Comparison of transesophageal Doppler methods with angiography for evaluation of the severity of mitral regurgitation

doi:10.1016/S0894-7317(98)70008-2

Journal of the American Society of Echocardiography

Volume 11, Issue 9, September 1998, Pages 882-892

https://doi.org/10.1016/S0894-7317(98)70008-2 Get rights and content

Abstract

Doppler evaluation of mitral regurgitation remains difficult; thus, a head-to-head comparison of the diagnostic accuracy of Doppler methods was undertaken. Fifty patients with native mitral regurgitation underwent multiplane transesophageal echocardiography within 5 days of catheterization. Angiographic grade of mitral regurgitation and, in 20 patients with grade II-IV regurgitation, invasively determined regurgitant stroke volume were compared with color Doppler area, regurgitant jet diameter, ratio of systolic to diastolic peak pulmonary venous flow velocities, and (based on the proximal convergence zone) maximal regurgitant flow rate and regurgitant orifice area. Rank correlation coefficients of angiographic grade with Doppler parameters were 0.61 for color jet area, –0.61 for pulmonary venous flow velocity ratio, 0.69 for color jet diameter, 0.79 for maximal regurgitant flow rate, and 0.78 for regurgitant orifice area (all P < .01). Convergence zone–based parameters also correlated best (r = 0.73) with invasively determined regurgitant stroke volume. Receiver operating characteristic curve analysis confirmed higher diagnostic accuracy for proximal jet width and proximal convergence zone parameters than for color jet area or pulmonary venous flow velocity ratio. Proximal convergence zone parameters and proximal color jet diameter best distinguished severe from mild forms of mitral regurgitation. (J Am Soc Echocardiogr 1998;11:882-92.)

Section snippets

Methods

Consecutive patients undergoing clinically indicated catheterization of the left and right side of the heart with a clinical indication for transesophageal echocardiography were prospectively included in the study if they had at least Sellers I mitral regurgitation on angiography. Exclusion criteria included the presence of a mitral valve prosthesis, an unstable clinical condition (including unstable angina), insufficient image quality (especially lack of a recognizable proximal convergence zone

Clinical and Hemodynamic Patient Characteristics

Of an initial group of 56 patients, 6 patients had to be excluded because of insufficient image quality, which precluded either use of the proximal convergence zone method (2 cases), reliable measurement of the proximal jet width (2 cases), or adequate pulmonary venous flow tracings (2 cases). Fifty patients (age 59 ± 14 years) fulfilled all inclusion criteria. Sixteen patients (32%) had Sellers I, 14 (27%) had Sellers II, 7 (14%) had Sellers III, and 13 (26%) had Sellers IV mitral

Motivation of the Study

In spite of the high sensitivity of Doppler echocardiography in detecting mitral regurgitation, and in spite of the “24 signs of severe mitral regurgitation,”²¹ assessment of the severity of this condition by Doppler remains difficult. The use of color Doppler jet size for severity grading is easy and intuitively appealing. Unfortunately this approach has substantial practical and theoretic drawbacks that make alternatives desirable, especially in the presence of more than mild regurgitation.

Conclusion

Of all transesophageal color Doppler parameters for estimation of the severity of mitral regurgitation, maximal regurgitant flow rate, regurgitant orifice area, and proximal jet width provide the best results compared with contrast angiography. They are clearly superior to color Doppler jet area and pulmonary venous flow ratio and should be systematically used whenever image quality is sufficient.

References (35)

