Accurate quantification of mitral regurgitation (TM) is important for the treatment and prognosis of the patient. Three-dimensional echocardiography allows the direct measurement of the regurgitating opening area (ROA) by 3D guided planimetry of the venous-contracta region (VCA). Our goal was to (1) establish 3D VCA ranges and threshold values for MR classification using the integrative 2D method recommended by the American Society of Echocardiography as a reference, and (2) compare 2D and 3D ROA methods to establish a common calibration for MR classification. Quantify aortic insufficiency (AR) using two-dimensional (2D) echocardiography, including measuring the width of the vein contract (VCW), remains a challenge. Three-dimensional (3D) echocardiography directly measures the vena-contracta region (ACV) regardless of rheological properties. We intended to evaluate the possibility of a 3D Vena Contracta Zone (3DVCA) as well as a Vena Contracta 2D Zone (2DVCA) when assessing the severity of AR. Bland Altman compares the volume of regurgitation (RV) derived from the vena-contracta area (RVVCA, black circles) and the PISA method (RVPISA, gray squares) with the RV calculated by the reference method (RV3D) in patients with functional mitral insufficiency (FMR group, diagram shown on the left) and degenerative (DMR group, diagram shown on the right). SD, standard deviation. We enrolled 52 adult patients (mean age, 54 ± 17 years; 30 women) with different functional degrees of TR and sinus rhythm. Patients with clear organic deformity, impaired tricuspid valve movement, atrial fibrillation or frequent premature stroke were excluded from the study.
A real-time three-dimensional echocardiography system (Sonos 7500 or iE33; Philips Medical Systems, Andover, MA) with a 2 MHz to 4 MHz xMATRIX transthoracic converter at 3,000 elements was used to capture full-volume, color three-dimensional Doppler images. Images were taken from low parasternal or apical views with gain, compression, and time-saving compensation settings optimized for image quality. Care was taken to include the entire right ventricle and tricuspid valve in the overall volume data set. Whole volume datasets were captured in wide-angle detection mode (93° × 80°), in which four wedge-shaped partial volumes (each 93° × 20°) were obtained from four different cardiac cycles during the retained breathing. The volumes of three-dimensional color Doppler images were captured as seven sub-bands, which were adjusted to a full Doppler volume (30° × 30°). Care was taken to include proximal convergence and the entire contracted vein in the color Doppler image set. All images were digitally stored and analyzed offline. Chin CH, Chen CH, Lo HS. The correlation between the three-dimensional area of the contracted vein and the index of aortic insufficiency in patients with aortic insufficiency. Echocardiography. 2010;27:161–6.
Correlations between the 3D vein-contracta region (ACV) and the 2D regurgitating opening area (ROA) in patients with degenerative renal renal insufficiency (MR) (A) and in patients with functional MRI (B). The solid line represents the linear regression adjustment across all points. the dotted line in B represents the identity line. The Bland-Altman diagrams show the ROA bias using the 2D method of proximal isovitcity surface and the 3D method of direct planimetry in patients with degenerative MR (C) and patients with functional MR (D). Accurate assessment of mitral regurgitation (TM) is important for clinical decision-making and prediction of outcomes. The calculation of an effective regurgitating opening area (ORA) using the proximal isovitural surface method (PISA) is a primary method for quantifying the mitral regurgitating opening zone (ROA). However, it requires flow and geometric (hemisphere) assumptions, which has limited its clinical application. Recently, 3D echocardiography has enabled the direct measurement of the effective regurgitating aperture area through 3D guided planimetry of the contracted vein region (ACV). This single measurement does not depend on geometric and flow assumptions; Therefore, it can enable direct and more accurate quantification of MR as 2D measurements.
In vitro validation and clinical studies have shown that direct planimetry of ACV is very possible, and this measurement is well correlated with ROA derived from the volumetric Doppler approach.1,2 However, there are currently no data on 3D ACV ranges and cut-off values for MR classification, compared to the standard baseline endpoints using the integrative 2D method proposed by the American Society of Echocardiography (ASE). This is the MR classification method used by most clinical echocardiography laboratories. Our objective was to (1) establish 3D VCA zones and threshold values for MR grade differentiation using the integrative 2D method as a reference, and (2) compare 2D and 3D VCA Doppler colors for MR classification. The calculation of an effective regurgitating aperture zone (ORA) using the proximal isovelessity surface method (PISA) is the main technique for quantifying the mitral regurgitant opening zone (ARM) by echocardiography. However, it requires flow and geometric (hemisphere) assumptions that have limited its clinical application. The development of color Doppler 3D echocardiography offers the possibility of directly measuring ROA by measuring the vena-contracta region (VCA) in a controlled 3D manner. However, there are no data on ranges and threshold values of ACV for the MR classification. In this study, direct planimetry of ACV by 3D echocardiography was compared to the integrative 2D method recommended by the American Society of Echocardiography as a reference.
This integrative method is widely used in clinical practice and therefore the most relevant. There were significant differences in ACC in patients with varying degrees of MRI. With a cut-off value of 0.41 cm2, the VCA reliably distinguishes between heavy and moderate MR. Compared to 3D ACV, PISA 2D underestimated MR in patients with functional MR. Multivariate regression analysis showed that functional MR as an etiology was the predictor of THE UNDEREStimation of MR by the PISA method. The three-dimensional ACV provides a unique, directly visualized and reliable measure of ROA that classifies the severity of MR with current clinical practice using the integrative 2D method recommended by the American Society of Echocardiography. The 3D VCA method improves the accuracy of the MR classification compared to the PISA 2D method by eliminating geometric and flow assumptions, allowing uniform clinical evaluation limits and ranges that apply regardless of etiology and aperture shape. Willett DL, Hall SA, Jessen ME, Wait MA, Grayburn PA. Evaluation of aortic insufficiency by transesophageal color Doppler imaging of the contracted vein: validation against an intraoperative aortic flow probe. J Am Coll Cardiol. 2001;37:1450–5.
Tricuspid insufficiency (TR) is associated with a poor prognosis, regardless of the underlying disease. The American Society of Echocardiography recommends using the vena-contracta width to quantify TR. Although a vein-contracta width >0.7 cm is considered a marker of heavy TR, there is no established vein-contracta width limit to distinguish between moderate and light tr. The transverse form of the contracta vein in TR has been reported to be more ellipsoid compared to mitral regurgitation. However, it appears that no studies have examined the contracta vein in functional TR, a major etiology of TR. If the cross-sectional shape of the vein contract in the functional TR is not circular, different cut-off values shall be applied depending on the two-dimensional plane used for the consideration. However, this issue has not yet been resolved. The tricuspid valve has three leaflets, resulting in coaptation along three radial lines between the leaflets. It is not known whether the transverse shape of the contracta vein in functional TR is triangular or ellipsoidal. If it is ellipsoidal, the direction of the maximum width of the contracted vein must be identified.
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