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Quantification of Mitral Regurgitation in Mitral Valve Prolapse by 3D Vena Contracta Area: Derived Cut-off Values and Comparison with 2D Multiparametric Approach.

BACKGROUND: Echocardiographic grading of mitral regurgitation (MR) in mitral valve prolapse (MVP) is challenging. 3D vena contracta area (3D VCA) has been proposed as valuable method. However, data defining the cut-off values of severity and validation in the subset of patients with MVP are scarce. The aim of this study was to validate the 3D VCA by 3D transesophageal color-Doppler echocardiography (3D-TEE) in patients with MVP and to define the cut-off values of severity grading. The secondary aim was to compare 3D VCA to the EROA-PISA method.

METHODS: 1138 patients with at least moderate MR who underwent TEE were included. 3D VCA was measured, the cut-off value and area under the curve (AUC) for the prediction of severe MR were estimated by ROC curve using guideline-suggested multiparametric approach as reference standard. In a subgroup of patients, 3D regurgitant volume (3D RV) and 3D fraction (3D RF) were calculated from mitral and left ventricular outflow tract stroke volumes to further validate 3D VCA against a 3D volumetric reference standard.

RESULTS: The optimal 3D VCA cut-off value for predicting severe MR was 0.45cm2 (specificity 0.87; sensitivity 0.90) with an AUC of 0.95 using multiparametric approach as reference. 3D VCA had a good linear correlation with EROA-PISA (r = 0.62, p<0.05) with larger values compared to EROA-PISA (0.63 cm2 vs 0.44cm2 , p<0.05). A cut-off of 0.50cm2 (AUC of 0.84, sensitivity 0.78, specificity 0.78) predicts an EROA-PISA of 0.40cm2 . 3D VCA had a good linear correlation with 3D RVOL (r= 0.56, p<0.01), with an AUC of 0.86 to predict a 3D RF > 50%.

CONCLUSIONS: The present study suggests 0.45 cm2 as the best cut-off value of 3D VCA to define severe MR in patients with MVP, showing an optimal agreement with the reference standard multiparametric approach and 3D RV.

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