Quantification of Mitral Regurgitation in Mitral Valve Prolapse by Three-Dimensional Vena Contracta Area: Derived Cutoff Values and Comparison With Two-Dimensional Multiparametric Approach.

BACKGROUND: Echocardiographic grading of mitral regurgitation (MR) in mitral valve prolapse (MVP) is challenging. Three-dimensional (3D) vena contracta area (VCA) has been proposed as a valuable method. However, data defining the cutoff values of severity and validation in the subset of patients with MVP are scarce. The aim of this study was to validate the 3D VCA by 3D color-Doppler transesophageal echocardiography (TEE) in patients with MVP and to define the cutoff values of severity grading. The secondary aim was to compare 3D VCA to the effective regurgitant orifice area estimation by proximal isovelocity surface area (EROA-PISA) method. METHODS: A total of 1,138 patients with at least moderate MR who underwent TEE were included. Three-dimensional VCA was measured, and the cutoff value and area under the curve (AUC) for the prediction of severe MR were estimated by receiver operating characteristic curve using a guideline-suggested multiparametric approach as the reference standard. In a subgroup of patients, 3D regurgitant volume (RV) and 3D fraction were calculated from mitral and left ventricular outflow tract stroke volumes to further validate 3D VCA against a 3D volumetric reference standard. RESULTS: The optimal 3D VCA cutoff value for predicting severe MR was 0.45 cm2 (specificity, 0.87; sensitivity, 0.90) with an AUC of 0.95 using a multiparametric approach as reference. Three-dimensional VCA had a good linear correlation with EROA-PISA (r = 0.62, P < .05) with larger values compared to EROA-PISA (0.63 cm2 vs 0.44 cm2, P < .05). A cutoff of 0.50 cm2 (AUC of 0.84; sensitivity, 0.78; specificity, 0.78) predicts an EROA-PISA of 0.40 cm2. Three-dimensional VCA had a good linear correlation with 3D RV (r = 0.56, P < .01), with an AUC of 0.86 to predict a 3D fraction >50%. CONCLUSIONS: The present study suggests 0.45 cm2 as the best cutoff value of 3D VCA to define severe MR in patients with MVP, showing an optimal agreement with the reference standard multiparametric approach and 3D RV.

In vitro and clinical validation of different correction algorithms for the two-dimensional proximal isovelocity surface area method in a low-velocity flow field for quantifying tricuspid regurgitation.

Background: The 2-dimensional proximal isovelocity surface area (2D PISA) method underestimates tricuspid regurgitation (TR) severity. Previously proposed correction algorithms should be further scrutinized. Methods: Two correction algorithms were tested. One approach involves dividing the 2D PISA effective regurgitant orifice area by a constant of 0.7 (EROA0.7). Another approach involves multiplying the unadjusted EROA by Vorifice/(Vorifice - Valiasing), where Vorifice denotes the TR jet velocity, and Valiasing represents the color aliasing velocity (EROAVo-Va). In vitro validation was performed on a commercially available multifunctional valve tester with different size orifices and peak pressure gradients. A true EROA was derived through the regurgitant volume (RVol) calculated from the tester. For clinical validation, RVol was calculated as the difference between the overall stroke volume and the forward stroke volume of the right ventricle. Volumetric EROA was derived by dividing the RVol by the TR velocity-time integral (VTI). The vena contracta area (VCA) was obtained through direct planimetry with 3D echocardiography. The mean of volumetric EROA and VCA served as the reference in clinical validation. Results: Excellent correlation between the calculated EROAs and the true EROA was observed in vitro (r=0.98, r=0.97, and r=0.98 for uncorrected EROA, EROAVo-Va, and EROA0.7, respectively; all P values <0.0001). EROAVo-Va underestimated the true EROA and averaged 33% (P=0.3163), while EROA0.7 overestimated the true EROA and averaged 8% (P=0.0032). Clinically, these methods consistently exhibited a notable underestimation that varied with the reference EROA. This systematic underestimation was mitigated by both algorithms when either the VCA (biases of 19.6, 15.1, and 11.8 mm2 for uncorrected EROA, EROAVo-Va, and EROA0.7, respectively) or the volumetric EROA (biases of 10.1, 5.6, and 2.3 mm2 for uncorrected EROA, EROAVo-Va, and EROA0.7, respectively) served as the reference. Their ability to distinguish severe TR was similar, with area under the curve values of 0.905, 0.903, and 0.893 for uncorrected EROA, EROAVo-Va, and EROA0.7, respectively. No statistically significant differences were observed for diagnostic accuracy (all P values >0.05). Conclusions: Using a correction factor of 0.7 in quantifying TR provides similar accuracy when compared to other techniques. This represents a valuable clinical tool for quickly correcting the underestimation of the 2D PISA method in TR. This simple method may increase the frequency of applying the correction and earlier recognition of patients with severe TR.

