Classification of valve stenosis and regurgitation

From ECHOpedia
Jump to navigation Jump to search

Aortic Valve

Aortic valve stenosis - severity

Recommendations for classification of AS severity[1]
  Aortic sclerosis Mild Moderate Severe
Aortic jet velocity (m/s) ≤2.5 m/s 2.6-2.9 3.0-4.0 >4.0
Mean gradient (mmHg) - <20 (<30a) 20-40b (30-50a) >40b (>50a)
AVA (cm2) - >1.5 1.0-1.5 <1
Indexed AVA (cm2/m2)   >0.85 0.60-0.85 <0.6
Velocity ratio   >0.50 0.25-0.50 <0.25
  • aESC Guidelines.[2]
  • bAHA/ACC Guidelines.[3]

Aortic regurgitation - severity

Application of specific and supportive signs, and quantitative parameters in the grading of aortic regurgitation severity[4]
  Mild Moderate Severe
Specific signs for AR severity
  • Central Jet, width < 25% of LVOTς
  • Vena contracta < 0.3 cmς
  • No or brief early diastolic flow reversal in descending aorta
  • Signs of AR>mild present but no criteria for severe AR
  • Central Jet, width ≥ 65% of LVOTς
  • Vena contracta > 0.6cmς
Supportive signs
  • Pressure half-time > 500 ms
  • Normal LV size
  • Intermediate values
  • Pressure half-time < 200 ms
  • Holodiastolic aortic flow reversal in descending aorta
  • Moderate or greater LV enlargement∗∗
Quantitative parametersψ
R Vol, ml/beat < 30 30-44 45-59 ≥ 60
RF % < 30 30-39 40-49 ≥ 50
EROA, cm2 < 0.10 0.10-0.19 0.20-0.29 ≥ 0.30
  • AR, Aortic regurgitation; EROA, effective regurgitant orifice area; LV, left ventricle; LVOT, left ventricular outflow tract; R Vol, regurgitant volume; RF, regurgitant fraction.
  • LV size applied only to chronic lesions. Normal 2D measurements: LV minor-axis ≤ 2.8 cm/m2, LV end-diastolic volume ≤ 82 ml/m2 (2).
  • ς At a Nyquist limit of 50–60 cm/s.
  • ∗∗ In the absence of other etiologies of LV dilatation.
  • ψ Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe regurgitation as shown.


Mitral Valve

Mitral regurgitation - severity

Application of specific and supportive signs, and quantitative parameters in the grading of mitral regurgitation severity[4]
  Mild Moderate Severe
Specific signs of severity
  • Small central jet <4 cm2 or <20% of LA areaψ
  • Vena contracta width <0.3 cm
  • No or minimal flow convergence
  • Signs of MR>mild present, but no criteria for severe MR
  • Vena contracta width ≥ 0.7cm with large central MR jet (area < 40% of LA) or with a wall-impinging jet of any size, swirling in LAψ
  • Large flow convergenceς
  • Systolic reversal in pulmonary veins
  • Prominent flail MV leaflet or ruptured papillary muscle
Supportive signs
  • Systolic dominant flow in pulmonary veins
  • A-wave dominant mitral inflowΦ
  • Soft density, parabolic CW Doppler MR signal
  • Normal LV size
  • Intermediate signs/findings
  • Dense, triangular CW Doppler MR jet
  • E-wave dominant mitral inflow (E >1.2 m/s)Φ Enlarged LV and LA size∗∗, (particularly when normal LV function is present).
Quantitative parametersφ
R Vol (ml/beat) < 30 30-44 45-59 ≥ 60
RF (%) < 30 30-39 40-49 ≥ 50
EROA (cm2) < 0.20 0.20-0.29 0.30-0.39 ≥ 0.40
  • CW, Continuous wave; EROA, effective regurgitant orifice area; LA, left atrium; LV, left ventricle; MV, mitral valve; MR, mitral regurgitation; R Vol, regurgitant volume; RF, regurgitant fraction.
  • LV size applied only to chronic lesions. Normal 2D measurements: LV minor axis ≤ 2.8 cm/m2, LV end-diastolic volume ≤ 82 ml/m2, maximal LA antero-posterior diameter ≤ 2.8 cm/m2, maximal LA volume ≤ 36 ml/m2 (2;33;35).
  • ∗∗ In the absence of other etiologies of LV and LA dilatation and acute MR.
  • ψ At a Nyquist limit of 50-60 cm/s.
  • Φ Usually above 50 years of age or in conditions of impaired relaxation, in the absence of mitral stenosis or other causes of elevated LA pressure.
  • ς Minimal and large flow convergence defined as a flow convergence radius < 0.4 cm and ≤ 0.9 cm for central jets, respectively, with a baseline shift at a Nyquist of 40 cm/s; Cut-offs for eccentric jets are higher, and should be angle corrected (see text).
  • φ Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe as shown.

