Echocardiography (Mitral valve)

Mitral valve Va and PISAr (Aliasing velocity, Proximal isovelocity surface area radius)

Mitral valve Vmax MR (Peak velocity mitral regurgitation)

EROA = 2π x PISAr² x Va / Vmax MR

Effective Regurgitant Orifice Area

Is the narrowest area of mitral regurgitation flow.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

Echocardiography: mitral regurgitation echo severity (Algorithm)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Chronic mitral regurgitation
	Mild	Moderate		Severe
Structural
Mitral valve morphology	None or mild leaflet abnormality (e.g., mild thickening, calcifications or prolapse, mild tenting)	Moderate leaflet abnormality or moderate tenting		Severe valve lesions (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
Left ventricle (Size)¹	Usually normal (LVEDV ≤150ml male, ≤106ml female)	Normal or mild dilated		Dilated² (LVEDV >150ml male, >106ml female)
Left atrium (Size)¹	Usually normal (LA volume ≤34ml/m²)	Normal or mild dilated		Dilated²
Qualitative doppler
RegJet_area Regurgitation jet area. (Nyquist limit 50-70cm/s)	Small, central, narrow, often brief (RegJet/LA area <20%)	Variable		Large central jet (RegJet/LA area >50%) or eccentric wall-impinging jet of variable size
Flow convergence (PISAr) (Nyquist limit 30-40cm/s)	Not visible, transient or small (PISAr <0,3cm)	Intermediate in size and duration		Large throughout systole (PISAr ≥1cm)
Regurgitant jet (CW doppler)	Faint/ partial/ parabolic	Dense but partial or parabolic		Holosystolic/ dense/ triangular
Semiquantitative
VCW (cm) Vena contracta width	<0,3cm	0,3 - 0,7cm		>0,7cm (>0,8cm)³
Pulmonary vein flow⁴	Systolic dominance (may be blunted in LV dysfunction or AF)	Normal or systolic blunting		Minimal to no systolic flow/ systolic flow reversal
Mitral inflow⁵	A wave dominant (A wave > E wave)	Variable		E wave dominant (E wave >1,2m/s)
Quantitative⁶
	Grade I	Grade II	Grade III	Grade IV
EROA (cm²) Effective regurgitant orifice area	<0,2	0,2 - 0,3	0,3 - 0,39	≥0,4
RegVol (ml) Regurgitant volume of mitral regurgitation	<30	30 - 44	45 - 59	≥60
RF (%) Regurgitant fraction of mitral valve	<30	30 - 39	40 - 49	≥50

Bolded qualitative and semiquantitative signs are considered specific for their MR grade.
All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body size, sex, and all other patient characteristics.

This pertains mostly to patients with primary
LV and LA can be within the ‘‘normal’’ range for patients with acute severe MR or with chronic severe MR who have small body size, particularly women, or with small LV size preceding the occurrence of MR.
For average between apical two- and four-chamber views (Biplane).
Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).
Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure.
Discrepancies among EROA, RF, and RegVol may arise in the setting of low or high flow states. Quantitative parameters can help subclassify the moderate regurgitation group.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Apical 4 chamber (A4C) focused left atrium

PISAr

Proximal isovelocity surface area radius

The radius of PISA is measured from the surface of the hemisphere to the narrowest portion of jet (Vena contracta).

Vena contracta is narrowest portion of jet as emerges from mitral orifice.
The flow convergence zone is the zone of increased flow velocity before the regurgitant orifice.

It´s used to calculate: EROA.
A4C (Apical 4 chamber) or A2C (Apical 2 chamber)

Zoom mode (focused on mitral valve)

