Functional classification of aortic regurgitation using cardiac computed tomography: comparison with surgical inspection

  • Hyun Jung Koo
  • Joon-Won Kang
  • Jeong A Kim
  • Joon Bum Kim
  • Sung-Ho Jung
  • Suk Jung Choo
  • Cheol Hyun Chung
  • Jae Won Lee
  • Tae-Hwan Lim
  • Dong Hyun YangEmail author
Original Paper


In patients with aortic regurgitation (AR), a precise preoperative assessment of aortic valve (AV) pathology is important if AV repair or sparing operation is an alternative option. The aim of this study was to assess the diagnostic accuracy of computed tomography (CT) for evaluating the AR mechanism compared with surgical inspection. 59 patients with AR who underwent AV surgery and preoperative cardiac CT were evaluated. AR mechanism was classified into type 1 (aortic dilatation or cusp perforation), type 2 (prolapsed cusp) and type 3 (cusp retraction). Agreement between CT and surgical inspection was obtained. Correlation between aortic regurgitant orifice (ARO) and imaging parameters were evaluated. On surgical inspection, type 1 AR was noted in 22 patients, type 2 in 16 and type 3 in 21. Agreement regarding the AR mechanism on CT was excellent (intra-class correlation coefficient, 0.81). At the patient level, the Cohen’s κ value for CT findings with surgical inspection was of 0.89. At the cusp level, moderate agreement was noted between CT and surgical inspection. In the per-cusp analysis, CT had a sensitivity of 72.6%, specificity of 85.1%, positive predictive value of 73.8% and negative predictive value of 84.3% for the detection of aortic cusp abnormality. The diameter, perimeter and area of aortic annulus had moderate correlation with ARO (r = 0.54–0.66, P < 0.001). CT-derived classification of AR mechanism showed excellent agreement with surgical inspection.


Aortic valve Aortic regurgitation Computed tomography Aortic valve repair Aortic valve replacement 



Aortic regurgitation


Aortic regurgitation orifice


Aortic valve


Aortic valve replacement


Confidence interval


Computed tomography


Left ventricle


Intra-class correlation coefficient


Transesophageal echocardiography



This work was supported by National Research Foundation of Korea (NRF) grants funded by the Korean government (MSIP) (NRF-2016R1A1A1A05921207 and NRF-2015R1A2A2A04003034) and by a Grant (2017-7208) from the Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea. This work was also funded by the Industrial Strategic technology development program (10072064) of the Ministry of Trade Industry and Energy of Korea. The content of this study is solely the responsibility of the authors and does not represent the official views of the funding sources, and the funding sources had no involvement in this study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.


The authors have no relationships relevant to the contents of this paper to disclose.

Supplementary material

10554_2018_1341_MOESM1_ESM.tif (7 mb)
Supplementary Fig. 1. Measurement of aortic regurgitant orifice and perpendicular image of the aortic valve in-plane view. (A) A 63-year-old female with an aortic valve operation planned because of severe central aortic regurgitation. The yellow line indicates 5-mm image slice thickness to obtain the aortic valve in-plane view in (B). (B) In the centre of three partial prolapsed aortic cusps, the aortic regurgitant orifice (red area inside the red dotted line, 65 mm2) is noted during the closing of the aortic valve at the end-diastolic phase of the heart. (C) From the aortic valve in-plane view obtained with a 1-mm slice thickness image, the perpendicular plane of the red dotted line through the aorta to the left ventricle direction was obtained as (D). (D) In this plane, prolapsed aortic cusps are well demonstrated. Ao, ascending aorta; LA, left atrium; LV, left ventricle; PA, pulmonary artery. (TIF 7187 KB)
10554_2018_1341_MOESM2_ESM.docx (16 kb)
Supplementary material 2 (DOCX 15 KB)


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Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2018

Authors and Affiliations

  • Hyun Jung Koo
    • 1
  • Joon-Won Kang
    • 1
  • Jeong A Kim
    • 2
  • Joon Bum Kim
    • 3
  • Sung-Ho Jung
    • 3
  • Suk Jung Choo
    • 3
  • Cheol Hyun Chung
    • 3
  • Jae Won Lee
    • 3
  • Tae-Hwan Lim
    • 1
  • Dong Hyun Yang
    • 1
    Email author
  1. 1.Department of Radiology and Research Institute of Radiology, Cardiac Imaging Center, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  2. 2.Department of Radiology, Ilsan Paik HospitalInje University College of MedicineGoyangRepublic of Korea
  3. 3.Department of Cardiovascular Surgery, Cardiac Imaging Center, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea

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