Clinical Reproducibility of the Visual Echocardiographic Scoring System of the Left Ventricular Filling Pressure

not-yet-known not-yet-known not-yet-known unknown Visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) scoring is a simple B-mode echocardiographic method to estimate left ventricular filling pressure (LVFP). We assessed the interobserver reproducibility of the VMT scoring between a resident doctor using a handheld ultrasound device and experienced sonographers using a stationary system in 27 inpatients. The VMT scores were consistent (weighted kappa of 0.97), indicating the method’s feasibility regardless of the operator experience or device type. VMT scoring is a potential, practical and reliable method for LVFP evaluation in diverse clinical settings, particularly those with limited access to expert echocardiography. not-yet-known not-yet-known not-yet-known unknown Clinical Reproducibility of the Visual Echocardiographic Scoring System of the Left Ventricular Filling Pressure Running title : Reproducibility of the VMT score Yuka Uruma, MD1*, Michito Murayama, JRDCS, PhD2,3, Wahei Uemura, MD4*, Namiko Sakai, MS1, Midori Shimomura, MS1, Kaori Nozaki, MS1, Yasuyuki Kunieda, MD, PhD1 1 Wakkanai City Hospital, 6-11-4, Chuo, Wakkanai 097-8555, Japan 2 Department of Medical Laboratory Sciences, Faculty of Health Sciences, Hokkaido University, N12, W5, Kita-ku, Sapporo 060-0812, Japan 3 Diagnostic Center for Sonography, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo 060-8648, Japan 4 Rishiri Island National Health Insurance Center Hospital, 11 Midorimachi, Kutsugata, Rishiri-cho, Rishiri-gun, Hokkaido 097-0401, Japan not-yet-known not-yet-known not-yet-known unknown *Corresponding author: Yuka Uruma, MDWakkanai City Hospital, 6-11-4, Chuo, Wakkanai 097-8555, Japan Tel: +81-162-23-2771; Fax: +81-162-23-5636; Email: [email protected] not-yet-known not-yet-known not-yet-known unknown Wahei Uemura, MD Rishiri Island National Health Insurance Center Hospital, 11 Midorimachi, Kutsugata, Rishiri-cho, Rishiri-gun, Hokkaido 097-0401, Japan not-yet-known not-yet-known not-yet-known unknown Tel: +81-163-84-2626; Fax: +81-163-84-2640; Email: [email protected] DATA AVAILABILITY STATEMENT not-yet-known not-yet-known not-yet-known unknown The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. FUNDING STATEMENT This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. CONFLICT OF THE INTEREST STATEMENT Yuka Uruma, Michito Murayama, Wahei Uemura, Namiko Sakai, Midori Shimomura, Kaori Nozaki, and Yasuyuki Kunieda do not have any relationship that could lead to a conflict of interest. ETHICS STATEMENT This study protocol was approved by the Research Ethics Committee of Wakkanai City Hospital and was conducted in accordance with the Declaration of Helsinki. PATIENT CONSENT STATEMENT All patients agreed to participate in this study, and informed consent was obtained through an opt-out website. Those who refused were excluded. PERMISSION TO REPRODUCE MATERIAL FROM OTHER SOURCES : Not applicable. All figures and tables are original and created by the authors. CLINICAL TRIAL REGISTRATION : Not applicable. ACKNOWLEDGMENTS: We would like to thank enago (https://www.enago.jp/) for English language editing.

