Assessment of the severity of valvular regurgitation by digital subtraction angiography compared to cineangiography

The purpose of this study was to evaluate whether the degree of valvular regurgitation could be reliably estimated by digital subtraction angiography using a 0 to 4+ scale of measurement identical to that applied in conventional cineangiography. Thirty-seven sets of angiograms, each consisting of a digital subtraction angiogram (DSA) and a cineangiogram (CINE) were obtained from 33 patients. Twenty-three angiogram sets were obtained from the ventricles, while 14 were performed in the ascending aorta. Both DSA and CINE images were analyzed for regurgitation by two independent observers. A weighted kappa statistical analysis, carried out to determine the extent to which the two observers agreed on DSA and CINE assessments, demonstrated excellent agreement. The degree of atrioventricular valve regurgitation manifested by DSA was not significantly different from that determined on CINE for either Observer A or B (1.8 ± 1.2 by CINE vs 2.1 ± 1.5 by DSA, 2.1 ± 1.4 vs 2.5 ± 1.0, respectively). However, occasional exceptions occurred in which the degree of atrioventricular valve regurgitation was overestimated by DSA as compared to CINE. Conversely, in 12 cases with aortic regurgitation, DSA overestimated the grade of regurgitation compared to CINE, 2.3 ± 1.1 by CINE vs 3.2 ± 0.8 by DSA (p < 0.01) for Observer A and 2.1 ± 1.2 vs 3.0 ± 1.0 (p < 0.01) for Observer B. The phenomenon which best explains these data is the occurrence of digital enhancement of myocardial opacification produced by coronary perfusion radiocontrast during angiography. Thus, although DSA generally yielded results comparable to conventional CINE in the quantitation of mitral regurgitation, this technique resulted in a systematic overestimation of the severity of aortic regurgitation.