View source for Classification of valve stenosis and regurgitation

=Aortic Valve=
==Aortic valve stenosis - severity==
{| class="wikitable" style="font-size:90%;"

|+'''Recommendations for classification of AS severity<cite>ASEVS</cite>'''

|-
! style="width:150px" | &nbsp;
! style="width:100px" | Aortic sclerosis
! style="width:100px" | Mild
! style="width:100px" | Moderate
! style="width:100px" | Severe

|-
| Aortic jet velocity (m/s)
| style="text-align:center" | &le;2.5 m/s
| style="text-align:center" | 2.6-2.9
| style="text-align:center" | 3.0-4.0
| style="text-align:center" | &gt;4.0

|-
| Mean gradient (mmHg)
| style="text-align:center" | -
| style="text-align:center" | &lt;20 (&lt;30<sup>a</sup>)
| style="text-align:center" | 20-40<sup>b</sup> (30-50<sup>a</sup>)
| style="text-align:center" | &gt;40<sup>b</sup> (&gt;50<sup>a</sup>)

|-
| AVA (cm<sup>2</sup>)
| style="text-align:center" | -
| style="text-align:center" | &gt;1.5
| style="text-align:center" | 1.0-1.5
| style="text-align:center" | &lt;1

|-
| Indexed AVA (cm<sup>2</sup>/m<sup>2</sup>)
| style="text-align:center" | &nbsp;
| style="text-align:center" | &gt;0.85
| style="text-align:center" | 0.60-0.85
| style="text-align:center" | &lt;0.6

|-
| Velocity ratio
| style="text-align:center" | &nbsp;
| style="text-align:center" | &gt;0.50 
| style="text-align:center" | 0.25-0.50 
| style="text-align:center" | &lt;0.25

|-
| colspan="5" |<ul>
<li><sup>a</sup>ESC Guidelines.<cite>ESCAS</cite></li>
<li><sup>b</sup>AHA/ACC Guidelines.<cite>AHAAS</cite></li>
</ul>

|}
==Aortic regurgitation - severity==
{| class="wikitable" style="font-size:90%;"

|+'''Application of specific and supportive signs, and quantitative parameters in the grading of aortic regurgitation severity<cite>ASERE</cite>'''

|-
! style="width:160px" | &nbsp;
! style="width:250px" | Mild 
! colspan="2" | Moderate 
! style="width:250px" | Severe

|-
! Specific signs for AR severity
| style="vertical-align:top" | <ul>
<li>Central Jet, width &lt; 25% of LVOT<sup>&sigmaf;</sup></li>
<li>Vena contracta &lt; 0.3 cm<sup>&sigmaf;</sup></li>
<li>No or brief early diastolic flow reversal in descending aorta</li>
</ul>
| style="vertical-align:top" colspan="2" | <ul><li>Signs of AR&gt;mild present but no criteria for severe AR</li></ul>
| style="vertical-align:top" | <ul>
<li>Central Jet, width &ge; 65% of LVOT<sup>&sigmaf;</sup></li>
<li>Vena contracta &gt; 0.6cm<sup>&sigmaf;</sup></li>
</ul>

|-
! Supportive signs
| style="vertical-align:top" | <ul>
<li>Pressure half-time &gt; 500 ms</li>
<li>Normal LV size<sup>&lowast;</sup></li>
</ul>
| style="vertical-align:top" colspan="2" | <ul><li>Intermediate values</li></ul>
| <ul>
<li>Pressure half-time &lt; 200 ms</li>
<li>Holodiastolic aortic flow reversal in descending aorta</li>
<li>Moderate or greater LV enlargement<sup>&lowast;&lowast;</sup></li>
</ul>

|-
| colspan="5" | '''Quantitative parameters<sup>&psi;</sup>'''

|-
| style="padding-left:12px" | R Vol, ml/beat
| align="center" | &lt; 30
| align="center" style="width:125px" | 30-44
| align="center" style="width:125px" | 45-59
| align="center" | &ge; 60

|-
| style="padding-left:12px" | RF %
| align="center" | &lt; 30
| align="center" | 30-39
| align="center" | 40-49
| align="center" | &ge; 50

|-
| style="padding-left:12px" | EROA, cm<sup>2</sup>
| align="center" | &lt; 0.10
| align="center" | 0.10-0.19
| align="center" | 0.20-0.29
| align="center" | &ge; 0.30

