Influence of Left Ventricular Function on the "Aortic Regurgitation Index" Proposed for the Hemodynamic Assessment of Postprocedural Aortic Regurgitation.

The aortic regurgitation (AR) index, proposed as an objective indicator of postprocedural AR, decreases in proportion to AR severity, besides reportedly providing additional prognostic information. Meanwhile, left ventricular (LV) function has also been considered an essential prognostic factor. This study aimed to clarify whether LV function affected the AR index using cardiac catheterization data.A retrospective study was performed in patients whose LV function was evaluated using a micromanometer-tipped catheter. Patients with grade 2 or higher AR were excluded to explore non-AR factors affecting the AR index value. The AR index was calculated as a ratio of the gradient between the aortic diastolic blood pressure (DBP) and the LV end-diastolic pressure (EDP) to the aortic systolic blood pressure (SBP): AR Index = [ (DBP - LVEDP) / SBP] × 100.A total of 64 patients [age, 62 (interquartile range: 48-70) years; LV ejection fraction, 19% (16%-26%) ] were examined. AR index values ranged from 18.3 to 68.6. Despite having no AR, two patients displayed an AR index < 25, indicating significant AR. Multiple-regression analysis revealed that LV diastolic stiffness (ß = -0.750, P < 0.001), LV max dP/dt (ß = -0.296, P = 0.006), and heart rate (ß = 0.284, P = 0.011) were independent determinants of the AR index value.Patients with impaired LV diastolic function and preserved systolic function had low AR index values. The additional prognostic information of the AR index may be related to LV diastolic function.

Meta-Analysis of Transthoracic Echocardiography Versus Cardiac Magnetic Resonance for the Assessment of Aortic Regurgitation After Transcatheter Aortic Valve Implantation.

Residual aortic regurgitation (AR) is a major complication after transcatheter aortic valve implantation (TAVI). Although the echocardiographic assessment of post-TAVI AR remains challenging, cardiac magnetic resonance (CMR) allows direct quantification of AR. The aim of this study was to review the level of agreement between 2-dimensional transthoracic echocardiography (2D TTE) and CMR on grading the severity of AR after TAVI, and determine the accuracy of TTE in detecting moderate or severe AR. Electronic databases were searched in order to identify studies comparing 2D TTE to CMR for post-TAVI AR assessment. Kappa coefficient was used to determine the level of agreement between the 2 imaging modalities. CMR was used as the reference standard in order to assess the diagnostic accuracy of 2D TTE. Seven studies were included in this systematic review. Six studies reported a low correlation between 2D TTE and CMR (kappa coefficient ranging from -0.02 to 0.41), whereas one study showed good agreement with a kappa coefficient of 0.72. Given the heterogeneity in the included studies the diagnostic accuracy of TTE was evaluated by estimating the hierarchical summary receiver operator characteristic curve. The area under the curve for detection of moderate or severe AR with TTE was 0.83 (95% confidence interval 0.79 to 0.86). In conclusion, despite the reported significant disconcordance between TTE and CMR grading of AR, TTE has sufficient ability to discriminate moderate or severe AR from mild or none AR after TAVI in the clinical setting. CMR should be considered when TTE results are equivocal.

Assessment of Unicuspid Aortic Valve Stenosis Using Multimodality Imaging, X-ray Radiography and Raman Analysis.

Unicuspid aortic valve (UAV) is an extremely rare form of congenital cardiac malformation, leading to aortic stenosis (AS), aortic regurgitation (AR), or both. We report the case of a 55-year-old man with unicommissural UAV associated with severe AS and mild AR using different multimodality imaging approaches. The excised UAV isolated after aortic valve replacement exhibited an eccentric "teardrop" opening with a slit-shaped unicommissural structure. Raman spectroscopic results indicated that 3 unevenly distributed components were deposited on the surface of the UAV, in which calcium hydroxyapatite and type-B carbonate apatite were the predominate components deposited on the surface, leading to severe AS formation.

