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Reproducibility and variability of the amount of tricuspid regurgitation with color Doppler echocardiography
proportional to the square root of the pressure gradient, which itself is influenced by flow volume. Similarly, the continuity equation by echocardiography also is based on flow-dependentvelocity data.It is not surprising therefore that these approachesare influenced by changesin flow. TEE permits in vivo quantitation of anatomic AVA, which is a direct measurementand not derived data. This study provides evidence that acute changes in stroke volume and cardiac output do not result in significant alterations in the anatomic AVA measured with multiplane TEE in patients with AS of moderate or severe degree. Thus, TEE could be useful in the assessment of severity of AS in both low- and high-output states. 1. Cannon SR, Richards KL, Crawford M. Hydraulic estimation of stenotic orifice area: a correction of the Gorlin formula. Circulation 1985;71:1170-1178. 2. Casale PN, Palacios IF, Abascal VM, Harrell L, Davidoff R, Weyman AE, Fifer MA. Effects of dobutamine on Gorlin and continuity equation valve areas and valve resistance in valvular aortic stenosis. Am J Cardiol 1992;70:1175-1179. 3. Bathe RJ, Wang Y, Jorgensen CR. Hemodynamic effects of exercise in isolated valvular aortic stenosis. Circulation 1971;44:1003-1013. 4. Paulus WJ, Sys SU, Heyndrickx GR, Andries E. Orifice variability of the stenotic aortic valve: evaluation before and after balloon aortic valvuloplasty. J Am Coil Car&l 1991;17:1263-1269.
5. Burwash IG, Thomas DD, Sadahiro M, Pearlman AS, Verrier ED, Thomas R, Kraft CD, Otto CM. Dependence of Gorlin formula and continuity equation valve areas on transvalvular volume flow rate in valvular aortic stenosis. Circulation 1994;89:827-835. 6. Stoddard MF, Arce J, Liddell NE, Peters G, Dillon S, Kupersmith J. Two-dimensional tramesophageal echocardiographic determination of aortic valve area in adults with mtic stenosis. Am Heart .I 1991:122:1415-1422. 7. Hoffman R, Flachskampf FA, Hanrath P. Planimetry of orifice area in aortic stenosis using multiplane tramesophageal echocardiography. .I Am Coil Cardiol 1993;22:529-534. 8. Hoffman T, Kasper W, Meinertz T, Spillner G, Schlosser V, Just H. Determination of aortic valve orifice area in a&c valve stenosis by two-dimensional transesophageal echocardiography. Am J Cardiol 1987;59:33&335. 9. Pandian NG, Hsu TL, Schwartz SL, Weintraub A, Cao QL, Schneider AT, Gordon G, England M, Simonetti J. Multiplane tramesophageal echocardiography. Imaging planes, echocardiographic anatomy, and clinical experience with a prototype phased array omniplane probe. Echocardiography 1992;9:649-666. IO. Flachskampf FA, Hoffman R, Verlande M, Schneider W, Ameling W, Hanrath P. Initial experience with a multiplane tramesophageal echotransducer: assessment of diagnostic potential. Eur Heart J 1992;13:1201-1206. 11. Roelandt JRTC, Thomson IR, Vletter WB, Brommersma P, Born N, Linker DT. Multiplane tramesophageal echocardiography: latest evolution in an imaging revolution. JAm Sot Echocardiogr 1992;5:361-367. 12. Forrester JS, Ganz W, Diamond G, McHugh T, Chonette DW, Swan HJC. Thermodilution cardiac output determination with a single flow-directed catheter. Am Heart J 1972;83:30&311. 13. St&z CW, Miller RG, Kelly GE, Raffin TA. Reliability of the thermodilution method in the determination of cardiac output in clinical practice. Am Rev Respir Dis 1982;126:1001-1004. 14. Gorlin R, Gorlin SG. Hydraulic formula for calculation of the area of the stenotic mitral valve, other cardiac valves, and central circulatory shunts. Am Heart J 1951;41:1-29.
Reproducibility and Variability of the Amount of Tricuspid Regur itation With Color Doppler Echocar P iography Byron
F. Vandenberg, MD, Richard W. Ayres, BMBS, Paul D. Lindower, Trudy L. Burns, PhD, and Richard E. Kerber, MD
he quantitation of tricuspid valve regurgitation by colT or flow Doppler echocardiographyis a validated and clinically useful technique.l4 Serial changesin the sever-
MD,
From the Cardiovascular Center, Departments of Internal Medicine, Preventive Medicine, and Environmental Health, University of Iowa, Iowa City, Iowa. Dr. Ayres is the recipient of an Overseas Clinical Fellowship from the Lions Heart Research Foundation of South Australia. Dr. Vandenberg’s address is: Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa 52245. Manuscript received March 1, 1994; revised manuscript received and accepted April 3, 1995.
