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• W4200495131 abstract "Aortic regurgitation (AR) is a common complication of continuous-flow left ventricular mechanical support. In the case of left ventricular assist devices (LVADs), 1 in 4 patients develops moderate or worse AR after 3 years.1Jorde UP Uriel N Nahumi N et al.Prevalence, significance, and management of aortic insufficiency in continuous flow left ventricular assist device recipients.Circ Heart Fail. 2014; 7: 310-319Google Scholar AR in the setting of LVAD results in a circular pattern of blood flow that can lead to diminished cardiac output, worsening heart failure, and increased mortality.2Toda K Fujita T Domae K et al.Late aortic insufficiency related to poor prognosis during left ventricular assist device support.Ann Thorac Surg. 2011; 92: 929-934Google Scholar Conventional echocardiographic methods of quantifying AR severity do not account for retrograde flow during the systolic period. Therefore, application of traditional grading based on static metrics, such as vena contracta width, potentially underestimates AR severity. Subtracting the Doppler-derived right ventricular outflow tract (RVOT) stroke volume from the calculated LVAD flow also is limited by error in measuring RVOT stroke volume with echocardiography. In HeartMate 2, diastolic flow acceleration and systolic-diastolic peak velocity ratio of outflow cannula have shown correlations with regurgitant fraction derived from echocardiography and right-sided heart catheterization.3Grinstein J Kruse E Sayer G et al.Accurate quantification methods for aortic insufficiency severity in patients with LVAD: Role of diastolic flow acceleration and systolic-to-diastolic peak velocity ratio of outflow cannula.JACC Cardiovasc Imaging. 2016; 9: 641-651Google Scholar An accurate assessment of AR in the setting of current mechanical ventricular support devices continues to present a diagnostic dilemma. Central to the assessment of regurgitant severity in a continuous-flow device is the measure of flow over time. Depiction of the flow convergence zone using color Doppler employing transesophageal echocardiography from a deep transgastric view allows for the calculation of the proximal isovelocity surface area (PISA). Although regurgitant orifices are frequently central, PISA is typically hemispheric in shape. The mathematical result of multiplying the PISA (cm2) by the color Doppler aliasing velocity (cm/s) is flow (cm3/s). In the case of a patient with an LVAD, the pressure gradient across the regurgitant aortic valve is relatively more constant than that of a ventricle in which the intracavitary pressure builds over the course of diastole. The duration of AR can be rather variable depending on the loading conditions, LVAD speed, and presence or absence of left ventricular contractile function. Accordingly, to measure the amount of regurgitation, one must accurately measure the duration of AR. There are 2 echocardiographic approaches with sufficient temporal resolution for this task: (1) M-mode PISA, and (2) continuous-wave Doppler. The aortic valve regurgitant volume can be estimated as 2π(PISA radius)^2 × aliasing velocity × duration of AR × heart rate. The following representative calculations based on an M-mode scan came from a patient with a HeartMate 3 LVAD and mild AR (Fig 1). This image was obtained using a transesophageal deep transgastric window with a Siemens Acuson SC2000 (Mountain View, CA). Using the zoom function, M-mode then was obtained across the flow convergence zone to measure a PISA radius during an expiratory breath hold. In this patient, the M-mode PISA radius was measured to be 0.25 cm. The aliasing velocity was 26 cm/s. The duration of AR by M-mode was 0.479 seconds. The heart rate was 90 beats/min. The AVRV calculation was 438 mL/min (4.86 mL/beat). A thermal dilution cardiac output was done simultaneously and subtracted from the LVAD flow as an alternative estimate of AVRV. The thermal dilution cardiac output (3.6 L/M) minus the LVAD flow (4.0 L/M) of 400 mL/min (4.44 mL/beat) coincided with the AVRV measured with M-mode PISA. Of note, the patient had minimal tricuspid valve regurgitation. The 2-dimensional blue area subtended by boundary created by the color Doppler aliasing and the aortic valve on the M-mode plot mathematically represents the AVRV (Fig 2). This approach is analogous to that described by Buck et al., using a software to integrate mitral regurgitant flow rate over the period of regurgitation to calculate regurgitant volume.4Buck T Plicht B Kahlert P et al.Effect of dynamic flow rate and orifice area on mitral regurgitant stroke volume quantification using the proximal isovelocity surface area method.JACC. 2008; 52: 767-778Google Scholar Although this approach may be a precise way of quantifying M-mode PISA, we have found in clinical practice that using the largest M-mode PISA radius may be more reliable as the measurement can be affected by the heart's translational motion. The following representative calculations using continuous-wave Doppler came from a patient with a HeartMate 3 LVAD and moderate AR (Fig 3). This image was obtained using a transesophageal deep transgastric window with a Philips CVX (Amsterdam, The Netherlands). The AR volume measured using the flow calculation method was 45 mL/beat; while the regurgitant volume using the effective regurgitant orifice area based on PISA and the velocity time integral was 48 mL/beat. For comparison, the volumetric Doppler using right ventricular outflow tract stroke volume and using LVAD flow of 4.52 L/min resulted in a regurgitant volume of 40 mL. The slight differences in calculated regurgitant volumes could be related to the built-in pulsatility of the HeartMate 3 LVAD that potentially could lead to overestimation or underestimation of the regurgitant volume. Clearly, clinical validation studies will be needed before routine application of PISA in the assessment of aortic regurgitation in the care of patients with continuous-flow devices. The concept of calculating flow from PISA multiplying it by the AR duration potentially provides a simple solution to a difficult clinical problem. There are no affiliations with or involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the manuscript (eg, employment, consultancies, stock ownership, honoraria, and expert testimony)." @default.
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• W4200495131 date "2022-04-01" @default.
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• W4200495131 title "A Novel Approach to Quantification of Aortic Regurgitation in Left Ventricular Assist Device" @default.
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