Strategy for optimal aortic regurgitation quantification by Doppler echocardiography: Agreement among different methods

Clinical

Investigdons

Imaging/Diagnostic

Testing

Strategy for optimal aortic regurgitation quantification by Doppler echocardiography: Agreement among different methods Artur EvangelIsta, MD, PFBC, Iierminio Car& de1 CastNo, MD, Francisco Calve, MD, Gaieti Pe rmanyer-Miralh MD, Caries Brotons, MD, Juan Angel, MD, Teresa Go&ez-&jas, MD, Pilar Tomos, MD, and Jordi Soler-Soler, FACC, FESC Earcelona, Spain

MD,

Background

ben-

Although

efit of combining

Methods jet area,

o ur

apical

with

ongiography;

chine

variability

a strategy

from

values

on considering

Jet width

had

permitted

the best

acceptable

not assessable vs 77%,

in 20%

regurgitant

fraction

respectively). apical

to 30%

this strotegy

pulmonary with

In 59 cases

permitted

concordance Jet width

ever,

were

was

better established,

results

particularly

flow

angiography without

Conclusions

when

with

is the best

obtained when

with

concomitant very

when

high

predictor

aortic (94

in 146

in which and

of 99) from

From Servei de Cardiologia, Hospital General Universikri Voll D ‘Hebron. Submiffed January 7, 1999; accepted November 1 I, 1999. Reprint requests: Arfur Evongelista, MD, Sen~i de Cardiologia, ~ospitol Universitar; Vail d ‘Hebron, Vail d ‘Hebron I 19.129, 08035 Eorcelono, Spain. E-mail: [email protected] Copyright 0 2000 by Mosby, Inc. 0002.8703/2000/$12.00 + 0 4/I/104503 doi: IO. I067/mh;.2000. I04503

methods

pulmonary

agreed

regurgitant

in iet width

P < .002 grade

flow

was

was

in short-axis

and

77%

coincided used

diameter

from

the jet was

pulmonary

methods eccentric

vs 53%,

and

PC .02,

iet width

method.

were (90%

iet area

in both

as a third

and

tested.

oufflow

The other

and

intermatested

fraction

when

P < .02),

vs 44%,

and

prospectively

reproducibility.

vs 65%,

correlated

interobserver

were

short-axis

were

the left ventricular

and

w h en severity

and

Overall,

(92%). quantification

on concordance

Doppler echocardiography is the most common noninvasive technique used to assess severity of aortic regurgitation (AR). Several methods for AR quantification have been described: color-flow mapping,‘-3 deceleration phase measurements by continuous-wave Doppler,4)s and regurgitant fraction (RF) by pulsed-wave Doppler.@ The majority show good correlations with angiographic results. Most echocardiographic laboratories use different Doppler methods in conjunction to quantify AR. However, the agreement among the different Doppler meth-

with

worse

decreased (77%

Heart

its ratio

but with

stenosis

[95%]

best

jet area

(84%

patients

(Am

the

(iet width, slope)

and ranges

the two

Apical

regurgitation

based

eccentric.

value

present

fraction

in aortic

a strategy

the jet wos

was

regurgitant

angiography

intraobserver

angiography

disease

parameters

quantification,

deceleration

and

respectively)

with

valve

Doppler and

defined

(r = 0.91),

0.86,

mitral

concordance,

that

reproducibility.

and

regurgitation

flow,

defined

grade

for aortic

patients), mitral

patients),

angiography

decreased

Concordance

was

were ( 158

severity

with and

(60 and

grade phase

(r = 0.87

of studies.

jet area

from

Agreement

jet area.

correlation

(r = 0.85) quantification

P < .O 1 ), in apical

severity

volidated defined.

phase

pulmonary

as the definitive

d’dI no t rm p r ov e th e correlation flow

each

been

not been

initial

from

In the validation

hove

has

In the

fraction for

studied.

methods

methods

2 phases.

regurgitant

range were

Doppler

different

s t u d y included

jet area,

bosed

Results

d’ffI erent

information

between

J 2000;

139:773-8

by Doppler iet width

and

echocardiography. another

Doppler

Howmethod

1.)

ods and the best combination that might increase accuracy in AR quantification have not been establishedtavl 1 despite their important implications for clinical practice. The aims of this study were to test the accuracy and reproducibility of different Doppler methods and to ascertain whether the combination of information of these methods improves accuracy in AR quantification in a large series of patients.

