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Aortic Valve
Aortic valve stenosis - severity
Recommendations for classification of AS severity[1]
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Aortic sclerosis
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Mild
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Moderate
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Severe
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Aortic jet velocity (m/s)
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≤2.5 m/s
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2.6-2.9
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3.0-4.0
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>4.0
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Mean gradient (mmHg)
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-
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<20 (<30a)
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20-40b (30-50a)
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>40b (>50a)
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AVA (cm2)
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-
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>1.5
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1.0-1.5
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<1
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Indexed AVA (cm2/m2)
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>0.85
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0.60-0.85
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<0.6
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Velocity ratio
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>0.50
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0.25-0.50
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<0.25
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- aESC Guidelines.[2]
- bAHA/ACC Guidelines.[3]
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Aortic regurgitation - severity
Application of specific and supportive signs, and quantitative parameters in the grading of aortic regurgitation severity[4]
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Mild
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Moderate
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Severe
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Specific signs for AR severity
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- Central Jet, width < 25% of LVOTς
- Vena contracta < 0.3 cmς
- No or brief early diastolic flow reversal in descending aorta
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- Signs of AR>mild present but no criteria for severe AR
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- Central Jet, width ≥ 65% of LVOTς
- Vena contracta > 0.6cmς
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Supportive signs
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- Pressure half-time > 500 ms
- Normal LV size∗
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- Pressure half-time < 200 ms
- Holodiastolic aortic flow reversal in descending aorta
- Moderate or greater LV enlargement∗∗
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Quantitative parametersψ
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R Vol, ml/beat
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< 30
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30-44
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45-59
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≥ 60
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RF %
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< 30
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30-39
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40-49
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≥ 50
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EROA, cm2
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< 0.10
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0.10-0.19
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0.20-0.29
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≥ 0.30
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- 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.
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Mitral Valve
Mitral regurgitation - severity
Application of specific and supportive signs, and quantitative parameters in the grading of mitral regurgitation severity[4]
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Mild
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Moderate
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Severe
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Specific signs of severity
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- Small central jet <4 cm2 or <20% of LA areaψ
- Vena contracta width <0.3 cm
- No or minimal flow convergence
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- Signs of MR>mild present, but no criteria for severe MR
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- 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
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Supportive signs
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- Systolic dominant flow in pulmonary veins
- A-wave dominant mitral inflowΦ
- Soft density, parabolic CW Doppler MR signal
- Normal LV size∗
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- Intermediate signs/findings
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- 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).
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Quantitative parametersφ
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R Vol (ml/beat)
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< 30
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30-44
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45-59
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≥ 60
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RF (%)
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< 30
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30-39
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40-49
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≥ 50
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EROA (cm2)
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< 0.20
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0.20-0.29
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0.30-0.39
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≥ 0.40
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- 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.
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Mitral stenosis - severity
Recommendations for classification of mitral stenosis severity[1]
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Mild
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Moderate
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Severe
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Specific findings
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Valve area (cm2)
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>1.5
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1.0-1.5
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<1.0
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Supportive findings
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Mean gradient (mmHg)a
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<5
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5-10
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>10
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Pulmonary artery pressure (mmHg)
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<30
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30-50
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>50
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- aAt heart rates between 60 and 80 bpm and in sinus rhythm.
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Mitral valve stenosis - Wilkins score
Assessment of mitral valve anatomy according to the Wilkins score[5]
Grade
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Mobility
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Thickening
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Calcification
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Subvalvular Thickening
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1
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Highly mobile valve with only leaflet tips restricted
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Leaflets near normal in thickness (4-5 mm)
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A single area of increased echo brightness
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Minimal thickening just below the mitral leaflets
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2
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Leaflet mid and base portions have normal mobility
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Midleaflets normal, considerable thickening of margins (5-8 mm)
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Scattered areas of brightness confined to leaflet margins
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Thickening of chordal structures extending to one-third of the chordal length
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3
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Valve continues to move forward in diastole, mainly from the base
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Thickening extending through the entire leaflet (5-8mm)
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Brightness extending into the mid-portions of the leaflets
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Thickening extended to distal third of the chords
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4
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No or minimal forward movement of the leaflets in diastole
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Considerable thickening of all leaflet tissue (>8-10mm)
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Extensive brightness throughout much of the leaflet tissue
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Extensive thickening and shortening of all chordal structures extending down to the papillary muscles
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- The total score is the sum of the four items and ranges between 4 and 16.
