Assessment of Asymptomatic Severe Aortic Regurgitation by Doppler-Derived Echo Indices: Comparison with Magnetic Resonance Quantification

Reliable quantification of aortic regurgitation (AR) severity is essential for clinical management. We aimed to compare quantitative and indirect echo-Doppler indices to quantitative cardiac magnetic resonance (CMR) parameters in asymptomatic chronic severe AR. Methods and Results: We evaluated 104 consecutive patients using echocardiography and CMR. A comprehensive 2D, 3D, and Doppler echocardiography was performed. The CMR was used to quantify regurgitation fraction (RF) and volume (RV) using the phase-contrast velocity mapping technique. Concordant grading of AR severity with both techniques was observed in 77 (74%) patients. Correlation between RV and RF as assessed by echocardiography and CMR was relatively good (rs = 0.50 for RV, rs = 0.40 for RF, p < 0.0001). The best correlation between indirect echo-Doppler and CMR parameters was found for diastolic flow reversal (DFR) velocity in descending aorta (rs = 0.62 for RV, rs = 0.50 for RF, p < 0.0001) and 3D vena contracta area (VCA) (rs = 0.48 for RV, rs = 0.38 for RF, p < 0.0001). Using receiver operating characteristic analysis, the largest area under curve (AUC) to predict severe AR by CMR RV was observed for DFR velocity (AUC = 0.79). DFR velocity of 19.5 cm/s provided 78% sensitivity and 80% specificity. The AUC for 3D VCA to predict severe AR by CMR RV was 0.73, with optimal cut-off of 26 mm2 (sensitivity 80% and specificity 66%). Conclusions: Out of the indirect echo-Doppler indices of AR severity, DFR velocity in descending aorta and 3D vena contracta area showed the best correlation with CMR-derived RV and RF in patients with chronic severe AR.

Prognostic value of three dimensional-vena contracta area in patients with secondary mitral regurgitation

Background Effective regurgitant orifice area (EROA) is an important quantitative measurement for mitral regurgitation (MR) grading. Yet, the accuracy of this method is limited in patients with secondary mitral regurgitation (SMR). Three-dimensional (3D) color Doppler echocardiography allows for the direct assessment of the vena contracta area (VCA). The prognostic value of 3D-VCA in patients with secondary MR has not been investigated. Purpose The aim of the present study was to assess the association between 3D-VCA and prognosis of patients with SMR. Methods A total of 218 patients (69% men, median age 74 years) with significant SMR were retrospectively analyzed. 3D-VCA was measured offline with dedicated software, from restored 3D color Doppler full volume datasets of the mitral valve (Figure 1). The population was divided according to the American College of Cardiology expert recommendation for the grading of severe MR (VCA ≥50 mm2 and VCA &lt;50 mm2). Patients were followed up for the combined end point of all-cause mortality or heart failure hospitalization. Results Of the total population, 63% had an ischemic etiology, 60% had atrial fibrillation and 25% cardiac resynchronization therapy. Patients with 3D-VCA ≥50 mm2 needed more diuretic therapy, had a larger left ventricle and atrium, and had more post-procedural residual MR. A total of 82% of patients underwent MitraClip device implantation, 17% had mitral valve repair and 1% had mitral valve replacement. During a median follow-up of 28 months, 130 (60%) met the combined end point (101 (46%) patients died and 81 (37%) were hospitalized due to heart failure). When dividing the population according to the cut-off of 3D-VCA, patients with a 3D-VCA≥50 mm2 had a worse prognosis compared with their counterparts (Figure 2). In a multivariable Cox regression analysis, 3D-VCA≥50 mm2 remained independently associated with the composite endpoint of all-cause mortality or heart failure hospitalization (HR=1.454, 95% CI 1.020–2.072, p=0.038). Conclusion In patients with SMR, a 3D-VCA ≥50 mm2 was independently associated with a combined endpoint of death or heart failure hospitalization. FUNDunding Acknowledgement Type of funding sources: None. Figure 1. Method of 3D-VCA measurement Figure 2. Kaplan-Meier survival curve