gitant jet, as viewed from the apical 4-chamber view. Intra- and interobserver variability in tracing was assessedby comparingjet areasand right atrial areastraced from identical video frames by the same and by different observers,respectively. Reproducibility of measurements was assessedby an observer tracing jet and atrial areas at 2 different sessions,blinded to the previous video frame locations. Variability and reproducibility of measurementswere determined by calculating the absolute value of the difference between 2 measurements divided by their mean X 100. In addition, the variability and reproducibility were determined by preserving the sign (i.e., variability and reproducibility were also calculated from the difference between the 2 measurements, without taking the absolute value), to demonstrate whether there may be a consistent trend toward over- or underestimation on the second measurements.Similarity of measurementswas estimated with intra- and interclasscorrelation coefficients.The squareroot of the mean squareerror from fitting a l-factor random-effectsmodel to the data pairs was used to reflect the error of measurement.Mean differences among the 5 measurements of jet area and right atria1 area were investigated by fitting a repeated-measuresanalysis of variance model, followed by 5 pairwise comparisons of observer 1, session 1 versus session 2; observer 1, session 1 versus session 3; observer 1, session 1 versus observer 2, session 1; observer 2, session 1 versus session 2; and observer 1,
198
JULY 15,
ity of regurgitation can be assessedwith jet area measurementsand jet area referencedto the right atrial area, but there are few data regarding the reproducibility of the measurements.Our purpose was to determine the reproducibility and variability of repeat measurementsof tricuspid regurgitation severity obtained by color flow Doppler echocardiography in randomly selectedpatients. ... Color Doppler echocardiograms from 15 patients (mean age 63 k 14 years) with tricuspid regurgitation were retrospectively reviewed. The echocardiograms were recorded for clinically indicated reasons. Patients were chosen for this study because they were participating in another study to validate hepatic vein Doppler in the quantitation of tricuspid regurgitation. Tricuspid regurgitation was quantitated by measuring the jet area and percentageof the right atrium occupied by the regur-
THE AMERICAN
JOURNAL
OF CARDIOIOGY@
VOL. 76
1995
I
FIGURE 1. Association of iet area (left, n = 15) and rcent iet area p”right, n = 12) measured at 2 sessions by a sin le observer. Das il ed line is the line of identity.
60
20
Jet Area (cm 2 ) session 1
Jet Area/ Rlghl Session Atrial Area 1 (%) 4.
15 10 5 0
0 0
Jet Area (cm 2 ) Session
2
20
40
60
00
Jet Area I Right Atrtal Area (X) Session2
session 3 versus observer 2, session 2. TABLE I Comparisons Between Measurements of Tricuspid Jet Area and Right Atrial Arec The experiment-wise error rate for the Jet Area/ 5 pairwise comparisons was 0.05. Right Right Jet areas were traced in all 15 paJet Area Atrial Area Atrial Area tients, and the right atrial wall could be traced in 12. The intraclass correlation Observer 1 Session 1 6.4 * 6.4 cm2 19.0 f 7.7 cm2 29 zt 21% coefficients we observed indicate that Session 2 (same frame) 6.7 * 6.6 cm2 20.2 in 7.7 cm2 30 * 22% the same observer can produce very lntraclass correlations 0.997 0.985 0.991 Error of measurement 0.3 cm2 1 .O cm2 2% similar area measurements, whether lO* 11% lntraobserver variability 5 f 2% 10*9% tracing the sameframes (p ~0.0001) or [sign preserved)** 7* 13 7+ 12 2+5 choosing and tracing new frames (p Session 3 (choose frame) 6.9 f 6.5 cm2 20.1 * 7.5 cm2 32 zt 22% ~0.0001) (Table I and Figure 1). The Introclass correlation§ 0.981 0.983 0.945 error of measurementfor a single obError of measurement 0.9 cm2 1 .O cm2 5% Introobserver reproducibility 16 i 13% 5 f 4% 18 * 12% servermeasuringthe sameframesfor jet 13 zt 16 14 * 17 2*7 Obse~~2ple=d areais 0.3 cm2, for right atrial area it is 1.0cm2,and for percentjet areait is 2% Session 1 (same frame) 6.4 k 6.2 cm2 21.1 * 8.3 cm2* 28 * 20% (Table I). The error of measurement, Interclass correlationil 0.998 0.991 0.993 Error of measurement when an observer chooses and traces 0.3 cm2 1.2 cm2 2% Interobserver variability 8 it 8% 7 * 5% 8 zt 7% new frames is the same for right atrial (sign preserved) 2* 12 6*5 -3 * 10 area,but it is considerably greaterfor jet Session 2 (choose frame) 6.4 * 6.2 cm2 21.7 * 8.1 cm2t 27 it 20t area(Table I [observer 1, session3; and lntraclass correlation* 0.991 0.984 0.977 observer 2, session 21). The interclass Error of measurement 0.6 cm2 1.1 cm2 3% Interobserver reproducibility 13 f 12 9*9 11 f 13 correlation coefficients indicate that (sign preserved) 1 i 18 9*9 -9* 14 there is a very strong (p
5. Rivera JM, Vandervoort PM, de Prada JAV, Mele D, Karson TH, Morehead A., Morris E, Weyman A, Thomas JD. Which physical factors detexmine tricuspid regurgitation jet area in the clinical setting? Am .I Car&l 1993;72:1305-1309.
