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Saeed M, Bersali A, Darwish A, Qamar F, Maragiannis D, El-Tallawi KC, Malahfji M, Shah DJ. Assessing Regurgitation Severity, Adverse Remodeling, and Fibrosis with CMR in Aortic Regurgitation. Curr Cardiol Rep 2024; 26:413-421. [PMID: 38517604 DOI: 10.1007/s11886-024-02044-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE OF REVIEW Cardiac magnetic resonance (CMR) is emerging as a valuable imaging modality for the assessment of aortic regurgitation (AR). In this review, we discuss the assessment of AR severity, left ventricular (LV) remodeling, and tissue characterization by CMR while highlighting the latest studies and addressing future research needs. RECENT FINDINGS Recent studies have further established CMR-based thresholds of AR severity and LV remodeling that are associated with adverse clinical outcomes, and lower than current guideline criteria. In addition, tissue profiling with late gadolinium enhancement (LGE) and extracellular volume (ECV) quantification can reliably assess adverse myocardial tissue remodeling which is also associated with adverse outcomes. The strengths and reproducibility of CMR in evaluating ventricular volumes, tissue characteristics, and regurgitation severity position it as an excellent modality in evaluating and following AR patients. Advanced CMR techniques for the detection of tissue remodeling have shown significant potential and merit further investigation.
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Affiliation(s)
- Mujtaba Saeed
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Akila Bersali
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Amr Darwish
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Fatima Qamar
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Dimitrios Maragiannis
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Kinan Carlos El-Tallawi
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Maan Malahfji
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Dipan J Shah
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
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Tsampasian V, Victor K, Bhattacharyya S, Oxborough D, Ring L. Echocardiographic assessment of aortic regurgitation: a narrative review. Echo Res Pract 2024; 11:1. [PMID: 38167345 PMCID: PMC10762934 DOI: 10.1186/s44156-023-00036-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/08/2023] [Indexed: 01/05/2024] Open
Abstract
Aortic regurgitation (AR) is the third most frequently encountered valve lesion and may be caused by abnormalities of the valve cusps or the aorta. Echocardiography is instrumental in the assessment of AR as it enables the delineation of valvular morphology, the mechanism of the lesion and the grading of severity. Severe AR has a major impact on the myocardium and carries a significant risk of morbidity and mortality if left untreated. Established and novel echocardiographic methods, such as global longitudinal strain and three-dimensional echocardiography, allow an estimation of this risk and provide invaluable information for patient management and prognosis. This narrative review summarises the epidemiology of AR, reviews current practices and recommendations with regards to the echocardiographic assessment of AR and outlines novel echocardiographic tools that may prove beneficial in patient assessment and management.
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Affiliation(s)
| | | | | | - David Oxborough
- Research Institute of Sports and Exercise Science and Liverpool Centre for Cardiovascular Science, Liverpool John Moores University, Liverpool, UK
| | - Liam Ring
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
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Zoghbi WA, Jone PN, Chamsi-Pasha MA, Chen T, Collins KA, Desai MY, Grayburn P, Groves DW, Hahn RT, Little SH, Kruse E, Sanborn D, Shah SB, Sugeng L, Swaminathan M, Thaden J, Thavendiranathan P, Tsang W, Weir-McCall JR, Gill E. Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2024; 37:2-63. [PMID: 38182282 DOI: 10.1016/j.echo.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.
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Affiliation(s)
- William A Zoghbi
- Houston Methodist Hospital, DeBakey Heart & Vascular Center, Houston, Texas.
| | - Pei-Ni Jone
- Lurie Children's Hospital, Northwestern University, Chicago, Illinois
| | | | - Tiffany Chen
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Paul Grayburn
- Baylor Scott & White Health, University of Texas Southwestern, Dallas, Texas
| | - Daniel W Groves
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rebecca T Hahn
- Columbia University Irving Medical Center, New York, New York
| | - Stephen H Little
- Houston Methodist Hospital, DeBakey Heart & Vascular Center, Houston, Texas
| | - Eric Kruse
- University of Chicago Medical Center, Chicago, Illinois
| | | | - Sangeeta B Shah
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | - Lissa Sugeng
- North Shore University Hospital, Manhasset, New York
| | - Madhav Swaminathan
- Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University, Durham, North Carolina
| | | | | | - Wendy Tsang
- University of Toronto, Toronto, Ontario, Canada
| | | | - Edward Gill
- University of Colorado School of Medicine, Aurora, Colorado
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García-Galindo A, Agujetas R, López-Mínguez JR, Ferrera C. Assessment of valve implantation in the descending aorta as an alternative for aortic regurgitation patients not treatable with conventional procedures. Biomech Model Mechanobiol 2022; 22:575-591. [PMID: 36550245 PMCID: PMC10097802 DOI: 10.1007/s10237-022-01665-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Aortic Regurgitation (AR) produces the entrance of an abnormal amount of blood in the left ventricle. This disease is responsible for high morbidity and mortality worldwide and may be caused by an aortic valve dysfunction. Surgical and transcatheter aortic valve replacement (TAVR) are the current options for treating AR. They have replaced older procedures such as Hufnagel's one. However, some physicians have reconsidered this procedure as a less aggressive alternative for patients not eligible for surgical or TAVR. Although Hufnagel suggested a 75% regurgitation reduction when a valve is placed in the descending aorta, a quantification of this value has not been reported. METHODS In this paper, CFD/FSI numerical simulation is conducted on an idealized geometry. We quantify the effect of placing a bileaflet mechanical heart valve in the descending aorta on a moderate-severe AR case. A three-element Windkessel model is employed to prescribe pressure outlet boundary conditions. We calculate the resulting flow rates and pressures at the aorta and first-generation vessels. Moreover, we evaluate several indices to assess the improvement due to the valve introduction. RESULTS AND CONCLUSIONS Regurgitation fraction (RF) is reduced from 37.5% (without valve) to 18.0% (with valve) in a single cardiac cycle. This reduction clearly shows the remarkable efficacy of the rescued technique. It will further ameliorate the left ventricle function in the long-term. Moreover, the calculations show that the implantation in that location introduces fewer incompatibilities' risks than a conventional one. The proposed methodology can be extended to any particular conditions (pressure waveforms/geometry) and is designed to assess usual clinical parameters employed by physicians.
