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Yang J, Huang Y, Li X, Jia Q, Deng H, Xie N, Huang M, Fei H. The effects of cardiac structure, valvular regurgitation, and left ventricular diastolic dysfunction on the diagnostic accuracy of Murray law-based quantitative flow ratio. Front Cardiovasc Med 2023; 10:1134623. [PMID: 37293286 PMCID: PMC10246742 DOI: 10.3389/fcvm.2023.1134623] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 05/08/2023] [Indexed: 06/10/2023] Open
Abstract
Objective The study aimed to investigate the diagnostic accuracy of Murray law-based quantitative flow ratio (μQFR) from a single angiographic view in patients with abnormal cardiac structure, left ventricular diastolic dysfunction, and valvular regurgitation. Background μQFR is a novel fluid dynamics method for deriving fractional flow reserve (FFR). In addition, current studies of μQFR mainly analyzed patients with normal cardiac structure and function. The accuracy of μQFR when patients had abnormal cardiac structure, left ventricular diastolic dysfunction, and valvular regurgitation has not been clear. Methods This study retrospectively analyzed 261 patients with 286 vessels that underwent both FFR and μQFR prior to intervention. The cardiac structure and function were measured using echocardiography. Pressure wire-derived FFR ≤0.80 was defined as hemodynamically significant coronary stenosis. Results μQFR had a moderate correlation with FFR (r = 0.73, p < 0.001), and the Bland-Altman plot presented no difference between the μQFR and FFR (0.006 ± 0.075, p = 0.192). With FFR as the standard, the diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of μQFR were 94.06% (90.65-96.50), 82.56% (72.87-89.90), 99.00% (96.44-99.88), 97.26 (89.91-99.30), and 92.96% (89.29-95.44), respectively. The concordance of μQFR/FFR was not associated with abnormal cardiac structure, valvular regurgitation (aortic valve, mitral valve, and tricuspid valve), and left ventricular diastolic function. Coronary hemodynamics showed no difference between normality and abnormality of cardiac structure and left ventricular diastolic function. Coronary hemodynamics demonstrated no difference among valvular regurgitation (none, mild, moderate, or severe). Conclusion μQFR showed an excellent agreement with FFR. The effect of abnormal cardiac structure, valvular regurgitation, and left ventricular diastolic function did not correlate with the diagnostic accuracy of μQFR. Coronary hemodynamics showed no difference in patients with abnormal cardiac structure, valvular regurgitation, and left ventricular diastolic function.
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Affiliation(s)
- Junqing Yang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Yuming Huang
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Xiaoshan Li
- Guangdong Medical University, Zhanjiang, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Qianjun Jia
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Huiliang Deng
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Nianjin Xie
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Meiping Huang
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Hongwen Fei
- Guangdong Medical University, Zhanjiang, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
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Altes A, Vermes E, Levy F, Vancraeynest D, Pasquet A, Vincentelli A, Gerber BL, Tribouilloy C, Maréchaux S. Quantification of primary mitral regurgitation by echocardiography: A practical appraisal. Front Cardiovasc Med 2023; 10:1107724. [PMID: 36970355 PMCID: PMC10036770 DOI: 10.3389/fcvm.2023.1107724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/20/2023] [Indexed: 03/12/2023] Open
Abstract
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.
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Affiliation(s)
- Alexandre Altes
- GCS-Groupement des Hôpitaux de l’Institut Catholique de Lille/Lille Catholic Hospitals, Heart Valve Center, Cardiology Department, ETHICS EA 7446, Lille Catholic University, Lille, France
- 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
| | | | - Franck Levy
- Department of Cardiology, Center Cardio-Thoracique de Monaco, Monaco, Monaco
| | - David Vancraeynest
- 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
| | - Agnès Pasquet
- 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
| | - André Vincentelli
- Cardiac Surgery Department, Centre Hospitalier Régional et Universitaire de Lille, Lille, France
| | - Bernhard L. 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
- GCS-Groupement des Hôpitaux de l’Institut Catholique de Lille/Lille Catholic Hospitals, Heart Valve Center, Cardiology Department, ETHICS EA 7446, Lille Catholic University, Lille, France
- Correspondence: Sylvestre Maréchaux
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Lee SM, Ng WH, Tang E, Foong S. Towards fluid force estimation of a water‐jetting aerial robot with hybrid kinematics‐force model. J FIELD ROBOT 2022. [DOI: 10.1002/rob.22079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Shawndy M. Lee
- Engineering Product Development Pillar (EPD) Singapore University of Technology and Design (SUTD) Singapore Singapore
| | - Wei H. Ng
- Engineering Product Development Pillar (EPD) Singapore University of Technology and Design (SUTD) Singapore Singapore
| | - Emmanuel Tang
- Engineering Product Development Pillar (EPD) Singapore University of Technology and Design (SUTD) Singapore Singapore
| | - Shaohui Foong
- Engineering Product Development Pillar (EPD) Singapore University of Technology and Design (SUTD) Singapore Singapore
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Color Doppler splay in mitral regurgitation: hemodynamic correlates and outcome in a clinical cohort. J Am Soc Echocardiogr 2022; 35:933-939. [DOI: 10.1016/j.echo.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/15/2022] [Accepted: 04/17/2022] [Indexed: 11/22/2022]
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Lee J, Gupta AN, Ma LE, Scott MB, Mason OR, Wu E, Thomas JD, Markl M. Valvular regurgitation flow jet assessment using in vitro 4D flow MRI: Implication for mitral regurgitation. Magn Reson Med 2021; 87:1923-1937. [PMID: 34783383 DOI: 10.1002/mrm.29082] [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: 06/25/2021] [Revised: 10/01/2021] [Accepted: 10/25/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the accuracy of four-dimensional (4D) flow MRI for direct assessment of peak velocity, flow volume, and momentum of a mitral regurgitation (MR) flow jets using an in vitro pulsatile jet flow phantom. We systematically investigated the impact of spatial resolution and quantification location along the jet on flow quantities with Doppler ultrasound as a reference for peak velocity. METHODS Four-dimensional flow MRI data of a pulsatile jet through a circular, elliptical, and 3D-printed patient-specific MR orifice model was acquired with varying spatial resolution (1.5-5 mm isotropic voxel). Flow rate and momentum of the jet were quantified at various axial distances (x = 0-50 mm) and integrated over time to calculate Voljet and MTIjet . In vivo assessment of Voljet and MTIjet was performed on 3 MR patients. RESULTS Peak velocities were comparable to Doppler ultrasound (3% error, 1.5 mm voxel), but underestimated with decreasing spatial resolution (-40% error, 5 mm voxel). Voljet was similar to regurgitant volume (RVol) within 5 mm, and then increased linearly with the axial distance (19%/cm) because of flow entrainment. MTIjet remained steady throughout the jet (2%/cm) as theoretically predicted. Four and 9 voxels across the jet were required to measure flow volume and momentum-time-integral within 10% error, respectively. CONCLUSION Four-dimensional flow MRI detected accurate peak velocity, flow rate, and momentum for in vitro MR-mimicking flow jets. Spatial resolution significantly impacted flow quantitation, which otherwise followed predictions of flow entrainment and momentum conservation. This study provides important preliminary information for accurate in vivo MR assessment using 4D flow MRI.
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Affiliation(s)
- Jeesoo Lee
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Aakash N Gupta
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Liliana E Ma
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michel B Scott
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - O'Neil R Mason
- Division of Cardiology, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Erik Wu
- Division of Cardiology, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - James D Thomas
- Division of Cardiology, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Michael Markl
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Biomedical Engineering, Northwestern University, McCormick School of Engineering, Evanston, Illinois, USA
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Basic Principles of the Echocardiographic Evaluation of Mitral Regurgitation. JACC Cardiovasc Imaging 2021; 14:843-853. [PMID: 33454273 DOI: 10.1016/j.jcmg.2020.06.049] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/15/2020] [Accepted: 06/24/2020] [Indexed: 11/22/2022]
Abstract
Mitral regurgitation (MR) is a common form of valvular heart disease that is associated with significant morbidity and mortality. Treatment decisions are completely dependent on accurate diagnosis of both mechanism and severity of MR, which can be challenging and is often done incorrectly. Transthoracic echocardiography is the most commonly used imaging test for MR; transesophageal echocardiography is often needed to better define morphology and MR severity, and is essential for guiding transcatheter therapies for MR. Multidetector computed tomography has become the standard to assess whether transcatheter valve replacement is an option because of its ability to assess valve sizing, access, and potential left ventricular outflow tract obstruction. Finally, cine cardiac magnetic resonance has been recommended by recent guidelines to quantify MR severity when the distinction between moderate and severe MR is indeterminate by echocardiography. This paper focuses on the main questions to be answered by imaging techniques and illustrates some common tips, tricks, and pitfalls in the assessment of MR.
