EACVI Ghid Reg Valvulare 2013

European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644 RECOMMENDATIONS
doi:10.1093/ehjci/jet105
Recommendations for the echocardiographic

assessment of native valvular regurgitation: an
executive summary from the European
Association of Cardiovascular Imaging
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Patrizio Lancellotti 1*, Christophe Tribouilloy2, Andreas Hagendorff 3,
Bogdan A. Popescu 4, Thor Edvardsen 5, Luc A. Pierard 1, Luigi Badano 6, and
Jose L. Zamorano 7, On behalf of the Scientific Document Committee of the European
Association of Cardiovascular Imaging: Thor Edvardsen, Oliver Bruder,
Bernard Cosyns, Erwan Donal, Raluca Dulgheru, Maurizio Galderisi, Patrizio
Lancellotti, Denisa Muraru, Koen Nieman, Rosa Sicari, Document reviewers: Erwan
Donal, Kristina Haugaa, Giovanni La Canna, Julien Magne, Edyta Plonska
1
Department of Cardiology, GIGA Cardiovascular Sciences, University of Liège Hospital, Valvular Disease Clinic, CHU Sart Tilman, Liège 4000, Belgium; 2Department of Cardiology,
University Hospital of Amiens, Picardie, France; 3Department für Innere Medizin, Kardiologie, Leipzig, Germany; 4Euroecolab, ‘Carol Davila’ University of Medicine and Pharmacy, Institute
of Cardiovascular Diseases, Bucharest, Romania; 5Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet and University of Oslo,
Oslo, Norway; 6Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy; and 7University Hospital Ramón y Cajal, Madrid, Spain
Received 7 May 2013; accepted after revision 12 May 2013
Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Echocardiography has become the primary non-
invasive imaging method for the evaluation of valvular regurgitation. The echocardiographic assessment of valvular regurgitation should integrate
the quantification of the regurgitation, assessment of the valve anatomy and function, as well as the consequences of valvular disease on cardiac
chambers. In clinical practice, the management of patients with valvular regurgitation thus largely integrates the results of echocardiography. It is
crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing regurgitation.
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Keywords Valvular regurgitation † Echocardiography † Recommendations † Aortic valve † Mitral valve † Tricuspid valve †
Pulmonary valve
requires the use of different echocardiographic modalities, should in-

Introduction tegrate multiple parameters, and should be combined with clinical
Doppler echocardiography is critical to initial and longitudinal assess- data. The present document aims to present an executive
ment of patients with valvular regurgitation. It provides detailed ana- summary of the recommendations papers published in the European
tomic and functional information and clarifies the mechanisms that Journal of Echocardiography on the assessment of native valvular
play a role in valvular regurgitation. Doppler echocardiography not regurgitation.2,3
only detects the presence of regurgitation, but also permits to under-
stand mechanisms of regurgitation, quantification of its severity, and
repercussions.1 – 3 In clinical practice, the management of patients
with valvular regurgitation largely integrates the results of echocardi-
General recommendations
ography. It is thus crucial to provide standards that aim at establishing Two-dimensional (2D) transthoracic echocardiography (TTE) is
a baseline list of measurements to be performed when assessing re- recommended as first-line imaging in valvular regurgitation and is
gurgitation. Practically, the evaluation of valvular regurgitation often sufficient for diagnosis. Two-dimensional transoesophageal
* Corresponding author. Tel: +32 436671 94; fax: +32 436671 95, Email: [email protected]
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2013. For permissions please email: [email protected]
612 P. Lancellotti et al.
echocardiography (TOE) is indicated when TTE is insufficient or echocardiography. The mode of acquisition, advantages, and limita-
when further diagnostic refinement is required. Three-dimensional tions of the various echo Doppler parameters used for the assess-
(3D) echocardiography provides realistic and intuitive anatomic ment of valvular regurgitation severity are detailed in Tables 1 and
images of valvular apparatus, which may provide additional informa- 2. Finally, the collected data are compared with the individual clinical
tion, particularly in patients with complex valve lesions, and allows context in order to stratify the management and the follow-up.6
more accurate quantitation of haemodynamic consequences of the When indicated for left-sided valves, a quantitative exercise echocar-
regurgitation on cardiac chambers.4 diography could help identify what might otherwise be considered as
a moderate valvular lesion as well as the ventricular and pulmonary
Valve assessment: recommendations consequences of the regurgitation. The use of stress echocardiog-
raphy in valvular heart disease is the subject of a different document.7
1. TTE is recommended as the first-line imaging modality in
valvular regurgitation. According to the clinical context and the grade of regurgitation, ap-
propriate monitoring will be delivered.6

2. TOE is advocated when TTE is of non-diagnostic value or
when further diagnostic refinement is required.
3. Three-dimensional echo can provide additional informa- LV size and function: recommendations
tion in patients with complex valve lesions. 1. The quantitative assessment of left ventricular (LV) dia-
4. TOE is not indicated in patients with a good-quality TTE meters, volumes, and ejection fraction is mandatory.
except in the operating room when a valve surgery is per- 2. The 2D measurement of LV diameters is strongly advo-
formed. cated if the M-mode line cannot be placed perpendicular
to the long-axis of the LV.
In practice, the evaluation of valvular regurgitation starts with 2D 3. The 2D-based biplane summation method of discs is the
TTE, which can orient readily to a severe regurgitation in the pres- recommended approach for the estimation of LV
ence of a major valvular defect or to a minor leak when the valve volumes and ejection fraction.
anatomy and leaflet motion are normal. The aetiology (cause of the 4. The 3D echo assessment of LV function provides more ac-
valve disease) and mechanism of the regurgitation (lesion/deform- curate and reproducible data.
ation resulting in valve dysfunction) including the dysfunction type 5. Contrast echo is indicated in patients with poor acoustic
(cusp motion abnormality) are described according to the Carpen- window.
tier’s classification of leaflet motion: Type I: normal leaflet motion, 6. The qualitative assessment of LV function is not recom-
Type II: excessive motion, and Type III: restrictive motion.5 mended.
Then, a careful assessment of the regurgitant jet by colour Doppler, 7. Left atrial volume is the recommended parameter to assess
using multiple views, can rapidly diagnose minimal regurgitation, its size.
which requires a priori no further quantification. In the other cases,
the use of a more quantitative method is advised when feasible
[vena contracta (VC); proximal isovelocity surface area (PISA)].
Aortic regurgitation
Estimation of the severity of valvular regurgitation: recommen- Aortic regurgitation (AR) is a common valvular disease. Echocardiog-
dations raphy plays a valuable role in the assessment and management of
1. The colour flow area of the regurgitant jet is not recom- patients with AR.1 – 3
mended to quantify the severity of valvular regurgitation.
2. Both VC measurement and the PISA method are recom- Anatomy and function of the aortic valve
mended to evaluate the severity of regurgitation when feas- The aortic valve consists of a complex of structures surrounding
ible. the aortic orifice along the outflow tract of the left ventricle (LV).8
3. Adjunctive parameters should be used when there is dis- Typically, the valve has three leaflets, which are semi-lunar in
cordance between the quantified degree of regurgitation shape. The cusps are inserted into a fibrous connective tissue
and the clinical context. sleeve, which is attached to the aorta media above (the valsalva
sinuses and the sino-tubular junction). Below, the cusps are attached
In the second step, the impact of the regurgitation on the ventricles, to the myocardium of the LV outflow tract (LVOT) and to the
the atria, and the pulmonary artery pressures is estimated. Ventricu- anterior mitral leaflet (virtual basal ring), below the anatomic
lar sizes and function are measured using diameters and/or volumes ventriculo-aortic junction. Hence, the true anatomic aortic annulus
(the biplane 2D method of discs or 3D echo when imaging is of is not actually the ring projected at the most basal leaflet inser-
proper quality) (Figure 1). Of note, ejection fraction is load dependent tion—as usually defined and measured with various imaging techni-
and often overestimates ventricular systolic performance. New para- ques—but a crown-like 3D structure. Of note, the size of the
meters (myocardial velocities, myocardial deformation by 2D strain, aortic annulus and root is influenced by inner pressure and is dynam-
or strain rate) are currently available for a better assessment of ven- ically changing during the cardiac cycle. Each cusp is attached along its
tricular function, but they still need to be validated in larger series of curved edge, and the cusps meet at three commissures that are
patients in the setting of valvular regurgitation. Atrial volumes can be equally spaced along the circumference of the sleeve at the
reliably measured by the biplane area–length method or 3D supra-aortic ridge. In normal aortic valve, the cusps are symmetrical,
Recommendations for the echocardiographic assessment of native valvular regurgitation 613

Figure 1 (A) M-Mode measurement of LV diameters; (B) estimation of LV volumes and ejection fraction by summation method of disc; (C ) 3D
echo assessment of LV volumes; (D) estimation of left atrial volume by the summation method of disc.
mobile, and free at the commissures, with equal overlap on the for assessing the mechanisms and causes of AR, as well as the
closure. The cusps are named left, right, and non-coronary cusps aortic root dimensions and morphology.9
based on the location of the coronary ostia.
Two-dimensional/M-mode findings in AR
Aetiology and mechanisms of AR Information about the cusp pathology (redundancy, restriction, cusp
AR results from disease of either the aortic leaflets or the aortic root height to indicate likely adequacy of coaptation, mobility/pliability,
that distorts the leaflets and prevents their correct apposition. thickness, integrity), commissure variations (fusion, splaying, attach-
Common causes of leaflet abnormalities that result in AR include ment site, and alignment), and root morphology (septal hypertrophy,
senile leaflet calcifications, bicuspid aortic valve, infective endocardi- annular size, sinus and sino-tubular junction dimension, and ascend-
tis, and rheumatic fever. Aortic causes of AR include annulo-aortic ing aorta dimension) should be provided. The presence of a flail valve
ectasia (idiopathic root dilatation), Marfan’s syndrome, aortic dissec- is specific for severe AR. In addition, 2D (reverse doming of the an-
tion, collagen vascular disease, and syphilis. The Carpentier’s classifi- terior mitral valve leaflet; basal septal hyperechogenic aspect) and
cation is also commonly used to describe the mechanism of AR M-mode (high frequency fluttering of the anterior mitral leaflet, the
(Figure 2) (Table 3).9 mitral valve chordae, or the interventricular septum; premature
Key point: In patients with AR, careful aortic valve analysis mitral valve closure; premature diastolic opening of the aortic
is mandatory. The echo report should include information valve) echo findings that can be associated with AR should be
about the aetiology, the lesion process, and the type of dys- looked for (Figure 3).
function. The likelihood of valve repair should also be dis- Key point: Additional echo findings are used as comple-
cussed in case of pure AR. mentary parameters to assess the severity of AR. The as-
sessment of the morphology and dimension of the aortic
Echocardiographic evaluation in AR root is mandatory.
The parasternal long-axis view is classically used to measure the LV
outflow tract, the aortic annulus, and the aortic sinuses dimensions. Assessment of AR severity
Colour flow Doppler
Leaflet thickness and morphology can be visualized from this
Colour flow imaging. Using colour flow Doppler, the regurgitant jet
window as well as from the parasternal short-axis view and the
into the LV during diastole can be visualized from multiple views.
apical five-chamber view. However, not uncommonly, 2D TTE The colour jet area and length are weakly correlated to the degree
does not allow a complete assessment of the anatomy and causes of AR, are affected by the aortic to LV diastolic pressure gradient
of AR. In this situation, if the acoustic window is optimal, 3D echo and LV compliance, and are often overestimated in the apical views.
could provide better delineation of the aortic valve morphology.4,8 They are not currently recommended to quantitate AR severity.
In some cases, TOE is needed particularly when TTE is insufficient Practically, colour flow Doppler serves for detection and initial
Table 1 Echocardiographic parameters used to quantify regurgitation severity: recordings
Parameters Aortic regurgitation (AR) Pulmonary regurgitation Mitral regurgitation (MR) Tricuspid regurgitation
(PR) (TR)
...............................................................................................................................................................................
Valve Visual assessment Visual assessment Visual assessment Visual assessment
morphology Multiple views Multiple views Multiple views Multiple views
Tricuspid annulus — — — Apical four-chamber view
diameter Lateral inner edge to septal
inner edge
Colour flow Optimize colour gain/scale Optimize colour gain/scale Optimize colour gain/scale Optimize colour gain/scale
regurgitant jet Parasternal long- and short-axis Evaluate in parasternal Evaluate in two views Evaluate in two views