Annular remodelling predicts outcome in isolated severe tricuspid regurgitation: a registry-based echocardiographic analysis.

AIMS: Depending on volume status, secondary tricuspid regurgitation (sTR) has a strong dynamic component. In contrast, associated structural dilatation of the tricuspid annulus and the right heart chambers may be less volume dependent. This study aimed to assess the prognostic value of right heart remodelling in isolated severe sTR (isoTR). METHODS AND RESULTS: A total of 36 000 patients from the longitudinal echocardiographic database of our tertiary centre were screened for severe isoTR [vena contracta (VC) ≥ 7 mm] in the absence of atrial fibrillation (AF), other valve disease, and/or reduced systolic left ventricular function. Echocardiographic examinations were re-read, focusing on right ventricular (RV) parameters and on quantitative and qualitative parameters of isoTR. All-cause mortality was defined as the primary endpoint. Two hundred and sixteen patients fulfilled the inclusion criteria. Severe TR was predominant; only few were classified in the new grades massive [n = 23 (10%)] and torrential TR [n = 4 (2%)]. During a median follow-up of 35 months (20-53), all-cause mortality was 31% (n = 67). Multivariate Cox regression analysis revealed no association of VC, effective regurgitant orifice area, or regurgitant volume with all-cause mortality. However, indexed RV end-diastolic diameter (P < 0.001), indexed right atrial dimensions (P = 0.019), and particularly tricuspid valve (TV) annulus diameter diastole index (P = 0.002) and TV annulus diameter systole index (P = 0.001) were significantly associated with outcome. CONCLUSION: Severe isolated TR in the absence of AF is a rare finding with a grim prognosis. Tricuspid annular diameter dimensions rather than quantitative measures of TR proved to be of significant prognostic value indicating a continuous remodelling leading to a 'point of no return' with a dismal outcome.

Spatiotemporal Complexity of Vena Contracta and Mitral Regurgitation Grading Using Three-Dimensional Echocardiographic Analysis.

BACKGROUND: Spatiotemporal complexity of the color Doppler vena contracta challenging the assumption of a circular and constant orifice may lead to mitral regurgitation (MR) grading inconsistencies. Using 3D transesophageal echocardiography, we characterized spatiotemporal vena contracta complexity and its impact on MR severity grading. METHODS: In 192 patients with suspected moderate or severe MR (100 primary MR [PMR]; 92 secondary MR [SMR]), we performed three-dimensional vena contracta area (VCA) quantification using single-frame (midsystolic or VCAmid, maximum or VCAmax) and multiframe (VCAmean) methods, as well as measures of orifice shape (shape index) and systolic variation of VCA. Vena contracta complexity and intermethod discrepancies were analyzed and correlated with functional class and pulmonary vein flow (PVF) patterns and with cardiac magnetic resonance (CMR) in a subset of cases (n = 20). RESULTS: The vena contracta was noncircular (shape index > 1.5) in 90% of patients. Severe noncircularity (shape index > 3) was more prevalent in SMR than in PMR (32.4% vs 14.6%). Variations of the VCA were more prominent in SMR than in PMR. VCAmid showed a low grading agreement with VCAmax (62%) and high grading agreement with VCAmean (83.3%). Pulmonary vein flow systolic reversal was associated with MR severity by VCA in SMR but not in PMR. VCAmid and VCAmean showed a stronger association with systolic flow reversal than VCAmax (area under the curve, 0.88, 0.86, and 0.79, respectively). In the subset of patients with CMR quantification, severe MR by VCAmax was graded as nonsevere by CMR more frequently compared with VCAmid and VCAmean. CONCLUSIONS: Highly prevalent spatiotemporal vena contracta complexity features in MR challenge the assumption of a circular and constant orifice. VCAmid seems the best single-frame approximation to multiframe quantification, and VCAmax may lead to severity overestimation.

