CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 AFRICA 9 Aortic regurgitation: multimodal assessment of quantification and impact Marie-Paule Bernadette N’Cho-Mottoh, Olivier Huttin, Christine Selton-Suty, Soukaina Scadi, Laura Filippetti, Pierre-Yves Marie Abstract Background: The assessment of severity of aortic regurgitation (AR) by transthoracic echocardiography (TTE) remains challenging in routine practice. Contemporary guidelines recommend cardiovascular magnetic resonance imaging (CMR) in patients with significant disease and suboptimal TTE images. The objective of this study was to assess the role of CMR in the evaluation of severity of AR and to compare both modalities in the quantification of regurgitation and left ventricular volumes. Methods: Fifty consecutive patients who had isolated chronic AR and who underwent TTE and CMR within an interval of less than three months between May 2009 and June 2020 were included. The main indication for CMR was difficulties in quantifying AR, either because of lack of multiparametric analysis (only one method possible) or because of discrepancies in the different methods by TTE. Results: In 25 patients, precise grading of AR was not possible by echocardiography. Among them, CMR finally detected seven patients with mild AR, 11 with moderate AR and seven with severe AR. For the 25 patients who had AR quantification by TTE, there was concordance between TTE and CMR in only seven patients (28%), and the AR was re-graded by CMR in 18 patients, including eight patients with severe AR by TTE and moderate AR by CMR. The concordance between TTE and CMR was weakly significant (intraclass correlation coefficient = 0.39, 95% confidence interval: 0.003– 0.67, p = 0.02). There was a moderate correlation between left ventricular volumes measured by TTE and by CMR (left ventricular end-diastolic volume: r = 0.57; p = 0.01; left ventricular end-systolic volume: r = 0.47, p = 0.01) but regurgitant volumes were not correlated (r = 0.04; p = 0.8). No TTE parameter of quantification was correlated with regurgitant volume measured by CMR. Conclusion: The concordance of AR quantification by CMR and TTE was weak. CMR re-graded some patients with severe AR by TTE into moderate AR. This should motivate practitioners to systematically assess all significant AR by CMR in order to improve quantification and optimise clinical management. Keywords: aortic regurgitation, quantification, multimodality, cardiac magnetic resonance Submitted 10/2/21, accepted 24/2/22 Published online 8/3/22 Cardiovasc J Afr 2023; 34: 9–15 www.cvja.co.za DOI: 10.5830/CVJA-2022-013 Reliable assessment of severity of valvular regurgitation is crucial in the prognosis and clinical management of patients with aortic regurgitation (AR).1 Transthoracic echocardiography (TTE) is the primary clinical imaging modality to assess severity of AR, but AR quantification remains challenging in routine practice.2 The current recommended echocardiographic assessment of AR uses both quantitative and semi-quantitative criteria. The proximal isovelocity surface area (PISA) method, using two-dimensional (2D) colour Doppler echocardiography is the most widely used approach to estimate the regurgitant volume (RVol) and effective regurgitant orifice area (EROA).3-5 However, this method has several limitations: difficulty in correctly identifying the flow convergence zone, confined flow convergence zones (patients with cusp perforation or commissural leaks), and obtuse flow convergence angles such as those with aneurysmal dilation of the ascending aorta.3 Contemporary guidelines2,6 recommend cardiovascular magnetic resonance imaging (CMR) in patients with significant disease and suboptimal TTE images, which acknowledges CMR’s superior capacity to quantify AR volume and regurgitant fraction by direct measurement of aortic blood flow and to accurately compare right ventricular (RV) and left ventricular (LV) stroke volumes.7,8 The objective of this study was to assess the role of CMR in the evaluation of severity of AR in current practice and to compare both modalities in the quantification of regurgitation and LV volumes. Methods This study was performed in the Cardiology Department of Nancy University Hospital Centre (Brabois Hospital). Three analysis and archiving databases were used: DxCare for clinical data, Echopac version R3 for echocardiographic data and Syngovia for CMR data. All consecutive patients who had isolated chronic AR and who underwent TTE and CMR within an interval of less than three months, from May 2009 to June 2020, were included (Fig. 1). Patients with primary cardiomyopathy and those with other significant valvular disease and atrial fibrillation were excluded. Echocardiographic examinations were performed using commercially available scanners (Vivid 7, Vivid 9 or Vivid 95, Department of Cardiology, Institut Lorrain du Cœur et des Vaisseaux, Nancy University Hospital, Vandoeuvre les Nancy, France Marie-Paule Bernadette N’Cho-Mottoh, MD, nchomottoh@yahoo.fr Olivier Huttin, MD, MSc Christine Selton-Suty, MD Soukaina Scadi, MD Laura Filippetti, MD Pierre-Yves Marie, MD, PhD Institut de Cardiologie d’Abidjan, Abidjan, Ivory Coast Marie-Paule Bernadette N’Cho-Mottoh, MD
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