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Zaidi A, Oxborough D, Augustine DX, Bedair R, Harkness A, Rana B, Robinson S, Badano LP. Echocardiographic assessment of the tricuspid and pulmonary valves: a practical guideline from the British Society of Echocardiography. Echo Res Pract 2020; 7:G95-G122. [PMID: 33339003 PMCID: PMC8052586 DOI: 10.1530/erp-20-0033] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/18/2020] [Indexed: 12/12/2022] Open
Abstract
Transthoracic echocardiography is the first-line imaging modality in the assessment of right-sided valve disease. The principle objectives of the echocardiographic study are to determine the aetiology, mechanism and severity of valvular dysfunction, as well as consequences on right heart remodelling and estimations of pulmonary artery pressure. Echocardiographic data must be integrated with symptoms, to inform optimal timing and technique of interventions. The most common tricuspid valve abnormality is regurgitation secondary to annular dilatation in the context of atrial fibrillation or left-sided heart disease. Significant pulmonary valve disease is most commonly seen in congenital heart abnormalities. The aetiology and mechanism of tricuspid and pulmonary valve disease can usually be identified by 2D assessment of leaflet morphology and motion. Colour flow and spectral Doppler are required for assessment of severity, which must integrate data from multiple imaging planes and modalities. Transoesophageal echo is used when transthoracic data is incomplete, although the anterior position of the right heart means that transthoracic imaging is often superior. Three-dimensional echocardiography is a pivotal tool for accurate quantification of right ventricular volumes and regurgitant lesion severity, anatomical characterisation of valve morphology and remodelling pattern, and procedural guidance for catheter-based interventions. Exercise echocardiography may be used to elucidate symptom status and demonstrate functional reserve. Cardiac magnetic resonance and CT should be considered for complimentary data including right ventricular volume quantification, and precise cardiac and extracardiac anatomy. This British Society of Echocardiography guideline aims to give practical advice on the standardised acquisition and interpretation of echocardiographic data relating to the pulmonary and tricuspid valves.
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Affiliation(s)
| | - David Oxborough
- Liverpool John Moores University, Research Institute for Sports and Exercise Science, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.,Department for Health, University of Bath, Bath, UK
| | - Radwa Bedair
- Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
| | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - Bushra Rana
- Imperial College Healthcare NHS Trust, London, UK
| | - Shaun Robinson
- North West Anglia NHS Foundation Trust, Peterborough, UK
| | - Luigi P Badano
- Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Wang W, Jiang Y, Li J, Gong K, Zhao L, Tang G, Meng Y, Wang Z. Diagnostic value of mitral regurgitant jet volume in the assessment of mitral regurgitation severity by general imaging three-dimensional quantification. Int J Cardiovasc Imaging 2020; 36:1963-1972. [DOI: 10.1007/s10554-020-01916-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 06/07/2020] [Indexed: 10/24/2022]
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9
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Affiliation(s)
- Richard Paul Steeds
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK .,Honorary Reader, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Saul G Myerson
- Cardiovascular Medicine, University of Oxford, Oxford, UK
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2020 Focused Update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation. J Am Coll Cardiol 2020; 75:2236-2270. [DOI: 10.1016/j.jacc.2020.02.005] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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11
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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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12
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Imaging Needs in Novel Transcatheter Tricuspid Valve Interventions. JACC Cardiovasc Imaging 2019; 11:736-754. [PMID: 29747849 DOI: 10.1016/j.jcmg.2017.10.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 09/26/2017] [Accepted: 10/05/2017] [Indexed: 02/01/2023]
Abstract
The advent of novel transcatheter therapies for severe tricuspid regurgitation (TR) has attracted much attention. Novel 3-dimensional imaging techniques have permitted analysis of the tricuspid valve (TV) anatomy from unparalleled views and better understanding of the underlying pathophysiology of TR. Grading TR and assessment of right ventricular function remain challenging, and although 2-dimensional echocardiography is the mainstay imaging technique to evaluate patients with severe TR the use of 3-dimensional echocardiography and cardiovascular magnetic resonance is increasing. The number of transcatheter interventions for TR is growing, and procedural success relies significantly on the pre-procedural evaluation of the anatomy of the TV, etiology and severity of TR, right ventricular size and function, and importantly, the anatomic relationships of the TV. The role of multimodality imaging in patient selection and procedural planning for transcatheter TV repair is reviewed.
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Imaging Assessment of Tricuspid Regurgitation Severity. JACC Cardiovasc Imaging 2019; 12:469-490. [DOI: 10.1016/j.jcmg.2018.07.033] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 01/30/2023]
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14
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Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2019; 32:1-64. [DOI: 10.1016/j.echo.2018.06.004] [Citation(s) in RCA: 692] [Impact Index Per Article: 138.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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O'Gara PT, Grayburn PA, Badhwar V, Afonso LC, Carroll JD, Elmariah S, Kithcart AP, Nishimura RA, Ryan TJ, Schwartz A, Stevenson LW. 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2017; 70:2421-2449. [PMID: 29055505 DOI: 10.1016/j.jacc.2017.09.019] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Mitral regurgitation (MR) is a complex valve lesion that can pose significant management challenges for the cardiovascular clinician. This Expert Consensus Document emphasizes that recognition of MR should prompt an assessment of its etiology, mechanism, and severity, as well as indications for treatment. A structured approach to evaluation based on clinical findings, precise echocardiographic imaging, and when necessary, adjunctive testing, can help clarify decision making. Treatment goals include timely intervention by an experienced heart team to prevent left ventricular dysfunction, heart failure, reduced quality of life, and premature death.
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Tidholm A, Bodegård-Westling A, Höglund K, Häggström J, Ljungvall I. Real-Time 3-Dimensional Echocardiographic Assessment of Effective Regurgitant Orifice Area in Dogs With Myxomatous Mitral Valve Disease. J Vet Intern Med 2017; 31:303-310. [PMID: 28109120 PMCID: PMC5354031 DOI: 10.1111/jvim.14642] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 11/01/2016] [Accepted: 11/22/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Effective regurgitant orifice area (EROA), calculated from the vena contracta width (VCW) as the narrowest portion of the proximal regurgitant jet, might be used to estimate severity of mitral regurgitation. However, this simplified assumption only holds when the EROA is circular, which might not be true in dogs with myxomatous mitral valve disease (MMVD). HYPOTHESIS Effective regurgitant orifice area in dogs with MMVD is noncircular, and using color Doppler real-time 3-dimensional (RT3D) echocardiography, measured EROA in the en face view will be significantly different from calculated EROA. ANIMALS Hundred and fifty-eight privately owned dogs with naturally occurring MMVD. MATERIALS AND METHODS Prospective observational study comparing en face view of EROA with calculated EROA using VCW in 4-chamber (4Ch) and 2-chamber (2Ch) view only or combined 4Ch and 2Ch views using RT3D echocardiography. RESULTS The calculated EROA using the 2Ch view showed a systematic underestimation of 17% compared with the measured en face EROA corrected for body surface area. The calculated EROA using 4Ch and 4Ch + 2Ch views showed less agreement with the en face EROA, and the difference between methods increased with increasing EROA. The difference between calculated and measured EROA showed a systematic underestimation of the calculated EROA by 36% (4Ch) and 33% (4Ch + 2Ch), respectively, compared to measured en face EROA. CONCLUSION AND CLINICAL IMPORTANCE When replacing measured EROA with calculated EROA using VCW measurements, the 2Ch view is preferred in dogs with MMVD.