|-
| colspan="5" | 
<ul>
<li><em>AR</em>, Aortic regurgitation; <em>EROA</em>, effective regurgitant orifice area; <em>LV</em>, left ventricle; <em>LVOT</em>, left ventricular outflow tract; <em>R Vol</em>, regurgitant volume; <em>RF</em>, regurgitant fraction.</li>
<li><sup>&lowast;</sup> LV size applied only to chronic lesions. Normal 2D measurements: LV minor-axis &le; 2.8 cm/m<sup>2</sup>, LV end-diastolic volume &le; 82 ml/m<sup>2</sup> (2).</li>
<li><sup>&sigmaf;</sup> At a Nyquist limit of 50–60 cm/s.</li>
<li><sup>&lowast;&lowast;</sup> In the absence of other etiologies of LV dilatation.</li>
<li><sup>&psi;</sup> Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe regurgitation as shown.</li>
</ul>

|}


=Mitral Valve=
==Mitral regurgitation - severity==
{| class="wikitable" style="font-size:90%;"

|+'''Application of specific and supportive signs, and quantitative parameters in the grading of mitral regurgitation severity<cite>ASERE</cite>'''

|-
! style="width:160px" | &nbsp;
! style="width:250px" | Mild 
! colspan="2" | Moderate 
! style="width:250px" | Severe

|-
! Specific signs of severity
| style="vertical-align:top" | <ul>
<li>Small central jet &lt;4 cm<sup>2</sup> or &lt;20% of LA area<sup>&psi;</sup></li>
<li>Vena contracta width &lt;0.3 cm</li>
<li>No or minimal flow convergence</li>
</ul>
| style="vertical-align:top" colspan="2" | <ul><li>Signs of MR&gt;mild present, but no criteria for severe MR</li></ul>
| style="vertical-align:top" | <ul>
<li>Vena contracta width &ge; 0.7cm <em>with</em> large central MR jet (area &lt; 40% of LA) or with a wall-impinging jet of any size, swirling in LA<sup>&psi;</sup></li>
<li>Large flow convergence<sup>&sigmaf;</sup></li>
<li>Systolic reversal in pulmonary veins</li>
<li>Prominent flail MV leaflet or ruptured papillary muscle</li>
</ul>

|-
! Supportive signs
| style="vertical-align:top" | <ul>
<li>Systolic dominant flow in pulmonary veins</li>
<li>A-wave dominant mitral inflow<sup>&Phi;</sup></li>
<li>Soft density, parabolic CW Doppler MR signal</li>
<li>Normal LV size<sup>&lowast;</sup></li>
</ul>
| style="vertical-align:top" colspan="2" | <ul><li>Intermediate signs/findings</li></ul>
| style="vertical-align:top" | <ul>
<li>Dense, triangular CW Doppler MR jet</li>
<li>E-wave dominant mitral inflow (E &gt;1.2 m/s)<sup>&Phi;</sup> Enlarged LV and LA size<sup>&lowast;&lowast;</sup>, (particularly when normal LV function is present).</li>
</ul>

|-
| colspan="5" | '''Quantitative parameters<sup>&phi;</sup>'''

|-
| style="padding-left:12px" | R Vol (ml/beat)
| align="center" | &lt; 30
| style="width:125px" align="center" | 30-44
| style="width:125px" align="center" | 45-59
| align="center" | &ge; 60

|-
| style="padding-left:12px" | RF (%)
| align="center" | &lt; 30
| align="center" | 30-39
| align="center" | 40-49
| align="center" | &ge; 50

|-
| style="padding-left:12px" | EROA (cm<sup>2</sup>)
| align="center" | &lt; 0.20
| align="center" | 0.20-0.29
| align="center" | 0.30-0.39
| align="center" | &ge; 0.40