Methods The study included 2 consecutive phases: in the initial phase, Doppler parameters were correlated with angiographic AR severity, ranges for semiquantitative estimation were defined, and intraobserver, interobserver, and intermachine variability of clifYerent Doppler methods were obtained; in the validation phase, the agreement with angiogmphic grades of these defined value ranges of Doppler parameters was prospectively assessed and the accuracy of a strategy based on taking as the dehnitive

Anvmcon 774

Evangelista

et al

Figure

1

Parosternol mal iet width severe

long-axis

color

at junction

AR. AO,

Aorta;

severity grade that in which the phase 2 coincided was tested.

Doppler

echocardiographic

of left ventricular IA,

left atrium;

2 best

Doppler

outflow

view tract

and

of o patient aortic

annulus

with

AR showing

(arrows).

measurement

Jet width

is 12 mm,

of proxiindicating

LV, left ventricle.

methods

of

Patients Two hundred eighteen consecutive patients with chronic AR were studied by Doppler echocardiography and cardiac catheterization with aortography in an interval of less than 24 hours. Only patients in sinus rhythm previously diagnosed with AR by echocardiography were included. Angiographic study was indicated in clinical practice in all cases. The population of the initial phase consisted of 60 patients (22 men, 38 women; mean age 61 f 13 years; range 21 to 74 years); 17 had concomitant aortic stenosis and 14 had associated mitral valve disease. In the validation phase, 158 patients (72 men, 86 women; mean age 54 f 14 years; range 18 to 75 years) were included; 40 had concomitant aortic stenosis and 46 had associated mitral valve disease. Etiology estimated by echocardiography was bicuspid valve in 25 cases (lbx), aortic valve prolapse in 8 (5%), degenerative aortic valve in 25 (I6%), and annular or root dilatation in 7 (4%). Rheumatic aortic valve was assumed in 39 cases (25%) with mitral stenosis. and in the remaining 54 cases (34%) the cause was unknown.

Echocardiographic

Heart Journal May 2000

studies

All studies were performed with commercially available systems (Viigmed CFM 750 or Hewlett-Packard Sonos 1000) with 2.5~MHz transducers. In a subsequent intermachine variabilit) study, a Vmgmed GE System Five machine was also used. The setup of the instrumentation was standardized as follows: (1) gain setting was optimized for image quality with the maximal color gain level that would not introduce a signal outside flow areas; (2) the narrowest sector angle that

allowed visualization of the jet area assessed was used to maximize color-flow imaging frame rate (8 to 15 Hz); (3) the variance mode was turned on; and (4) parameters of low velocity filter 0.25 m/s and aliasing velocities of 0.44 to 0.70 m/s were set.

Color

Doppler

Three parameters were measured. (1) Regurgitant jet width was defined as the smallest diameter of the jet at the junction of the left ventricular outflow tract and the aortic annulus in the parastemal long axis view (Figure 1). Extreme care was taken with eccentric jets to take the measurement perpendicular to the jet direction. The anteroposterior diameter of the left ventricular outflow tracf (LVOD) was measured in the standard parastemal long-axis view in end diastole and the jet width/LVOD ratio calculated. (2) Jet short-axis area at just subvalvular level was planimetered from the parasternal short-axis view. The same frame at which jet area was obtained was used to measure left ventricular outflow area (LVOA) in end diastole and the short-axis jet area/LVOA ratio calculated. (3) The apical j-chamber (Figure 2) or apical long-axis views were used to measure the apical jet area. Left ventricle area (LVA) was measured in end diastole from the apical 4-chamber view, and the apical jet area/LVA ratio was calculated. The imaging plane was angled during the examination fo show the maximal regurgitant jet diameter or area. When mitral valve disease was present, the apical long-axis view was used preferably to separate the AR jet from forward mitral flow jet. Mean values of measurements in 3 cardiac cycles were considered. Jet direction was categorized as either eccentric. if the main axis of the jet was directed toward the anterior mitral leaflet or the interventricular septum, or central, if the main axis of the jet was directed toward the apex.

