Automatic Detection of Vena Contracta Width for the Mitral Regurgitation Assessment

Automatic Detection of Vena Contracta Width for the Mitral

Regurgitation Assessment

Kalpana Saini

*Dept of Electrical Engineering, Indian institute of Technology Roorkee, Uttarakhand, India, 247667

# Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education

Abstract: The aim of this paper is to derive an automatic method for vena contracta width detection for the severity of

regurgitation (MR). Vena contracta width is the efficient method to grading the severity of MR, but it is very difficult to locate

this narrowest part exactly in transthoracic echocardiography

there is a need to develop such method which is able to find out the vena contracta width. A

between the results obtained from the computing method and results obtained by the clinicians.

Keywords: Echocardiography; Transthoracic;

1. Introduction

Mitral regurgitation is the most common disease

of heart. Perfect assessment is required for the quick

and correct therapy of the mitral valve. In literature

many noninvasive techniques based on Doppler

echocardiography [1–9] have been discussed.

At present interest in color Doppler imaging for

vena contracta for the assessment of mitral

regurgitation is increasing progressively [10

vena contracta is the narrowest part of the regugitant

jet can also be called as ‘neck’ of the jet [12] and

having location just downstream from the orifice and

before the jet area [13] as in fig.1. Vena contracta is

slightly smaller than the mitral orifice due to

boundary effects, so the effective regurgitant orifice

area (EROA) can be measured by the vena contracta

[14]. If the orifice is fixed then the size of the vena

contracta is independent of driving pressure and flow

rate [15]. But for dynamic regugitant orifice vena

contracta may change with hemodynamic or during

the cardiac cycle [16]. Research [17 –20] shows that

the regurgitant orifice size can be presented by the

vena contracta width obtained from the color Doppler

imaging. Hence in recent studies measurement of

vena contracta is the mostly used method for the MR

assessment [10, 1, 21 –23].

In [1, 22, 24, 10] vena contracta is to be assumed

as the accurate method for finding out the severity of

MR, using TTE or TEE method. Literature [

[22] shows that vena contracta diameter can also be

measured by TTE with a good feasibility (between

95% and 97%). But recent study shows that the

determination of vena contracta is more feasible by

TEE [26]. In case of mitral regurgitation, the ven


Regurgitation Assessment

Kalpana Saini*, M.L.Dewal

*, Manojkumar Rohit

#

Dept of Electrical Engineering, Indian institute of Technology Roorkee, Uttarakhand, India, 247667

Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education

& Research, Chandigarh, India, 160012

The aim of this paper is to derive an automatic method for vena contracta width detection for the severity of

Vena contracta width is the efficient method to grading the severity of MR, but it is very difficult to locate

transthoracic echocardiography (TTE) as well as in transesophageal echocardiography

there is a need to develop such method which is able to find out the vena contracta width. A comparison also has been made

between the results obtained from the computing method and results obtained by the clinicians.

Transthoracic; Transesophageal; Mitral; Regurgitation; Vena contracta.

Mitral regurgitation is the most common disease

of heart. Perfect assessment is required for the quick

valve. In literature

many noninvasive techniques based on Doppler

9] have been discussed.

At present interest in color Doppler imaging for

vena contracta for the assessment of mitral

regurgitation is increasing progressively [10–11]. The

vena contracta is the narrowest part of the regugitant

jet can also be called as ‘neck’ of the jet [12] and

having location just downstream from the orifice and

before the jet area [13] as in fig.1. Vena contracta is

orifice due to

boundary effects, so the effective regurgitant orifice

area (EROA) can be measured by the vena contracta

[14]. If the orifice is fixed then the size of the vena

contracta is independent of driving pressure and flow

c regugitant orifice vena

contracta may change with hemodynamic or during

20] shows that

the regurgitant orifice size can be presented by the

vena contracta width obtained from the color Doppler

t studies measurement of

vena contracta is the mostly used method for the MR

In [1, 22, 24, 10] vena contracta is to be assumed

as the accurate method for finding out the severity of

MR, using TTE or TEE method. Literature [1] and

vena contracta diameter can also be

measured by TTE with a good feasibility (between

95% and 97%). But recent study shows that the

determination of vena contracta is more feasible by

TEE [26]. In case of mitral regurgitation, the vena

contracta diameter can vary over time, particularly in

the case of mitral regurgitation [28]. In some

literature [28-30] it is suggested that vena contracta

diameter should be measured at the time of its

maximal width for mitral regurgitation.