BRIEF REPORTS
199
5. Burwash IG, Thomas DD, Sadahiro M, Pearlman AS, Verrier ED, Thomas R, Kraft CD, Otto CM. Dependence of Gorlin formula and continuity equation valve areas on transvalvular volume flow rate in valvular aortic stenosis. Circulation 1994;89:827-835. 6. Stoddard MF, Arce J, Liddell NE, Peters G, Dillon S, Kupersmith J. Two-dimensional tramesophageal echocardiographic determination of aortic valve area in adults with mtic stenosis. Am Heart .I 1991:122:1415-1422. 7. Hoffman R, Flachskampf FA, Hanrath P. Planimetry of orifice area in aortic stenosis using multiplane tramesophageal echocardiography. .I Am Coil Cardiol 1993;22:529-534. 8. Hoffman T, Kasper W, Meinertz T, Spillner G, Schlosser V, Just H. Determination of aortic valve orifice area in a&c valve stenosis by two-dimensional transesophageal echocardiography. Am J Cardiol 1987;59:33&335. 9. Pandian NG, Hsu TL, Schwartz SL, Weintraub A, Cao QL, Schneider AT, Gordon G, England M, Simonetti J. Multiplane tramesophageal echocardiography. Imaging planes, echocardiographic anatomy, and clinical experience with a prototype phased array omniplane probe. Echocardiography 1992;9:649-666. IO. Flachskampf FA, Hoffman R, Verlande M, Schneider W, Ameling W, Hanrath P. Initial experience with a multiplane tramesophageal echotransducer: assessment of diagnostic potential. Eur Heart J 1992;13:1201-1206. 11. Roelandt JRTC, Thomson IR, Vletter WB, Brommersma P, Born N, Linker DT. Multiplane tramesophageal echocardiography: latest evolution in an imaging revolution. JAm Sot Echocardiogr 1992;5:361-367. 12. Forrester JS, Ganz W, Diamond G, McHugh T, Chonette DW, Swan HJC. Thermodilution cardiac output determination with a single flow-directed catheter. Am Heart J 1972;83:30&311. 13. St&z CW, Miller RG, Kelly GE, Raffin TA. Reliability of the thermodilution method in the determination of cardiac output in clinical practice. Am Rev Respir Dis 1982;126:1001-1004. 14. Gorlin R, Gorlin SG. Hydraulic formula for calculation of the area of the stenotic mitral valve, other cardiac valves, and central circulatory shunts. Am Heart J 1951;41:1-29.
Reproducibility and Variability of the Amount of Tricuspid Regur itation With Color Doppler Echocar P iography Byron
F. Vandenberg, MD, Richard W. Ayres, BMBS, Paul D. Lindower, Trudy L. Burns, PhD, and Richard E. Kerber, MD
he quantitation of tricuspid valve regurgitation by colT or flow Doppler echocardiographyis a validated and clinically useful technique.l4 Serial changesin the sever-
MD,
From the Cardiovascular Center, Departments of Internal Medicine, Preventive Medicine, and Environmental Health, University of Iowa, Iowa City, Iowa. Dr. Ayres is the recipient of an Overseas Clinical Fellowship from the Lions Heart Research Foundation of South Australia. Dr. Vandenberg’s address is: Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa 52245. Manuscript received March 1, 1994; revised manuscript received and accepted April 3, 1995.
