Three-dimensional color Doppler: a clinical study in patients with mitral regurgitation.

OBJECTIVES: The purpose of this study was to assess the clinical feasibility of three-dimensional (3D) reconstruction of color Doppler signals in patients with mitral regurgitation. BACKGROUND: Two-dimensional (2D) color Doppler has limited value in visualizing and quantifying asymmetric mitral regurgitation. Clinical studies on 3D reconstruction of Doppler signals in original color coding have not yet been performed in patients. We have developed a new procedure for 3D reconstruction of color Doppler. METHODS: We studied 58 patients by transesophageal 3D echocardiography. The jet area was assessed by planimetry and the jet volumes by 3D Doppler. The regurgitant fractions, the volumes, and the angiographic degree of mitral regurgitation were assessed in 28 patients with central jets and compared with those of 30 patients with eccentric jets. RESULTS: In all patients, jet areas and jet volumes significantly correlated with the angiographic grading (r = 0.73 and r = 0.90), the regurgitant fraction (r = 0.68 and r = 0.80) and the regurgitant volume (r = 0.66 and r = 0.90). In patients with central jets, significant correlations were found between jet area and angiography (r = 0.86), regurgitant fraction (r = 0.64) and regurgitant volume (r = 0.78). No significant correlations were found between jet area and angiography (r = 0.53), regurgitant fraction (r = 0.52) and regurgitant volume (r = 0.53) in the group of patients with eccentric jets. In contrast, jet volumes significantly correlated with angiography (r = 0.90), regurgitant fraction (r = 0.75) and regurgitant volume (r = 0.88) in the group of patients with eccentric jets. CONCLUSIONS: Three-dimensional Doppler revealed new images of the complex jet geometry. In addition, jet volumes, assessed by an automated voxel count, independent of manual planimetry or subjective estimation, showed that 3D Doppler is also capable of quantifying asymmetric jets.

Complete localization of disulfide bonds in GM2 activator protein.

Lysosomal degradation of ganglioside GM2 by hexosaminidase A requires the presence of a small, non-enzymatic cofactor, the GM2-activator protein (GM2AP). Lack of functional protein leads to the AB variant of GM2-gangliosidosis, a fatal lysosomal storage disease. Although its possible mode of action and functional domains have been discussed frequently in the past, no structural information about GM2AP is available so far. Here, we determine the complete disulfide bond pattern of the protein. Two of the four disulfide bonds present in the protein were open to classical determination by enzymatic cleavage and mass spectrometry. The direct localization of the remaining two bonds was impeded by the close vicinity of cysteines 136 and 138. We determined the arrangement of these disulfide bonds by MALDI-PSD analysis of disulfide linked peptides and by partial reduction, cyanylation and fragmentation in basic solution, as described recently (Wu F, Watson JT, 1997, Protein Sci 6:391-398).

Purification of acid sphingomyelinase from human placenta: characterization and N-terminal sequence.

Human placental acid sphingomyelinase (ASM) was purified by sequential chromatography on Con A-Sepharose, octyl-Sepharose and Matrex gel red A. Final purification to apparent homogeneity was achieved by immunoaffinity chromatography employing polyclonal anti-ASM antibodies. The antibodies also allowed specific detection of ASM by Western blotting at various stages of purification. The ASM activity was enriched about 110,000-fold over that of the crude extract, yielding an enzyme preparation with a specific activity of about 1 mmol/h per mg protein in a detergent-containing assay system. Analysis of the final preparation by SDS-PAGE resulted in a single protein band with a molecular mass of approximately 75 kDa, which was reduced to approximately 60 kDa after complete deglycosylation. Microsequencing of the purified ASM revealed the N-terminal amino acid sequence of the mature placental enzyme.

Three-dimensional color Doppler reconstruction of intracardiac blood flow in patients with different heart valve diseases.

