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NORMAL VALVE AREAS

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Mitral valve 4–5 cm2
Aortic valve 3–4 cm2
Pulmonic valve 3.5–4.5 cm2
Tricuspid valve 5–8 cm2

MITRAL VALVE

Parameters for Determining the Severity of Mitral Regurgitation1

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MR severity*
Mild Moderate Severe
Structural
MV morphology None or mild leaflet abnormality (e.g., mild thickening, calcifications or prolapse, mild tenting) Moderate leaflet abnormality or moderate tenting Severe valve lesions (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
LV and LA size Usually normal Normal or mildly dilated Dilated
Qualitative Doppler
Color flow jet area§ Small, central, narrow, often brief Variable Large central jet (>50% of LA) or eccentric wall-impinging jet of variable size
Flow convergence Not visible, transient or small Intermediate in size and duration Large throughout systole
CWD jet Faint/partial/parabolic Dense but partial or parabolic Holosystolic/dense/triangular
Semiquantitative
VCW (cm) <0.3 Intermediate ≥0.7 (>0.8 for biplane)
Pulmonary vein flow# Systolic dominance (may be blunted in LV dysfunction or AF) Normal or systolic blunting# Minimal to no systolic flow/systolic flow reversal
Mitral inflow** A-wave dominant Variable E-wave dominant (>120 cm/s)
Quantitative††,‡‡
EROA, 2D PISA (cm2) <0.20 0.20–0.29 0.30–0.39 ≥0.40 (may be lower in secondary MR with elliptical ROA)
RVol (mL) <30 30–44 45–59†† ≥60 (may be lower in low-flow conditions)
RF (%) <30 30–39 40–49 ≥50

Abbreviations: ROA, Regurgitant orifice area.

Bolded qualitative and semiquantitative signs are considered specific for their MR grade.

*All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body size, sex, and all other patient characteristics.

This pertains mostly to patients with primary MR.

LV and LA can be within the “normal” range for patients with acute severe MR or with chronic severe MR who have small body size, particularly women, or with small LV size preceding the occurrence of MR.

§With Nyquist limit 50–70 cm/s.

Small flow convergence is usually <0.3 cm, and large is ≥1 cm at a Nyquist limit of 30–40 cm/s.

For average between apical two- and four-chamber views.

#Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).

**Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure.

††Discrepancies among EROA, RF, and RVol may arise in the setting of low- or high-flow states.

‡‡Quantitative parameters can help subclassify the moderate regurgitation group.

Calculation of the quantitative parameters of mitral regurgitation

  1. Vena Contracta

    Narrowest width of the mitral regurgitation jet as it emerges from the coaptation site of the leaflets

  2. Regurgitant Volume

    Regurgitant Volume(RVolMitral)=SVMV...

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