Comparative Assessment of Mitral Regurgitation Severity by Transthoracic Echocardiography and Cardiac Magnetic Resonance Using an Integrative and Quantitative Approach

Published:November 06, 2015DOI:
      Although transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) are validated in quantitation of mitral regurgitation (MR), discrepancies may occur. This study assesses the agreement between TTE and CMR in MR and evaluates characteristics and clinical outcome of patients with discrepancy. From our institutional database, 70 subjects with MR underwent both TTE and CMR within 30 days (median 3 days). MR was evaluated semiquantitatively (n = 70) using a 4-grade scale and quantitatively (n = 60) with calculation of regurgitant volume (RVol) and regurgitant fraction (RF). Of the 70 subjects, qualitative assessment by TTE yielded 30 subjects with mild MR, 17 moderate, and 23 moderately severe or severe MR. Exact concordance in MR grade was seen in 50% and increased to 91% when considering concordance within one grade of severity (κ = 0.44). A modest correlation was observed for RVol and RF between both methods (r = 0.59 and 0.54, respectively, p <0.0001). Ten patients had a significant discrepancy in quantitative MR (difference in RF >20%); the frequency of secondary MR was higher (100% vs 46%; p = 0.003) in patients with discrepancy. Although interobserver variability in RF was higher with TTE compared with CMR (−5.5 ± 15% vs 0.1 ± 7.3%), patients with discrepancy were equally distributed by severity and clinical outcome without an overestimation by either method. In conclusion, there is a modest agreement between TTE and CMR in assessing MR severity. In patients with discrepancy, there is a higher prevalence of functional MR, without a consistent overestimation of MR severity by either method.
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        • Nishimura R.A.
        • Otto C.M.
        • Bonow R.O.
        • Carabello B.A.
        • Erwin 3rd, J.P.
        • Guyton R.A.
        • O'Gara P.T.
        • Ruiz C.E.
        • Skubas N.J.
        • Sorajja P.
        • Sundt 3rd, T.M.
        • Thomas J.D.
        • American College of Cardiology/American Heart Association Task Force on Practice G
        2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2014; 63: 2438-2488
        • Enriquez-Sarano M.
        • Avierinos J.F.
        • Messika-Zeitoun D.
        • Detaint D.
        • Capps M.
        • Nkomo V.
        • Scott C.
        • Schaff H.V.
        • Tajik A.J.
        Quantitative determinants of the outcome of asymptomatic mitral regurgitation.
        N Engl J Med. 2005; 352: 875-883
        • Zoghbi W.A.
        • Enriquez-Sarano M.
        • Foster E.
        • Grayburn P.A.
        • Kraft C.D.
        • Levine R.A.
        • Nihoyannopoulos P.
        • Otto C.M.
        • Quinones M.A.
        • Rakowski H.
        • Stewart W.J.
        • Waggoner A.
        • Weissman N.J.
        • American Society of Echocardiography
        Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography.
        J Am Soc Echocardiogr. 2003; 16: 777-802
        • Rokey R.
        • Sterling L.L.
        • Zoghbi W.A.
        • Sartori M.P.
        • Limacher M.C.
        • Kuo L.C.
        • Quinones M.A.
        Determination of regurgitant fraction in isolated mitral or aortic regurgitation by pulsed Doppler two-dimensional echocardiography.
        J Am Coll Cardiol. 1986; 7: 1273-1278
        • Thavendiranathan P.
        • Phelan D.
        • Thomas J.D.
        • Flamm S.D.
        • Marwick T.H.
        Quantitative assessment of mitral regurgitation: validation of new methods.
        J Am Coll Cardiol. 2012; 60: 1470-1483
        • Cranney G.B.
        • Lotan C.S.
        • Dean L.
        • Baxley W.
        • Bouchard A.
        • Pohost G.M.
        Left ventricular volume measurement using cardiac axis nuclear magnetic resonance imaging. Validation by calibrated ventricular angiography.
        Circulation. 1990; 82: 154-163
        • Myerson S.G.
        Heart valve disease: investigation by cardiovascular magnetic resonance.
        J Cardiovasc Magn Reson. 2012; 14: 7
        • Kon M.W.
        • Myerson S.G.
        • Moat N.E.
        • Pennell D.J.
        Quantification of regurgitant fraction in mitral regurgitation by cardiovascular magnetic resonance: comparison of techniques.
        J Heart Valve Dis. 2004; 13: 600-607
        • Hendel R.C.
        • Patel M.R.
        • Kramer C.M.
        • Poon M.
        • Hendel R.C.
        • Carr J.C.
        • Gerstad N.A.
        • Gillam L.D.
        • Hodgson J.M.
        • Kim R.J.
        • Kramer C.M.
        • Lesser J.R.
        • Martin E.T.
        • Messer J.V.
