Echocardiographic aortic to mitral valve opening area ratio for determining the presence and severity of mitral regurgitation

A simple and accurate noninvasive method to quantify the degree of mitral regurgitation (MR) is lacking. Therefore, the ratio of the aortic (AVO) to mitral valve opening area (MVO) from 2-dimensionally guided M-mode echocardiographic tracings was examined as an estimate for the presence and severity of MR. Seventy-two patients who had undergone catheterization were studied: 49 with idiopathic dilated cardiomyopathy, 7 with coronary artery disease and 16 with organic MR. Twenty-eight patients had no MR (group I), 23 had mild/moderate MR (group II) and 21 had severe MR (group III). The AVO/MVO ratio was 0.86 +/- 0.2 in group I, 0.53 +/- 0.1 in group II and 0.31 +/- 0.1 in group III (p less than 0.001). An AVO/MVO ratio of 0.65 or less predicted MR with a sensitivity of 98% and a specificity of 86%. Furthermore, a strong relation was found between the ratio and the angiographic severity of MR. Thus, the AVO/MVO ratio is a simple echocardiographic parameter for detecting the presence and severity of MR.     

Effect of aortic valve replacement for aortic stenosis on severity of mitral regurgitation

The severity of mitral regurgitation (MR) was determined by color Doppler echocardiography in 44 adult patients with severe symptomatic aortic stenosis before and after isolated aortic valve replacement. Preoperative MR was absent in 17, mild in 14, moderate in 11 and severe in 2 patients. Three to 388 (mean 58) days after surgery, 14 patients continued to have no MR. In the other 30 patients, MR decreased in 18 (60%), remained unchanged in 8 (27%) and increased in only 4 (13%). Furthermore, in 13 patients with significant (moderate or severe) MR, the severity decreased in 12 (92%). Thus, the severity of MR often decreases after aortic valve replacement for aortic stenosis.     

Transesophageal Doppler echocardiography of pulmonary venous flow: a new marker of mitral regurgitation severity.

Pulmonary venous flow varies with different cardiac conditions. Flow patterns in response to mitral regurgitation have not been well studied, but flows may vary enough to differentiate among different grades of regurgitation. Accordingly, pulmonary venous flow velocities were recorded in 50 consecutive patients referred for outpatient (n = 26) or intraoperative (mitral valve repair; n = 24) echocardiographic examination for mitral regurgitation. Recordings were made of right and left upper pulmonary veins with pulsed wave Doppler transesophageal echocardiography. Mitral regurgitation was graded from 1+ to 4+ by an independent observer using transesophageal color flow mapping. The results of cardiac catheterization performed 5 weeks earlier in 43 of the patients were also graded for mitral regurgitation by an independent observer. Pulmonary venous flow patterns, the presence of reversed systolic flow and peak systolic and diastolic flow velocities were compared with the severity of mitral regurgitation indicated by each technique. Of the 28 patients with 4+ regurgitation by transesophageal color flow mapping, 26 (93%) had reversed systolic flow. The sensitivity of reversed systolic flow in detecting 4+ mitral regurgitation by transesophageal color flow mapping was 93% and the specificity was 100%. The sensitivity and specificity of reversed systolic flow in detecting 4+ mitral regurgitation by cardiac catheterization were 86% and 81%, respectively. Discordant flows were observed in 9 (24%) of 38 patients; the left vein usually showed blunted systolic flow and the right showed reversed systolic flow. In 22 intraoperative patients, there was "normalization" of pulmonary venous systolic flow after mitral valve repair in the postcardiopulmonary bypass study compared with the prebypass study after the mitral regurgitant leak was corrected.(ABSTRACT TRUNCATED AT 250 WORDS)     

Magnetic resonance assessment of aortic and mitral regurgitation.

Magnetic resonance imaging provides an accurate method for the measurement of left and right ventricular volume. The ratio of left ventricular stroke volume to right ventricular stroke volume was calculated from contiguous transverse magnetic resonance images and was used to measure the severity of regurgitation in 18 patients with aortic regurgitation and 10 with mitral regurgitation. Cardiac anatomy was well demonstrated, allowing an assessment of relative chamber volumes and associated abnormalities, although valve abnormality was not well seen. There was a weak correlation between magnetic resonance measurements of left ventricular end diastolic volume and stroke volume ratio. The stroke volume ratio differed significantly in four groups with increasing angiographic severity of regurgitation, and all but the group with trivial regurgitation differed significantly from normal. There was good correlation between magnetic resonance and radionuclide measurements of left ventricular ejection fraction and stroke volume ratio, although the stroke volume ratio was consistently overestimated by radionuclide ventriculography. Correlation was less good for the right ventricular ejection fraction, which was underestimated by radionuclide ventriculography. It is concluded that magnetic resonance imaging provides valuable information in patients with valvar regurgitation, and serves as a suitable standard by which to judge conventional techniques.     