V isually assessed time difference between the mitral valve and tricuspid valve opening (VMT) scoring is a simple B-mode echocardiographic method to estimate left ventricular filling pressure (LVFP). We assessed the interobserver reproducibility of the VMT scoring between a resident doctor using a handheld ultrasound device and experienced sonographers using a stationary system in 27 inpatients. The VMT scores were consistent (weighted kappa of 0.97), indicating the method’s feasibility regardless of the operator experience or device type. VMT scoring is a potential, practical and reliable method for LVFP evaluation in diverse clinical settings, particularly those with limited access to expert echocardiography. not-yet-known not-yet-known not-yet-known unknown KEYWORDS: Heart failure, VMT score, left ventricular filling pressure, echocardiography, interobserver agreement, reproducibility NON-STANDARD ABBREVIATIONS AND ACRONYMS HF Heart failure IVC Inferior vena cava LV Left ventricular LVFP Left ventricular filling pressure MV Mitral valve RA Right atrial TV Tricuspid valve US Ultrasound VMT Visually assessed time difference between the mitral valve and tricuspid valve opening not-yet-known not-yet-known not-yet-known unknown 1 INTRODUCTION Heart failure (HF) is a leading cause of hospitalization and requires effective management. 1 Echocardiography plays a vital role in the assessment of patients with HF. Left ventricular (LV) filling pressure (LVFP) is an important parameter in echocardiographic evaluation, with an elevated LVFP being associated with poor clinical outcomes in patients with HF. 2 The visually assessed time difference between the mitral valve (MV) and tricuspid valve (TV) opening (VMT) score has emerged as a promising tool for LVFP estimation using only the B-mode in echocardiography. 3,4,5 Previous studies have reported that a VMT score of ≥2 was associated with adverse clinical outcomes in patients with HF, showing a wide range of LV ejection fraction. 2,6 Furthermore, the VMT score exhibited high diagnostic accuracy for patients with acute HF presenting with dyspnea, outperforming lung ultrasonography. 7 These findings indicate the potential of the VMT score to improve HF diagnosis and risk stratification. not-yet-known not-yet-known not-yet-known unknown The recent development of handheld ultrasound (US) devices has the potential to revolutionize the availability and integration of echocardiography into medical practice, particularly for noncardiology medical professionals.8 However, whether the VMT score can be correctly assessed by beginners in echocardiography and handheld US remains unknown. Therefore, the present study aimed to evaluate the interobserver agreement for the VMT score between a resident doctor and experienced cardiac sonographers to validate the reproducibility of the VMT score regardless of clinical experience and to determine whether it is suitable for use in diverse settings in primary care. not-yet-known not-yet-known not-yet-known unknown 2 MATERIALS AND METHODS not-yet-known not-yet-known not-yet-known unknown 2.1 Study population We conducted a prospective observational study including adult patients admitted to Wakkanai City Hospital from June to July 2024. We initially enrolled 30 consecutive patients scheduled to undergo echocardiography performed by cardiac sonographers. Patients with poor echocardiographic images were excluded. Ultimately, 27 patients were included in the final analysis. not-yet-known not-yet-known not-yet-known unknown 2.2 Echocardiographic examination Each patient underwent two echocardiographic examinations on the same day within 5 h. First, transthoracic echocardiography was performed by a resident doctor at the bed side using a handheld US on the hospital ward. Subsequently, a standard transthoracic echocardiography was performed by cardiac sonographers on the same patient in the echocardiography lab using a high-end stationary US. The resident and the sonographers were blinded to each other’s findings. Both observers independently evaluated the VMT score for each patient. not-yet-known not-yet-known not-yet-known unknown The VMT score was evaluated as a marker of elevated LVFP.3,4,5 Based on the earlier opening of the MV than TV in the presence of a higher LVFP than the right atrial (RA) pressure, the scoring system consists of (i) visual assessment of the time sequence of atrioventricular valve openings and (ii) estimated RA pressure based the findings in the inferior vena cava (IVC). To observe the time sequence of the atrioventricular valve openings, apical or subcostal four-chamber images with a 15–20 cm depth were acquired. The time sequence of the MV and TV opening was visually assessed using slow playback, if needed, and graded as follows: 0 = TV opening first, 1 = simultaneous, and 2 = MV opening first. (Figure 1) When a marker of abnormal RA pressure (the IVC diameter was >21 mm and collapsed to <50 % with sniffing) was detected,9 1 point was added and the VMT score was calculated as four grades from 0 to 3. Then, VMT ≥2 was considered to indicate an elevated LVFP. not-yet-known not-yet-known not-yet-known unknown 2.3 Outcome assessment Other physicians or surgeons confirmed the clinical diagnosis based on physical examination, laboratory data, chest X-ray, electrocardiogram, echocardiographic findings other than the VMT score, and clinical course at the follow-up visit. 