CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 12 AFRICA Table 2 shows the distribution of patients by number of TTE quantification methods. Only one method of quantification had been possible in 20 (40%) patients. Among the 30 patients who had more than one method of quantification, five (10%) had discrepancies in results. Therefore, for 25 (50%) cases, the operator had difficulty in assessing AR severity and considered TTE as inconclusive for the quantification of AR. Finally, with TTE, AR was considered mild in eight (16 %) patients, moderate in seven (14%), severe in 10 (20%) and inconclusive in 25 (50%) patients. The main indication for use of 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. The indication for use of CMR was inconclusive TTE in 25 (50%) patients, aortic bicuspid valve in 13 (26%), valvular aortic prosthesis in eight (16%) and ascending aortic assessment in 17 (34%) patients. Among the 25 patients (50%) with non-conclusive TTE results, CMR was also indicated in six patients (12%) for aortic bicuspid valve, three (6%) for aortic prosthesis and four patients (8%) for ascending aortic assessment. Among all patients, AR quantification by CMR was as follows: 14 patients (28%) had mild AR, 26 (52%) had moderate AR and 10 had (20%) severe AR. Among the 25 patients (50%) with inconclusive TTE, CMR finally detected 14% with mild AR (seven patients), 22% with moderate AR (11 patients) and 14% with severe AR (seven patients). Among the 25 patients (50%) who had AR graded by TTE, quantification of AR was concordant with both methods in seven patients (14%). Compared to CMR, AR was underestimated in six (12%) patients (five considered mild by TTE and moderate by CMR, and one considered moderate by TTE and severe by CMR). AR was overestimated in 12 (24%) patients (eight considered severe by TTE and moderate by CMR, and four considered moderate by TTE and mild by CMR) (Table 3). Therefore, AR was re-graded by CMR in 18 (36%) patients. The concordance between the two AR quantification modalities (TTE and CMR) was weakly significant (ICC = 0.39, 95% CI: 0.003–0.67, p = 0.02). Among all patients, six (12%) had a LVEDDTTE > 70 mm. Out of these six patients, AR grade using TTE was determined as follows: severe in three (6%) patients, inconclusive in two (4%) and mild in one patient (2%). The three patients who had severe AR using TTE were classified as severe by CMR in two patients and moderate in one. The two with inconclusive AR were classified as moderate in one patient and severe in the other using CMR. Lastly, the only patient with mild AR on TTE was classified as moderate on CMR. Twenty-five patients (50%) had inconclusiveARquantification on TTE. Among them, seven had severe AR on CMR and five had subsequent aortic valvular replacement. Two patients with severe AR on CMR had medical therapy and close follow up. All patients with possible AR quantification using TTE, and severe AR on CMR, had aortic valve replacement (Fig. 5). Among the six patients with LVEDDTTE > 70 mm, three had aortic valvular replacement (two patients with severe AR on TTE and CMR, and one with inconclusive AR on TTE and severe AR on CMR). LV volume measurements were performed on all patients, both by TTE and CMR (Table 2). LV volumes were lower with TTE than with CMR: LVEDVTTE vs LVEDVCMR (95.9 ± 27.4 vs 133.3 ± 38.1 ml/m², p < 0.01) and LVESVTTE vs LVESVCMR (65.0 ± 25.5 vs 41.1 ± 21.1 ml/m², p < 0.01). On the other hand, LVEFTTE was higher than LVEFCMR (54.1 ± 10.5 vs 51.8 ± 8.6%, p = 0.03). Table 1. Clinical data Patient characteristics Number (%) or mean ± SD Age (years) 52.1 ± 16.1 Gender (male) 38 (76) Systolic blood pressure (mmHg) 135.1 ± 20.1 Diastolic blood pressure (mmHg) 72.2 ± 10.4 Heart rate (bpm) 69.8 ± 13.0 Body surface area (m²) 1.9 ± 0.2 Body mass index (kg/m²) 25.7 ± 4.6 Hypertension 27 (54) Diabetes mellitus 2 (4) Dyslipidaemia 6 (12) Coronary artery disease 5 (10) NYHA class I 38 (76) II 6 (12) III 5 (10) IV 1 (2) NYHA, New York Heart Association. Table 2. TTE and CMR data TTE and CMR data Number (%) or mean ± SD LVEDVTTE (ml/m²) 95.9 ± 27.4 LVESVTTE (ml/m²) 41.1 ± 21.1 LVEDDTTE (mm) 61.4 ± 7.8 LVESDTTE (mm) 43.2 ± 9.1 LVEFTTE (%) 54.1 ± 10.5 RVolTTE (ml) 53.3 ± 21.6 EDVDA (cm/s) 18.1 ± 6.4 PHT (ms) 460.6 ± 153.1 Vena contracta (mm) 5.3 ± 2.4 Inconclusive quantification by TTE 25 (50) Number of quantification methods by TTE One method 20 (40) Two methods 14 (28) Three methods 8 (16) Four methods 8 (16) Disagreement between TTE methods 5 (10) LVEDVCMR (ml/m²) 133.3 ± 38.1 LVESVCMR (ml/m²) 65.1 ± 25.5 RFCMR (%) 35.5 ± 14.1 RVolCMR (ml) 29.7 ± 17.1 LVEFCMR (%) 51.8 ± 8.6 Late gadolinium enhancement 5 (10) TTE, transthoracic echocardiography; CMR, cardiovascular magnetic resonance imaging; LVEDV, left ventricular end-diastolic volume; LVESV, left ventricular end-systolic volume; LVEDD, left ventricular end-diastolic dimension; LVESD, left ventricular end-systolic dimension; LVEF, left ventricular ejection fraction; RVol, regurgitant volume; EDVDA, end-diastolic velocity in the descending aorta; PHT, pressure half-time; RF, regurgitant fraction. Table 3. Comparison of AR severity on TTE and CMR AR severity, n (%) CMR Mild Moderate Severe TTE Mild 3 (6) 5 (10) 0 (0) Moderate 4 (8) 2 (4) 1 (2) Severe 0 (0) 8 (16) 2 (4) Inconclusive 7 (14) 11 (22) 7 (14) AR, aortic regurgitation; TTE, transthoracic echocardiography; CMR, cardiovascular magnetic resonance imaging
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