Single coronary ostium in a patient with quadricuspid aortic valve combined with aneurysmal ascending aortic dilatation.

BACKGROUND: The presence of a fourth aortic valve cusp (quadricupsid aortic valve) is a rare congenital malformation and is often accompanied by other anomalies of the adjacent cardiovascular structures. Among these concomitant anomalies, simultaneous association of both a single coronary ostium and aneurysmal ascending aortic dilation in combination with the quadricupsid aortic valve has not been reported yet. CASE PRESENTATION: We experienced the case of a 56-year-old female patient presenting as aortic regurgitation resulted from malcoaptation of quadricupsid aortic valve. The patient had also accompanying aneurysmal ascending aortic dilatation and coronary ostial anomaly. Surgical correction (aortic valve replacement with mechanical devices and supracoronary aortic replacement with prosthetic graft) was performed without any complications. CONCLUSIONS: The technological development of preoperative imaging studies enable the physician to encounter the quadricuspid aortic valve with other associated malformations more often unlike previous reports. With review on the quadricuspid aortic valve, we discussed a surgical considerations for the treatment of this anomaly.

Florida Sleeve Procedure Is Durable and Improves Aortic Valve Function in Marfan Syndrome Patients.

BACKGROUND: The Florida sleeve (FS) procedure was developed as a simplified approach for repair of functional type I aortic insufficiency secondary to aortic root aneurysm. We evaluated postoperative aortic valve function, long-term survival, and freedom from reoperation in Marfan syndrome patients who underwent the FS procedure at our center. METHODS: All Marfan syndrome patients undergoing FS procedure from May 2002 to December 2014 were included. Echocardiography assessment included left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), ejection fraction, and degree of aortic insufficiency (none = 0, minimal = 1, mild = 2, moderate = 3, severe = 4). Social Security Death Index and primary care physicians' report were used for long-term follow-up. RESULTS: Thirty-seven Marfan syndrome patients, 21 (56.8%) men and 16 (43%) women with mean age of 35.08 ± 13.45 years underwent FL repair at our center. There was no in-hospital or 30-day death or stroke. Two patients required reoperation due to bleeding. Patients' survival rate was 94% at 1 to 8 years. Freedom from reoperation was 100% at 8 years. Twenty-five patients had postoperative follow-up echocardiography at 1 week. Aortic insufficiency grade significantly decreased after the procedure (preoperative mean ± SD: 1.76 ± 1.2 versus 1-week postoperative mean ± SD: 0.48 ± 0.71, p < 0.001), and mean LVEDD decreased from 52.23 ± 5.29 mm to 47.53 ± 8.89 mm (p = 0.086). Changes in LVESD (35.33 ± 9.97 mm to 36.58 ± 9.82 mm, p = 0.58) and ejection fraction (57.65% ± 6.22% to 55% ± 10.83%, p = 0.31) were not significant. CONCLUSIONS: The FS procedure can be performed safely in Marfan syndrome patients with immediate improvement in aortic valve function. Long-term survival and freedom from reoperation rates are encouraging.

Hemodynamic Assessment of Aortic Regurgitation After Transcatheter Aortic Valve Replacement: The Diastolic Pressure-Time Index.