Mid-systole (ECG: The beginning of T wave).
Color doppler

Nyquist limit (Aliasing velocity): 30-40cm/s

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Chronic mitral regurgitation
	Mild	Moderate		Severe
Structural
Mitral valve morphology	None or mild leaflet abnormality (e.g., mild thickening, calcifications or prolapse, mild tenting)	Moderate leaflet abnormality or moderate tenting		Severe valve lesions (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
Left ventricle (Size)¹	Usually normal (LVEDV ≤150ml male, ≤106ml female)	Normal or mild dilated		Dilated² (LVEDV >150ml male, >106ml female)
Left atrium (Size)¹	Usually normal (LA volume ≤34ml/m²)	Normal or mild dilated		Dilated²
Qualitative doppler
RegJet_area Regurgitation jet area. (Nyquist limit 50-70cm/s)	Small, central, narrow, often brief (RegJet/LA area <20%)	Variable		Large central jet (RegJet/LA area >50%) or eccentric wall-impinging jet of variable size
Flow convergence (PISAr) (Nyquist limit 30-40cm/s)	Not visible, transient or small (PISAr <0,3cm)	Intermediate in size and duration		Large throughout systole (PISAr ≥1cm)
Regurgitant jet (CW doppler)	Faint/ partial/ parabolic	Dense but partial or parabolic		Holosystolic/ dense/ triangular
Semiquantitative
VCW (cm) Vena contracta width	<0,3cm	0,3 - 0,7cm		>0,7cm (>0,8cm)³
Pulmonary vein flow⁴	Systolic dominance (may be blunted in LV dysfunction or AF)	Normal or systolic blunting		Minimal to no systolic flow/ systolic flow reversal
Mitral inflow⁵	A wave dominant (A wave > E wave)	Variable		E wave dominant (E wave >1,2m/s)
Quantitative⁶
	Grade I	Grade II	Grade III	Grade IV
EROA (cm²) Effective regurgitant orifice area	<0,2	0,2 - 0,3	0,3 - 0,39	≥0,4
RegVol (ml) Regurgitant volume of mitral regurgitation	<30	30 - 44	45 - 59	≥60
RF (%) Regurgitant fraction of mitral valve	<30	30 - 39	40 - 49	≥50

Bolded qualitative and semiquantitative signs are considered specific for their MR grade.
All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body size, sex, and all other patient characteristics.

This pertains mostly to patients with primary
LV and LA can be within the ‘‘normal’’ range for patients with acute severe MR or with chronic severe MR who have small body size, particularly women, or with small LV size preceding the occurrence of MR.
For average between apical two- and four-chamber views (Biplane).
Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).
Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure.
Discrepancies among EROA, RF, and RegVol may arise in the setting of low or high flow states. Quantitative parameters can help subclassify the moderate regurgitation group.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Va

Aliasing velocity

Manually set value on the echocardiography machine.
It´s used to calculate: EROA.
Nyquist limit: 50-70cm/s

Baseline is shifted in the direction of mitral regurgitation jet to 30-40cm/s.
Aliasing occurs: If the blood flow from the probe (blue) exceeds the Va speed (38.5cm/s).

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

A4C (apical 4 chamber view) CW doppler of mitral valve

Vmax MR

Peak velocity mitral regurgitation

It´s used to calculate: EROA.
A4C (Apical 4 chamber)
Mid-systole (ECG: The beginning of T wave).
CW doppler

Place the cursor between mitral leaflet tips.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

VCW

Vena contracta width

Narrowest portion of jet as emerges from mitral orifice.
Vena contracta is diameter of EROA (Effective Regurgitant Orifice Area).
A4C (Apical 4 chamber) or A2C (Apical 2 chamber)

Zoom mode (focused on mitral valve)

Mid-systole (ECG: The beginning of T wave).
Color doppler

Nyquist limit (Aliasing velocity): 30-40cm/s

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Chronic mitral regurgitation
	Mild	Moderate		Severe
Structural
Mitral valve morphology	None or mild leaflet abnormality (e.g., mild thickening, calcifications or prolapse, mild tenting)	Moderate leaflet abnormality or moderate tenting		Severe valve lesions (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
Left ventricle (Size)¹	Usually normal (LVEDV ≤150ml male, ≤106ml female)	Normal or mild dilated		Dilated² (LVEDV >150ml male, >106ml female)
Left atrium (Size)¹	Usually normal (LA volume ≤34ml/m²)	Normal or mild dilated		Dilated²
Qualitative doppler
RegJet_area Regurgitation jet area. (Nyquist limit 50-70cm/s)	Small, central, narrow, often brief (RegJet/LA area <20%)	Variable		Large central jet (RegJet/LA area >50%) or eccentric wall-impinging jet of variable size
Flow convergence (PISAr) (Nyquist limit 30-40cm/s)	Not visible, transient or small (PISAr <0,3cm)	Intermediate in size and duration		Large throughout systole (PISAr ≥1cm)
Regurgitant jet (CW doppler)	Faint/ partial/ parabolic	Dense but partial or parabolic		Holosystolic/ dense/ triangular
Semiquantitative
VCW (cm) Vena contracta width	<0,3cm	0,3 - 0,7cm		>0,7cm (>0,8cm)³
Pulmonary vein flow⁴	Systolic dominance (may be blunted in LV dysfunction or AF)	Normal or systolic blunting		Minimal to no systolic flow/ systolic flow reversal
Mitral inflow⁵	A wave dominant (A wave > E wave)	Variable		E wave dominant (E wave >1,2m/s)
Quantitative⁶
	Grade I	Grade II	Grade III	Grade IV
EROA (cm²) Effective regurgitant orifice area	<0,2	0,2 - 0,3	0,3 - 0,39	≥0,4
RegVol (ml) Regurgitant volume of mitral regurgitation	<30	30 - 44	45 - 59	≥60
RF (%) Regurgitant fraction of mitral valve	<30	30 - 39	40 - 49	≥50

Bolded qualitative and semiquantitative signs are considered specific for their MR grade.
All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body size, sex, and all other patient characteristics.