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Mitral stenosis - routine measurements
Recommendations for data recording and measurement in routine use for mitral stenosis quantitation[1]
Data element
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Recording
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Measurement
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Planimetry
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- 2D parasternal short-axis view
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- contour of the inner mitral orifice
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- determine the smallest orifice by scanning from apex to base
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- include commissures when opened
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- positioning of measurement plan can be oriented by 3D echo
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- in mid-diastole (use cine-loop)
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- lowest gain setting to visualize the whole mitral orifice
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- average measurements if atrial fibrillation
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Mitral flow
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- continuous-wave Doppler
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- mean gradient from the traced contour of the diastolic mitral flow
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- apical windows often suitable (optimize intercept angle)
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- pressure half-time from the descending sLope of the E-wave (mid-diastole slope if not linear)
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- adjust gain setting to obtain well-defined flow contour
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- average measurements if atrial fibrillation
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Systolic pulmonary artery pressure
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- continuous-wave Doppler
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- maximum velocity of tricuspid regurgitant flow
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- multiple acoustic windows to optimize intercept angle
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- estimation of right atrial pressure according to inferior vena cava diameter
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Valve anatomy
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- parasternal short-axis view
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- valve thickness (maximum and heterogeneity)
- commissural fusion
- extension and location of localized bright zones (fibrous nodutes or calcification)
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- parasternal long-axis view
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- valve thickness
- extension of calcification
- valve pliability
- subvalvular apparatus (chordal thickening, fusion, or shortening)
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- apical two-chamber view
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- subvalvular apparatus (chordal thickening, fusion, or shortening)
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Detail each component and summarize in a score
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Echocardiographic and Doppler parameters used in grading tricuspid regurgitation severity[4]
Parameter
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Mild
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Moderate
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Severe
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Tricuspid valve
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Usually normal
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Normal or abnormal
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Abnormal/Flail leaflet/Poor coaptation
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RV/RA/IVC size
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Normal∗
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Normal or dilated
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Usually dilated∗∗
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Jet area-central jets (cm2)§
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< 5
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5-10
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> 10
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VC width (cm)Φ
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Not defined
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Not defined, but < 0.7
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> 0.7
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PISA radius (cm)ψ
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≤ 0.5
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0.6-0.9
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> 0.9
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Jet density and contour–CW
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Soft and parabolic
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Dense, variable contour
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Dense, triangular with early peaking
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Hepatic vein flow†
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Systolic dominance
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Systolic blunting
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Systolic reversal
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- 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).
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Tricuspid stenosis - severity
Findings indicative of haemodynamically significant tricuspid stenosis[1]
Specific findings
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Mean pressure gradient
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≥5 mmHg
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Inflow time-velocity integral
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>60 cm
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T1/2
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≥190 ms
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Valve area by continuity equationa
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≤1 cm2
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Supportive findings
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Enlarged right atrium ≥moderate
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DHated inferior vena cava
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- 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.
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Pulmonary Valve
Pulmonary regurgitaion - severity
Echocardiographic and Doppler parameters used in grading pulmonary regurgitation severity[4]
Parameter
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Mild
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Moderate
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Severe
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Pulmonic valve
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Normal
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Normal or abnormal
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Abnormal
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RV size
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Normal∗
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Normal or dilated
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Dilated
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Jet size by color Doppler§
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Thin (usually < 10 mm in length) with a narrow origin
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Intermediate
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Usually large, with a wide origin; May be brief in duration
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Jet density and deceleration rate –CW†
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Soft; Slow deceleration
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Dense; variable deceleration
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Dense; steep deceleration, early termination of diastolic flow
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Pulmonic systolic flow compared to systemic flow –PWφ
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Slightly increased
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Intermediate
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Greatly increased
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- 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.
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Pulmonary stenosis - severity
Grading of pulmonary stenosis[1]
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Mild
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Moderate
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Severe
|
Peak velocity (m/s)
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<3
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3-4
|
>4
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Peak gradient (mmHg)
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<36
|
36-64
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>64
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