Time-varying effective mitral valve area:: prediction and validation using cardiac MRI and Doppler echocardiography in normal subjects

Precise knowledge of the volume and rate of early rapid left ventricular (LV) filling elucidates kinematic aspects of diastolic physiology. The Doppler E wave velocity-time integral (VTI) is conventionally used as the estimate of early, rapid-filling volume; however, this implicitly requires the assumption of a constant effective mitral valve area (EMVA). We sought to evaluate whether the EMVA is truly constant throughout early, rapid filling in 10 normal subjects using cardiac magnetic resonance imaging (MRI) and contemporaneous Doppler echocardiography, which were synchronized via ECG. LV volume measurements as a function of time were obtained via MRI, and transmitral flow values were measured via Doppler echocardiography. The synchronized data were used to predict EMVA as a function of time during early diastole. Validation involved EMVA determination using 1) the short-axis echocardiographic images near the mitral valve leaflet tips, 2) the distance between leaflet tips in the echocardiographic parasternal long-axis view, and 3) the distance between leaflet tips from the MRI LV outflow tract view. Predicted EMVA values varied substantially during early rapid filling, and observed EMVA values agreed well with predictions. We conclude that the EMVA is not constant, and its variation causes LV volume to increase faster than is reflected by the VTI. These results reveal the mechanism of early rapid volumetric increase and directly affect the significance and physiological interpretation of the VTI of the Doppler E wave. Application to subjects in selected pathophysiological subsets is in progress.