This pertains mostly to patients with primary
LV and LA can be within the ‘‘normal’’ range for patients with acute severe MR or with chronic severe MR who have small body size, particularly women, or with small LV size preceding the occurrence of MR.
For average between apical two- and four-chamber views (Biplane).
Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).
Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure.
Discrepancies among EROA, RF, and RegVol may arise in the setting of low or high flow states. Quantitative parameters can help subclassify the moderate regurgitation group.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Dominant mitral A wave (A wave > E wave)

Apical 4 chamber (A4C). Mitral valve PW doppler

A wave_dominant

Dominant mitral A wave (A wave > E wave)

A4C (Apical 4 chamber).
Diastole (ECG: The end of T wave - R wave).
PW doppler.

Sample volume between mitral leaflet tips.

Suggest mild mitral regurgitation.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Chronic mitral regurgitation
	Mild	Moderate		Severe
Structural
Mitral valve morphology	None or mild leaflet abnormality (e.g., mild thickening, calcifications or prolapse, mild tenting)	Moderate leaflet abnormality or moderate tenting		Severe valve lesions (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
Left ventricle (Size)¹	Usually normal (LVEDV ≤150ml male, ≤106ml female)	Normal or mild dilated		Dilated² (LVEDV >150ml male, >106ml female)
Left atrium (Size)¹	Usually normal (LA volume ≤34ml/m²)	Normal or mild dilated		Dilated²
Qualitative doppler
RegJet_area Regurgitation jet area. (Nyquist limit 50-70cm/s)	Small, central, narrow, often brief (RegJet/LA area <20%)	Variable		Large central jet (RegJet/LA area >50%) or eccentric wall-impinging jet of variable size
Flow convergence (PISAr) (Nyquist limit 30-40cm/s)	Not visible, transient or small (PISAr <0,3cm)	Intermediate in size and duration		Large throughout systole (PISAr ≥1cm)
Regurgitant jet (CW doppler)	Faint/ partial/ parabolic	Dense but partial or parabolic		Holosystolic/ dense/ triangular
Semiquantitative
VCW (cm) Vena contracta width	<0,3cm	0,3 - 0,7cm		>0,7cm (>0,8cm)³
Pulmonary vein flow⁴	Systolic dominance (may be blunted in LV dysfunction or AF)	Normal or systolic blunting		Minimal to no systolic flow/ systolic flow reversal
Mitral inflow⁵	A wave dominant (A wave > E wave)	Variable		E wave dominant (E wave >1,2m/s)
Quantitative⁶
	Grade I	Grade II	Grade III	Grade IV
EROA (cm²) Effective regurgitant orifice area	<0,2	0,2 - 0,3	0,3 - 0,39	≥0,4
RegVol (ml) Regurgitant volume of mitral regurgitation	<30	30 - 44	45 - 59	≥60
RF (%) Regurgitant fraction of mitral valve	<30	30 - 39	40 - 49	≥50

Bolded qualitative and semiquantitative signs are considered specific for their MR grade.
All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body size, sex, and all other patient characteristics.

This pertains mostly to patients with primary
LV and LA can be within the ‘‘normal’’ range for patients with acute severe MR or with chronic severe MR who have small body size, particularly women, or with small LV size preceding the occurrence of MR.
For average between apical two- and four-chamber views (Biplane).
Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).
Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure.
Discrepancies among EROA, RF, and RegVol may arise in the setting of low or high flow states. Quantitative parameters can help subclassify the moderate regurgitation group.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