Amerlcon Heart Journal Volume 139, Number 5

Figure

Color

Evongelisto

2

Doppler

Abbreviations

Table

1. Mean

values

assessment

of severity

as in Figure

1.

and

defined

value

of AR from

ranges

of Doppler

apical

S-chamber

parameters

view.

for each

Jet area

angiographic

Angiographic I 8 2.9 + <4 2.2 f <3 0.2 f co.3 14.8 f <20 14.5 f <20 176f41 <200

n

JW (mm) Range

Apical JA (cm21 Range Short-oxisJA (cm2) Range RFP(%) Ronge RFM(%) Range Slope (cm/s2) Range

II

0.9 0.6 0.1 8.1 9.8

pulmonary flow,

RFM, RF from mitral flow.

RF was calculated as regurgitant flow outflow. Regurgitant flow was determined between aortic flow and a reference flow: mitral flow. IMethods for deriving stroke outflow, pulmonary outflow (Figure 3). and been previously described.‘,lz

divided by aortic as the difference pulmonary flow or volumes of aortic mitral inflow have

JW, Jet width; JA. jet oreo; RFP, RF from

Pulsed-wave

Continuous-wave

et cd 775

Doppler

Doppler

Continuous-wave Doppler recordings were obtained from the cardiac apex from either the apical 5-chamber or S&amber view. Color Doppler was used to align the Doppler beam parallel to flow. Diastolic deceleration slope was determined

17 5.3 k 1.4 4-7 4.2 + 0.9 3-5 0.5 + 0.2 0.3-0.6 32.0 f 9.2 20-40 28.8 xi 7.9 20-35 239f48 200.275

is 8 cm2,

severity

indicating

grade

severe

assessed

AR.

in the initial

severity III

IV

19 8.2 k 1.6 7-10 5.6+ 1.1 5-7 0.8 f 0.3 0.6-l 48.3 k 10.1 40-60 45.9f 11.1 35-55 283+50 275.350

16 12.5 f 2.6 >lO 10.2 f 2.9 a7 1.5 + 0.6 >l 68.1 k9.7 a60 63.4 + 11.2 >55 387+46 >350

as the slope of a straight line drawn along the peak throughout diastole, as previously described.”

Intraobserver, variabilities

phase

interobserver,

velocities

and intermachine

Intraobserver and interobserver variability were assessed in the first 30 consecutive patients of the initial phase. For assessment of intermachine variability, the remaining 30 patients of this phase were included. The same observer performed 2 studies with an interval of 24 hours by using different echocardiographic apparatuses, the Hewlett-Packard and Vingmed CFM 750. Because the study was begun in 1992 when current machines were not available, we decided to repeat an inter-

776

Evongeltsta

et al

Figure

3

Example flow.

of quantification

Top,

velocity tricular

Aortic

of RF in a patient

annular

by pulsed-wave outflow.

lar outflow volume

207

artery.

Other

Top,

tract ml;

Doppler Pulmonary

velocity right

diameter

(26

abbreviations

outflow

as in Figure

AR. integral

diameter

(20

Doppler stroke

Measurement long-axis 39

mm)

cm).

41

of stroke view.

Right, integral

ml.

RF, 80%.

volume

Bottom,

of stroke

short-axis 13 cm).

of left ventricular

Left ventricular

Measurement

in parasternal

(time-velocity volume

view.

volume

Bottom,

Left ventricular

RV, Right

outflow

ventricle,

outtract

of right Right

outflow

ven-

ventricustroke

PU, pulmonary

1.

machine variability study with 30 stable additional patients b) using old and new generation machines. a System Five GE and a HP Sonos 1000, adjusting the setting of the newer machine to characteristics near those previously mentioned.

Cardiac

left,

in parasternal

(time-velocity annular

by pulsed-wave ventricular

with

mm)

catheterization

Angiographic AR was diagnosed from the aortic root angiograms performed in the 60” left anterior oblique view. AR severity (1 to 4+) was graded according to standard critcria’3 by one observer unaware of the results of the echocardiographic studies.

best discrimination between severity grades. Reproducibilit) of all measurements was analyzed by percent agreement according to Waded severity and K index. Good reproducibility was considered when the K index was greater than 0.75, whereas acceptable reproducibility was considered when the K statistic was behveen 0.40 and 0.75. In the validation phase the agreement observed behveell Doppler and angiographic srverit~ grades was assessed by the K index and x2 test. Definitive AR severity by Doppler study was accepted as established when agreement between 2 Doppler methods with the best correlation with angiography in the preliminary phase was obtained. Student t test was applied when appropriate. All the statistical tests were considered significant at a level of P < .05.

