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Ranard LS, Bonow RO, Nishimura R, Mack MJ, Thourani VH, Bavaria J, O'Gara PT, Bax JJ, Blanke P, Delgado V, Leipsic J, Lang RM, Michelena HI, Cavalcante JL, Vahl TP, Leon MB, Rigolin VH. Imaging Methods for Evaluation of Chronic Aortic Regurgitation in Adults: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1953-1966. [PMID: 37940233 DOI: 10.1016/j.jacc.2023.08.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/21/2023] [Indexed: 11/10/2023]
Abstract
A global multidisciplinary workshop was convened to discuss the multimodality diagnostic evaluation of aortic regurgitation (AR). Specifically, the focus was on assessment tools for AR severity and analyzing evolving data on the optimal timing of aortic valve intervention. The key concepts from this expert panel are summarized as: 1) echocardiography is the primary imaging modality for assessment of AR severity; however, when data is incongruent or incomplete, cardiac magnetic resonance may be helpful; 2) assessment of left ventricular size and function is crucial in determining the timing of intervention; 3) recent evidence suggests current cutpoints for intervention in asymptomatic severe AR patients requires further scrutiny; 4) left ventricular end-systolic volume index has emerged as an additional parameter that has promise in guiding timing of intervention; and 5) the role of additional factors (including global longitudinal strain, regurgitant fraction, and myocardial extracellular volume) is worthy of future investigation.
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Affiliation(s)
- Lauren S Ranard
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Robert O Bonow
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Rick Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Mack
- Division of Cardiothoracic Surgery, Heart Hospital Baylor Plano, Baylor Healthcare System, Plano, Texas, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Joseph Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick T O'Gara
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Philipp Blanke
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Victoria Delgado
- Department of Cardiology, Hospital University Germans Trias i Pujol, Badalona, Spain
| | - Jonathon Leipsic
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Roberto M Lang
- Section of Cardiology, Heart and Vascular Center, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - João L Cavalcante
- Division of Cardiology, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Torsten P Vahl
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Martin B Leon
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vera H Rigolin
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA.
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Reid A, Blanke P, Bax JJ, Leipsic J. Multimodality imaging in valvular heart disease: how to use state-of-the-art technology in daily practice. Eur Heart J 2021; 42:1912-1925. [PMID: 33186469 DOI: 10.1093/eurheartj/ehaa768] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/15/2020] [Accepted: 09/08/2020] [Indexed: 12/16/2022] Open
Abstract
Our understanding of the complexities of valvular heart disease (VHD) has evolved in recent years, primarily because of the increased use of multimodality imaging (MMI). Whilst echocardiography remains the primary imaging technique, the contemporary evaluation of patients with VHD requires comprehensive analysis of the mechanism of valvular dysfunction, accurate quantification of severity, and active exclusion extravalvular consequences. Furthermore, advances in surgical and percutaneous therapies have driven the need for meticulous multimodality imaging to aid in patient and procedural selection. Fundamental decision-making regarding whom, when, and how to treat patients with VHD has become more complex. There has been rapid technological advancement in MMI; many techniques are now available in routine clinical practice, and their integration into has the potential to truly individualize management strategies. This review provides an overview of the current evidence for the use of MMI in VHD, and how various techniques within each modality can be used practically to answer clinical conundrums.