views short-axis view Measure blood pressure Measure blood pressure
VC width PT-LAX is preferred (apical Parasternal short-axis view Two orthogonal planes Apical four-chamber view
four-chamber view if not Optimize colour gain/scale (PT-LAX, apical Optimize colour gain/scale
available) and identify the 3 four-chamber view) Identify the three components
Optimize colour gain/scale components of the Optimize colour gain/scale of the regurgitant jet (VC,
Identify the three components regurgitant jet Identify the three components PISA, jet into RA)
of the regurgitant jet (VC, Reduce the colour sector size of the regurgitant jet (VC, Reduce the colour sector size
PISA, jet into LV) and imaging depth to PISA, jet into LA) and imaging depth to
Reduce the colour sector size maximize frame rate Reduce the colour sector size maximize frame rate
and imaging depth to Expand the selected zone and imaging depth to Expand the selected zone
maximize frame rate (Zoom) and find the best maximize frame rate (Zoom)
Expand the selected zone frame for measurement Expand the selected zone Use the cine-loop to find the
(Zoom) Measure the smallest VC (Zoom) best frame for measurement
Use the cine-loop to find the Use the cine-loop to find the Measure the smallest VC
best frame for measurement best frame for measurement (immediately distal to the
Measure the smallest VC Measure the smallest VC regurgitant orifice,
(immediately distal to the (immediately distal to the perpendicular to the
regurgitant orifice, regurgitant orifice, direction of the jet)
perpendicular to the perpendicular to the
direction of the jet) direction of the jet)
PISA method Apical five-chamber for central Parasternal short-axis view Apical four-chamber Apical four-chamber
jets (PT-LAX for eccentric Optimize colour flow imaging Optimize colour flow imaging Optimize colour flow imaging
jets) of PR and zoom the of MR of TR
Optimize colour flow imaging selected region Zoom the image of the Zoom the image of the
of AR Decrease the Nyquist limit regurgitant mitral valve regurgitant tricuspid valve
Zoom the image of the (colour flow zero baseline) Decrease the Nyquist limit Decrease the Nyquist limit
regurgitant aortic valve Measure the PISA radius at (colour flow zero baseline) (colour flow zero baseline)
Increase the Nyquist limit in mid-systole using the first With the cine-mode select the With the cine-mode select the
apical views/decrease or aliasing and along the best PISA best PISA
increase in PT-LAX direction of the ultrasound Display the colour off and on to Display the colour off and on to
With the cine-mode select the beam visualize the MR orifice visualize the TR orifice
best PISA Measure PR peak velocity and Measure the PISA radius at Measure the PISA radius at
Display the colour off and on to TVI (CW) mid-systole using the first mid-systole using the first
visualize the AR orifice Calculate flow rate, EROA, R aliasing and along the aliasing and along the
Measure the PISA radius at Vol direction of the ultrasound direction of the ultrasound
diastole using the first aliasing beam beam
and along the direction of the Measure MR peak velocity and Measure TR peak velocity and
ultrasound beam TVI (CW) TVI (CW)
Measure AR peak velocity and Calculate flow rate, EROA, R Calculate flow rate, EROA, R
TVI (CW) Vol Vol
Calculate flow rate, EROA, R
Vol
CW regurgitant Apical five-chamber Parasternal short-axis view Apical four-chamber Apical four-chamber
jet profile CW AR jet
Pressure half-time Apical five-chamber CW PR Doppler — —
CW AR Doppler
Diastolic flow PW Doppler — — —
reversal in Proximal descending aorta/
descending abdominal aorta
aorta
Continued
Table 1 Continued
Parameters Aortic regurgitation (AR) Pulmonary regurgitation Mitral regurgitation (MR) Tricuspid regurgitation
(PR) (TR)
...............................................................................................................................................................................
Pulmonary vein — — Apical four-chamber —
flow Sample volume of PW placed
into the right upper
pulmonary vein
Interrogate the different
pulmonary veins when
possible
Hepatic vein flow — — — Subcostal view

Sample volume of PW placed
into the hepatic vein
Peak E velocity — — Apical four-chamber Apical four-chamber
Sample volume of PW placed at Sample volume of PW placed at
mitral leaflet tips tricuspid leaflet tips
Ventricular size Use preferably the Simpson Use preferably the RV Use preferably the Simpson Use preferably the RV
method to assess the LV dimension from the apical method to assess the LV dimension from the apical
four-chamber view four-chamber view
AR, aortic regurgitation; CW, continuous wave; EROA, effective regurgitant orifice area; LA, left atrium; LV, left ventricle; MR, mitral regurgitation; PR, pulmonary regurgitation; PT-LAX,
parasternal long-axis view; PW, pulsed wave; RA, right atrium; RV, right ventricle; R Vol, regurgitant volume; TR, tricuspid regurgitation; TVI, time-velocity integral; VC, vena contracta.
visual assessment of AR. Central jets are suggestive of rheumatic of the VC is affected by several factors as the presence of multiple
disease, whereas eccentric jets are often associated with aortic valve jets. In this situation, the respective widths of the VC are not addi-
prolapse or perforation. Colour-coded M-mode is suitable for time- tive. The concept of VC is indeed based on the assumption that the
course of flow signals during the heart cycle (Figure 4). The diameter regurgitant orifice is almost circular. The orifice is however often
and the cross-sectional area of the jet at its origin are semi-quantitative elliptic or irregular, which changes the width of the VC in different
colour Doppler indexes of AR severity. The maximum colour jet diam- views. Three-dimensional colour Doppler echo has been shown to
eter (width) is measured in diastole immediately below the aortic valve be a possible useful tool in the visualization of the actual shape of
(at the junction of the LV outflow tract and aortic annulus) in the para- the regurgitant orifice.13
sternal long-axis view. The jet width is proportional to the size of the Key point: When feasible, the measurement of the VC
aortic valve defect. However, since it assumes a circular regurgitant width is recommended to quantify AR. Intermediate VC
orifice, if the orifice shape is irregular, as in bicuspid valve, the colour values (3–6 mm) need confirmation by a more quantitative
jet width is less related to the degree of regurgitation. Its accuracy method, when feasible. The VC can often be obtained in ec-
can thus be improved by normalizing the jet width for the LV
centric jet. In case of multiple jets, the respective values of
outflow tract diameter. The cross-sectional area of the jet from the
VC width are not additive. The assessment of the VC by
parasternal short-axis view and its ratio to the LV outflow tract area
is also semi-quantitative parameters of AR severity. Although these 3D echo is still reserved for research purposes.
measurements suffer from a high inter-observer variability, a jet The flow convergence method. The assessment of the flow convergence
width ratio .65% is a strong argument for severe AR.10 zone has been less extensively studied in AR than in mitral regurgita-
Key point: The colour flow area of the regurgitant jet, as a tion (MR).14,15 Imaging of the flow convergence zone is obtained
single parameter, is not recommended to quantify the se- from the apical three or five-chamber or parasternal long-axis or
verity of AR. The colour flow imaging should only be used upper right parasternal views. The radius of the PISA is measured
for a visual assessment of AR. A more quantitative approach at diastole using the first aliasing. R Vol and EROA are obtained
is required when more than a small central AR jet is using the standard formulas (Figures 6 and 7).The flow convergence
observed. or PISA method has several limitations. Firstly, it is not feasible in a sig-
nificant percentage of patients with AR due to interposition of valve
VC width. For AR, imaging of the VC—the regurgitant jet as it tra- tissue and difficulty in correctly identifying the flow convergence
verses the aortic orifice or the effective regurgitant area—is zone. Non-planar or confined flow convergence zones that invalidate
obtained from the parasternal long-axis view.11 – 13 Practically, the the hemispheric assumption are potential causes of either under- or
VC represents the smallest flow diameter at the level of the over-estimation of AR severity by the PISA method. Accordingly,
aortic valve in the LV outflow tract, immediately below the flow caution should be exercised when using the PISA method in patients
convergence region (Figure 5). It provides thus an estimate of the with obtuse flow convergence angles, such as those with aneurysmal
size of the effective regurgitant orifice area (EROA) and is smaller dilation of the ascending aorta or those with confined flow conver-
than the regurgitant jet width in the LV outflow tract (expansion gence zone such as could occur in patients with cusp perforation
of the jet immediately below the VC). Using a Nyquist limit of or commissural leaks. Grading of the severity of AR classifies regur-
50–60 cm/s, a VC width of ,3 mm correlates with mild AR, gitation as mild, moderate, or severe, and subclassifies the moderate
whereas a width .6 mm indicates severe AR. The measurement regurgitation group into ‘mild-to-moderate’ (EROA of 10 –19 mm or
Table 2 Echocardiographic parameters used to quantify regurgitation severity: advantages and limitations
Parameters Usefulness/advantages Limitations

...............................................................................................................................................................................
Valve morphology Flail valve is specific for severe regurgitation (i.e. Other abnormalities are non-specific for severe valvular
ruptured PMs in MR) regurgitation
Tricuspid annulus diameter in TR Dilatation sensitive for severe TR Dilatation seen in other conditions
Need to be confirmed in further studies
Colour flow regurgitant jet Ease of use Can be inaccurate for estimation of regurgitation severity
Evaluates the spatial orientation of regurgitant jet Influenced by technical and haemodynamic factors
Good screening test for mild vs. severe regurgitation Expands unpredictably below the orifice in AR or PR
Underestimates eccentric jet adhering the atrial wall

