November 1, 2025Echocardiography1 citations

Diagnostic COncordance in Aortic Regurgitation Severity AssessMent: A ComPARative Study Between Cardiologists With Different Level of Expertise, the COMPARE‐AR Study

GVGiacomo Maria VianiEpatocentro Ticino HBHekuran BytyciEnte Ospedaliero Cantonale VVVincenzo Viccaro

Structured PICO

Which echocardiographic parameter provides the highest interobserver reproducibility for assessing chronic aortic regurgitation severity?

Population

99 patients referred for transthoracic echocardiography (TTE) for chronic aortic regurgitation (AR) evaluation, with a subset of 22 patients also undergoing cardiac magnetic resonance (CMR).

Intervention

Echocardiographic assessment of AR severity using pressure half-time (PHT), vena contracta width (VCW), and PISA-derived parameters (EROA) by expert cardiologists and trainees.

Comparator

Comparison between different echocardiographic parameters, between expert cardiologists and trainees, and with CMR-derived parameters.

Outcome

Interobserver agreement (reproducibility) of echocardiographic parameters measured by Cohen's Kappa.surrogate

Vena contracta width is the most reproducible echocardiographic parameter for assessing aortic regurgitation severity across different levels of operator expertise, while CMR provides excellent reproducibility when TTE is inconclusive.

Abstract

PURPOSE: Accurate echocardiographic assessment of chronic aortic regurgitation (AR) is challenging and subject to interobserver variability. We aim to evaluate reproducibility of guideline-recommended echocardiographic parameters in real-world practice and to assess cardiac magnetic resonance (CMR) as a complementary modality. METHODS: We retrospectively analyzed 99 patients referred to us for transthoracic echocardiography (TTE) for AR evaluation. A subset of 22 patients also underwent CMR. AR severity was independently graded according to ESC and ASE guidelines by two expert cardiologists and two trainees using semi-quantitative and quantitative parameters: pressure half-time (PHT), vena contracta width (VCW), and PISA-derived parameters, such as regurgitant orifice area (EROA). Interobserver agreement was analyzed using Cohen's Kappa, Bland-Altman analysis, and intraclass correlation coefficients. RESULTS: VCW showed the highest reproducibility (overall κ = 0.77), strong agreement across groups (EXACT team κ = 0.7, TRAIN team κ = 0.86), and high feasibility (68.7%). PHT demonstrated poor interobserver consistency (overall κ = 0.36), wide intra-team variability (EXACT team κ = 0.30 vs. TRAIN team κ = 0.39), and high feasibility (77.8%). EROA showed moderate agreement (overall κ = 0.55, EXACT team κ = 0.64, TRAIN team κ = 0.74) and low feasibility (30.3%). CMR-derived parameters (forward flow, backflow, and regurgitant fraction) displayed excellent reproducibility even between novice and expert readers. CONCLUSIONS: VCW is the most reliable echocardiographic parameter for AR assessment, while PHT and EROA are limited by variability and feasibility, respectively. Given its reproducibility and independence from operator expertise, CMR should be considered early when TTE findings are inconclusive. A simplified TTE-first approach, followed by timely CMR, may optimize staging and management of chronic AR.

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