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Affiliation(s)
- A García-Galindo
- Departamento de Ingeniería Mecánica, Energética y de los Materiales and Instituto de Computación Científica Avanzada (ICCAEx), Universidad de Extremadura, E-06006, Badajoz, Spain
| | - R Agujetas
- Departamento de Ingeniería Mecánica, Energética y de los Materiales and Instituto de Computación Científica Avanzada (ICCAEx), Universidad de Extremadura, E-06006, Badajoz, Spain
| | - J R López-Mínguez
- Sección de Cardiologıa Intervencionista, Servicio de Cardiologıa, Hospital Universitario de Badajoz, Avda. de Elvas s/n, E-06006, Badajoz, Spain
| | - C Ferrera
- Departamento de Ingeniería Mecánica, Energética y de los Materiales and Instituto de Computación Científica Avanzada (ICCAEx), Universidad de Extremadura, E-06006, Badajoz, Spain.
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Vermes E, Iacuzio L, Levy F, Bohbot Y, Renard C, Gerber B, Maréchaux S, Tribouilloy C. Role of Cardiovascular Magnetic Resonance in Native Valvular Regurgitation: A Comprehensive Review of Protocols, Grading of Severity, and Prediction of Valve Surgery. Front Cardiovasc Med 2022; 9:881141. [PMID: 35872899 PMCID: PMC9300884 DOI: 10.3389/fcvm.2022.881141] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/07/2022] [Indexed: 11/15/2022] Open
Abstract
Valvular regurgitation is common in developed countries with an increasing prevalence due to the aging of the population and more accurate diagnostic imaging methods. Echocardiography is the gold standard method for the assessment of the severity of valvular heart regurgitation. Nonetheless, cardiovascular magnetic resonance (CMR) has emerged as an additional tool for assessing mainly the severity of aortic and mitral valve regurgitation in the setting of indeterminate findings by echocardiography. Moreover, CMR is a valuable imaging modality to assess ventricular volume and flow, which are useful in the calculation of regurgitant volume and regurgitant fraction of mitral valve regurgitation, aortic valve regurgitation, tricuspid valve regurgitation, and pulmonary valve regurgitation. Notwithstanding this, reference values and optimal thresholds to determine the severity and prognosis of valvular heart regurgitation have been studied lesser by CMR than by echocardiography. Hence, further larger studies are warranted to validate the potential prognostic relevance of the severity of valvular heart regurgitation determined by CMR. The present review describes, analyzes, and discusses the use of CMR to determine the severity of valvular heart regurgitation in clinical practice.
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Affiliation(s)
- Emmanuelle Vermes
- Department of Cardiology, Amiens University Hospital, Amiens, France
- *Correspondence: Emmanuelle Vermes,
| | - Laura Iacuzio
- Department of Cardiology, Center Cardio-Thoracique de Monaco, Monaco, Monaco
| | - Franck Levy
- Department of Cardiology, Center Cardio-Thoracique de Monaco, Monaco, Monaco
| | - Yohann Bohbot
- Department of Cardiology, Amiens University Hospital, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
| | - Cédric Renard
- Department of Radiology, Amiens University Hospital, Amiens, France
| | - Bernhard Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium
| | - Sylvestre Maréchaux
- Department of Cardiology, Heart Valve Center, Lille Catholic University Hospital, Lille, France
| | - Christophe Tribouilloy
- Department of Cardiology, Amiens University Hospital, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
- Christophe Tribouilloy,
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Lancellotti P, Pibarot P, Chambers J, La Canna G, Pepi M, Dulgheru R, Dweck M, Delgado V, Garbi M, Vannan MA, Montaigne D, Badano L, Maurovich-Horvat P, Pontone G, Vahanian A, Donal E, Cosyns B. Multi-modality imaging assessment of native valvular regurgitation: an EACVI and ESC council of valvular heart disease position paper. Eur Heart J Cardiovasc Imaging 2022; 23:e171-e232. [PMID: 35292799 DOI: 10.1093/ehjci/jeab253] [Citation(s) in RCA: 126] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 01/10/2023] Open
Abstract
Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Imaging is pivotal in the evaluation of native valve regurgitation and echocardiography is the primary imaging modality for this purpose. The imaging assessment of valvular regurgitation should integrate quantification of the regurgitation, assessment of the valve anatomy and function, and the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation largely relies on the results of imaging. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing native valve regurgitation. The present document aims to present clinical guidance for the multi-modality imaging assessment of native valvular regurgitation.
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Affiliation(s)
- Patrizio Lancellotti
- Department of Cardiology, Valvular Disease Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, 4000 Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, Italy.,Anthea Hospital, Via Camillo Rosalba, 35, Bari, Italy
| | - Philippe Pibarot
- Department of Medicine, Québec Heart & Lung Institute, Laval University, 2725, chemin Sainte-Foy, Québec, Canada
| | - John Chambers
- Emeritus Professor of Clinical Cardiology, Guy's and St Thomas' Hospital, London SE1 7EH, UK
| | - Giovanni La Canna
- Cardiovascular Department, IRCCS Humanitas Clinical and Research Hospital, Applied Diagnostic Echocardiography, 20089 Rozzano, Milan, Italy
| | - Mauro Pepi
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| | - Raluca Dulgheru
- Department of Cardiology, Valvular Disease Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, 4000 Liège, Belgium
| | - Mark Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2 2300 RC Leiden, The Netherlands
| | - Madalina Garbi
- Royal Papworth Hospital, Cambridge University Health Partner, Cambridge Biomedical Campus, CB2 0AY Cambridge, UK
| | - Mani A Vannan
- Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, GA, USA
| | - David Montaigne
- University of Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, F-59000 Lille, France
| | - Luigi Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, 20089 Milan, Italy.,Department of Cardiac, Metabolic and Neural Sciences, Istituto Auxologico Italiano, IRCCS, 20089 Milan, Italy
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, 1083 Budapest, Hungary
| | | | - Alec Vahanian
- UFR Medecine, Université de Paris, Site Bichat, 16 rue Huchard, 75018 Paris, France.,LVTS INSERM U1148, GH Bichat, 46, rue Henri Huchard, 75018 Paris, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Rennes, France
| | - Bernard Cosyns
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
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7