Statistics In the initial phase of the study. Doppler parameter measurements and degree of angiogrxphic severity were correlated b! linear regression analysis and Pearson correlation test. To test for the equality of correlation coefficients, the Fisher z tmnsformation was used.‘.’ The mean + SD of Doppler parameters was determined for each angiographic severity grade. Range values for all Doppler pammeters were arbitrarily defined on the basis of the results looting for the whole numbers that permitted the

Results Initial phase: Correlation between parameters and angiography Reproducibility study. found between all I>oppler graphic AR grades (Figure obtained

with

jet

width

Doppler

Signifkant correlations parameters and angio4). The best correlation (I’ = 0.91,

P < .OOl) and

were was the

American Heart journal Volume 139, Number 5

Table

II.

Evangelista

lntraobserver,

interobserver,

and

JW Apical JA Short-axis JA RFP RFM Slope JW/LVOD Apical JA/LVA Short-axis JA/LVOA

intermachine

variability

of Doppler

parameters:

Agreement

between

severity

grades

lntraobrerver

Interobserver

%

K index

%

IC index

%

K index

%

90 89 75 82 69 77 83 75 67

0.86 0.85 0.66 0.76 0.58 0.68 0.77 0.66 0.55

83 82 67 75 60 69 80 66 68

0.77 0.75 0.54 0.66 0.45 0.58 0.73 0.54 0.56

93 77 71 77 73 73 82 68 62

0.91 0.69 0.61 0.67 0.63 0.64 0.76 0.56 0.50

87 78 70 82 62 74 83 78 54

Intermachine

(I)

et al 777

lntermachine

(II) K index 0.8 1 0.69 0.59 0.76 0.49 0.64 0.77 0.69 0.38

Abbreviations OS in Table I. ln intermochine I, Vingmed CFM 750 and HP Sonos 1000 were used; in intermachine II, Vingmed GE System Five and HP Sonor 1000 were used.

Figure

Figure

4

5

r 1

100

.91

I” 1

33

I

0.6

.74

0.6

0.4

0.2

-

a 58

1:

JW

(%)

Correlation

between

and angiogrophic cases area; 90,

JW,

RFP, RF from

lar outflow lar outflow

tract oreo tract

values

Doppler AJA,

area

flow;

Jet width

diometer ratio;

of Doppler

ratio;

SJA (%)

of phase

AJA

RFM, (%)

at base

SJA,

short-axis

RF from = apical

”

48 SLO

1. Number

mitral

= iet width/left

(%)

= Short-oxis

80

AJA

JW Percentage methods

parameters

is shown

iet area;

80

I

48 RFM

method

apical

pulmonary slope.

52 RFP

in 60 patients

by each Jet width;

deceleration

ventricle

absolute

severity

assessoble

columns.

49 SJA (%)

54 AJA (%)

84%

of

ment

of

Doppler

iet

(158

flow;

Figure

of cases had

was

in which

net agreement

obtained ongiography

patients)

SJA

RFP the severity with

excluding

grade

nonassessoble phase.

cases

SLO of Doppler

angiography.

discordance

of validation

RFM

Net cases

from

Abbreviations

overall

agreeand series as in

4.

ventricu-

iet area/left

iet area/left

ventricu-

ratio.

worst with the deceleration slope (r = .74, P < .Ol>. Correlations for the ratios jet width/LVOD, short-axis jet area/LVOA, and apical jet area/LVA were worse than when jet measurements were considered alone. Mean values of Doppler parameters and defined value ranges for each angiographic severity grade are shown in Table I. Variability of the AR severity grades quantified by different Doppler parameters is shown in Table II.

Validation phase Regurgitant flow features and assessable studies. Of the 158 patients, the jet was central in 90 cases and eccentric in 68. Most of the diagnosed cases of bicuspid and aortic valve prolapse had eccentric jets (26 [79X] of 33). Jet width was not assessable in 3 cases (2%) one of which had a markedly eccentric jet; apical jet area could not be measured in 8 cases (5%) with concomitant mitral stenosis, and short-axis jet area was not correctly defined in 33 cases (20%). RF from pulmonary flow could not be assessed in 14 cases (9%) because the lateral wall of the pulmonary annulus was not cor-

Amwcan

778

Evongelisto

et al

May 2000

Table Ill. AR severity

grades

quantified

by Doppkr

methods

and angiography

JW +ed$Y

I II III

1

2

20 2

3 42 5

IV Angiographic

Global ” % Agreement K Aortic stenosis n % Agreement K Mitral valve disease ” % Agreement K Central jet n % Agreement K Eccentric jet ” % Agreement K Abbreviations