An Integrative, Multiparametric Approach to Mitral Regurgitation Evaluation: A Case-Based Illustration.

Echocardiography is the first-line modality for assessing mitral regurgitation (MR). In addition to evaluation of the MR jet characteristics, echocardiography can provide quantitative parameters of MR severity. This case series illustrates the importance of integrating multiple parameters in the evaluation of MR and the role of multimodality imaging. (Level of Difficulty: Advanced.).

Gradient and pressure recovery of a self-expandable transcatheter aortic valve depends on ascending aorta size: In vitro study.

Objective: In this study we aimed to understand the role of interaction of the Medtronic Evolut R transcatheter aortic valve with the ascending aorta (AA) by evaluating the performance of the valve and the pressure recovery in different AA diameters with the same aortic annulus size. Methods: A 26-mm Medtronic Evolut R valve was tested using a left heart simulator in aortic root models of different AA diameter (D): small (D = 23 mm), medium (D = 28 mm), and large (D = 34 mm) under physiological conditions. Measurements of pressure from upstream to downstream of the valve were performed using a catheter at small intervals to comprehensively assess pressure gradient and pressure recovery. Results: In the small AA, the measured peak and mean pressure gradient at vena contracta were 11.5 ± 0.5 mm Hg and 7.8 ± 0.4 mm Hg, respectively, which was higher (P < .01) compared with the medium (8.1 ± 0.4 mm Hg and 5.2 ± 0.4 mm Hg) and large AAs (7.4 ± 1.0 mm Hg and 5.4 ± 0.6 mm Hg). The net pressure gradient was lower for the case with the medium AA (4.1 ± 1.2 mm Hg) compared with the small AA (4.7 ± 0.8 mm Hg) and large AA (6.1 ± 1.4 mm Hg; P < .01). Conclusions: We have shown that small and large AAs can increase net pressure gradient, because of the direct interaction of the Medtronic Evolut R stent with the AA (in small AA) and introducing higher level of turbulence (in large AA). AA size might need to be considered in the selection of an appropriate device for transcatheter aortic valve replacement.

3D localization of vena contracta using Doppler ICE imaging in tricuspid valve interventions.

PURPOSE: Tricuspid valve (TV) interventions face the challenge of imaging the anatomy and tools because of the 'TEE-unfriendly' nature of the TV. In edge-to-edge TV repair, a core step is to position the clip perpendicular to the coaptation gap. In this study, we provide a semi-automated method to localize the VC from Doppler intracardiac echo (ICE) imaging in a tracked 3D space, thus providing a pre-mapped location of the coaptation gap to assist device positioning. METHODS: A magnetically tracked ICE probe with Doppler imaging capabilities is employed in this study for imaging three patient-specific TVs placed in a pulsatile heart phantom. For each of the valves, the ICE probe is positioned to image the maximum regurgitant flow for five cardiac cycles. An algorithm then extracts the regurgitation imaging and computes the exact location of the vena contracta on the image. RESULTS: Across the three pathological, patient-specific valves, the average distance error between the detected VC and the ground truth model is [Formula: see text]mm. For each of the valves, one case represented the outlier where the algorithm misidentified the vena contracta to be near the annulus. In such cases, it is recommended to retake the five-second imaging data. CONCLUSION: This study presented a method for ultrasound-based localization of vena contracta in 3D space. Mapping such anatomical landmarks has the potential to assist with device positioning and to simplify tricuspid valve interventions by providing more contextual information to the interventionalists, thus enhancing their spatial awareness. Additionally, ICE can be used to provide live US and Doppler imaging of the complex TV anatomy throughout the procedure.

