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11, 2012




Quantitative Assessment of Mitral Regurgitation

How Best to Do It

Paaladinesh Thavendiranathan, MD,* Dermot Phelan, MBBCH, PHD,*

Patrick Collier, MBBCH, PHD,* James D. Thomas, MD,* Scott D. Flamm, MD, MBA,
Thomas H. Marwick, MBBS, PHD, MPH*
Cleveland, Ohio

JACC: CARDIOVASCULAR IMAGING CME 5. Claim your CME credit and receive your certif-
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CME Editor: Ragavendra R. Baliga, MD
This article has been selected as this issues CME CME Objective for This Article: At the end of this
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org by selecting the CME tab on the top navigation 1) gain an appreciation of the various imaging
bar. modalities and methods available for quantification
of mitral regurgitation severity; 2) understand stan-
Accreditation and Designation Statement dardized methods for image acquisition and post-
The American College of Cardiology Foundation processing that would improve the accuracy and
(ACCF) is accredited by the Accreditation Council reproducibility of the quantification methods; and 3)
for Continuing Medical Education (ACCME) to understand limitations of some of the quantification
provide continuing medical education for physicians. methods as well as gain an appreciation for some of
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From the *Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; and the Imaging Institute, Cleveland Clinic,
Cleveland, Ohio. Dr. Flamm has received honorarium from Philips Healthcare. All other authors have reported that they
have no relationships relevant to the contents of this paper to disclose.
Manuscript received May 21, 2012; revised manuscript received July 12, 2012, accepted July 23, 2012.
1162 Thavendiranathan et al. JACC: CARDIOVASCULAR IMAGING, VOL. 5, NO. 11, 2012

Quantitative Assessment of Mitral Regurgitation NOVEMBER 2012:116175

Quantitative Assessment of Mitral Regurgitation

How Best to Do It

Decisions regarding surgery for mitral regurgitation (MR) are predicated on the accurate quantification of MR severity. Quantitative
parameters, including vena contracta width, regurgitant volume and fraction, and effective regurgitant orifice area have prognostic
significance and are recommended to be obtained from patients with more than mild MR. New tools for MR quantification have
been provided by 3-dimensional echocardiography, cardiac magnetic resonance, and cardiac computed tomography, but limited
guidance on appropriate image acquisition and post-processing techniques has hindered their clinical application and reproduc-
ibility. This review describes optimal image acquisition and post-processing methods for quantification of MR. (J Am Coll Cardiol
Img 2012;5:116175) 2012 by the American College of Cardiology Foundation

Accurate quantification of mitral regurgitation IMAGE ACQUISITION FOR VCW. A modified para-
(MR) severity is important for decisions regarding sternal long-axis view is best to image the VC with
surgery (1) and predicting risk (2). Current guide- the transducer laterally translated or angulated, if
lines propose integration of specific, supportive, and necessary, to allow complete visualization of the
quantitative echocardiographic features to classify MR jet (3). Although apical transthoracic echocar-
severity of MR (3,4). The latterincluding vena diography (TTE) acquisitions with the transducer
contracta width (VCW), regurgitant volume perpendicular to the mitral coaptation plane can be
(RVol) and fraction (RF), and effective regurgitant used, this is generally not recommended because of
orifice area (EROA)are recommended in patients limitations in lateral spatial resolution. A 2-chamber
with more than mild MR (3). Although these view should not be used because this view is
quantitative techniques can be accurate and repro- oriented parallel to the line of leaflet coaptation and
ducible in single centers (5,6), there can be signif- may exaggerate the MR severity when the MR jet is
icant interobserver variability among centers (7). asymmetrical, with the longer axis occurring
Recent technological advances in 3-dimensional through the coaptation line. The transducer should
echocardiography (3DE), cardiac magnetic reso- be adjusted as necessary to obtain the largest MR jet
nance (CMR), and cardiac computed tomography size. The focus should be moved to the valve, and
(CCT) have provided new tools for MR quantifi- the depth and sector width should be minimized to
cation (Table 1). Although CCT has the highest focus on the valve. The color sector should be as
spatial resolution, its role in MR quantification is narrow as possible to maximize lateral and temporal
limited by temporal resolution and the inability to resolution (3). An aliasing velocity of 50 to 70 cm/s
assess flow. This review describes optimal image should be used, with the color Doppler gain set just
acquisition and post-processing methods for quan- below the threshold for noise. Ideally, the proximal
tification of MR using 2-dimensional echocardiog- flow convergence region (PFCR), the VC, and the
raphy (2DE) and the newer modalities. downstream expansion of the MR jet should be
included in the acquisition (Fig. 1).
VCW measurements can also be performed
Vena Contracta
using transesophageal echocardiography (TEE)
at a midesophageal level with an image acquired
2DE (transthoracic and transesophageal). The vena
perpendicular to the mitral commissural plane
contracta (VC) is the narrowest portion of the MR
(120) with image optimization as for TTE.
jet, at or just downstream of the mitral regurgitant
Because of the proximity to the mitral valve,
orifice. The VCW is a measure of the EROA.
multiplanar capabilities, and higher resolution,
VCW measurements are less influenced by instru-
VCW measurements with TEE are more accurate
ment settings than other quantitative techniques (3)
than those with TTE (3).
and are accurate indicators of MR severity, regard-
less of the MR etiology and jet direction (5). HOW TO MEASURE THE VCW. After image quality is
However, small measurement errors can lead to determined to be adequate, each systolic frame should
misclassification of MR severity. be examined to identify the frame with the largest and
JACC: CARDIOVASCULAR IMAGING, VOL. 5, NO. 11, 2012 Thavendiranathan et al. 1163
NOVEMBER 2012:116175 Quantitative Assessment of Mitral Regurgitation