The aim of this paper to develop an image

processing based technique by which vena contracta

width can be find out automatically during mitral

regurgitation. Color Doppler echocardiography is

used for collecting the images. These images are in

RGB color space. First step in preprocessing stage is

to separate the color jet which is formed in left

ventricle. Then covert this RGB color space to gray

scale. After this preprocessing stage vena contracta

width had been detected.

This paper describes a method by which a clinician

is able to find out vena contracta width automatically

during MR. Accurate assessment is helpful to cure,

replace or maintain the valve.


Dept of Electrical Engineering, Indian institute of Technology Roorkee, Uttarakhand, India, 247667

Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education

The aim of this paper is to derive an automatic method for vena contracta width detection for the severity of the mitral

Vena contracta width is the efficient method to grading the severity of MR, but it is very difficult to locate

echocardiography (TEE). So

comparison also has been made

contracta diameter can vary over time, particularly in

the case of mitral regurgitation [28]. In some

30] it is suggested that vena contracta

diameter should be measured at the time of its

maximal width for mitral regurgitation.

The aim of this paper to develop an image

processing based technique by which vena contracta

width can be find out automatically during mitral

regurgitation. Color Doppler echocardiography is

used for collecting the images. These images are in

or space. First step in preprocessing stage is

to separate the color jet which is formed in left

ventricle. Then covert this RGB color space to gray

scale. After this preprocessing stage vena contracta

thod by which a clinician

is able to find out vena contracta width automatically

Accurate assessment is helpful to cure,

International Journal of Computer Science and Management Research Vol 2 Issue 5 May 2013 ISSN 2278-733X

Kalpana Saini et.al. www.ijcsmr.org 2455

Fig. 1. Color Doppler image with Mitral regurgitation

2. Clinical Methods for Assessmen

regurgitation

There are normally three methods with color

Doppler echocardiography for quantifying the

regurgitation severity. These are regurgitation jet

area, flow convergence (PISA) and vena contracta

width. In the present paper vena

considered for our research work. Because the jet

area is good method but less accurate compare to

vena contracta and PISA is very time consuming.

Fig. 2 shows the regions for the flow convergence, jet

area and vena contracta formation.

Fig. 2. Representation of different zones for the Doppler methods

2.1 Jet area:

Jet area is the mosaic pattern formed just beyond

the mitral leaflets. Large jet area in the left ventricle

shows the more MR than small jets. It is the fastest

method for the assessment of regurgitant severity.

Severity grade can also be decided just by

visualization of the jet. The relation between jet area

and MR severity is shown in many papers [29

32].There are many technical and hemodynamic

limitations so the jet area method is less sensitive

about the severity of MR. Such as in case of patients

with acute severe MR as well as low blood pressure

and elevated pressure in LA shows a small eccentric

flow jet area. In case of hypertension jet area is large

for mild MR. Atrium size also affects the jet area

size. Central directed color flow jet into L

the times appear larger because of the red blood cells

appear all sides of the jets. But the eccentric jet that

touches the atrium wall appears similar or lesser

severity. Pulse repetition frequency (PRF) and color

gain affect the jet size significantly. In slandered

technique aliasing velocity or the Nyquist limit

Fig. 1. Color Doppler image with Mitral regurgitation

2. Clinical Methods for Assessment of Mitral

There are normally three methods with color

Doppler echocardiography for quantifying the

regurgitation severity. These are regurgitation jet

area, flow convergence (PISA) and vena contracta

width. In the present paper vena contracta is

considered for our research work. Because the jet

area is good method but less accurate compare to

vena contracta and PISA is very time consuming.