(Coanda effect) in MR or TR
VC width Relatively quick and easy Not valid for multiple jets
Relatively independent of haemodynamic and Small values; small measurement errors leads to large %
instrumentation factors error
Not affected by other valve leak Intermediate values need confirmation
Good for extremes regurgitation: mild vs. severe Affected by systolic changes in regurgitant flow
Can be used in eccentric jet Lacks published data in PR
PISA method Can be used in eccentric jets PISA shape affected
Not affected by the aetiology of regurgitation or other by the aliasing velocity
valve leak in case of non-circular orifice
Quantitative: estimates lesion severity (EROA) and by systolic changes in regurgitant flow
volume overload (R Vol) by adjacent structures (flow constraints)
Flow convergence at 50 cm/s alerts to significant MR PISA radius is more a hemi-ellipse
Large flow convergence at 28 cm/s alerts to Errors in PISA measurement are squared
significant TR Inter-observer variability
Not valid for multiple jets
Feasibility limited by aortic valve calcifications in AR
Validated in only few studies in TR
Lacks published data in PR
CW regurgitant jet profile Simple, easily available Qualitative, complementary finding
Complete signal difficult to obtain in eccentric jet
Pressure half-time in AR or PR Simple Affected by LV compliance, blood pressure, acuity
Diastolic flow reversal in the Simple Affected by sample volume location and acuteness of AR
descending aorta in AR Affected by aortic compliance.
Brief velocity reversal is normal
Cut-off validated for distal aortic arch
Pulmonary vein flow in MR Simple Affected by LA pressure, atrial fibrillation
Systolic flow reversal is specific for severe MR Not accurate if MR jet is directed into the sampled vein
Hepatic vein flow in TR Simple Affected by RA pressure, atrial fibrillation
Systolic flow reversal is specific for severe TR
Peak E velocity in MR or TR Simple, easily available Affected by atrial pressure, atrial fibrillation, ventricular
Usually increased in severe regurgitation relaxation
Complementary finding
Atrial and ventricular size Dilatation is sensitive for chronic severe regurgitation Dilatation observed in other conditions (non-specific)
Normal size almost excludes severe chronic May be normal in acute severe regurgitation
regurgitation
AR, aortic regurgitation; CW, continuous wave, EROA, effective regurgitant orifice area; MR, mitral regurgitation, PISA, proximal isovelocity surface area; PM, papillary muscle;
PR, pulmonary regurgitation; RA, right atrium; R Vol, regurgitant volume; TR, tricuspid regurgitation; VC, vena contracta.
Highlighted: parameters specific to a valvular regurgitation.
a regurgitant volume, R Vol of 20– 44 mL) and ‘moderate-to-severe’ Pulsed Doppler

(EROA of 20–29 mm2 or an R Vol of 45 –59 mL). An EROA Doppler volumetric method. The pulse wave (PW) Doppler method can
≥30 mm2 or an R Vol ≥60 mL indicates severe AR. be used as an alternative method to quantify the AR severity.1 – 3 In the
Key point: When feasible, the PISA method is highly absence of significant MR, the mitral inflow is used to calculate the sys-
recommended to quantify the severity of AR. It can be temic stroke volume (see ‘Mitral regurgitation’ section). The pulmonic
used in both central and eccentric jets. In eccentric AR site can be used in patients with significant MR. The total stroke
volume is derived from the LVOT stroke volume. This approach is time-
jets, we recommend to use the parasternal long-axis view
consuming and is associated with several drawbacks. In general, a regur-
to evaluate the flow convergence zone. An EROA gitant fraction (R Vol divided by the LVOT stroke volume) .50% indi-
≥ 30 mm2 or an R Vol ≥ 60 mL indicates severe AR. cates severe AR.
Table 3 Functional classification of AR lesions
Dysfunction Echo findings

................................................................................
Type I: enlargement of the Dilatation of any components of the
aortic root with normal aortic root (aortic annulus, sinuses
cusps of valsalva, sinotubular junction)
Type IIa: cusp prolapse with
eccentric AR jet
Cusp flail Complete eversion of a cusp into the
LVOT in long-axis views
Partial cusp prolapse Distal part of a cusp prolapsing into the
LVOT (clear bending of the cusp

body on long-axis views and the
presence of a small circular
structure near the cusp free edge on
short-axis views)
Whole cusp prolapse Free edge of a cusp overriding the
plane of aortic annulus with
billowing of the entire cusp body
into the LVOT (presence of a large
circular or oval structure
immediately beneath the valve on
short-axis views)
Type IIb: free edge Presence of an eccentric AR jet
fenestration with without definite evidence of cusp
eccentric AR jet prolapse
Type III: poor cusps quality or Thickened and rigid valves with
Figure 2 Mechanisms of AR according to the Carpentier’s func-
quantity reduced motion
tional classification. Type: aortic annulus dilatation; Type IIa: pro-
Tissue destruction (endocarditis)
lapse of the left coronary cusp (arrow); Type III: rheumatic aortic Large calcification spots/extensive
valve disease with restricted cusp motion. calcifications of all cusps interfering
with cusp motion
The degree of calcification of the aortic valve is scored as follows:
Diastolic flow reversal in the descending aorta (or peripheral arteries). AR Grade1: no calcification.
can lead to diastolic flow reversal in the aorta. The flow reversal is Grade 2: isolated small calcification spots.
best imaged in the upper descending aorta at the aortic isthmus Grade 3: bigger calcification spots interfering with cusp motion.
level from a suprasternal view by using PW Doppler. The sample Grade 4: extensive calcifications of all cusps with restricted cusp
volume is placed just distal to the origin of the left subclavican motion.
artery and it is aligned as much as possible along the major axis of
the aorta. The Doppler filter is decreased to its lowest setting to
allow detection of low velocities (,10 cm/s). With milder degrees or mild AR, significant overlap between moderate and severe AR
of regurgitation, there is a brief reversal of flow limited to early dia- exists in more dense jet tracings. Practically, the CW density does
stole. As the degree of the regurgitation increases, the duration and not provide useful information about the severity of AR. The
the velocity of the reversal flow during diastole increase. It grading by this method is qualitative. The rate of deceleration of
becomes sustained throughout diastole at velocities exceeding
the diastolic regurgitant jet and the derived pressure half-time
20 cm/s in severe AR (end-diastolic velocity measured at peak
reflect both the degree of regurgitation and the ventricular end-
R-wave) (Figure 8). This cut-off value has been validated in the prox-
imal descending aorta just beneath the aortic isthmus.16 Significant diastolic pressures. As the degree of AR increases, the aortic diastolic
holodiastolic reversal in the abdominal aorta is also a very specific pressure decreases and the LV end-diastolic pressure increases.17,18
sign of severe AR. The late diastolic jet velocity is thus reduced and the pressure half-
Key point: The measurement of the diastolic flow reversal time shortened. A pressure half-time of ,200 ms is consistent
in the descending and abdominal aorta is recommended, with severe AR, whereas a value .500 ms suggests mild AR. Of
when assessable. It should be considered as the strongest note, the pressure half-time is however influenced by chamber com-
additional parameter for evaluating the severity of AR. pliance, the acuteness of AR (i.e. in severe acute AR, the PHT is almost
always short) and the aorto-ventricular pressure gradient.
Continuous wave Doppler of the AR jet Key point: The CW Doppler density of the AR jet does not
Continuous wave (CW) Doppler of the AR jet is classically best provide useful information about the severity of AR. The as-
obtained from the apical five-chamber view (Figure 9). However, sessment of the pressure half-time requires good Doppler
effort should be made to obtain correct Doppler angle in order to beam alignment. A careful probe angulation is often
minimize errors related to possible ultrasound beam misalignment. needed. Because of the influence by chamber compliance
For eccentric jets, better signals may be obtained from the right para- and chamber pressures, it can only serve only as a comple-
sternal window. While faint spectral display is compatible with trace mentary finding for the assessment of AR severity.

Figure 3 (A) Measurements of the aortic diameters. (i) valve annulus, (ii) aortic sinuses, (iii) sinotubular junction, (iv) proximal ascending aorta; (B)
example of AR jet impinging on the anterior mitral valve leaflet with a reverse doming of the anterior mitral valve leaflet; (C ) M-mode recording
showing early mitral valve closure in a patient with severe AR; (D) M-mode recording showing the fluttering motion of the anterior mitral leaflet
in a patient with severe AR.
Figure 4 (A) Colour Doppler showing a severe AR; (B) colour-coded M-mode depicting the time-dependency of flow signal during the heart cycle.
Consequences of AR on LV size and function Key point: LV diameters, volumes, and ejection fraction
The presence of severe AR has significant haemodynamic effects, should always be measured and reported. It is strongly
primarily on the LV. AR imposes additional volume load on the recommended to index the LV diameters and volumes to
LV. In acute AR, the LV is classically not enlarged, while in the the body surface area.
chronic situation, the LV progressively dilates and irreversible
LV damage may occur. Hence, dilatation is sensitive for Integrating indices of severity
chronic significant AR while the normal size almost excludes The echocardiographic assessment of AR includes integration of data
severe chronic AR. However, dilatation can be observed in from 2D/3D imaging of the aortic root, aortic valve, and LV as well as
other conditions (non-specific) or may be absent in acute severe Doppler measures of regurgitation severity (Table 4). Effort should be
AR. made to quantify the degree of regurgitation, except in the presence

Figure 5 (A) Semi-quantitative assessment of AR severity using the vena contracta width (VC). The three components of the regurgitant jet (flow
convergence zone, vena contracta, jet turbulence) are obtained. PT-LAX: parasternal long-axis view; (B) assessment of the VC in a patient with an AR
jet directed towards the septum.
Figure 6 Quantitative assessment of AR severity using the PISA method. Stepwise analysis of AR: (A) parasternal long-axis view (PT-LAX); (B)
colour-flow display; (C ) zoom of the selected zone; (D) downward shift of zero baseline to obtain a hemispheric PISA; (E) measure of the PISA
radius using the first aliasing; (F ) Continuous wave Doppler of AR jet allowing calculation the effective regurgitant orifice area (EROA) and regurgitant
volume (R Vol). TVI, time-velocity integral.
of mild or less AR. Both the VC width and the PISA method are Pulmonary regurgitation
recommended, whenever possible. Adjunctive parameters help to
consolidate about the severity of AR and should be widely used par- A slight amount of pulmonary regurgitation (PR) has been reported in
ticularly when there is discordance between the quantified degree of 40 –78% of patients with normal pulmonary valves. Acquired
AR and the clinical context. These parameters should be interpreted mild-to-moderate PR is most often seen in patients with pulmonary
according the chronicity of AR and the LV remodelling. hypertension with dilatation of the pulmonary artery. Severe PR is

Figure 7 Quantitative assessment of AR severity using the PISA method from the apical five-chamber view (CV). R Vol: regurgitant volume; EROA,
effective regurgitant orifice area; TVI, time-velocity integral; Va, aliasing velocity.
Figure 8 A pulsed Doppler recording within the descending aorta from a patient with severe AR demonstrates flow reversal throughout diastole.
An end-diastolic flow velocity .20 cm/s is indicative of severe AR.
uncommon and usually observed in patients with anatomic abnor- however thinner because of the lower pressures in the right than in
malities of the valve or after valvulotomy.19 There are very few vali- the left heart system.
dated studies owing to the low prevalence rates and difficulties in
imaging.
Aetiology and mechanisms
Pulmonary regurgitation may be caused by congenital anomalies
Anatomy and function of the pulmonary (quadricuspid or bicuspid valves), hypoplasia, post-repair of Tetral-
valve ogy of Fallot, or prolapse of the pulmonary valve. Other causes
The pulmonary valve is a three leaflet structure, anatomically similar include infective endocarditis, carcinoid syndrome, and rheumatic
to the aortic valve (Figure 10). The pulmonic valve structure is heart disease. Carcinoid syndrome results in shortening and

Figure 9 Three examples of AR are provided, all taken from the parasternal long-axis view using colour Doppler (top) and from the apical five-
chamber view using continuous wave Doppler (mid). The vena contracta (VC) increases with the severity of AR. The pressure half-time (PHT)
decreases with more severe AR, whereas the left ventricular outflow time velocity (LVOT TVI) integral increases.
Table 4 Grading the severity of AR
Parameters Mild Moderate Severe