best visualized VC. The largest VC can occur at (12). The spatial and temporal resolution of the 3D
different points in the cardiac cycle depending on the acquisition can be maximized by adjusting the acquisition
underlying etiology of MR. The image should be sector (minimal lateral width and elevation height to
zoomed prior to measurement. The VCW is the cover the mitral valve) and the color Doppler sector
narrowest dimension of the neck between the PFCR (small as possible) and by increasing the number of heart
and flow expansion in the atrium just distal to the beats over which the acquisition is obtained (i.e., using
mitral valve (Fig. 1B). It should be measured from electrocardiogram-gated acquisition). A full-volume
one end of the color jet to the other end perpen- acquisition is then obtained. Newer ultra- ABBREVIATIONS
dicular to the MR jet (Fig. 1B). In the context of sound systems will allow real-time optimi- AND ACRONYMS
multiple MR jets, individual VCWs are not addi- zation of the 3D color Doppler in live 3D
tive; however, the cross-sectional area calculated mode or single heart-beat full-volume 2DE 2-dimensional

using a shape assumption (Fig. 1C) can be additive. mode, but the acquisition should still be echocardiography

gated. End-expiratory breath-hold is desir- 3DE 3-dimensional

CONTRACTA AREA. The first step in image acqui- able for gated acquisitions, and all 3D vol-
AROA anatomic regurgitant
sition for vena contracta area (VCA) is to ensure umes should be checked perpendicular to
orifice area
good-quality electrocardiogram tracing for trigger- the ultrasound sweep plane to ensure that
CCT cardiac computed
ing. The transthoracic transducer position or the stitching artifacts are absent (Fig. 2H). Sev- tomography
TEE plane that provides the best 2-dimensional eral different 3D volumes using different CMR cardiac magnetic
(2D) view of the mitral valve and the MR jet should transducer positions or TEE imaging planes resonance

be the starting point for the 3-dimensional (3D) should be obtained to ensure that good- EROA effective regurgitant
acquisition. With TTE (Online Fig. 1), either quality data are available for post-processing. orifice area

parasternal or apical TTE transducer positions can LV left ventricle/ventricular

HOW TO MEASURE VCA. Using 2D long-
be used; most studies describing this technique have axis images (systolic phase) that are auto- LVOT left ventricular outflow
used apical images (8 11). Before 3D acquisition, matically generated from the 3D volume
the 2D image should be optimized as described MR mitral regurgitation
by post-processing software (Figs. 2A and
previously, with inclusion of the PFCR, VC, and at PC phase contrast
2B, green and red boxes), the longitudinal
least one-third of the downstream jet in the image. planes (red and green lines) are adjusted to PFCR proximal flow
convergence region
During 3D acquisition, gain and compression set- bisect the regurgitant jet in both images.
tings should be in the midrange (50 to 60 units) PISA proximal isovelocity
Each systolic frame is then examined to surface area
identify the frame in which the MR jet is RF regurgitant fraction
Table 1. Tools for Mitral Regurgitation Quantication the largest and best visualizedthe timing ROI region of interest
of this may vary, depending on the etiol-
Suggested RV right ventricle/ventricular
Modality Order of Use ogy of MR (13,14). Once this systolic
RVol regurgitant volume
VC 3DEVC area 1 frame is identified, the short-axis plane
SSFP steady-state free
2DEVC width 2 (Figs. 2A and 2B, blue line) is moved up precession
CMRVC width or area 3 and down orthogonal to the regurgitant jet
SV stroke volume
RVol/RF CMRmultiple methods* 1 and tilted (in the jet direction) until the
TEE transesophageal
3DE 2DELV SV by endocardial 2 cross-sectional area of the VC can be echocardiography
contouring; aortic SV by 2DE or 3DE
visualized (Fig. 2E, blue box). VCA is the TTE transthoracic
2DEquantitative Doppler method 3
narrowest cross-sectional area of the color echocardiography
3DEnovel color Doppler method
Doppler jet at valve coaptation level or just VCA vena contracta area
within the left atrium. Adjacent systolic VCW vena contracta width
frames are re-examined in the short-axis VENC velocity encoding
2DEvolumetric method 3
plane to identify the largest VCA in systole
AROA 3DEAROA 1 VSD ventricular septal defect
while the short-axis plane (blue line) is still
VTI velocity time integral
at the VC. The en face image should then be
viewed on full screen and magnified for
*Preferred method is difference between left ventricular (LV) endocardial
contouring and aortic phase-contrast imaging. Needs further validation direct planimetry of the color flow signal (Fig. 2E)
before clinical use. Ideally should use a method of 3-dimensional (3D)
reconstruction of the proximal isovelocity surface area (PISA). 3D Echocar- (11). An example of this measurement using TTE is
diography (3DE) and cardiac magnetic resonance (CMR) anatomic regurgitant
orice area (AROA) measurements should only be used if the regurgitant
provided in the Online Appendix (Online Fig. 1).
orice is expected to be large (i.e., moderate or severe mitral regurgitation). Several steps may help better delineate the axial
2DE 2-dimensional echocardiography; CT computed tomography;
EROA effective regurgitant orice area; RF regurgitant fraction; RVol location of measurement and improve reproducibility.
regurgitant volume; SV stroke volume; VC vena contracta.
Removal of the B-mode image (Figs. 2C and 2D)
1164 Thavendiranathan et al. JACC: CARDIOVASCULAR IMAGING, VOL. 5, NO. 11, 2012

