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Archives of cardiovascular diseases
Volume 111, n° 8-9
pages 507-517 (août 2018)
Doi : 10.1016/j.acvd.2017.10.008
Received : 8 July 2017 ;  accepted : 30 October 2017
Clinical research

Quantitative assessment of primary mitral regurgitation using left ventricular volumes obtained with new automated three-dimensional transthoracic echocardiographic software: A comparison with 3-Tesla cardiac magnetic resonance
Quantification des fuites mitrales primaires en utilisant les volumes ventriculaires gauches obtenus à l’aide d’un nouveau logiciel automatique en échocardiographie tridimensionnelle: comparaison avec l’IRM cardiaque 3-Tesla
 

Franck Levy a, , Sylvestre Marechaux b, Laura Iacuzio a, Elie Dan Schouver a, Anne Laure Castel b, Manuel Toledano b, Stephane Rusek a, Vincent Dor a, Christophe Tribouilloy c, d, Gilles Dreyfus a
a Centre Cardiothoracique de Monaco, 98000, Monaco 
b Groupement des Hôpitaux de l’Institut Catholique de Lille/Faculté Libre de Médecine, Université Lille Nord de France, 59000 Lille, France 
c Department of Cardiology, University Hospital Amiens, 80000 Amiens, France 
d INSERM U-1088, Jules Verne University of Picardie, 80025 Amiens, France 

Corresponding author at: Centre Cardiothoracique de Monaco, 11 bis, Avenue d’Ostende, 98000, Monaco.Centre Cardiothoracique de Monaco11 bis, Avenue d’Ostende98000Monaco
Summary
Background

Quantitative assessment of primary mitral regurgitation (MR) using left ventricular (LV) volumes obtained with three-dimensional transthoracic echocardiography (3D TTE) recently showed encouraging results. Nevertheless, 3D TTE is not incorporated into everyday practice, as current LV chamber quantification software products are time consuming.

Aims

To investigate the accuracy and reproducibility of new automated fast 3D TTE software (HeartModelA.I.; Philips Healthcare, Andover, MA, USA) for the quantification of LV volumes and MR severity in patients with isolated degenerative primary MR; and to compare regurgitant volume (RV) obtained with 3D TTE with a cardiac magnetic resonance (CMR) reference.

Methods

Fifty-three patients (37 men; mean age 64±12 years) with at least mild primary isolated MR, and having comprehensive 3D TTE and CMR studies within 24h, were eligible for inclusion. MR RV was calculated using the proximal isovelocity surface area (PISA) method and the volumetric method (total LV stroke volume minus aortic stroke volume) with either CMR or 3D TTE.

Results

Inter- and intraobserver reproducibility of 3D TTE was excellent (coefficient of variation10%) for LV volumes. MR RV was similar using CMR and 3D TTE (57±23mL vs 56±28mL; P =0.22), but was significantly higher using the PISA method (69±30mL; P <0.05 compared with CMR and 3D TTE). The PISA method consistently overestimated MR RV compared with CMR (bias 12±21mL), while no significant bias was found between 3D TTE and CMR (bias 2±14mL). Concordance between echocardiography and CMR was higher using 3D TTE MR grading (intraclass correlation coefficient [ICC]=0.89) than with PISA MR grading (ICC=0.78). Complete agreement with CMR grading was more frequent with 3D TTE than with the PISA method (76% vs 63%).

Conclusion

3D TTE RV assessment using the new generation of automated software correlates well with CMR in patients with isolated degenerative primary MR.

The full text of this article is available in PDF format.
Résumé
Contexte

La quantification des insuffisances mitrales primaires (IM) obtenue par l’ échocardiographie transthoracique tridimensionnelle (ETT 3D) a récemment été proposée et mais semble limitée en pratique par sa durée d’obtention.

Objectifs

Evaluer la précision et la reproductibilité de l’évaluation des volumes ventriculaires et de la sévérité d’une insuffisance mitrale effectuée par un nouveau logiciel 3D automatisé (HeartModelA.I.; Philips Healthcare, Andover, MA, USA) en pratique quotidienne; effectuer une comparaison de ces paramètres avec ceux obtenus en IRM.

Méthodes

Cinquante trois patients (37 hommes; d’âge moyen 64±12ans) porteurs d’une IM au moins minime pouvant bénéficier d’une exploration échocardiographique et remnographique complète dans un délai de 24heures étaient éligibles pour une inclusion dans l’étude. Le volume régurgitant (VR) de l’IM était calculé en utilisant la méthode de la PISA (Proximal Isovelocity Surface Area) et une méthode volumétrique (différence entre le volume d’éjection ventriculaire total et le volume d’éjection aortique) en ETT 3D et en IRM.