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Affiliation(s)
- Anna Reid
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
| | - Philipp Blanke
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Jonathon Leipsic
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
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Song I, Park JA, Choi BH, Ko SM, Shin JK, Chee HK, Kim JS. Morphological and Functional Evaluation of Quadricuspid Aortic Valves Using Cardiac Computed Tomography. Korean J Radiol 2016; 17:463-71. [PMID: 27390538 PMCID: PMC4936169 DOI: 10.3348/kjr.2016.17.4.463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 04/12/2016] [Indexed: 11/15/2022] Open
Abstract
Objective The aim of this study was to identify the morphological and functional characteristics of quadricuspid aortic valves (QAV) on cardiac computed tomography (CCT). Materials and Methods We retrospectively enrolled 11 patients with QAV. All patients underwent CCT and transthoracic echocardiography (TTE), and 7 patients underwent cardiovascular magnetic resonance (CMR). The presence and classification of QAV assessed by CCT was compared with that of TTE and intraoperative findings. The regurgitant orifice area (ROA) measured by CCT was compared with severity of aortic regurgitation (AR) by TTE and the regurgitant fraction (RF) by CMR. Results All of the patients had AR; 9 had pure AR, 1 had combined aortic stenosis and regurgitation, and 1 had combined subaortic stenosis and regurgitation. Two patients had a subaortic fibrotic membrane and 1 of them showed a subaortic stenosis. One QAV was misdiagnosed as tricuspid aortic valve on TTE. In accordance with the Hurwitz and Robert's classification, consensus was reached on the QAV classification between the CCT and TTE findings in 7 of 10 patients. The patients were classified as type A (n = 1), type B (n = 3), type C (n = 1), type D (n = 4), and type F (n = 2) on CCT. A very high correlation existed between ROA by CCT and RF by CMR (r = 0.99) but a good correlation existed between ROA by CCT and regurgitant severity by TTE (r = 0.62). Conclusion Cardiac computed tomography provides comprehensive anatomical and functional information about the QAV.
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Affiliation(s)
- Inyoung Song
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Jung Ah Park
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Bo Hwa Choi
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Sung Min Ko
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Je Kyoun Shin
- Department of Thoracic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Hyun Keun Chee
- Department of Thoracic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Jun Seok Kim
- Department of Thoracic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
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Picard FA, Garçon P, Chaudeurge A, Simion C, Cador R. [Planimetric measurement of the regurgitant orifice area using tridimensional transoesophageal echocardiography for aortic regurgitation, reproducibility and feasibility]. Ann Cardiol Angeiol (Paris) 2014; 63:293-299. [PMID: 24953201 DOI: 10.1016/j.ancard.2014.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 05/14/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND Aortic regurgitation is mainly evaluated by trans-thoracic echocardiography using multi-parametric qualitative and semi quantitative tools. All those parameters can fail to meet expectations, resulting in an imperfect diagnostic reliability and assessment of aortic regurgitation severity can be challenging. OBJECTIVES We sought to evaluate feasibility and intra- and inter-observer reproducibility of aortic regurgitant orifice area measured by planimetry with tridimensional trans-esophageal echocardiography on patients with at least grade 2/4 aortic regurgitation. PATIENTS AND METHODS Consecutive patients with at least grade 2/4 aortic regurgitation measured by trans-thoracic echocardiography and referred for trans-esophageal echocardiography for any reason were included. Planimetric reconstructions of regurgitant orifice area were studied and reproducibility indexes between senior and junior observers were calculated. RESULTS Twenty-three patients were included in this study. Intra- and inter-observer reproducibility were excellent with an ICC of 0.95 [0.88-0.98], P<0.0001 and 0.91 [0.79-0.96], P<0.0001, respectively. Mean length of the measurement was 6.6±0.9min [CI95% 6.23-7.01]. CONCLUSION Planimetric measurement of the aortic regurgitant orifice using tridimensional trans-esophageal echocardiography seems to be feasible and has great intra- and inter-observer reproducibility. Reconstruction durations were compatible with a daily use. There is a need now to investigate the reliability of this measurement as compared with the reference technique.
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Affiliation(s)
- F-A Picard
- Service de cardiologie, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France.