OBJECTIVES: Assessment of aortic regurgitation (AR) immediately after transcatheter aortic valve replacement (TAVR) is essential to guide further intervention in cases of relevant AR. It was the aim of this study to identify a simple and reproducible hemodynamic parameter for the assessment of AR. BACKGROUND: Relevant AR after TAVR is present in up to 21% of cases and might be associated with adverse long-term outcomes. METHODS: Three hundred sixty-two consecutive patients who were treated with TAVR for symptomatic aortic valve stenosis were analyzed. AR was assessed by aortic root angiography according to the Sellers classification. For hemodynamic evaluation, the diastolic pressure-time (DPT) index was calculated after TAVR: the area between the aortic and left ventricular pressure-time curves was measured during diastole and divided by the duration of diastole to calculate the DPT index. The DPT index was finally adjusted for the respective systolic blood pressure: DPT indexadj = (DPT index/systolic blood pressure) × 100. RESULTS: Patients with angiographically nonrelevant AR (grade <2) had higher DPT indexadj (30.7 ± 6.8) compared with those with relevant AR (grade ≥2) (26.2 ± 5.8) (p < 0.05). Patients with DPT indexadj ≤27.9 had significantly higher 1-year mortality risk in comparison with those with DPT indexadj >27.9: 41.4% versus 13.5% (hazard ratio: 3.8; 95% confidence interval: 2.4 to 5.9; p [log rank-test] < 0.001). In multivariate regression analysis, DPT indexadj ≤27.9 was the strongest independent predictor of 1-year mortality (hazard ratio: 2.5; 95% confidence interval: 1.8 to 3.7; p < 0.001). CONCLUSIONS: DPT indexadj is a simple, investigator-independent parameter that should be considered to differentiate between relevant and nonrelevant AR after TAVR.

Assessment of the regurgitant orifice area in aortic regurgitation with dual-source CT: Comparison with cardiovascular magnetic resonance.

BACKGROUND: Regurgitant orifice area (ROA) measurements by cardiac CT have not been compared with a quantitative classification of aortic regurgitation (AR) severity based on regurgitant fraction by phase-contrast cardiovascular magnetic resonance (PC-CMR). OBJECTIVES: To compare ROA using dual-source CT (DSCT) with the grade of AR using PC-CMR for obtaining the cutoff values of the ROA allowing for grading of AR severity. METHODS: We retrospectively enrolled 208 patients (81 women, mean age 53.3 ± 14.4 years) with AR who underwent DSCT and CMR. DSCT data sets were reconstructed in 10% steps from 0% to 90% of the R-R interval to measure ROA. Grades of AR were determined by regurgitant fraction using PC-CMR. Receiver operating characteristic curves were calculated to differentiate between grades of AR and ROA. RESULTS: Sixty-three patients with mild AR, 80 with moderate AR, and 65 with severe AR by PC-CMR were enrolled. Quantification of the ROA by DSCT (mean, 27 ± 21 mm2) was significantly correlated with the grade of AR by PC-CMR (r = 0.83). In the receiver operating characteristic analysis, discrimination (mild vs moderate and moderate vs severe) among grades of AR with DSCT was accurate when cutoff ROAs of 15 mm2 and 23 mm2 in comparison with PC-CMR were used. CONCLUSIONS: The cutoff values of the ROA by DSCT allow for grading of AR severity determined by PC-CMR but are lower than those previously published, using transthoracic echocardiography as the reference standard. A multicenter study is necessary with a wide range of population for obtaining cutoff ROAs.

Quantitative assessment of paravalvular regurgitation following transcatheter aortic valve replacement.

BACKGROUND: Paravalvular aortic regurgitation (PAR) following transcatheter aortic valve implantation (TAVI) is well acknowledged. Despite improvements, echocardiographic measurement of PAR largely remains qualitative. Cardiovascular magnetic resonance (CMR) directly quantifies AR with accuracy and reproducibility. We compared CMR and transthoracic echocardiography (TTE) analysis of pre-operative and post-operative aortic regurgitation in patients undergoing both TAVI and surgical aortic valve replacement (AVR). METHODS: Eighty-seven patients with severe aortic stenosis undergoing TAVI (56 patients) or AVR were recruited. CMR (1.5 T) and transthoracic echocardiography (TTE) were carried out pre-operatively and a median of 6 days post-operatively. The CMR protocol included regurgitant aortic flows using through-plane phase-contrast velocity. None/trivial, mild, moderate and severe AR by CMR was defined as ≤8%, 9-20%, 21-39%, >40% regurgitant fractions respectively. RESULTS: Pre- and post-operative left ventricular ejection fraction (LVEF) was similar. Post-procedure aortic regurgitant fraction using CMR was higher in the TAVI group (TAVI 16 ± 13% vs. AVR 4 ± 4%, p < 0.01). Comparing CMR to TTE, 27 of 56 (48%) TAVI patients had PAR which was at least one grade more severe on CMR than TTE (Z = -4.56, p <0.001). Sensitivity analysis confirmed the difference in PAR grade between TTE and CMR in the TAVI group (Z = -4.49, p < 0.001). CONCLUSION: When compared to CMR based quantitative analysis, TTE underestimated the degree of paravalvular aortic regurgitation. This underestimation may in part explain the findings of increased mortality associated with mild or greater AR by TTE in the PARTNER trial. Paravalvular aortic regurgitation post TAVI assessed as mild by TTE may in fact be more severe.

