Novel 3-D-EROA quantification by color Doppler echocardiography serves as a reliable tool to identify severe mitral valve regurgitation before percutaneous mitral valve repair

Frederic-Joaquim Schwarz (Tübingen)1, T. Harm (Tübingen)1, M. Zdanyte (Tübingen)2, A. Goldschmied (Tübingen)2, L. Baas (Tübingen)1, P. Aidery (Tübingen)2, S. Shcherbyna (Tübingen)1, I. Toskas (Tübingen)1, T. Keller (Tübingen)1, I. Kast (Tübingen)1, J. Schreieck (Tübingen)2, T. Geisler (Tübingen)2, M. Gawaz (Tübingen)2, K. A. L. Müller (Tübingen)2

1Universitätsklinikum Tübingen Innere Medizin III, Kardiologie und Angiologie Tübingen, Deutschland; 2Universitätsklinikum Tübingen Innere Medizin III, Kardiologie und Kreislauferkrankungen Tübingen, Deutschland



Mitral regurgitation (MR) often leads to hospitalization of patients with drastic symptoms due to heart failure. A precise quantification of MR severity is essential for decision-making, treatment, and outcome of patients.  Echocardiography is the primary, essential diagnostic tool and 3D Color doppler facilitates estimation of MR but selection of patients with severe MR and necessity of invasive treatment remains challenging.


In this study, we investigate the diagnostic value of effective regurgitation orifice area (EROA) quantification by 3D compared to 2D echocardiography in patients with MR and highlight the improved discrimination of MR severity in patients undergoing transcatheter edge-to-edge repair (TEER).


We consecutively enrolled fifty patients with primary or secondary and at least moderate MR undergoing 2D and 3D color Doppler echocardiography prior to TEER. Improved accuracy of MR grading by 3D EROA was compared to the reference standard including two-dimensional measures.


Measures of 2D- and 3D echocardiography including EROA revealed significant differences regarding the correct grading of MR severity compared to the established reference standard. Quantification of EROA remarkably varies between 2D and 3D echocardiography and the discrimination between moderate and severe MR was significantly (p=0.001) different using 2D or 3D EROA, respectively. 3D EROA correlated significantly (r=0.501, p<0.001) better with the pre-defined MR severity compared to 2D EROA. We detected crucial differences in the correct identification of severe MR between 2D and 3D techniques, thus 2D color Doppler echocardiography significantly (p<0.0001) underestimates EROA due to clinical and morphological parameters. In patients with severe MR undergoing TEER, the assessment of 3D measures including EROA resulted in improved diagnostic accuracy.


Our study elucidates that quantification of MR by EROA using three-dimensional echocardiography improves diagnostic precision in patients with severe MR; the currently recommended 2D echocardiographic approach significantly underestimated severity of MR in patients undergoing TEER.


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