Predominant Posterior Annular Dilatation Is Associated with Vena Contracta Morphology in Atrial Functional Tricuspid Regurgitation.

BACKGROUND: The exact relationship between tricuspid valve geometry and vena contracta (VC) morphology has pathophysiologic and mechanistic implications in patients with atrial functional tricuspid regurgitation (AF-TR). The aim of this study was to investigate tricuspid valve geometric and VC morphologic characteristics and compare them between AF-TR and ventricular functional tricuspid regurgitation (VF-TR) in sinus rhythm. METHODS: Transesophageal three-dimensional echocardiography data sets of the tricuspid valve were acquired in 439 patients with moderate to severe tricuspid regurgitation. Forty-eight patients with AF-TR and 48 with VF-TR in sinus rhythm matched for age, sex, body surface area, and VC area according to three-dimensional echocardiography-based pathogenic stratification were selected. VC morphology was determined by the ratio of anteroposterior to anterolateral-posteromedial diameter using color Doppler three-dimensional echocardiography. RESULTS: Patients with AF-TR had higher posterior annular perimeter/total annular perimeter ratios than patients with VF-TR in sinus rhythm (P < .001). Despite similar VC areas, patients with AF-TR had larger VC anteroposterior diameters and smaller VC anterolateral-posteromedial diameters, with resultant higher VC anteroposterior/anterolateral-posteromedial diameter ratios (P < .001). On multivariable analyses, posterior annular perimeter (coefficient = 0.013; 95% CI, 0.001 to 0.024) and posterior leaflet length/annular perimeter ratio (coefficient = -2.372; 95% CI, -3.591 to -1.154) were multivariable determinants of VC morphology in AF-TR. Additionally, posterior annular perimeter/total annular perimeter was strongly related to right atrial volume in AF-TR but not in VF-TR. CONCLUSIONS: Possible contributions to the initial mechanism of AF-TR include right atrial remodeling, predominant posterior annular dilatation, and insufficient adaptive posterior leaflet growth, which may have therapeutic implications in this setting.

Diagnostic value of vena contracta area measurement using three-dimensional transesophageal echocardiography in assessing the severity of aortic regurgitation.

PURPOSE: Transthoracic echocardiography (TTE) provides noninvasively quantitative assessment of aortic regurgitation (AR) severity, but its diagnostic accuracy depends on image quality. Two-dimensional transesophageal echocardiography (TEE) is a semi-invasive procedure that is excellent in evaluating AR mechanism. However, quantitative assessment may be challenging due to restrictions in probe manipulation. This study aimed to investigate the diagnostic value of three-dimensional TEE to measure the vena contracta area (3DVCA) of AR. METHODS: The subjects comprised 62 patients (age, 65 ± 16 years) whose AR was evaluated using TEE. The 3DVCA and semi-quantitative TEE parameters, such as the ratio of AR jet width to left ventricular outflow tract (jet/LVOT) and the vena contracta width (VCW) of AR jet, were compared using angiography grade and quantitative TTE measurements including regurgitant volume (RVol) and effective regurgitant orifice area (EROA). The diagnostic accuracy was determined using receiver operating characteristic (ROC) analysis, and the reproducibility of 3DVCA was also evaluated. RESULTS: In 3DVCA, less overlap between angiography grades were observed. Correlation with RVol or EROA was better in 3DVCA than in Jet/LVOT or VCW. The area under the ROC curve was .737 for jet/LVOT, .773 for VCW, and .849 for 3DVCA, respectively. The optimal cutoff value of 3DVCA was ≥.31 cm2 for grading severe AR. Inter- and intra-observer reproducibility of 3DVCA were .92 and .97, respectively. CONCLUSIONS: The 3DVCA method using TEE showed high diagnostic accuracy and reproducibility. 3DVCA deserves use in accurately assessing AR severity, especially in patients who present difficulty in quantitative Doppler assessment using TTE.

Comprehensive assessment of the aortic valve in critically ill patients for the non-cardiologist. Part II: Chronic aortic regurgitation of the native valve.

