Appendix D. Native Valve Areas, Velocities, and Gradients

Normal Valve Areas

Listen

| Print

Mitral valve

4-5 cm2

Aortic valve

3-4 cm2

Pulmonic valve

3.5-4.5 cm2

Tricuspid valve

5-8 cm2

Parameters for the Determination of the Severity of Mitral Regurgitation1

| Print

Mild

Moderate

Severe

Structural Parameters

LA size

Normala

Normal or dilated

Usually dilatedb

LV size

Normala

Normal or dilated

Usually dilatedb

Mitral leaflets or support apparatus

Normal or abnormal

Abnormal, flail leaflet, or ruptured papillary muscle

Doppler Parameters

Color flow jet areac

Small, central jet (usually <4 cm2 or <20% of LA area)

Variable

Large central jet (usually >10 cm2 or >40% of LA area) or variable size wall-impinging jet swirling in LA

Mitral inflow–PW

A-wave dominantd

Variable

E-wave dominantd (E usually 1.2 m/s)

Jet density–CW

Incomplete or faint

Dense

Jet contour–CW

Parabolic

Usually parabolic

Early peaking–triangular

Pulmonary vein flow

Systolic dominancee

Systolic bluntinge

Systolic flow reversalf

Quantitative Parametersg

VC width (cm)

<0.3

0.3-0.69

≥0.7

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 Doppler; LA, left atrium; EROA, effective regurgitant orifice area; LV, left ventricle; PW, pulsed-wave Doppler; RF, regurgitant fraction; R Vol, regurgitant volume; VC, vena contracta.

aUnless there were other reasons for LA or LV dilation. Normal 2D measurements: LV minor axis ≤2.8 cm/m2, LV end-diastolic volume ≤82 mL/m2, maximal LA anteroposterior diameter ≤2 cm/m2, maximal LA volume ≤36 mL/m2.

bException: acute mitral regurgitation.

cAt a Nyquist limit of 50-60 cm/s.

dUsually above 50 years of age or in conditions of impaired relaxation, in the absence of mitral stenosis or other causes of elevated LA pressure.

eUnless other reasons for systolic blunting (eg, atrial fibrillation, elevated left atrial pressure).

fPulmonary venous systolic flow reversal is specific but not sensitive for severe MR.

gQuantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe.

Calculation of the Quantitative Parameters of Mitral Regurgitation

| Print

Vena Contracta
Narrowest width of the mitral regurgitation jet as it emerges from the coaptation site of the leaflets
Regurgitant Volume
Regurgitant Fraction
Effective Regurgitant Orifice Area (EROA)
Proximal Isovelocity Surface Area

Parameters for the Determination of the Severity of Mitral Stenosis2

| Print

Indicator

Mild

Moderate

Severe

Mean pressure gradient (mm Hg)

<5

5-10

>10

Pressure half-time (ms)

90-150

150-219

>220

Mitral valve area (cm2)

>1.5

1.0-1.5

<1.0

Pulmonary artery pressure (mm Hg)

<30

30-50

>50

Mitral valve resistance (dyne.s.cm−5)

>85

Methods for Determining Mitral Valve Area (MVA)

| Print

Planimetry
Tracing the mitral orifice obtained from the TG basal SAX view
Pressure Gradient
Tracing the entire envelope of the CWD spectrum of mitral inflow, from the beginning of early diastolic flow (E wave) to the end of flow due to atrial contraction (A wave)
Pressure Half-time (P1/2T)
Deceleration Time
Continuity Equation
1—Determine the diameter (D) of the LVOT in the ME LAX view: Cross-Sectional Area (CSALVOT) = 0.785* D2
2—Utilizing the PW Doppler in the transgastric view, determine the VTI in the LVOT: VTILVOT
3—In the midesophageal four-chamber view, determine the VTI of the mitral valve: VTIMV
Proximal Isovelocity Surface Area (PISA)
where PISA (surface area of the hemisphere) = 2π * (radius of the shell)2 * α/180, where α = Angle subtended by the mitral leaflets

Echo Score Index for Rheumatic Mitral Stenosis3

| Print

Grades

Mobility

Leaflet Thickening

Subvalvular Thickening

Calcification

1

Highly mobile valve, only leaflet tips are restricted

Normal thickness (4-5 mm)

Minimal thickening just below leaflets

Single area of increased echo brightness

2

Leaflet mid and base portions have normal mobility

Mid leaflets are normal, marked thickening of margins (5-8 mm)

Thickening of chordal structures extending up to one-third chordal length

Scattered areas of brightness confined to margins

3

Valve continues to move forward in diastole

Entire leaflet is thickened (5-8 mm)

