Valvular Heart Disease
Determinants of pulmonary venous flow reversal in mitral regurgitation and its usefulness in determining the severity of regurgitation

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Abstract

Pulmonary venous flow (PVF) reversal is observed in mitral regurgitation (MR) and can be detected by Doppler echocardiography. However, the determinants of PVF alterations in MR have not been analyzed with simultaneous quantitative methods, and the diagnostic accuracy of flow reversal is uncertain. Prospectively, in 128 patients with isolated MR of various degrees (regurgitant fraction 4% to 81%), Doppler echocardiography was used to measure PVF velocity simultaneously to quantify MR by 2 methods and to perform a comprehensive hemodynamic assessment. Systolic PVF velocity was 4 ± 56 cm/s (systolic flow reversal in 39 patients) and showed the strongest correlations with mitral effective regurgitant orifice (r = −0.56, p <0.0001). In multivariate analysis, larger effective regurgitant orifice (p <0.0001), eccentric jets (p = 0.0023), longer jets (p = 0.0033), and lower mitral regurgitant velocity (p = 0.0015) were independent determinants of decreased systolic PVF velocity. In organic MR, increased filling pressures were associated with systolic PVF reversal. Blunted systolic flow was associated with shorter mitral deceleration time (p <0.0001) and enlarged left atrium (p = 0.0007). For the diagnosis of severe MR (regurgitant orifice ≥35 mm2, regurgitant fraction ≥50%), systolic flow reversal sensitivity was 61% and 60%, and specificity was 92% and 85%, respectively. Among 29 patients in whom surgery demonstrated severe mitral lesions, 12 (41%) had no systolic flow reversal preoperatively. In patients with MR, the determinants of systolic PVF are complex and, in addition to the degree of MR, include the hemodynamic consequences of MR, jet characteristics, left ventricular filling, and left atrial volume alterations. Consequently, systolic PVF reversal is a useful sign of severe MR but of relatively low sensitivity, emphasizing the importance of quantifying MR.

Section snippets

Patients

The study was conducted prospectively in the routine practice of the echocardiographic laboratory in patients examined by 1 of the authors. The inclusion criteria were (1) presence of pure isolated MR of at least mild degree, (2) high-quality recording by transthoracic pulsed-wave Doppler of the pulmonary venous velocities, (3) simultaneous Doppler echocardiographic quantitation of MR by at least 2 methods, and (4) comprehensive hemodynamic assessment with Doppler echocardiography. The

Results

The population included 128 patients (mean age 67 ± 13 years; 75% men). Forty-nine patients had ischemic/functional MR, and 79 had organic MR. A wide distribution of MR was noted, with a mean regurgitant fraction of 41% ± 18% by quantitative Doppler and 40% ± 18% by quantitative 2-dimensional echocardiography (range 4% to 81%). In the 24 normal subjects, the absolute value of the difference between mitral and aortic stroke volume was 3.3 ± 4.7 ml and between left ventricular and aortic stroke

Discussion

The present study shows that in patients with MR, systolic PVF is significantly decreased compared with that of normal subjects. However, an important and new result of the present study is that the determinants of PVF are complex, involving not only the degree of regurgitation as measured by effective regurgitant orifice but also other determinants, in particular, jet characteristics, diastolic left ventricular filling pattern, and left atrial volume and filling pressures. Consequently, for

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