Rationale and Objectives
Evaluate quantification of the aortic regurgitant fraction and volume with computed tomography (CT).
Materials and Methods
Fifty-three patients with aortic regurgitation (AR) and 29 controls were examined with 64-multi-detector CT coronary angiography and transthoracic echocardiography (TTE). A dedicated software algorithm employing three-dimensional segmentation of left ventricle (LV) and right ventricle (RV) volumes and LV mass was applied. AR volume and fraction was calculated based on RV and LV stroke volumes (SV) and compared with echocardiography. The aortic regurgitant orifice area (ROA) was measured by CT.
Results
A good correlation of the AR fraction and AR volume determined by CT compared to echocardiography was found for mild, moderate, and severe AR with 14.2% ± 9, 28.8% ± 8, and 57.9% ± 9 ( r = 0.95, P < .001) for AR fraction, and 15.7 mL ± 11.33 mL ± 14, and 98.9 mL ± 36 for AR volume ( r = 0.92, P < .0001), respectively. CT correctly classified severity of AR in 93% of patients based of AR-fraction, and in 89% based on AR volume. The sensitivity and specificity of CT were 98% and specificity 90.3%. The specificity improved to 97%, if the ROA by CT was added as diagnostic criterion.
Conclusion
Aortic regurgitation fraction and volume can be accurately quantified from CT coronary angiography datasets. These parameters can assist clinical management, e.g. in case of pending cardiac surgery decision.
The prognosis of patients with chronic aortic regurgitation (AR) depends on determining the optimal time point of aortic valve surgery. There is consensus that surgery is indicated in symptomatic patients with severe AR, but controversy exists regarding the management and timing of surgery in asymptomatic or mildly symptomatic patients .
In these patients, the indication for surgery is based on accurately staging severity of AR and on identifying early signs of left ventricular (LV) dysfunction or pathological ventricular dilatation. LV ejection fraction (EF) is an independent predictor of overall survival besides the AR severity ; however, left ventricular ejection fraction (LVEF) is not the most sensitive parameter to identify early signs of impaired contractile dysfunction .
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Materials and methods
Study Population and Design
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Inclusion criteria
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Exclusion criteria
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CT Examination Technique
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Postprocessing
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TTE
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Statistical Analysis
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Results
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Table 1
Study Population (82 Patients)
Age (y) 58 ± 16 (range, 31–87) Gender ( n ) 29 females (35%) Body surface area (m 2 ) 1.8 ± 0.3 (1.4–2.4) Height (cm) 172 ± 7.7 (157–193) Weight (kg) 74 ± 12.8 (43–111) Aortic regurgitation grade by TTE Mild (n/n, %) 19/53 (36%) Moderate (n/n, %) 15/53 (28%) Severe (n/n, %) 19/53 (36%) Normal (control) (n) 29 Functional anatomy of AR (types 1–3 ∗ ) (53 patients) Type 1 (root dilatation) 25 (47%) Type 2 (cusp prolapsed) 6 (11.3%) Type 3 (IE or restrictive) † 3 (5.6%) None of above (eg, degenerative-asymmetric valve closure) 17 (32%) Aortic dissection 2 (3.8%) Aortic root size (cm) 3.5 ± 0.7 (range, 1.9–6.3) Concomitant aortic stenosis 17/53 (32%) Mild AR 15/19 (79%) Moderate AR 2/15 (1.3%) Severe AR 0/19 (0%)
AR, aortic regurgitation; IE, infective endocarditis; TTE, transthoracic echocardiography.
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Quantification of AR
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Table 2
Aortic Regurgitant Fraction, Volume, and the Anatomic Regurgitant Orifice Area (ROA): CT versus TTE
Aortic Regurgitation TTE n = 53 Control
Group
n = 29P Value ∗ Mild
n = 19 Moderate
n = 16 Severe
n = 19 CT AR-fract (%) 14.2 ± 9 28.8 ± 8 57.9 ± 9 −0.4 ± 7 <.001 AR vol (mL) 15.7 ± 11 32.8 ± 3.8 98.9 ± 36 0.5 ± 7 <.001 Correct graduationby AR fract%(n/n, %) 19/19 (100%) 12/15 (80%) 18/19 (94.8%) 26/31 (84%) Correct graduation byAR vol (n/n, %) 18/19 (94.8%) 12/15 (80%) 17/19 (89.5%) 26/31 (84%) ROA (cm 2 ) 0.09 ± 0.1 (range, 0–0.46) 0.4 ± 0.1 (range, 0.38–64) 0.80 ± 0.4 (range,0.32–1.53)
AR vol, aortic regurgitant volume; AR-fract, aortic regurgitant fraction; ROA, regurgitation orifice area.
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Quantification of LV and RV Volumes, Function, and Myocardial Mass
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Table 3
LV and RV Volume, Function, and Myocardial Mass
Aortic Regurgitationby TTE n = 53 Control
Group
n = 29P Value Mild
n = 19 Moderate
n = 16 Severe
n = 19 Total in AR CT LVESV (mL) 59.4 ± 5 83 ± 14 142 ± 16 96 ± 62 60 ± 18 <.001 ∗ LVEDV (mL) 162 ± 36 194 ± 52 312 ± 99 224.5 ± 96 147 ± 24 .001 LVSV (mL) 101 ± 22 111 ± 22 161 ± 51 129 ± 47 87 ± 16 <.001 ∗ LVEF (%) 63 ± 9 59 ± 14 55 ± 12 59.5 ± 12 60.6 ± 8 .69 RVEDV (mL) 181 ± 33 175 ± 29 195 ± 56 184 ± 42 170 ± 31 .188 RVESV (mL) 97 ± 21 96 ± 23 116 ± 36 104 ± 36 86 ± 21 .03 ∗ RVSV (mL) 84 ± 21 87 ± 23 81 ± 53 78 ± 20 84 ± 16 .243 RVEF (%) 46 ± 5 44 ± 6 37 ± 10 42 ± 9 51 ± 6 <.001 ∗ LV mass (g) 205 ± 41 223 ± 59 287 ± 91 240 ± 46 139 ± 10 <.001
CT, computed tomography; EDV, end-diastolic volume; EF, ejection fraction; ESV, end-systolic volume; LV, left ventricular; RV, right ventricular.
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Discussion
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Limitations
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Conclusion
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