RegJet_{soft density}

Regurgitant jet soft density

Density and contour of regurgitant jet

Density is proportional to the number of red blood cells reflecting the signal

A4C (Apical 4 chamber).
Systole (ECG: R wave - The end of T wave).
CW doppler
Compare density with nonregurgitant flow
Dense signal suggests significant MR, whereas a faint signal is likely to be mild or trace MR.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Chronic mitral regurgitation
	Mild	Moderate		Severe
Structural
Mitral valve morphology	None or mild leaflet abnormality (e.g., mild thickening, calcifications or prolapse, mild tenting)	Moderate leaflet abnormality or moderate tenting		Severe valve lesions (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
Left ventricle (Size)¹	Usually normal (LVEDV ≤150ml male, ≤106ml female)	Normal or mild dilated		Dilated² (LVEDV >150ml male, >106ml female)
Left atrium (Size)¹	Usually normal (LA volume ≤34ml/m²)	Normal or mild dilated		Dilated²
Qualitative doppler
RegJet_area Regurgitation jet area. (Nyquist limit 50-70cm/s)	Small, central, narrow, often brief (RegJet/LA area <20%)	Variable		Large central jet (RegJet/LA area >50%) or eccentric wall-impinging jet of variable size
Flow convergence (PISAr) (Nyquist limit 30-40cm/s)	Not visible, transient or small (PISAr <0,3cm)	Intermediate in size and duration		Large throughout systole (PISAr ≥1cm)
Regurgitant jet (CW doppler)	Faint/ partial/ parabolic	Dense but partial or parabolic		Holosystolic/ dense/ triangular
Semiquantitative
VCW (cm) Vena contracta width	<0,3cm	0,3 - 0,7cm		>0,7cm (>0,8cm)³
Pulmonary vein flow⁴	Systolic dominance (may be blunted in LV dysfunction or AF)	Normal or systolic blunting		Minimal to no systolic flow/ systolic flow reversal
Mitral inflow⁵	A wave dominant (A wave > E wave)	Variable		E wave dominant (E wave >1,2m/s)
Quantitative⁶
	Grade I	Grade II	Grade III	Grade IV
EROA (cm²) Effective regurgitant orifice area	<0,2	0,2 - 0,3	0,3 - 0,39	≥0,4
RegVol (ml) Regurgitant volume of mitral regurgitation	<30	30 - 44	45 - 59	≥60
RF (%) Regurgitant fraction of mitral valve	<30	30 - 39	40 - 49	≥50

Bolded qualitative and semiquantitative signs are considered specific for their MR grade.
All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body size, sex, and all other patient characteristics.

This pertains mostly to patients with primary
LV and LA can be within the ‘‘normal’’ range for patients with acute severe MR or with chronic severe MR who have small body size, particularly women, or with small LV size preceding the occurrence of MR.
For average between apical two- and four-chamber views (Biplane).
Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).
Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure.
Discrepancies among EROA, RF, and RegVol may arise in the setting of low or high flow states. Quantitative parameters can help subclassify the moderate regurgitation group.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

RegJet/LA area = RegJet_area/LA area x 100

Ratio RegJet_area/LA area

Ratio area of the jet to the left atrium area.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Chronic mitral regurgitation
	Mild	Moderate		Severe
Structural
Mitral valve morphology	None or mild leaflet abnormality (e.g., mild thickening, calcifications or prolapse, mild tenting)	Moderate leaflet abnormality or moderate tenting		Severe valve lesions (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
Left ventricle (Size)¹	Usually normal (LVEDV ≤150ml male, ≤106ml female)	Normal or mild dilated		Dilated² (LVEDV >150ml male, >106ml female)
Left atrium (Size)¹	Usually normal (LA volume ≤34ml/m²)	Normal or mild dilated		Dilated²
Qualitative doppler
RegJet_area Regurgitation jet area. (Nyquist limit 50-70cm/s)	Small, central, narrow, often brief (RegJet/LA area <20%)	Variable		Large central jet (RegJet/LA area >50%) or eccentric wall-impinging jet of variable size
Flow convergence (PISAr) (Nyquist limit 30-40cm/s)	Not visible, transient or small (PISAr <0,3cm)	Intermediate in size and duration		Large throughout systole (PISAr ≥1cm)
Regurgitant jet (CW doppler)	Faint/ partial/ parabolic	Dense but partial or parabolic		Holosystolic/ dense/ triangular
Semiquantitative
VCW (cm) Vena contracta width	<0,3cm	0,3 - 0,7cm		>0,7cm (>0,8cm)³
Pulmonary vein flow⁴	Systolic dominance (may be blunted in LV dysfunction or AF)	Normal or systolic blunting		Minimal to no systolic flow/ systolic flow reversal
Mitral inflow⁵	A wave dominant (A wave > E wave)	Variable		E wave dominant (E wave >1,2m/s)
Quantitative⁶
	Grade I	Grade II	Grade III	Grade IV
EROA (cm²) Effective regurgitant orifice area	<0,2	0,2 - 0,3	0,3 - 0,39	≥0,4
RegVol (ml) Regurgitant volume of mitral regurgitation	<30	30 - 44	45 - 59	≥60
RF (%) Regurgitant fraction of mitral valve	<30	30 - 39	40 - 49	≥50

Bolded qualitative and semiquantitative signs are considered specific for their MR grade.
All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body size, sex, and all other patient characteristics.