Apical 3

4

30 12

1 40

1

2

23 13 1

27 6

in validation

between

severity

grades

estimated

by Doppler

phase Short-axis

JA 3

4

1

3 22 3

reverih/ grader were 24 grade I, 45 grade II, 36 grade III, and 53 grade IV. Abbreviations

Table IV. Agreement

Heart Journal

parameters

JA

1

2

3

14

3 6

2 17 21 12

5 46

1

4

10

5 35

(IS in Table I

and

angiography

in validation

phase

JW

Apical JA

Short-axis JA

RFP

RFM

Slope

155 85% 0.80

150 79% 0.71

126 69% 0.58

144 75% 0.66

107 71% 0.60

118 52% 0.34

33 88% 0.81

34 77% 0.66

27 AA% 0.23

28 53% 0.31

33 62% 0.44

24 54% 0.3 1

A6 90% 0.90

40 65% 0.48

33 73% 0.61

A6 84% 0.78

-

31 48% 0.29

88 90% 0.89

85 78% 0.70

74 69% 0.59

82 76% 0.67

57 73% 0.63

72 57% 0.37

67 77% 0.67

65 80% 0.74

52 69% 0.54

62 74% 0.63

50 68% 0.59

46 46% 0.32

OS in Table I.

rectly identified. Methods with a greater number of nonassessable studies were RF from mitral flow in 5 1 cases (32X), 46 of which had associated mitral valve disease, and the slope in 40 cases (25%). Doppler and angiographic agreement: Influence of specific variables. Agreement in AR severity grades

between Doppler methods and angiography is detailed in Table III. Methods showing greater concordance were jet width (SS%), apical jet area (79%), and RF from pulmonary flow (75%). Two-grade disparity with aortography was observed in no case with jet width, in 1 with apical jet area, in 2 with RF from pulmonary flow and short-axis jet area, in 4 with RF from mitral flow, and in 9 with deceleration slope. Eccentric jet direction decreased agreement between jet width and angiography (90% vs 77%, P c .Ol); most disparities (15 [94%] of 16) were caused by jet width underestimation (Table IV). Associated mitral valve disease decreased apical jet area agreement from 84% to 65% (P < .02), and concomitant aortic stenosis

decreased RF from pulmonary flow agreement from 77% to 53% (P < .02) and short-axis jet area from 77% to 44% (P < ,002). Strategy in methods election. The net percentage of cases in which AR severity grades of Doppler methods and angiography was the same as is shown in Figure 5. Concordance in severity grades between the different Doppler methods ranged from 44% to 67%. By applying the defmed strategy, when jet width and apical jet area coincided in severity, agreement with angiography was very high (94 [95%] of 99). In the remaining 59 cases (37%) in which these methods failed to agree, the severity of RF from pulmonary flow, the third best method in the initial phase, was considered. This method coincided with jet width in 30 cases and with apical jet area in 19. Short-axis jet area had to be considered in 10 cases because no agreement was reached among previous methods. Overall, this strategy permitted concordance with aortography in 146 cases (92%), 85 (94%) with central jet, and 61 (90%) with eccentric jet (Figure 6).

Ame,,con Heart Journoi Volume I39 Number 5

Evangelista

RFP

RFM

2

1 15

6

1

32 6

3

4

5 21 11

1

Figure

6 40

et al 779

Slope

1

2

3

7 2 1

2 19 8 3

7 12 4

4

1

2

6 10

3 18 12

4 38

10

3

4

8 13 10

3 25

6

n= 158

n=30

n=19

” =lO

1 n=27

n=94

n=8

n=17

n=146

Concordance with w+praphy

(80%)

(95%)

STEP I

Algorithm

used

cal jet area

to quantify

coincided,

between

2 methods,

and

apical

with

agreement angiography

RF from

iet area

among was

AR severity,

agreement

with

pulmonary

in 19. Agreement

3 methods,

short-axis

STEP I I

taking

into

account

angiography flow

was

was

with (et areo

used was

( STEP 111

best 95%

(Step

angiography used

(92%)

parameters (94

of 99)

in phase (Step

II). This method of these (Step

1. When

I). When

coincided

patients

Ill). With

Global

was

90%.

this strategy

(et width

there with

was

(et width

In 10 patients global

and

api-

disagreement

agreement

in 30 cases without with

92%.