Aortic regurgitation after transcatheter aortic valve implantation (TAVI) - Angiographic, echocardiographic and hemodynamic assessment in relation to one year outcome.

BACKGROUND: Aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) remains a relatively frequent and life-limiting complication. However, the most prognostically discriminative (and therefore preferred) technique of AR evaluation after TAVI is not yet clearly defined. The aim of this study was to compare angiographic, echocardiographic and hemodynamic assessment of AR after TAVI in relation to one year outcome. METHODS AND RESULTS: In this single center prospective cohort study, angiography (AR grading), echocardiography (AR quantification using color Doppler flow mapping) and invasive hemodynamics (AR index) were assessed before and after TAVI. All patients were followed up to at least one year. A total of 111 consecutive (very) high-risk patients with severe, symptomatic aortic valve stenosis underwent TAVI. No concordant relation could be demonstrated between angiographic, echocardiographic and invasive assessment of AR after TAVI. AR index <25 post TAVI was significantly influenced by left ventricular posterior wall thickness (odds ratio: 1.276, p=0.030) and AR index pre TAVI (odds ratio: 0.948, p=0.019). Neither angiographic nor hemodynamic AR assessments were able to discriminate between good or significantly decreased one year survival. In contrast, color Doppler flow mapping of AR after TAVI was highly reproducible, and able to differentiate between good or significantly decreased one year survival (AR grades 0-I: one year survival 87% vs. AR grades II-III-IV: one year survival 68%, p=0.035). CONCLUSION: Echocardiography using color Doppler flow mapping is the preferred technique to assess prognostically relevant AR after TAVI.

Assessment of paravalvular regurgitation following TAVR: a proposal of unifying grading scheme.

Paravalvular regurgitation (PVR) is a frequent complication of transcatheter aortic valve replacement that has been shown to be associated with increased mortality. The objective of this article is to review the most up-to-date information about the assessment and management of PVR and to propose a new more comprehensive and unifying scheme for grading PVR severity. A multimodality, multiparametric, integrative approach including Doppler echocardiography, cineangiography, hemodynamic assessment, and/or cardiac magnetic resonance is essential to accurately assess the severity of PVR and the underlying etiology. Corrective procedures such as balloon post-dilation, valve-in-valve, or leak closure may be considered, depending on the severity, location, and etiology of PVR.

Minimally invasive aortic valve replacement provides equivalent outcomes at reduced cost compared with conventional aortic valve replacement: A real-world multi-institutional analysis.