gitant jet, as viewed from the apical 4-chamber view. Intra- and interobserver variability in tracing was assessedby comparingjet areasand right atrial areastraced from identical video frames by the same and by different observers,respectively. Reproducibility of measurements was assessedby an observer tracing jet and atrial areas at 2 different sessions,blinded to the previous video frame locations. Variability and reproducibility of measurementswere determined by calculating the absolute value of the difference between 2 measurements divided by their mean X 100. In addition, the variability and reproducibility were determined by preserving the sign (i.e., variability and reproducibility were also calculated from the difference between the 2 measurements, without taking the absolute value), to demonstrate whether there may be a consistent trend toward over- or underestimation on the second measurements.Similarity of measurementswas estimated with intra- and interclasscorrelation coefficients.The squareroot of the mean squareerror from fitting a l-factor random-effectsmodel to the data pairs was used to reflect the error of measurement.Mean differences among the 5 measurements of jet area and right atria1 area were investigated by fitting a repeated-measuresanalysis of variance model, followed by 5 pairwise comparisons of observer 1, session 1 versus session 2; observer 1, session 1 versus session 3; observer 1, session 1 versus observer 2, session 1; observer 2, session 1 versus session 2; and observer 1,
198
JULY 15,
ity of regurgitation can be assessedwith jet area measurementsand jet area referencedto the right atrial area, but there are few data regarding the reproducibility of the measurements.Our purpose was to determine the reproducibility and variability of repeat measurementsof tricuspid regurgitation severity obtained by color flow Doppler echocardiography in randomly selectedpatients. ... Color Doppler echocardiograms from 15 patients (mean age 63 k 14 years) with tricuspid regurgitation were retrospectively reviewed. The echocardiograms were recorded for clinically indicated reasons. Patients were chosen for this study because they were participating in another study to validate hepatic vein Doppler in the quantitation of tricuspid regurgitation. Tricuspid regurgitation was quantitated by measuring the jet area and percentageof the right atrium occupied by the regur-
THE AMERICAN
JOURNAL
OF CARDIOIOGY@
VOL. 76
1995
I
FIGURE 1. Association of iet area (left, n = 15) and rcent iet area p”right, n = 12) measured at 2 sessions by a sin le observer. Das il ed line is the line of identity.
60
20
Jet Area (cm 2 ) session 1
Jet Area/ Rlghl Session Atrial Area 1 (%) 4.
15 10 5 0
0 0
Jet Area (cm 2 ) Session
2
20
40
60
00
Jet Area I Right Atrtal Area (X) Session2
session 3 versus observer 2, session 2. TABLE I Comparisons Between Measurements of Tricuspid Jet Area and Right Atrial Arec The experiment-wise error rate for the Jet Area/ 5 pairwise comparisons was 0.05. Right Right Jet areas were traced in all 15 paJet Area Atrial Area Atrial Area tients, and the right atrial wall could be traced in 12. The intraclass correlation Observer 1 Session 1 6.4 * 6.4 cm2 19.0 f 7.7 cm2 29 zt 21% coefficients we observed indicate that Session 2 (same frame) 6.7 * 6.6 cm2 20.2 in 7.7 cm2 30 * 22% the same observer can produce very lntraclass correlations 0.997 0.985 0.991 Error of measurement 0.3 cm2 1 .O cm2 2% similar area measurements, whether lO* 11% lntraobserver variability 5 f 2% 10*9% tracing the sameframes (p ~0.0001) or [sign preserved)** 7* 13 7+ 12 2+5 choosing and tracing new frames (p Session 3 (choose frame) 6.9 f 6.5 cm2 20.1 * 7.5 cm2 32 zt 22% ~0.0001) (Table I and Figure 1). The Introclass correlation§ 0.981 0.983 0.945 error of measurementfor a single obError of measurement 0.9 cm2 1 .O cm2 5% Introobserver reproducibility 16 i 13% 5 f 4% 18 * 12% servermeasuringthe sameframesfor jet 13 zt 16 14 * 17 2*7 Obse~~2ple=d areais 0.3 cm2, for right atrial area it is 1.0cm2,and for percentjet areait is 2% Session 1 (same frame) 6.4 k 6.2 cm2 21.1 * 8.3 cm2* 28 * 20% (Table I). The error of measurement, Interclass correlationil 0.998 0.991 0.993 Error of measurement when an observer chooses and traces 0.3 cm2 1.2 cm2 2% Interobserver variability 8 it 8% 7 * 5% 8 zt 7% new frames is the same for right atrial (sign preserved) 2* 12 6*5 -3 * 10 area,but it is considerably greaterfor jet Session 2 (choose frame) 6.4 * 6.2 cm2 21.7 * 8.1 cm2t 27 it 20t area(Table I [observer 1, session3; and lntraclass correlation* 0.991 0.984 0.977 observer 2, session 21). The interclass Error of measurement 0.6 cm2 1.1 cm2 3% Interobserver reproducibility 13 f 12 9*9 11 f 13 correlation coefficients indicate that (sign preserved) 1 i 18 9*9 -9* 14 there is a very strong (p
5. Rivera JM, Vandervoort PM, de Prada JAV, Mele D, Karson TH, Morehead A., Morris E, Weyman A, Thomas JD. Which physical factors detexmine tricuspid regurgitation jet area in the clinical setting? Am .I Car&l 1993;72:1305-1309.
BRIEF REPORTS
199