Quantitative Assessment of Mitral Regurgitation NOVEMBER 2012:116175

Figure 1. VCW Measurement

(A) Color-suppressed parasternal long-axis image and (B) the mitral regurgitation (MR) jet with the vena contracta width (VCW) measure-
ment are shown. (C) Calculation of the vena contracta area using a circle assumption. EROA effective regurgitant orice area; PFCR
proximal ow convergence region.

allows examination of the long-axis color Doppler to the initial user-defined plane (blue plane) may
alone to more easily identify the narrowest neck of the allow selection of the best VCA to planimeter
color jet. The B-mode can then be turned back on to (Fig. 2G).
confirm location relative to the site of valve coaptation. CMR imaging and CCT: image acquisition and measure-
Reformatting the 3D volume (Fig. 2F) to obtain an en ment of VCW and VCA. Although not referred to as
face view of the VCA can be a guide to the shape of vena contracta, the base of flow void at the mitral
the expected VCA in the short-axis plane (Fig. 2E). valve can be measured using long-axis CMR cines
Automatically generated multislice planes parallel (Figs. 3A and 3B) (15). The base of flow void at the

Figure 2. VCA Measurement With Multiplanar Reformat of the 3D TEE Data

(A and B) Systolic 2-dimensional planes created from the volume data (F). (C and D) MR jet with the B-mode turned off to better delin-
eate the VC. (E) Short-axis (en face) view of the vena contracta area (VCA) with planimetry showing an area of 0.60 cm2 (consistent with
severe MR). (F) Volume data. (G) Multiple parallel en face views of the VCA (parallel dotted lines in C and D) that can be used to
choose the best image for planimetry. (H) Illustration of stitching artifact. Abbreviation as in Figure 1.
JACC: CARDIOVASCULAR IMAGING, VOL. 5, NO. 11, 2012 Thavendiranathan et al. 1165
NOVEMBER 2012:116175 Quantitative Assessment of Mitral Regurgitation

mitral valve is typically better seen with fast gradient

echo cines with longer echo times than the more
commonly used steady-state free precession (SSFP)
cines. A 3- or 4-chamber cine can be used for this
measurement; however, if the prescribed plane is not
through the site of MR, the jet could be missed. Each
systolic frame should be examined carefully to identify
the frame with the largest MR jet. The image should
then be zoomed, and the VCW measured as the
width of the flow void at or just distal to the mitral
The MR jet can be visualized and measured using
long-axis phase contrast (PC) acquisitions with in-
plane phase encoding (Figs. 3C and 3D), and short-
axis PC imaging with through-plane phase encoding
(Figs. 3E and 3F) can be used to measure the vena
contracta area. This method is based on using 2
orthogonal long-axis cines/PC images as reference
planes to plan short axis slices. Each short axis slice is
examined to identify the slice position with the small-
est VCA. From this slice, the systolic phase with the
largest VCA is zoomed for planimetry. Although this
technique has the potential for MR severity assess-
ment, it is not widely used and is subject to significant Figure 3. VC Measurement With Cardiac Magnetic Resonance Imaging
variability depending on the acquisition parameters (A and B) Use of steady-state free precession (SSFP) cine to measure the
(slice thickness and frame rate), post-processing meth- VCW. (C and D) Use of SSFP cine with 4-chamber phase contrast (PC) image
ods, and experience of the user. However, in our with in-plane velocity encoding. (E and F) Short-axis PC image (with
through-plane phase encoding) illustrating the VCA (arrow) that could be
experience, the long-axis or short-axis cine or PC planimetered. Abbreviations as in Figures 1 and 2.
images may be useful to detect the presence of MR
and provide visual assessment of severity.
VC assessment is currently not possible with in zoom mode and the focus moved to the annulus
CCT. (Figs. 4A and 4B). The 4-chamber view should not
include any part of the left ventricular outflow tract
RVol and Fraction Measurements (LVOT), and the atrium and ventricle should not be
foreshortened. The cine-loop should consist of at least
2 cardiac cycles to allow choice of the best cycle for
2D Echocardiography (TTE and TEE). Mitral RVol can
analysis. Inflow velocities are measured using pulsed-
be calculated using the proximal isovelocity surface
wave Doppler with a 1- to 3-mm sample placed at the
area (PISA) technique (using the EROA and MR
mitral annulus in the exact plane in which the annular
velocity time integral [VTI]), using the VCW
diameter is measured. Data for 3 to 5 beats in sinus
technique (based on EROA calculated using the
rhythm and 5 to 10 beats in atrial fibrillation should
cross-sectional area [Fig. 4] and MR VTI), or by
be obtained at a sweep speed of 50 to 100 mm/s
calculating the difference between mitral inflow and
(Fig. 4C). Spectral Doppler tracings should be of
aortic outflow stroke volume (SV). The latter
good quality with adequate gain settings and ab-
method, which is described in the following section,
sence of spectral broadening. Breath-holding will
is only valid in the absence of other valvular disease
improve the consistency of the obtained pulsed-
or intracardiac shunts (3). The RF is calculated as
wave Doppler recording.
RVol/mitral inflow SV.
Aortic SV requires a zoomed parasternal long-
IMAGE ACQUISITION FOR RVOL AND RF. Mitral in- axis cine-loop to measure the LVOT diameter (Fig. 4D),
flow SV is obtained from apical 4-chamber (or with the depth and focus set to optimize visualiza-
optionally 2-chamber) cine-loops. The depth tion of the LVOT perpendicular to the ult-
should be minimized and the sector-width reduced rasound beam. The basal insertion points of the
to focus on the mitral valve and left ventricle (LV). aortic leaflets and the proximal aortic root should
The image should be centered on the mitral annulus be clearly seen in the acquisition (Fig. 4D). At
1166 Thavendiranathan et al. JACC: CARDIOVASCULAR IMAGING, VOL. 5, NO. 11, 2012