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Affiliation(s)
- A Tidholm
- Anicura Albano Animal Hospital, Danderyd, Sweden.,Department of Clinical Sciences, Faculty of Veterinary Medicine, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | | | - K Höglund
- Department of Anatomy, Physiology and Biochemistry, Faculty of Veterinary Medicine, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - J Häggström
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - I Ljungvall
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Swedish University of Agricultural Sciences, Uppsala, Sweden
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Hung J, Levine RA. Pixels or Pixie Dust? Grading of mitral regurgitation using intensity analysis of continuous wave Doppler. Heart 2016; 103:177-178. [DOI: 10.1136/heartjnl-2016-310293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Wang W, Lin Q, Wu W, Jiang Y, Lan T, Wang H. Quantification of Mitral Regurgitation by General Imaging Three-Dimensional Quantification: Feasibility and Accuracy. J Am Soc Echocardiogr 2014; 27:268-76. [DOI: 10.1016/j.echo.2013.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Indexed: 11/25/2022]
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Minami T, Kawano H, Yamachika S, Tsuneto A, Kaneko M, Kawano Y, Minami S, Eishi K, Maemura K. Comparison of the Diagnostic Power of Transthoracic and Transesophageal Echocardiography to Detect Ruptured Chordae Tendineae. Int Heart J 2012; 53:225-9. [DOI: 10.1536/ihj.53.225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Takako Minami
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | | | - Akira Tsuneto
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Masayuki Kaneko
- Department of Cardiology, Cardiovascular Center, Oita Oka Hospital
| | - Yasuko Kawano
- Cardiology Division, Shunkaikai Nagasaki Kita Hospital
| | - Shigeki Minami
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Kiyoyuki Eishi
- Department of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
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Szymanski C, Levine RA, Tribouilloy C, Zheng H, Handschumacher MD, Tawakol A, Hung J. Impact of mitral regurgitation on exercise capacity and clinical outcomes in patients with ischemic left ventricular dysfunction. Am J Cardiol 2011; 108:1714-20. [PMID: 21943932 DOI: 10.1016/j.amjcard.2011.07.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 07/12/2011] [Accepted: 07/12/2011] [Indexed: 10/17/2022]
Abstract
There is uncertainty and debate regarding whether ischemic mitral regurgitation (MR) is a secondary epiphenomenon resulting from left ventricular (LV) dysfunction or confers an independent effect on exercise capacity and outcomes. We tested whether ischemic MR negatively affects exercise capacity and cardiovascular morbidity and mortality in patients with coronary artery disease (CAD) and those with inferior wall motion abnormality independent of LV dysfunction. Clinical follow-up over 5 years was obtained in 77 patients (64 ± 10 years old, LV ejection fraction 54 ± 11%) with at least mild ischemic MR from CAD and evidence of inferior wall motion abnormality who had exercise stress testing with perfusion imaging within 24 hours of echocardiography. Patients with active heart failure, ischemia, intrinsic valve disease, pulmonary and vascular diseases were excluded. Exercise capacity (METs, peak double product) was tested for relation to MR (vena contracta [VC] and jet area), LV size and function, and pulmonary pressures. Cox proportional hazards analysis assessed whether MR predicted cardiovascular events including hospitalization for heart failure, acute coronary syndrome, and myocardial infarction and cardiovascular and total mortalities. Univariate correlation identified MR with VC (r = -0.674, p <0.0001) and MR jet area (r = -0.575, p <0.0001) as determinants of decreased functional capacity evaluated by METs, with VC the stronger predictor. MR VC >2 mm (moderate ischemic MR) and age were independent predictors of cardiovascular events and death (hazard ratio 6.72 for MR, p = 0.04). In conclusion, in patients with CAD and LV inferior wall motion abnormality, MR negatively affects exercise capacity and is associated with increased cardiovascular morbidity and mortality. This effect appears independent of degree of LV dysfunction.
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Lin BA, Forouhar AS, Pahlevan NM, Anastassiou CA, Grayburn PA, Thomas JD, Gharib M. Color Doppler Jet Area Overestimates Regurgitant Volume when Multiple Jets are Present. J Am Soc Echocardiogr 2010; 23:993-1000. [DOI: 10.1016/j.echo.2010.06.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Indexed: 11/29/2022]
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Little SH, Igo SR, McCulloch M, Hartley CJ, Nosé Y, Zoghbi WA. Three-dimensional ultrasound imaging model of mitral valve regurgitation: design and evaluation. ULTRASOUND IN MEDICINE & BIOLOGY 2008; 34:647-654. [PMID: 18255217 PMCID: PMC3348787 DOI: 10.1016/j.ultrasmedbio.2007.08.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Revised: 07/06/2007] [Accepted: 08/27/2007] [Indexed: 05/25/2023]
Abstract
We describe the development of a cardiac flow model and imaging chamber to permit Doppler assessment of complex and dynamic flow events. The model development included the creation of a circulatory loop with variable compliance and resistance; the creation of a secondary regurgitant circuit; and incorporation of an ultrasound imaging chamber to allow two-dimensional (2D) and three-dimensional (3D) Doppler characterization of both simple and complex models of valvular regurgitation. In all, we assessed eight different pulsatile regurgitant volumes through each of four rigid orifices differing in size and shape: 0.15 cm(2) circle, 0.4 cm(2) circle, 0.35 cm(2) slot and 0.4 cm(2) arc. The achieved mean (and range) hemodynamic measures were: peak trans-orifice pressure gradient 117 mm Hg (40 to 245 mm Hg), trans-orifice peak Doppler velocity 560 cm/s (307 to 793 cm/s), Doppler time-velocity integral 237 cm (111 to 362 cm), regurgitant volume 43 mL (11 to 84 mL) and orifice area 0.32 cm(2) (0.15 to 0.4 cm(2)). The model was designed to optimize Doppler signal quality while reflecting anatomic structural relationships and flow events. The 2D color Doppler, 3D color Doppler and continuous wave Doppler quality was excellent whether the data were acquired from the imaging window parallel or perpendicular to the long-axis of flow. This model can be easily adapted to mimic other intracardiac flow pathology or assess future Doppler applications.
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Affiliation(s)
- Stephen H. Little
- The Department of Cardiology, the Methodist Hospital and the Echocardiography Laboratory of The Methodist DeBakey Heart Center, Houston, TX, USA
| | - Stephen R. Igo
- The Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Marti McCulloch
- The Department of Cardiology, the Methodist Hospital and the Echocardiography Laboratory of The Methodist DeBakey Heart Center, Houston, TX, USA
| | - Craig J. Hartley
- The Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Yukihiko Nosé
- The Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - William A. Zoghbi
- The Department of Cardiology, the Methodist Hospital and the Echocardiography Laboratory of The Methodist DeBakey Heart Center, Houston, TX, USA
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Thomas JD, Popović ZB. Assessment of left ventricular function by cardiac ultrasound. J Am Coll Cardiol 2006; 48:2012-25. [PMID: 17112991 DOI: 10.1016/j.jacc.2006.06.071] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2006] [Revised: 06/02/2006] [Accepted: 06/19/2006] [Indexed: 12/27/2022]
Abstract
Our understanding of the physical underpinnings of the assessment of cardiac function is becoming increasingly sophisticated. Recent developments in cardiac ultrasound permit exploitation of many of these newer physical concepts with current echocardiographic machines. This review will first focus on the current approach to the assessment of cardiovascular hemodynamics by cardiac ultrasound. The next focus will be the assessment of global cardiac mechanics in systole and diastole. Finally, relationships between the cardiac structure and regional myocardial function, and the way regional function can be quantified by ultrasound, will be presented. This review also discusses the clinical impact of echocardiography and its future directions and developments.