This pertains mostly to patients with primary
LV and LA can be within the ‘‘normal’’ range for patients with acute severe MR or with chronic severe MR who have small body size, particularly women, or with small LV size preceding the occurrence of MR.
For average between apical two- and four-chamber views (Biplane).
Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).
Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure.
Discrepancies among EROA, RF, and RegVol may arise in the setting of low or high flow states. Quantitative parameters can help subclassify the moderate regurgitation group.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

RegJet_area

Regurgitation jet area

It´s used to calculate: RegJet/LA area
A4C (Apical 4 chamber)

Zoom mode (focused on mitral valve)

Systole (ECG: R wave - The end of T wave).
Color doppler

Nyquist limit (Aliasing velocity): 50-70cm/s

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

LA area

Left atrial area

It´s used to calculate: RegJet/LA area
A4C (Apical 4 chamber)

Zoom mode (focused on mitral valve)

End-systole (ECG: The end of T wave).

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

A4C (Apical 4 chamber view) LA pulmonary veins focus, systole, PW doppler

PV_{reversal flow}

Pulmonary vein systolic flow reversal

Systolic flow reversal in the pulmonary veins
A4C (Apical 4 chamber).
Systole (ECG: R wave - The end of T wave)
PW doppler

Sample volume from right (or left) pulmonary vein.
Color doppler (helps with blood flow identification).

Systolic flow reversal in the pulmonary veins suggests severe mitral regurgitation.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Chronic mitral regurgitation
	Mild	Moderate		Severe
Structural
Mitral valve morphology	None or mild leaflet abnormality (e.g., mild thickening, calcifications or prolapse, mild tenting)	Moderate leaflet abnormality or moderate tenting		Severe valve lesions (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
Left ventricle (Size)¹	Usually normal (LVEDV ≤150ml male, ≤106ml female)	Normal or mild dilated		Dilated² (LVEDV >150ml male, >106ml female)
Left atrium (Size)¹	Usually normal (LA volume ≤34ml/m²)	Normal or mild dilated		Dilated²
Qualitative doppler
RegJet_area Regurgitation jet area. (Nyquist limit 50-70cm/s)	Small, central, narrow, often brief (RegJet/LA area <20%)	Variable		Large central jet (RegJet/LA area >50%) or eccentric wall-impinging jet of variable size
Flow convergence (PISAr) (Nyquist limit 30-40cm/s)	Not visible, transient or small (PISAr <0,3cm)	Intermediate in size and duration		Large throughout systole (PISAr ≥1cm)
Regurgitant jet (CW doppler)	Faint/ partial/ parabolic	Dense but partial or parabolic		Holosystolic/ dense/ triangular
Semiquantitative
VCW (cm) Vena contracta width	<0,3cm	0,3 - 0,7cm		>0,7cm (>0,8cm)³
Pulmonary vein flow⁴	Systolic dominance (may be blunted in LV dysfunction or AF)	Normal or systolic blunting		Minimal to no systolic flow/ systolic flow reversal
Mitral inflow⁵	A wave dominant (A wave > E wave)	Variable		E wave dominant (E wave >1,2m/s)
Quantitative⁶
	Grade I	Grade II	Grade III	Grade IV
EROA (cm²) Effective regurgitant orifice area	<0,2	0,2 - 0,3	0,3 - 0,39	≥0,4
RegVol (ml) Regurgitant volume of mitral regurgitation	<30	30 - 44	45 - 59	≥60
RF (%) Regurgitant fraction of mitral valve	<30	30 - 39	40 - 49	≥50

Bolded qualitative and semiquantitative signs are considered specific for their MR grade.
All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body size, sex, and all other patient characteristics.

This pertains mostly to patients with primary
LV and LA can be within the ‘‘normal’’ range for patients with acute severe MR or with chronic severe MR who have small body size, particularly women, or with small LV size preceding the occurrence of MR.
For average between apical two- and four-chamber views (Biplane).
Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).
Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure.
Discrepancies among EROA, RF, and RegVol may arise in the setting of low or high flow states. Quantitative parameters can help subclassify the moderate regurgitation group.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

VTI MV (Velocity time integral mitral valve inflow) PW doppler

SV_MV = CSA_MV x VTI MV

Stroke volume of mitral valve

It´s used to calculate: RegVol_MV and RF_MV

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

MV_diameter

Mitral valve diameter

It´s used to calculate: CSA_MV and SV_MV
A4C (Apical 4 chamber)
Diastole (ECG: The end of T wave - R wave)
Method: Inner edge to inner edge

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

VTI MV

Velocity time integral mitral valve inflow

It´s used to calculate: SV_MV
A4C (Apical 4 chamber)
Diastole (ECG: The end of T wave - R wave)
PW doppler

Sample volume between mitral leaflet tips.