An improved perception of the magnitude and dynamics of intracardiac flow disturbances has been made possible by the advent of 3-dimensional (3-D) color Doppler, a new diagnostic procedure developed at our institution. This study describes the new insights derived from 3-D reconstruction of color Doppler flow patterns in patients with different heart valve diseases. The color Doppler flow data from 153 multiplanar transesophageal or transthoracic echocardiographic examinations has been obtained from 133 patients with heart valve disease; 73 patients had mitral regurgitation, 15 had mitral stenosis, 18 had aortic regurgitation, 26 had aortic stenosis, and 21 patients had tricuspid regurgitation. Four patients had pulmonary regurgitation associated with mitral valve disease. The 3-D reconstructions of color Doppler flow signals were accomplished by means of the "Heidelberg Raytracing model," developed at our institution. The 3-D color Doppler reconstructions were obtained in all patients. The 3-D images revealed for the first time the complex spatial distribution of the blood flow abnormalities in the heart chambers caused by different heart valve diseases. New patterns of intracardiac blood flow disturbances were observed and classified. Three-dimensional color Doppler provides a unique noninvasive method that can be easily applied for studying intracardiac blood flow disturbances in clinical practice.

Iridoid biosynthesis in staphylinid rove beetles (Coleoptera: Staphylinidae, Philonthinae).

The biosynthesis of chrysomelidial and plagiodial was studied in the rove beetle subtribe Philonthina (Staphylinidae). Glandular homogenates were found to convert synthetic (2E,6E)-[trideuteromethyl-5,5-(2)H(5)]octa-2,6-diene-1,8-diol (10) into nor-chrysomelidial (14) and nor-plagiodial (13). The overall transformation requires; i) oxidation of the substrate at C(1) and C(8), ii) cyclization of the resulting dialdehyde to nor-plagiodial followed by iii) isomerization to give nor-chrysomelidial. The oxidase requires molecular oxygen as a cofactor and operates with removal of the pro-R hydrogen from C(1) and C(8) of synthetic (1R,8R,2E,6E)-[1,8-(2)H(2)]-2,6-dimethyl-octa-2,6-diene-1,8-diol (15), producing a dialdehyde along with H(2)O(2). Unlike enzymes from iridoid-producing leaf beetle larvae, the Philonthus enzyme is able to oxidize saturated substrates such as citronellol. Crude protein extracts prepared from Philonthus glands by ammonium sulfate precipitation, were found to produce hydrogen peroxide at a rate of 0.085+/-0.003 ng H(2)O(2) (ng protein)(-1) hr(-1) with nerol as an oxidase substrate. The cyclase operates with opposite stereochemistry to the enzyme(s) from Phaedon cochleariae and other herbivorous leaf beetles, specifically removing the C(5)-H(R) hydrogen atom from (4R,5S,2E,6E)-[4,5-(2)H(2)]-2-methyl-octa-2,6-diene-1,8-diol (17). These findings have enabled us to construct a detailed account of iridoid biosynthesis in rove beetles, which resembles the biosynthetic route in leaf beetle larvae, but exhibits distinct stereochemical differences.

The impact of 3-dimensional reconstructions on operation planning in liver surgery.

BACKGROUND: Operation planning in liver surgery depends on the precise understanding of the 3-dimensional (D) relation of the tumor to the intrahepatic vascular trees. To our knowledge, the impact of anatomical 3-D reconstructions on precision in operation planning has not yet been studied. HYPOTHESIS: Three-dimensional reconstruction leads to an improvement of the ability to localize the tumor and an increased precision in operation planning in liver surgery. DESIGN: We developed a new interactive computer-based quantitative 3-D operation planning system for liver surgery, which is being introduced to the clinical routine. To evaluate whether 3-D reconstruction leads to improved operation planning, we conducted a clinical trial. The data sets of 7 virtual patients were presented to a total of 81 surgeons in different levels of training. The tumors had to be assigned to a liver segment and subsequently drawn together with the operation proposal into a given liver model. The precision of the assignment to a liver segment according to Couinaud classification and the operation proposal were measured quantitatively for each surgeon and stratified concerning 2-D and different types of 3-D presentations. RESULTS: The ability of correct tumor assignment to a liver segment was significantly correlated to the level of training (P<.05). Compared with 2-D computed tomography scans, 3-D reconstruction leads to a significant increase of precision in tumor localization by 37%. The target area of the resection proposal was improved by up to 31%. CONCLUSION: Three-dimensional reconstruction leads to a significant improvement of tumor localization ability and to an increased precision of operation planning in liver surgery.

Assessment of mitral regurgitant jets by three-dimensional color Doppler.