Fig. 2 shows the regions for the flow convergence, jet

g. 2. Representation of different zones for the Doppler methods

Jet area is the mosaic pattern formed just beyond

the mitral leaflets. Large jet area in the left ventricle

shows the more MR than small jets. It is the fastest

method for the assessment of regurgitant severity.

Severity grade can also be decided just by the

visualization of the jet. The relation between jet area

and MR severity is shown in many papers [29-

32].There are many technical and hemodynamic

limitations so the jet area method is less sensitive

about the severity of MR. Such as in case of patients

with acute severe MR as well as low blood pressure

and elevated pressure in LA shows a small eccentric

flow jet area. In case of hypertension jet area is large

for mild MR. Atrium size also affects the jet area

size. Central directed color flow jet into LA most of

the times appear larger because of the red blood cells

appear all sides of the jets. But the eccentric jet that

touches the atrium wall appears similar or lesser

Pulse repetition frequency (PRF) and color

icantly. In slandered

technique aliasing velocity or the Nyquist limit

should be 50–60 cm/s, and color gain should be such

that it eliminates the random color speckle generated

from the nonmoving regions. Color jet area is also

affected by the flow momentum. Grading by color jet

is given as that in case mild MR jet area is less than

4cm2 or less than 20% of the LA area trace. Moderate

MR having jet area values between 4 cm

Whereas in more area of jet than 10 cm

case of severe MR.

2.2. Proximal Isovelocity Surface Area (PISA) or

Flow Convergence Method (FC):

The flow convergence method provides a way of

finding out the effective regurgitant orifice area

(EROA). It estimates the area of orifice. This method

is based on (1) Flow dynamics properties a

continuity principle. The PISA method [33], [34] can

be understood by the fig. 2. When the blood forces

from the chamber to the orifice with a constant

flow, it particles accelerates towards the orifice along

a series of streamlines until the velocity reach its

maximum value at the orifice. Acceleration of

particles occurs creates a hemisphere path whose

centre is orifice itself. As the particles accelerate

then color changes from dark red to orange and then

to yellow. When hemispheres reach at the aliasing

velocity v cm/s then it will turns to blue. Distance of

this hemisphere to orifice i.e. the radius of the

hemisphere is r cm. because the flow rate of FC is

equal to the flow equal to orifice flow rate. So if the

velocity of the regurgitant orifice is represented as

orificeV then

22 orificer v EROA Vπ = ×

or EROA

Although it gives the better performance than

the jet area but it is very time consuming whereas the

jet area is the fast method. Other limitation is that it is

based on certain assumptions such that regurgitant

orifice assumed to be circular. But

orifice is not circular then the shape of hemisphere is

also changed. If there is multiple regurgitating

orifices then the flow converges method may be

completely inaccurate. There is also significant effect

of the gain adjustment.

2.3 Vena contracta

The cross sectional area is directly related to the

regurgitant orifice area. Due complex and

unpredictable shape the regurgitant orifice area is

very difficult to measure. For such a measurement jet

60 cm/s, and color gain should be such

that it eliminates the random color speckle generated

from the nonmoving regions. Color jet area is also

m. Grading by color jet

is given as that in case mild MR jet area is less than

or less than 20% of the LA area trace. Moderate

MR having jet area values between 4 cm2 to 10 cm

2.