Impact of the implantation of one MitraClip on the mitral valve anatomy: NTR vs. XTR

Funding Acknowledgements Type of funding sources: None. Introduction Percutaneous mitral repair using MitraClips (MC) for severe symptomatic regurgitation (MR) has emerge as an alternative treatment for selected high risk surgical patients. Despite the high number of cases treated with both iterations of the MC, the small NTR and the big XTR, the impact of the device size on the mitral valve area (MVA), the morphology of the annulus, the severity of the MR and the use of multiple device is still unknown. Methods High quality volume focused on the MV were acquired during each intervention. Using a dedicated 3-D analysis software the dimensions of the annulus, the MVA and the 3-D vena contracta area (VCA) were evaluated before and after clipping. After implantation, the area of both orifices were measured independently and summed. Results A total of 120 patients were included, 63 received a NTR and 57 a XTR. Before clipping, XTR cases had bigger MVA (5.9+/-1.7 vs. 4.9+/-1.3 cm2, p .001), a trend toward bigger VCA (0.56+/-0.7 vs. 0.51+/-0.9 cm2, p .073) and no difference in the anteroposterior (AP, 3.5 [3.1-4] vs. 3.5 [3.3-3.8] cm, p .47) and the lateromedial (LM, 4.2 [3.8-4.5] vs. 4.3 [4.0-4.5] cm) diameter of the annulus compared to NTR cases. One MC implantation produced a significant decrease of all these parameters but only MVA was significantly more reduce by XTR (Figure 1). The patients receiving a NTR as first MC did not need more often a second clip (31/63 vs. 26/57, p .072). Conclusions On average, both devices produce a MVA reduction of more than 50% and an indirect annuloplasty mainly in the anteroposterior direction. The use of an XTR as first MC do not decrease the probability of the necessity of a second one. All these parameters should be carefully taken into account when defining the implantation strategy. Abstract Figure.

Vena contracta area size predicts effectiveness of interventional edge-to-edge repair in tricuspid valve regurgitation

Funding Acknowledgements Type of funding sources: None. Background Percutaneous tricuspid valve edge-to-edge repair (pTVR) is a promising interventional technique for patients with tricuspid regurgitation (TR), but guidance regarding patient selection and echocardiographic screening is lacking. The aim of this study was to identify echocardiographic measurements which may predict pTVR success. Methods Before and after pTVR, echocardiographic data, including 3D full-volume datasets, were obtained and quantified. Right ventricular assessments included ejection fraction (RVEF3D) and diastolic (RVVd3D) and systolic (RVVs3D) volumes. Also evaluated were: right atrial (RA) volume, effective regurgitant orifice area by PISA method (EROAPISA), vena contracta area (VCA3D) by multiplanar reconstruction from a 3D colour Doppler loop (Figure 1a), maximal diastolic tricuspid annulus area from a 3D zoom image (Figure 1b), and tricuspid tenting area. TR severity was graded according to EROAPISA and VCA3D as grade 1+ to 5+. Results Patients (n= 44, age 72 ± 9 years, 20 male) with at least moderate to severe TR undergoing pTVR were consecutively included. The patients were divided into groups according to their post-pTVR TR grade. Group 1 had TR grade ≤2+, and group 2 had TR grade ≥3+.Echocardiographic parameters before pTVR for both groups are presented in Table 1. As expected, patients with TVR ≥3+ after pTVR had significantly worse pre-intervention echocardiographic measurements of TR severity, valve dimensions, and chamber volumes. ROC curves for the prediction of TR ≤2+ (mild to moderate) after pTVR (defined as VCA3D &lt;0.75 cm² and EROAPISA &lt;0.4 cm²) were drawn for different echocardiographic features (Figure 2). VCA3D by 3D colour Doppler yielded the highest area under the ROC curve followed by TV anatomy measurements (Annulus area3D, Tenting area) and right atrial volume. Conclusion A thorough evaluation of TR and valve dimensions by 3D echocardiography, particulary the evaluation of VCA3D by 3D colour Doppler, aids in the prediction of the probability of pTVR success. Abstract Figure.