|-
| colspan="5" | <ul>
<li><em>CW</em>, Continuous wave; <em>EROA</em>, effective regurgitant orifice area; <em>LA</em>, left atrium; <em>LV</em>, left ventricle; <em>MV</em>, mitral valve; <em>MR</em>, mitral regurgitation; <em>R Vol</em>, regurgitant volume; <em>RF</em>, regurgitant fraction.</li>
<li><sup>&lowast;</sup> LV size applied only to chronic lesions. Normal 2D measurements: LV minor axis &le; 2.8 cm/m<sup>2</sup>, LV end-diastolic volume &le; 82 ml/m<sup>2</sup>, maximal LA antero-posterior diameter &le; 2.8 cm/m<sup>2</sup>, maximal LA volume &le; 36 ml/m<sup>2</sup> (2;33;35).</li>
<li><sup>&lowast;&lowast;</sup> In the absence of other etiologies of LV and LA dilatation and acute MR.</li>
<li><sup>&psi;</sup> At a Nyquist limit of 50-60 cm/s.</li>
<li><sup>&Phi;</sup> 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.</li>
<li><sup>&sigmaf;</sup> Minimal and large flow convergence defined as a flow convergence radius &lt; 0.4 cm and &le; 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).</li>
<li><sup>&phi;</sup> Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe as shown.</li>
</ul>

|}
==Mitral stenosis - severity==
{| class="wikitable" style="font-size:90%;"

|+'''Recommendations for classification of mitral stenosis severity<cite>ASEVS</cite>'''

|-
! style="width:200px" | &nbsp;
! style="width:80px" | Mild 
! style="width:80px" | Moderate
! style="width:80px" | Severe

|-
| colspan="4" | '''Specific findings'''

|-
| style="padding-left:12px" | Valve area (cm<sup>2</sup>)
| align="center" | &gt;1.5
| align="center" | 1.0-1.5
| align="center" | &lt;1.0

|-
| colspan="4" | '''Supportive findings'''

|-
| style="padding-left:12px" | Mean gradient (mmHg)<sup>a</sup>
| align="center" | &lt;5
| align="center" | 5-10
| align="center" | &gt;10

|-
| style="padding-left:12px" | Pulmonary artery pressure (mmHg)
| align="center" | &lt;30
| align="center" | 30-50
| align="center" | &gt;50

|-
| colspan="4" | <ul><li><sup>a</sup>At heart rates between 60 and 80 bpm and in sinus rhythm.</li></ul>

|}
==Mitral valve stenosis - Wilkins score==
{| class="wikitable" style="font-size:90%;"

|+'''Assessment of mitral valve anatomy according to the Wilkins score<cite>Wilkins</cite>'''

|-
! style="width:50px" | Grade
! style="width:170px" | Mobility 
! style="width:170px" | Thickening 
! style="width:170px" | Calcification 
! style="width:170px" | Subvalvular Thickening

|-
| style="vertical-align:top" | 1
| style="vertical-align:top" | Highly mobile valve with only leaflet tips restricted
| style="vertical-align:top" | Leaflets near normal in thickness (4-5 mm)
| style="vertical-align:top" | A single area of increased echo brightness
| style="vertical-align:top" | Minimal thickening just below the mitral leaflets

|-
| style="vertical-align:top" | 2
| style="vertical-align:top" | Leaflet mid and base portions have normal mobility
| style="vertical-align:top" | Midleaflets normal, considerable thickening of margins (5-8 mm)
| style="vertical-align:top" | Scattered areas of brightness confined to leaflet margins
| style="vertical-align:top" | Thickening of chordal structures extending to one-third of the chordal length

|-
| style="vertical-align:top" | 3
| style="vertical-align:top" | Valve continues to move forward in diastole, mainly from the base
| style="vertical-align:top" | Thickening extending through the entire leaflet (5-8mm)
| style="vertical-align:top" | Brightness extending into the mid-portions of the leaflets
| style="vertical-align:top" | Thickening extended to distal third of the chords

|-
| style="vertical-align:top" | 4
| style="vertical-align:top" | No or minimal forward movement of the leaflets in diastole
| style="vertical-align:top" | Considerable thickening of all leaflet tissue (&gt;8-10mm)
| style="vertical-align:top" | Extensive brightness throughout much of the leaflet tissue
| style="vertical-align:top" | Extensive thickening and shortening of all chordal structures extending down to the papillary muscles

|-
| colspan="5" |<ul><li>The total score is the sum of the four items and ranges between 4 and 16.</li></ul>

|}






















==Mitral stenosis - routine measurements==
{| class="wikitable" style="font-size:90%;"

|+'''Recommendations for data recording and measurement in routine use for mitral stenosis quantitation<cite>ASEVS</cite>'''