MG Spain et al.
Quantitative assessment of mitral regurgitation by Doppler color flow imaging: angiographic and hemodynamic correlations
J Am Coll Cardiol
(1989)
R Castello et al.
Quantitation of mitral regurgitation by transesophageal echocardiography with Doppler color flow mapping: correlation with cardiac catheterization
J Am Coll Cardiol
(1992)
M Enriquez-Sarano et al.
Effective regurgitant orifice area: a noninvasive Doppler development of an old hemodynamic concept
J Am Coll Cardiol
(1994)
JM Rivera et al.
Quantification of mitral regurgitation with the proximal flow convergence method: a clinical study
Am Heart J
(1992)
JM Rivera et al.
Quantification of tricuspid regurgitation by means of the proximal flow convergence method: a clinical study
Am Heart J
(1994)
M Enriquez-Sarano et al.
Effective mitral regurgitant orifice area: clinical use and pitfalls of the proximal isovelocity surface area method
J Am Coll Cardiol
(1995)
GY Xie et al.
Quantification of mitral regugitant volume by the color Doppler proximal isovelocity surface area method: a clinical study
J Am Soc Echocardiogr
(1995)
PA Grayburn et al.
Multiplane transesophageal echocardiographic assessment of mitral regurgitation by Doppler color flow mapping of the vena contracta
Am J Cardiol
(1994)
R Castello et al.
Evaluation of pulmonary venous flow by transesophageal echocardiography in subjects with a normal heart: comparison with transthoracic echocardiography
J Am Coll Cardiol
(1991)
AL Klein et al.
Effects of mitral regurgitation on pulmonary venous flow and left atrial pressure: an intraoperative transesophageal echocardiographic study
J Am Coll Cardiol
(1992)

O Kamp et al.

Value of pulmonary venous flow characteristics in the assessment of severity of native mitral valve regurgitation: an angiographic correlated study

J Am Soc Echocardiogr

(1992)

RD Sellers et al.

Retrograde cardioangiography in acquired cardiac disease: technic, indications, and interpretation of 700 cases

Am J Cardiol

(1964)

NB Schiller et al.

Transesophageal echocardiography in the evaluation of mitral regurgitation: the twenty-four signs of severe mitral regurgitation

Cardiol Clin

(1993)

DJ Sahn

Instrumentation and physical factors related to visualization of stenotic and regurgitant jets by Doppler color flow mapping

J Am Coll Cardiol

(1988)

S Akamatsu et al.

Mitral prosthetic dehiscence with laminar regurgitant flow signals assessed by transesophageal echocardiography

Chest

(1993)

T Utsunomiya et al.

Doppler color flow “proximal isovelocity surface area” method for estimating volume flow rate: effects of orifice shape and machine factors

J Am Coll Cardiol

(1991)

SA Barclay et al.

The shape of the proximal isovelocity surface area varies with regurgitant orifice size and distance from orifice: computer simulation and model experiments with color M-mode technique

J Am Soc Echocardiogr

(1993)

Cited by (30)

