twinkling artifact occurs behind diseased cardiac valves, although the phenomenon is not well described. This study sought to determine the presence of the color Doppler twinkling artifact in calcified cardiac valves in vitro using soft tissue radiography for reference. Seventeen specimens of diseased cardiac valves from patients undergoing valve replacement surgery were studied. The overall sensitivity and specificity for the detection of calcifications using the presence of the twinkling artifact were 66.7% and 81.8%, respectively. If valves with only microcalcifications or smooth calcifications were eliminated from the analysis, all (100%) of the three valves with irregular macrocalcifications exhibited the twinkling artifact. It is important to recognize this artifact because it may lead to misdiagnosis of vascular flow in echocardiography.

Clinical and functional characterisation of rheumatic mitral regurgitation in children and adolescents including the brain natriuretic peptide

Rheumatic fever is a public health problem of universal distribution, predominantly affecting individuals in developing countries. In individuals less than 20 years of age, pure mitral regurgitation is the most commonly found condition in chronic rheumatic valve disease. In the present study, rheumatic mitral regurgitation was assessed in children and adolescents, addressing its clinical (duration of the disease, symptoms, use of benzathine penicillin, and number of outbreaks of the acute phase of rheumatic fever), electrocardiographic (left atrium abnormality and/or left ventricle hypertrophy) and echocardiographic characteristics (left atrium and ventricle measurements, ejection fraction and pulmonary artery pressure), as well as plasma dose of N-terminal portion of the brain natriuretic peptide through electrochemiluminescence immunoassay. Fifty-three patients were studied. The patients had moderate (41.5%) or severe (58.5%) rheumatic mitral regurgitation; had not undergone surgery; were not in the acute phase of the disease; and were being treated at a paediatric cardiology reference hospital in Northeastern Brazil. Mean patient age was 10.6 years (minimum of 3 and maximum of 19 years). With the exception of the ejection fraction, the echocardiographic variables had a significant correlation to the natriuretic peptide, demonstrating that this hormone reflects the haemodynamic consequences of mitral regurgitation. It was concluded that cardiac remodelling that occurs in rheumatic mitral regurgitation in children and adolescents leads to the production of the brain natriuretic peptide, which could be used as a complementary diagnostic tool in the follow-up of such patients.

Isolated cleft in the posterior mitral valve leaflet: a congenital form of mitral regurgitation

BACKGROUND

Isolated congenital cleft of the posterior leaflet of the mitral valve is a rare cause of mitral regurgitation (MR). This study describes the clinical, echocardiographic, and intraoperative findings as well as treatment options.

METHODS

Adults with an isolated cleft of the posterior mitral valve leaflet diagnosed by transthoracic echocardiography were evaluated with respect to clinical, echocardiographic, preoperative and intraoperative findings, and different surgical strategies.

RESULTS

The prevalence of isolated cleft of the posterior mitral valve leaflet in all patients examined was 0.11% (n = 22 out of 19 320 evaluated echocardiograms); male gender was predominant (73%). Dyspnea on exertion was present in almost all patients with at least moderate regurgitation. The predominant localization of the cleft was within segment P2 (59%), followed by a cleft between P1/P2 (18%). An isolated cleft in segment P3 or segment P1 occurred twice in each segment (n = 2; 9%) and between P2/P3 once (n = 1; 5%). Regurgitation was severe in 50% (n = 11), moderate in 9% (n = 2), mild in 27% (n = 6), and only trivial in 14% (n = 3) of the patients. Surgical treatment involved reconstruction with ring annuloplasty in 45% (n = 10) and replacement in 4.5% (n = 1). A total of 11 patients (50%) with mostly mild or trivial mitral regurgitation were treated medically only.

CONCLUSION

Two-dimensional high-resolution cross-sectional echocardiography allows the distinct diagnosis of a clefted posterior leaflet, whereas clinical presentation, electrocardiogram, chest x-ray, and angiography are failing to identify the correct etiology of MR in patients with isolated posterior leaflet cleft mitral valve (IPLCMV). Patients with moderate to severe MR were treated surgically with excellent outcome.

Validation of a new score for the assessment of mitral stenosis using real-time three-dimensional echocardiography

BACKGROUND

The aim of this study was to validate a new real-time three-dimensional echocardiography (RT3DE) score for evaluating patients with mitral stenosis (MS).

METHODS

A two-staged study was conducted. In the first stage, the feasibility of a new RT3DE score was assessed in 17 patients with MS. The second stage was planned to validate the RT3DE score in 74 consecutive patients undergoing percutaneous mitral valvuloplasty. The new RT3DE score was constructed by dividing each mitral valve (MV) leaflet into 3 scallops and was composed of 31 points (indicating increasing abnormality), including 6 points for thickness, 6 for mobility, 10 for calcification, and 9 for subvalvular apparatus involvement. The total RT3DE score was calculated and defined as mild (<8), moderate (8-13), or severe (>or=14). MV morphology was assessed using Wilkins's score and compared with the new RT3DE score.

RESULTS

In the first stage, the RT3DE score was feasible and easily applied to all patients, with good interobserver and intraobserver agreement. In the second stage, RT3DE improved MV morphologic assessment, particularly for the detection of calcification and commissural splitting. Both scores were correlated for assessment of thickness and calcification (r = 0.63, P < .0001, and r = 0.44, P < .0001, respectively). Predictors of optimal percutaneous mitral valvuloplasty success by Wilkins's score were leaflet calcification and subvalvular apparatus involvement, and those by RT3DE score were leaflet mobility and subvalvular apparatus involvement. The incidence and severity of mitral regurgitation were associated with high-calcification RT3DE score.