|-
! Data element
! Recording
! Measurement

|-
! rowspan="5" | Planimetry

|-
| style="vertical-align:top; " | - 2D parasternal short-axis view
| style="vertical-align:top; " | - contour of the inner mitral orifice

|-
| style="vertical-align:top; " | - determine the smallest orifice by scanning from apex to base
| style="vertical-align:top; " | - include commissures when opened

|-
| style="vertical-align:top; " | - positioning of measurement plan can be oriented by 3D echo
| style="vertical-align:top; " | - in mid-diastole (use cine-loop)

|- 
| style="vertical-align:top" | - lowest gain setting to visualize the whole mitral orifice
| style="vertical-align:top" | - average measurements if atrial fibrillation

|-
! rowspan="4" | Mitral flow

|-
| style="vertical-align:top; " | - continuous-wave Doppler
| style="vertical-align:top; " | - mean gradient from the traced contour of the diastolic mitral flow

|-
| style="vertical-align:top; " | - apical windows often suitable (optimize intercept angle)
| style="vertical-align:top; " | - pressure half-time from the descending sLope of the E-wave (mid-diastole slope if not linear)

|-
| style="vertical-align:top" | - adjust gain setting to obtain well-defined flow contour
| style="vertical-align:top" | - average measurements if atrial fibrillation

|-
! rowspan="3" | Systolic pulmonary artery pressure

|-
| style="vertical-align:top; " | - continuous-wave Doppler
| style="vertical-align:top; " | - maximum velocity of tricuspid regurgitant flow

|-
| style="vertical-align:top" | - multiple acoustic windows to optimize intercept angle
| style="vertical-align:top" | - estimation of right atrial pressure according to inferior vena cava diameter

|-
! rowspan="8" | Valve anatomy

|-
| rowspan="2" style="vertical-align:top; " | 
- parasternal short-axis view

|-
| style="vertical-align:top; " | 
- valve thickness (maximum and heterogeneity)<br>
- commissural fusion<br>
- extension and location of localized bright zones (fibrous nodutes or calcification)

|-
| rowspan="2" style="vertical-align:top; " | 
- parasternal long-axis view

|-
| style="vertical-align:top; " | 
- valve thickness<br>
- extension of calcification<br>
- valve pliability<br>
- subvalvular apparatus (chordal thickening, fusion, or shortening)
|-
| rowspan="2" style="vertical-align:top" | - apical two-chamber view

|-
| style="vertical-align:top; " | - subvalvular apparatus (chordal thickening, fusion, or shortening)<br>
|-
| colspan="2"|
Detail each component and summarize in a score

|}





{| class="wikitable" style="font-size:90%;"

|+'''Echocardiographic and Doppler parameters used in grading tricuspid regurgitation severity<cite>ASERE</cite>'''

|-
! style="width:200px" | Parameter 
! style="width:200px" | Mild 
! style="width:200px" | Moderate
! style="width:200px" | Severe

|-
| Tricuspid valve
| Usually normal
| Normal or abnormal
| Abnormal/Flail leaflet/Poor coaptation

|-
| RV/RA/IVC size
| Normal<sup>&lowast;</sup>
| Normal or dilated
| Usually dilated<sup>&lowast;&lowast;</sup>

|-
| Jet area-central jets (cm<sup>2</sup>)<sup>&sect;</sup>
| &lt; 5
| 5-10
| &gt; 10

|-
| VC width (cm)<sup>&Phi;</sup>
| Not defined
| Not defined, but &lt; 0.7
| &gt; 0.7

|-
| PISA radius (cm)<sup>&psi;</sup>
| &le; 0.5
| 0.6-0.9
| &gt; 0.9

|-
| Jet density and contour–CW
| Soft and parabolic
| Dense, variable contour
| Dense, triangular with early peaking

|-
| Hepatic vein flow&dagger;
| Systolic dominance
| Systolic blunting
| Systolic reversal

|-
| colspan="4" |
<ul>
<li><em>CW</em>, Continuous wave Doppler; <em>IVC</em>, inferior vena cava; <em>RA</em>, right atrium; <em>RV</em>, right ventricle; <em>VC</em>, vena contracta width.</li>
<li><sup>&lowast;</sup> 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 &le; 4.3 cm, RV end-diastolic area &le; 35.5 cm<sup>2</sup>, maximal RA medio-lateral and supero-inferior dimensions &le; 4.6 cm and 4.9 cm respectively, maximal RA volume &le; 33 ml/m<sup>2</sup>(35;89).</li>
<li><sup>&lowast;&lowast;</sup> Exception: acute TR.</li>
<li><sup>&sect;</sup> 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.</li>
<li><sup>&Phi;</sup> At a Nyquist limit of 50-60 cm/s.</li>
<li><sup>&psi;</sup> Baseline shift with Nyquist limit of 28 cm/s.</li>
<li>&dagger; Other conditions may cause systolic blunting (eg. atrial fibrillation, elevated RA pressure).</li>
</ul>
|}