Trace along the edge of the modal velocity to measure the area under the curve.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

LVOT diameter (Left ventricular outflow tract diameter)

LVOT VTI (Velocity time integral of left ventricular outflow tract)

SV_AoV = CSA_LVOT x VTI_LVOT

Stroke volume of aortic valve

It´s used to calculate: RegVol_MV
Calculate it in the top menu: AV

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

LVOT VTI (Velocity time integral of left ventricular outflow tract) PW doppler

RegVol_MV = SV_MV - SV_AoV

Regurgitant volume of mitral regurgitation

It´s used to calculate: RF_MV.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Chronic mitral regurgitation
	Mild	Moderate		Severe
Structural
Mitral valve morphology	None or mild leaflet abnormality (e.g., mild thickening, calcifications or prolapse, mild tenting)	Moderate leaflet abnormality or moderate tenting		Severe valve lesions (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
Left ventricle (Size)¹	Usually normal (LVEDV ≤150ml male, ≤106ml female)	Normal or mild dilated		Dilated² (LVEDV >150ml male, >106ml female)
Left atrium (Size)¹	Usually normal (LA volume ≤34ml/m²)	Normal or mild dilated		Dilated²
Qualitative doppler
RegJet_area Regurgitation jet area. (Nyquist limit 50-70cm/s)	Small, central, narrow, often brief (RegJet/LA area <20%)	Variable		Large central jet (RegJet/LA area >50%) or eccentric wall-impinging jet of variable size
Flow convergence (PISAr) (Nyquist limit 30-40cm/s)	Not visible, transient or small (PISAr <0,3cm)	Intermediate in size and duration		Large throughout systole (PISAr ≥1cm)
Regurgitant jet (CW doppler)	Faint/ partial/ parabolic	Dense but partial or parabolic		Holosystolic/ dense/ triangular
Semiquantitative
VCW (cm) Vena contracta width	<0,3cm	0,3 - 0,7cm		>0,7cm (>0,8cm)³
Pulmonary vein flow⁴	Systolic dominance (may be blunted in LV dysfunction or AF)	Normal or systolic blunting		Minimal to no systolic flow/ systolic flow reversal
Mitral inflow⁵	A wave dominant (A wave > E wave)	Variable		E wave dominant (E wave >1,2m/s)
Quantitative⁶
	Grade I	Grade II	Grade III	Grade IV
EROA (cm²) Effective regurgitant orifice area	<0,2	0,2 - 0,3	0,3 - 0,39	≥0,4
RegVol (ml) Regurgitant volume of mitral regurgitation	<30	30 - 44	45 - 59	≥60
RF (%) Regurgitant fraction of mitral valve	<30	30 - 39	40 - 49	≥50

Bolded qualitative and semiquantitative signs are considered specific for their MR grade.
All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body size, sex, and all other patient characteristics.

This pertains mostly to patients with primary
LV and LA can be within the ‘‘normal’’ range for patients with acute severe MR or with chronic severe MR who have small body size, particularly women, or with small LV size preceding the occurrence of MR.
For average between apical two- and four-chamber views (Biplane).
Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).
Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure.
Discrepancies among EROA, RF, and RegVol may arise in the setting of low or high flow states. Quantitative parameters can help subclassify the moderate regurgitation group.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