BACKGROUND: Several single-center studies have reported excellent outcomes with minimally invasive aortic valve replacement (mini-AVR). Although criticized as requiring more operative time and complexity, mini-AVR is increasingly performed. We compared contemporary outcomes and cost of mini-AVR versus conventional AVR in a multi-institutional regional cohort. We hypothesized that mini-AVR provides equivalent outcomes to conventional AVR without increased cost. METHODS: Patient records for primary isolated AVR (2011-2013) were extracted from a regional, multi-institutional Society of Thoracic Surgeons database and stratified by conventional versus mini-AVR, performed by either partial sternotomy or right thoracotomy. To compare similar patients, a 1:1 propensity-matched cohort was performed after adjusting for surgeon; operative year; and Society of Thoracic Surgeons risk score, including age and risk factors (n = 289 in each group). Differences in outcomes and cost were analyzed. RESULTS: A total of 1341 patients underwent primary isolated AVR, of which 442 (33%) underwent mini-AVR at 17 hospitals. Mortality, stroke, renal failure, and other major complications were equivalent between groups. Mini-AVR was associated with decreased ventilator time (5 vs 6 hours; P = .04) and decreased blood product transfusion (25% vs 32%; P = .04). A greater percentage of mini-AVR patients were discharged within 4 days of the operation (15.2% vs 4.8%; P < .001). Consequently, total hospital costs were lower in the mini-AVR group ($36,348 vs $38,239; P = .02). CONCLUSIONS: Mortality and morbidity outcomes of mini-AVR are equivalent to conventional AVR. Mini-AVR is associated with decreased ventilator time, blood product use, early discharge, and reduced total hospital cost. In contemporary clinical practice, mini-AVR is safe and cost-effective.

Contrast echocardiography: a novel technique for assessment of total aortic regurgitation following transapical aortic valve implantation.

OBJECTIVES: Aortic regurgitation (AR) is a possible complication following transcatheter aortic valve implantation (TAVI) which is associated with less-favourable outcomes. Quantification of total regurgitation caused by multiple, multidirectional jets remains controversial. The purpose of this study was to assess the usefulness of retrograde contrast echocardiography in quantification of total AR following TAVI and to evaluate its prognostic significance. METHODS: In 245 patients following Edwards Sapien valve (Edwards Lifesciences, Irvine, CA, USA) implantation, we performed retrograde contrast transoesophageal echocardiography to quantify AR immediately after TAVI. The contrast (20 ml agitated gelatine polysuccinate, Gelafundin 4%, Braun, Melsungen, Germany) was injected as a bolus into the sinotubular junction of the aorta through a pigtail catheter. We measured the area of the regurgitant cloud during mid- to end-diastole. A regurgitant area of ≥3.8 cm2 was determined as an indicator of relevant AR. Sensitivity of this was compared through angiography and Doppler echocardiography. To assess whether AR identified by this novel method independently determined survival, a multivariate model was applied. RESULTS: Angiography, Doppler echocardiography and contrast echocardiography recognized 15, 23 and 56 patients with relevant regurgitation. Multivariate analysis including a regurgitant area of ≥3.8 cm2, New York Heart Association (NYHA) class IV, age and creatinine concentration identified a regurgitant area of ≥3.8 cm2 (P=0.027) as independent risk factor for 2-year survival. CONCLUSIONS: Contrast echocardiography is a simple method for quantification of total AR following TAVI and is more sensitive than angiography or Doppler echocardiography. Its clinical relevance is demonstrated by the impact of the AR detected by contrast echocardiography on survival.

Comparison of two- and three-dimensional transthoracic echocardiography to cardiac magnetic resonance imaging for assessment of paravalvular regurgitation after transcatheter aortic valve implantation.