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Tower-Rader A, Mathias IS, Obuchowski NA, Kocyigit D, Kumar Y, Donnellan E, Bolen M, Phelan D, Flamm S, Griffin B, Cho L, Svensson LG, Pettersson G, Popovic Z, Kwon D. Sex-based differences in left ventricular remodeling in patients with chronic aortic regurgitation: a multi-modality study. J Cardiovasc Magn Reson 2022; 24:12. [PMID: 35193584 PMCID: PMC8862390 DOI: 10.1186/s12968-022-00845-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/16/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Significant aortic regurgitation (AR) leads to left ventricular (LV) remodeling; however, little data exist regarding sex-based differences in LV remodeling in this setting. We sought to compare LV remodeling and AR severity, assessed by echocardiography and cardiovascular magnetic resonance (CMR), to discern sex-based differences. METHODS Patients with ≥ moderate chronic AR by echocardiography who underwent CMR within 90 days between December 2005 and October 2015 were included. Nonlinear regression models were built to assess the effect of AR regurgitant fraction (RF) on LV remodeling. A generalized linear model and Bland Altman analyses were constructed to evaluate differences between CMR and echocardiography. Referral for surgical intervention based on symptoms and LV remodeling was evaluated. RESULTS Of the 243 patients (48.3 ± 16.6 years, 58 (24%) female), 119 (49%) underwent surgical intervention with a primary indication of severe AR, 97 (82%) men, 22 (18%) women. Significant sex differences in LV remodeling emerged on CMR. Women demonstrated significantly smaller LV end-diastolic volume index (LVEDVI) (96.8 ml/m2 vs 125.6 ml/m2, p < 0.001), LV end-systolic volume index (LVESVI) (41.1 vs 54.5 ml/m2, p < 0.001), blunted LV dilation in the setting of increasing AR severity (LVEDVI p value < 0.001, LVESVI p value 0.011), and LV length indexed (8.32 vs 9.69 cm, p < 0.001). On Bland Altman analysis, a significant interaction with sex and LV diameters was evident, demonstrating a significant increase in the difference between CMR and echocardiography measurements as the LV enlarged in women: LVEDVI (p = 0.006), LVESVI (p < 0.001), such that echocardiographic measurements increasingly underestimated LV diameters in women as the LV enlarged. LV length was higher for males with a linear effect from RF (p < 0.001), with LV length increasing at a higher rate with increasing RF for males compared to females (two-way interaction with sex p = 0.005). Sphericity volume index was higher for men after adjusting for a relative wall thickness (p = 0.033). CONCLUSIONS CMR assessment of chronic AR revealed significant sex differences in LV remodeling and significant echocardiographic underestimation of LV dilation, particularly in women. Defining optimal sex-based CMR thresholds for surgical referral should be further developed. TRIAL REGISTRATION NA.
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Affiliation(s)
- Albree Tower-Rader
- Department of Cardiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Yawkey 5B, Boston, MA, 02114, USA
| | - Isadora Sande Mathias
- Department of Cardiology, Houston Methodist Hospital, Weill Cornell Medical College, 6565 Fannin St., Houston, TX, 77030, USA
| | - Nancy A Obuchowski
- Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Duygu Kocyigit
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Yash Kumar
- Case Western University, 10900 Euclid Ave, Cleveland, OH, 44106-7017, USA
| | - Eoin Donnellan
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Michael Bolen
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Dermot Phelan
- Sanger Heart & Vascular Institute, Atrium Health, 1237 Harding Place, MOB1 Suite 5000, Charlotte, NC, 28204, USA
| | - Scott Flamm
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Brian Griffin
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Leslie Cho
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Lars G Svensson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Gosta Pettersson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Zoran Popovic
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Deborah Kwon
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA.
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Hlubocká Z, Kočková R, Línková H, Pravečková A, Hlubocký J, Dostálová G, Bláha M, Pěnička M, Linhart A. Assessment of Asymptomatic Severe Aortic Regurgitation by Doppler-Derived Echo Indices: Comparison with Magnetic Resonance Quantification. J Clin Med 2021; 11:jcm11010152. [PMID: 35011893 PMCID: PMC8745471 DOI: 10.3390/jcm11010152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/14/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
Reliable quantification of aortic regurgitation (AR) severity is essential for clinical management. We aimed to compare quantitative and indirect echo-Doppler indices to quantitative cardiac magnetic resonance (CMR) parameters in asymptomatic chronic severe AR. Methods and Results: We evaluated 104 consecutive patients using echocardiography and CMR. A comprehensive 2D, 3D, and Doppler echocardiography was performed. The CMR was used to quantify regurgitation fraction (RF) and volume (RV) using the phase-contrast velocity mapping technique. Concordant grading of AR severity with both techniques was observed in 77 (74%) patients. Correlation between RV and RF as assessed by echocardiography and CMR was relatively good (rs = 0.50 for RV, rs = 0.40 for RF, p < 0.0001). The best correlation between indirect echo-Doppler and CMR parameters was found for diastolic flow reversal (DFR) velocity in descending aorta (rs = 0.62 for RV, rs = 0.50 for RF, p < 0.0001) and 3D vena contracta area (VCA) (rs = 0.48 for RV, rs = 0.38 for RF, p < 0.0001). Using receiver operating characteristic analysis, the largest area under curve (AUC) to predict severe AR by CMR RV was observed for DFR velocity (AUC = 0.79). DFR velocity of 19.5 cm/s provided 78% sensitivity and 80% specificity. The AUC for 3D VCA to predict severe AR by CMR RV was 0.73, with optimal cut-off of 26 mm2 (sensitivity 80% and specificity 66%). Conclusions: Out of the indirect echo-Doppler indices of AR severity, DFR velocity in descending aorta and 3D vena contracta area showed the best correlation with CMR-derived RV and RF in patients with chronic severe AR.
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Affiliation(s)
- Zuzana Hlubocká
- Department of Cardiovascular Medicine, General University Hospital, 12808 Prague, Czech Republic; (G.D.); (A.L.)
- Correspondence: ; Tel.: +420-224-962-635
| | - Radka Kočková
- Department of Cardiology, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic; (R.K.); (A.P.); (M.B.)
| | - Hana Línková
- Department of Cardiology, Royal Vinohrady University Hospital, 10034 Prague, Czech Republic;
| | - Alena Pravečková
- Department of Cardiology, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic; (R.K.); (A.P.); (M.B.)
| | - Jaroslav Hlubocký
- Department of Cardiovascular Surgery, General University Hospital, 12808 Prague, Czech Republic;
| | - Gabriela Dostálová
- Department of Cardiovascular Medicine, General University Hospital, 12808 Prague, Czech Republic; (G.D.); (A.L.)
| | - Martin Bláha
- Department of Cardiology, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic; (R.K.); (A.P.); (M.B.)
| | - Martin Pěnička
- Onze-Lieve-Vrouwziekenhuis Aalst Clinic, Cardiovascular Centre Aalst, 9300 Aalst, Belgium;
| | - Aleš Linhart
- Department of Cardiovascular Medicine, General University Hospital, 12808 Prague, Czech Republic; (G.D.); (A.L.)