CONCLUSION

The new RT3DE score is feasible and highly reproducible for the assessment of MV morphology in patients with MS. It can provide incremental prognostic information in addition to Wilkins's score.

Direct measurement of vena contracta area by real-time 3-dimensional echocardiography for assessing severity of mitral regurgitation

We tested the hypothesis that the vena contracta (VC) cross-sectional area in patients with mitral regurgitation (MR) can be reproducibly measured by real-time 3-dimensional (3D) echocardiography and correlates well with the volumetric effective regurgitant orifice area (EROA). Earlier MR repair requires accurate noninvasive measures, but practically, the VC area is difficult to image in 2-dimensional views, which are often oblique to it. 3D echocardiography can provide an otherwise unobtainable true cross-sectional view. In 45 patients with mild or greater MR, 44% eccentric, 2-dimensional and 3D VC areas were measured and correlated with the EROA derived from the regurgitant stroke volume. Real-time 3D echocardiography of the VC area correlated and agreed well with the EROA for both central and eccentric jets (r(2) = 0.86, SEE 0.02 cm(2), difference 0.04 +/- 0.06 cm(2), p = NS). For eccentric jets, 2-dimensional echocardiography overestimated the VC width compared with 3D echocardiography (p = 0.024) and correlated more poorly with the EROA (r(2) = 0.61 vs 0.85, p <0.001), causing clinical misclassification in 45% of patients with eccentric MR. The interobserver variability for the 3D VC area was 0.03 cm(2) (7.5% of the mean, r = 0.95); the intraobserver variability was 0.01 cm(2) (2.5% of the mean, r = 0.97). In conclusion, real-time 3D echocardiography accurately and reproducibly quantified the vena contracta cross-sectional area in patients with both central and eccentric MR. Rapid acquisition and intuitive analysis promote practical clinical application of this central, directly visualized, measure and its correlation with outcome.

Fontan Operation: A Comparison of Lateral Tunnel with Extracardiac Conduit

BACKGROUND

The purpose of this report is to compare the outcome of the extracardiac (EC) with the lateral tunnel (LT) Fontan.

METHODS

From January 1990 to October 2004, the Fontan operation was performed in 162 patients, of which 49 were EC and 113 were LT. Cardiac morphology and ventricular dominance were similar, except EC patients were older and had a greater frequency of heterotaxy syndrome, and LT patients had a higher incidence of hypoplastic left heart syndrome. Preoperative transpulmonary gradient, ventricular end-diastolic pressure, McGoon index, room air saturation, and cardiac rhythm were similar. EC patients underwent superior caval pulmonary connection, and LT patients underwent hemi-Fontan. Cardiopulmonary bypass time was similar, but fewer EC patients needed aortic cross-clamping. Fenestration was more frequent in LT patients (EC, 16% versus LT, 73%; p < 0.01).

RESULTS

Overall operative mortality was 1.8% (EC, 1 versus LT, 2; p = NS). Postoperative transpulmonary gradient, readmission for chylous effusion, and change in ejection fraction relative to preoperative level did not differ between cohorts. Resource utilization was higher in the EC group. The loss of sinus rhythm and the frequency of all neurologic events did not differ. There were seven late deaths (EC 4 versus LT 3; p = NS). Actuarial survival at 5 years was not significantly different (EC, 90% versus LT, 95%; p = 0.08).

CONCLUSIONS

The EC and LT operation had comparable early and late mortality, readmission for chylous effusion, preservation of sinus rhythm, and frequency of all neurologic events. The more frequently fenestrated LT cohort used fewer resources.

Functional mitral regurgitation in heart failure

Mitral regurgitation commonly occurs in patients with heart failure. Systolic dysfunction is the hallmark of dilated cardiomyopathy. Mitral functional regurgitation is mitral incompetence in the absence of intrinsic lesions of the mitral valve apparatus. Echocardiography can make a major contribution to the diagnosis of cardiomyopathies. A more careful anatomic and hemodynamic evaluation of mitral regurgitation mechanisms is possible with spectral Doppler, color Doppler, three-dimensional echocardiography and transesophageal echocardiography. Functional mitral regurgitation is due to the incomplete closure of mitral leaflets and is based on alterations of mitral annulus, left ventricular dimensions, function and geometry, left atrial dimensions and function. Knowledge of the mechanisms of mitral regurgitation helps us to gain an insight into therapeutic interventions that modify the mechanistic factors. Medical therapy reduces the tethering forces and also augments transmitral pressure; surgical approaches can modify geometric relationships in the left ventricular chamber and resynchronization therapy can improve co-ordinated timing of mechanical activation of papillary muscles.

Strukturierter Datensatz zur Befunddokumentation in der Echokardiographie?Version 2004

A standardized documentation of echocardiographic studies is necessary to provide comparability of data and to realize software-based documentation and electronic communication, both essential for quality management in echocardiography.Therefore, the subgroup on "Standardization and LV function" of the working group on cardiovascular ultrasound of the German Cardiac Society developed a consensus report for documentation of echocardiographic studies, which was first published in 2000. This report represents the current update of the standardized documentation for echocardiography; its impact for quality management in conjunction with the "guidelines echocardiography" is discussed.