Thickening of chordal structures to the distal one-third

Brightness to midportions of leaflets and leaflet margins

4

No or minimal movement forward

All leaflet tissue has marked thickening (> 8-10 mm)

Extensive thickening and shortening of all chordal structures down to papillary muscles

Extensive brightness through much of leaflet tissue

Aortic Valve

Listen

Parameters for the Determination of the Severity of Aortic Regurgitation1

| Print

Mild

Moderate

Severe

Structural Parameters

LA size

Normala

Normal or dilated

Usually dilatedb

Aortic leaflets

Normal or abnormal

Abnormal, flail, or wide coaptation defect

Doppler Parameters

Jet width in LVOT–color flowc

Small in central jets

Intermediate

Large in central jets; variable in eccentric jets

Jet density–CW

Incomplete or faint

Dense

Jet deceleration rate–CW (PHT, ms)d

Slow >500

Medium 500-200

Steep <200

Diastolic flow reversal in descending aorta–PW

Brief, early diastolic reversal

Intermediate

Prominent holodiastolic reversal

Quantitative Parameterse

VC width (cm)c

<0.3

0.3-0.60

>0.6

Jet width/LVOT width (%)c

<25

25-45, 46-64

≥65

Jet CSA/LVOT CSA (%)c

<5

5-20, 21-59

≥60

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; CSA, cross-sectional area; CW, continuous-wave Doppler; EROA, effective regurgitant orifice area; LV, left ventricle; LVOT, left ventricular outflow tract; PHT, pressure half-time; PW, pulsed-wave Doppler; R Vol, regurgitant volume; RF, regurgitant fraction; VC, vena contracta.

aUnless there were other reasons for LV dilation. Normal 2D measurements: LV minor axis ≤2.8 cm/m2.

bException would be acute AR, in which chambers have not had time to dilate.

cAt a Nyquist limit of 50-60 cm/s.

dPHT is shortened with increasing LV diastolic pressure and vasodilator therapy, and may be lengthened in chronic adaptation to severe AR.

eQuantitative parameters can sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe regurgitation as shown.

Calculation of the Quantitative Parameters of Aortic Regurgitation

| Print

Vena Contracta
Narrowest width of the aortic regurgitation jet at or just distal to the orifice
Regurgitant Volume
Regurgitant Fraction
Effective Regurgitant Orifice Area (EROA)

Parameters for the Determination of the Severity of Aortic Stenosis2

| Print

Indicator

Mild

Moderate

Severe

Peak jet velocity (m/s)

<3.0

3.0-4.0

>4.0

Mean gradient (mm Hg)

<20

20-40

>40

Aortic valve area (cm2)

>1.5

1.0-1.5

<1.0

Dimensionless index

>0.50

0.25-0.50

<0.25

Indexed valve area (cm2/m2)

>0.85

0.60-0.85

<0.6

Methods for Determining Aortic Valve Area (AVA)

| Print

Planimetry
Tracing the aortic orifice obtained from the ME AV SAX view
Pressure Gradient
Tracing the CWD spectral envelope of the of the flow across the aortic valve obtained in the TG LAX or deep TG LAX views and applying the Bernoulli equation
Modified Bernoulli: Δ P = 4 (V22 − V12) where
V2 = Transvalvular velocity
V1 = Subvalvular (LVOT) velocity
Simplified Bernoulli: Δ P = 4 V22 if V1 <1.5 m/s
Aortic Valve Area (AVA) Using the Continuity Equation
1—Determine the diameter (D) of the LVOT in the ME LAX view. Cross-sectional area (CSALVOT) = 0.785* D2
2—Utilizing the CW Doppler in the transgastric view, determine the VTI in the ascending aorta: VTIAorta
3—Utilizing the PW Doppler in the transgastric view, determine the VTI in the LVOT: VTI LVOT

Pulmonic Valve

Listen

Parameters for the Determination of the Severity of Pulmonary Regurgitation1

| Print

Parameter

Mild

Moderate

Severe

Pulmonic valve

Normal

Normal or abnormal

Abnormal

RV size

Normala

Normal or dilated

Dilatedb

Jet size by color Dopplerc

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–CWd

Soft; slow deceleration

Dense; variable deceleration

Dense; steep deceleration, early termination of diastolic flow

Pulmonic systolic flow compared to systemic flow–PWe

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.

aUnless there are other reasons for RV enlargement. Normal 2D measurements from the apical four-chamber view: RV mediolateral end-diastolic dimension ≤4.3 cm, RV end-diastolic area ≤35.5cm2.

bException: acute PR.

cAt a Nyquist limit of 50-60 cm/s.

dSteep deceleration is not specific for severe PR.

eCutoff values for regurgitant volume and fraction are not well validated.