Inadequate diastolic closure of the aortic valve causes aortic regurgitation (AR). Diastolic regurgitation towards the left ventricle (LV) causes LV volume overload, resulting in eccentric LV remodelling. Transthoracic echocardiography (TTE) is the first line examination in the work-up of AR. TTE allows quantification of left ventricular end-diastolic diameter and volume and left ventricular ejection fraction, which are key elements in the clinical decision making regarding the timing of valve surgery. The qualitative echocardiographic features contributing to the AR severity grading are discussed: fluttering of the anterior mitral valve leaflet, density and shape of the continuous wave Doppler signal of the AR jet, colour flow imaging of the AR jet width, and holodiastolic flow reversal in the descending thoracic aorta and abdominal aorta. Volumetric assessment of the AR is performed by measuring the velocity time integral of the left ventricular outflow tract (LVOT) and transmitral valve (MV) plane, and diameters of LVOT and MV. We explain how the regurgitant fraction and effective regurgitant orifice area (EROA) can be calculated. Alternatively, the proximal isovelocity surface area can be used to determine the EROA. We overview the utility of pressure half time and vena contracta width to assess AR severity. Further, we discuss the role of transoesophageal echocardiography, echocardiography speckle tracking strain imaging, cardiac magnetic resonance imaging and computed tomography of the thoracic aorta in the work-up of AR. Finally, we overview the criteria for valve surgery in AR.

Dynamic Systolic Changes in Tricuspid Regurgitation Vena Contracta Size and Proximal Isovelocity Surface Area in Hypoplastic Left Heart Syndrome: A Three-Dimensional Color Doppler Echocardiographic Study.

BACKGROUND: The aims of this study were to investigate the dynamic changes in the vena contracta (VC) and proximal isovelocity surface area (PISA) through systole in patients with hypoplastic left heart syndrome and tricuspid regurgitation and to identify the stage of systole (early, mid, or late) in which VC and PISA radius are optimal. METHODS: Twenty-eight patients with hypoplastic left heart syndrome were prospectively studied using continuous two-dimensional (2D) and three-dimensional (3D) echocardiography. Two-dimensional VC width, 3D VC area, and PISA radii (2D and 3D) were measured frame by frame throughout systole. The maximal 2D VC width, 3D VC area, and PISA radii in the first, middle, and last thirds of systole were compared, and correlations were explored with 3D tricuspid annular areas, right atrial volumes, and right ventricular volumes. RESULTS: In all, 35 data sets that met inclusion criteria were analyzed. On frame-by-frame analysis, maximal 2D VC width and 3D VC area were found in the first third of systole in 17% and 20% of studies, in the second third in 34% and 31%, and in the final third in 49% and 49%. Similarly, the maximal 2D and 3D PISA radii were found in the first third of systole in 26% and 17% of studies, in the second third in 28% and 34%, and in the final third in 46% and 49%. CONCLUSIONS: In hypoplastic left heart syndrome, detailed temporal analysis of tricuspid regurgitation-associated VC and PISA by 2D and 3D echocardiography reveals no reliable pattern predicting when in systole these parameters peak. Frame-by-frame measurement is necessary for identification of maximal VC and PISA radius on 2D and 3D color Doppler echocardiography because the severity of tricuspid regurgitation could be underestimated because of temporal variability in VC and PISA.

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 validation of partition values for quantitative parameters to grade functional tricuspid regurgitation severity by conventional echocardiography.