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Affiliation(s)
- James D Thomas
- Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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25
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Paszczuk A, Wiegers SE. Quantitative assessment of mitral insufficiency: its advantages and disadvantages. Heart Fail Rev 2006; 11:205-17. [PMID: 17041761 DOI: 10.1007/s10741-006-0100-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Anna Paszczuk
- Hospital of University of Pennsylvania, Pennsylvania, USA
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26
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Rivera M. El valor del orificio regurgitante en la cuantificación de la válvula insuficiente. Rev Esp Cardiol 2006; 59:997-9. [PMID: 17125708 DOI: 10.1157/13093975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Buck T, Plicht B, Hunold P, Mucci RA, Erbel R, Levine RA. Broad-beam spectral Doppler sonification of the vena contracta using matrix-array technology: A new solution for semi-automated quantification of mitral regurgitant flow volume and orifice area. J Am Coll Cardiol 2005; 45:770-9. [PMID: 15734624 DOI: 10.1016/j.jacc.2004.11.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Accepted: 10/06/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate broad-beam spectral Doppler sonification of the vena contracta using a matrix-array transducer for quantification of mitral regurgitation (MR). BACKGROUND Noninvasive assessment of the severity of valvular regurgitation remains challenging. A recent technique measures regurgitant flow directly at the vena contracta based on the product of velocity times backscattered Doppler power (proportional to orifice area). That approach, however, has been limited by relatively narrow conventional beamwidths. Matrix-array transducers, recently developed for three-dimensional imaging, can potentially provide broader beams. Therefore, we addressed the hypothesis that deliberate broadening of the Doppler beam can encompass larger regurgitant cross-sectional areas to capture a broader range of regurgitant flows. METHODS A matrix-array transducer system was modified to provide a three-dimensionally expanded spectral Doppler sample volume. Calculations of orifice area, flow rate, and regurgitant stroke volume (RSV) from Doppler power were automated on board a routinely used echocardiographic scanner and tested in vitro. In 24 patients with isolated MR, RSV was compared with magnetic resonance imaging (MRI) mitral inflow minus aortic outflow from phase-velocity maps. RESULTS The calculated flow rate and RSV correlated and agreed well with reference values in vitro (r = 0.98 to 0.99) and in patients (r = 0.93, mean difference 0.4 +/- 3.2 ml, p = NS vs. 0), with sufficient sonification to measure flow orifices up to 0.85 cm in diameter. Agreement with MRI was comparable in 17 patients with central and seven with eccentric jets (p = NS vs. 0). CONCLUSIONS The broad-beam spectral Doppler technique provides accurate, largely automated quantification of regurgitant flow rate and integrated RSV directly at the lesion. The accuracy related to broader sonification is made possible by the new matrix-array transducer design.
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Affiliation(s)
- Thomas Buck
- West German Heart Center Essen, University Duisburg-Essen, Essen, Germany.
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Kuperstein R, Feinberg MS, Eldar M, Schwammenthal E. Physical determinants of systolic murmur intensity in aortic stenosis. Am J Cardiol 2005; 95:774-6. [PMID: 15757610 DOI: 10.1016/j.amjcard.2004.11.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2004] [Revised: 11/22/2004] [Accepted: 11/22/2004] [Indexed: 11/23/2022]
Abstract
We investigated which physical parameter has the greatest impact on the perceived loudness of a systolic murmur in aortic stenosis. Loudness of murmur in aortic stenosis correlated best with peak momentum transfer--and thus with body size--so that loud murmurs predict severe disease less reliably in larger patients.
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Kanzaki H, Bazaz R, Schwartzman D, Dohi K, Sade LE, Gorcsan J. A mechanism for immediate reduction in mitral regurgitation after cardiac resynchronization therapy: insights from mechanical activation strain mapping. J Am Coll Cardiol 2004; 44:1619-25. [PMID: 15489094 DOI: 10.1016/j.jacc.2004.07.036] [Citation(s) in RCA: 240] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2004] [Revised: 07/14/2004] [Accepted: 07/19/2004] [Indexed: 12/17/2022]
Abstract
OBJECTIVES We tested the hypothesis that an immediate reduction in mitral regurgitation (MR) after cardiac resynchronization therapy (CRT) results from improved coordinated timing of the papillary muscle insertion sites, using the novel approach of mechanical activation strain mapping. BACKGROUND Heart failure patients with left bundle branch block often benefit acutely from CRT; however, the role and mechanism of reduction of MR are unclear. METHODS Twenty-six consecutive patients undergoing CRT with at least mild MR were studied (ejection fraction 24 +/- 6%; QRS duration 168 +/- 30 ms). Echocardiographic Doppler and strain imaging was performed immediately before and the day after CRT, as well as in 10 normal control subjects. Mechanical activation sequence maps were constructed using longitudinal strain from 12 basal and mid-LV sites, with color coding of time-to-peak strain. RESULTS Mitral regurgitation by the volumetric method consistently decreased after CRT: regurgitant volume from 40 +/- 20 ml to 24 +/- 17 ml and regurgitant fraction from 40 +/- 12% to 25 +/- 14% (both: p < 0.001 vs. baseline). Normal controls had uniform segmental time-to-peak strain, with a difference of only 12 +/- 8 ms between all segments. In contrast, CRT patients at baseline had a 106 +/- 74 ms time delay between papillary muscle insertion sites (p < 0.001 vs. normal). This interpapillary muscle time delay shortened after CRT to 39 +/- 43 ms (p < 0.001 vs. baseline) and was significantly correlated with reductions in mitral regurgitant fraction (r = 0.77, p < 0.001). CONCLUSIONS Cardiac resynchronization therapy significantly and immediately reduced MR. Improved coordinated timing of mechanical activation of papillary muscle insertion sites appears to be a mechanistic contributor to immediate MR reduction by CRT.
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Affiliation(s)
- Hideaki Kanzaki
- University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213-2582, USA
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30
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Vitarelli A, Conde Y, Cimino E, Leone T, D'Angeli I, D'Orazio S, Stellato S. Assessment of severity of mechanical prosthetic mitral regurgitation by transoesophageal echocardiography. BRITISH HEART JOURNAL 2004; 90:539-44. [PMID: 15084553 PMCID: PMC1768237 DOI: 10.1136/hrt.2003.026823] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the ability of colour Doppler transoesophageal echocardiography (TOE) to assess quantitatively prosthetic mitral valve insufficiency. METHODS 47 patients were studied with multiplane TOE and cardiac catheterisation. Proximal jet diameter was measured as the largest diameter of the vena contracta. Regurgitant area was measured by planimetry of the largest turbulent jet during systole. Flow convergence zone was considered to be present when a localised area of increased systolic velocities was apparent on the left ventricular side of the valve prosthesis. Pulmonary vein flow velocity was measured at peak systole and diastole. RESULTS Mean (SD) proximal jet diameter was 0.63 (0.16) cm, with good correlation with angiographic grades (r = 0.83). Mean (SD) maximum colour jet area was 7.9 (2.5) cm2 (r = 0.69) with worse correlation if a single imaging plane was used for measurements (r = 0.62). The ratio of systolic to diastolic peak pulmonary flow velocity averaged 0.7 (1.3) cm (r = -0.66) with better correlation (r = -0.71) if patients with atrial fibrillation were excluded. Mean (SD) regurgitant flow rate was 168 (135) ml/s and regurgitant orifice area was 0.56 (0.43) cm2, with good correlation with angiography (r = 0.77 and r = 0.78, respectively). CONCLUSIONS TOE correctly identified angiographically severe prosthetic mitral regurgitation, mainly by the assessment of the flow convergence region and the proximal diameter of the regurgitant jet.
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Affiliation(s)
- A Vitarelli
- Department of Cardiology, La Sapienza University, Rome, Italy.
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Deserranno D, Greenberg NL, Thomas JD, Garcia MJ. A new automated method for the quantification of mitral regurgitant volume and dynamic regurgitant orifice area based on a normalized centerline velocity distribution using color M-mode and continuous wave Doppler imaging. J Biomech Eng 2003; 125:62-9. [PMID: 12661197 DOI: 10.1115/1.1531111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Previous echocardiographic techniques for quantifying valvular regurgitation (PISA) are limited by factors including uncertainties in orifice location and hemispheric convergence assumption. Using computational fluid dynamics simulations, we developed a new model for the estimation of orifice diameter and regurgitant volume without the aforementioned assumptions of the PISA technique. Using experimental data obtained from the in vitro flow model we successfully validated our new model. The model output (y) and reference (x) values were in close agreement (y = 0.95x + 0.38, r = 0.96, error = 1.68 +/- 7.54% for the orifice diameter and y = 1.18x - 4.72, r = 0.93, error = 6.48 +/- 16.81% for the regurgitant volume).