| | - P Garçon
- Service de cardiologie, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
| | - A Chaudeurge
- Service de cardiologie, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
| | - C Simion
- Service de cardiologie, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
| | - R Cador
- Service de cardiologie, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
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Kim DH, Handschumacher MD, Levine RA, Sun BJ, Jang JY, Yang DH, Kang JW, Song JM, Kang DH, Lim TH, Song JK. Aortic valve adaptation to aortic root dilatation: insights into the mechanism of functional aortic regurgitation from 3-dimensional cardiac computed tomography. Circ Cardiovasc Imaging 2014; 7:828-35. [PMID: 25051951 DOI: 10.1161/circimaging.113.001976] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The 3-dimensional relationship between aortic root and cusp is essential to understand the mechanism of aortic regurgitation (AR) because of aortic root dilatation (ARD). We sought to test the hypothesis that the stretched cusps in ARD enlarge to compensate for ARD. METHODS AND RESULTS Computed tomography imaged 92 patients (57 with ARD, 29 with moderate to severe AR, 28 without significant AR) and 35 normal controls. Specialized 3-dimensional software measured individual cusp surface areas relative to maximal mid-sinus cross-sectional area and minimal 3-dimensional annular area, coaptation area fraction, and asymmetry of sinus volumes and intercommissural distances. Total open cusp surface area increased (P<0.001) from 7.6±1.4 cm(2)/m(2) in normals to 12.9±2.2 cm(2)/m(2) in AR-negative and 15.2±3.3 cm(2)/m(2) in AR-positive patients. However, the ratio of closed cusp surface area to maximal mid-sinus area, reflecting cusp adaptation, decreased from normals to AR-negative to AR-positive patients (1.38±0.20, 1.15±0.15, 0.88±0.15; P<0.001), creating the lowest coaptation area fraction. Cusp distensibility (closed diastolic versus open area) decreased from 20% in controls and AR-negative patients to 5% in AR-positive patients (P<0.001). Multivariate determinants of AR and coaptation area fraction reflected both sinus size and cusp-to-annular adaptation. ARD was also progressively asymmetrical with root size, and individual cusp surface areas failed to match this asymmetry. CONCLUSIONS Aortic cusp enlargement occurs in ARD, but cusp adaptation and distensibility become limited in prominent, asymmetrical ARD, leading to AR. Optimal AR repair tailored to individual patient anatomy can benefit from appreciating valve adaptation and 3-dimensional relationships; understanding cusp adaptation mechanisms may ultimately provide therapeutic opportunities to improve such compensation.
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Affiliation(s)
- Dae-Hee Kim
- From the Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea (D.-H. Kim, B.J.S., J.Y.J., D.H.Y., J.-W.K., J.-M.S., D.-H. Kang, T.-H.L., J.-K.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.D.H., R.A.L.)
| | - Mark D Handschumacher
- From the Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea (D.-H. Kim, B.J.S., J.Y.J., D.H.Y., J.-W.K., J.-M.S., D.-H. Kang, T.-H.L., J.-K.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.D.H., R.A.L.)
| | - Robert A Levine
- From the Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea (D.-H. Kim, B.J.S., J.Y.J., D.H.Y., J.-W.K., J.-M.S., D.-H. Kang, T.-H.L., J.-K.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.D.H., R.A.L.)
| | - Byung Joo Sun
- From the Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea (D.-H. Kim, B.J.S., J.Y.J., D.H.Y., J.-W.K., J.-M.S., D.-H. Kang, T.-H.L., J.-K.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.D.H., R.A.L.)
| | - Jeong Yoon Jang
- From the Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea (D.-H. Kim, B.J.S., J.Y.J., D.H.Y., J.-W.K., J.-M.S., D.-H. Kang, T.-H.L., J.-K.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.D.H., R.A.L.)
| | - Dong Hyun Yang
- From the Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea (D.-H. Kim, B.J.S., J.Y.J., D.H.Y., J.-W.K., J.-M.S., D.-H. Kang, T.-H.L., J.-K.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.D.H., R.A.L.)
| | - Joon-Won Kang
- From the Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea (D.-H. Kim, B.J.S., J.Y.J., D.H.Y., J.-W.K., J.-M.S., D.-H. Kang, T.-H.L., J.-K.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.D.H., R.A.L.)
| | - Jong-Min Song
- From the Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea (D.-H. Kim, B.J.S., J.Y.J., D.H.Y., J.-W.K., J.-M.S., D.-H. Kang, T.-H.L., J.-K.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.D.H., R.A.L.)
| | - Duk-Hyun Kang
- From the Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea (D.-H. Kim, B.J.S., J.Y.J., D.H.Y., J.-W.K., J.-M.S., D.-H. Kang, T.-H.L., J.-K.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.D.H., R.A.L.)
| | - Tae-Hwan Lim
- From the Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea (D.-H. Kim, B.J.S., J.Y.J., D.H.Y., J.-W.K., J.-M.S., D.-H. Kang, T.-H.L., J.-K.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.D.H., R.A.L.)
| | - Jae-Kwan Song
- From the Cardiac Imaging Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea (D.-H. Kim, B.J.S., J.Y.J., D.H.Y., J.-W.K., J.-M.S., D.-H. Kang, T.-H.L., J.-K.S.); and Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (M.D.H., R.A.L.).
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