Whereas in more area of jet than 10 cm2 shows the

. Proximal Isovelocity Surface Area (PISA) or

Flow Convergence Method (FC):

The flow convergence method provides a way of

finding out the effective regurgitant orifice area

(EROA). It estimates the area of orifice. This method

cs properties and (2) the

continuity principle. The PISA method [33], [34] can

be understood by the fig. 2. When the blood forces

from the chamber to the orifice with a constant

flow, it particles accelerates towards the orifice along

eamlines until the velocity reach its

maximum value at the orifice. Acceleration of

particles occurs creates a hemisphere path whose

centre is orifice itself. As the particles accelerate

then color changes from dark red to orange and then

hemispheres reach at the aliasing

cm/s then it will turns to blue. Distance of

this hemisphere to orifice i.e. the radius of the

cm. because the flow rate of FC is

equal to the flow equal to orifice flow rate. So if the

velocity of the regurgitant orifice is represented as

22

orifice

r vEROA

V

π=

(1)

Although it gives the better performance than

the jet area but it is very time consuming whereas the

jet area is the fast method. Other limitation is that it is

based on certain assumptions such that regurgitant

orifice assumed to be circular. But in actual if the

orifice is not circular then the shape of hemisphere is

also changed. If there is multiple regurgitating

orifices then the flow converges method may be

completely inaccurate. There is also significant effect

The cross sectional area is directly related to the

regurgitant orifice area. Due complex and

unpredictable shape the regurgitant orifice area is

very difficult to measure. For such a measurement jet



is to be image in short axis plane. In clinical settings,

it is very difficult to localize the narrowest area from

the jet. So a correlation is measured between the VC

width which is measured from the zoomed view of

the parasternal long axis and apical views, and the

EROA by quantitative Doppler [1]. Relation between

EROA and VC width is also being given in other

literatures [29, 26, 24]. This relation shows good

results even in eccentric MR [23]. The VC width is

the one dimensional measurement whereas EROA is

the two dimensional so there are some limitations

also. But in [1] it is shown that VC width is the much

better tool for measurement of severity of MR. Such

as VC width less than 0.3cm indicates the mild MR.

If this value is in between 0.3 and 0.5 then it is the

case of moderate MR. But if the VC width is more

than 0.5cm than it indicates the severe MR.

In any view the localization of the VC width is

very difficult. So an experienced clinician is required

for the measurement of such narrowest portion. This

is very time consuming also to locate the exact VC.

So this paper is introducing a technique to locate the

VC and find out the VC width automatically.

3. Automatic detection of VC width: The

Proposed Method

Block diagram in fig. 3 shows the steps of the

proposed method for automatic detection of vena

contracta width.

Fig. 3. Algorithm for vena contracta width detection

At the preprocessing stage the ROI ie. the color

area has been detected. After that the image has been

converted to gray scale from color image,

processing. Next step is to detect the jet area in which

vena contracta exists. For this region growing

proceeding by morphological operation have been

done. There may be some spurious areas also

generated so need to remove these areas so that able

to concentrate on the main area.

In clinical settings,

it is very difficult to localize the narrowest area from

the jet. So a correlation is measured between the VC

width which is measured from the zoomed view of

the parasternal long axis and apical views, and the

ppler [1]. Relation between

EROA and VC width is also being given in other

literatures [29, 26, 24]. This relation shows good

results even in eccentric MR [23]. The VC width is

the one dimensional measurement whereas EROA is

e some limitations

shown that VC width is the much

better tool for measurement of severity of MR. Such

as VC width less than 0.3cm indicates the mild MR.

If this value is in between 0.3 and 0.5 then it is the

t if the VC width is more

than 0.5cm than it indicates the severe MR.

In any view the localization of the VC width is

very difficult. So an experienced clinician is required

for the measurement of such narrowest portion. This

also to locate the exact VC.

So this paper is introducing a technique to locate the

VC and find out the VC width automatically.

Automatic detection of VC width: The

Block diagram in fig. 3 shows the steps of the

proposed method for automatic detection of vena

Fig. 3. Algorithm for vena contracta width detection

preprocessing stage the ROI ie. the color

the image has been

from color image, for further

processing. Next step is to detect the jet area in which

vena contracta exists. For this region growing

proceeding by morphological operation have been

urious areas also

generated so need to remove these areas so that able

Now aim is to find out the vena contracta width

from this area. We need to count the elements in each

row in this area. As shown in fig. 4 the row

the minimum pixels inside the jet area is the region

where vena contracta exist. The total number of

pixels in this region is the vena contracta width in

pixels.

