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Comparative Study
. 2018 Jan 15;20(1):5.
doi: 10.1186/s12968-017-0426-7.

Tricuspid flow and regurgitation in congenital heart disease and pulmonary hypertension: comparison of 4D flow cardiovascular magnetic resonance and echocardiography

Mieke M P Driessen  1   2 , Marjolijn A Schings  1   3 , Gertjan Tj Sieswerda  1 , Pieter A Doevendans  1 , Erik H Hulzebos  4 , Marco C Post  5 , Repke J Snijder  6 , Jos J M Westenberg  7 , Arie P J van Dijk  8 , Folkert J Meijboom  1 , Tim Leiner  9
Affiliations
Comparative Study

Tricuspid flow and regurgitation in congenital heart disease and pulmonary hypertension: comparison of 4D flow cardiovascular magnetic resonance and echocardiography

Mieke M P Driessen et al. J Cardiovasc Magn Reson. .

Abstract

Background: Tricuspid valve (TV) regurgitation (TR) is a common complication of pulmonary hypertension and right-sided congenital heart disease, associated with increased morbidity and mortality. Estimation of TR severity by echocardiography and conventional cardiovasvular magnetic resonance (CMR) is not well validated and has high variability. 4D velocity-encoded (4D-flow) CMR was used to measure tricuspid flow in patients with complex right ventricular (RV) geometry and varying degrees of TR. The aims of the present study were: 1) to assess accuracy of 4D-flow CMR across the TV by comparing 4D-flow CMR derived TV effective flow to 2D-flow derived effective flow across the pulmonary valve (PV); 2) to assess TV 4D-flow CMR reproducibility, and 3) to compare TR grade by 4D-flow CMR to TR grade by echocardiography.

Methods: TR was assessed by both 4D-flow CMR and echocardiography in 21 healthy subjects (41.2 ± 10.5 yrs., female 7 (33%)) and 67 RV pressure-load patients (42.7 ± 17.0 yrs., female 32 (48%)). The CMR protocol included 4D-flow CMR measurement across the TV, 2D-flow measurement across the PV and conventional planimetric measurements. TR grading on echocardiographic images was performed based on the international recommendations. Bland-Altman analysis and intra-class correlation coefficients (ICC) were used to asses correlations and agreement.

Results: TV effective flow measured by 4D-flow CMR showed good correlation and agreement with PV effective flow measured by 2D-flow CMR with ICC = 0.899 (p < 0.001) and mean difference of -1.79 ml [limits of agreement -20.39 to 16.81] (p = 0.084). Intra-observer agreement for effective flow (ICC = 0.981; mean difference - 1.51 ml [-12.88 to 9.86]) and regurgitant fraction (ICC = 0.910; mean difference 1.08% [-7.90; 10.06]) was good. Inter-observer agreement for effective flow (ICC = 0.935; mean difference 2.12 ml [-15.24 to 19.48]) and regurgitant fraction (ICC = 0.968; mean difference 1.10% [-7.96 to 5.76]) were comparable. In 25/65 (38.5%) TR grade differed by at least 1 grade using 4D-flow CMR compared to echocardiography.

Conclusion: TV effective flow derived from 4D-flow CMR showed excellent correlation to PV effective flow derived from 2D-flow CMR, and was reproducible to measure TV flow and regurgitation. Twenty-five out of 65 patients (38.5%) were classified differently by at least one TR grade using 4D-flow CMR compared to echocardiography.

Keywords: 4D-flow MRI; Congenital heart disease; Echocardiography; Pulmonary hypertension; Tricuspid regurgitation.

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Conflict of interest statement

Authors’ information

Not applicable.

Dr. John Oshinski served as a Guest Editor for this manuscript.

Ethics approval and consent to participate

The Ethical Review boards of all participating centers approved the study and written informed consent was obtained from all participants prior to inclusion. The primary ethical review committee was at University medical Center Utrecht (number METC-11-003). The ethical review boards of both Radboud University medical Center (number 2011/329) and Antonius Hospital Nieuwegein (number LTME/L-11.34/RV-def) also extended their approval.

Consent for publication

In the current manuscript, data is not reducible to a patient. However, in all patients consent for publication was obtained in all patients upon prior to inclusion (part of informed consent).

Competing interests

The authors declare that they have no competing interests. M.P. has received lecture fees from Bayer, Actelion and Pfizer. M.D. has received a research grant from the ICIN-Netherlands heart house (Utrecht, the Netherlands).

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Example of 4D flow. Example of 4D-flow CMR analysis. In a-d the annular plane is reconstructed perpendicular to the flow direction, in figure e + f the flow contours are drawn in the reconstructed through-plane flow slice
Fig. 2
Fig. 2
Accuracy of 4D-flow CMR. a) depicts the correlation between effective flow across the tricuspid valve using 4D-flow CMR (4D-flow TV) and effective flow across the pulmonary valve using 2D-flow CMR (2D-flow PV). b) depicts a Bland-Altman analysis with the difference between both effective flow measurements on the x-axis and the average of both measurements on the y-axis
Fig. 3
Fig. 3
Tricuspid valve 2D-flow versus 4D-flow. Bland-Altman plots of tricuspid valve effective flow using a static annular plane (similar to 2D flow) versus effective flow across the pulmonary valve (a) and versus 4D flow (b). c) depicts tricuspid regurgitant fraction using a static annular plane (2D flow on y-axis) versus 4D flow (x-axis)
Fig. 4
Fig. 4
Reproducibility of 4D flow CMR measurements. a&b Bland-Altman analysis of intra-observer repeated measurements of effective flow (a) and regurgitation (b). c&d Bland-Altman analysis of inter-observer repeated measurements of effective flow (c) and regurgitation (d)
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