This strategy was the most useful in the different circumstances studied, except when mitral valve disease was present, in which case if jet width and RF from pulmonary flow had been considered the first methods and short-axis jet area the third, the need to use the third method would drop from 78% to 50% of these cases, although final agreement with aortography would have been only slightly better, increasing from 89% to 91%.

Discussion The results of this study show the measurement of jet width to be the best Doppler method in chronic AR

quantifkation. Jet width/LVOD ratio does not improve accuracy of estimation and decreases reproducibility. Apical jet area and RF from pulmonary flow permit acceptable quantification, but with less reproducibility. Short-axis jet area, RF from mitral flow, and slope are not assessable in 20% to 30% of cases. Eccentric jet decreases jet width and aortogmphy agreement, the presence of mitral valve disease affects apical jet area, and concomitant aortic stenosis decreases accuracy of short-axis jet area and RF from pulmonary flow. Taking into account these limitations, the strategy based on the concordance of the 2 best Doppler methods permits better agreement with angiography than any of the methods considered individually, particularly when the jet is eccentric.

Amerlcon

780

Evangelista

et al

Intraobserver, interobserver, and intermachine variability Some studies have assessed the reproducibility of Doppler parameters in AR quantification,1~4~8~10~15-19 but most of them considered only measurement reproducibility on the videotape, thus not including variability ln the obtained images. In this study, absolute value of jet width was the parameter with the best reproducibility. However, variability increased when the jet width/LVOD ratio was considered. Short-axis jet area has limitations15 because small changes in the level of left ventricular ouflow tract being studied imply significant differences in jet area. Mitral and pulmonary annulus measurement limits RF reproducibility.‘6.‘7 Although apical jet area has been considered to be of suboptimal reproducibillty,‘s,l9 in this study apical jet area had acceptable intraobserver and interobserver variability but was the method most influenced by intermachine variability. The subsequent variability study performed with 2 different generation machines yielded not significantly different results when similar settings were attempted in both. Doppler methods vs angiographic severity The jet width/LVOD ratio is widely accepted as one of the most accurate methods in AR quantification. L lo, l 1 Nevertheless, the benefit of this ratio with respect to the absolute value of jet width has recently been questioned. lo In our results jet width was superior to jet width/L.VOD ratio, indicating that this single measurement is sufficient and more practical. Our study is the first to describe the absolute values of this parameter ln the semiquantitative estimation of AR. The use of apical jet area has been questioned in clinical practice because size of jet color depends on the regurgitant flow volume and pressure gradient,20 compliance of the receiving chamber, and different algorithms of echocardiographic machines.21,2z However, some of these variables are foreseeable and have little influence on chronic stable AR. RF from pulmonary flow permits better results when the lateral wall of the pulmonary annulus is well defined6; this was not possible in fewer than 10% of patients.23 Short-axis jet area, RF from mitral flow and deceleration slope by continuous-wave Doppler have important limitations: substantial overlap among severity grades was observed,5~10~11 and acceptable image quality can only be obtained in 60% to 70% of patients. Influence of some variables on accuracy of Doppler methods The influence of jet eccentricity on jet width methods has rarely been considered. In our series, as in others,” eccentric jet direction signikantly decreased jet width/anglogmphy agreement (90% vs 78%), in most cases because of underestimation. Cohen et al24 found

Heart Journal May 2000

that most patients with bicuspid and aortic valve prolapse in surgical findings had an eccentric AR jet. In these cases the regurgitant orifice is often asymetric and jet width could underestimate AR.z5 Accuracy of apical jet area methods decreases when mitral valve dis ease is present, particularly when AR jet is directed toward the mitral valve.1~10 The acceptable results of apical jet area in this study could be related to the use of nonstandard planes from the apical long-axis view for optimum jet area definition. Doppler information integration In clinical practice different Doppler methods are used for AR quantification; because the accuracy of these methods is influenced by different variables and interclass overlap, at least 2 different methods yielding concordant results should be obtained before the severity of regurgitation is established. Recently, some studies26J7 proposed an integrated approach to AR quantification, taking into account the best methods in a sequential way. However, these algorithms have not been validated.26 and some of the Doppler parameters used may be modified by the same variables in different sequential steps.27 In view of our comprehensive results, we used jet width and apical jet area because they are feasible methods with good correlations with angiographic severity. In 37% of cases in which there was no concordance between these 2 methods, RF from pulmonary flow, and later short-axis jet area, were used. This strategy improved results in the different circumstances studied, except when mitral valve disease was present, in which case the use of RF from pulmonary flow and short-axis jet area as a second and third method, respectively, proved to have advantages. Study limitations This study has several limitations. Aortic root angiography for the grading of aortic insufficiency, even when done carefully by experienced angiographers, is not an ideal reference standard. Nevertheless, it is the usual form of quantifying AR in clinical practice. Although one of the aims of the study was to assess intermachine variability of Doppler methods, the results obtained cannot be generalized to other echocardiographic machines. Cutoff values used for semiquantitative estimation are influenced by the methods and color Doppler instruments used and should thus be verified by each group. Finally, these results cannot be extrapolated when acute AR or atria1 fibrillation are present. Estimation of AR severity by the assessment of the flows of descending thoracic aorta or abdominal aorta was not considered in this study. This technique is limited because it can be measured in only 60% to 70% of patients and is not appropriate for semiquantitative estimation in 4 grades of severity.3Js