Mitral stenosis - severity

Recommendations for classification of mitral stenosis severity[1]
  Mild Moderate Severe
Specific findings
Valve area (cm2) >1.5 1.0-1.5 <1.0
Supportive findings
Mean gradient (mmHg)a <5 5-10 >10
Pulmonary artery pressure (mmHg) <30 30-50 >50
  • aAt heart rates between 60 and 80 bpm and in sinus rhythm.

Mitral valve stenosis - Wilkins score

Assessment of mitral valve anatomy according to the Wilkins score[5]
Grade Mobility Thickening Calcification Subvalvular Thickening
1 Highly mobile valve with only leaflet tips restricted Leaflets near normal in thickness (4-5 mm) A single area of increased echo brightness Minimal thickening just below the mitral leaflets
2 Leaflet mid and base portions have normal mobility Midleaflets normal, considerable thickening of margins (5-8 mm) Scattered areas of brightness confined to leaflet margins Thickening of chordal structures extending to one-third of the chordal length
3 Valve continues to move forward in diastole, mainly from the base Thickening extending through the entire leaflet (5-8mm) Brightness extending into the mid-portions of the leaflets Thickening extended to distal third of the chords
4 No or minimal forward movement of the leaflets in diastole Considerable thickening of all leaflet tissue (>8-10mm) Extensive brightness throughout much of the leaflet tissue Extensive thickening and shortening of all chordal structures extending down to the papillary muscles
  • The total score is the sum of the four items and ranges between 4 and 16.

Mitral stenosis - routine measurements

Recommendations for data recording and measurement in routine use for mitral stenosis quantitation[1]
Data element Recording Measurement
Planimetry
- 2D parasternal short-axis view - contour of the inner mitral orifice
- determine the smallest orifice by scanning from apex to base - include commissures when opened
- positioning of measurement plan can be oriented by 3D echo - in mid-diastole (use cine-loop)
- lowest gain setting to visualize the whole mitral orifice - average measurements if atrial fibrillation
Mitral flow
- continuous-wave Doppler - mean gradient from the traced contour of the diastolic mitral flow
- apical windows often suitable (optimize intercept angle) - pressure half-time from the descending sLope of the E-wave (mid-diastole slope if not linear)
- adjust gain setting to obtain well-defined flow contour - average measurements if atrial fibrillation
Systolic pulmonary artery pressure
- continuous-wave Doppler - maximum velocity of tricuspid regurgitant flow
- multiple acoustic windows to optimize intercept angle - estimation of right atrial pressure according to inferior vena cava diameter
Valve anatomy

- parasternal short-axis view

- valve thickness (maximum and heterogeneity)
- commissural fusion
- extension and location of localized bright zones (fibrous nodutes or calcification)

- parasternal long-axis view

- valve thickness
- extension of calcification
- valve pliability
- subvalvular apparatus (chordal thickening, fusion, or shortening)

- apical two-chamber view
- subvalvular apparatus (chordal thickening, fusion, or shortening)

