J Cardiovasc Ultrasound.  2013 Jun;21(2):81-89.

Automated Quantification of Mitral Regurgitation by Three Dimensional Real Time Full Volume Color Doppler Transthoracic Echocardiography: A Validation with Cardiac Magnetic Resonance Imaging and Comparison with Two Dimensional Quantitative Methods

• Son JW
• Chang HJ
• Lee JK
• Chung HJ
• Song RY
• Kim YJ
• Datta S
• Heo R
• Shin SH
• Cho IJ
• Shim CY
• Hong GR
• Chung N

Abstract

BACKGROUND
Accurate assessment of mitral regurgitation (MR) severity is crucial for clinical decision-making and optimizing patient outcomes. Recent advances in real-time three dimensional (3D) echocardiography provide the option of real-time full volume color Doppler echocardiography (FVCD) measurements. This makes it practical to quantify MR by subtracting aortic stroke volume from the volume of mitral inflow in an automated manner.
METHODS
Thirty-two patients with more than a moderate degree of MR assessed by transthoracic echocardiography (TTE) were consecutively enrolled during this study. MR volume was measured by 1) two dimensional (2D) Doppler TTE, using the proximal isovelocity surface area (PISA) and the volumetric quantification methods (VM). Then, 2) real time 3D-FVCD was subsequently obtained, and dedicated software was used to quantify the MR volume. MR volume was also measured using 3) phase contrast cardiac magnetic resonance imaging (PC-CMR). In each patient, all these measurements were obtained within the same day. Automated MR quantification was feasible in 30 of 32 patients.
RESULTS
The mean regurgitant volume quantified by 2D-PISA, 2D-VM, 3D-FVCD, and PC-CMR was 72.1 +/- 27.7, 79.9 +/- 36.9, 69.9 +/- 31.5, and 64.2 +/- 30.7 mL, respectively (p = 0.304). There was an excellent correlation between the MR volume measured by PC-CMR and 3D-FVCD (r = 0.85, 95% CI 0.70-0.93, p < 0.001). Compared with PC-CMR, Bland-Altman analysis for 3D-FVCD showed a good agreement (2 standard deviations: 34.3 mL) than did 2D-PISA or 2D-VM (60.0 and 62.8 mL, respectively).
CONCLUSION
Automated quantification of MR with 3D-FVCD is feasible and accurate. It is a promising tool for the real-time 3D echocardiographic assessment of patients with MR.

Keyword

Mitral regurgitation; 3D echocardiography; Quantitative evaluation

MeSH Terms

Echocardiography
Echocardiography, Doppler, Color
Echocardiography, Three-Dimensional
Evaluation Studies as Topic
Humans
Magnetic Resonance Imaging
Magnetic Resonance Spectroscopy
Magnetics
Magnets
Mitral Valve Insufficiency
Stroke Volume

Figure

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  Fig. 1 Quantitative analysis of mitral regurgitation by 3D-FVCD. 3D image acqusition of LVOT (A) and mitral inflow (B) in same apical long axis plane. Automated anatomy detection of the LV endocardial border, mitral annulus, LVOT, and placement of three dimensional hemispheric flow sampling planes in the MA and LVOT (C). Flow-time curve derived from automatic flow volume aggregation at each frame in the cardiac cycle, and the automated calculation of the mitral and aortic SVs of both the MA and LVOT flow in 3 cardiac cycles (D). 3D: three dimension, FVCD: full volume color Doppler echocardiography, LVOT: left ventricular outflow tract, LV: left ventricle, MA: mitral annulus, SV: stroke volume.

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  Fig. 2 Flow de-aliasing: flow aliasing in the LVOT (A, white arrow) and MA planes (B, white arrowhead) are well visualized. Even after automated de-aliasing, there are still visible notches in LVOT flow (C, white arrows) and MA flow (C, white arrowheads) indicating incomplete de-aliasing on flow-time curve. Additional operator defined de-aliasing adjustment is performed, resulting in completely de-aliased flow (D). LVOT: left ventricular outflow tract, MA: mitral annulus.

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  Fig. 3 Correlation and agreement between tests. Linear regression plots showing correlation between RV-3D-FVCD and PC-CMR (A); RV-2D-VM and PC-CMR (B); RV-2D-PISA and PC-CMR (C). Bland-Altman analysis for 3D-FVCD (D) shows better limits of agreement and smaller bias than 2D-VM (E) and 2D-PISA (F). RV: regurgitant volume, 3D: three dimension, FVCD: full volume color Doppler echocardiography, PC: phase contrast, CMR: cardiac magnetic resonance imaging, 2D: two dimension, VM: volumetric method, PISA: proximal isovelocity surface area, MR: mitral regurgitation, SD: standard deviation.

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  Fig. 4 A representative case comparing the quantitative analysis of MR by different tests. MR volume by 2D-PISA (A) is underestimated compared with MR volume estimated by PC-CMR (D) due to the eccentric nature of MR with irregular, horizontally ellipsoid PISA morphology (white arrow). MR volume quantified by 2D-VM (B) is overestimated because of oversizing of the MA. MR volume by 3D-FVCD (C) shows excellent agreement with PC-CMR (D), despite the presence of flow aliasing (white arrowhead). MR: mitral regurgitation, 2D: two dimension, PISA: proximal isovelocity surface area, PC: phase contrast, CMR: cardiac magnetic resonance imaging, VM: volumetric method, 3D: three dimension, FVCD: full volume color Doppler echocardiography.

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