...............................................................................................................................................................................
Qualitative
Aortic valve morphology Normal/abnormal Normal/abnormal Abnormal/flail/large coaptation defect
Colour flow AR jet widtha Small in central jets Intermediate Large in central jet, variable in eccentric jets
CW signal of AR jet Incomplete/faint Dense Dense
Diastolic flow reversal in the Brief, protodiastolic Intermediate Holodiastolic flow reversal (end-diastolic
descending aorta flow reversal velocity .20 cm/s)
Diastolic flow reversal in the Absent Absent Present
abdominal aorta
Semi-quantitative
VC width (mm) ,3 Intermediate ≥6
Pressure half-time (ms)b .500 Intermediate ,200
Quantitative
EROA (mm2) ,10 10–19; 20–29d ≥30
R Vol (mL) ,30 30–44; 45–59d ≥60
+ LV sizec
AR, aortic regurgitation; CW, continuous wave; LA, left atrium; EROA, effective regurgitant orifice area; LV, left ventricle; R Vol, regurgitant volume; VC, vena contracta.
a
At a Nyquist limit of 50 –60 cm/s.
b
Pressure half-time is shortened with increasing LV diastolic pressure, vasodilator therapy, and in patients with a dilated compliant aorta or lengthened in chronic AR.
c
Unless for other reasons, the LV size is usually normal in patients with mild AR. In acute severe AR, the LV size is often normal. Accepted cut-off values for non-significant LV enlargement: LV
end-diastolic diameter ,56 mm, LV end-diastolic volume ,82 mL/m2, LV end-systolic diameter ,40 mm, LV end-systolic volume ,30 mL/m2.
d
Grading of the severity of AR classifies regurgitation as mild, moderate, or severe, and subclassifies the moderate regurgitation group into ‘mild-to-moderate’ (EROA of 10 –19 mm or
an R Vol of 20 –44 mL) and ‘moderate-to-severe’ (EROA of 20 –29 mm2 or an R Vol of 45 –59 mL).

Figure 10 Two-dimensional and 3D echo recordings of the pulmonic valve. PT-SAX, parasternal short-axis view.
thickening of the pulmonary valve leaflets, similar to the involvement from the subcostal view. Although this measurement suffers from a
of the tricuspid valve. Myxomatous valve is rare, resulting in thicken- high inter-observer variability, a jet width that occupies .50 –65%
ing, redundancy, and sagging of the pulmonary valve leaflets. of the RV outflow tract width measured in the same frame suggests
severe PR.23
Detection of reversal colour Doppler flow in pulmonary arteries is
Echocardiographic evaluation in PR a very specific sign of severe PR.
TTE, TOE, or 3D echo could provide useful information regarding
anomalies of cusp number (bicuspid or quadricuspid valves), VC width. Although the VC width is probably a more accurate method
motion (doming or prolaspe), or structure (hypoplasia, dysplasia, than the jet width to evaluate PR severity by colour Doppler, it lacks
absence of pulmonary valve). The evaluation of the pulmonary validation studies (Figures 11 and 12). As for other regurgitations, the
same limitations are applicable. The shape of the VC is complex in
valve anatomy is, however, more difficult than for other valves
most cases. The value of 3D echo has not yet been defined.24
(limited by poor acoustic access). With 2D echo, typically only one
or two leaflets of the pulmonary valve can be simultaneously visua- The flow convergence method. In some patients, the flow convergence
lized. On occasion, the pulmonary valve can be seen in a short-axis zone can be assessed (Figure 13). However, no studies have examined
view. In adults, visualization of the pulmonary valve is obtained the clinical accuracy of this method in quantifying the severity of PR.
from the parasternal short-axis view at the level of the aortic valve
or from a subcostal approach. The role of TOE in PR is limited Pulsed Doppler
since the pulmonary valve is more difficult to image with TOE (far Theoretically, PW Doppler assessment of the forward and reverse
from the probe). The views that maximize visualization of the pul- flows at the pulmonary annulus and in the pulmonary artery can
monary valve include horizontal plane imaging at the level of the been used to calculate R Vol and regurgitant fraction. The pulmonary
short-axis aortic valve (‘inflow-outflow view’) and a deep gastric annulus should be measured carefully during early ejection (2–3
view in the 1208 imaging plane (outflow view). frames after the R-wave on the ECG), just below the valve. This tech-
nique is subject to errors in measurement and is not well validated.25
Assessment of PR severity
Determination of the PR severity has been less validated than deter- Continuous wave Doppler
mination of AR severity. There is no clinically accepted method of quantifying PR using CW
Doppler. The density of the CW signal provides a qualitative
Colour flow Doppler measure of regurgitation.26 In mild PR, there is a slow deceleration
Colour flow imaging. Detection of PR relies almost exclusively on of the jet velocity. A rapid deceleration rate with termination of
colour flow imaging. PR is diagnosed by documenting a diastolic jet flow in mid-to-late diastole is not specific but compatible with
in the right ventricular (RV) outflow tract directed towards the RV. severe regurgitation. In patients with congenital disease, a pressure
Pathological PR is distinguished from physiological PR by a longer dur- half-time ,100 ms yields good sensitivity and specificity for severe
ation of flow (holodiastolic) and a wider jet as the regurgitant jet PR.27 The pressure half-time is dependant not only on PR severity,
crosses the pulmonic valve.20 Functional PR jets are usually very but also on diastolic intrapulmonary pressures and on diastolic prop-
small, central, and spindle shaped. In severe PR, where equalization
erties of the RV, with shorter pressure half-time when RV physiology
of the diastolic pulmonary artery and RV pressures occurs earlier
is restrictive.
in diastole, the colour jet area can be brief and inaccurate (depend-
ency on the driving pressure).21 The assessment of PR severity is
usually estimated by the diameter of the jet at its origin.22 The Consequences of PR
maximum colour jet diameter (width) is measured in diastole imme- The evaluation of the size and function of the RV in the absence of pul-
diately below the pulmonic valve (at the junction of the RV outflow monary hypertension provides indirect clues to the severity of PR.
tract and pulmonary annulus) in the parasternal short-axis view or Evidence of RV dilatation is, however, not specific for severe PR.

Figure 11 Assessment of PR severity by using colour-flow imaging. Top: measurements of the right ventricular outflow tract dimension (RVOT)
and regurgitant jet width in two patients with TR. Bottom: continuous wave Doppler recordings.
Figure 12 Example of a patient with a severe PR: (A) left, complete lack of valve coaptation and right, the measurement of the vena contracta width
(VC); (B) colour-coded M-mode depicting the time-dependency of flow signal during the heart cycle; (C) continuous Doppler recording of PR
showing a rapid flow deceleration during the diastole (red arrow) and increased systolic flow velocity (not related to concomitant pulmonary sten-
osis).
Nevertheless, its absence suggests milder degree of PR or acute PR. (TR), the RV function is classically evaluated by the RV volumes and
Of note, dilatation can be observed in other conditions (non-specific) the RV fractional area change. 3D echocardiography allows more ac-
or may be absent in acute severe PR. As for tricuspid regurgitation curate evaluation of RV ejection fraction than 2D. The utility of the

Figure 13 Assessment of PR by the PISA method.
Table 5 Grading the severity of PR

...............................................................................................................................................................................
Qualitative
Pulmonic valve morphology Normal Normal/abnormal Abnormal
Colour flow PR jet widtha Small, usually ,10 mm in length with a Intermediate Large, with a wide origin; may be brief
narrow origin in duration
Reversal flow in pulmonary arteries Absent Absent Present
CW signal of PR jetb Faint/slow deceleration Dense/variable Dense/steep deceleration, early
termination of diastolic flow
Pulmonic vs. aortic flow by PW Normal or slightly increased Intermediate Greatly increased
Semi-quantitative
VC width (mm) Not defined Not defined Not defined
Pressure half-timec Not defined Not defined ,100 ms
Jet width ratio Not defined Not defined .50–65%
Quantitative
EROA (mm2) Not defined Not defined Not defined
R Vol (mL) Not defined Not defined Not defined
+RV sized
PR, pulmonic regurgitation; CW, continuous wave; EROA, effective regurgitant orifice area; PW, pulse wave; RV, right ventricle; R Vol, regurgitant volume; VC, vena contracta.
a
At a Nyquist limit of 50 – 60 cm/s.
b
Steep deceleration is not specific for severe PR.
c
Pressure half-time is shortened with increasing RV diastolic pressure.
d
Unless for other reasons, the RV size is usually normal in patients with mild PR. In acute severe PR, the RV size is often normal. Accepted cut-off values for non-significant RV enlargement
(measurements obtained from the apicalfour4-chamber view): Mid-RV dimension ≤33 mm, RV end-diastolic area ≤28 cm2, RV end-systolic area ≤16 cm2, RV fractional area change
.32%, maximal.
other indices deriving from tissue Doppler imaging has not been ex- absence of extensive data on the quantitation of PR, the experts rec-
tensively examined in the context of PR unrelated to congenital heart ommend to assess the PR severity by using the different approaches
disease. available and to corroborate each other.
Key point: Grading of PR severity remains difficult since
Integrating indices of severity standards for the quantification of PR are less robust than
The echocardiographic assessment of PR includes integration of data for AR. The VC is probably the most accurate approach. If
from 2D/3D imaging of the pulmonary valve and RV as well as possible, the PISA method could provide the quantitative
Doppler measures of regurgitation severity (Table 5). In the evaluation of PR. In all cases, it is recommended to
corroborate the results of these methods with the other Aetiology and mechanisms of MR
available parameters. According to aetiology, MR can be classified as primary (i.e. organic/
structural: intrinsic valvular disease) or secondary (i.e. functional/
non-structural: without evident structural abnormalities of the
Mitral regurgitation mitral valve) whereas the mechanism is based on Carpentier’s classi-
fication of leaflet motion: Type I: normal leaflet motion, Type II: ex-
MR is increasingly prevalent in Europe despite the reduced incidence
cessive motion, Type III: restrictive motion (A: systolic/diastolic and
of rheumatic disease.5 Echocardiography plays a key role in the as-
B: systolic) (Figure 14). Causes of primary MR include most commonly
sessment and management of patients with MR.
degenerative disease (Barlow, fibroelastic degeneration, Marfan,
Ehlers-Danlos, annular calcification), rheumatic disease, toxic valvu-
lopathy, and endocarditis. Ruptured papillary muscle secondary to
Anatomy and function of the mitral valve

myocardial infarction is included as primary ischaemic MR.
Normal mitral valve function depends on perfect function of the
Degenerative disease, the most common surgical MR cause, covers a
complex interaction between the mitral leaflets, the subvalvular ap-
large spectrum of lesions (Figure 15): (i) isolated billowing with leaflets
paratus (chordae tendineae, and papillary muscles), the mitral
tips remaining intra-ventricular to flail leaflet with valvular eversion
annulus, and the LV. An imperfection in any one of these components
[the leaflet tip is directed towards the left atrium (LA)], (ii) isolated
can cause the valve to leak.28 The normal mitral valve has two leaflets;
scallop to multi-segment (or generalized) prolapse (the leaflet tip is
the posterior attached to the two-thirds of the annular plane and the
directed towards the LV and the coaptation line is behind the
anterior, to the remaining one-third. They are each divided into three
annular plane), (iii) thin/non-redundant leaflets to thick/excess
scallops: A1, A2, A3 and P1, P2, P3. A1 and P1 correspond to the ex-
tissue (Barlow’s disease).
ternal, anterolateral portion of their respective leaflet, close to the
Secondary MR develops despite a structurally normal mitral valve in
anterolateral commissure, and the left atrial appendage. In opposite,
the context of ischaemic heart disease, dilated cardiomyopathy, or
A3 and P3 are internal, close the posteromedial commissure, and the
severe LA dilatation.29,30 It results from an imbalance between the
tricuspid annulus.
Figure 14 Mechanisms of mitral regurgitation according to the Carpentier’s functional classification.