AIMS: Quantitative echocardiography parameters are seldom used to grade tricuspid regurgitation (TR) severity due to relative paucity of validation studies and lack of prognostic data. To assess the relationship between TR severity and the composite endpoint of death and hospitalization for congestive heart failure (CHF); and to identify the threshold values of vena contracta width (VCavg), effective regurgitant orifice area (EROA), regurgitant volume (RegVol), and regurgitant fraction (RegFr) to define low, intermediate, and high-risk TR based on patients' outcome data. METHODS AND RESULTS: A cohort of 296 patients with at least mild TR underwent 2D, 3D, and Doppler echocardiography. We built statistical models (adjusted for age, NYHA class, left ventricular ejection fraction, and pulmonary artery systolic pressure) for VCavg, EROA, RegVol, and RegFr to study their relationships with the hazard of outcome. The tertiles of the derived hazard values defined the threshold values of the quantitative parameters for TR severity grading. During 47-month follow-up, 32 deaths and 72 CHF occurred. Event-free rate was 14%, 48%, and 93% in patients with severe, moderate, and mild TR, respectively. Severe TR was graded as VCavg > 6 mm, EROA > 0.30 cm2, RegVol > 30 mL, and RegF > 45%. CONCLUSION: This outcome study demonstrates the prognostic value of quantitative parameters of TR severity and provides prognostically meaningful threshold values to grade TR severity in low, intermediate, and high risk.

Sources of Variability in Vena Contracta Area Measurement for Tricuspid Regurgitation Severity Grading: Comparison of Technical Settings and Vendors.

BACKGROUND: Previous studies found different cutoffs of vena contracta area (VCA) to define severe tricuspid regurgitation (TR). The aim of this study was to investigate the factors associated with such variability by comparing technical variables and vendors. METHODS: Sixty-nine patients with scheduled tricuspid surgery were included in this prospective study. For each patient, TR data sets were obtained on three-dimensional color Doppler transthoracic echocardiography on at least two of three systems: GE Vivid E95 (n = 39), Siemens SC2000 Prime (n = 64), and Philips EPIQ 7C (n = 60). VCA was measured using default settings or with color baseline shifted on all three platforms and with minimal color gain (10%-20%) on the GE platform. RESULTS: Color gain reduction and baseline shift caused significant change sin VCA measurement (-46% and 10%, respectively). Intervendor comparison exhibited wide limits of agreement (narrowest range, -74% to 167%), with either default or optimized settings. Different technical settings, platforms, and reference methods all produced different VCA cutoffs for severe TR. CONCLUSIONS: VCA measurement in TR is sensitive to technical factors and demonstrates intervendor variability. Technical variables in VCA measurement should be reported in detail to allow comparison among research studies. The same vendor and settings should be used for longitudinal analysis of TR VCA in the same patient in multivendor echocardiography laboratories.

Predictors of residual mitral regurgitation after left ventricular assist device implantation.

Patients with advanced heart failure often have functional mitral regurgitation. Left ventricular assist device implantation improves functional mitral regurgitation through left ventricular unloading. However, residual mitral regurgitation after left ventricular assist device implantation leads to adverse outcomes, and whether patients need concomitant mitral valve surgery is not fully elucidated. Therefore, this study aimed to elucidate the predictors of residual mitral regurgitation and to describe the temporal changes in residual mitral regurgitation. We retrospectively enrolled 15 patients with implantable continuous-flow left ventricular assist device, who had significant mitral regurgitation on echocardiography before left ventricular assist device implantation. Three patients had residual mitral regurgitation (mitral regurgitation color jet area/left atrial area >0.2) 1 month after left ventricular assist device implantation. We investigated factors associated with residual mitral regurgitation and compared patients with or without residual mitral regurgitation. On univariate analysis, mitral valve tethering area and mitral regurgitation vena contracta before left ventricular assist device implantation were significantly associated with residual mitral regurgitation (odds ratio, 1.03; p = 0.036 and odds ratio, 10.45; p = 0.0087). One month after left ventricular assist device implantation, the mean pulmonary capillary wedge pressure and pulmonary artery pressure were higher in patients with residual mitral regurgitation (pulmonary capillary wedge pressure: 11.3 ± 3.5 vs 6.4 ± 3.4 mmHg, p = 0.029 and pulmonary artery pressure: 21.3 ± 4.0 vs 15.9 ± 3.3 mmHg, p = 0.023). However, the mitral regurgitation grading and hemodynamics were not significantly different 6 months after left ventricular assist device implantation. The hospitalization-free survival was not significantly different between the two groups. Mitral valve tethering area and mitral regurgitation vena contracta were predictors of residual mitral regurgitation. Residual mitral regurgitation improved until 6 months after left ventricular assist device implantation and might not affect the prognosis.