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Affiliation(s)
- Dimitri Deserranno
- Cleveland Clinic Foundation, Department of Cardiology, Cardiovascular Imaging, 9500 Euclid Ave, Desk F15, Cleveland, OH 44195, USA.
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Affiliation(s)
- James D Thomas
- Department of Cardiology, Desk F15, 9500 Euclid Avenue, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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33
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Lebrun F, Lancellotti P, Piérard LA. Quantitation of functional mitral regurgitation during bicycle exercise in patients with heart failure. J Am Coll Cardiol 2001; 38:1685-92. [PMID: 11704381 DOI: 10.1016/s0735-1097(01)01605-9] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We sought to examine the feasibility and reliability of quantifying mitral regurgitation (MR) during exercise by Doppler echocardiography in patients with heart failure and to assess the relationship between dynamic MR and systolic pulmonary artery pressure changes. BACKGROUND The severity of MR can be quantified by using several echocardiographic methods. Quantitation of MR during dynamic exercise has not yet been performed. METHODS Symptom-limited, semi-supine two-dimensional and Doppler echocardiograms during bicycle exercise were obtained in 27 consecutive patients with heart failure and functional MR. Regurgitant volume was measured at rest and during exercise by the proximal isovelocity surface area (PISA) method and by quantitative Doppler echocardiography. Exercise-induced changes in regurgitant volume were compared with changes in the regurgitant jet area to left atrial area ratio, vena contracta width and trans-tricuspid pressure gradient. RESULTS The regurgitant volume measured by the PISA method increased from 21 +/- 12 ml (range 5 to 55) at rest to 39 +/- 23 ml (range 8 to 85) during exercise (p < 0.0001). The difference between two observers was low for both rest (2.0 +/- 2.7 ml) and exercise measurements (3.5 +/- 6.2 ml). The regurgitant volume measured by quantitative Doppler echocardiography increased from 29 +/- 13 to 49 +/- 24 ml (p = 0.0001). Excellent correlation between the two methods was obtained with exercise (r = 0.92). Exercise-induced changes in regurgitant volume, as measured by the PISA method, correlated well with regurgitant volume changes measured by quantitative Doppler echocardiography (r = 0.88), changes in vena contracta width (r = 0.82) and changes in trans-tricuspid pressure gradient (r = 0.73), but not with changes in regurgitant jet area to left atrial area ratio (r = 0.29). Seventeen patients stopped exercise because of fatigue and 10 because of dyspnea. These 10 patients exhibited greater increases in regurgitant volume (34 +/- 6 vs. 11 +/- 8 ml), corresponding to a significant elevation of the trans-tricuspid gradient (48 +/- 14 vs. 20 +/- 14 mm Hg). CONCLUSIONS Quantitation of functional MR during exercise is feasible in patients with heart failure. There is a good correlation between regurgitant volume measured during exercise by the PISA method and that obtained by quantitative Doppler echocardiography, suggesting that the technique is reliable. An increase in mitral regurgitant volume during dynamic exercise correlates well with elevation of systolic pulmonary artery pressure.
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Affiliation(s)
- F Lebrun
- Division of Cardiology, University Hospital Liège, Liege, Belgium
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Sitges M, Jones M, Shiota T, Prior DL, Qin JX, Tsujino H, Bauer F, Kim YJ, Deserranno D, Greenberg NL, Cardon LA, Zetts AD, Garcia MJ, Thomas JD. Interaliasing distance of the flow convergence surface for determining mitral regurgitant volume: a validation study in a chronic animal model. J Am Coll Cardiol 2001; 38:1195-202. [PMID: 11583903 DOI: 10.1016/s0735-1097(01)01502-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We aimed to validate a new flow convergence (FC) method that eliminated the need to locate the regurgitant orifice and that could be performed semiautomatedly. BACKGROUND Complex and time-consuming features of previously validated color Doppler methods for determining mitral regurgitant volume (MRV) have prevented their widespread clinical use. METHODS Thirty-nine different hemodynamic conditions in 12 sheep with surgically created flail leaflets inducing chronic mitral regurgitation were studied with two-dimensional (2D) echocardiography. Color Doppler M-mode images along the centerline of the accelerating flow towards the mitral regurgitation orifice were obtained. The distance between the two first aliasing boundaries (interaliasing distance [IAD]) was measured and the FC radius was mathematically derived according to the continuity equation (R(calc) = IAD/(1 - radicalv(1)/v(2)), v(1) and v(2) being the aliasing velocities). The conventional 2D FC radius was also measured (R(meas)). Mitral regurgitant volume was then calculated according to the FC method using both R(calc) and R(meas). Aortic and mitral electromagnetic (EM) flow probes and meters were balanced against each other to determine the reference standard MRV. RESULTS Mitral regurgitant volume calculated from R(calc) and R(meas) correlated well with EM-MRV (y = 0.83x + 5.17, r = 0.90 and y = 1.04x + 0.91, r = 0.91, respectively, p < 0.001 for both). However, both methods resulted in slight overestimation of EM-MRV (Delta was 3.3 +/- 2.1 ml for R(calc) and 1.3 +/- 2.3 ml for R(meas)). CONCLUSIONS Good correlation was observed between MRV derived from R(calc) (IAD method) and EM-MRV, similar to that observed with R(meas) (conventional FC method) and EM-MRV. The R(calc) using the IAD method has an advantage over conventional R(meas) in that it does not require spatial localization of the regurgitant orifice and can be performed semiautomatedly.
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Affiliation(s)
- M Sitges
- Cardiovascular Imaging Center, Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Schmidt A, Pazin-Filho A, Almeida-Filho OC, Gallo-Júnior L, Marin-Neto JA, Maciel BC. Effects of blood viscosity on proximal flow convergence calculations of regurgitant flow rate and jet dimensions as evaluated by color Doppler flow mapping: an in vitro study. J Am Soc Echocardiogr 2001; 14:569-79. [PMID: 11391285 DOI: 10.1067/mje.2001.113545] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
There are limited data on the potential influence of blood viscosity on the quantification of valvular regurgitation by color Doppler in the clinical setting. This study was designed to evaluate the effects of blood viscosity on jet dimensions and the proximal flow convergence (proximal isovelocity surface area, PISA) method of estimating valvular insufficiency severity. We used an in vitro flow model filled with human blood at varying hematocrits (15%, 35%, and 55%) and blood viscosity (blood/water viscosity: 2.6, 4.8, 9.1) in which jets were driven through a known orifice (16 mm(2)) into a 110-mL compliant receiving chamber (compliance: 2.2 mL/mm Hg) by a power injection pump. Blood injections (2 and 4 mL) at flow rates of 4, 6, 8, 10, and 12 mL/s were performed. Proximal flow convergence and spatial distribution of jets were imaged by a 3.5-MHz transducer. Pressure and volume in the flow model were kept constant before each injection. Ultrasound settings were the same for all experiments. Jet area decreased significantly with increasing blood viscosity, but the difference in jet dimensions was much larger for lower than for higher flow rates and for highest blood viscosity. Estimation of flow rate by the PISA method was not significantly influenced by blood viscosity. Blood viscosity has a major influence in jet area, especially for lower flow rates, but did not change significantly the grading of regurgitation by the PISA method. Thus this factor should be considered for determining the method of choice when quantification of valvular regurgitation is performed in patients with anemia or polycythemia.