        • Redberg R.F.
        • Rubin G.D.
        • Rumsfeld J.S.
        • Taylor A.J.
        • Weigold W.G.
        • Woodard P.K.
        • Brindis R.G.
        • Hendel R.C.
        • Douglas P.S.
        • Peterson E.D.
        • Wolk M.J.
        • Allen J.M.
        • Patel M.R.
        • American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group; American College of Radiology; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance; American Society of Nuclear Cardiology; North American Society for Cardiac Imaging; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology
        ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology.
        J Am Coll Cardiol. 2006; 48: 1475-1497
        • Schulz-Menger J.
        • Bluemke D.A.
        • Bremerich J.
        • Flamm S.D.
        • Fogel M.A.
        • Friedrich M.G.
        • Kim R.J.
        • von Knobelsdorff-Brenkenhoff F.
        • Kramer C.M.
        • Pennell D.J.
        • Plein S.
        • Nagel E.
        Standardized image interpretation and post processing in cardiovascular magnetic resonance: Society for Cardiovascular Magnetic Resonance (SCMR) board of trustees task force on standardized post processing.
        J Cardiovasc Magn Reson. 2013; 15: 35
        • Bland J.M.
        • Altman D.G.
        Statistical methods for assessing agreement between two methods of clinical measurement.
        Lancet. 1986; 1: 307-310
        • Suzuki J.
        • Caputo G.R.
        • Kondo C.
        • Higgins C.B.
        Cine MR imaging of valvular heart disease: display and imaging parameters affect the size of the signal void caused by valvular regurgitation.
        AJR Am J Roentgenol. 1990; 155: 723-727
        • Levine R.A.
        • Triulzi M.O.
        • Harrigan P.
        • Weyman A.E.
        The relationship of mitral annular shape to the diagnosis of mitral valve prolapse.
        Circulation. 1987; 75: 756-767
        • Piazza N.
        • de Jaegere P.
        • Schultz C.
        • Becker A.E.
        • Serruys P.W.
        • Anderson R.H.
        Anatomy of the aortic valvar complex and its implications for transcatheter implantation of the aortic valve.
        Circ Cardiovasc Interv. 2008; 1: 74-81
        • Quinones M.A.
        • Otto C.M.
        • Stoddard M.
        • Waggoner A.
        • Zoghbi W.A.
        • Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography
        Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography.
        J Am Soc Echocardiogr. 2002; 15: 167-184
        • Cawley P.J.
        • Maki J.H.
        • Otto C.M.
        Cardiovascular magnetic resonance imaging for valvular heart disease: technique and validation.
        Circulation. 2009; 119: 468-478
        • Grayburn P.A.
        • Carabello B.
        • Hung J.
        • Gillam L.D.
        • Liang D.
        • Mack M.J.
        • McCarthy P.M.
        • Miller D.C.
        • Trento A.
        • Siegel R.J.
        Defining “severe” secondary mitral regurgitation: emphasizing an integrated approach.
        J Am Coll Cardiol. 2014; 64: 2792-2801
        • Gelfand E.V.
        • Hughes S.
        • Hauser T.H.
        • Yeon S.B.
        • Goepfert L.
        • Kissinger K.V.
        • Rofsky N.M.
        • Manning W.J.
        Severity of mitral and aortic regurgitation as assessed by cardiovascular magnetic resonance: optimizing correlation with Doppler echocardiography.
        J Cardiovasc Magn Reson. 2006; 8: 503-507
        • Cawley P.J.
        • Hamilton-Craig C.
        • Owens D.S.
        • Krieger E.V.
        • Strugnell W.E.
        • Mitsumori L.
        • D'Jang C.L.
        • Schwaegler R.G.
        • Nguyen K.Q.
        • Nguyen B.
        • Maki J.H.
        • Otto C.M.
        Prospective comparison of valve regurgitation quantitation by cardiac magnetic resonance imaging and transthoracic echocardiography.
        Circ Cardiovasc Imaging. 2013; 6: 48-57
        • Kizilbash A.M.
        • Hundley W.G.
        • Willett D.L.
        • Franco F.
        • Peshock R.M.
        • Grayburn P.A.
        Comparison of quantitative Doppler with magnetic resonance imaging for assessment of the severity of mitral regurgitation.
        Am J Cardiol. 1998; 81: 792-795
        • Uretsky S.
        • Gillam L.
        • Lang R.
        • Chaudhry F.A.
        • Argulian E.
        • Supariwala A.
        • Gurram S.
        • Jain K.
        • Subero M.
        • Jang J.J.
        • Cohen R.
        • Wolff S.D.
        Discordance between echocardiography and MRI in the assessment of mitral regurgitation severity: a prospective multicenter trial.
        J Am Coll Cardiol. 2015; 65: 1078-1088