Quantitative Assessment of Mitral Regurgitation NOVEMBER 2012:116175

Figure 4. Mitral Inow and Aortic Outow Stroke Volume Measurement

(A to C) Measurement of mitral annular diameter and mitral inow velocity time integral (VTI). (D and E) Same measurement for the left ven-
tricular outow tract. (F) Illustration of regurgitant volume and regurgitant fraction (RF) calculation. Abbreviation as in Figure 1.

least 2 cardiac cycles should be acquired. The the pulsed-wave Doppler (modal velocities) should
apical 5- or 3-chamber view is then used to place then be traced to obtain a VTI (Fig. 4C). Mitral
a 3- to 5-mm pulsed-wave sample approximately inflow SV (mitral valve cross-sectional area mitral
5 mm proximal to the aortic valve to measure inflow VTI) is measured from averaging annular and
LVOT flow velocities in the center of the LVOT, Doppler measurements over multiple cardiac cycles.
at the location where LVOT diameter is mea- LV SV obtained by the biplane Simpson method can
sured (Fig. 4E). The closing click of the aortic be used as a surrogate for mitral inflow SV (17) in the
valve is often seen when the sample volume is absence of other sources of variability in SV measure-
correctly positioned (16). ment such as ventricular septal defect (VSD) and
These measurements can also be obtained with aortic regurgitation.
TEE using midesophageal views for the mitral For the aortic SV, LVOT diameter measure-
annular and LVOT dimensions (0 and 120) and ments should be taken from inner edge to inner
mitral inflow pulsed-wave Doppler (0 or 90). A edge using a zoomed image (Fig. 4D). Although
transgastric view is needed to obtain the LVOT the largest diameter from 3 to 5 repeated measure-
Doppler measurements. ments is often used (16), an average of the mea-
HOW TO CALCULATE RVOL AND RF. With the surements may be more robust. The LVOT pulsed-
4-chamber cine-loop (Fig. 4A), the mitral annular wave Doppler should be traced for multiple heart
diameter is measured at the base of the leaflets beats with the considerations described for the
during early diastole to mid-diastole, 1 frame after mitral valve. The aortic SV (ml) LVOT cross-
the leaflets begin to close after passive filling (16). sectional area (r2) LVOT VTI.
Using this diameter, the cross-sectional area of the This method of MR assessment is challenging
mitral annulus can be calculated using (D/2)2, technically, and operator experience is important to
assuming that the annulus is circular (3). Alterna- ensure reproducibility. Centers that are successful
tively, the annular measurements from the 2- and with this method first use the technique to ensure
4-chamber views can be used to calculate the area that calculations of mitral inflow and aortic outflow
using an ellipse assumption ([D/2 for 2 cham- SV match in patients without mitral or aortic valve
ber] [D/2 for 4 chamber]). The brightest edge of disease or VSD before applying it to patients with
JACC: CARDIOVASCULAR IMAGING, VOL. 5, NO. 11, 2012 Thavendiranathan et al. 1167
NOVEMBER 2012:116175 Quantitative Assessment of Mitral Regurgitation

MR. Assumptions about circular geometry of the both the color Doppler velocity data and area to
mitral valve and LVOT can add to further errors in calculate SV at each orifice (Fig. 5) (18). Although
MR quantification. this technique has been validated using 2DE (19),
3D echocardiography (TTE). IMAGE ACQUISITION 3D studies have shown accuracy in separate mea-
AND MEASUREMENT OF RVOL AND RF. MR RVol surement of mitral and aortic SV (20,21), with only
can be measured using the difference in LV SV preliminary data on MR quantification (22). Only a
obtained from a 3D acquisition of the LV (differ- brief description of this technique is provided;
ence between LV end-diastolic and systolic vol- previous publications have provided further acqui-
umes) and aortic SV measured using the 2D sition details (18,20,21).
method (described previously) or 3D method (de- A full-volume 3D acquisition of the LV includ-
scribed in the next section). High-volumerate 3D ing the mitral and aortic valve with color Doppler
full-volume acquisition (30 volumes/s) from an sector covering both valves in the same volume or
apical window, without stitching artifact and drop- acquired as 2 separate volumes depending on the
outs, should be used to measure LV SV. This temporal resolution (minimum volume rate 10/s)
method is only valid in the absence of other sources is needed (Fig. 5). Color Doppler settings should be
of variability in SV measurement such as VSD and adjusted to avoid color bleeding into B-mode, and
aortic regurgitation. the Nyquist limit should be maximized. Breath-
Mitral RVol and RF can also be calculated with holding is required for gated acquisition. Custom
3DE using the VCA (described previously) or software is necessary for the quantification of SV
PISA technique (described in the next section). using user-defined planes at the valves (20,21). The
POTENTIAL NOVEL METHOD FOR RVOL AND RF ability to measure mitral inflow and aortic outflow
QUANTIFICATION. A novel method used to calcu- SV with a single 3D acquisition in an automated
late RVol and RF is to obtain 3D color Doppler manner (18) may encourage the use of this method
acquisitions at the mitral and aortic valves and use for MR quantification (22).