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Affiliation(s)
- A Schmidt
- Division of Cardiology, Department of Internal Medicine, University Hospital, Medical School of Ribeirão Preto, University of São Paulo, Brazil
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Pu M, Prior DL, Fan X, Asher CR, Vasquez C, Griffin BP, Thomas JD. Calculation of mitral regurgitant orifice area with use of a simplified proximal convergence method: initial clinical application. J Am Soc Echocardiogr 2001; 14:180-5. [PMID: 11241013 DOI: 10.1067/mje.2001.110139] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
To validate a previously proposed simplified proximal flow convergence method for calculating mitral regurgitant orifice area (ROA), a prospective study was conducted in ambulatory patients and in patients undergoing open heart surgery. Assuming a pressure difference between the left ventricle and left atrium of approximately 100 mm Hg (jet velocity [v(p)] 500 cm/s) and setting the color aliasing velocity (v(a)) to 40 cm/s, we simplified the conventional proximal convergence method formula (ROA = 2pi(r2)v(a)/v(p)) to r2/2, where r is the radius of the proximal convergence isovelocity hemisphere. For 57 ambulatory patients with a wide range of mitral regurgitant severity (1 to 4+), ROA was calculated by the conventional (x) and simplified (y) methods, demonstrating excellent accuracy (r = 0.92; P <.001; DeltaROA [y - x] = 0.004 +/- 0.08 cm2). For 24 intraoperative patients, ROA calculated by the simplified formula (y) correlated well with the pulsed Doppler-thermodilution method (x) (r = 0.84; P <.01; DeltaROA [y - x] = -0.002 +/- 0.08cm2). This simplified proximal convergence formula yields an accurate assessment of ROA for a wide range of regurgitant severity, while the time required for this measurement is shortened by half (1.5 +/- 0.5 minutes versus 3.2 +/- 0.7 minutes). This may increase the frequency of calculating ROA in the clinical laboratory.
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Affiliation(s)
- M Pu
- Cardiovascular Imaging Center, Department of Cardiology, The Cleveland Clinic Foundation, Ohio 44195-5064, USA
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Guo Z, Boughner DR, Dietrich JM, Pflugfelder PW, Durand LG, Loew M, Fenster A. Quantitative assessment of in vitro jets based on three-dimensional color Doppler reconstruction. ULTRASOUND IN MEDICINE & BIOLOGY 2001; 27:235-243. [PMID: 11316532 DOI: 10.1016/s0301-5629(00)00337-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Three-dimensional (3-D) color Doppler imaging of flow jets was performed to investigate the effects of flow rate and orifice size on jet volumes. Flow jets were generated using a flow model to simulate mitral regurgitation. This flow model consisted of a ventricular chamber, a valvular plate and an atrial chamber. Steady flow was driven through circular orifices having diameters of 2.5, 3.5, 4.5, and 6 mm, respectively, with flow rates of 5, 10, 15, 20, and 25 mL/s to form free jets in the atrial chamber. An ATL Ultramark 9 HDI system was used to perform 3-D color Doppler imaging of the flow jets. A transesophageal probe was rotated by a stepper motor to create 3-D color Doppler images of the jets. The color jet volumes for different hemodynamic conditions were measured and then compared with the theoretical predictions. Results showed that the jet volume estimated from the 3-D color Doppler was directly proportional to the flow rate and inversely proportional to the orifice size. The estimated jet volumes correlated well (r > 0.95) with theoretical predictions. This study supports the use of color jet volume as a parameter to quantify mitral regurgitation.
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Affiliation(s)
- Z Guo
- Department of Electrical and Computer Engineering, The George Washington University, Washington, DC 20052, USA.
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Firstenberg MS, Vandervoort PM, Greenberg NL, Smedira NG, McCarthy PM, Garcia MJ, Thomas JD. Noninvasive estimation of transmitral pressure drop across the normal mitral valve in humans: importance of convective and inertial forces during left ventricular filling. J Am Coll Cardiol 2000; 36:1942-9. [PMID: 11092668 DOI: 10.1016/s0735-1097(00)00963-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES We hypothesized that color M-mode (CMM) images could be used to solve the Euler equation, yielding regional pressure gradients along the scanline, which could then be integrated to yield the unsteady Bernoulli equation and estimate noninvasively both the convective and inertial components of the transmitral pressure difference. BACKGROUND Pulsed and continuous wave Doppler velocity measurements are routinely used clinically to assess severity of stenotic and regurgitant valves. However, only the convective component of the pressure gradient is measured, thereby neglecting the contribution of inertial forces, which may be significant, particularly for nonstenotic valves. Color M-mode provides a spatiotemporal representation of flow across the mitral valve. METHODS In eight patients undergoing coronary artery bypass grafting, high-fidelity left atrial and ventricular pressure measurements were obtained synchronously with transmitral CMM digital recordings. The instantaneous diastolic transmitral pressure difference was computed from the M-mode spatiotemporal velocity distribution using the unsteady flow form of the Bernoulli equation and was compared to the catheter measurements. RESULTS From 56 beats in 16 hemodynamic stages, inclusion of the inertial term ([deltapI]max = 1.78+/-1.30 mm Hg) in the noninvasive pressure difference calculation significantly increased the temporal correlation with catheter-based measurement (r = 0.35+/-0.24 vs. 0.81+/-0.15, p< 0.0001). It also allowed an accurate approximation of the peak pressure difference ([deltapc+I]max = 0.95 [delta(p)cathh]max + 0.24, r = 0.96, p<0.001, error = 0.08+/-0.54 mm Hg). CONCLUSIONS Inertial forces are significant components of the maximal pressure drop across the normal mitral valve. These can be accurately estimated noninvasively using CMM recordings of transmitral flow, which should improve the understanding of diastolic filling and function of the heart.
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Affiliation(s)
- M S Firstenberg
- Cardiovascular Imaging Center, Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA
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39
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Diebold B, Delouche A, Decesare A, Delouche P, Guglielmi JP, Herment A. Fluid mechanics of regurgitant jets and calculation of the effective regurgitant orifice in free or complex configurations. J Biomech 2000; 33:677-84. [PMID: 10807988 DOI: 10.1016/s0021-9290(00)00005-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The velocity fields of turbulent jets can be described using a single formula which includes two empirical constants: k(core) determining the length of the central core and k(turb) the jet widening. Flow models simulating jet adhesion, confinement and noncircular orifices were studied using laser Doppler anemometer and the modifications of the constants were derived from series of velocity profiles. In circular free jets, k(core) was found equal to 4.1 with a variability of 1.4%. In complex configurations, its variability was equal to 15.2%. For k(turb), the value for free circular jets was of 45.2 with a variability of 6.0% and this variability in complex configurations was significantly higher (30. 1%, p=0.025). The correlation between the actual orifice size and the jet extension was poor (r=0.52). However, the almost constant value of k(core) allowed to define a new algorithm calculating the regurgitant orifice diameter with the use of outlines of the jet image (r=0.89). In conclusion, the fluid mechanics of regurgitant jets is modified in complex configurations but, due to the relative independency of the central core, velocity fields could be used to evaluate the dimensions of the effective regurgitant orifice.
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Affiliation(s)
- B Diebold
- INSERM, U. 494, Hopital Broussais, 96 rue Didot, 75674, Paris Cedex, France.
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40
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Giuliatti S, Gallo L, Almeida-Filho OC, Schmidt A, Marin-Neto JA, Pelá CA, Maciel BC. A pulsatile flow model for in vitro quantitative evaluation of prosthetic valve regurgitation. Braz J Med Biol Res 2000; 33:341-6. [PMID: 10719387 DOI: 10.1590/s0100-879x2000000300013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A pulsatile pressure-flow model was developed for in vitro quantitative color Doppler flow mapping studies of valvular regurgitation. The flow through the system was generated by a piston which was driven by stepper motors controlled by a computer. The piston was connected to acrylic chambers designed to simulate "ventricular" and "atrial" heart chambers. Inside the "ventricular" chamber, a prosthetic heart valve was placed at the inflow connection with the "atrial" chamber while another prosthetic valve was positioned at the outflow connection with flexible tubes, elastic balloons and a reservoir arranged to mimic the peripheral circulation. The flow model was filled with a 0.25% corn starch/water suspension to improve Doppler imaging. A continuous flow pump transferred the liquid from the peripheral reservoir to another one connected to the "atrial" chamber. The dimensions of the flow model were designed to permit adequate imaging by Doppler echocardiography. Acoustic windows allowed placement of transducers distal and perpendicular to the valves, so that the ultrasound beam could be positioned parallel to the valvular flow. Strain-gauge and electromagnetic transducers were used for measurements of pressure and flow in different segments of the system. The flow model was also designed to fit different sizes and types of prosthetic valves. This pulsatile flow model was able to generate pressure and flow in the physiological human range, with independent adjustment of pulse duration and rate as well as of stroke volume. This model mimics flow profiles observed in patients with regurgitant prosthetic valves.