Refining Severe Tricuspid Regurgitation Definition by Echocardiography with a New Outcomes-Based "Massive" Grade.

BACKGROUND: Current echocardiographic guidelines recommend that tricuspid regurgitation (TR) severity be graded in three categories, following assessment of specific parameters. Findings from recent trials have shown that the severity of TR frequently far exceeds the current definition of severe. We postulated that a grading approach that emphasizes outcomes could be useful to identify patients with severe TR at increased risk of mortality. METHODS: We identified 284 patients with echocardiograms demonstrating severe functional TR, defined as vena contracta (VC) ≥ 0.7 cm. Demographics and mortality data were obtained from the medical records. Patients were divided into study (n = 122 patients with three-dimensional images) and validation (n = 162) cohorts. The VC was measured in both the right ventricular (RV) inflow and apical four-chamber views and averaged. For the study cohort, tricuspid annular, RV end-diastolic (basal, mid, long axis) dimensions, tricuspid leaflet tenting height and area, RV free-wall longitudinal strain, and RV volumes were measured from two- and three-dimensional data sets. A K-partition algorithm was used in the study cohort to derive a mortality-related cutoff VC value, above which TR was termed "massive." The ability of this VC cutoff to identify patients at greater mortality risk was then tested in the validation cohort using Kaplan-Meier survival analysis. RESULTS: In the study cohort, VC > 0.92 cm (massive TR) was optimally associated with worse survival. Tricuspid annular and RV size were larger in the massive group (P < .05), while there were no significant differences in demographics between the TR groups. Importantly, in the independent validation cohort, the above VC cutoff also correlated with increased mortality in the massive group (log-rank P < .05). CONCLUSIONS: Among patients traditionally defined as having severe TR, a subset exists with massive TR, resulting in greater adverse RV remodeling and increased mortality. These patients may derive the greatest benefit from emerging percutaneous therapies.

New Imaging Markers of Clinical Outcome in Asymptomatic Patients with Severe Aortic Regurgitation.

Background: Determining the value of new imaging markers to predict aortic valve (AV) surgery in asymptomatic patients with severe aortic regurgitation (AR) in a prospective, observational, multicenter study. Methods: Consecutive patients with chronic severe AR were enrolled between 2015-2018. Baseline examination included echocardiography (ECHO) with 2- and 3-dimensional (2D and 3D) vena contracta area (VCA), and magnetic resonance imaging (MRI) with regurgitant volume (RV) and fraction (RF) analyzed in CoreLab. Results: The mean follow-up was 587 days (interquartile range (IQR) 296-901) in a total of 104 patients. Twenty patients underwent AV surgery. Baseline clinical and laboratory data did not differ between surgically and medically treated patients. Surgically treated patients had larger left ventricular (LV) dimension, end-diastolic volume (all p < 0.05), and the LV ejection fraction was similar. The surgical group showed higher prevalence of severe AR (70% vs. 40%, p = 0.02). Out of all imaging markers 3D VCA, MRI-derived RV and RF were identified as the strongest independent predictors of AV surgery (all p < 0.001). Conclusions: Parameters related to LV morphology and function showed moderate accuracy to identify patients in need of early AV surgery at the early stage of the disease. 3D ECHO-derived VCA and MRI-derived RV and RF showed high accuracy and excellent sensitivity to identify patients in need of early surgery.

Comprehensive Evaluation of Tricuspid Regurgitation Location and Severity Using Vena Contracta Analysis: A Color Doppler Three-Dimensional Transesophageal Echocardiographic Study.