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9
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Truedsson F, Polte CL, Gao SA, Johnsson ÅA, Bech-Hanssen O, Lagerstrand KM. Importance of complex blood flow in the assessment of aortic regurgitation severity using phase contrast magnetic resonance imaging. Int J Cardiovasc Imaging 2021; 37:3561-3572. [PMID: 34273066 PMCID: PMC8604828 DOI: 10.1007/s10554-021-02341-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/02/2021] [Indexed: 01/10/2023]
Abstract
This study aimed to investigate if and how complex flow influences the assessment of aortic regurgitation (AR) using phase contrast MRI in patients with chronic AR. Patients with moderate (n = 15) and severe (n = 28) chronic AR were categorized into non-complex flow (NCF) or complex flow (CF) based on the presence of systolic backward flow volume. Phase contrast MRI was performed repeatedly at the level of the sinotubular junction (Ao1) and 1 cm distal to the sinotubular junction (Ao2). All AR patients were assessed to have non-severe AR or severe AR (cut-off values: regurgitation volume (RVol) ≥ 60 ml and regurgitation fraction (RF) ≥ 50%) in both measurement positions. The repeatability was significantly lower, i.e. variation was larger, for patients with CF than for NCF (≥ 12 ± 12% versus ≥ 6 ± 4%, P ≤ 0.03). For patients with CF, the repeatability was significantly lower at Ao2 compared to Ao1 (≥ 21 ± 20% versus ≥ 12 ± 12%, P ≤ 0.02), as well as the assessment of regurgitation (RVol: 42 ± 34 ml versus 54 ± 42 ml, P < 0.001; RF: 30 ± 18% versus 34 ± 16%, P = 0.01). This was not the case for patients with NCF. The frequency of patients that changed in AR grade from severe to non-severe when the position of the measurement changed from Ao1 to Ao2 was higher for patients with CF compared to NCF (RVol: 5/26 (19%) versus 1/17 (6%), P = 0.2; RF: 4/26 (15%) versus 0/17 (0%), P = 0.09). Our study shows that complex flow influences the quantification of chronic AR, which can lead to underestimation of AR severity when using PC-MRI.
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Affiliation(s)
- Frida Truedsson
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, 413 45, Gothenburg, Sweden. .,Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden. .,Sahlgrenska University Hospital, MR-Centre, Bruna stråket 13, 413 45, Gothenburg, Sweden.
| | - Christian L Polte
- Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, 413 45, Gothenburg, Sweden.,Department of Cardiology, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.,Department of Clinical Physiology, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.,Department of Radiology, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Sinsia A Gao
- Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, 413 45, Gothenburg, Sweden.,Department of Clinical Physiology, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Åse A Johnsson
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, 413 45, Gothenburg, Sweden.,Department of Radiology, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Odd Bech-Hanssen
- Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, 413 45, Gothenburg, Sweden.,Department of Clinical Physiology, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Kerstin M Lagerstrand
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, 413 45, Gothenburg, Sweden.,Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
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10
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Canan A, Ashwath R, Agarwal PP, François C, Rajiah P. Multimodality Imaging of Transposition of the Great Arteries. Radiographics 2021; 41:338-360. [PMID: 33481689 DOI: 10.1148/rg.2021200069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Transposition of the great arteries (TGA) is a congenital conotruncal abnormality characterized by discordant connections between the ventricles and great arteries, with the aorta originating from the right ventricle (RV), and the pulmonary artery (PA) originating from the left ventricle (LV). The two main types of TGA are complete transposition or dextro-transposition of the great arteries (D-TGA), commonly referred to as d-loop, and congenitally corrected transposition (CCTGA), commonly referred to as l-loop or L-TGA. In D-TGA, the connections between the ventricles and atria are concordant, whereas in CCTGA they are discordant, with the left atrium connected to the RV, and the right atrium connected to the LV. D-TGA manifests during the neonatal period and can be surgically managed by atrial switch operation (AtrSO), arterial switch operation (ASO), Rastelli procedure, or Nikaidoh procedure. Arrhythmia, systemic ventricular dysfunction, baffle stenosis, and baffle leak are the common complications of AtrSO, whereas supravalvular pulmonary or branch PA stenosis, neoaortic dilatation, and coronary artery narrowing are the common complications of ASO. CCTGA may manifest late in life, even in adulthood. Surgeries for associated lesions such as tricuspid regurgitation, subpulmonic stenosis, and ventricular septal defect may be performed. A double-switch operation that includes both the atrial and arterial switch operations constitutes anatomic correction for CCTGA. Imaging plays an important role in the evaluation of TGA, both before and after surgery, for helping define the anatomy, quantify hemodynamics, and evaluate complications. Transthoracic echocardiography is the first-line imaging modality for presurgical planning in children with TGA. MRI provides comprehensive morphologic and functional information, particularly in adults after surgery. CT is performed when MRI is contraindicated or expected to generate artifacts. The authors review the imaging appearances of TGA, with a focus on pre- and postsurgical imaging. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Arzu Canan
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (A.C.); Department of Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa (R.A.); Department of Radiology, University of Michigan, Ann Arbor, Mich (P.P.A.); and Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (C.F., P.R.)
| | - Ravi Ashwath
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (A.C.); Department of Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa (R.A.); Department of Radiology, University of Michigan, Ann Arbor, Mich (P.P.A.); and Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (C.F., P.R.)
| | - Prachi P Agarwal
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (A.C.); Department of Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa (R.A.); Department of Radiology, University of Michigan, Ann Arbor, Mich (P.P.A.); and Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (C.F., P.R.)
| | - Christopher François
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (A.C.); Department of Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa (R.A.); Department of Radiology, University of Michigan, Ann Arbor, Mich (P.P.A.); and Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (C.F., P.R.)
| | - Prabhakar Rajiah
- From the Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (A.C.); Department of Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa (R.A.); Department of Radiology, University of Michigan, Ann Arbor, Mich (P.P.A.); and Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (C.F., P.R.)