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Affiliation(s)
- S Giuliatti
- Departamento de Física, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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41
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Affiliation(s)
- S K Heinle
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas 75216, USA
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42
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Myers JG, Anayiotos AS, Elmahdi AM, Perry GJ, Fan PH, Nanda NC. Color Doppler velocity accuracy proximal to regurgitant orifices: influence of orifice aspect ratio. ULTRASOUND IN MEDICINE & BIOLOGY 1999; 25:771-792. [PMID: 10414895 DOI: 10.1016/s0301-5629(99)00023-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Many noninvasive methodologies used for the accurate evaluation of valvular regurgitation require precise velocity measurements from ultrasound instruments. Previous studies have indicated that velocity measurements from color Doppler (CD) instruments are susceptible to errors due to the interaction of the ultrasound beam and the proximal orifice flow field. This study examined the influence of high aspect ratio (AR) orifices on the CD velocity error. Center line velocity error distributions for orifices ranging from 7.07 to 78.5 mm2, varying in shape from circular to an AR = 8 ellipse, were evaluated using a numerical model of the ultrasound beam and the simulated regurgitant flow field. An in vitro study was also performed and confirmed the findings of the numerical model. The study showed that increasing AR does not significantly change the error characteristics. The study confirmed that orifice size is the dominant factor in the error distribution, and that corrections speculated for circular orifices can be extended to elliptical orifices without significant errors.
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Affiliation(s)
- J G Myers
- The School of Engineering, The University of Alabama at Birmingham, 35294, USA
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Dilek L, Atalay S, Gumus H, Imamoglu A, Tutar E, Altug N. Quantitation of Doppler color flow jet areas for mitral regurgitation in children: angiographic correlation. Int J Cardiol 1999; 69:41-7. [PMID: 10362371 DOI: 10.1016/s0167-5273(99)00004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Eighteen patients with chronic isolated rheumatic mitral regurgitation aged between 7 and 19 years (mean age +/-SD, 12.69+/-3.47 years) were analyzed with color Doppler imaging. Sixteen patients were performed cardiac catheterization within 24 h. Jets were classified as eccentric and central. Regurgitant jet area and its ratio to left atrial area and body surface area were measured by Doppler color flow imaging. Regurgitant volume and regurgitant fractions were calculated with angiography. There was a good correlation between regurgitant jet area and angiographic grade of mitral regurgitation (P<0.01). The correlation between regurgitant jet area/left atrial area ratios and angiographic grade of mitral regurgitation was limited (P<0.01). There was excellent correlation between regurgitant jet area/body surface area and angiographic regurgitant fraction (r = 0.85; P<0.001). There was also a good correlation between regurgitant jet area and regurgitant fraction (r = 0.82; P<0.001). However, the relation of regurgitant jet area/left atrial area to regurgitant fraction was weak (r = 0.72; P<0.01). In conclusion, the measurement of regurgitant fraction and its ratios to left atrial area and body surface area by color Doppler flow imaging can predict the angiographic severity in children who have even eccentric regurgitant jets.
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Affiliation(s)
- L Dilek
- Department of Pediatric Cardiology, Ankara University, Medical School, Turkey
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44
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De Simone R, Glombitza G, Vahl CF, Albers J, Meinzer HP, Hagl S. Three-dimensional color Doppler: a new approach for quantitative assessment of mitral regurgitant jets. J Am Soc Echocardiogr 1999; 12:173-85. [PMID: 10070181 DOI: 10.1016/s0894-7317(99)70133-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Color Doppler echocardiography does not provide adequate information about the severity of mitral regurgitation in patients with eccentric mitral regurgitation. We have developed a new procedure for 3-dimensional (3D) color Doppler reconstruction and for segmentation of regurgitant jets. The volume of regurgitant jets was compared with jet area in 63 patients with mitral regurgitation. Mitral regurgitation was assessed by angiography, regurgitant fraction and volume by pulsed Doppler, JA by planimetry, and JV by 3-dimensional Doppler. Twenty-eight patients with central jets were compared with 35 patients with eccentric jets. In the patients with eccentric jets, JV showed significant correlations with regurgitant volume (r = 0.90; P <.01) and regurgitant fraction (r = 0.76; P < .01) and was able to separate groups with different degrees of mitral regurgitation (P <.01). Three-dimensional Doppler revealed origin, direction, and spatial spreading of complex jet geometry. JV, a new parameter of mitral regurgitation, was also capable of quantifying asymmetrical jets.
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Affiliation(s)
- R De Simone
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany.
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45
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Miró Palau V, Salvador A, Rincón De Arellano A, Cebolla R, Algarra F. Clinical value of parameters derived by the application of the proximal isovelocity surface area method in the assessment of mitral regurgitation. Int J Cardiol 1999; 68:209-16. [PMID: 10189010 DOI: 10.1016/s0167-5273(98)00355-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED To determine the clinical value of several parameters derived by application of the proximal isovelocity surface area method in the assessment of mitral regurgitation (MR), 28 consecutive patients with angiographic diagnosis of MR underwent color Doppler echocardiography within 48 h of cardiac catheterization. Aliasing velocities (V(N)) were baseline-shifted to 25 cm/s and the maximal radius (R) was measured from the first aliasing boundary to the tips of the mitral valve. By continuity, the regurgitant orifice area (ROA) and regurgitant stroke volume (RSV(PISA)) were obtained. We have related them to the angiographic grade, and with determination of the regurgitant stroke volume (RSV(DE)) and the regurgitant fraction (RF), we calculated the volume of the transmitral flow according to Fisher's method. RESULTS RSV(DE) correlated well with RSV(PISA) (r = 0.98). A clear relation existed between the isovelocity radius and the RSV(DE) and RF (r = 0.95 and 0.88, respectively). A radius of 8 mm or more was identified well with an RSV(DE) of 40 cm3 or more (sensitivity: 100%, specificity: 95%) and an RF of 35% or more (sensitivity: 88%, specificity: 94%). The ROA was closely related to the RSV(DE) and RF, with r = 0.92 and 0.88, respectively. An ROA of 20 mm2 or more identified well patients with RSV(DE) values of 40 cm3 or more and RF values of 35% or more. The radius, RSV(PISA) and ROA were closely related to the angiographic grade of MR (r = 0.91, 0.83 and 0.92, respectively). A radius of 7 mm or more identified patients with grade III or IV of regurgitation (sensitivity: 82%, specificity: 94%), while an ROA of 15 mm2 or more discriminated well significant regurgitation (sensitivity: 91%, specificity: 94%). CONCLUSIONS Parameters derived by application of the proximal isovelocity surface area method provide quantitative information that can be helpful in predicting the severity of mitral regurgitation noninvasively.
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Affiliation(s)
- V Miró Palau
- Servicio de Cardiología, Hospital Universitario La Fe, Valencia, Spain.