2.4 Statistical analyses Continuous variables were expressed as mean ± standard deviation. Student’s t -test was employed to compare the continuous variables between the groups. When appropriate, categorical variables were expressed as numbers (%) and compared using the chi-squared test or Fisher’s exact test. Weighted kappa statistics was used to assess interobserver agreement for VMT score grading. 10 As a 2- or 3-point difference in the VMT score between observers represents greater disagreement than a 1-point difference, the weighted kappa was calculated (assigning partial agreement for a 1-point difference) instead of a standard (unweighted) kappa. IBM SPSS (version 25 for Windows, IBM Co., Armonk, NY, USA), R software (version 4.0.3; R Foundation for Statistical Computing, Vienna, Austria), and Excel (version 2024, BellCurve for Excel; Social Survey Research Information, Tokyo, Japan) were used for all statistical analyses. For all tests, P <0.05 was considered to indicate statistical significance. 3 RESULTS 3.1 Patient characteristics Table 1 presents the clinical characteristics of the 27 patients stratified by the VMT score. Among them, 16 (59%) had a VMT score of 0 or 1 and 11 (41%) had a score of 2 or 3. Preoperative examinations were more predominant in patients with VMT ≤1. Ischemic heart disease was the most common underlying cardiac disease, and almost half of the patients had hypertension. 3.2 Reproducibility of the VMT score Interobserver agreement analysis was conducted based on the VMT scores determined by the resident (Y.U.) and the cardiac sonographers (N.S., M.S. and K.N.) for each patient who were blinded to the clinical, hemodynamic, and other echocardiographic data. The weighted kappa value was 0.97, indicating an almost-perfect agreement in the VMT grading between the novice and the expert observers ( Table 2 ). 4 DISCUSSION This study found that the VMT score can be evaluated with excellent interobserver reproducibility, even when the assessments are conducted by individuals with different levels of US experience and using different echocardiography equipment. The almost-perfect agreement between the resident using a handheld device and the experienced sonographers using a standard machine highlights the robustness of VMT scoring. Although the interobserver agreement for the VMT score exhibited high reproducibility, discrepancies were observed in 3 out of 27 cases (Table 2), resulting in disagreement in terms of the presence or absence of elevated LVFP. These discrepancies were found to primarily arose from errors in the IVC measurement, where the resident doctor either measured the aorta instead of the IVC or relied on unclear echocardiographic images, leading to incorrect assessment of the RA pressure component. The findings of this study indicate the potential of VMT scoring as a reliable and reproducible method for LVFP estimation, even for less-experienced practitioners. Moreover, as both handheld and stationary US can accurately measure the VMT score, the VMT score can be evaluated regardless of the type of US device. However, challenges remain, particularly in patients with suboptimal imaging conditions, such as those who are overweight or unable to assume optimal positions. In these cases, the acquisition of clear MV and TV images is difficult, which can compromise accuracy. In addition, whereas apical and subcostal four-chamber views were effective for assessing the VMT score, the incorporation of parasternal views may improve visualization and accuracy in difficult cases. The simplicity of the VMT score, which does not require Doppler functionality, highlights its utility in resource-constrained settings and its accessibility for clinicians with varying levels of US expertise. not-yet-known not-yet-known not-yet-known unknown 5 STUDY LIMITATIONS The present study has several limitations that need to be acknowledged. First, the resident doctor and cardiac sonographers did not simultaneously perform echocardiography. Although both procedures were performed on the same day, changes in patient status over time could potentially affect the findings. Second, a single resident performed all the handheld scans, whereas the standard examinations were performed by multiple sonographers. While this reflects real-world practice, it could introduce variability in the method. Third, as the study only included patients who were admitted and scheduled for echocardiography, potential selection bias could not be excluded. Finally, the sample size was small. Therefore, larger, multicenter studies and broader patient populations, including outpatients, are warranted to confirm our findings. not-yet-known not-yet-known not-yet-known unknown 6 CONCLUSION VMT scoring proved to be a practical, reproducible, and reliable method for assessing LVFP using only B-mode echocardiography. It is considered to be valuable for physicians owing to its ease of use and adaptability, regardless of the level of clinical experience or the type of US system available. The use of VMT scoring has the potential to improve HF diagnosis and management in various clinical settings. not-yet-known not-yet-known not-yet-known unknown