Résultats

La reproductibilité inter et intra observateur de l’ETT 3D pour les volumes ventriculaires étaient excellentes (coefficient de variation ≤ 10%). Le VR était comparable en utilisant l’IRM et l’ETT 3D (57±23mL vs 56±28mL; p =0,22) mais significativement plus élevé en utilisant la PISA (69±30mL; p <0,05 comparé à l’IRM ou à l’ETT 3D). La PISA avait tendance à systématiquement surestimer le VR en comparaison avec l’IRM (biais=12±21mL), alors qu’un biais non significatif était retrouvé entre l’ETT 3D et l’IRM (biais=2±14mL). La concordance entre l’échocardiographie et l’IRM était meilleure en utilisant la gradation de la sévérité de l’IM basée sur l’ETT 3D (ICC=0,89) que celle basée sur la PISA (ICC=0,78). Une corrélation complète était plus fréquemment retrouvée avec la gradation de la sévérité par l’IRM en utilisant l’ETT 3D qu’avec la PISA (76% vs 63%).

Conclusions

L’estimation du VR par une nouvelle génération de logiciels d’acquisition et d’analyse automatique des volumes ETT 3D est bien corrélée avec celle obtenue en IRM dans l’IM isolée primaire dégénérative.

The full text of this article is available in PDF format.

Abbreviations : 2D, 3D, CI, CMR, COV, EDV, ESV, LV, LVOT, MR, PISA, RV, TTE

Keywords : 3D echocardiography, Mitral regurgitation, 3-Tesla cardiac magnetic resonance

Mots clés : Echocardiographie 3D, Insuffisance mitrale, IRM 3-tesla


Background

Accurate quantification of primary mitral regurgitation (MR) is essential for clinical decision-making regarding surgery [1]. Current guidelines propose integration of qualitative, semiquantitative and quantitative criteria for grading the severity of MR [1, 2]. Two-dimensional (2D) transthoracic echocardiography (TTE) is the first-line method for the assessment of MR severity. Cardiac magnetic resonance (CMR), using a combination of left ventricular (LV) volumetric measurements and aortic flow quantification with phase-contrast velocity mapping [3], has emerged as a reproducible and accurate alternative method for quantifying MR. Discrepant grading in MR severity between 2D TTE and CMR was reported recently [4]. The proximal isovelocity surface area (PISA) method is currently the main quantitative method for MR grading, but shows some reproducibility issues in routine clinical practice [5]. Other quantitative tools to assess MR severity have been proposed. Mitral regurgitant volume (RV) can be calculated as the difference between total LV stroke volume obtained by echocardiography and Doppler LV forward flow. Despite promising landmark reports using 2D TTE [6, 7], this method has not received wide acceptance in clinical practice, as quantification of LV volumes by 2D TTE is frequently flawed by significant variability, foreshortening and reliance upon geometric models. Three-dimensional (3D) echocardiography does not rely on geometric assumptions for volume calculations, and is not subject to plane positioning errors [8]. Compared with CMR, which is the gold standard for cardiac chamber quantification, LV volumes calculated from 3D TTE showed significantly smaller bias and lower intra- and interobserver variability than 2D TTE [8]. Quantitative assessment of primary mitral MR regurgitation using LV volumes obtained with 3D TTE recently showed encouraging results [9]. Nevertheless, time-consuming workflow and the need for 3D expertise have limited integration of 3D quantification into clinical practice [10]. Recently, initial validation of new automated 3D TTE software has shown good accuracy and reproducibility, with promising time saving [10].

Thus, the aims of this prospective study were to investigate the accuracy and reproducibility of new automated fast 3D TTE software (HeartModelA.I.; Philips Healthcare, Andover, MA, USA) for the quantification of LV volumes and MR RV in patients with isolated degenerative primary MR, and to compare RVs obtained with the PISA method and 3D TTE with a CMR reference.

Methods

The study was conducted in two centres (Monaco Heart Centre, Monaco; and Groupement des Hôpitaux de l’Institut Catholique de Lille, Lille, France). Over a 12-month period, 62 patients with at least isolated mild primary MR, and having comprehensive 3D TTE and CMR studies, were eligible for inclusion. Exclusion criteria were: more than mild aortic stenosis, aortic regurgitation or mitral stenosis; intracardiac shunt; standard contraindications to magnetic resonance imaging; and poor TTE image quality. Institutional review board approval was obtained before conducting the study. The study was conducted in accordance with institutional policies, national legislation and the revised Helsinki declaration.