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11
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Alvarez A, Martinez V, Pizarro G, Recio M, Cabrera JÁ. Clinical use of 4D flow MRI for quantification of aortic regurgitation. Open Heart 2020; 7:e001158. [PMID: 32153789 PMCID: PMC7046971 DOI: 10.1136/openhrt-2019-001158] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/27/2019] [Accepted: 01/07/2020] [Indexed: 12/20/2022] Open
Abstract
Objective The main objective of the present study was to compare the use of four-dimensional (4D) flow MRI with the habitual sequence (two-dimensional phase-contrast (2DPC) MRI) for the assessment of aortic regurgitation (AR) in the clinical routine. Methods This was a retrospective, observational cohort study of patients with varying grades of AR. For the purposes of the present study, we selected all the cases with a regurgitant fraction (RF)>5% as determined by 2DPC MRI (n=34). In all cases, both sequences (2DPC and 4D flow MRI) were acquired in a single session to ensure comparability. We compared the results of the two techniques by evaluating forward flow, regurgitant flow and regurgitation fraction. Then, the patients were divided into subgroups to determine if these factors had any influence on the measurements: aortic diameter (≤ vs >38 mm), valve anatomy (tricuspid vs bicuspid/quadricuspid), stenosis (gradient ≥15 vs <15) and region of interest location (aortic valve vs sinotubular junction). Results No statistically significant differences were observed between the two techniques with Pearson’s correlation coefficients (r) of forward flow (r=0.826/p value<0001), regurgitant flow (r=0.866/p value<0001) and RF (r=0.761/p value<0001). Conclusions The findings of this study confirm the value of 4D flow MRI for grading AR in clinical practice with an excellent correlation with the standard technique (2DPC MRI).
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Affiliation(s)
- Ana Alvarez
- Imaging Department, Hospital Universitario Quironsalud Madrid, Madrid, Spain.,Universidad Europea de Madrid, Madrid, Spain
| | - Vicente Martinez
- Imaging Department, Hospital Universitario Quironsalud Madrid, Madrid, Spain
| | - Gonzalo Pizarro
- Universidad Europea de Madrid, Madrid, Spain.,Department of Cardiology, Complejo Hospitalario Ruber Juan Bravo, Madrid, Spain
| | - Manuel Recio
- Imaging Department, Hospital Universitario Quironsalud Madrid, Madrid, Spain
| | - Jose Ángel Cabrera
- Department of Cardiology, Hospital Universitario Quironsalud Madrid, Madrid, Madrid, Spain
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12
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Zoghbi W, Adams D, Bonow R, Enriquez-Sarano M, Foster E, Grayburn P, Hahn R, Han Y, Hung J, Lang R, Little S, Shah D, Shernan S, Thavendiranathan P, Thomas J, Weissman N. Recommendations for noninvasive evaluation of native valvular regurgitation
A report from the american society of echocardiography developed in collaboration with the society for cardiovascular magnetic resonance. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2020. [DOI: 10.4103/2543-1463.282191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Pure Aortic Regurgitation in Pediatric Patients. Am J Cardiol 2019; 124:1731-1735. [PMID: 31586532 DOI: 10.1016/j.amjcard.2019.08.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/13/2019] [Accepted: 08/19/2019] [Indexed: 01/09/2023]
Abstract
Aortic regurgitation (AR) continues to be an important cause of morbidity and mortality in pediatric patients. Although echocardiographic parameters are well established for the adults, there are no clear cut-off values for AR severity in children. Cardiac magnetic resonance (CMR) imaging is considered a "gold standard" for a quantitative evaluation of the AR, but it is not widely available. This study assesses which echo parameter can accurately define AR severity as assessed by CMR in pediatric patients. A total of 27 pediatric patients (12 ± 3 years, range 6 to 18 years) with different degree of AR underwent echo assessment within an average of 35 days from CMR. CMR included phase-contrast velocity-encoded imaging for the measurement of regurgitant fraction (RF). Severe AR was defined as RF >33%. Echo evaluation included vena contracta, pressure half time, the ratio between the AR jet and the left ventricular outflow tract diameter (jet/left ventricular outflow tract), presence of holodiastolic reversal flow in abdominal aorta, the ratio between the velocity-time integral of the reversal flow over the forward flow in descending aorta (echoRF). Among the studied parameters, the strongest predictor of severe AR, as assessed by CMR, was echoRF. Receiver-operating characteristic curve showed, for a cutoff >0.38, an area under the curve of 0.886 (p <0.0001), a sensitivity of 71%, and a specificity of 100%. Correlation coefficient between echoRF and RF was R = 0.929 (p <0.0001). In conclusion, echoRF is a strong echo-Doppler marker of severe AR in the pediatric population. This parameter should be routinely added in the standard echo evaluation of pediatric patients with AR.
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14
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Kammerlander AA, Wiesinger M, Duca F, Aschauer S, Binder C, Zotter Tufaro C, Nitsche C, Badre-Eslam R, Schönbauer R, Bartko P, Beitzke D, Loewe C, Hengstenberg C, Bonderman D, Mascherbauer J. Diagnostic and Prognostic Utility of Cardiac Magnetic Resonance Imaging in Aortic Regurgitation. JACC Cardiovasc Imaging 2019; 12:1474-1483. [DOI: 10.1016/j.jcmg.2018.08.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/17/2018] [Accepted: 08/21/2018] [Indexed: 10/27/2022]
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15
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Myerson SG. Optimizing the Assessment of Aortic Regurgitation: The Importance of Quantity and Quality. JACC Cardiovasc Imaging 2018; 12:1484-1486. [PMID: 30448127 DOI: 10.1016/j.jcmg.2018.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 09/06/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Saul G Myerson
- Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, Oxford, United Kingdom.
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16
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Popović ZB, Desai MY, Griffin BP. Decision Making With Imaging in Asymptomatic Aortic Regurgitation. JACC Cardiovasc Imaging 2018; 11:1499-1513. [DOI: 10.1016/j.jcmg.2018.05.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/07/2018] [Accepted: 05/18/2018] [Indexed: 10/28/2022]
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17
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Lee JC, Branch KR, Hamilton-Craig C, Krieger EV. Evaluation of aortic regurgitation with cardiac magnetic resonance imaging: a systematic review. Heart 2017; 104:103-110. [PMID: 28822982 DOI: 10.1136/heartjnl-2016-310819] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 07/31/2017] [Indexed: 11/03/2022] Open
Abstract
This review summaries the utility, application and data supporting use of cardiac magnetic resonance imaging (CMR) to evaluate and quantitate aortic regurgitation. We systematically searched Medline and PubMed for original research articles published since 2000 that provided data on the quantitation of aortic regurgitation by CMR and identified 11 articles for review. Direct aortic measurements using phase contrast allow quantitation of volumetric flow across the aortic valve and are highly reproducible and accurate compared with echocardiography. However, this technique requires diligence in prescribing the correct imaging planes in the aorta. Volumetric analytic techniques using differences in ventricular volumes are also highly accurate but less than phase contrast techniques and only accurate when concomitant valvular disease is absent. Comparison of both aortic and ventricular data for internal data verification ensures fidelity of aortic regurgitant data. CMR data can be applied to many types of aortic valve regurgitation including combined aortic stenosis with regurgitation, congenital valve diseases and post-transcatheter valve placement. CMR also predicts those patients who progress to surgery with high overall sensitivity and specificity. Future studies of CMR in patients with aortic regurgitation to quantify the incremental benefit over echocardiography as well as prediction of cardiovascular events are warranted.