Progress in mitral and aortic regurgitation

Over the past 15 years there has been rapid and dramatic change in the therapy for valvular heart disease. When mitral and aortic regurgitation are severe, they inevitably cause left ventricular damage, eventually resulting in death. However, when surgical correction of these lesions is timed appropriately, longevity can approach that of a normal population after surgery. As surgical techniques have improved, surgery is now indicated earlier in the course of these diseases. It is clear that some patients with mitral and aortic regurgitation require surgery even though they are entirely asymptomatic. However, it must be emphasized that mitral and aortic regurgitation are quite different from one another. These different lesions result in different loading conditions, different pathophysiologies, and have different means for surgical correction. All of these issues impact on the proper timing of surgery and are discussed. Copyright © 2001 by W.B. Saunders Company

Progress in Cardiovascular Diseases, Vol. 43, No. 6 (May/June) 2001: pp 457-475     

Echocardiographic assessment of severity of aortic regurgitation.

An echocardiographic study of left ventricular diameter was made in 27 patients with aortic regurgitation. Comparison was made with a group of 21 normal subjects and a group of 6 patients with large left ventricles without valvar regurgitation. Total stroke volume, total left ventricular output, and ejection fraction were derived by the method of cubing the left ventricular diameter to give approximate left ventricular volumes at and-diastole and end-systole. The patients were assessed independently and placed into three grades of severity. The eechocardiographic dimensions of patients with mild aortic regurgitation were not significantly different from those of the normal subjects. With increasing severity of aortic regurgitation, there were increases in group values for left ventricular diameter, total stroke volume, and total left ventricular output. The ejection fraction was depressed below the normal range in only one patient with aortic regurgitation. It is concluded that echocardiographic measurement of left ventribular dimensions is of value in assessing the severity of aortic regurgitation.     

Echocardiographic assessment of severity of aortic regurgitation.

An echocardiographic study of left ventricular diameter was made in 27 patients with aortic regurgitation. Comparison was made with a group of 21 normal subjects and a group of 6 patients with large left ventricles without valvar regurgitation. Total stroke volume, total left ventricular output, and ejection fraction were derived by the method of cubing the left ventricular diameter to give approximate left ventricular volumes at and-diastole and end-systole. The patients were assessed independently and placed into three grades of severity. The eechocardiographic dimensions of patients with mild aortic regurgitation were not significantly different from those of the normal subjects. With increasing severity of aortic regurgitation, there were increases in group values for left ventricular diameter, total stroke volume, and total left ventricular output. The ejection fraction was depressed below the normal range in only one patient with aortic regurgitation. It is concluded that echocardiographic measurement of left ventribular dimensions is of value in assessing the severity of aortic regurgitation.     

Predictive value of pulmonary venous flow patterns in detecting mitral regurgitation and left ventricular abnormalities.

OBJECTIVE: To determine whether abnormalities in pulmonary venous flow (PVF) patterns detected by transesophageal echocardiography (TEE) correlate with the severity of mitral regurgitation (MR) or the presence of left ventricular (LV) abnormalities, and to demonstrate whether a normal PVF pattern predicts the absence of structural heart disease. DESIGN: Review of all TEEs performed at a tertiary care cardiac hospital over a four-month period. PATIENTS: Among 195 studies, 100 fulfilled the inclusion criteria. RESULTS: PVF was categorized into three patterns, which have been described previously. A normal PVF pattern predicted the absence of clinically significant MR with a high degree of certainty (positive predictive value [PPV] 98%). However, it did not predict the absence of structural cardiac disease (PPV 64%). A PVF pattern that showed systolic flow reversal was strongly predictive of the presence of significant MR (sensitivity 86%, specificity 100%, PPV 100%). The frequency of significant MR in this group was much higher than in patients with normal PVF (12 of 12 versus one of 66, P<0.0001). Patients with a blunted PVF pattern were more likely than patients with a normal PVF to have LV abnormalities (18 of 22 versus 23 of 66, P=0.0005). However, a blunted PVF was not associated with clinically significant MR. CONCLUSIONS: A normal PVF does not rule out the absence of LV abnormalities but confirms the absence of significant MR. Systolic flow reversal is highly predictive of the presence of significant MR. A blunted PVF is more likely to be associated with LV abnormalities than with MR and has limited usefulness in the diagnosis of significant MR.     

Myocardial supply-demand ratio in aortic regurgitation.