Echocardiography

All patients underwent comprehensive 2D and 3D transthoracic echocardiographic studies, using a commercially-available ultrasound system (EPIQ 7C; Philips Healthcare). For transthoracic evaluation of the mitral valve, the Carpentier nomenclature was applied to the mitral valve leaflets (anterior leaflet A1, A2 and A3=lateral, middle and medial scallops, respectively; posterior leaflet P1, P2 and P3=lateral, middle and medial scallops, respectively). The anterolateral commissures and posteromedial commissures were also inserted in the 2D TTE examination.

Quantitative Doppler assessment of MR

Echocardiographic data for MR grading were acquired according to a standardized protocol with multiple 2D incidences. PISA radius was measured in midsystole, in either apical or parasternal views, as appropriate, with the lower Nyquist limit set to 30–40cm/s and zoomed in on the area of flow convergence. Mitral RV (RV PISA) was calculated using the PISA technique as previously described [1], and RV PISA was categorized as recommended by the American Heart Association/American College of Cardiology [11]: mild, <30mL; mild to moderate, 30–44mL; moderate to severe, 45–59mL; and severe, ≥60mL.

Quantitative volumetric assessment of MR

3D volumes were acquired with an X5-1 matrix array transducer (5–1MHz), from the standard apical four-chamber window, with the patient in the left lateral decubitus position. The left ventricle and left atrium were centred along the volume axis by adjusting depth and sector. Sector width was adjusted and narrowed to increase the frame rates of the volume. Special care was taken to ensure optimal gain and compression, to minimize dropout of the LV myocardial borders. Novel acquisition mode allowed fast acquisition of full-volume data sets, with a high volume rate. Multiple consecutive cardiac beats could be acquired during a single breath-hold.

All 3D volumes were obtained in digital format, and stored for analysis by dedicated automated quantification software (HeartModel). This new commercially-available software is a unique model-based segmentation algorithm using knowledge-based identification followed by patient-specific adaptation [10]. After initiating the programme, the software automatically identifies heart chambers, and determines the end-diastolic and end-systolic frames using motion analysis. The software then automatically builds end-diastolic and end-systolic 3D volumes. As recommended by the vendor, the HeartModel 80–40 was chosen as the “standard” default setting value for 3D TTE study. The software then reveals a display of 2D views (apical two-, three- and four-chamber views) from a 3D volume, and allows global and regional editing of the end-diastolic volume (EDV) and end-systolic volume (ESV) borders. Volume borders could be edited regionally or globally by moving the entire border when the user was not fully satisfied with the automated LV contour [12]. 3D LV total stroke volume was obtained using the difference between HeartModel EDV and ESV. LV forward stroke volume was calculated as the product of the LV outflow tract (LVOT) velocity-time integral and the LVOT cross-sectional area. To obtain the cross-sectional area, the LVOT diameter was measured from inner edge to inner edge using a magnified image, with depth and focus set to optimize visualization of the LVOT perpendicular to the ultrasound beam, and allowing clear visualization of the basal insertion points of the aortic leaflets. The LVOT velocity-time integral was obtained classically from an apical five-chamber view using pulse-wave Doppler. Mitral RV HeartModel was obtained off-line by measuring the difference in LV total stroke volume (obtained from 3D HeartModel acquisition) and aortic forward stroke volume.

CMR technique

All patients underwent comprehensive TTE and CMR studies within 24h, in similar haemodynamic states. Patients were imaged with a 3-Tesla Skyra scanner (Siemens, Erlangen, Germany), with 18-channel body flex coils and 45mT/m gradients, or a 3-Tesla Discovery™ 750w (GE Healthcare, Chicago, IL, USA), equipped with a 24-channel torso phased-array coil for signal reception. Assessment of cardiac function was performed with a cine steady-state free precession pulse sequence, with retrospective gating, in end-expiration breath-hold. The following projections were acquired: two-chamber, four-chamber and parallel contiguous short axis (to cover the entire LV from the mitral plane to the apex). CMR data were processed offline using dedicated software, with semiautomatic edge detection and manual correction of the endocardial contour by an experienced independent observer blinded to the results of the TTE. On the cine images, LV ejection fraction, EDV and ESV were calculated using the standard formula. Data were analysed by dedicated software: cvi42®, version 5.1 (Circle Cardiovascular Imaging, Calgary, AB, Canada) or ADW cardiacVX (GE Healthcare). Aortic phase contrast was performed 10mm above the tip of the aortic valve, perpendicular to the aorta. Aortic outflow volume was derived from quantitative flow measurements. Regurgitant volume (RV CMR) was calculated as the difference between LV total stroke volume obtained from CMR acquisition and aortic forward flow volume (obtained from phase contrast analysis). RV CMR was categorized using American Heart Association/American College of Cardiology guidelines [11]: mild, <30mL; mild to moderate, 30–44mL; moderate to severe, 45–59mL; and severe, ≥60mL.