Figure 15 (A) In normal mitral valve, the coaptation (red point) occurs beyond the mitral annular plane (line); (B) billowing mitral valve is observed
when a part of the mitral valve body protrudes into the left atrium (arrow); (C and D) Mitral valve prolapse is defined as abnormal systolic displace-
ment of 1 (C posterior prolapse) or both leaflets into the left atrium below the annular (D bileaflet prolapse); (E) flail of the anterior leaflet (arrow).
forces acting on mitral leaflets and LV-generated closing forces. LV re- localization of the origin of the regurgitant jet may identify prolapsing
modelling and the resulting tethering of the mitral valve play a major segments. The TTE parasternal long-axis and the TOE sagittal view at
role in the genesis of secondary MR. Chronic secondary ischaemic 1208 classically show A2 and P2. With TOE, angulation of the
MR results, in 95% of the cases, from a type IIIb dysfunction. The re- probe towards the aortic valve allows the visualization of A1 and
strictive motion occurs essentially during systole and is more fre- P1 and towards the tricuspid, the visualization of A3 and P3. In
quent in patients with previous posterior infarction (asymmetric apical four-chamber view, appreciation of A3, A2, and P1 (internal to
pattern).31 In this setting, the traction on the anterior leaflet by sec- external) is possible as the TTE two-chamber view or the TOE view
ondary chordae can induce the so-called ‘seagull sign’ (Figure 16A). In at 408 to 608 with TOE displays P3, A2, and P1 (left to right,
patients with idiopathic dilated cardiomyopathy or with both anter- bi-commissural view). The precise location of the involved leaflets/
ior and inferior infarctions, both leaflets exhibit a reduced systolic scallops, the description of the presence and extent of calcifications
motion leading to incomplete coaptation (symmetric pattern) and the extent of anatomic changes are fundamental parameters to
(Figure 16B). Rarely, in ischaemic MR, the mechanism of MR is be provided. A flail leaflet, a ruptured papillary muscle or a large co-
related to fibrosis and elongation of the papillary muscle. aptation defect is specific for severe MR.
Rheumatic MR is characterized by variable thickening of the leaflets Of note, with 2D TTE, the diagnosis of prolapse should be made in
especially at the level of their free edge. Fibrosis of the chordae is fre- the parasternal or eventually the apical long-axis view, but not in the
quent, especially of those attached to the posterior valve explaining apical four-chamber view, because the saddle-shaped annulus may
the rigidity and reduced motion of the posterior leaflet in diastole lead to false positive diagnosis. Using the parasternal long-axis TTE
(Type IIIa). view, annular dilatation is identified when the ratio annulus/anterior
In some patients, the posterior leaflet remains in a semi-open pos- leaflet is .1.3 (in diastole) or when the annulus diameter is
ition throughout the cardiac cycle and the motion of the anterior .35 mm.32 The normal contraction of the mitral annulus (decrease
leaflet in systole produces a false aspect of prolapse. in the annular area in systole) is 25%.33 When available, the 3D
imaging provides a comprehensive evaluation of the mitral valve
Echocardiographic evaluation in MR morphology (Figure 19). This technique has been shown to be super-
Mitral valve morphology ior to describe mitral pathology, especially for anterior leaflet defects
Two-dimensional TTE and TOE are often used to accurately assess and commissural involvement in degenerative disease and commis-
the mitral valve morphology (Figures 17 and 18). The TTE parasternal sural fusion in the rheumatic process. The ‘en face’ view of the
short-axis view and the TOE transgastric view at 08 permit the assess- valve from the atrial perspective is identical to the surgical view in
ment of the six scallops and, with colour Doppler imaging, the the operating room.8
Predictors of successful valve repair

Several echocardiographic parameters can help to identify patients at
risk of treatment failure. In primary MR, some predictors of unsuc-
cessful repair have been reported: the presence of a large central
regurgitant jet, severe annular dilatation (.50 mm), involvement
of ≥3 scallops especially if the anterior leaflet is involved, and exten-
sive valve calcification (Table 6).34 Moreover, the lack of valve tissue is
also an important predictor of unsuccessful repair both in rheumatic
valve disease and in patients who have had infective endocarditis with
large valve perforation.
In secondary ischaemic MR, patients with a mitral diastolic annulus
diameter ≥37 mm, a systolic tenting area ≥1.6 cm2, and a severe

functional ischaemic MR could have a 50% probability of recurrence
of regurgitation after mitral valve repair.35 Pre-operatively (TTE),
several parameters are associated with an increased risk of mitral
valve repair failure (Table 7 33) (Figure 20).
Key point: The echocardiographic report should provide
clues on the likelihood of valve repair.
Assessment of MR severity
Colour flow Doppler
Colour flow imaging. Colour flow imaging is the most common way to
assess MR severity.36 The general assumption is that as the severity of
the MR increases, the size and the extent of the jet into the LA also
increase. Theoretically, larger colour jets that extend deep into the
Figure 16 (A) Ischaemic MR with a predominant posterior leaflet LA represent more MR than smaller thin jets that appear just
restriction (arrows) leading to an asymmetric tenting pattern. The beyond the mitral leaflets. However, the relationship between jet
restriction on the anterior leaflet due excessive stretching by the size and MR severity presents a large range of variability because, in
strut chordate provides the typical seagull sign (white arrow). addition to regurgitation severity, the colour flow display depends
The colour jet is originating centrally but is directed laterally on many technical and haemodynamic factors. For a similar severity,
towards the lateral wall of the left atrium. (B) Ischaemic MR with a patients with increased LA pressure or with eccentric jets that hug
bileaflet restriction (arrows) leading to a symmetric tenting pattern. the LA wall or in whom the LA is enlarged may exhibit smaller jets
The colour jet is originating and directed centrally into the left atrium. area than those with normal LA pressure and size or with central
jets (Figure 21).37 In acute MR, even centrally directed jets may be
Figure 17 Mitral valvular segmentation analysis with 2D TOE. (A, B, and C) Views obtained at 08: (A) five-chamber view depicting A1 and P1, four-
chamber view depicting A2 and P2; downwards four-chamber view depicting A3 and P3; (D) bicommissural view; (E) view at 1208 visualizing A2 and
P2; (F) transgastric view at 08 depicting each scallop.

Figure 18 Mitral valvular segmentation analysis with 2D TTE. (A) 2D TTE parasternal long-axis view depicting A2 and P2; (B) A1 and P1 (tilting of
the probe towards the aortic valve); (C) A3 and P3 [tilting of the probe towards the tricuspid (Tr) valve]; (D) 2D TTE parasternal short-axis view
depicting each scallop; (E) four-chamber view depicting A3, A2, and P1; (F) bicommissural view. For (B) and (D) see above.
Figure 19 Real-time 3D TOE volume rendering of the mitral valve. Left: classical TEE view; right: surgical view. A1, A2, A3: anterior mitral valve
scallops; P1, P2, P3: posterior mitral valve scallops; ANT COMM: anterolateral commissure; POST COMM: posteromedial commissure.
misleadingly small. Furthermore, as this method is a source of many VC width. The VC is the area of the jet as it leaves the regurgitant
errors, it is not recommended to assess MR severity. Nevertheless, orifice; it reflects thus the regurgitant orifice area.38,39 The VC is typ-
the detection of a large eccentric jet adhering, swirling, and reaching ically imaged in a view perpendicular to the commissural line
the posterior wall of the LA is in favour of severe MR. Conversely, (Figure 22). Averaging measurements over at least two to three
small thin jets that appear just beyond the mitral leaflets usually indi- beats and using two orthogonal planes, whenever possible is recom-
cate mild MR. mended. A VC ,3 mm indicates mild MR, whereas a width ≥7 mm
Key point: The colour flow area of the regurgitant jet is defines severe MR.
not recommended to quantify the severity of MR. The The concept of VC is based on the assumption that the regurgitant
colour flow imaging should only be used for detecting MR. orifice is almost circular. The orifice is roughly circular in primary MR;
A more quantitative approach is required when more than while in secondary MR, it appears to be rather elongated along the
a small central MR jet is observed. mitral coaptation line and non-circular.40,41 Thus, the VC could
Table 6 Probability of successful mitral valve repair in MR based on echo findings
Aetiology Dysfunction Calcification Mitral annulus Probability

dilatation of repair
..............................................................................................................................................................................
Degenerative II: Localized prolapse (P2 and/or A2) No/localized Mild/moderate Feasible
Secondary I or IIIb No Moderate Feasible
Barlow II: Extensive prolapse (≥3 scallops, posterior commissure) Localized (annulus) Moderate Difficult
Rheumatic IIIa but pliable anterior leaflet Localized Moderate Difficult
Severe barlow II: Extensive prolapse (≥3 scallops, anterior commissure) Extensive (annulus+leaflets) Severe Unlikely
Endocarditis II: Prolapse but destructive lesions No No/mild Unlikely
Rheumatic IIIa but stiff anterior leaflet Extensive (annulus+leaflets) Moderate/ Unlikely

severe
Secondary IIIb but severe valvular deformation No No or severe Unlikely
(Figure 24) The apical four-chamber view is classically recommended

