American Society of Echocardiography Algorithm for Degenerative Mitral Regurgitation

Uretsky, Seth; Animashaun, Islamiyat Babs; Sakul, Sakul; Aldaia, Lillian; Marcoff, Leo; Koulogiannis, Konstantinos; Argulian, Edgar; Rosenthal, Mark; Wolff, Steven; Gillam, Linda D.

doi:10.1016/j.jcmg.2021.10.006

Cited by 21 publications

(11 citation statements)

References 15 publications

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“…Gao et al first investigated the ability of the ASE algorithm to rule in severe MR defined by CMR, proven postoperative LV reverse remodeling and improved functional class (176). Recently, Uretsky et al observed in a subgroup of 48 patients who underwent MV intervention and post-operative CMR that severe MR by CMR was associated with LV reverse remodeling (defined as change in LVEDV after intervention), whereas "definitely severe MR" by the ASE algorithm was not (177). However, whether a significant decrease in LVDEV after MV intervention necessary implies that MR would be severe is uncertain.…”

Section: Discrepancies Arising From the Integrated Multiparametric Ap...mentioning

confidence: 99%

Quantification of primary mitral regurgitation by echocardiography: A practical appraisal

Altes

Vermès²,

Lévy³

et al. 2023

Front. Cardiovasc. Med.

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The accurate quantification of primary mitral regurgitation (MR) and its consequences on cardiac remodeling is of paramount importance to determine the best timing for surgery in these patients. The recommended echocardiographic grading of primary MR severity relies on an integrated multiparametric approach. It is expected that the large number of echocardiographic parameters collected would offer the possibility to check the measured values regarding their congruence in order to conclude reliably on MR severity. However, the use of multiple parameters to grade MR can result in potential discrepancies between one or more of them. Importantly, many factors beyond MR severity impact the values obtained for these parameters including technical settings, anatomic and hemodynamic considerations, patient's characteristics and echocardiographer' skills. Hence, clinicians involved in valvular diseases should be well aware of the respective strengths and pitfalls of each of MR grading methods by echocardiography. Recent literature highlighted the need for a reappraisal of the severity of primary MR from a hemodynamic perspective. The estimation of MR regurgitation fraction by indirect quantitative methods, whenever possible, should be central when grading the severity of these patients. The assessment of the MR effective regurgitant orifice area by the proximal flow convergence method should be used in a semi-quantitative manner. Furthermore, it is crucial to acknowledge specific clinical situations in MR at risk of misevaluation when grading severity such as late-systolic MR, bi-leaflet prolapse with multiple jets or extensive leak, wall-constrained eccentric jet or in older patients with complex MR mechanism. Finally, it is debatable whether the 4-grades classification of MR severity would be still relevant nowadays, since the indication for mitral valve (MV) surgery is discussed in clinical practice for patients with 3+ and 4+ primary MR based on symptoms, specific markers of adverse outcome and MV repair probability. Primary MR grading should be seen as a continuum integrating both quantification of MR and its consequences, even for patients with presumed “moderate” MR.

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Section: Discrepancies Arising From the Integrated Multiparametric Ap...mentioning

confidence: 99%

Quantification of primary mitral regurgitation by echocardiography: A practical appraisal

Altes

Vermès²,

Lévy³

et al. 2023

Front. Cardiovasc. Med.

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“…This approach is understandable because of the reported discordance between echocardiography and CMR in terms of grading MR severity [ 77 , 78 , 79 ]. The agreement between echocardiography and CMR for grading severe MR using the integrative approach was only 31%, which is ultimately equivalent to or less than chance [ 80 ]. These results question the ability to a quantitative assessment of cardiac hemodynamics by echocardiography.…”

Section: Implications Derived From the Current Underestimation Of Car...mentioning

confidence: 99%

Valid and Reproducible Quantitative Assessment of Cardiac Volumes by Echocardiography in Patients with Valvular Heart Diseases—Possible or Wishful Thinking?