Statistical analysis

Data for study population and TTE and CMR measurements are presented as numbers and percentages or means±standard deviations after testing for normal distribution (Kolmogorov–Smirnov test). CMR and TTE measurements were compared by Student's paired t tests or Wilcoxon rank tests, as appropriate. Correlation and agreement between CMR and TTE measurements were assessed by Pearson's correlations, intraclass correlation coefficients (ICCs) and Bland–Altman comparisons. Test–retest and inter- and intraobserver variability were examined for 3D TTE measurements in a group of 16 patients selected at random. For interobserver variability, measurements were performed in all patients by one observer, then repeated offline on two separate days by two independent observers who were blinded to each other's measurements and the study time point. For intraobserver variability, one observer analysed the data twice (analyses undertaken 1 week apart), and was blinded to the data from the first read. For test–retest reproducibility, a first 3D volume was obtained, then, after repositioning of the patient and the transducer, a second 3D volume was acquired by a different observer. Variability data are presented as concordance correlation coefficients and as coefficients of variation (COVs). All statistical analyses were performed using commercially-available software (MedCalc, version 16.8; MedCalc Software, Mariakerke, Belgium). All P values are the result of two-tailed tests. A value of P <0.05 was considered significant.

Results
Study population and feasibility

Nine patients (14%) were excluded because of insufficient echogenicity in 3D TTE. Thus, the final study group consisted of 53 patients (37 men; mean age 64±12 years). The baseline demographic and clinical characteristics of the 53 patients are displayed in Table 1. The average 3D volume rate was good (20±2Hz, range 15–25Hz), even in patients with 3D TTE LV volumes >200mL (n =16; 19±2Hz, range 15–22Hz).

Reproducibility of 3D TTE measurements

Using HeartModel, intraobserver variabilities for EDV and ESV were excellent (r =0.96, COV=4% and r =0.95, COV=4%, respectively; all P <0.0001) (Figure 1). Interobserver variabilities for EDV and ESV were r =0.78, COV=9% and r =0.79, COV=10%, respectively (all P <0.0001). Test–retest variabilities for EDV and ESV were r =0.97, COV=5% and r =0.96, COV=7%, respectively (all P <0.0001).



Figure 1


Figure 1. 

Intraobserver (A), interobserver (B) and test–retest (C) variability for left ventricular end-diastolic volume (EDV) and end-systolic volume (ESV) obtained with three-dimensional HeartModel software, using linear regressions.

Zoom

Comparison of 3D TTE LV volumes with CMR

EDV obtained by the different methods was 203±62mL by CMR and 191±53mL by HeartModel (P =0.0001) (Table 2). Despite systematic underestimation of EDV with HeartModel compared with CMR (bias=−12±22mL), a significant correlation was found between the two measurements (r =0.93; P <0.0001) (Figure 2A and Table 3). ESV obtained by the different methods was 76±33mL by CMR and 70±31mL by HeartModel (P =0.03). Despite systematic underestimation of ESV with HeartModel compared with CMR (bias=−6±20mL), a significant correlation was found between the measurements (r =0.81; P <0.0001) (Figure 2B and Table 3). LV ejection fraction was similar between CMR and HeartModel (63±9% vs 64±8%, respectively; P =0.31). A significant correlation was found between the two measurements (r =0.81; P <0.0001), with good agreement (bias=0.8±5.5%) (Figure 2C and Table 3).



Figure 2


Figure 2. 

Linear regression (left) and Bland–Altman (right) diagrams of comparison between three-dimensional transthoracic echocardiography using HeartModel (HM) software and cardiac magnetic resonance (CMR) for the assessment of: (A) left ventricular end-diastolic volume (EDV); (B) left ventricular end-systolic volume (ESV); and (C) left ventricular ejection fraction (EF). SD: standard deviation.