Table 7 Unfavourable TTE characteristics for mitral for optimal visualization of the PISA. However, the parasternal long-
valve repair in secondary MR33 or short-axis view is often useful for visualization of the PISA in case of
anterior mitral valve prolapse. The area of interest is optimized by
Mitral valve deformation lowering imaging depth and reducing the Nyquist limit to 15–
Coaptation distance ≥1 cm
40 cm/s. The radius of the PISA is measured at mid-systole using
Tenting area .2.5–3 cm2
the first aliasing. R Vol and EROA are obtained using the standard for-
Complex jets originating centrally and posteromedially
Postero-lateral angle .458 (high posterior leaflet tethering) mulas (Figure 25). Qualitatively, the presence of flow convergence at a
Local LV remodelling Nyquist limit of 50– 60 cm/s should alert to the presence of severe
Interpapillary muscle distance .20 mm MR. Grading of the severity of primary MR classifies regurgitation
Posterior papillary-fibrosa distance .40 mm as mild, moderate, or severe, and subclassifies the moderate regurgi-
Lateral wall motion abnormality tation group into ‘mild-to-moderate’ (EROA of 20–29 mm or an R
Global LV remodelling Vol of 30 –44 mL) and ‘moderate-to-severe’ (EROA of 30–
EDD .65 mm, ESD .51 mm (ESV .140 mL) (low likelihood of 39 mm2 or an R Vol of 45– 59 mL). Quantitatively, primary MR is con-
reverse LV remodelling after repair and poor long-term outcome) sidered severe if EROA is ≥40 mm2 and R Vol ≥60 mL. In secondary
Systolic sphericity index .0.7
MR, the thresholds of severity, which are of prognostic value, are
20 mm2 and 30 mL, respectively.45 EROA is the most robust param-
EDD, end-diastolic diameter; ESD, end-systolic diameter; ESV, end-systolic volume;
eter as it represents a marker of lesion severity. A large EROA can
LV, left ventricle.
lead to large regurgitant kinetic energy (large RVol) but also to poten-
tial energy, with low RVol but high LA pressure.
The PISA method faces several advantages and limitations
appear at the same time narrow in the four-chamber view and broad (Figures 26–29).2,3,44 The colour M-mode is important to assess
in the two-chamber view. Moreover, conventional 2D colour the variation of MR flow and the related PISA during systole
Doppler imaging does not provide appropriate orientation of 2D (Figure 26). The PISA radius is most frequently constant in patients
scan planes to obtain an accurate cross-sectional view of the VC. In with rheumatic MR. It frequently increases progressively with a
case of multiple MR jets, the respective widths of the multiple VC maximum during the second half of systole in patients with mitral
are not additive. Such characteristics may be better appreciated valve prolapse. In the presence of functional MR, there is a dynamic
and measured by 3D echocardiography. In secondary MR, an variation of the regurgitant orifice area with early and late systolic
average of VC widths (four- and two-chamber views) has been peaks and a mid-systolic decrease. These changes reflect the phasic
shown to be better correlated with the 3D VC area. An average variation in transmitral pressure that acts to close the mitral leaflets
value .8 mm on 2D echo (Figure 23) has been reported to define more effectively when pressure reaches its peak in mid-systole.46
severe MR for all aetiologies of MR including functional MR.42,43 The PISA method is based on the assumption of hemispheric sym-
These data need, however, to be confirmed in further studies. metry of the velocity distribution proximal to the circular regurgitant
Key point: When feasible, the measurement of VC is lesion, which may not hold for eccentric jets, multiple jets, or
recommended to quantify MR. Intermediate VC values complex or elliptical regurgitant orifices. Practically, the geometry
(3–7 mm) need confirmation by a more quantitative of the PISA varies, depending on the shape of the orifice and mitral
method, when feasible. The VC can often be obtained in ec- valve leaflets surrounding the orifice. In functional MR, the PISA
centric jet. In case of multiple jets, the respective values of might look like an ellipsoidal shape and two separate MR jets origin-
the VC width are not additive. The assessment of the VC ating from the medial and lateral sides of the coaptation line can be
by 3D echo is still reserved for research purposes. observed on 2D echo. When the shape of the flow convergence
The flow convergence method. The flow convergence method is the zone is not a hemisphere, the PISA method may underestimate the
most recommended quantitative approach whenever feasible.44 degree of functional MR, particularly when the ratio of long-axis

Figure 20 Echo morphological parameters that are measured in ischaemic MR. (A) global LV remodelling [diameter, LV volumes, sphericity index
(SI ¼ L/l; L, major axis; l, minor axis)]; (B) local LV remodelling (1: apical displacement of the posteromedial papillary muscle; 2: second order chord-
ate; 3: interpapillary muscle distance); (C) mitral valve deformation [1: systolic tenting area (TA); 2: coaptation distance (CD) ; 3: postero-lateral angle
(PLA)].
Figure 21 Visual assessment of mitral regurgitant jet using colour-flow imaging. Examples of two patients with severe mitral regurgitation:
(A) large central jet; (B) large eccentric jet with a clear Coanda effect. CV, four-chamber view.

Figure 22 Semi-quantitative assessment of MR severity using the vena contracta width (VC). The three components of the regurgitant jet (flow
convergence zone, vena contracta, jet turbulence) are obtained. CV, chamber view; PT-LAX, parasternal long-axis view.
Figure 23 Semi-quantitative assessment of MR severity using the vena contracta width (VC) obtained from the apical four-chamber and two-
chamber views (CV) in a patient with ischaemic functional MR. The mean vena contracta is calculated (6+10/2 ¼ 8 mm).
length to short-axis length of the 3D regurgitant orifice is .1.5.47 ≥ 40 mm2 or an R Vol ≥ 60 mL indicates severe organic
When the EROA is calculated with the hemispheric assumption MR. In functional ischaemic MR, an EROA ≥ 20 mm2 or an
(using the vertical PISA), the horizontal length of PISA is ignored. In R Vol ≥ 30 mL identifies a subset of patients at an increased
organic MR, the shape of the PISA is rounder, which minimizes the risk of cardiovascular events.
risk of EROA underestimation (Figure 29). These findings could
explain why the threshold used to define a severe functional MR is in-
ferior to that used for organic MR. Careful consideration of the 3D Pulsed Doppler
Doppler volumetric method. The quantitative PW Doppler method can
geometry of PISA may be of interest in evaluating the severity of func-
be used as an additive or alternative method, especially when the
tional MR. The best 3D echo method to quantitate MR severity
PISA and the VC are not accurate or not applicable. This approach
remains to be defined. is time-consuming and is associated with several drawbacks.1 – 3,48
Key point: When feasible, the PISA method is highly Briefly, mitral R Vol is obtained by calculating the difference
recommended to quantitate the severity of MR. It can be between the total stroke volume (product of the mitral annulus
used in both central and eccentric jets. An EROA area—pd2/4 ¼ 0.785 d2, where d is the mitral annulus diameter—

Figure 24 Quantitative assessment of MR severity using the PISA method. Stepwise analysis of MR: (A) apical four-chamber view (CV); (B) colour-
flow display; (C) zoom of the selected zone; (D) downward shift of zero baseline to obtain a hemispheric PISA; (E) measure of the PISA radius using the
first aliasing; (F) continuous wave Doppler of MR jet allowing calculation the effective regurgitant orifice area (EROA) and regurgitant volume (R Vol).
TVI, time-velocity integral.
and mitral inflow TVI) and systemic stroke volume (obtained by S-wave becomes frankly reversed. As unilateral pulmonary flow re-
multiplying the LVOT area—pd2/4 ¼ 0.785 d2, where d is the versal can occur at the site of eccentric MR jets if the jet is directed
LVOT diameter—by LVOT TVI). This calculation is inaccurate in into the sampled vein, sampling through all pulmonary veins is recom-
the presence of significant AR. mended, especially during TOE. Although the evaluation of the right
Key point: The Doppler volumetric method is a time- upper pulmonary flow can often be obtained using TTE, evaluation is
consuming approach that is not recommended as a first-line best performed using TOE with the pulsed Doppler sample placed
method to quantify MR severity. 1 cm deep into the pulmonary vein. Atrial fibrillation and elevated
LA pressure from any cause can blunt forward systolic pulmonary
Anterograde velocity of mitral inflow: mitral to aortic TVI ratio. In the vein flow. Therefore, blunting of pulmonary venous flow lacks of spe-
absence of mitral stenosis, the increase in the transmitral flow cificity for the diagnosis of severe MR, whereas systolic pulmonary
that occurs with increasing MR severity can be detected as higher flow reversal is specific for severe MR.
flow velocities during early diastolic filling (increased E velocity). Key point: Both the pulsed Doppler mitral to aortic TVI
In the absence of mitral stenosis, a peak E velocity .1.5 m/s ratio and the systolic pulmonary flow reversal are specific
suggests severe MR. Conversely, a dominant A-wave (atrial contrac-
for severe MR. They represent the strongest additional para-
tion) basically excludes severe MR. These patterns are more applic-
meters for evaluating MR severity.
able in patients older than 50 years or in conditions of impaired
myocardial relaxation. The pulsed Doppler mitral to aortic TVI
ratio is also used as an easily measured index for the quantification
of isolated pure organic MR. Mitral inflow Doppler tracings are Continuous wave Doppler of MR jet
obtained at the mitral leaflet tips and aortic flow at the annulus Peak MR jet velocities by CW Doppler typically range between 4 and
level in the apical four-chamber view. A TVI ratio .1.4 strongly sug- 6 m/s. This reflects the high systolic pressure gradient between the LV
gests severe MR, whereas a TVI ratio ,1 is in favour of mild MR and LA. The velocity itself does not provide useful information about
(Figure 30).49 the severity of MR. Conversely, the signal intensity (jet density) of the
CW envelope of the MR jet can be a qualitative guide to MR severity.
Pulmonary venous flow. The pulsed Doppler evaluation of the pulmon-
A dense MR signal with a full envelope indicates more severe MR than
ary venous flow pattern is another aid for grading the severity of MR
(Figure 30).50 In normal individuals, a positive systolic wave (S) fol- a faint signal (Figure 30). The CW Doppler envelope may be truncated
lowed by a smaller diastolic wave (D) is classically seen in the (notched) with a triangular contour and an early peak velocity (blunt).
absence of diastolic dysfunction. With increasing the severity of This indicates elevated LA pressure or a prominent regurgitant pres-
MR, there is a decrease of the S-wave velocity. In severe MR, the sure wave in the LA due to severe MR. In eccentric MR, it may be

Figure 25 Quantification of MR using the PISA method. To avoid the underestimation of the regurgitant volume, the ratio of the aliasing velocity
(Va) to peak orifice velocity (vel) is maintained ,10%.
Figure 26 Four examples of flow convergence zone changes during systole using the colour M-Mode. (A and B) Functional MR [(A) early and late
peaks and mid-systolic decreases; (B) early systolic peak], (C) rheumatic MR with an end-systolic decrease in the flow convergence zone, (D) M mitral
valve prolaspe (late systolic enhancement).

Figure 27 Examples of eccentric MR that can still be perfectly assessed by using the PISA method.
Figure 28 (A) Example of a flat flow convergence zone; (B) presence of two jets; (C and D) distorted and constrained flow convergence zone by
the lateral myocardial wall.

Figure 29 Three-dimensional shape of the flow convergence in functional (A) (hemielliptic) and organic MR (B) (hemispheric).
Figure 30 Three examples of various degrees of MR, mild (A), moderate (B), and severe (C) are provided. The regurgitant jet area (RJA) as well as
the mitral E wave velocity increase with the severity of MR. In severe MR, the continuous wave Doppler signal of the regurgitant jet is truncated,
triangular, and intense. Notching of the continuous wave envelope (cut-off sign) can occur in severe MR. TVI, time-velocity integral. Mild MR,
normal pulmonary vein flow pattern; moderate MR, blunt forward systolic pulmonary vein flow in a patient with moderate MR; severe MR, reversed
systolic pulmonary flow in a patient with severe MR. S, systolic wave; (D) diastolic wave.
difficult to record the full-CW envelope of the jet because of its ec- Consequences of MR
centricity, whereas the signal intensity shows dense features. The presence of severe primary MR has significant haemodynamic
Key point: The CW Doppler density of the MR jet is a effects, primarily on the LV and LA. In acute primary MR, the LV is clas-
qualitative parameter of MR severity. sically not enlarged while the LV ejection fraction usually increases in
response to the increased preload. In the chronic compensated report is mandatory.1 The quantitative assessment of myo-
phase (the patient could be asymptomatic), the forward stroke cardial function (systolic myocardial velocities, strain, strain
volume is maintained through an increase in LV ejection fraction. rate) is reasonable, particularly in asymptomatic patients
Such patients typically have LV ejection fraction .65%. In this with severe primary MR and borderline values in terms of
phase, the LA remodels and dilates but the LA pressure is often LV ejection fraction (60–65%) or LV end-systolic diameter
normal. In the chronic decompensated phase (the patient could (close to 40 mm or 22 mm/m2).
still be asymptomatic or may fail to recognize deterioration in clinical
status), the forward stroke volume decreases and the LA pressure Integrating indices of severity
increases significantly. The LV contractility can thus decrease silently The echocardiographic assessment of MR includes integration of data
and irreversibly. However, the LV ejection fraction may still be in the from 2D/3D imaging of the valve and ventricle as well as Doppler mea-
low normal range despite the presence of significant myocardial dys- sures of regurgitation severity (Table 8). Effort should be made to quan-
function. Hence, dilatation is sensitive for chronic significant MR, tify the degree of regurgitation, except in the presence of mild or