==Tricuspid stenosis - severity==
{| class="wikitable" style="font-size:90%;"

|+'''Findings indicative of haemodynamically significant tricuspid stenosis<cite>ASEVS</cite>'''

|-
| colspan="2" | '''Specific findings'''

|-
| style="width:190px; padding-left:12px" | Mean pressure gradient
| style="width:80px" | &ge;5 mmHg

|-
| style="padding-left:12px" | Inflow time-velocity integral
| &gt;60 cm

|-
| style="padding-left:12px" | <em>T</em><sub>1/2</sub>
| &ge;190 ms

|-
| style="padding-left:12px" | Valve area by continuity equation<sup>a</sup>
| &le;1 cm<sup>2</sup>

|-
| colspan="2" | '''Supportive findings'''

|-
| style="padding-left:12px" | Enlarged right atrium &ge;moderate
|

|-
| style="padding-left:12px" | DHated inferior vena cava
|

|-
| colspan="2" | <ul>
<li><sup>a</sup>Stroke 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 &le;1 cm<sup>2</sup> implies a significant haemodynamic burden imposed by the combined lesion.
</li>
</ul>
|}


=Pulmonary Valve=
==Pulmonary regurgitaion - severity==
{| class="wikitable" style="font-size:90%;"

|+'''Echocardiographic and Doppler parameters used in grading pulmonary regurgitation severity<cite>ASERE</cite>'''

|-
! style="width:200px" | Parameter 
! style="width:200px" | Mild 
! style="width:200px" | Moderate
! style="width:200px" | Severe

|-
| Pulmonic valve
| Normal
| Normal or abnormal
| Abnormal

|-
| RV size
| Normal<sup>&lowast;</sup>
| Normal or dilated
| Dilated

|-
| Jet size by color Doppler<sup>&sect;</sup>
| Thin (usually &lt; 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&dagger;
| Soft; Slow deceleration
| Dense; variable deceleration
| Dense; steep deceleration, early termination of diastolic flow

|-
| Pulmonic systolic flow compared to systemic flow –PW<sup>&phi;</sup>
| Slightly increased
| Intermediate
| Greatly increased

|-
| colspan="4" |
<ul>
<li><em>CW</em>, Continuous wave Doppler; <em>PR</em>, pulmonic regurgitation; <em>PW</em>, pulsed wave Doppler; <em>RA</em>, right atrium; <em>RF</em>, regurgitant fraction; <em>RV</em>, right ventricle.</li>
<li><sup>&lowast;</sup> Unless there are other reasons for RV enlargement. Normal 2D measurements from the apical 4-chamber view; RV medio-lateral end-diastolic dimension &le; 4.3 cm, RV end-diastolic area &le; 35.5 cm<sup>2</sup>(89).</li>
<li><sup>&lowast;&lowast;</sup> Exception: acute PR</li>
<li><sup>&sect;</sup> At a Nyquist limit of 50-60 cm/s.</li>
<li><sup>&phi;</sup> Cut-off values for regurgitant volume and fraction are not well validated.</li>
<li>&dagger; Steep deceleration is not specific for severe PR.</li>
</ul>

|}

==Pulmonary stenosis - severity==
{| class="wikitable" style="font-size:90%;"

|+'''Grading of pulmonary stenosis<cite>ASEVS</cite>'''

|-
! style="width:150px" | &nbsp;
! style="width:80px" | Mild
! style="width:80px" | Moderate
! style="width:80px" | Severe

|-
| Peak velocity (m/s)
| align="center" | &lt;3
| align="center" | 3-4
| align="center" | &gt;4

|-
| Peak gradient (mmHg)
| align="center" | &lt;36
| align="center" | 36-64
| align="center" | &gt;64

|}