Zoom

Concordance between echocardiography and CMR

RV was 57±23mL by CMR, 69±30mL by the PISA method (P =0.0001 with CMR) and 56±28mL by HeartModel (P =0.22 with CMR) (Table 2 and Figure 3).



Figure 3


Figure 3. 

Comparison of regurgitant volume (RV) obtained by the proximal isovelocity surface area (PISA) method, by cardiac magnetic resonance (CMR) and by a volumetric method using new three-dimensional HeartModel (HM) software.

Zoom

There was significant overestimation of RV using the PISA method compared with CMR (bias=12±21mL), and a moderate correlation was found between the two measurements (r =0.70; P <0.0001) (Figure 4 and Table 3). Individual data for RV determined by the different methods according to the MR grade determined by RV CMR are presented in Figure 5. A contingency table of RV CMR and RV PISA assessment of MR severity is shown in Table 4. There was complete agreement in only 34 of 53 patients (64%). Concordance was good between the two modalities (ICC=0.78; 95% confidence interval [CI] 0.63–0.88; P <0.0001). If patients were categorized into four grades (mild, mild to moderate, moderate to severe and severe MR), concordance between PISA and CMR grading was good (ICC=0.82; 95% CI 0.68–0.90; P <0.0001). None of the patients with mild MR using RV PISA grading had severe MR on CMR. When considering patients with severe MR using RV PISA grading, only 19/33 (61%) had concordant severe MR on CMR.



Figure 4


Figure 4. 

Linear regression (left) and Bland–Altman (right) diagrams of comparison of regurgitant volume (RV) as determined by (A) the proximal isovelocity surface area (PISA) method and (B) a volumetric method using new three-dimensional HeartModel (HM) software, taking cardiac magnetic resonance (CMR) RV as reference. SD: standard deviation.

Zoom



Figure 5


Figure 5. 

Individual data of regurgitant volume (RV) as determined by (A) the proximal isovelocity surface area (PISA) method and (B) a volumetric method using new three-dimensional HeartModel (HM) software, according to the mitral regurgitation severity determined by cardiac magnetic resonance.

Zoom

RV HeartModel was similar compared with CMR (bias=−2±12mL), and a substantial correlation was found between the two measurements (r =0.89; P <0.0001) (Figure 4 and Table 3). A contingency table of RV CMR and RV HeartModel assessment of MR severity is shown in Table 5. There was complete agreement in 43 of 53 patients (81%). Concordance was good between the two modalities (ICC=0.89; 95% CI 0.81–0.94; P <0.0001). If patients were categorized into four grades (mild, mild to moderate, moderate to severe and severe MR), concordance between HeartModel and CMR grading was excellent (ICC=0.90; 95% CI 0.83–0.94; P <0.0001). None of the patients with mild MR using RV HeartModel grading had severe MR on CMR. When considering patients with severe MR using RV HeartModel grading, 18/21 (86%) had concordant severe MR on CMR.

Comparison between mid-late systolic MR and holosystolic MR showed no significant difference in effective regurgitant orifice area and RV obtained by CMR, the PISA method or HeartModel (Table 6). Using a CMR reference, mid-late systolic MR was more frequently moderate (9/13; 69%) than severe (4/13; 31%). In patients with mid-late systolic MR, MR severity was more frequently overestimated by RV PISA compared with RV HeartModel (3/13; 23% vs 1/13; 8%, respectively) compared with a CMR reference. The bias between RV PISA and RV CMR was similar between holosystolic and mid-late systolic MR (12.6±23mL vs 10.6±19mL, respectively). Overestimation of RV HeartModel compared with RV CMR tended to be more important in mid-late systolic MR than in holosystolic MR (bias 6±12mL vs 1±12mL, respectively).

Discussion

This study shows that 3D TTE using the new generation of automated software is a reproducible and accurate imaging modality for the assessment of MR RV using LV volumes in patients with isolated degenerative primary MR, compared with CMR.