Effect of Dynamic Flow Rate and Orifice Area on Mitral Regurgitant Stroke Volume Quantification Using the Proximal Isovelocity Surface Area Method
2008, Journal of the American College of Cardiology
Citation Excerpt :
Rivera et al. (32) first described the practical application of a standard single-point PISA method for calculation of MRSV in a way that the largest PISA radius during systole was determined under the assumption of its coincidence with peak regurgitant velocity at midsystole. Other investigators adopted this approach (3,11,12,21,28) despite the fact that because of a different dynamic pattern of MR the largest PISA radius does not coincide with midsystolic peak regurgitant velocity in all cases, as shown by Schwammenthal et al. (13) and confirmed by our study results. The assumption of coincidence of the largest PISA radius and peak regurgitant velocity was fundamentally violated in functional MR, in which the PISA radius is largest in early and late systole when regurgitant velocity is lowest, and the PISA radius is smallest when regurgitant velocity is highest in midsystole.
This study sought to determine the effect of dynamic variations of mitral regurgitant flow rate (MRFR) and effective regurgitant orifice area (EROA) on mitral regurgitant stroke volume (MRSV) quantification using 4 different single-point and time-integral proximal isovelocity surface area (PISA) methods using magnetic resonance imaging (MRI) for reference.
Using PISA provides measures of MRFR, but calculating MRSV is challenging because of dynamic variations in the flow profile dependent on the underlying mechanism of mitral regurgitation (MR). Although various single-point and time-integral approaches have been described to overcome this limitation, uncertainty exists about the accuracy and feasibility of these methods in routine clinical practice.
In 73 patients with MR of different etiologies, MRSV was calculated from an apical 4-chamber view using the following 4 hemispheric PISA methods: 1) PISA-velocity–time integral (VTI) = midsystolic MRFR by PISA × regurgitant flow VTI/peak velocity; 2) simplified PISA = midsystolic MRFR/3.25; 3) serial PISA =sum of instantaneous MRFRs over serial 2-dimensional frames; and 4) M-mode PISA = time-integral of MRFRs from color M-mode. The MRSV by MRI was calculated from mitral inflow minus aortic outflow.
Single-point PISA methods yielded greater underestimation of MRSV (mean error: −13.3 ± 10.2 ml [PISA-VTI]; −13.5 ± 10.3 ml [simplified PISA]), particularly in functional MR, compared with time-integral PISA methods accounting for variations of MRFR and EROA over time (mean error: −8.0 ± 6.4 ml [M-mode PISA]; −8.7 ± 7.4 ml [serial PISA]).
Depending on the underlying mechanism of MR, dynamic variations of MRFR and EROA revealed important limitations of MRSV calculation using single-point and time-integral PISA methods.
Direct Assessment of Size and Shape of Noncircular Vena Contracta Area in Functional Versus Organic Mitral Regurgitation Using Real-Time Three-Dimensional Echocardiography
2008, Journal of the American Society of Echocardiography
Vena contracta width (VCW) as an estimate of effective regurgitant orifice area (EROA) is an accepted parameter of mitral regurgitation (MR) severity. However, uncertainty exists in cases in which VCW at the same time appears narrow in 4-chamber (4CH) view and broad in 2-chamber (2CH) view as common in functional MR with noncircular or slit-like regurgitant orifices. We therefore hypothesized that new real-time 3-dimensional color Doppler echocardiography (RT3DE) can be used for direct assessment of the size and shape of vena contracta area (VCA) in an en face view and to determine the potential error of conventional VCW measurement on estimation of EROA.
RT3DE was performed in 57 patients with relevant MR of different etiologies. Manual tracing of VCA in a cross-sectional plane through the vena contracta was compared with VCW in 4CH and 2CH views. As a comparative approach to VCA-3D, EROA was calculated using the hemispheric and hemielliptic proximal isovelocity surface (PISA) area method.
Direct measurement of VCA-3D was feasible in all patients within 2.6 ± 0.7 minutes. RT3DE revealed significant asymmetry of VCA in functional compared with organic MR (P < .001). Among all patients, VCW-4CH and VCW-2CH correlated only moderately to VCA-3D (r =.77; r =.80). Mean VCW correlated and agreed best with VCA-3D (r =.90). VCA-3D correlated and agreed well with EROA by hemielliptic PISA (r = .96, mean error: −0.09 ± 0.14 cm²) compared with significant underestimation of hemispheric PISA in noncircular lesions.
Direct assessment of VCA using RT3DE revealed significant asymmetry of VCA in functional MR compared with organic MR, resulting in poor estimation of EROA by single VCW measurements.
Intraoperative Echocardiography in Mitral Valve Repair
2008, Practice of Clinical Echocardiography, Thrid Edition
Dynamic quantitative echocardiographic evaluation of mitral regurgitation in the operating department
2006, Journal of the American Society of Echocardiography