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Affiliation(s)
- James C Lee
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Kelley R Branch
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Christian Hamilton-Craig
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA.,Centre for Advanced Imaging, University of Queensland, Brisbane, Queensland, Australia.,Department of Cardiology, Heart & Lung Institute, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Eric V Krieger
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA.,Seattle Adult Congenital Heart Service, University of Washington School of Medicine, Seattle, Washington, USA
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18
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19
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Avitabile CM, Whitehead KK, Fogel MA, Kim DW, Kim TS, Rose JD, Keller MS, Fu GL, Harris MA. Holodiastolic Flow Reversal at the Descending Aorta on Cardiac Magnetic Resonance is Neither Sensitive Nor Specific for Significant Aortic Regurgitation in Patients with Congenital Heart Disease. Pediatr Cardiol 2016; 37:1284-9. [PMID: 27312779 DOI: 10.1007/s00246-016-1430-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Abstract
Holodiastolic flow reversal in the descending aorta on echocardiogram suggests significant aortic regurgitation. The study aim was to determine whether the presence of holodiastolic flow reversal on cardiac magnetic resonance imaging (MRI) correlates with aortic valve regurgitant fraction. We retrospectively reviewed 166 cardiac MRIs (64 % male, age 14.1 ± 9.5 years) from January 2011 to May 2012 where velocity mapping was acquired at both the aortic valve and the descending aorta at the level of the diaphragm. Descending aorta velocity maps were checked for baseline offset using a static reference region. Holodiastolic flow reversal was defined as flow reversal throughout diastole both before and after baseline correction. Significant aortic regurgitation was defined as regurgitant fraction >10 %. Aortic valve regurgitant fraction was <10 % in 144 patients (Group A), 10-20 % inclusive in 7 patients (Group B), and >20 % in 15 patients (Group C). Though the aortic valve regurgitant fraction was significantly higher for patients with holodiastolic flow reversal versus those without (8.5 ± 14.2 vs. 3.8 ± 6.6 %, p = 0.02), holodiastolic flow reversal was present in 32 Group A patients (22 %). In comparison, 4 Group B patients (57 %) and 7 Group C patients (47 %) had holodiastolic flow reversal. The sensitivity (Groups B and C) was 0.5, and the specificity (Group A) was 0.78. Holodiastolic flow reversal in the descending aorta on cardiac MRI was neither sensitive nor specific for predicting significant aortic regurgitation in this study population. Holodiastolic flow reversal in the absence of significant aortic regurgitation may be a relatively common finding in patients with congenital heart disease.
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Affiliation(s)
- Catherine M Avitabile
- Division of Cardiology, St. Christopher's Hospital for Children, 160 East Erie Avenue, Philadelphia, PA, 19134, USA. .,Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Kevin K Whitehead
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Mark A Fogel
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Daniel W Kim
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Timothy S Kim
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Julian D Rose
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Marc S Keller
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Gregory L Fu
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Matthew A Harris
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA
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Abdelghani M, Soliman OI, Schultz C, Vahanian A, Serruys PW. Adjudicating paravalvular leaks of transcatheter aortic valves: a critical appraisal. Eur Heart J 2016; 37:2627-44. [DOI: 10.1093/eurheartj/ehw115] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 03/01/2016] [Indexed: 12/18/2022] Open
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Cavalcante JL, Lalude OO, Schoenhagen P, Lerakis S. Cardiovascular Magnetic Resonance Imaging for Structural and Valvular Heart Disease Interventions. JACC Cardiovasc Interv 2016; 9:399-425. [DOI: 10.1016/j.jcin.2015.11.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 11/30/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022]
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22
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Multimodality Noninvasive Imaging of Thoracic Aortic Aneurysms: Time to Standardize? Can J Cardiol 2016; 32:48-59. [DOI: 10.1016/j.cjca.2015.09.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 09/10/2015] [Accepted: 09/11/2015] [Indexed: 01/16/2023] Open
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23
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Assessment of Post-Procedural Aortic Regurgitation After TAVR. JACC Cardiovasc Imaging 2015; 8:993-1003. [DOI: 10.1016/j.jcmg.2015.02.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 01/30/2015] [Accepted: 02/17/2015] [Indexed: 11/17/2022]
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24
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Multimodality Imaging of Diseases of the Thoracic Aorta in Adults: From the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:119-82. [DOI: 10.1016/j.echo.2014.11.015] [Citation(s) in RCA: 409] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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25
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Kusunose K, Cremer PC, Tsutsui RS, Grimm RA, Thomas JD, Griffin BP, Popović ZB. Regurgitant Volume Informs Rate of Progressive Cardiac Dysfunction in Asymptomatic Patients With Chronic Aortic or Mitral Regurgitation. JACC Cardiovasc Imaging 2015; 8:14-23. [DOI: 10.1016/j.jcmg.2014.09.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/15/2014] [Accepted: 09/22/2014] [Indexed: 11/25/2022]
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26
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Assessment of Hemodynamics by Magnetic Resonance Imaging. CONGENIT HEART DIS 2015. [DOI: 10.1007/978-4-431-54355-8_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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27
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Direct measurement of aortic regurgitation with phase-contrast magnetic resonance is inaccurate: proposal of an alternative method of quantification. Pediatr Radiol 2014; 44:1358-69. [PMID: 24939669 DOI: 10.1007/s00247-014-3017-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 02/12/2014] [Accepted: 04/25/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Phase-contrast magnetic resonance (MR) has been widely used for quantification of aortic regurgitation. However there is significant practice variability regarding where and how the blood flow data are acquired. OBJECTIVE To compare the accuracy of flow quantification of aortic regurgitation at three levels: the ascending aorta at the level of the right pulmonary artery (level 1), the aortic valve hinge points at end-diastole (level 2) and the aortic valve hinge points at end-systole (level 3). MATERIALS AND METHODS We performed cardiovascular MR in 43 children with aortic regurgitation. By using phase-contrast MR, we measured the systolic forward, diastolic retrograde and net forward flow volume indices at three levels. At each level, the following comparisons were made: (1) systolic forward flow volume index (FFVI) versus left ventricular cardiac index (LVCI) measured by cine ventricular volumetry; (2) retrograde flow volume index (RFVI) versus estimated aortic regurgitation volume index (which equals LVCI minus pulmonary blood flow index [QPI]); (3) net forward flow volume index (NFVI) versus pulmonary blood flow index. RESULTS The forward flow volume index, retrograde flow volume index and net forward flow volume index measured at each of the three levels were significantly different except for the retrograde flow volume index measured at levels 1 and 3. There were good correlations between the forward flow volume index and the left ventricular cardiac index at all three levels, with measurement at level 2 showing the best correlation. Compared to the forward flow volume indices, the retrograde flow volume index had a lower correlation with the estimated aortic regurgitation volume indices and had widely dispersed data with larger prediction intervals. CONCLUSION Large variations in systolic forward, diastolic retrograde and net forward flow volumes were observed at different levels of the aortic valve and ascending aorta. Direct measurement of aortic regurgitation volume and fraction is inaccurate and should be abandoned. Instead, calculation of the aortic regurgitation volume from more reliable data is advised. We recommend subtracting pulmonary blood flow from systolic forward flow measured at the aortic valve hinge points at end-diastole as a more accurate and consistent method for calculating the volume of aortic regurgitation.