.A,,,er~can Heor~Journal Volume 139, Number 5

Evangelista

Conclusions Jet width at its origin is the best predictor of AR severity, but the eccentric jet direction may cause underestimation. The jet width/LVOD ratio does not improve accuracy and decreases reproducibility. Jet area in the apical view is the second most useful method but has low intermachine reproducibility and is limited when mitral valve disease is present. When jet width and jet area in apical view coincide in severity, concordance with angiography is excellent. If disparity exists, RF or short-axis jet area should be considered. This strategy may permit better results in AR quantification than any Doppler method alone.

graphic

determination

validation

1984;70:425-3 13.

pretations

ity of color

Doppler

volume

regurgitant

ciency

by Doppler

color

et al. Evaluation

flow mapping.

J Am Coil Cardiol

19.

9:952-9. 2. Baumgartner,

Kratzer

regurgitation rophy.

oortic

coded

Doppler

by different

Doppler

with ultrafast

AJ, Ferraro insufficiency

tomography.

RP, Kern MJ, et al. Quontitotive

1986;8:

wave

Doppler

ment of the hemodynamic

consequences

means

evaluation

of

Doppler

of continuous-wove

et 01. Quantitative of oortic

recordings.

A, tto H, tnoue

fraction

of oortic

R, Sterling

fraction

1985;72:523-9. WA,

mitral or aortic

echocardiography.

8. Enriquez-Sarano assessment

regurgitant Circulation 11, Zoghbi

in isolated

dimensional

M, Bailey

of volvular

by

J Am Coil Cordial

23.

with oortic 10.

Dolon

MS, Costello by Doppler

HeortJ

Circulation

1986;7:

UM,

method

I, Gost D, et 01. Validity

J 1994;15:

12. Lewis JF, Kuo LC, Nelson

in the assessment

JG, et 01. Pulsed Doppler

Cohen

et al. Calibration

quantitative

of

10:33440.

hemodynamic

of color

conditions

grading

system

in for

1987;75:837-46.

SM. Do Doppler

color

flow algorithms

NC, et al. tntramachine

1994;89:2

El, Come

orifice

GI, Duffy

for 1990;

PC, et 01. Progressive

in patients 1998;

with chronic

images

of

enlargement

aortic

of

regurgitation.

J

1 1:259-65.

Cl, Klein Al, et al. Color

regurgitation

correlation.

with surgical

and interma-

Doppler

14 l-9.

determination

Doppler

and twadimen-

of the mechanism

of aortic

J Am Sot Echocardiogr

1996;

5. Al, Eichharn

color

Padial

LR, Oliver

26.

color

sionol echocardiogrophic

assessment

EJ, Brickner

ME, et al. Aortic

in vitro determinant flow mopping.

M, et al. Doppler of aortic

valve

morphology:

regurgitant

J Am Coil Cardiol

A, Vivaldi

of progression

of proximal

iet width by

1990;16:405-12. echocardiographic

regurgitation.

Am J Cardiol

1997;80:306-14.

regurgi-

27.

Zarauzo

J, Ares

approach

Am 28.

Tribouilloy just beneath diogrophy:

echocordio

ond echc+

A, Nondo

SC, Orav

Doppler

regurgita-

1227-34.

in

evaluotian

sense? J Am Sot Echocordiogr

Reimald

1-8.

of continuous-wave of oortic

voriability

flow make

M, Gonzirlez

Vilcher

to the quantification

of aortic

echocardiography.