This study evaluated 2-dimensional (2D) transthoracic echocardiography (TTE) using Valve Academic Research Consortium-2 (VARC-2) criteria and 3-dimensional (3D) TTE for assessment of aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) in comparison with cardiac magnetic resonance (CMR) imaging. In 71 patients, 2D TTE, 3D TTE, and CMR imaging were performed to assess AR severity after TAVI. Using 2D TTE, AR severity was graded according to VARC-2 criteria and regurgitant volume (RVol) was determined. Three-dimensional color Doppler TTE allowed direct planimetry of the vena contracta area of the paravalvular regurgitation jet and calculation of the RVol as product with the velocity-time integral. RVol by CMR imaging was measured by phase-contrast velocity mapping in the ascending aorta. After TAVI, mean RVol determined by CMR imaging was 9.2 ± 9.6 ml/beat and mean regurgitant fraction was 13.3 ± 10.3%. AR was assessed as none or mild in 58 patients (82%) by CMR imaging. Correlation of 3D TTE and CMR imaging on RVol was better than correlation of 2D TTE and CMR imaging (r = 0.895 vs 0.558, p <0.001). There was good agreement between RVol by CMR imaging and by 3D TTE (mean bias = 2.4 ml/beat). Kappa on grading of AR severity was 0.357 between VARC-2 and CMR imaging versus 0.446 between 3D TTE and CMR imaging. Intraobserver variability for analysis of RVol of AR after TAVI was 73.5 ± 52.2% by 2D TTE, 16.7 ± 21.9% by 3D TTE, and 2.2 ± 2.0% by CMR imaging. In conclusion, 2D TTE considering VARC-2 criteria has limitations in the grading of AR severity after TAVI when CMR imaging is used for comparison. Three-dimensional TTE allows quantification of AR with greater accuracy than 2D TTE. Observer variability on RVol after TAVI is considerable using 2D TTE, significantly less using 3D TTE, and very low using CMR imaging.

Prevalence, significance, and management of aortic insufficiency in continuous flow left ventricular assist device recipients.

BACKGROUND: Aortic insufficiency (AI) is increasingly recognized as a complication of continuous flow left ventricular assist device support; however, its long-term prevalence, clinical significance, and efficacy of potential interventions are not well known. METHODS AND RESULTS: We studied the prevalence and management of AI in 232 patients with continuous flow left ventricular assist device at our institution. Patients with aortic valve (AV) surgery before left ventricular assist device implantation were excluded from analysis. To examine the prevalence of de novo AI, patients without preoperative AI were divided into a retrospective and a prospective cohort based on whether a dedicated speed optimization study had been performed at the time of discharge. Forty-three patients underwent AV repair at the time of implant, and 3 subsequently developed greater than mild AI. In patients without surgical AV manipulation and no AI at the time of implant, Kaplan-Meier analysis revealed that freedom from greater than mild de novo AI at 1 year was 77.6±4.2%, and that at least moderate AI is expected to develop in 37.6±13.3% after 3 years. Nonopening of the AV was strongly associated with de novo AI development in patients without prospective discharge speed optimization. Seven of 21 patients with at least moderate AI developed symptomatic heart failure requiring surgical intervention. CONCLUSIONS: AI is common in patients with continuous flow left ventricular assist devices and may lead to clinical decompensation requiring surgical correction. The prevalence of AI is substantially less in patients whose AV opens, and optimized loading conditions may reduce AI prevalence in those patients in whom AV opening cannot be achieved.

Incidence, outcome and correlates of residual paravalvular aortic regurgitation after transcatheter aortic valve implantation and importance of haemodynamic assessment.

AIMS: Residual paravalvular aortic regurgitation (PAR) after transcatheter aortic valve implantation (TAVI) is common. We therefore evaluated incidence, determinants and outcome of PAR after TAVI. METHODS AND RESULTS: Data from 167 consecutive transcatheter TAVI patients were analysed. PAR was graded by angiography and the pressure gradient between diastolic aortic pressure and left ventricular end-diastolic pressure (∆PDAP-LVEDP) after implantation. TAVI was technically successful in all patients. Mortality was 9% and 20% at 30 days and one year, respectively. Post-procedural PAR was absent in 54 patients (32.3%). Mild PAR was found in 89 (53.3%), moderate in 21 (12.6%), and moderate-to-severe in three patients (1.8%). Cardiovascular mortality at 30 days and one year was increased in patients with moderate and moderate-to-severe PAR compared to patients with no and mild PAR (46% vs. 4% and 73% vs. 7%, respectively, p<0.001). Receiver operating characteristic curve analysis suggested ∆PDAP-LVEDP ≤18 mmHg as a novel predictor of mortality, with an area under the curve of 0.97. CONCLUSIONS: In patients undergoing TAVI, moderate and moderate-to-severe PAR was observed in 14.4% and associated with increased cardiovascular mortality. A pressure gradient ∆PDAP-LVEDP≤18 mmHg carries adverse prognosis and requires further intervention.