whereas normal size almost excludes severe chronic MR. obviously severe MR. Both the VC width and the PISA method are
However, dilatation can be observed in other conditions or may be recommended. Adjunctive parameters help to consolidate about
absent in acute severe MR and is, therefore, a non-specific finding. the severity of MR and should be widely used particularly when
Of note, the excess regurgitant blood entering the LA may induce there is discordance between the quantified degree of MR and the clin-
a progressive rise in pulmonary arterial pressure and a significant tri- ical context. For instance, a modest regurgitant volume reflects severe
cuspid annular dilatation. Secondary MR has a different physiology, as MR when it develops acutely into a small, non-compliant LA and it may
it is the consequence of an initial ventricular disease. The LV and LA cause pulmonary congestion and systemic hypotension.
dilatation are in excess to the degree of MR. The LA pressure is often
elevated despite lower regurgitant volume than in primary MR.
Key point: When MR is more than mild MR, providing the
TR
LV diameters, volumes, and ejection fraction as well as the TR is a common finding. Since it is mostly asymptomatic and not easily
LA dimensions (preferably LA volume) and the pulmonary audible on physical examination, it is frequently only diagnosed by
arterial systolic pressure in the final echocardiographic echocardiography performed for other indications. Although a
Table 8 Grading the severity of primary MR

...............................................................................................................................................................................
Qualitative
MV morphology Normal/abnormal Normal/abnormal Flail leaflet/ruptured PMs
Colour flow MR jet Small, central Intermediate Very large central jet or eccentric jet adhering,
swirling and reaching the posterior wall of the LA
Flow convergence zonea No or small Intermediate Large
CW signal of MR jet Faint/parabolic Dense/parabolic Dense/triangular
Semi-quantitative
VC width (mm) ,3 Intermediate ≥7 (.8 for biplane)b
Pulmonary vein flow Systolic dominance Systolic blunting Systolic flow reversalc
Mitral inflow A wave dominantd Variable E-wave dominant (.1.5 m/s)e
TVI mit /TVI Ao ,1 Intermediate .1.4
Quantitative
EROA (mm2) ,20 20–29; 30–39g ≥40
R Vol (mL) ,30 30–44; 45–59g ≥60
+ LV and LA size and the systolic pulmonary arterial pressuref
CW, continuous wave; LA, left atrium; EROA, effective regurgitant orifice area; LV, left ventricle; MR, mitral regurgitation; R Vol, regurgitant volume; VC, vena contracta.
a
b
For average between apical four- and two-chamber views.
c
Unless other reasons of systolic blunting (atrial fibrillation, elevated LA pressure).
d
Usually after 50 years of age.
e
In the absence of other causes of elevated LA pressure and of mitral stenosis.
f
Unless for other reasons, the LA and LV size and the pulmonary pressure are usually normal in patients with mild MR. In acute severe MR, the pulmonary pressures are usually elevated
while the LV size is still often normal. In chronic severe MR, the LV is classically dilated. Accepted cut-off values for non-significant left-sided chambers enlargement: LA volume ,36 mL/m2,
LV end-diastolic diameter ,56 mm, LV end-diastolic volume ,82 mL/m2, LV end-systolic diameter ,40 mm, LV end-systolic volume ,30 mL/m2, LA diameter ,39 mm, LA volume
,29 mL/m2.
g
Grading of severity of organic MR classifies regurgitation as mild, moderate, or severe, and subclassifies the moderate regurgitation group into ‘mild-to-moderate’ (EROA of 20 to
29 mm or a R Vol of 30 to 44 mL) and ‘moderate-to-severe’ (EROA of 30 –39 mm2 or a R Vol of 45 –59 mL).

Figure 31 Mechanisms of MR according to the Carpentier’s functional classification.
Figure 32 Two-dimensional and 3D echo recordings of the tricuspid valve. (A) Parasternal long-axis view; (B) parasternal short-axis view at the
level of the aortic valve; (C) apical four-chamber view; (D) subcostal view. A, anterior leaflet; S, septal leaflet; P, posterior leaflet.
mild degree of TR is frequent and benign, moderate, and severe TR the leaflets, resulting in secondary TR. As for secondary MR, second-
are associated with poor prognosis. ary TR begets TR. Indeed, TR itself leads to further RV dilation and
dysfunction, right atrial enlargement, more tricuspid annular dilata-
Anatomy and function of the tricuspid tion and tethering, and worsening TR. With increasing TR, the RV
valve dilates and eventually fails, causing increased RV diastolic pressure
The tricuspid valve complex is similar to the mitral valve but has and, in advanced situation a shift of the interventricular septum
greater variability. It consists of the annulus, leaflets, RV, papillary towards the LV. Such ventricular interdependence might reduce
muscles, and chordae tendinae. The tricuspid valve is located the LV cavity size (pure compression), causing restricted LV filling
between the right atrium (RA) and the RV and is placed in a slightly and increased LV diastolic and pulmonary artery pressure. The tricus-
more apical position than the mitral valve.51 The tricuspid valve has pid annular dilatation, the loss of its contraction and the increased
three leaflets of unequal size: the anterior leaflet is usually the tethering are probably the most important factors in the develop-
largest and extends from the infundibular region anteriorly to ment of TR. Indeed, the tricuspid annulus is not saddle shaped

the inferolateral wall posteriorly; the septal leaflet extends anymore; it becomes flat, planar and distorted.52,53
from the interventricular septum to the posterior ventricular A variety of primary disease processes can affect the tricuspid valve
border; the posterior leaflet attaches along the posterior margin of complex directly and lead to valve incompetence: infective endocar-
the annulus from the septum to the inferolateral wall. The insertion ditis, congenital disease like Ebstein anomaly or atrioventricular canal,
of the septal leaflet of the tricuspid valve is characteristically apical rheumatic fever (commissural fusion, shortening and retraction of
relative to the septal insertion of the anterior mitral leaflet. one or more leaflets and of the chordae tendinee), carcinoid syn-
drome (lack of commissural fusion, thickened valve with markedly
Aetiology and mechanisms restricted motion during cardiac cycle), endomyocardial fibrosis,
The most common cause of TR is not a primary tricuspid valve myxomatous degeneration of the tricuspid valve leading to prolapse
disease (organic TR) but rather an impaired valve coaptation (sec- or flail tricuspid valve, penetrating and non-penetrating trauma, and
ondary or functional TR) caused by dilation of the RV and/or of the iatrogenic damages during cardiac surgery, biopsies, and catheter
tricuspid annulus due to left-sided heart valve diseases, pulmonary placement in right heart chambers.54
hypertension, congenital heart defects, and cardiomyopathy.52 The Carpentier’s classification remains the most common used
The progressive remodelling of the RV cavity leads to tricuspid functional classification in TR: type I: leaflet perforation (infective
annular dilatation, papillary muscle displacement and tethering of endocarditis) or more frequently by annular dilatation; type II:
Figure 33 Visual assessment of tricuspid regurgitant jet using colour-flow imaging. (A) Large central jet; (B) eccentric jet with a clear Coanda effect.
CV, four-chamber view.
prolapse of one or more leaflets (tricuspid valve prolapse); and Assessment of TR severity
type III: restricted motion as the consequence of rheumatic Colour flow Doppler
disease, significant calcifications, toxic valvulopathy, functional TR Grading the severity of TR is in principle similar to MR. However,
(Figure 31). because standards for determining the TR severity are less robust
than for MR, the algorithms for relating colour flow-derived para-
meters to TR severity are less well developed.
Echocardiographic evaluation in TR
Tricuspid valve morphology Colour flow imaging. Colour-flow imaging is useful to recognize small
The three main TTE views allowing the tricuspid valve visualization jets, but the assessment of larger TR jets has important limitations.59
are the parasternal (long-axis view of RV inflow, short-axis view at Indeed, flow jets that are directed centrally into the RA generally
the level of the aortic valve), the apical 4-chamber and the subcostal appear larger than eccentric wall-impinging jets with similar or
worse severity. Basically, multiple windows (apical four-chamber,
views. TOE for the tricuspid valve is possible with the 4-chamber view

parasternal long- and short-axis views, subcostal view) are recom-
at 0 degree in the basal transoesophageal and oesogastric junction
mended to assess TR severity by colour-flow analysis. The general as-
planes. TOE is of interest for the diagnosis of endocarditis, venous sumption is that larger colour jets that extend deep into the RA
catheters and pacemakers lead infection, and visualization of traumat- represent more TR than smaller thin jets that are seen just beyond
ic rupture of the tricuspid valve. However, it is rarely possible to visu- the tricuspid leaflets. As for MR, this method is a source of many
alize by 2D echo the three leaflets simultaneously (usually from a errors and is limited by several technical and haemodynamic
modified subcostal view). Therefore, the designation of individual factors. Furthermore, colour flow imaging is not recommended for
leaflets of the tricuspid valve should be done with caution unless a assessing TR severity (Figure 33). Nevertheless, the detection of a
simultaneous view of all three cusps is obtained. Real-time 3D TTE large eccentric jet adhering, swirling, and reaching the posterior
is more routinely available and allows, with its unique capability of wall of the RA is in favour of severe TR. Conversely, small thin
obtaining a short-axis plane of the tricuspid valve, simultaneous visu- central jets usually indicate mild TR.
alization of the three leaflets moving during the cardiac cycle, their Key point: The colour flow area of the regurgitant jet is
commissures and their attachment to the tricuspid annulus.52 – 54 not recommended to quantify the severity of TR. The
(Figure 32)
In the pathologic TR, a complete understanding of leaflet morph-
ology and of the pathophysiological mechanisms underlying TR could
potentially lead to improved techniques for valve repair and to design
physiologically suitable annular rings. It should be stressed that TR is
most often seen in patients with multiple valvular disease especially
aortic or mitral valve disease. In secondary TR, increased tethering
(apical displacement of the tricuspid leaflets) can be evaluated by
the measurement of the systolic tenting area (area between the tri-
cuspid annulus and the tricuspid leaflets body) and the coaptation dis-
tance (distance between the tricuspid annular plane and the point of
coaptation) in mid-systole from the apical 4-chamber view. A tenting
area .1 cm2 has been shown to be associated with severe TR.55 The
tricuspid annulus shows a non-planar structure with an elliptical
saddle-shaped pattern, having two high points (oriented superiorly
towards the RA) and two low points (oriented inferiorly towards
the RV that is best seen in mid-systole).56 Normal tricuspid valve
annulus diameter in adults is 28 + 5 mm in the four-chamber view.
Significant tricuspid annular dilatation is defined by a diastolic diam-
eter of .21 mm/m2 (.35 mm). The normal contraction (decrease
in the annular area in systole) of the tricuspid annulus is 25%.
Predictors of successful valve repair