Figure 5. 3-Dimensional Color Doppler Used to Quantify Mitral Inow and Aortic Outow Stroke Volumes

(A to C) Patient without MR. The mitral inow stroke volumes (SVs) range from 80.0 to 77.1 ml depending on the RR interval; similarly,
the aortic SVs range from 72.1 to 75.0 ml. On average (average of 3 beats), there is minimal difference between the inow and outow
SVs. (D to F) Patient with mild MR. On average, there is 17 ml of mitral regurgitant volume. Abbreviation as in Figure 1.
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Quantitative Assessment of Mitral Regurgitation NOVEMBER 2012:116175

CMR. Mitral RVol and RF can be obtained with angiography acquisitions to define a slice position
CMR using direct and indirect methods. Indirect orthogonal to the tubular aorta at pulmonary
methods include measurement of the difference artery bifurcation (Online Figs. 4E and 4F).
between: 1) LV SV by planimetry of short-axis cine Through-plane VENC should be used with the
images and aortic SV using PC imaging; 2) LV and VENC at 150 cm/s and increased if aliasing is
RV SVs by planimetry; or 3) mitral inflow and present.
aortic outflow SVs by using PC imaging. The direct HOW TO MEASURE RVOL AND RF BY CMR. LV CON-
method uses short-axis PC imaging at the level of TOURING FOR LV SV. Accurate contouring of the
the mitral valve with through-plane phase encoding LV and right ventricle (RV) requires practice
to directly measure RVol. before it can be used for clinical quantification of
IMAGE ACQUISITION. CINE IMAGES. For the first 2 MR RVol and RF. Methods for accurate and
indirect MR quantification techniques, breath-held reproducible quantification (23,24) are described
short-axis cine images (ideally using SSFP pulse in the Online Appendix. Once LV and RV SV
sequences) extending from the base to the apex of are obtained, the difference in these volumes
the LV are necessary (23,24). The technique for provides the MR RVol, assuming that no other
acquisition of short-axis cines (23,24) is summa- valvular lesions or intracardiac shunts are present.
PC ANALYSIS. The PC acquisition provides magni-
rized in the Online Appendix and Online Figures 2
tude and phase images (Fig. 6). Regions of interest
and 3.
(ROIs) over the area of flow can either be drawn on
PC IMAGES. Acquisition of PC images at the mitral
the magnitude image and transferred to the phase
valve can be challenging because of through-plane
image or drawn directly on the phase image. For
translation of the annulus. To measure mitral inflow
mitral inflow SV quantification, an ROI encom-
SV, short-axis PC acquisition with through-plane
passing only the mitral inflow orifice should be
phase encoding should be set up at the mitral
carefully drawn through all acquired systolic frames
annular plane or slightly into the LV using both the
(Figs. 6C to 6F). This ensures that the mitral inflow
horizontal long-axis and vertical long-axis cine
measurement is not contaminated by other flows.
diastolic frames (Online Figs. 4A and 4B). The
Although this is done in a semi-automated manner,
initial velocity encoding (VENC) should be 100 to it can be time intensive and subject to interobserver
150 cm/s with higher VENC if aliasing is present. variability. Once all ROIs are drawn, mitral inflow
For direct measurement of RVol, through-plane SV is automatically computed using velocity data in
PC imaging similar to that described previously the phase image and the ROI (Fig. 6G). Similarly
should be acquired with a slice position placed on for the aortic SV, an ROI is drawn encompassing
the atrial side of the mitral valve tips during peak the inner edge of the aortic wall (Figs. 6H and
systole (but avoiding the highest flow velocities at 6I). This is less subjective because the aortic wall
the regurgitant orifice), perpendicular to the pre- is usually well defined, allowing automated prop-
dominant direction of the MR jet (25) (Online agation of the ROI from one image with subse-
Figs. 4C and 4D). Either long-axis cines or PC quent minor adjustments of each frame if needed.
images in which the MR jet is clearly visualized With these data, the MR RVol can be calculated
should be used as reference images. VENC settings as the difference between the mitral inflow
of 4 to 6 m/s are necessary. Although described in (Fig. 6G) and aortic outflow SVs (Fig. 6J) by PC
one study (25), this approach is mostly appropriate imaging or as the difference between LV SV by
for central jets of MR because alignment perpen- planimetry and aortic SV by PC data. RF is the
dicular to eccentric jets is challenging and more RVol divided by the mitral inflow SV or the LV
prone to errors. planimetry SV.
The optimal slice position for aortic SV measure- If the PC images are used for the direct quanti-
ments is still controversial (26,27). The level of the fication of RVol, an ROI should be drawn on each
mid ascending aorta at the pulmonary artery bifur- systolic frame to encompass the regurgitant flow on
cation has been reported to be the best location the phase images (Online Fig. 5). Integration of
(28), and the most contemporary literature provid- flow through systole over this ROI results in com-
ing MR severity grades with CMR used this posi- putation of RVol.
tion (29). Aortic PC acquisition can be set up using Cardiac Computed Tomography. I M A G E A C Q U I S I -
coronal and sagittal cine images with adequate TION AND ANALYSIS. Current CT technology does
visualization of the aorta or magnetic resonance not allow flow measurements across the valves.
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NOVEMBER 2012:116175 Quantitative Assessment of Mitral Regurgitation