BACKGROUND: Color Doppler echocardiography is a standard technique for assessing mitral regurgitation before and after mitral valvuloplasty. Mitral valve prolapse produces complex eccentric jet flows that cannot be visualized and measured by two-dimensional color Doppler echocardiography. The aim of this study was to evaluate the clinical impact of three-dimensional color Doppler echocardiography, a new technique developed at our institution, for assessing mitral regurgitation. METHODS: Forty-five patients with mitral regurgitation underwent intraoperative transesophageal echocardiography and three-dimensional Doppler data acquisition. The grade of mitral regurgitation was assessed by angiography. The jet areas were calculated by planimetry from conventional color Doppler; the jet volumes were obtained by three-dimensional Doppler data. RESULTS: New patterns of mitral regurgitant flows were recognized according to the origin, direction, and spatial spreading into the left atrium. Conventional jet areas failed to separate the groups of patients with different degrees of regurgitation, whereas the jet volumes were able to divide patients with different regurgitation grades. No significant correlation was found between jet area and angiographic grading (r = 0.63, p = NS). Jet volumes were significantly correlated to angiography (r = 0.89, p < 0.001). CONCLUSIONS: Three-dimensional color Doppler echocardiography revealed new patterns of regurgitant flow and allowed a more accurate semiquantitative assessment of complex asymmetrical regurgitant jets.

Three-dimensional color Doppler: a new approach for quantitative assessment of mitral regurgitant jets.

Color Doppler echocardiography does not provide adequate information about the severity of mitral regurgitation in patients with eccentric mitral regurgitation. We have developed a new procedure for 3-dimensional (3D) color Doppler reconstruction and for segmentation of regurgitant jets. The volume of regurgitant jets was compared with jet area in 63 patients with mitral regurgitation. Mitral regurgitation was assessed by angiography, regurgitant fraction and volume by pulsed Doppler, JA by planimetry, and JV by 3-dimensional Doppler. Twenty-eight patients with central jets were compared with 35 patients with eccentric jets. In the patients with eccentric jets, JV showed significant correlations with regurgitant volume (r = 0.90; P <.01) and regurgitant fraction (r = 0.76; P < .01) and was able to separate groups with different degrees of mitral regurgitation (P <.01). Three-dimensional Doppler revealed origin, direction, and spatial spreading of complex jet geometry. JV, a new parameter of mitral regurgitation, was also capable of quantifying asymmetrical jets.

Three-dimensional color Doppler for assessing mitral regurgitation during valvuloplasty.

OBJECTIVE: Transesophageal color Doppler (or 2D Doppler) is the most widely used technique for intraoperative assessment of mitral valve repair. However, the most severe mitral regurgitations produce eccentric jet flows which cannot be assessed by 2D imaging. Up to now the indications for surgical intervention and intraoperative decisions after valve repair have been based on 2D Doppler examinations. Aim of this study was to compare conventional 2D Doppler to three-dimensional (3D) Doppler for assessing residual regurgitation in patients after mitral valvuloplasty. METHODS: Twenty-four patients were referred to surgery for mitral valve repair. They underwent transesophageal echocardiography and 3D data acquisition during mitral valve reconstruction. Conventional assessment of mitral valve regurgitation, measured by color Doppler jet area, was compared to the volume of regurgitant jets obtained by 3D Doppler. Regurgitant volume and fraction were measured by pulsed Doppler and two-dimensional echocardiography. The 3D reconstructions of color Doppler data were accomplished by means of the 'Heidelberg Raytracing Algorithm' developed at our institution. RESULTS: The jet areas did not show any significant correlation to the regurgitant fraction (r = 45; P = NS) or regurgitant volumes (r = 0.40; P = NS). In contrast the jet volumes correlated significantly to regurgitant fraction (r = 0.71; P < 0.01) and regurgitant volume (r = 0.85; P < 0.01). The reproducibility analysis of repeated jet volume and jet area measurements also showed that the parameter jet volume has a lower variability and higher agreement of repeated measurements than jet area. CONCLUSIONS: Three-dimensional color Doppler flow imaging revealed the complex geometry of eccentric regurgitant jets and showed that the assessment of mitral regurgitation, based on conventional 2D Doppler, can be misleading. This new technique has a great potential for becoming a reference method for assessing mitral valve repair.

Virtual surgery in a (tele-)radiology framework.