Persistent or recurrent TR has been reported in up to 20– 50% of
patients undergoing mitral valve surgery.57 In secondary TR, this
has been related to the extent of tricuspid leaflet restriction and to
the severity of tricuspid annular dilatation.52 Both the severity of pre-
operative TR and RV dysfunction contributes to residual post-
Figure 34 Semi-quantitative assessment of TR severity using the
operative TR. Similarly, severe tricuspid valve tethering predicts re-
vena contracta width (VC). The three components of the regurgi-
sidual TR after tricuspid valve annuloplasty. A tenting area tant jet (flow convergence zone, vena contracta, jet turbulence)
.1.63 cm2 and a tethering distance .0.76 cm are good predictors are obtained. CV, chamber view.
of residual TR after tricuspid valve surgery.58

Figure 35 Quantitative assessment of TR severity using the PISA method. Stepwise analysis of MR: (A) apical four-chamber view (CV); (B) colour-
flow display; (C) zoom of the selected zone; (D) downward shift of zero baseline to obtain a hemispheric PISA; (E) measure of the PISA radius using the
first aliasing; (F) continuous wave Doppler of TR jet allowing calculation the effective regurgitant orifice area (EROA), and regurgitant volume (R Vol).
TVI, time-velocity integral.
colour flow imaging should only be used for diagnosing TR. studies.62 – 64 The apical four-chamber view and the parasternal
A more quantitative approach is required when more than a long- and short-axis views are classically recommended for optimal
small central TR jet is observed. visualization of the PISA. The area of interest is optimized by lowering
imaging depth and the Nyquist limit to 15 –40 cm/s. The radius of
VC width. The VC width of the TR is typically imaged in the apical four- the PISA is measured at mid-systole using the first aliasing (Figure 30).
chamber view using the same settings as for MR (Figure 34). Averaging Qualitatively, a TR PISA radius ≥9 mm at a Nyquist limit of 28 cm/s
measurements over at least two to three beats is recommended. A alerts to the presence of severe TR, whereas a radius ,5 mm sug-
VC ≥7 mm is in favour of severe, whereas a diameter ,6 mm may gests mild TR.63 An EROA ≥40 mm2 or an R Vol of ≥45 mL indicates
be either mild or moderate TR.60 The geometry of the regurgitant severe TR. The PISA method faces several advantages and limita-
orifice of secondary TR is usually more complex than the one of tions.1 – 3 It could underestimate the severity of TR by up to 30%.
MR and not necessarily circular.52 A poor correlation has been sug- This method is also less accurate in eccentric jets. To note, the
gested between the 2D VC width and the 3D assessment of the number of studies having evaluated the value of the flow convergence
EROA. This could underline the poor accuracy of the 2D VC width method in TR are still limited.
in eccentric jets. With 3D echo, an EROA .75 mm2 seems to indi- Key point: When feasible, the measurement of the PISA
cate severe TR.61 However, these data need to be confirmed in radius is reasonable to quantify the TR severity. A TR PISA
further studies. radius >9 mm at a Nyquist limit of 28 cm/s indicates
Key point: When feasible, the measurement of the VC is severe TR.
recommended to quantify TR. A VC width ≥ 7 mm defines
severe TR. Lower values are difficult to interpret. In case Pulsed Doppler
of multiple jets, the respective values of the VC width are Doppler volumetric method. The quantitative PW Doppler method has
not additive. The assessment of the VC by 3D echo is still not been validated to quantify the TR severity. This approach is not
recommended.
reserved to research purposes.
Anterograde velocity of tricuspid inflow. Similar to MR, the severity of TR
The flow convergence method. Although providing quantitative assess- will affect the early tricuspid diastolic filling (E velocity). In the absence
ment, clinical practice reveals that the flow convergence method is of tricuspid stenosis, the peak E velocity increases in proportion to
rarely applied in TR (Figure 35) also because one of the basic assump- the degree of TR. Tricuspid inflow Doppler tracings are obtained at
tions (circularity of regurgitant orifice) for its application is rarely met the tricuspid leaflet tips. A peak E velocity .1 m/s suggests severe
in secondary TR. This approach has been validated in small TR (Figure 36).

Figure 36 Four examples of various degrees of TR, mild (A), moderate (B), severe (C ), and massive (D) are provided. The regurgitant jet area (RJA)
as well as the tricuspid E-wave velocity increase with the severity of TR. In severe TR, the continuous wave Doppler signal of the regurgitant jet is
truncated, triangular, and intense. The peak velocity of TR (continuous wave Doppler) allows the estimation of pulmonary pressure except in case of
massive TR, since the Bernouilli equation is not applicable.
Hepatic vein flow. The pulsed Doppler evaluation of the hepatic regurgitant pressure wave in the RA due to severe TR. Marked re-
venous flow pattern is another aid for grading TR. In normal indivi- spiratory variation (decreased TR velocity with inspiration) suggests
duals, the pattern of flow velocity consists of anterograde systolic, an elevated RA pressure (Kussmaul’s sign on physical examination).
transient flow reversal as the TV annulus recoils at the end of The TR jet can be used to determine RV or pulmonary artery systolic
systole, anterograde diastolic, and a retrograde A-wave caused by pressure. This is done by calculating the RV to RA pressure gradient
atrial contraction. Such hepatic flow patterns are affected by respir-
using the modified Bernoulli equation and then adding an assumed RA
ation. With increasing the severity of TR, there is a decrease in hepatic
pressure. To note, the velocity of the TR jet by itself does not provide
vein systolic velocity. In severe TR, systolic flow reversal occurs
(Figure 37). The sensitivity of flow reversal for severe TR is 80%.59 useful information about the severity of TR. For instance, massive TR
Thus, the absence of systolic flow reversal does not rule out severe is often associated with a low jet velocity (,2 m/s) as there is near
TR. Blunted systolic hepatic vein flow can be observed in case of ab- equalization of RV and RA pressures.66 In some case, a high-velocity
normal right atrial and RV compliance, atrial fibrillation, and elevated jet that represents only mild TR may be present when severe pulmon-
right atrial pressure from any cause.65 Blunting of hepatic flow may ary hypertension is present.
thus lack of specificity. Retrograde systolic flow can also be seen
with colour flow Doppler. It can be associated with phasic spontan-
eous appearance of some contrast in the hepatic vein. Consequences of TR
Key point: The systolic hepatic flow reversal is specific for Signs of severe TR include RA and RV dilatation, a dilated and pulsatile
severe TR. It represents the strongest additional parameter inferior vena cava and hepatic vein, a dilated coronary sinus, and sys-
for evaluating the severity of TR. tolic bowing of the interatrial septum towards the LA. An end-systolic
RV eccentricity index .2—obtained by dividing the longest right
Continuous wave Doppler of TR jet lateral distance by the distance connecting the ventricular septum
As for MR, the CW envelope of the TR jet can be a guide to TR se- and the RV free wall—is in favour of severe TR (sensitivity of
verity. A dense TR signal with a full envelope indicates more severe 79%).55 Conversely, a poor correlation between the RV area, the
TR than a faint signal. The CW Doppler envelope may be truncated fractional area change and the degree of TR has been reported. More-
(notched) with a triangular contour and an early peak velocity (blunt), over, evidence of right heart dilatation is not specific for TR but can
which is indicative of elevated right atrial pressure or a prominent be noted in other conditions (pulmonary valve regurgitation,

Figure 37 Subcostal echocardiogram recorded in a patient with severe TR. (A–C) The colour Doppler confirms retrograde flow into the vena
cava and hepatic vein in systole consistent with TR (red); (D) A spectral Doppler recording from a hepatic vein, also confirming the systolic retrograde
flow.
Table 9 Grading the severity of TR

...............................................................................................................................................................................
Qualitative
Tricuspid valve morphology Normal/abnormal Normal/abnormal Abnormal/flail/large coaptation defect
Colour flow TR jeta Small, central Intermediate Very large central jet or eccentric wall-impinging jet
CW signal of TR jet Faint/parabolic Dense/parabolic Dense/triangular with early peaking (peak ,2 m/s in massive TR)
Semi-quantitative
VC width (mm)a Not defined ,7 .7
PISA radius (mm)b ≤5 6 –9 .9
Hepatic vein flowc Systolic dominance Systolic blunting Systolic flow reversal
Tricuspid inflow Normal Normal E-wave dominant (≥1 m/s)d
Quantitative
EROA (mm2) Not defined Not defined ≥40
R Vol (mL) Not defined Not defined ≥45
+ RA/RV/IVC dimensione
CW, continuous wave; EROA, effective regurgitant orifice area; RA, right atrium; RV, right ventricle; R Vol, regurgitant volume; TR, tricuspid regurgitation; VC, vena contracta.
a
b
Baseline Nyquist limit shift of 28 cm/s.
c
Unless other reasons of systolic blunting (atrial fibrillation, elevated RA pressure).
d
In the absence of other causes of elevated RA pressure.
e
Unless for other reasons, the RA and RV size and IVC are usually normal in patients with mild TR. An end-systolic RV eccentricity index .2 is in favour of severe TR. In acute severe TR,
the RV size is often normal. In chronic severe TR, the RV is classically dilated. Accepted cut-off values for non-significant right-sided chambers enlargement (measurements obtained from the
apical four-chamber view): Mid-RV dimension ≤33 mm, RV end-diastolic area ≤28 cm2, RV end-systolic area ≤16 cm2, RV fractional area change .32%, maximal 2D RA volume
≤33 mL/m2.
An IVC diameter ,2.1 cm is considered normal.
left-to-right atrial shunt, anomalous venous return). However, its References

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two-dimensional and Doppler echocardiography. J Am Soc Echo 2003;16:777 – 802.
patients with mitral valve disease, subnormal RV ejection fraction at
2. Lancellotti P, Tribouilloy C, Hagendorff A, Moura L, Popescu BA, Agricola E et al.
rest is associated with decreased exercise tolerance and mortality. In European Association of Echocardiography. European Association of Echocardiog-
operated patients, an RV ejection fraction ,20% predicted post- raphy recommendations for the assessment of valvular regurgitation. Part 1: aortic
and pulmonary regurgitation (native valve disease). Eur J Echocardiogr 2010;11:
operative death.67 Progressive RV dysfunction may also result from
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European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644 RECOMMENDATIONS

Recommendations for the echocardiographic

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Received 7 May 2013; accepted after revision 12 May 2013

requires the use of different echocardiographic modalities, should in-

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Table 1 Echocardiographic parameters used to quantify regurgitation severity: recordings

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Parameters Usefulness/advantages Limitations

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a regurgitant volume, R Vol of 20– 44 mL) and ‘moderate-to-severe’ Pulsed Doppler

Table 3 Functional classification of AR lesions

Dysfunction Echo findings

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Table 4 Grading the severity of AR

Parameters Mild Moderate Severe

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Table 5 Grading the severity of PR

Parameters Mild Moderate Severe

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Figure 14 Mechanisms of mitral regurgitation according to the Carpentier’s functional classification.

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Predictors of successful valve repair

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Table 6 Probability of successful mitral valve repair in MR based on echo findings

Aetiology Dysfunction Calcification Mitral annulus Probability

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(Figure 24) The apical four-chamber view is classically recommended

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Table 8 Grading the severity of primary MR

Parameters Mild Moderate Severe

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Predictors of successful valve repair

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Table 9 Grading the severity of TR

Parameters Mild Moderate Severe

left-to-right atrial shunt, anomalous venous return). However, its References

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