Figure 6. Mitral Inow and Aortic Outow SV Quantication With Through-Plane PC Imaging

(A) Magnitude image. (B) Systolic phase-contrast (PC) image. (C to F) Representative diastolic PC images with manual planimetry (red) of
the inow orices. (G) Time-volume curve illustrating the mitral inow SV. (H) Ascending aorta magnitude image. (I) 2 representative
phase images with planimetry of the aorta during systole. (J) Outow time-volume curve from illustrating aortic SV. In this case with con-
comitant aortic regurgitation, both forward and reverse volume curves are shown. LV left ventricle; RV right ventricle; other abbrevi-
ation as in Figure 5.

However, one study has illustrated RVol and RF PISA (EROA, RVol, RF) and Anatomic Regurgitant
measurement using LV and RV contouring similar Orifice Area
to that described for CMR (30). This technique
requires a retrospectively gated cardiac acquisition 2D Echocardiography (TTE and TEE). IMAGE ACQUI-
with multiphase reconstruction followed by either SITION FOR PISA. The PFCR should be imaged
semiautomated calculation of LV and RV SV or from an apical view (TTE) or the midesophageal
calculation of ventricular SV using reconstructed view (TEE). The optimal PFCR is usually seen in
short-axis slices to perform endocardial contouring either the 4- or 3-chamber view. First, the mitral
identical to CMR. Despite the feasibility of this valve should be centered in the image with the
method, CCT is still limited by temporal resolution sector optimized by width and depth to ensure the
and the need for retrospectively gated acquisition, highest possible temporal and spatial resolution
which increases radiation exposure. In addition, the (Fig. 7). The color sector is adjusted to include the
LV/RV SV method is only valid in the absence of mitral valve, a portion of the ventricle, and base of
concomitant valvular disease or intracardiac shunt- the atrium. Aliasing velocity should be adjusted
ing. This technique should therefore be the last either by baseline-shifting the color in the direction
resort for MR severity quantification. of the MR to 30 to 40 cm/s or by lowering the
1170 Thavendiranathan et al. JACC: CARDIOVASCULAR IMAGING, VOL. 5, NO. 11, 2012

Quantitative Assessment of Mitral Regurgitation NOVEMBER 2012:116175

Figure 7. EROA and RVol Quantication Using Transesophageal Echocardiography in a Patient With Moderately Severe MR

(A and B) The proximal isovelocity surface area radius is measured from the rst aliasing velocity to the leaet using color compare (A
vs. B). (C) Continuous wave Doppler is used to compute the VTI. (D) Illustration of effective regurgitant orice area (EROA) and regurgi-
tant volume (RVol) calculation. AV aliasing velocity; other abbreviations as in Figures 1 and 4.

Nyquist limit to optimize visualization of the RVol/mitral inflow or LV SV (also see the section
PFCR (31). The color Doppler variance map on RVol and RF measurements above)
should be turned off (usually the default with most
software). The cine-loop is then reviewed frame-
by-frame during systole to identify the largest 2r 2 Aliasing Velocity cm

PFCR where the first isovelocity shell is clearly EROA
visualized. A continuous wave (CW) Doppler MR Vmax
cursor is then aligned parallel to MR flow to
obtain the peak velocity of the MR (Vmax, cm/s)
A simplified formula can be used as a rapid
and the MR VTI (VTIMR, cm), with velocity
screening tool. With the Nyquist limit at 40 cm/s
measurements taken from the outer border of the
and the MR peak velocity assumed to be 500 cm/s,
envelope (Fig. 7C) (16).
then the formula simplifies to EROA r2/2. This
HOW TO MEASURE EROA, RVOL, AND RF USING THE method makes a number of assumptions and should
PISA TECHNIQUE. In measurement of the radius of only be used as a screening tool or when CW
the PFCR (Fig. 7), recognition of the outer surface Doppler is not obtained. A number of important
(red-blue interface of first aliasing velocity) is easier considerations regarding the PISA technique are
than identification of the center of the MR orifice. summarized in the Online Appendix and Online
Use of color compare/suppress options or switch- Figure 6. Perhaps most important is that using the
ing the color Doppler on and off can improve largest PFCR may overestimate severity when MR
accuracy in identifying this point (Figs. 7A and 7B). is not pansystolic.
The EROA is calculated using the continuity prin- 3D echocardiography (TTE and TEE). IMAGE ACQUI-
ciple with the below formula (Fig. 7). RVol can SITION FOR PISA QUANTIFICATION. With TTE,
then be calculated as EROA VTIMR and RF is 3D PFCR should be imaged from an apical view,
JACC: CARDIOVASCULAR IMAGING, VOL. 5, NO. 11, 2012 Thavendiranathan et al. 1171
NOVEMBER 2012:116175 Quantitative Assessment of Mitral Regurgitation