Method for Determining Pulmonic Valve Area

| Print

Pressure Gradient

Tracing the CWD spectral envelope of the flow across the pulmonic valve obtained in the UE aortic arch SAX view and applying the Bernoulli equation.

Parameters for the Determination of the Severity of Pulmonary Stenosis2

| Print

Stenosis Severity

Mild

Moderate

Severe

Two-dimensional findings

Leaflet morphology

Usually normal

Thickening

Thickening +/− calcifications

Leaflet mobility

Normal

Moderately restricted

Severely restricted; doming

RV hypertrophy

Usually absent

Usually present

Doppler findings

Color Doppler

Turbulent outflow

Peak velocity (m/s)

<3

3-4

>4

Peak gradient (mm Hg)

<36

36-64

>64

Tricuspid Valve

Listen

Parameters for the Determination of the Severity of Tricuspid Regurgitation1

| Print

Parameter

Mild

Moderate

Severe

Tricuspid valve

Usually normal

Normal or abnormal

Abnormal, flail leaflet, poor coaptation

RV/RA/IVC size

Normala

Normal or dilated

Usually dilatedb

Jet area–central jets (cm2)c

<5

5-10

>10

VC width (cm)d

Not defined

Not defined, but <0.7

>0.7

PISA radius (cm)e

≤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 flowf

Systolic dominance

Systolic blunting

Systolic reversal

CW, continuous-wave Doppler; IVC, inferior vena cava; RA, right atrium; RV, right ventricle; VC, vena contracta.

aUnless there are other reasons for RA or RV dilation. Normal 2D measurements from the apical four-chamber view: RV mediolateral end-diastolic dimension ≤4.3 cm; RV end-diastolic area ≤35.5cm2; maximal RA mediolateral and superoinferior dimensions ≤4.6 cm and 4.9 cm, respectively; maximal RA volume ≤33 mL/m2.

bException: acute TR.

cAt 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.

dAt a Nyquist limit of 50-60 cm/s.

eBaseline shift with Nyquist limit of 28 cm/s.

fOther conditions may cause systolic bunting (eg, atrial fibrillation, elevated RA pressure).

Method for Determining Tricuspid Valve Area (TVA)

| Print

Pressure Gradient

Tracing the entire envelope of the CWD spectrum of tricuspid inflow, from the beginning of early diastolic flow (E wave) to the end of flow due to atrial contraction (A wave).

Parameters for the Determination of the Severity of Tricuspid Stenosis2

| Print

Stenosis Severity

Mild

Moderate

Severe

Two-dimensional findings

Leaflet morphology

Usually normal

Thickening

Thickening +/− calcifications

Leaflet mobility

Normal

Moderately restricted

Severely restricted; doming

Right-side chambers

Can be normal

Dilated

Significantly dilated

Doppler findings

Color Doppler

Turbulent inflow

Inflow velocity (m/s)

<0.7

>0.7

>>0.7

Mean diastolic gradient

≤2

≥5

Pressure half-time

≥190 ms

Area by continuity equation

≤1 cm2

References

Listen

1. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003;16:777-802. [PubMed: 12835667]

2. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr. 2009;22:1-23; quiz 101-102. [PubMed: 19130998]

3. Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios IF. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988;60:299-308. [PubMed: 3190958]

Send Email

Citation

Jump to a Section

Normal Valve Areas

Mitral Valve

Parameters for the Determination of the Severity of Mitral Regurgitation1

Calculation of the Quantitative Parameters of Mitral Regurgitation

Parameters for the Determination of the Severity of Mitral Stenosis2

Methods for Determining Mitral Valve Area (MVA)

Echo Score Index for Rheumatic Mitral Stenosis3

Aortic Valve

Parameters for the Determination of the Severity of Aortic Regurgitation1

Calculation of the Quantitative Parameters of Aortic Regurgitation

Parameters for the Determination of the Severity of Aortic Stenosis2

Methods for Determining Aortic Valve Area (AVA)

Pulmonic Valve

Parameters for the Determination of the Severity of Pulmonary Regurgitation1

Method for Determining Pulmonic Valve Area

Parameters for the Determination of the Severity of Pulmonary Stenosis2

Tricuspid Valve

Parameters for the Determination of the Severity of Tricuspid Regurgitation1

Method for Determining Tricuspid Valve Area (TVA)

Parameters for the Determination of the Severity of Tricuspid Stenosis2

References

Pop-up div Successfully Displayed