This paper presents telemedicine as an extension of a teleradiology framework through tools for virtual surgery. To classify the described methods and applications, the research field of virtual reality (VR) is broadly reviewed. Differences with respect to technical equipment, methodological requirements and areas of application are pointed out. Desktop VR, augmented reality, and virtual reality are differentiated and discussed in some typical contexts of diagnostic support, surgical planning, therapeutic procedures, simulation and training. Visualization techniques are compared as a prerequisite for virtual reality and assigned to distinct levels of immersion. The advantage of a hybrid visualization kernel is emphasized with respect to the desktop VR applications that are subsequently shown. Moreover, software design aspects are considered by outlining functional openness in the architecture of the host system. Here, a teleradiology workstation was extended by dedicated tools for surgical planning through a plug-in mechanism. Examples of recent areas of application are introduced such as liver tumor resection planning, diagnostic support in heart surgery, and craniofacial surgery planning. In the future, surgical planning systems will become more important. They will benefit from improvements in image acquisition and communication, new image processing approaches, and techniques for data presentation. This will facilitate preoperative planning and intraoperative applications.

Virtual planning of liver resections: image processing, visualization and volumetric evaluation.

Operability of a liver tumor depends on its three dimensional relation to the intrahepatic vascular trees as well as the volume ratio of healthy to tumorous tissue. Precise operation planning is complicated by anatomic variability and distortion of the vascular trees by the tumor or preceding liver resections. We have developed a computer based 3D virtual operation planning system which is ready to go in routine use. The main task of a system in this domain is a quantifiable patient selection by exact prediction of post-operative liver function. It provides the means to measure absolute and relative volumes of the organ structures and resected parenchyma. Another important step in the pre-operative phase is to visualize the relation between the tumor, the liver and the vessel trees for each patient. The new 3D operation planning system offers quantifiable liver resection proposals based on individualized liver anatomy. The results are presented as 3D movies or as interactive visualizations as well as in quantitative reports.

[Virtual surgical planning in liver surgery]. / Virtuelle Operationsplanung in der Leberchirurgie.

UNLABELLED: The operability of a liver tumour depends on its three-dimensional relation to the intrahepatic vascular trees which define autonomously functioning liver (sub-)segments. The aim of our study was to establish a computer-based three-dimensional volumetric operation planning system for the liver. METHODS: Using data from routine helical CT scans the three tissue subclasses of liver parenchyma, liver vessels and liver tumour were segmented semiautomatically. A dedicated segmenting tool was established using region growing algorithms in combination with an "intelligent" border finder. Visualisation is performed by the "Heidelberg Raytracer". The vascular trees are visualised as 3D graphs. Pseudoconnections between portal and hepatic venous trees are separated automatically. Security margins are calculated and the system presents a virtual resection proposal. RESULTS: The 3D anatomy of the liver can be visualised in high quality resulting in good depth perception. Security margins are demonstrated. Dependent liver parenchyma can be recognized automatically on the basis of the vascular trees. The system offers a individualised resection proposal including the tumour, security margin and dependent liver parenchyma. CONCLUSION: Three-dimensional presentation of the individual liver anatomy of a given patient facilitates the perception of the pathology. Virtual reality combined with artificial intelligence allows calculation of complete resection protocols, which can be quantified and modified interactively. This will make operation planning more objective; patient selection may be improved, and in cases of difficult tumour localisation different resection strategies may be tested. Thus virtual reality in liver surgery will improve teaching, surgical training and planning. It may lead to improved surgical care.

Interactive realtime Doppler-ultrasound visualization of the heart.

Heart valve insufficiencies can optimally be assessed using transesophageal, triggered, three-dimensional ultrasound imaging. The dynamic ultrasound data contain morphological as well as functional components which are recorded and displayed simultaneously. It allows the visualization of intracardiac motion which is an important parameter to detect abnormal flow caused by defect valves. A realtime reconstruction is desired to get a spatial impression on the one hand and to interactively clip parts of the volume on the other hand. Therefore, we use the OpenGL Volumizer API. Scalability of the visualization was tested with respect to different workstations and graphics resources using a Multipipe Utility library. The combination of both APIs enables a visualization of volumetric and functional data with frame rates up to 10 frames per second. By using the proposed method, it is possible to visualize the jet in the original color-coding which is employed during a conventional two-dimensional examination for displaying the velocity values. The morphological and the functional data are handled as two independent data channels. A good scalability from low cost up to high end graphic workstations is given by the use of the MPU. The quality of the resulting 3D images allows exact differentiation of heart valve insufficiencies to support the diagnostic procedure.

Technical aspects of virtual liver resection planning.