with the best initial transducer position determined image should be carefully examined to ensure that
by 2D imaging. With TEE, the midesophageal no dropouts are present and that the valve is within
long-axis view from which the MR is best seen the acquired volume throughout the cardiac cycle.
should be selected. After 2D image and color Alternatively, a full 3D volume (12), including the
optimization, the transducer should be adjusted to LV and the mitral valve, can also be used to
place the PFCR at the center of the acquisition measure the AROA. However, the need for gated
volume. Color Doppler baseline shifting can be acquisitions predisposes this technique to stitching
performed at the time of acquisition or during artifacts. The AROA can also be measured with 3D
post-processing, depending on the software. Mis- TTE using zoom or full-volume acquisitions, al-
alignment artifacts can be avoided by acquisition of though the accuracy and feasibility of this method is
the full volume with suspended or shallow respira- yet to be described.
tion or using a single heart beat acquisition (al-
HOW TO MEASURE THE PISA. Although several
though this is at the cost of reduced temporal
resolution). The single beat method is best used to methods for 3D PISA quantification have been
optimize the B-mode and color Doppler in real- described (3335), no standard method exists. Four
time 3D (e.g., to steer the beam to ensure that the quadrants are displayed in the post-processing soft-
MR jet is included in the volume or to change ware (Figs. 8A, 8B, 8D, and 8E). The first step is to
lateral width or elevation height of the volume to obtain an optimal view of the MR jet (see VCA
include a larger portion of the mitral valve) before section) (Figs. 8A and 8B). The PFCR size can vary
subsequent high-resolution acquisition over several throughout systole depending on the etiology of the
cardiac cycles. The acquired volume should be MR. Although the systolic frame with the largest
examined to ensure that the complete MR jet was and best visualized PFCR should be used for
captured and that no artifacts are present. A CW analysis, this may overestimate the severity of MR.
spectrum of the MR jet is necessary to calculate the The color Doppler aliasing velocity is shifted in the
EROA and RVol. direction of the MR jet to between 20 to 40 cm/s.
Then the axial (blue) plane is moved to the base of
IMAGE ACQUISITION FOR ANATOMIC REGURGI- the PFCR (ventricular side of the mitral valve) and
TANT ORIFICE AREA MEASUREMENT. For plani- adjusted using both of the long-axis views (red and
metry of the anatomic regurgitant orifice area green boxes) to obtain an en face view of the base of
(AROA) using TEE, 2 different acquisitions can be the PFCR (Figs. 8C and 8D). This view provides a
used from the midesophageal position: zoom-mode measure of the length (D1) and width (D2) of the
or full-volume acquisition (12); the only contempo- base of the PFCR. With this view, the red or green
rary study used zoom-mode (32). We position the lines (planes) can be moved along the base of the
3D-zoomed image from an optimized 2D view of PFCR (Fig. 8C, red lines) to obtain a long-axis
the mitral valve (e.g., at 120). With 2 orthogonal view of the PFCR with the largest vertical radius
views of the mitral valve, the 3D volume sector is (34,36). The radius should be measured as de-
planned by adjusting the height of the volume scribed for 2D PISA (Fig. 8F; color can be turned
sector to include the mitral valve leaflets in systole off during post-processing to aid this process).
and diastole and by lengthening the volume sector PISA is calculated from the traditional hemisphere
to include the entire mitral annulus and at least a formula (2rz) or the hemiellipse assumption (us-
portion of the aortic valve for orientation (Online ing the radius, length, and width). Alternatively, the
Fig. 7). The size of the 3D volume sector affects the 3D surface area of the PISA can be measured using
temporal resolution of the acquisition and should be complex surface reconstruction from multiple 2D
adjusted to obtain a volume rate 10 volumes/s.
measurements (33,35,36), but this is impractical.
The line density should be set at medium or high
Recent preliminary work has illustrated a method of
(with each 3D system, the user should first identify
automated segmentation of the 3D PFCR without
the appropriate gain and line density settings in
shape assumptions (37). The accuracy of this tech-
patients without MR to ensure that the acquisition
nique in the clinical setting remains undefined.
does not have dropouts, particularly at the coapta-
tion lines that may mimic a regurgitant orifice). The HOW TO MEASURE THE AROA. With post-
3D volume should then be turned downward (to- processing software, the 3D volume should first be
ward the viewer) and rotated to orient the aortic tilted to visualize the mitral coaptation line from
valve in the 12 oclock position (12) (Online Fig. 7), the atrial aspect (Online Fig. 8D). The 2 planes on
customarily referred to as the surgeons view. The the 3D image should then be adjusted to place one
1172 Thavendiranathan et al. JACC: CARDIOVASCULAR IMAGING, VOL. 5, NO. 11, 2012

Quantitative Assessment of Mitral Regurgitation NOVEMBER 2012:116175

Figure 8. PISA Measured From a 3-Dimensional Full-Volume Color Doppler Acquisition

(A and B) The systolic long-axis views are optimized to visualize the MR jet. The largest systolic proximal isovelocity surface area (PISA) is
used to adjust the short-axis plane (blue line) to obtain an en face view of the base of the PISA (C and D). (E) The color Doppler base-
line is adjusted to 39.6 cm/s. (F) Multiple orthogonal views can be generated (C and D, red planes) to obtain the largest 2-dimensional
PFCR. The radius, length, and width measurements are shown (A and D), and the longest PISA radius is shown (F). Abbreviations as in
Figure 1.