To analyze the relationship between the myocardial supply and demand for oxygen in patients with aortic regurgitation, the ratio of the diastolic pressure-time index (DPTI) over the systolic pressure-time index (SPTI) was derived from recordings of pressure during cardiac catheterization in 24 patients with aortic regurgitation, and this ratio was compared with that in 14 normal subjects and in ten patients with congestive cardiomyopathy (an ejection fraction less than 0.30). Patients with aortic regurgitation had a DPTI/SPTI of 0.75 +/- 0.06 (mean +/- SE), which was lower than in the normal subjects (1.24 +/- 0.06) and patients with cardiomyopathy (1.06 +/- 0.03) (P less than 0.001). Among the patients with aortic regurgitation, the 13 with a DPTI/SPTI below 0.70 had more severe aortic regurgitation than the 11 with a DPTI/SPTI above 0.70. Aortic regurgitation results in a reduced myocardial supply-demand ratio, as measured by the DPTI/SPTI, which is related to the severity of the valvular regurgitation and is not present in patients with left ventricular dysfunction secondary to congestive cardiomyopathy.     

Evaluation of left ventricular performance in aortic stenosis, aortic regurgitation and mitral regurgitation from the stroke work/left ventricular mass ratio.

Evaluation of left ventricular performance in aortic stenosis, aortic regurgitation and mitral regurgitation from the stroke work/left ventricular mass ratio. Europ. J. Cardiol., 10/4, 279--294. 132 patients with a pure valvular dysfunction affecting a single orifice, namely aortic stenosis, aortic or mitral regurgitation, were studied. All patients, including 20 control subjects, underwent hemodynamic examination of both right and left heart chambers including left cineangiography. Using the stroke work index/myocardial mass ratio (SWI/MLV), for which the limits in normal subjects are narrow (0.81 +/- 0.03 . g-1) it was possible to divide these patients into three groups: Group I (SWI/MLV greater than 0.87 gm . g-1) characterized by a proportionately greater increase in stroke work index than myocardial mass (hyperfunctioning ventricle). Group II (0.87 gm . g-1 greater than or equal to SWI/MLV greater than or equal to 0.75 gm . g-1) characterized by a parallel increase in stroke work index and myocardial mass (normally functioning ventricle). Group III (SWI/MLV less than 0.75 gm . g-1) for which the increase in myocardial mass was proportionately greater than that of the stroke work index (hypofunctioning ventricle). As one progresses from group I to III, there is a concomitant fall in ventricular function with decreased mean velocity of circumferential fiber shortening (VCF), ejection fraction (EF) and increased enddiastolic volume (EDV) together with the hypertrophy of the left ventricle during the last stage. We conclude that the SWI/MLV ratio is an easy to calculate index, independent of the unerlying dysfunction, which evaluates left ventricular function by taking into account the myocardial mass.     

Non-invasive assessment of aortic and mitral regurgitation

A non-invasive method for the assessment of the degree of regurgitationin aortic and mitral regurgitation is presented. Regurgitantvolume was obtained by subtracting effective stroke volume (SV_eff),determined with a CO₂-rebreathing method, from total strokevolume (SV_tot) determined by M-mode echocardiography. Regurgitantvolume and a non-invasive regurgitant index (SV_tot/SV_eff) werecompared with semiquantitative angiography in 49 patients [meanage = 62±11 (SD) years], who on the basis of the angiographywere allocated to four different groups (no, slight, moderateand severe regurgitation). Eighteen normal subjects [mean age= 26±9 (SD) years], not subjected to angiography, servedas a control group and are included in the group without regurgitation.When the cube formula was used for the determination of SV_tot,the average regurgitant volumes for the different groups were:0.5±24 (SD), 15±22, 85±48 and 138±65mland the corresponding SV_tot/SV_eff ratios were: 1.0±0.3,l.2±0.3, 2.4±0.8 and 3.8± 1.5, respectively.There were significant differences (P<0.01) between the groupswith slight, moderate and severe regurgitation respectivelyboth for regurgitant volume and regurgitant index, but no significantdifference between the group with slight regurgitation and thegroup without regurgitation. This study suggests that the severityof aortic and mitral regurgitation can be estimated non-invasivelyby the combined use of a CO2-rebreathing method and echocardiography.     