et al. 2023

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The analysis of left ventricular function is predominantly based on left ventricular volume assessment. Especially in valvular heart diseases, the quantitative assessment of total and effective stroke volumes as well as regurgitant volumes is necessary for a quantitative approach to determine regurgitant volumes and regurgitant fraction. In the literature, there is an ongoing discussion about differences between cardiac volumes estimated by echocardiography and cardiac magnetic resonance tomography. This viewpoint focuses on the feasibility to assess comparable cardiac volumes with both modalities. The former underestimation of cardiac volumes determined by 2D and 3D echocardiography is presumably explained by methodological and technical limitations. Thus, this viewpoint aims to stimulate an urgent and critical rethinking of the echocardiographic assessment of patients with valvular heart diseases, especially valvular regurgitations, because the actual integrative approach might be too error prone to be continued in this form. It should be replaced or supplemented by a definitive quantitative approach. Valid quantitative assessment by echocardiography is feasible once echocardiography and data analysis are performed with methodological and technical considerations in mind. Unfortunately, implementation of this approach cannot generally be considered for real-world conditions.

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“…Echocardiography is the diagnostic method of choice in VHD [ 7 ]. While the integrative approach has been recommended for analysis of valvular regurgitations [ 8 ], its use may lead to incongruent findings [ 9 , 10 ]. Hence, an exclusively quantitative robust method would be desirable.…”

Section: Introductionmentioning

confidence: 99%

“…Severe discordances between echocardiography and cardiac magnetic resonance imaging (MRI) for grading MR severity were recently found [ 9 , 10 , 41 ]. In addition, the debatable data were reported in trials of interventional MR therapy for LVSV tot and regurgitant volume through the MV (RegVol MR ), documenting low flow conditions which are not compatible with live conditions [ 42 – 44 ], reveal the weakness of the echocardiographic integrative approach, if plausibility of hemodynamics is not considered.…”

Section: Introductionmentioning

confidence: 99%

Expert proposal to analyze the combination of aortic and mitral regurgitation in multiple valvular heart disease by comprehensive echocardiography

Hagendorff¹,

Helfen

Brandt

et al. 2023

Clin Res Cardiol

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The assessment of valvular pathologies in multiple valvular heart disease by echocardiography remains challenging. Data on echocardiographic assessment—especially in patients with combined aortic and mitral regurgitation—are rare in the literature. The proposed integrative approach using semi-quantitative parameters to grade the severity of regurgitation often yields inconsistent findings and results in misinterpretation. Therefore, this proposal aims to focus on a practical systematic echocardiographic analysis to understand the pathophysiology and hemodynamics in patients with combined aortic and mitral regurgitation. The quantitative approach of grading the regurgitant severity of each compound might be helpful in elucidating the scenario in combined aortic and mitral regurgitation. To this end, both the individual regurgitant fraction of each valve and the total regurgitant fraction of both valves must be determined. This work also outlines the methodological issues and limitations of the quantitative approach by echocardiography. Finally, we present a proposal that enables verifiable assessment of regurgitant fractions. The overall interpretation of echocardiographic results includes the symptomatology of patients with combined aortic and mitral regurgitation and the individual treatment options with respect to their individual risk. In summary, a reproducible, verifiable, and transparent in-depth echocardiographic investigation might ensure consistent hemodynamic plausibility of the quantitative results in patients with combined aortic and mitral regurgitation. Graphic abstract The quantitative approach to assess LV volumes in combined AR and MR patients: explanation and algorithm of how to determine the relevant target parameters. LVSVeff—effective left ventricular (LV) stroke volume, LVSVforward—forward LV stroke volume through the aortic valve (AV), LVSVtot—total LV stroke volume, RegVolAR—regurgitant volume through the AV, RegVolMR—regurgitant volume through the mitral valve (MV), LVfilling volume = LVMV-Inflow − transmitral LV inflow, LVOT—left ventricular outflow tract, RFAR—regurgitant fraction of aortic regurgitation (AR), RFMR—regurgitant fraction of mitral regurgitation (MR), RVSVeff —effective right ventricular (RV) stroke volume, RVSVforward—forward RV stroke volume through the pulmonary valve, RVSVtot—total RV stroke volume.

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American Society of Echocardiography Algorithm for Degenerative Mitral Regurgitation

Cited by 21 publications

References 15 publications

Quantification of primary mitral regurgitation by echocardiography: A practical appraisal

Quantification of primary mitral regurgitation by echocardiography: A practical appraisal

Valid and Reproducible Quantitative Assessment of Cardiac Volumes by Echocardiography in Patients with Valvular Heart Diseases—Possible or Wishful Thinking?

Expert proposal to analyze the combination of aortic and mitral regurgitation in multiple valvular heart disease by comprehensive echocardiography

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