Assessment of annular distensibility in the aortic valve.

OBJECTIVES The recent introduction of transcatheter aortic heart valves into clinical practice has driven the need to develop methodologies to size such valves without access to the annulus in the manner hitherto possible with open heart surgery. To date, sizing has largely been done according to manufacturer-supplied guidelines based on transoesophageal echocardiography or multidetector computed tomography. We sought to examine how the diameter of the aortic valve annulus stretches under typical pressures encountered in normal and diseased states. In particular, we sought to measure how the area-derived diameter, Dcsa, i.e. the diameter derived from a cross-sectional area, varies with distending pressure. METHODS We conducted testing on 14 explanted pig hearts. Placing each heart in a 37 °C bath, an EndoFLIP EF-325 catheter (Crospon, Galway, Ireland) was introduced into the aortic valve transapically. The catheter allows intra-balloon pressure and up to 16 area-derived diameters to be measured simultaneously, thus permitting the shape of a lumen to be observed. By dividing the minimum area-derived diameter by distending pressure, a measure of distensibility (mm/mmHg) could be determined. Once the balloon was centred, balloon pressure was ramped between 100 and 200 mmHg, and the area-derived diameter was calculated at each pressure. RESULTS Between 100 and 200 mmHg, the mean (SD) increase in diameter was found to be 3.0 (1.5) mm. Distensibility in the different hearts ranged from 0 to 0.05 mm/mmHg. In some cases, the diameter change over the pressure range was negligible, whereas in one case, the diameter change over the range was 5 mm. Whereas different nominal values of diameter are to be expected, a significant variation in the degree of distensibility was observed. CONCLUSIONS Distensibility of the aortic valve annulus is highly variable. Measurement of this parameter in addition to nominal annulus diameter may suggest occasions where a larger transcatheter aortic-valve implantation valve than would be suggested by annulus diameter measurement alone, could be deployed safely with an objective of reducing regurgitation where the annulus is sufficiently distensible.

Quantitative assessment of pure aortic valve regurgitation with dual-source CT.

AIM: To assess the severity of pure aortic regurgitation by measuring regurgitation volumes (RV) and fractions (RF) with dual-source computed tomography (DSCT) as compared to magnetic resonance imaging (MRI) and echocardiography. MATERIALS AND METHODS: Thirty-eight patients (15 men, 23 women; mean age 46±11 years) with isolated aortic valve regurgitation underwent retrospectively electrocardiogram (ECG)-gated DSCT, echocardiography, and MRI. Stroke volumes of the left and right ventricles were measured at DSCT and MRI. Thus, RVs and RFs were calculated and compared. The agreement between DSCT and MRI was tested by intraclass correlation coefficient and Bland-Altman analyses. Spearman's rank order correlation and weighted κ tests were used for testing correlations of AR severity between DSCT results and corresponding echocardiographic grades. RESULTS: The RV and RF measured by DSCT were not significantly different from those measured using MRI (p=0.71 and 0.79). DSCT correlated well with MRI for the measurement of RV (r(I)=0.86, p<0.001) and calculation of the RF (r(I) =0.90, p<0.001). Good agreement between the techniques was obtained by using Bland-Altman analyses. The severity of regurgitation estimated by echocardiography correlated well with DSCT (r(s)=0.95, p<0.001) and MRI (r(s)=0.95, p<0.001). Inter-technique agreement between DSCT and two-dimensional transthoracic echocardiography (2DTTE) regarding the grading of the severity of AR was excellent (κ=0.90), and good agreement was also obtained between MRI and 2DTTE assessments of the severity of AR (κ=0.87). CONCLUSION: DSCT using a volume approach can be used to quantitatively determine the severity of pure aortic regurgitation when compared with MRI and echocardiography.