Comparison of Mitral Regurgitant Volume Assessment between Proximal Flow Convergence and Volumetric Methods in Patients with Significant Primary Mitral Regurgitation: An Echocardiographic and Cardiac Magnetic Resonance Imaging Study

doi:10.1016/j.echo.2022.03.005

Journal of the American Society of Echocardiography

Volume 35, Issue 7, July 2022, Pages 671-681

https://doi.org/10.1016/j.echo.2022.03.005 Get rights and content

Highlights

•
Mitral RVols obtained by PISA and volumetric methods differ markedly.
•
LV size is independently associated with the magnitude of this difference.
•
Mitral RVol by volumetric methods but not PISA is correlated with LV size.
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Mitral RVol should be routinely normalized to LV total stroke volume.

Background

Discrepancies have been observed between transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR) severity grading in primary mitral regurgitation (MR).

Objectives

We sought to compare mitral regurgitant volume (RVol) determined by the TTE proximal flow convergence (proximal isovelocity surface area [PISA]) method and by volumetric methods (TTE and CMR) and to study the relationship between left ventricle (LV) size and RVol obtained by either the PISA or volumetric methods.

Methods

Two centers prospectively recruited 188 patients with at least moderate to severe primary MR due to prolapse in sinus rhythm who underwent TTE and CMR examinations. Regurgitant volume was estimated by either PISA (PISA-RVol) or volumetric methods (LV total stroke volume-systolic aortic forward outflow volume) using either CMR (CMR-RVol) or TTE (TTE-RVol).

Results

The PISA-RVol was weakly correlated with CMR-RVol and TTE-RVol (r = 0.29 and 0.30, respectively; P < .001 for both). On multivariable analysis, smaller CMR-left ventricular end-diastolic volume (LVEDV) and absence of mitral annular disjunction independently correlated with increased magnitude of RVol difference between PISA and volumetric methods. While PISA-RVol and LVEDV were unrelated, CMR-RVol and TTE-RVol moderately correlated with LVEDV (r = 0.66 and 0.68, respectively; P < .001 for both). In contrast, LVEDV and regurgitant fraction (RVol/LV total stroke volume), assessed with either TTE or CMR, were poorly correlated (r = 0.17, P = .02; and r = 0.12, P = .10, respectively).

Conclusions

Mitral RVol values estimated by PISA and volumetric methods are not directly comparable. The expected proportional relationship between volumetric RVol and LV size, which was not observed with PISA-RVol, suggests that PISA-RVol would be inaccurate. Given that RVol assessed with volumetric methods depends on LV size, determination of a unique RVol threshold for severe MR is challenging. In contrast to RVol, calculating regurgitant fraction by volumetric methods allows the quantification of MR severity independently from LV size.

Graphical abstract

Section snippets

Study Population

This prospective study was conducted among patients referred to two heart valve centers (Catholic Institute Hospital Group, Lille, France, and Monaco Heart Center, Monaco) between 2013 and 2020 for evaluation of primary MR. Inclusion criteria were age 18 years or older, significant (moderate to severe or severe according to current guidelines) chronic primary MR due to prolapse in sinus rhythm, and CMR and TTE assessment. Exclusion criteria were MR from an etiology other than mitral valve

Results

The study population included 188 patients (Lille = 84; Monaco, n = 104; 48 women [26%]; median age, 66 years [57-73]; Table 1). Fifty-two patients (26%) had MAD, mostly those who displayed bileaflet prolapse (21/27 patients). The distribution of time between TTE and CMR studies was as follows: performed the same day, 64%; between 1 and 30 days, 23%; between 30 and 90 days, 13%. Interobserver variability was good for both PISA-RVol (ICC = 0.90; 95% CI, [0.77-0.96]; CV = 6.8%) and CMR-RVol

Discussion

The present study demonstrated in patients with significant primary MR due to prolapse that (1) the mitral RVols obtained by the PISA method displayed poor correlation with those obtained with a volumetric method (CMR, TTE), precluding direct comparison. Moreover, even though the PISA method, compared with the CMR volumetric method, on average overestimated mitral RVol, for a substantial proportion of patients, the PISA-RVol value was similar to or lower than that obtained with the volumetric

Conclusion

This study based on a “real-world” cohort of patients with chronic significant primary MR due to valve prolapse shows that mitral RVol values estimated by TTE and CMR are not directly comparable. The expected proportional relationship between RVol obtained using volumetric methods and LV size, which was unexpectedly not observed with RVol-PISA, suggests that PISA-RVol would be inaccurate. Given that RVol values obtained by volumetric methods are highly dependent on LV size, determination of a

Acknowledgments

We thank the Délégation à la Recherche Clinique et de l’Innovation of the Lille Catholic Institute Hospital Group for technical help and Gerald Pope, Medical and Scientific Translations.

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The assessment of ventricular secondary mitral regurgitation (v-SMR) severity through effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) calculations using the proximal isovelocity surface area (PISA) method and the two-dimensional echocardiography volumetric method (2DEVM) is prone to underestimation. Accordingly, we sought to investigate the accuracy of the three-dimensional echocardiography volumetric method (3DEVM) and its association with outcomes in v-SMR patients.
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After a mean follow-up of 20 ±11 months, 98 patients (43%) reached the end point. Regurgitant volume and EROA calculated by 3DEVM were larger than those calculated by 2DEVM and PISA. Using receiver operating characteristic curve analysis, both EROA (area under the curve, 0.75; 95% CI, 0.68-0.81; P = .008) and RegVol (AUC, 0.75; 95% CI, 0.68-0.82; P = .02) measured by 3DEVM showed the highest association with the outcome at 2 years compared to PISA and 2DEVM (P < .05 for all). Kaplan-Meier analysis demonstrated a significantly higher rate of events in patients with EROA ≥ 0.3 cm² (cumulative survival at 2 years: 28% ± 7% vs 32% ± 10% vs 30% ± 11%) and RegVol ≥ 45 mL (cumulative survival at 2 years: 21% ± 7% vs 24% ± 13% vs 22% ± 10%) by 3DEVM compared to those by PISA and 2DEVM, respectively. In Cox multivariable analysis, 3DEVM EROA remained independently associated with the end point (hazard ratio, 1.02, 95% CI, 1.00-1.05; P = .02). The model including EROA by 3DEVM provided significant incremental value to predict the combined end point compared to those using 2DEVM (net reclassification index = 0.51, P = .003; integrated discrimination index = 0.04, P = .014) and PISA (net reclassification index = 0.80, P < .001; integrated discrimination index = 0.06, P < .001).
Effective regurgitant orifice area and RegVol calculated by 3DEVM were independently associated with the end point, improving the risk stratification of patients with v-SMR compared to the 2DEVM and PISA methods.
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: Drs. A.A. and F.L. should be considered similar in author order.

: Conflicts of Interest: None.

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2022 by the American Society of Echocardiography.

Highlights

Background

Objectives

Methods

Results

Conclusions

Graphical abstract

Section snippets

Study Population

Results

Discussion

Conclusion

Acknowledgments

J Am Coll Cardiol

Arch Cardiovasc Dis

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Cardiothorac Vasc Anesth

JACC Cardiovasc Imaging

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J Am Coll Cardiol

J Am Soc Echocardiogr

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J Am Coll Cardiol

Am J Cardiol

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Am J Cardiol

JACC Cardiovasc Imaging

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