RF_MV = RegVol_MV / SV_MV x 100

Regurgitant fraction of mitral valve

Regurgitation fraction of mitral regurgitation.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Chronic mitral regurgitation
	Mild	Moderate		Severe
Structural
Mitral valve morphology	None or mild leaflet abnormality (e.g., mild thickening, calcifications or prolapse, mild tenting)	Moderate leaflet abnormality or moderate tenting		Severe valve lesions (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
Left ventricle (Size)¹	Usually normal (LVEDV ≤150ml male, ≤106ml female)	Normal or mild dilated		Dilated² (LVEDV >150ml male, >106ml female)
Left atrium (Size)¹	Usually normal (LA volume ≤34ml/m²)	Normal or mild dilated		Dilated²
Qualitative doppler
RegJet_area Regurgitation jet area. (Nyquist limit 50-70cm/s)	Small, central, narrow, often brief (RegJet/LA area <20%)	Variable		Large central jet (RegJet/LA area >50%) or eccentric wall-impinging jet of variable size
Flow convergence (PISAr) (Nyquist limit 30-40cm/s)	Not visible, transient or small (PISAr <0,3cm)	Intermediate in size and duration		Large throughout systole (PISAr ≥1cm)
Regurgitant jet (CW doppler)	Faint/ partial/ parabolic	Dense but partial or parabolic		Holosystolic/ dense/ triangular
Semiquantitative
VCW (cm) Vena contracta width	<0,3cm	0,3 - 0,7cm		>0,7cm (>0,8cm)³
Pulmonary vein flow⁴	Systolic dominance (may be blunted in LV dysfunction or AF)	Normal or systolic blunting		Minimal to no systolic flow/ systolic flow reversal
Mitral inflow⁵	A wave dominant (A wave > E wave)	Variable		E wave dominant (E wave >1,2m/s)
Quantitative⁶
	Grade I	Grade II	Grade III	Grade IV
EROA (cm²) Effective regurgitant orifice area	<0,2	0,2 - 0,3	0,3 - 0,39	≥0,4
RegVol (ml) Regurgitant volume of mitral regurgitation	<30	30 - 44	45 - 59	≥60
RF (%) Regurgitant fraction of mitral valve	<30	30 - 39	40 - 49	≥50

Bolded qualitative and semiquantitative signs are considered specific for their MR grade.
All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body size, sex, and all other patient characteristics.

This pertains mostly to patients with primary
LV and LA can be within the ‘‘normal’’ range for patients with acute severe MR or with chronic severe MR who have small body size, particularly women, or with small LV size preceding the occurrence of MR.
For average between apical two- and four-chamber views (Biplane).
Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).
Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure.
Discrepancies among EROA, RF, and RegVol may arise in the setting of low or high flow states. Quantitative parameters can help subclassify the moderate regurgitation group.

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

LVEDV (Left ventricular end-diastole volume)

LVESV (Left ventricular end-systole volume)

LV EF = (LVEDV - LVESV) / LVEDV x 100

Left ventricular ejection fraction (Biplane Method of Discs)

Ejection fraction is the predominant method for assessing global systolic function

and is derived from the LVEDV and LVESV.

Calculate it in the top menu: Left ventricle

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Left ventricle (Ejection fraction)
	Male				Female
	Normal range	Mildly abnormal	Moderately abnormal	Severely abnormal	Normal range	Mildly abnormal	Moderately abnormal	Severely abnormal
LV EF (%) Left ventricular ejection fraction (Biplane)	52 - 72	41 - 51	30 - 40	<30	54 - 74	41 - 53	30 - 40	<30

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

LA volume

Left atrial volume (Biplane)

A4C (Apical 4 chamber) and A2C (Apical 2 chamber).
End-systole (ECG: The end of T wave).
Preferred technique is method of disk summation (modified biplane).

Trace the LA inner border, excluding the area under the MV annulus, pulmonary veins, and LA appendage from the A4C and A2C views.

Calculate it in the top menu: Atria and IVC

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Left atrium (Volume)
	Male				Female
	Normal range	Mildly abnormal	Moderately abnormal	Severely abnormal	Normal range	Mildly abnormal	Moderately abnormal	Severely abnormal
LA volume (ml/m²) Left atrial volume (Biplane)	16 - 34	35 - 41	42 - 48	>48	16 - 34	35 - 41	42 - 48	>48

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

Apical 4 Chamber View (A4C) zoomed left ventricle

LVEDV

Left ventricular end-diastole volume

A4C (zoomed left ventricle), A2C (zoomed left ventricle).
End-diastole (ECG: R wave).
Preferred technique is Biplane Method of Discs (modified Simpson’s rule).
Measured from the A4C and A2C views (preferably an LV focused view) tracing the endocardial – blood pool interface

Papillary muscles should be excluded from the cavity tracing.
Maximize LV area and avoid foreshortening.

