Circulation, Vol 90, 307-322, Copyright © 1994 by American Heart Association
E Schwammenthal, C Chen, F Benning, M Block, G Breithardt and RA Levine
BACKGROUND: The proximal flow convergence method, a quantitative color
Doppler flow technique, has been validated recently for calculating
regurgitant flow and orifice area. We investigated the potential of the
method as a tool to study different pathophysiological mechanisms of mitral
valve incompetence by assessing the time course of regurgitant flow and
orifice area and analyzed the implications for quantification of mitral
regurgitation. METHODS AND RESULTS: Fifty-six consecutive patients with
mitral regurgitation of different etiologies were studied. The
instantaneous regurgitant flow rate Q(t) was computed from color M-mode
recordings of the proximal flow convergence region and divided by the
corresponding orifice velocity V(t) to obtain the instantaneous orifice
area A(t). Regurgitant stroke volume (RSV) was obtained by integrating
Q(t). Mean regurgitant flow rate Qm was calculated by RSV divided by
regurgitation time. Peak-to-mean regurgitant flow rates Qp/Qm and orifice
areas Ap/Am were calculated to assess the phasic character of Q(t) and
A(t). In the first 24 patients (group 1), computation of Qm and RSV from
the color Doppler recordings was compared with the conventional pulsed
Doppler method (r = .94, SEE = 29.4 mL/s and r = .95, SEE = 9.7 mL) as well
as with angiography (rs = .93 and rs = .94, P < .001). The temporal
variation of Q(t) and A(t) was studied in the next 32 patients (group 2):
In functional regurgitation in dilated cardiomyopathy (n = 12), there was a
constant decrease in A(t) throughout systole with an increase during left
ventricular relaxation; Ap/Am was 5.49 +/- 3.17. In mitral valve prolapse
(n = 6), A(t) was small in early systole, increasing substantially in
midsystole, and decreasing mildly during left ventricular relaxation; Ap/Am
was 2.48 +/- 0.26. In rheumatic mitral regurgitation (n = 14), a roughly
constant regurgitant orifice area during most of systole was found in 4
patients. In the other patients there was significant variation of A (t)
and the time of its maximum; Ap/Am was 1.81 +/- 0.56. ANOVA demonstrated
that the differences in Ap/Am were related to the etiology of mitral
regurgitation (P < .0001). To verify that the calculated variation in
regurgitant orifice area during the cardiac cycle reflects an actual
variation, the ability of the method to predict a constant orifice area
throughout systole was tested experimentally in a canine model of mitral
regurgitation. Five flow stages were produced by implanting fixed grommet
orifices of different sizes into the anterior mitral leaflet. A constant
regurgitant orifice area was correctly predicted throughout systole with a
mean percent error of -1.8 +/- 4% (from -6.9% to +5.8%); the standard
deviation of the individual curves calculated at 10% intervals during
systole averaged 13.3% (from 3.6% to 19.6%). In addition, functional mitral
regurgitation caused by ventricular dysfunction was produced
pharmacologically in five dogs, and the color M-mode recordings of the
proximal flow convergence region were obtained with the transducer placed
directly on the heart instead of the chest, thus ruling out a significant
effect of translational motion on the observed flow pattern. The pattern of
regurgitant flow variation was identical to that observed in patients.
CONCLUSIONS: The proximal flow convergence method demonstrates that
regurgitant flow and orifice area vary throughout systole in distinct
patterns characteristic of the underlying mechanism of mitral incompetence.
Therefore, in addition to the potential of the method as a tool to quantify
mitral regurgitation, it allows analysis of the pathophysiology of
regurgitation in the individual patient, which may be helpful in clinical
decision making. Calculating mitral regurgitant flow rate and volume from
the time- varying proximal flow field (ie, without assuming a constant
orifice area that would produce overestimation in individual patients)
provides excellent agreement with independent te
ARTICLES
Dynamics of mitral regurgitant flow and orifice area. Physiologic application of the proximal flow convergence method: clinical data and experimental testing
Hospital of the Westfalische Wilhelms University of Munster, Germany.
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