Operability of a liver tumor is depending on its three dimensional relation to the intrahepatic vascular trees which define autonomously functioning liver (sub-)segments. Precise operation planning is complicated by anatomic variability, distortion of the vascular trees by the tumor or preceding liver resections. Because of the missing possibility to track the deformation of the liver during the operation an integration of the resection planning system into an intra-operative navigation system is not feasible. So the main task of an operation planning system in this domain is a quantifiable patient selection by exact prediction of post-operative liver function and a quantifiable resection proposal. The system quantifies the organ structures and resection volumes by means of absolute and relative values. It defines resection planes depending on security margins and the vascular trees and presents the data in visualized form as a 3D movie. The new 3D operation planning system offers quantifiable liver resection proposals based on individualized liver anatomy. The results are visualized in digital movies as well as in quantitative reports.

[Volumetric analysis and visualization of cardiologic ultrasound data]. / Volumetrische Analyse und Visualisierung kardiologischer Ultraschalldaten.

BACKGROUND: Echocardiography is a standard imaging technique for the assessment of heart valve disease. The good spatial and temporal resolution is the basis for different methods which provide information about the severity of such defects. Dynamic colour visualisation and volumetric measurements of regurgitant jets are a new evaluating tool for the assessment of heart valve insufficiencies. METHODS: The regurgitant jet volume of 58 patients was evaluated on an external work-station after segmentation of the left atrium and compared to regurgitant volume; the correlation was good. This result is valid for central jets as well as for eccentric jets. CONCLUSIONS: Measurement of regurgitant jet volume is a method which considers the three-dimensional shape of the examined volume. Real-time visualisation techniques which support the interactive clipping of morphological structures provide dynamic visualisation of intracardiac flow during the heart cycle. Dynamic colour visualisation of jets together with myocardial structures allows the assignment of intracardiac flow to morphological structures.

Molecular analysis of a GM2-activator deficiency in two patients with GM2-gangliosidosis AB variant.

Lysosomal degradation of ganglioside GM2 by beta-hexosaminidase A (hex A) requires the presence of the GM2 activator protein (GM2AP) as an essential cofactor. A deficiency of the GM2 activator causes the AB variant of GM2 gangliosidosis, a recessively inherited disorder characterized by excessive neuronal accumulation of GM2 and related glycolipids. Two novel mutations in the GM2 activator gene (GM2A) have been identified by the reverse-transcriptase-PCR method--a three-base deletion, AAG262-264, resulting in a deletion of Lys88, and a single-base deletion, A410, that causes a frameshift. The latter results in substitution of 33 amino acids and the loss of another 24 amino acid residues. Both patients are homoallelic for their respective mutations inherited from their parents, who are heteroallelic at the GM2A locus. Although the cultured fibroblasts of both patients produce normal levels of activator mRNA, they lack a lysosomal form of GM2AP. Pulse/chase labeling of cultured fibroblasts of the patients, in presence and absence of brefeldin A, indicates a premature degradation of both--mutant and truncated--GM2APs in the endoplasmic reticulum or Golgi. These results were supported by in vitro translation experiments and expression of the mutated proteins. When the mutated GM2APs were expressed in Escherichia coli, both mature GM2AP forms turned proved to exhibit only residual activities in an in vitro assay.

Expression of the three alternative forms of the sphingolipid activator protein precursor in baby hamster kidney cells and functional assays in a cell culture system.

Sphingolipid activator proteins (SAPs) are non-enzymatic glycoproteins required for lysosomal degradation of various sphingolipids with short oligosaccharide chains by their respective exohydrolases. Four of these (SAP-A to SAP-D or saposins A to D) are derived from a common precursor by proteolytic processing. Alternative splicing of the SAP-precursor gene results in insertion of additional 6 or 9 bases of exon 8' or 8, respectively, into the SAP-B coding region of the transcribed mRNAs. To examine the features of the three different SAP-precursor proteins (prosaposins), the respective cDNAs were stably expressed in baby hamster kidney cells. Pulse-chase experiments with transfected cells and endocytosis studies on human fibroblasts showed that synthesis, transport, and maturation of all SAP-precursor led to formation of the four mature SAPs (SAP-A to SAP-D). In order to determine the biological function of the three different SAP-B isoforms, SAP-precursor-deficient human fibroblasts were loaded with recombinant SAP-precursor proteins with or without 2- and 3-amino acid insertions, respectively, purified from the medium of the baby hamster kidney cells. They were found to stimulate at nanomolar concentrations the turnover of biosynthetically labeled ceramide, glucosylceramide, and lactosylceramide. Since the physiological function of SAP-B is to stimulate the degradation of sulfatide by arylsulfatase A (EC 3.1.6.1) and globotriaosylceramide by beta-galactosidase (EC 3.2.1.23) loading studies with the respective exogenously labeled lipids on SAP-precursor-deficient fibroblasts were performed. Addition of different purified SAP-precursors to the medium of the lipid-loaded fibroblasts showed positive stimulation of the lipid degradation by all three SAP-B isoforms derived from the SAP-precursors. These findings establish that all three forms of the SAP-B can function as sulfatide/globotriaosylceramide activator.