Calculate it in the top menu: Left ventricle

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)

Left ventricle (Volume)
	Male				Female
	Normal range	Mildly abnormal	Moderately abnormal	Severely abnormal	Normal range	Mildly abnormal	Moderately abnormal	Severely abnormal
LVEDV (ml) Left ventricular end-diastole volume (Biplane)	62 - 150	151 - 174	175 - 200	>200	46 - 106	107 - 120	121 - 130	>130
LVEDV (ml/m2) Left ventricular end-diastole volume (Biplane)	34 - 74	75 - 89	90 - 100	>100	29 - 61	62 - 70	71 - 80	>80
LVESV (ml) Left ventricular end-systole volume (Biplane)	21 - 61	62 - 73	74 - 85	>85	14 - 42	43 - 55	56 - 67	>67
LVESV (ml/m2) Left ventricular end-systole volume (Biplane)	11 - 31	32 - 38	39 - 45	>45	8 - 24	25 - 32	33 - 40	>40

Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI (2015)

PSAX (parasternal short axis) level of MV (mitral valve)

MVA

Mitral valve area

PSAX (level of MV)
Mid-diastole (ECG: The beginning of P wave)
An anatomical orifice is measured.

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice (2009)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

Mitral stenosis
	Mild	Moderate	Severe
MVA (cm²)* Mitral valve area	>1,5	1 - 1,5	<1
meanPG MV (mmHg) Mitral valve mean pressure gradient	<5	5 - 10	>10
RVSP_(SPAP) (mmHg) Right ventricular systolic pressure	<30	30 - 50	>50

* Specific findings

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice (2009)

A4C (apical 4 chamber view) CW doppler of mitral stenosis

meanPG MV

Mitral valve mean pressure gradient

A4C (Apical 4 chamber)
Diastole (ECG: The end of T wave - R wave)
CW doppler

Place the cursor in the middle of mitral valve.
Trace along the edge of the modal velocity to measure the area under the curve.

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice (2009)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

Mitral stenosis
	Mild	Moderate	Severe
MVA (cm²)* Mitral valve area	>1,5	1 - 1,5	<1
meanPG MV (mmHg) Mitral valve mean pressure gradient	<5	5 - 10	>10
RVSP_(SPAP) (mmHg) Right ventricular systolic pressure	<30	30 - 50	>50

* Specific findings

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice (2009)

Vmax TR (Peak tricuspid regurgitation systolic jet velocity) CW doppler

RAP (Right atrial pressure), IVC, IVC sniff

RVSP_(SPAP) = 4 x Vmax TR² + RAP

Right ventricular systolic pressure

RVSP = SPAP (Systolic Pulmonary Artery Pressure)

RVSP = SPAP (in absence of RVOT obstruction)

Calculate it in the top menu: RV pressure.

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice (2009)

Guidelines for performing a comprehensive TTE examination in adults: Recommendations from the ASE (2018)

Mitral stenosis
	Mild	Moderate	Severe
MVA (cm²)* Mitral valve area	>1,5	1 - 1,5	<1
meanPG MV (mmHg) Mitral valve mean pressure gradient	<5	5 - 10	>10
RVSP_(SPAP) (mmHg) Right ventricular systolic pressure	<30	30 - 50	>50

* Specific findings

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice (2009)

Echocardiography

Mitral valve

Va

VCW

PISAr

Vmax MR

EROA

A wavedominant

RegJetsoft density

RegJetarea

LA area

RegJet/LA area

PVreversal flow

SVAoV

MVdiameter

VTI MV

SVMV

RegVolMV

RFMV

LV EF

LA volume

LVEDV

MVA

meanPG MV

RVSP(SPAP)

EROA = 2π x PISAr2 x Va / Vmax MR

PISAr

Va

Vmax MR

VCW

A wavedominant

RegJetsoft density

RegJet/LA area = RegJetarea/LA area x 100

RegJetarea

LA area

PVreversal flow

SVMV = CSAMV x VTI MV

MVdiameter

VTI MV

SVAoV = CSALVOT x VTILVOT

RegVolMV = SVMV - SVAoV

RFMV = RegVolMV / SVMV x 100

LV EF = (LVEDV - LVESV) / LVEDV x 100

LA volume

LVEDV

MVA

meanPG MV

RVSP(SPAP) = 4 x Vmax TR2 + RAP

A wave_dominant

RegJet_{soft density}

RegJet_area

PV_{reversal flow}

SV_AoV

MV_diameter

SV_MV

RegVol_MV

RF_MV

RVSP_(SPAP)

EROA = 2π x PISAr² x Va / Vmax MR

A wave_dominant

RegJet_{soft density}

RegJet/LA area = RegJet_area/LA area x 100

RegJet_area

PV_{reversal flow}

SV_MV = CSA_MV x VTI MV

MV_diameter

SV_AoV = CSA_LVOT x VTI_LVOT

RegVol_MV = SV_MV - SV_AoV

RF_MV = RegVol_MV / SV_MV x 100

RVSP_(SPAP) = 4 x Vmax TR² + RAP