Detail each component and summarize in a score


Tricuspid Valve

Tricuspid regurgitation - severity

Echocardiographic and Doppler parameters used in grading tricuspid regurgitation severity[4]
Parameter Mild Moderate Severe
Tricuspid valve Usually normal Normal or abnormal Abnormal/Flail leaflet/Poor coaptation
RV/RA/IVC size Normal Normal or dilated Usually dilated∗∗
Jet area-central jets (cm2)§ < 5 5-10 > 10
VC width (cm)Φ Not defined Not defined, but < 0.7 > 0.7
PISA radius (cm)ψ ≤ 0.5 0.6-0.9 > 0.9
Jet density and contour–CW Soft and parabolic Dense, variable contour Dense, triangular with early peaking
Hepatic vein flow† Systolic dominance Systolic blunting Systolic reversal
  • CW, Continuous wave Doppler; IVC, inferior vena cava; RA, right atrium; RV, right ventricle; VC, vena contracta width.
  • Unless there are other reasons for RA or RV dilation. Normal 2D measurements from the apical 4-chamber view: RV medio-lateral end-diastolic dimension ≤ 4.3 cm, RV end-diastolic area ≤ 35.5 cm2, maximal RA medio-lateral and supero-inferior dimensions ≤ 4.6 cm and 4.9 cm respectively, maximal RA volume ≤ 33 ml/m2(35;89).
  • ∗∗ Exception: acute TR.
  • § At a Nyquist limit of 50-60 cm/s. Not valid in eccentric jets. Jet area is not recommended as the sole parameter of TR severity due to its dependence on hemodynamic and technical factors.
  • Φ At a Nyquist limit of 50-60 cm/s.
  • ψ Baseline shift with Nyquist limit of 28 cm/s.
  • † Other conditions may cause systolic blunting (eg. atrial fibrillation, elevated RA pressure).

Tricuspid stenosis - severity

Findings indicative of haemodynamically significant tricuspid stenosis[1]
Specific findings
Mean pressure gradient ≥5 mmHg
Inflow time-velocity integral >60 cm
T1/2 ≥190 ms
Valve area by continuity equationa ≤1 cm2
Supportive findings
Enlarged right atrium ≥moderate
DHated inferior vena cava
  • aStroke volume derived from left or right ventricular outflow. In the presence of more than mild TR, the derived valve area will be underestimated. Nevertheless, a value ≤1 cm2 implies a significant haemodynamic burden imposed by the combined lesion.

Pulmonary Valve

Pulmonary regurgitaion - severity

Echocardiographic and Doppler parameters used in grading pulmonary regurgitation severity[4]
Parameter Mild Moderate Severe
Pulmonic valve Normal Normal or abnormal Abnormal
RV size Normal Normal or dilated Dilated
Jet size by color Doppler§ Thin (usually < 10 mm in length) with a narrow origin Intermediate Usually large, with a wide origin; May be brief in duration
Jet density and deceleration rate –CW† Soft; Slow deceleration Dense; variable deceleration Dense; steep deceleration, early termination of diastolic flow
Pulmonic systolic flow compared to systemic flow –PWφ Slightly increased Intermediate Greatly increased
  • CW, Continuous wave Doppler; PR, pulmonic regurgitation; PW, pulsed wave Doppler; RA, right atrium; RF, regurgitant fraction; RV, right ventricle.
  • Unless there are other reasons for RV enlargement. Normal 2D measurements from the apical 4-chamber view; RV medio-lateral end-diastolic dimension ≤ 4.3 cm, RV end-diastolic area ≤ 35.5 cm2(89).
  • ∗∗ Exception: acute PR
  • § At a Nyquist limit of 50-60 cm/s.
  • φ Cut-off values for regurgitant volume and fraction are not well validated.
  • † Steep deceleration is not specific for severe PR.

Pulmonary stenosis - severity

Grading of pulmonary stenosis[1]
  Mild Moderate Severe
Peak velocity (m/s) <3 3-4 >4
Peak gradient (mmHg) <36 36-64 >64


References

Click on the reference to link directly to the manuscript

Error fetching PMID 3730205:
Error fetching PMID 16458610:
Error fetching PMID 19130998:
Error fetching PMID 3190958:
Error fetching PMID 17259184:
Error fetching PMID 18848134:
Error fetching PMID 12835667:
Error fetching PMID 19187853:
  1. Error fetching PMID 19130998: [ASEVS]
  2. Error fetching PMID 17259184: [ESCAS]
  3. Error fetching PMID 12835667: [ASERE]
  4. Error fetching PMID 3190958: [Wilkins]
  5. Error fetching PMID 3730205: [Foale]
  6. ISBN:0812112075 [Weyman]
  7. Error fetching PMID 16458610: [ASE]
  8. Error fetching PMID 18848134: [ACCAS]
  9. Error fetching PMID 19187853: [ASEDF]
  10. ISBN:9031362352 [Hamer]

All Medline abstracts: PubMed | HubMed