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Tsutsui RS, Borowski A, Tang WHW, Thomas JD, Popović ZB. Precision of echocardiographic estimates of right atrial pressure in patients with acute decompensated heart failure. J Am Soc Echocardiogr 2014; 27:1072-1078.e2. [PMID: 25022574 DOI: 10.1016/j.echo.2014.06.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several methods that estimate right atrial pressure (RAP) from echocardiographic parameters have been proposed. However, their precision (i.e., how much they decrease RAP estimation uncertainty) is unknown. The aim of this prospective study was to evaluate and compare the precision of previously proposed RAP estimates in patients with acute decompensated heart failure. METHODS Echocardiographic and invasive hemodynamic data were acquired in 75 patients with acute decompensated heart failure. Measurements were made at the start and 48 to 72 hours after the beginning of treatment. RAP was estimated by method 1, using the cutoffs defined by inferior vena cava diameter (IVCd) and IVCd percentage change (IVCd%change) during inspiration, and by method 2, using IVCd%change and systolic to diastolic hepatic flow ratio (S/Dhep). Method 3 was used in patients with sinus rhythm, using the ratio of early tricuspid inflow and early diastolic tissue Doppler tricuspid annular velocities (E/E'ta). RAP was also estimated by resting IVCd, IVCd during inspiration, IVCd%change, right ventricular regional isovolumetric relaxation time, E/E'ta, right atrial volume index, S/Dhep, right ventricular Tei index, right ventricular E/A, and right atrial emptying fraction. Precision gain was measured as the difference between the standard deviation of RAP and the standard error of the estimate of RAP. RESULTS Method 1 (r = 0.48, P < .05), IVCd during inspiration (r = 0.49, P < .0001), IVCd%change (r = 0.41, P < .0001) and IVCd (r = 0.40, P < .0001) had the highest correlation with RAP. The highest gain in precision was also observed with the above methods (9%, 13%, 9%, and 8%, respectively). All other parameters had poor correlation with RAP. CONCLUSION In patients with advanced heart failure, echocardiographic RAP prediction methods showed only modest precision. Furthermore, none of the tested methods resulted in clinically relevant improvements of RAP estimates. Estimating RAP from a single IVCd measurement is at least as precise as using complex prediction methods.
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Affiliation(s)
- Rayji S Tsutsui
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Allen Borowski
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - W H Wilson Tang
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - James D Thomas
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Zoran B Popović
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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29
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Kusunose K, Agarwal S, Marwick TH, Griffin BP, Popović ZB. Decision Making in Asymptomatic Aortic Regurgitation in the Era of Guidelines. Circ Cardiovasc Imaging 2014; 7:352-62. [DOI: 10.1161/circimaging.113.001177] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background—
The decision-making role of exercise echocardiography in the surgical timing for aortic regurgitation remains a matter of debate because of limited data on its link with outcome. The aim of this study was to assess the role of echocardiographic measurements at rest and during exercise as predictors of valve surgery in asymptomatic aortic regurgitation.
Methods and Results—
Comprehensive resting and exercise echocardiography was performed in 159 consecutive patients (50±15 years; 80% male) with isolated moderately severe to severe aortic regurgitation and preserved left ventricular (LV) function (LV ejection fraction >50%, LV end-diastolic dimension ≤70 mm, LV end-systolic dimension ≤50 mm or ≤25 mm/m
2
) in whom initial management was expectant. Echocardiographic measurements were performed at rest and during exercise. LV and right ventricular (RV) longitudinal strain was analyzed at rest using velocity vector imaging. Valve surgery was performed in 50 patients (31%) during 30±21 months. After adjustment for age and sex in a multivariable Cox proportional-hazards model, exercise tricuspid annular plane systolic excursion (TAPSE; hazards ratio [HR], 0.48;
P
=0.001) was associated with valve surgery-free, independent of resting LV strain (HR, 1.63;
P
=0.005), exercise LV end-diastolic volume (HR, 1.38;
P
=0.048), and resting RV strain (HR, 1.69;
P
=0.002). In sequential Cox models, a model based on clinical data (χ
2
, 20.4) was improved by resting LV strain (χ
2
, 30.1;
P
=0.001), resting RV strain (χ
2
, 49.7;
P
<0.001), and further increased by exercise TAPSE (χ
2
, 64.4;
P
<0.001).
Conclusions—
In asymptomatic aortic regurgitation, resting LV strain, resting RV strain, and exercise TAPSE were independently associated with the need for earlier aortic surgery.