1. Mozzini C, Cominacini L, Casadei A, et al. Ultrasonography heart failure: A story that matters. Curr Probl Cardiol. 2019;44:116-136. doi: 10.1016/j.cpcardiol.2018.05.003. 2. Murayama M, Iwano H, Obokata M, et al. Visual echocardiographic scoring system of the left ventricular filling pressure and outcomes of heart failure with preserved ejection fraction. Eur Heart J Cardiovasc Imaging. 2022;23:616-626. doi: 10.1093/ehjci/jeab208. 3. Murayama M, Iwano H, Nishino H, et al. Simple two-dimensional echocardiographic scoring system for the estimation of left ventricular filling pressure. J Am Soc Echocardiogr. 2021;34:723-734. doi: 10.1016/j.echo.2021.02.013. 4. Aoyagi H, Iwano H, Tamaki Y, et al. Non-invasive assessment of left ventricular filling pressure in aortic stenosis. Echocardiography. 2024;41:e15808. doi: 10.1111/echo.15808. 5. Nishino H, Murayama M, Iwano H, et al. Validation of left ventricular filling pressure evaluation by order of tricuspid and mitral valve opening in patients with atrial fibrillation. Circ Cardiovasc Imaging. 2024;17:e017134. doi: 10.1161/CIRCIMAGING.124.017134. 6. Yue Y, Wu X, Guan X, et al. The prognostic value of the visually assessed time difference between mitral valve and tricuspid valve opening score for patients with heart failure with mildly reduced ejection fraction. Clin Cardiol. 2024;47:10.1002/clc.24223. doi: 10.1002/clc.24223. 7. Tamaki Y, Iwano H, Murayama M, et al. Application of an echocardiographic scoring system of left ventricular filling pressure to diagnose acute heart failure in patients complaining dyspnea. J Cardiol. 2023;82:62-68. doi: 10.1016/j.jjcc.2023.04.016. 8. Duvall WL, Croft LB, Goldman ME. Can hand-carried ultrasound devices be extended for use by the noncardiology medical community? Echocardiography. 2003;20:471-476. doi: 10.1046/j.1540-8175.2003.03070.x. 9. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2016;17:412. doi: 10.1093/ehjci/jew041. 10. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159-174. doi: 10.2307/2529310. not-yet-known not-yet-known not-yet-known unknown Table 1. Demographic and clinical patient characteristics | Number, n (%) | 27 | 16 (59) | 11 (41) | NA | | Age (years) | 76 ± 12 | 72 ± 12 | 81 ± 12 | 0.095 | | Female, n (%) | 15 (56) | 8 (50) | 7 (64) | 0.696 | | Electrocardiography, n (%) | |||| | Atrial fibrillation | 9 (33) | 3 (19) | 6 (55) | 0.097 | | Others | 3 (11) | 1 (6) | 2 (18) | 0.549 | | Cardiac disease, n (%) | |||| | History of heart failure | 5 (19) | 1 (6) | 4 (36) | 0.125 | | Ischemic heart disease | 6 (22) | 2 (13) | 4 (36) | 0.187 | | Valvular heart disease | 4 (15) | 2 (13) | 2 (18) | 1 | | Comorbidity, n (%) | |||| | Hypertension | 13 (48) | 8 (50) | 5 (45) | 1 | | Diabetes mellitus | 7 (26) | 4 (25) | 3 (27) | 1 | | Dyslipidemia | 8 (30) | 5 (31) | 3 (27) | 1 | | Chronic kidney disease | 5 (19) | 2 (13) | 3 (27) | 0.371 | | Purpose of echocardiography, n (%) | |||| | Heart failure evaluation | 6 (22) | 2 (13) | 4 (36) | 0.187 | | Post-acute coronary syndrome | 4 (15) | 1 (6) | 3 (27) | 0.273 | | Preoperative examination | 9 (33) | 8 (50) | 1 (9) | 0.042 | | Others | 8 (30) | 5 (31) | 3 (27) | 1 | VMT: Visually assessed time difference between the mitral valve and tricuspid valve opening ; NA: not applicable. Table 2. Reproducibility of the VMT score not-yet-known not-yet-known not-yet-known unknown | 0 | 1 | 2 | 3 | Total | || | Resident with portable US | 0 | 2 | 1 | 0 | 0 | 3 | | 1 | 2 | 9 | 1 | 0 | 12 | | | 2 | 0 | 2 | 6 | 1 | 9 | | | 3 | 0 | 0 | 1 | 2 | 3 | | | Total | 2 | 12 | 8 | 3 | 27 | not-yet-known not-yet-known not-yet-known unknown VMT: Visually assessed time difference between the mitral valve and tricuspid valve opening; US: ultrasound. not-yet-known not-yet-known not-yet-known unknown FIGURES Figure1 not-yet-known not-yet-known not-yet-known unknown FIGURE LEGENDS not-yet-known not-yet-known not-yet-known unknown VMT score was graded as 0 for TV opening first, 1 for simultaneous opening and 2 for MV opening first. Supplementary Material File (graphical abstract.docx) - Download - 13.60 KB Information & Authors Information Version history Copyright This work is licensed under a Non Exclusive No Reuse License.

Authors Metrics & Citations Metrics Article Usage 155views 82downloads Citations Download citation Yuka Uruma, Michito Murayama, Wahei Uemura, et al. Clinical Reproducibility of the Visual Echocardiographic Scoring System of the Left Ventricular Filling Pressure. Authorea. 06 October 2025. DOI: https://doi.org/10.22541/au.175978834.44374069/v1 DOI: https://doi.org/10.22541/au.175978834.44374069/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu. Cited by - Interobserver Reproducibility of the Visual Echocardiographic Scoring System for Left Ventricular Filling Pressure, Cureus, (2026).https://doi.org/10.7759/cureus.103693 Loading...