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      Quantification of mitral regurgitation in patients with hypertrophic cardiomyopathy using aortic and pulmonary flow data: impacts of left ventricular outflow tract obstruction and different left ventricular segmentation methods

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          Cardiovascular magnetic resonance (CMR) imaging in patients with hypertrophic cardiomyopathy (HCM) enables the assessment of not only left ventricular (LV) hypertrophy and scarring but also the severity of mitral regurgitation. CMR assessment of mitral regurgitation is primarily based on the difference between LV stroke volume (LVSV) and aortic forward flow (Ao) measured using the phase-contrast (PC) technique. However, LV outflow tract (LVOT) obstruction causing turbulent, non-laminar flow in the ascending aorta may impact the accuracy of aortic flow quantification, leading to false conclusions regarding mitral regurgitation severity. Thus, we decided to quantify mitral regurgitation in patients with HCM using Ao or, alternatively, main pulmonary artery forward flow (MPA) for mitral regurgitation volume (MRvol) calculations.


          The analysis included 143 prospectively recruited subjects with HCM and 15 controls. MRvol was calculated as the difference between LVSV computed with either the inclusion (LVSV incl) or exclusion (LVSV excl) of papillary muscles and trabeculations from the blood pool and either Ao (MRvol Aoi or MRvol Aoe) or MPA (MRvol MPAi or MRvol MPAe). The presence or absence of LVOT obstruction was determined based on Doppler echocardiography findings.


          MRvol Aoi was higher than MRvol MPAi in HCM patients with LVOT obstruction [47.0 ml, interquartile range (IQR) = 31.5–60.0 vs. 35.5 ml, IQR = 26.0–51.0; p < 0.0001] but not in non-obstructive HCM patients (23.0 ml, IQR = 16.0–32.0 vs. 24.0 ml, IQR = 15.3–32.0; p = 0.26) or controls (18.0 ml, IQR = 14.3–21.8 vs. 20.0 ml, IQR = 14.3–22.0; p = 0.89). In contrast to controls and HCM patients without LVOT obstruction, in HCM patients with LVOT obstruction, aortic flow-based MRvol (MRvol Aoi) was higher than pulmonary-based findings (MRvol MPAi) (bias = 9.5 ml; limits of agreement: −11.7–30.7 with a difference of 47 ml in the extreme case). The differences between aortic-based and pulmonary-based MRvol values calculated using LVSV excl mirrored those derived using LVSV incl. However, MRvol values calculated using LVSV excl were lower in all the groups analyzed (HCM with LVOT obstruction, HCM without LVOT obstruction, and controls) and with all methods of MRvol quantification used ( p ≤ 0.0001 for all comparisons).


          In HCM patients, LVOT obstruction significantly affects the estimation of aortic flow, leading to its underestimation and, consequently, to higher MRvol values than those obtained with MPA-based MRvol calculations.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12968-017-0417-8) contains supplementary material, which is available to authorized users.

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          Most cited references 27

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          A concordance correlation coefficient to evaluate reproducibility.

           Aigu L. Lin (1989)
          A new reproducibility index is developed and studied. This index is the correlation between the two readings that fall on the 45 degree line through the origin. It is simple to use and possesses desirable properties. The statistical properties of this estimate can be satisfactorily evaluated using an inverse hyperbolic tangent transformation. A Monte Carlo experiment with 5,000 runs was performed to confirm the estimate's validity. An application using actual data is given.
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            Guidelines and protocols for cardiovascular magnetic resonance in children and adults with congenital heart disease: SCMR expert consensus group on congenital heart disease

            Cardiovascular magnetic resonance (CMR) has taken on an increasingly important role in the diagnostic evaluation and pre-procedural planning for patients with congenital heart disease. This article provides guidelines for the performance of CMR in children and adults with congenital heart disease. The first portion addresses preparation for the examination and safety issues, the second describes the primary techniques used in an examination, and the third provides disease-specific protocols. Variations in practice are highlighted and expert consensus recommendations are provided. Indications and appropriate use criteria for CMR examination are not specifically addressed.
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              American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with hypertrophic cardiomyopathy: Endorsed by the American Society of Nuclear Cardiology, Society for Cardiovascular Magnetic Resonance, and Society of Cardiovascular Computed Tomography.


                Author and article information

                J Cardiovasc Magn Reson
                J Cardiovasc Magn Reson
                Journal of Cardiovascular Magnetic Resonance
                BioMed Central (London )
                21 December 2017
                21 December 2017
                : 19
                [1 ]GRID grid.418887.a, Magnetic Resonance Unit, Department of Radiology, , Institute of Cardiology, ; Warsaw, Poland
                [2 ]GRID grid.418887.a, Department of Interventional Cardiology and Angiology, , Institute of Cardiology, ; Warsaw, Poland
                [3 ]GRID grid.418887.a, Department of Cardiomyopathy, , Institute of Cardiology, ; Warsaw, Poland
                [4 ]GRID grid.418887.a, Department of Congenital Heart Diseases, , Institute of Cardiology, ; Warsaw, Poland
                [5 ]ISNI 0000 0001 2306 7492, GRID grid.8348.7, Oxford Centre for Clinical Magnetic Resonance Research, , John Radcliffe Hospital, ; Headington, Oxford, UK
                [6 ]GRID grid.418887.a, Department of Coronary and Structural Heart Diseases, , Institute of Cardiology, ; Warsaw, Poland
                [7 ]GRID grid.418887.a, Unit for Screening Studies in Inherited Cardiovascular Diseases, , Institute of Cardiology, ; Warsaw, Poland
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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