Fig. 4. Counting for elements inside the object

Total number of nonzero elements

object is given as in equation (2)

j n

ij

i m

E e=

=

=∑

Where ij

e is the th

ij element inside the object i.e.

itthe element at the th

i row and

contracta width can be find out as in

min( )widthVC E=

This value is in pixels. To compare with clinical data

it is good to convert this value to centimeters.

4. Experiments and discussion

Figure 5 shows the original images with mitral

regurgitation taken from PGIMER Chandigarh.

cases have been taken in this research work.

parasternal and long axis views are taken to the

detection of regurgitation jet.

Figure 6 shows the images with region of interest

from where vena contracta width can be find out.

This is the color area in which VC exist.

Figure 7 shows the images after segmentation

process. From this figure we can see that there is

pixel value is 1 inside the ROI and zero outside the

ROI.

Now aim is to find out the vena contracta width

from this area. We need to count the elements in each

row in this area. As shown in fig. 4 the row showing

the minimum pixels inside the jet area is the region

where vena contracta exist. The total number of

pixels in this region is the vena contracta width in

Fig. 4. Counting for elements inside the object

Total number of nonzero elements in arrow inside the

(2)

inside the object i.e.

row and th

j column. Vena

contracta width can be find out as in equation (3)

(3)

This value is in pixels. To compare with clinical data

it is good to convert this value to centimeters.

Figure 5 shows the original images with mitral

regurgitation taken from PGIMER Chandigarh. Nine

cases have been taken in this research work.

parasternal and long axis views are taken to the

Figure 6 shows the images with region of interest

from where vena contracta width can be find out.

This is the color area in which VC exist.

Figure 7 shows the images after segmentation

process. From this figure we can see that there is

1 inside the ROI and zero outside the



Fig.5. Color Doppler images with mitral regurgitation

Fig. 6. Object extracted Images

Fig.5. Color Doppler images with mitral regurgitation

Fig. 6. Object extracted Images

Fig. 7. Final segmented images for vena contracta width

It can be analyzed from table 1 that the automatic

vena contracta width detection method proposed here

satisfies the severity grade given by the clinician.

Table 1. MR severity grade checking

5. Conclusion

Here TTE images have been taken for the

experiment in the case of valvular regurgitations.

Vena contracta diameter is directly related to the

effective regurgitant orifice area (EROA). Automatic

Images Vena

Contracta

width in

(pixels)

Vena

Contracta

width

(Cm)

1 13 0.58

2 14 0.61

3 8 0.46

4 12 0.56

5 8 0.46

6 12 0.56

7 11 0.54

8 11 0.54

9 9 0.39

Fig. 7. Final segmented images for vena contracta width

It can be analyzed from table 1 that the automatic

vena contracta width detection method proposed here

satisfies the severity grade given by the clinician.

Table 1. MR severity grade checking

Here TTE images have been taken for the

experiment in the case of valvular regurgitations.

Vena contracta diameter is directly related to the

orifice area (EROA). Automatic

MR

Severity

(by

Proposed

method)

MR

Severity

(by

Clinician)

severe severe

severe severe

moderate moderate

severe severe

moderate moderate

severe severe

severe severe

severe severe

moderate moderate



detection of vena contracta width presented in this

paper gives a time saving method for finding out the

severity of MR. there is no need to zoom out the vana

contracta width portion in this method. Zooming the

view increase the burring in the image. VCW is not

load independent in MR because short-term changes

in loading conditions produce dynamic changes in the

regurgitant orifice. Cause of MR does not always

predict accurately whether the regurgitant orifice is

fixed or dynamic.

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Automatic Detection of Vena Contracta Width for the Mitral Regurgitation Assessment

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