Three-dimensional color Doppler flow reconstruction and its clinical applications.

The visualization and quantification of intracardiac blood flow have always been a challenging task for the cardiologist. The advent of color Doppler flow imaging substantially enhanced the clinical diagnosis of heart valve disease. Three-dimensional (3-D) color Doppler, a new diagnostic procedure, refines the diagnostic value of color Doppler by providing unique spatial and temporal information about the actual extension, direction, origin, and size of intracardiac flows. Here, we describe the procedure for 3-D color Doppler reconstruction of intracardiac blood flow velocities and reveal the varied findings in different heart pathologies that cause blood flow disturbances. An automated procedure for the segmentation of turbulent and laminar flows, which allows for the measurement of mitral regurgitant jet volumes, is one of the first 3-D quantitative approaches to the clinical assessment of mitral valve regurgitation. The major technical advances of this procedure include the direct use of digital color Doppler velocity data and an automatic voxel count of the turbulent jet flows. Three-dimensional color Doppler not only can disclose the spatial complex geometry of intracardiac blood flow disturbances but also can quantitatively assess the severity of mitral valve regurgitation.

Biosynthesis, processing, and intracellular transport of GM2 activator protein in human epidermal keratinocytes. The lysosomal targeting of the GM2 activator is independent of a mannose-6-phosphate signal.

The processing, intracellular transport, and endocytosis of the GM2 activator protein (GM2AP), an essential cofactor of beta-hexosaminidase A for the degradation of ganglioside GM2, was investigated in human epidermal keratinocytes. The GM2AP precursor is synthesized as an 18-kDa peptide, which is singly glycosylated, resulting in 22-kDa high mannose and 24-27-kDa complex glycoforms. A small portion of the 22-kDa form bears phosphomannosyl residues. About 30% of the GM2AP precursor is secreted during 12 h after synthesis, consisting almost exclusively of complex glycoforms. In a post-Golgi compartment, the intracellular remainder is converted to a 20-kDa mature form within 24 h, bearing a heavily trimmed N-glycan on a 17-kDa backbone. Interestingly, even nonglycosylated GM2AP is delivered to the lysosome, as shown by tunicamycin treatment and subcellular fractionation. Also, its endocytosis is independent of carbohydrate-linked signals and is even more effective for nonglycosylated GM2AP. We conclude that a mannose-6-phosphate-independent pathway for the lysosomal delivery of GM2AP exists in cultured human keratinocytes.

Three-dimensional Doppler. Techniques and clinical applications.

AIMS: Colour Doppler is the most widely used technique for assessing valve disease, but eccentric regurgitant jets cannot be visualized and measured by conventional 2D techniques. We have developed a new procedure for three-dimensional (3D) reconstruction of colour Doppler signals. METHODS AND RESULTS: Fifty patients with mitral regurgitation underwent transoesophageal echocardiography and 3D acquisition. The severity of mitral regurgitation was assessed by angiography and the regurgitant volumes were measured by pulsed Doppler. The jet areas were calculated by planimetry from conventional colour Doppler; the jet volumes were obtained by 3D Doppler. A higher degree of mitral regurgitation was found in the patients with eccentric jets. While jet areas showed poor correlation with regurgitant volumes (r = 0.61), jet volumes correlated significantly with regurgitant volumes (r = 0.93; P < 0.001). While jet areas failed to identify patients with different grades of regurgitation, jet volumes could so discriminate. CONCLUSIONS: 3D Doppler revealed new patterns of regurgitant flow and allowed a more accurate semiquantitative assessment of complex asymmetrical regurgitant jets. Three-dimensional colour Doppler has a great potential for becoming a reference method for the assessment of patients with heart valve disease.