Determination of vena contracta and its value in evaluating severity of aortic regurgitation

BACKGROUND AND AIMS OF THE STUDY: Recent studies evaluating the severity of valvular insufficiencies have focused on the effective regurgitant orifice area (EROA), which corresponds hydrodynamically to the cross-sectional area of the vena contracta (VC). The study aim was to quantify aortic regurgitation (AR) by using color Doppler imaging of the VC. METHODS: Fifty-five patients with chronic AR were enrolled into the study. VC was visualized by transthoracic echocardiography from the apical echocardiographic window. The quantitative Doppler (QD) method, depending on mitral and aortic stroke volumes, was taken as a reference method. EROA, regurgitant volume (RV) and regurgitant fraction (RF) were calculated using both VC and QD simultaneously in all patients, and the results obtained with each method were compared. RESULTS: EROA(QD) (r = 0.96), RFQD (r = 0.84), RVQD (r = 0.82), and AR grade 3+ or 4+ (r = 0.74) were statistically significantly correlated with VC (4.8+/-1.2 mm). In the multivariate analysis, VC was related only to EROA(QD). The EROA (r = 0.96, p <0.001; mean difference 0+/-0.03 cm2, SEE = 0.004 and p >0.05), RV (r = 0.97, p <0.001; mean difference =1.3+/-4.8 cm3, SEE = 0.65 cm3 and p >0.05) and RF (r = 0.93, p <0.001; mean difference = 1.46+/-4.9%, SEE = 0.66% and p >0.05) obtained by both methods agreed well with each other. VC had a sensitivity of 80%, a specificity of 86%, and an accuracy of 84% in determining severe AR for VC > or =5.5 mm. CONCLUSION: The vena contracta can be visualized using a transthoracic approach from the apical window. The severity of AR can be evaluated using the VC width itself, and also in combination with Doppler data.     

中性粒细胞与淋巴细胞比值对急性胰腺炎严重性的预测价值

目的探索中性粒细胞与淋巴细胞比值对急性胰腺炎严重性的预测作用。方法对2010年9月-2011年9月住院的96例急性胰腺炎病例进行分析。以Ranson评分≥3分为重症胰腺炎标准。对患者入院后首次血常规检查结果的白细胞总数、中性粒细胞与淋巴细胞比值进行均数比较,Spearman相关性检验、ROC分析以及计算预测的敏感性、特异性、阳性拟然比、阳性预测值及准确度。结果重症急性胰腺炎20例,轻症急性胰腺炎76例。重症急性胰腺炎患者白细胞总数明显较轻症急性胰腺炎患者白细胞总数多[(15.16±5.06)×109/L vs(11.05±1.76)×109/L,P=0.000],重症急性胰腺炎患者中性粒细胞与淋巴细胞比值明显较轻症急性胰腺炎患者的比值大(18.95±12.13 vs 6.63±3.44,P=0.000)。白细胞总数及中性粒细胞与淋巴细胞比值与SAP的Spearman相关系数分别为0.419、P=0.000及0.571、P=0.000。白细胞总数对重症急性胰腺炎预测的AUC为0.798(95%CI:0.670～0.925),最佳预测分界点为12.55×109/L;中性粒细胞与淋巴细胞比值对重症急性胰腺炎预测的AUC为0.906(95%CI:0.830～0.981),最佳预测分界点为7.85。白细胞总数和中性粒细胞与淋巴细胞比值预测重症急性胰腺炎的敏感性、特异性、阳性拟然比、阳性预测值及准确度分别为70.00%、86.84%、5.32、58.33%、83.33%和85.00%、92.11%、10.77、73.91%、90.63%。两者AUC比较,Z=4.59>1.96,P<0.05。结论中性粒细胞与淋巴细胞比值对急性胰腺炎严重性的预测具有较高的价值。     

Correlation of echo-Doppler aortic valve regurgitation index with angiographic aortic regurgitation severity

We assessed aortic regurgitation (AR) severity by utilizing multiple echo-Doppler variables in comparison with AR severity by aortic root angiography. Patients were divided into 3 groups: mild, moderate, and severe. An AR index (ARI) was developed, comprising 5 echocardiographic parameters: ratio of color AR jet height to left ventricular outlet flow diameter, AR signal density from continuous-wave Doppler, pressure half-time, left ventricular end-diastolic diameter, and aortic root diameter. There was a strong correlation between AR severity by angiography and the calculated echo-Doppler ARI (r = 0.84, p = 0.0001). As validated by aortic angiography, the ARI is an accurate reflection of AR severity.     

Underestimation of severity of mitral regurgitation with varying hemodynamics.

Transesophageal echocardiography (TEE) is a valuable technique to assess mitral valve anatomy and the mechanism of mitral regurgitation (MR). We present the case of a 35-year-old woman with severe MR due to restrictive motion of the posterior mitral leaflet, who was referred for mitral annuloplasty. Under physiologic circumstances, a severe (grade 3+) MR was present, whereas in the operating room during general anesthesia, the MR had disappeared almost completely. The downgrading of MR due to general anesthesia and the associated mechanisms of this phenomenon are discussed in this case.