parallel and the second perpendicular to the com- CMR Image acquisition and measurement of the
missural line (cutting through the aortic valve), AROA. For CMR AROA measurement, additional
generating an intercommisural and outflow tract dedicated imaging orthogonal to flow direction is
view, respectively (Online Figs. 8A and 8B) (32). necessary (26). This involves identification of the
Using these 2 long-axis views, the 2 planes (blue presence and direction of the regurgitant jet in
and red lines) are moved parallel to the assumed long-axis cines or PC acquisitions (Fig. 9), followed
location of the MR orifice in each of the systolic by prescription of a short-axis SSFP cine slice at the
frames and then rotated along the assumed regur- origin of the jet, orthogonal to the direction of the
gitant jet direction to identify the maximal regur- MR jet (using 2 long-axis planes as reference) (26).
gitant orifice (a 2D color Doppler acquisition Images should be acquired in end-expiratory
viewed separately can help with this orientation). breath-hold, with a slice thickness of 5 to 8 mm
The axial plane (blue line) is positioned orthog- (thinner is preferred to reduce volume averaging), a
onal to the 2 previous planes and moved up and temporal resolution of 45 ms, and 20 cardiac
down through the coaptation line to identify the phases per cardiac cycle (26,38). Five slices (2 above
smallest regurgitant orifice (Online Fig. 8C). The and 2 below the first plane chosen at the origin of
AROA is zoomed, and planimetry is performed the jet) with 50% overlap are acquired to ensure that
using the area tool to carefully follow the inner the AROA is captured (26). The short-axis cines
border of the leaflets. This same technique can be should be carefully examined to identify the slice
used if a 3D full-volume data set is used for position that contains the smallest regurgitant ori-
fice during systole. From this slice, the cardiac
CMR IMAGING AND CCT. PISA cannot be measured phase showing the largest orifice should be used to
with CMR or CCT, but AROA can be measured planimetry the inner contour of the orifice at the
directly by both methods. point of brightest pixels.
JACC: CARDIOVASCULAR IMAGING, VOL. 5, NO. 11, 2012 Thavendiranathan et al. 1173
NOVEMBER 2012:116175 Quantitative Assessment of Mitral Regurgitation

Figure 9. Direct Planimetry of the AROA With Short-Axis SSFP Cines

With 2 long-axis images where the MR is seen (A and B), a short-axis image orthogonal to the MR ow is acquired (C). The anatomic
regurgitant orice area (AROA) can then be identied on the short-axis cine for planimetry (C, red arrow). (D to F) A second patient with
mitral valve prolapse; the AROA is not seen in an early systolic frame (E). However, later in systole, 2 regurgitant orices are seen (F, red
arrows). Abbreviations as in Figures 1 and 2.

CCT Image acquisition and measurement of the planimetry (39). One approach is to first obtain a 4-,
AROA. A retrospectively gated acquisition with re- 2-, or 3-chamber view of the LV including the mitral
construction of multiple systolic phases (5% incre- valve using multiplanar reconstruction (Fig. 10). Us-
ments), slice thickness of 0.75 to 1.0 mm with ing these long-axis views of the ventricle and the cine
0.5-mm increments, and medium soft kernel are mode, the systolic phase in which the noncoaptation
appropriate. Multiplanar reconstruction is used to of the leaflets is the largest should be chosen. Then an
obtain an en face view of the regurgitant orifice for image perpendicular to these planes and parallel to the

Figure 10. AROA Measurement by Computed Tomography Multiplanar Reformat

Four- and 2-chamber views (A and C) obtained from the volume data (B) are used to obtain an en face view of the mitral regurgitant
orice (D) to enable planimetry. (E) Zoomed view of D with planimetry. Abbreviation as in Figure 9.
1174 Thavendiranathan et al. JACC: CARDIOVASCULAR IMAGING, VOL. 5, NO. 11, 2012

Quantitative Assessment of Mitral Regurgitation NOVEMBER 2012:116175

regurgitant orifice is generated by moving a plane up also potential pitfallsfor example, VCA and volu-
and down along the point of noncoaptation to obtain metric calculations may be limited by both temporal
the smallest AROA for planimetry (inner contour of and spatial resolution. In patients with difficult surface
the orifice). imaging, CMR may provide information from all 3
approaches, of which the volumetric methods are best
Conclusions established. Although CCT imaging can be used in
quantification under certain scenarios, this is at the
Accurate estimation of MR severity is clinically im- cost of higher radiation doses.
portant in selected patients. There are fundamentally
3 approachesVC, measurement of RVol and RF,
The authors thank Deborah Agler, RDCS, for her
and measurement of orifice area. In daily practice,
advice regarding echocardiography image acquisi-
although a thorough understanding of the methodol-
tion and post-processing methods.
ogy and attention to detail allows maximum informa-
tion to be obtained from traditional 2D techniques, Reprint requests and correspondence: Dr. Thomas H. Mar-
the 2D techniques are not reliable or accurate in all wick, Menzies Research Institute, 17 Liverpool Street,
patients. 3D imaging is particularly helpful when there Hobart, Tas 7000, Australia. E-mail: tom.marwick@
are multiple or complicated jets. However, there are

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nance for direct assessment of ana- mitral regurgitation. Am J Cardiol For supplementary material and gures, please
tomic regurgitant orifice in mitral re- 2007;99:1440 7. see the online version of this article.

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