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Affiliation(s)
- Kenya Kusunose
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (K.K., S.A., T.H.M., B.P.G., Z.B.P.); and Menzies Research Institute, Tasmania, Australia (T.H.M.)
| | - Shikhar Agarwal
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (K.K., S.A., T.H.M., B.P.G., Z.B.P.); and Menzies Research Institute, Tasmania, Australia (T.H.M.)
| | - Thomas H. Marwick
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (K.K., S.A., T.H.M., B.P.G., Z.B.P.); and Menzies Research Institute, Tasmania, Australia (T.H.M.)
| | - Brian P. Griffin
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (K.K., S.A., T.H.M., B.P.G., Z.B.P.); and Menzies Research Institute, Tasmania, Australia (T.H.M.)
| | - Zoran B. Popović
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (K.K., S.A., T.H.M., B.P.G., Z.B.P.); and Menzies Research Institute, Tasmania, Australia (T.H.M.)
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30
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Sugimoto M, Kajino H, Kajihama A, Nakau K, Murakami N, Azuma H. Assessment of pulmonary arterial pressure by velocity-encoded cine magnetic resonance imaging in children with congenital heart disease. Circ J 2013; 77:3015-22. [PMID: 24088305 DOI: 10.1253/circj.cj-13-0626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Velocity-encoded cine magnetic resonance imaging (VEC-MRI) has recently been reported as effective for assessing not only pulmonary blood flow (Qp) but also pulmonary arterial pressure (PAP) in adults. However, there have been few reports on the usefulness of VEC-MRI for assessing PAP in children with congenital heart disease (CHD). METHODS AND RESULTS We evaluated 34 children with CHD. Qp and systemic blood flows (Qs) were determined by cardiac catheterization and VEC-MRI. The right-to-left Qp ratio (R/L) was measured by pulmonary perfusion scintigraphy and VEC-MRI. The pulmonary-to-systemic blood pressure ratio (Pp/Ps) was determined by cardiac catheterization. The acceleration time (AcT), ejection time (ET), peak velocity (PV), acceleration volume (AcV), and maximal change in flow rate during ejection (MCFR) in the pulmonary arteries, which were standardized by body surface area, were determined by VEC-MRI. The children were divided into 2 groups according to Pp/Ps. The Qs, R/L ratio and Qp/Qs obtained by VEC-MRI strongly correlated with those obtained by catheterization and scintigraphy. No significant differences in AcT, ET, AcT/ET, PV, or AcV were observed between the 2 groups. However, a significant difference was observed in MCFR. Furthermore, a significant correlation was observed between the MCFR and Pp/Ps. CONCLUSIONS This study clearly demonstrated that VEC-MRI is useful for assessing not only blood flow, but also PAP, by referring to MCFR in children.
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31
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Harvey JJ, Hoey ETD, Ganeshan A. Imaging of the aortic valve with MRI and CT angiography. Clin Radiol 2013; 68:1192-205. [PMID: 24034550 DOI: 10.1016/j.crad.2013.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 06/20/2013] [Accepted: 07/15/2013] [Indexed: 12/31/2022]
Abstract
The aortic valve may be affected by a wide range of congenital and acquired diseases. Echocardiography is the main non-invasive imaging technique for assessing patho-anatomical alterations of the aortic valve and adjacent structures and in many cases is sufficient to establish a diagnosis and/or guide treatment decisions. Recent technological advances in magnetic resonance imaging (MRI) and multidetector computed tomography (MDCT) have enabled these techniques to play a complimentary role in certain clinical scenarios and as such can be useful problem-solving tools. Radiologists should be familiar with the indications, advantages, and limitations of MRI and MDCT in order to advise and direct an appropriate imaging strategy depending upon the clinical scenario. This article reviews the role of MRI and MDCT angiography for assessment of the aortic valve including relevant anatomy, scan acquisition protocols, and post-processing methods. An approach to interpretation and the key imaging features of commonly encountered aortic valvular diseases are discussed.
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Affiliation(s)
- J J Harvey
- Department of Radiology and Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Edgbaston, UK
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32
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Dahiya A, Bolen M, Grimm RA, Rodriguez LL, Thomas JD, Marwick TH. Development of a consensus document to improve multireader concordance and accuracy of aortic regurgitation severity grading by echocardiography versus cardiac magnetic resonance imaging. Am J Cardiol 2012; 110:709-14. [PMID: 22651878 DOI: 10.1016/j.amjcard.2012.04.052] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Revised: 04/26/2012] [Accepted: 04/26/2012] [Indexed: 11/30/2022]
Abstract
Current guidelines recommend a multiparametric echocardiographic assessment of aortic regurgitation (AR). However, the absence of a hierarchical weighting of discordant parameters could cause interobserver variability. In the present study, we sought to define and improve the interobserver variability of AR assessment. Seventeen level 3 readers graded 20 randomly selected patients with AR. The readers also provided a usefulness score for each parameter, depending on its influence on their decision of the AR severity grade. A consensus strategy was subsequently formulated and validated against cardiac magnetic resonance imaging in a separate group of 80 patients. The readers were updated with the consensus document and recalibrated using the same cases. Agreement was statistically assessed using Randolph's free-marginal multirater kappa. At baseline, no uniform approach was used to combine the individual parameters, contributing to the interobserver variability (overall kappa 0.5). A consensus strategy to categorize AR severity was developed in which the left ventricular volume took precedence over the other parameters and was used to differentiate chronic severe AR from less severe categories. Recalibration of the readers using this consensus strategy improved concordance (kappa increased to 0.7). The new strategy also improved the accuracy relative to cardiac magnetic resonance imaging, as evidenced by full agreement on severe AR between the consensus document-based grading and AR severity defined by cardiac magnetic resonance imaging in the separate validation group of 80 patients. In conclusion, grading of chronic AR using a multiparametric approach has suboptimal consistency between readers and a left ventricular volume-based consensus document improved concordance and accuracy.
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33
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To ACY, Desai MY. Role of cardiac magnetic resonance imaging in assessing ischemic and nonischemic cardiomyopathies. Expert Rev Cardiovasc Ther 2012; 10:223-33. [PMID: 22292878 DOI: 10.1586/erc.11.194] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
One of the diagnostic challenges in cardiology is the assessment of patients with suspected cardiomyopathies. The traditional approach involves clinical history and examination, followed by echocardiography and invasive angiography. Advances in cardiac MRI enable cardiologists to comprehensively assess both ischemic and nonischemic cardiomyopathies, providing information regarding cardiac anatomy, myocardial and valve functions, as well as tissue characterization.
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Affiliation(s)
- Andrew C Y To
- Department of Cardiovascular Medicine, North Shore Hospital, Auckland, New Zealand
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