BACKGROUND: The clinical significance of three-dimensional (3D) vena contracta area (VCA) in tricuspid regurgitation (TR) is not fully elucidated. The aim of this study was to investigate the diagnostic accuracy of 3D VCA using 3D echocardiography-derived regurgitation volume as a reference standard. METHODS: One hundred sixteen patients with at least moderate TR underwent two-dimensional transthoracic and color Doppler 3D transesophageal echocardiography. The 3D vena contracta, which was located at the narrowest neck of the TR jet just above and toward the right atrial side of the flow convergence zone, was assessed for TR location and severity. RESULTS: As for TR location, patients with severe functional TR had the highest prevalence of central jet location among TR subgroups, whereas patients with severe primary TR showed a greater spatial extent of TR jet location involved compared with the moderate TR group (P < .05 for both). As for TR severity, a 3D VCA cutoff value of 0.61 cm2 discriminated severe TR with sensitivity of 78% and specificity of 97% in the total patient population (area under the curve = 0.93, P < .001). Multivariate analysis revealed that 3D VCA, a dilated right ventricle, and hepatic vein systolic reversal were independently associated with regurgitant volume (P < .001 for all). The χ2 value for the model that incorporated clinical and two-dimensional integrative parameters and 3D VCA > 0.61 cm2 to evaluate severe TR was significantly higher than that for the model that incorporated only clinical and two-dimensional integrative parameters (P = .001). CONCLUSIONS: Three-dimensional VCA has independent and incremental diagnostic value for evaluating severe TR. Comprehensive evaluation of TR location and severity using 3D vena contracta analysis may help in treatment selection for TR.

Predicting the Number of Edge-to-Edge Repair Devices Needed to Adequately Treat Mitral Regurgitation Using Transesophageal Echocardiography.

OBJECTIVES: Increased utilization and highly variable costs seen with percutaneous mitral valve edge-to-edge repair have made cost cutting strategies of significant interest. Mitral regurgitation etiology, the number of devices used, and experience all play a role in variability. Currently a paucity of data exists in predicting the number of devices. Any associations found between echocardiography parameters and the number of devices used could help with pre-procedure planning and device placement strategies, ultimately reducing variability and costs. DESIGN: In this retrospective analysis the authors evaluated the ability of established and novel three-dimensional (3D) mitral regurgitation measures, namely 3D vena contracta area and vena contracta length, to predict the number of devices used. Other factors evaluated include mitral valve area and ejection fraction. All factors were compared using the Mann Whitney rank sum tests. PARTICIPANTS: Patients over 18 years old undergoing the MitraClip procedure. SETTING: Catheterization Laboratory. MAIN RESULTS: No relationship was found between 3D parameters and the number of devices used, but mitral valve area was strongly associated with the use of multiple devices. CONCLUSION: The 3D parameters of interest were not associated with the use of multiple devices, but the mitral valve area was associated. Further studies are needed to determine if this relationship is predictive.

Diagnostic Value of 3-Dimensional Vena Contracta Area for the Quantification of Residual Mitral Regurgitation After MitraClip Procedure.

OBJECTIVES: The authors sought to define the feasibility and performance of 3-dimensional (3D) vena contracta area (VCA) measurement in evaluating total residual mitral regurgitation (MR) following percutaneous edge-to-edge clip (E-EC) mitral valve repair. BACKGROUND: Residual MR severity after percutaneous repair is not only a determinant of procedural success, but also a major prognostic factor. To date, no single echocardiographic method has been recommended for post-procedural MR quantification, with the evaluation currently relying on a complex, multiparametric appraisal. METHOD: The authors performed a retrospective study of patients undergoing the E-EC procedure, for which baseline and post-repair 3D color Doppler transesophageal echocardiogram datasets were available. Total VCA was recorded as the sum of individual VCAs (if more than 1) and compared with an expert multiparametric appraisal of MR severity as the reference standard. Receiver-operating characteristic analysis was performed. RESULTS: 155 patient studies were available for review. Total VCA correlated with hemodynamic parameters and was significantly reduced after E-EC. Receiver-operating characteristic analysis demonstrated a VCA threshold of 0.27 cm2 for identification of ≥moderate MR, with good diagnostic accuracy (area under the curve 0.81) and a negative predictive value of 92%. Smaller VCA was associated with clinical New York Heart Association functional class improvement at 30-day follow-up. CONCLUSIONS: Measurement of VCA is feasible using 3D color Doppler transesophageal echocardiography and provides reliable quantification of MR following E-EC transcatheter mitral valve repair.