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46
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Anayiotos AS, Smith BK, Kolda M, Fan P, Nanda NC. Morphological evaluation of a regurgitant orifice by 3-D echocardiography: applications in the quantification of valvular regurgitation. ULTRASOUND IN MEDICINE & BIOLOGY 1999; 25:209-223. [PMID: 10320310 DOI: 10.1016/s0301-5629(98)00161-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The clinical evaluation of blood flow regurgitation through a heart valve or stenotic lesion is an unresolved problem. The proximal flowfield region has been the study focus in the last few years; however, investigators have failed to identify an accurate and reliable calculation scheme due to lack of geometric information about the shape and size of the regurgitating or stenotic orifice. Presented here is a superior method of calculation, by using three-dimensional (3-D) echocardiography combined with Doppler velocimetry. The geometric structure of the orifice in a regurgitating porcine prosthetic valve in vitro was formulated by 3-D image construction of sequentially obtained 2-D images. The velocity flowfield was accessed by color Doppler flow mapping (CD) and continuous-wave Doppler (CW). Two accurate methods of calculation of regurgitant variables were developed. The first method calculated peak regurgitant flow rate from CD and the second method calculated regurgitant flow volume from CW. Both methods showed excellent correlation with the corresponding true values from an electromagnetic flowmeter. The promising preliminary results in such a realistic porcine model indicate the possibility of establishing a routine procedure to be tested in the clinical setting.
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Affiliation(s)
- A S Anayiotos
- School of Engineering, University of Alabama at Birmingham, 35294-4460, USA.
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47
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Morillas PJ, Martínez-Dolz L, Rueda J, Lauwers C, Almenar L, Miró V, Ten F, Osa A, Salvador A, Palencia M, Algarra F. [The measurement of jet width at its origin in assessing mitral prosthetic regurgitation. The effect of the spatial disposition of the jet]. Rev Esp Cardiol 1999; 52:31-6. [PMID: 9989135 DOI: 10.1016/s0300-8932(99)74862-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION AND OBJECTIVES The study was performed to test the influence of the jet spatial disposition on the correlation degree between the measurement of the jet width at its origin and the severity of mitral prosthetic regurgitation by transesophageal Doppler color flow imaging. MATERIAL AND METHODS In 165 patients with mitral valve prosthesis which were submitted for transesophageal echocardiography examination due to suspected prosthetic dysfunction, we studied 126 with pathological mitral regurgitation. On these patients, studies of jet spatial disposition, maximum width in its origin and severity quantification by means of maximum regurgitation area were performed. RESULTS For the free jet group of patients (90), jet width at its origin correlated with maximal regurgitation area (r = 0.75); whereas for the wall jet group (36), the correlation degree was 0.59. We observed a relationship (p < 0.05) between severe mitral regurgitation assessed by maximal regurgitant jet size and jet width > or = 5 mm in both groups: the sensitivity and specificity of 72.7% and 95% respectively for free jets, and 70.7% and 64.4% for wall jets. CONCLUSIONS The correlation between the area measurement and the width in its origin is better for free jets than for wall jets. A statistically significant relationship between the presence of severe mitral regurgitation and width in its origin > or = 5 mm could be observed, independently of the jet spatial disposition.
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Affiliation(s)
- P J Morillas
- Servicio de Cardiología, Hospital Universitario La Fe, Valencia
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48
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Zarauza J, Ares M, Vílchez FG, Hernando JP, Gutiérrez B, Figueroa A, Vázquez de Prada JA, Durán RM. An integrated approach to the quantification of aortic regurgitation by Doppler echocardiography. Am Heart J 1998; 136:1030-41. [PMID: 9842017 DOI: 10.1016/s0002-8703(98)70160-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although different Doppler methods have been proposed for the quantification of aortic regurgitation, no study has prospectively compared these methods with each other and their correlation with angiography. The aim of this study was to prospectively analyze the usefulness of different Doppler echocardiography parameters by testing all such parameters in each patient. METHODS Fifty-one patients with aortic regurgitation underwent 2-dimensional and Doppler echocardiographic studies and catheterization. The following Doppler indexes were analyzed and compared with aortography. Color Doppler: (1) jet color height/left ventricular outflow tract height in parasternal long-axis view, and (2) jet color area/left ventricular outflow tract area in short-axis view. Continuous Doppler: (3) regurgitant flow pressure half-time, (4) regurgitant flow time velocity integral (in centimeters), and (5) regurgitant flow time velocity integral (in centimeters)/diastolic period (in milliseconds). Pulsed Doppler in thoracic and abdominal aorta: (6) time velocity integral of diastolic reverse flow (in centimeters), (7) time velocity integral of systolic anterograde flow/integral of diastolic reverse flow, (8) (time velocity integral of diastolic reverse flow/diastolic period) x 100, and (9) diastolic reverse flow duration/diastolic period (as a percentage). We compared these parameters with severity of regurgitation measured by angiography and classified as mild, moderate, or severe. RESULTS The most useful parameters were (1) jet color height/left ventricular outflow tract height (correctly classified 42 of 49 patients), (2) (time velocity integral of diastolic reverse flow/diastolic period) x 100 in the thoracic aorta (correctly classified 41 of 46 patients), and (3) (time velocity integral of diastolic reverse flow/diastolic period) x 100 in the abdominal aorta (correctly classified 42 of 49 patients). Sequential integration of these 3 parameters correctly classified 96% of patients (44 of 46 patients) and was achieved in 90% of cases. CONCLUSION An integrated combination of several Doppler parameters can quickly and accurately classify the degree of aortic regurgitation as determined by angiography.
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Affiliation(s)
- J Zarauza
- Servicio de Cardiología y Hemodinámica, Hospital Universitario Marqués de Valdecilla, Cantabaria, Spain
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Sun JP, Yang XS, Qin JX, Greenberg NL, Zhou J, Vazquez CJ, Griffin BP, Stewart WJ, Thomas JD. Quantification of mitral regurgitation by automated cardiac output measurement: experimental and clinical validation. J Am Coll Cardiol 1998; 32:1074-82. [PMID: 9768735 DOI: 10.1016/s0735-1097(98)00329-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To develop and validate an automated noninvasive method to quantify mitral regurgitation. BACKGROUND Automated cardiac output measurement (ACM), which integrates digital color Doppler velocities in space and in time, has been validated for the left ventricular (LV) outflow tract but has not been tested for the LV inflow tract or to assess mitral regurgitation (MR). METHODS First, to validate ACM against a gold standard (ultrasonic flow meter), 8 dogs were studied at 40 different stages of cardiac output (CO). Second, to compare ACM to the LV outflow (ACMa) and inflow (ACMm) tracts, 50 normal volunteers without MR or aortic regurgitation (44+/-5 years, 31 male) were studied. Third, to compare ACM with the standard pulsed Doppler-two-dimensional echocardiographic (PD-2D) method for quantification of MR, 51 patients (61+/-14 years, 30 male) with MR were studied. RESULTS In the canine studies, CO by ACM (1.32+/-0.3 liter/min, y) and flow meter (1.35+/-0.3 liter/min, x) showed good correlation (r=0.95, y=0.89x+0.11) and agreement (deltaCO(y-x)=0.03+/-0.08 [mean+/-SD] liter/min). In the normal subjects, CO measured by ACMm agreed with CO by ACMa (r=0.90, p < 0.0001, deltaCO=-0.09+/-0.42 liter/min), PD (r=0.87, p < 0.0001, deltaCO=0.12+/-0.49 liter/min) and 2D (r=0.84, p < 0.0001, deltaCO=-0.16+/-0.48 liter/min). In the patients, mitral regurgitant volume (MRV) by ACMm-ACMa agreed with PD-2D (r= 0.88, y=0.88x+6.6, p < 0.0001, deltaMRV=2.68+/-9.7 ml). CONCLUSIONS We determined that ACM is a feasible new method for quantifying LV outflow and inflow volume to measure MRV and that ACM automatically performs calculations that are equivalent to more time-consuming Doppler and 2D measurements. Additionally, ACM should improve MR quantification in routine clinical practice.
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Affiliation(s)
- J P Sun
- Cardiovascular Imaging Center, Department of Cardiology, The Cleveland Clinic Foundation, Ohio 44195, USA
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Abstract
Echocardiography is routinely performed for the evaluation of valvular regurgitation. Different applications of Doppler echocardiography have been successfully applied to detect and quantify valvular regurgitation. Recent advances in color Doppler made possible the study of the dynamic behavior of the regurgitant orifice and, along with continuous wave Doppler, can provide data on the regurgitant volume and fraction. Doppler echocardiography can also be used to follow serial changes in these hemodynamically important parameters after medical or surgical therapy.
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Affiliation(s)
- S F Nagueh
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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