Hemodynamic modifications induced by general anesthesia could lead to underestimation of mitral regurgitation (MR) severity in the operating department and potentially serious consequences. The intraoperative severity of MR was prospectively compared with the preoperative baseline evaluation using dynamic quantitative transesophageal echocardiography in 25 patients who were stable with MR 2/4 or greater undergoing coronary bypass, mitral valve operation, or both. Significant changes in the severity of MR using transesophageal echocardiographic criteria occurred after the induction of general anesthesia and with phenylephrine. Quantitative transesophageal echocardiographic evaluation of MR using effective orifice area and vena contracta, and the use of phenylephrine challenge, were useful to avoid underestimating MR severity in the operating department.
Reproducibility of the proximal flow convergence method in mitral and tricuspid regurgitation
2004, American Heart Journal
The follow-up of patients with mitral and tricuspid regurgitation is important for their clinical treatment. We aimed to evaluate the reproducibility of the flow convergence method in mitral and tricuspid regurgitation.
The proximal flow convergence region was imaged with color Doppler ultrasound scanning echocardiography in 83 patients with mitral regurgitation, tricuspid regurgitation, or both. Proximal isovelocity surface area radii for aliasing velocities of 27 to 29 cm/s and 41 to 43 cm/s were repeatedly measured by the same experienced investigator on different days and by experienced and less experienced investigators at 1 day.
In mitral regurgitation, the intraobserver variability rate was 0.2% ± 13.5% (2.8% ± 13.3%) and the interobserver variability was 0.1% ± 13.8% (1.7% ± 18.0%) for an aliasing velocity of 27 to 29 cm/s (41–43 cm/s). For the aliasing velocity of 27 to 29 cm/s (41–43 cm/s), the 95% ranges for change of the proximal isovelocity surface area radii were ± 2.7 mm (± 1.8 mm) for measurements repeated by the same investigator and ± 2.7 mm (± 2.4 mm) for different investigators. Interobserver variability was independent of the investigators' experience. Similar data were achieved in tricuspid regurgitation.
The proximal flow convergence method is acceptably reproducible in mitral and tricuspid regurgitation independent of the investigators experience. For the aliasing velocity of 27 to 29 cm/s (41–43 cm/s), the proximal isovelocity surface area radius has to change for >2.7 (2.4) mm before an altered severity of mitral or tricuspid regurgitation in a single patient can be assumed.
Survey of observer variation in transesophageal echocardiography: Comparison of anesthesiology and cardiology literature
2003, Journal of Cardiothoracic and Vascular Anesthesia
$Objective:$ Transesophageal echocardiographic examination tends to be somewhat observer and experience dependent, and observer bias can arise easily when data are calculated and interpreted by unskilled, nonblinded, or single observers. The study plan was to see whether authors have adequately described how observer bias is minimized in their studies. Thus, a study was conducted systematically reviewing methods reported in transesophageal echocardio graphy articles in peer-reviewed anesthesiology journals versus those reported in peer-reviewed cardiology journals.
$Interventions:$ After MEDLINE searches of the literature published from 1997 through 1999, the authors investigated 56 anesthesiology reports and 56 randomly selected, year-matched cardiology reports. An 8-item questionnaire was developed that examined several factors: the number of observers and their experience levels, whether observers were blind to clinical data, whether low-quality images were excluded, the use of on-line or off-line analysis, and observer variability.
$Main results:$ The analysis revealed inadequacies in reporting of important information that relates to bias and quality in 91.1% of anesthesiology and 98.2% of cardiology articles. Observer variability was not reported in 50.0% of the anesthesiology reports and 67.9% of the cardiology reports; however, difference between the 2 bodies of literature was not significant. The journal impact factor was significantly higher for the cardiology literature than for the anesthesiology literature (2.42 [0.386–10.893] v 1.07 [0.664–3.439]; median [range], p < 0.001).
$Conclusion:$ Articles reviewed had at least some inadequacies in reporting the methods to minimize observer bias in both the anesthesiology and cardiology literature. Reporting methodology standards in TEE examinations remain to be established.

View all citing articles on Scopus

^☆: From the Med. Klinik I and Institut für Biometrie, Universitätsklinikum RWTH, and The Cleveland Clinic Foundation.

^☆☆: This study was conducted within the framework of INVADYN, a European research program.

^★: Reprint requests: Frank A. Flachskampf, MD, The Cleveland Clinic Foundation, Desk F15, 9500 Euclid Ave, Cleveland, OH 44195.

^★★: 27/1/92160

View full text

Comparison of transesophageal Doppler methods with angiography for evaluation of the severity of mitral regurgitation☆,☆☆,★,★★

Abstract

Section snippets

Methods

Clinical and Hemodynamic Patient Characteristics

Motivation of the Study

Conclusion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Am Heart J

J Am Coll Cardiol

J Am Soc Echocardiogr

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

Am J Cardiol

Cardiol Clin

J Am Coll Cardiol

Chest

J Am Coll Cardiol

J Am Soc Echocardiogr