Echocardiography is the first-line modality for the assessment of MR severity, providing numerous variables derived mainly from Doppler imaging. Recently, considerable controversy has arisen regarding discordance between TTE and CMR in assessing MR severity [4]. Quantitative comparison of MR severity using RV obtained with both modalities revealed only modest correlation. Alternative echocardiographic quantitative methods to assess RV using volumetric calculation have been proposed. Despite promising reports using 2D TTE [7], this method has not received wide acceptance in clinical practice, as 2D TTE is subject to underestimation of LV volumes because of foreshortening or assumptions about LV shape. 3D echocardiography does not rely on geometric assumptions for volume calculations, and is not subject to plane positioning errors [8]. Compared with CMR, which is the gold standard for cardiac chamber quantification, LV volumes calculated from 3D TTE showed significantly smaller bias and lower intra- and interobserver variability than 2D TTE [8, 13]. We found excellent 3D TTE reproducibility using HeartModel, with low inter- and intraobserver variability and a COV10% for all variables, which is consistent with previous data [10, 12, 14, 15]. This new automated application uses knowledge-based identification of LV chambers followed by patient-specific adaptation [10]. This reliable automated detection of heart chambers does not need user input, which improves the consistency of measurements and reduces the time required for analysis [10]. Using this new software, LV volumes (EDV, ESV and stroke volume) appeared to be well correlated with CMR (r =0.93, r =0.81 and r =0.83, respectively; all P <0.0001), with clinically acceptable bias (−12±22mL, −6±20mL and −5±22mL, respectively). Accurate and reliable assessment of LV volume and LV remodelling is a key point in MR. Ideally, longitudinal follow-up of patients with MR will involve multiple imaging modalities. Nevertheless, CMR suffers from several limitations [16], such as limited availability, local expertise or the presence of cardiac pacemakers and implantable cardioverter-defibrillators. 3D TTE using new-generation automated software may offer a reliable and accurate surrogate imaging modality for LV volume quantification and remodelling in routine practice.

A recent study [9] reported encouraging results for the quantitative assessment of primary MR using LV volumes obtained with 3D TTE, showing accurate discrimination of patients with severe MR, defined using a multivariable integrative approach, as recommended [1]. In clinical practice, the PISA method is currently the main echocardiographic method for RV estimation. CMR assessment of RV is a different approach, derived from volumetric calculation, which may explain modest correlations reported between RV obtained with these two modalities. CMR-derived RV appears to be systematically lower than RV obtained with echocardiography, particularly compared with the PISA method [4, 17, 18, 19, 20, 21]. Our study confirms this tendency, as RV CMR was, on average, 12±21mL lower than RV PISA, comparable with previous results [21]. This overestimation of RV by the PISA method may lead to discordance in grading between CMR and echocardiography [4]. Using a volumetric 3D TTE approach, we found excellent correlations and low bias between 3D TTE- and CMR-derived RV estimations. Such concordance in MR severity assessment may occur because the methods are based on the same physical principles, relying on volumetric estimation. Complete agreement with CMR grading was also more frequent with 3D TTE than with the PISA method (76% vs 63%). This may be because of more frequent overestimation of MR severity with the PISA method than with 3D TTE in case of mid-late systolic MR (23% vs 8% in our series). Multiple assumptions, eccentric jet direction and phasic variation of PISA may explain this overestimation. On the other hand, there are no uniform CMR thresholds for grading severity of regurgitation [22]. Because of the paucity of data, the general cut-offs for RV recommended by echocardiography and American College of Cardiology/American Heart Association guidelines are used [22]. Nevertheless, a recent study [21] reported that CMR-derived RVs associated with severe primary MR (39mL) were lower than established cut-offs values based on echocardiography.

Study limitations

We did not use ultrasound contrast agent in any patient in this study, which could have improved the feasibility of 3D TTE. Nevertheless, our study provides insight into real-life echocardiographic practice, and the performance of the 3D software with echocardiographic contrast agents is unknown [10]. Echocardiographic MR grading was based on RV estimation in our study, rather than on an integrative approach, as we aimed to compare each echocardiographic method with a CMR reference. Quantification of RV using a volumetric method can only be achieved in patients with isolated MR. However, most adults have significant regurgitation of only a single valve, making this approach clinically applicable in most cases. Pulsed Doppler estimation of RV was not performed systematically.

In the present study, we did not specifically study patients in whom the shape of flow convergence region was not optimal, as the PISA method is known to overestimate RV in this setting. Another limitation is cardiac arrhythmia. Nevertheless, recent data suggest that 3D TTE remains reliable in atrial fibrillation, provided that averaged values of LV volumes are measured during multiple consecutive beats [14]. As this study was done in routine practice, we did not record the time required for all 3D analyses in all patients. Previous studies specifically showed a reduction in the duration of examination using this software [10]. The correlation between RV HeartModel, symptoms and outcome deserves further research.

Conclusions

3D TTE RV assessment using a new generation of automated software correlates well with CMR in patients with isolated degenerative primary MR.

Sources of funding

None.

Disclosure of interest

The authors declare that they have no competing interest.

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