Doppler

with and

for mitral and aoriic

Doppler

NC,

extreme

Circulation

jets. Circulation

25. Taylor

104 l-5.

opprooch.

stimulation

1 1579-84.

colour

AP, Nanda

pulsotile

an important

for determin-

of aortic

o procticol

pressor

E, et al. Interobserver

in transesophageol

Doppler

in patients

1994;24:

R, Vrain JA, et 01. Quontitotion

Kruck

and colour

tion. Eur Heart

variability

9:508-l

two-

1273-8.

1993;87:84

echocardiography

J Am Coil Cordial

24.

1995;129:1014-20.

1 1. Wilkenshoff Doppler

Doppler

JB, et 01. Quantitative

et al. A simplified

echocardiography:

Doppler

of regurgitant

by pulsed

J Am Coil Cordial

by Doppler

regurgitation.

tation

regurgitation

regurgitation.

fraction

by twodimensional

flows

in patients

Eur Heart J 1989;

during

Am Sac Echocardiogr

to noninvasive

et al. Determination

KR, Sewart

9. Xie GY, Berk MR, Smith MD, ing regurgitant

Fan PH, Anayiotos chine

assess

regurgitation

M, et 01. A new approach

simulation.

et 01. Observer

1988;

G, Moro

Lobodzinski

disturbed

cold

flow jet areas

for o reliable

incompetence.

the regurgitant

echocardiography. 7. Rokey

o foundation

JM,

of

of valvular

3:310-5.

echocardiography.

1987;10:135-41.

evaluation

flow mapping

mapping

22.

R, Smith MD,

6. Kitobotake

DF, Yoganathan

Doppler

aortic

Am

and computer

MG,

color

J Am Coil Cordial V, D’Angelo

Switzer

vitro:

134 l-7.

PA, Hondshoe

of Doppler

regurgitation.

tech-

evaluations

1990;3:285-93.

PA, Spain

and mitral

2 1. Gardin

by continuous

J Am Coil Cordial 5. Groyburn

J Am Sot Echo

aortic

1992;124:995-1001.

4. Labovitz

exercise,

echocordiog-

echocordiographic

computed

during

of two-dimensional

of

J Am

R. Left and right ventricular

variability

JA, et al. Semiquantitation

regurgitotion.

serial measurements

angio

20.

GD, Rumberger

and comparison

HeartJ

cross-sectional

2.

lA, et al. Reproducibil-

of aortic

evaluation

of aortic

G,et 01. Quontitation

J 1998;9:380-7.

RA, Vonk

regurgitation

niques

oortic

by colour

Eur Heart

3. Nishimura

G, Helmreich

and other p. 106-l

A, et al. Errors in measurements

M, Omoto

Groyburn

Dall’Aglio

analysis

Press; 1978.

and echo-Doppler

Clinical

and inter-

1 1:355-60.

regurgitation

regurgitation.

1987;

G, Amico

echocardiography:

the quantitotion

of oar-tic insuffi-

10:899-903.

for invasive

vasodilation.

NC,

quantification

M, Matsumura

aortic

regression

flaw

cardioangiog-

1964;14:437-47.

Duxbury

1997;

fractions.

by Doppler

clinical

Circulation

indications

EW, von Herwerden

S, D’Ambrosio

stroke

18. Smith MD, F, Nonda

Boston:

TP, Steyerberg

17. Wong

References

Lt. Applied

methods.

Sot Echocardiogr

technique,

Am J Cardiol

DG, Kupper

multivariable 15. Willems

output:

window.

K, et al. Left retrograde disease:

cases.

Eur Heart J 1990;

We thank Irene Moral for statistical collaboration and Christine 0 ‘Hara for help with the English version of the paper.

1, Perry GJ, Helmcke

cardiac

in 700

Kleinbourn

and cardiac

1.

in acquired

16. Iliceto

volume

using the apical

Sellers RD, Levy MJ, Amplatz raphy

14.

of stroke

of two new methods

et 01 781

Heart

Am Heart J 1998;

C, Avin6e the aortic

by Doppler

136: 1030-4

1.

P, Shen WF, et al. End diastolic isthmus

a new predictor

J 199 1;65:37-40.

F, et al. An integrated regurgitation

assessed

of the aortic

by pulsed regurgitant

flow velocity

Doppler fraction.

echocarBr