Recommendations for Noninvasive Evaluation of Native ...

1 ASE GUIDELINES AND STANDARDSR ecommendations for Noninvasive Evaluation ofNative Valvular RegurgitationA Report from the American Society of EchocardiographyDeveloped in Collaboration with the Society for CardiovascularMagnetic ResonanceWilliam A. Zoghbi, MD, FASE (Chair), David Adams, RCS, RDCS, FASE, Robert O. Bonow, MD,Maurice Enriquez-Sarano, MD, Elyse Foster, MD, FASE, Paul A. Grayburn, MD, FASE,Rebecca T. Hahn, MD, FASE, Yuchi Han, MD, MMSc,*Judy Hung, MD, FASE, Roberto M. Lang, MD, FASE,Stephen H. Little, MD, FASE, Dipan J. Shah, MD, MMSc,*Stanton Shernan, MD, FASE,Paaladinesh Thavendiranathan, MD, MSc, FASE,*James D.

2 Thomas, MD, FASE, andNeil J. Weissman, MD, FASE,Houston and Dallas, Texas; Durham, North Carolina; Chicago, Illinois; Rochester,Minnesota; San Francisco, California; New York, New York; Philadelphia, Pennsylvania; Boston, Massachusetts;Toronto, Ontario, Canada; and Washington, DCTABLE OF CONTENTSI. Introduction 305II. Evaluation of Valvular Regurgitation: General Considerations 305A. Identifying the Mechanism of Regurgitation 305B. Evaluating Valvular Regurgitation with Echocardiography 3051. General Principles 305a. Comprehensive imaging 306b.

3 Integrative interpretation 306c. Individualization 306d. Precise language 3062. Echocardiographic Imaging 306a. Valve structure and severity of regurgitation 306b. Impact of regurgitation on cardiac remodeling 3073. Color Doppler Imaging 307a. Jet characteristics and jet area 308b. Vena contracta 309c. Flow convergence 3094. Pulsed Doppler 310a. Forward flow 310b. Flow reversal 3105. Continuous Wave Doppler 310a. Spectral density 310b. Timing of regurgitation 310c. Time course of the regurgitant velocity 3106.

4 Quantitative Approaches to Valvular Regurgitation 311a. Quantitative pulsed Doppler method 311b. Quantitative volumetric method 312c. Flow convergence method (proximal isovelocity surfacearea [PISA] method) 312 From Houston Methodist Hospital, Houston, Texas ( , , ); DukeUniversity Medical Center, Durham, North Carolina ( ); NorthwesternUniversity, Chicago, Illinois ( , ); Mayo Clinic, Rochester, Minnesota( ); University of California, San Francisco, California ( ); BaylorUniversity Medical Center, Dallas, Texas ( ); Columbia University MedicalCenter, New York, New York, ( ).

5 Hospital of the University ofPennsylvania, Philadelphia, Pennsylvania ( ); Massachusetts GeneralHospital, Boston, Massachusetts ( ); University of Chicago, Chicago, Illinois( ); Brigham and Women s Hospital, Boston, Massachusetts ( );Toronto General Hospital, University Health Network, University of Toronto,Toronto, Ontario, Canada ( ); and MedStar Health Research Institute,Washington, DC ( ).The following authors reported no actual or potential conflicts of interest in relationto this document: David Adams, RCS, RDCS, FASE; Robert O.

6 Bonow, MD; JudyHung, MD, FASE; Stephen H. Little, MD, FASE; Paaladinesh Thavendiranathan,MD, MSc; and Neil J. Weissman, MD, FASE. The following authors reported rela-tionships with one or more commercial interests: Maurice Enriquez-Sarano, MD,received research support from Edwards LLC; Elyse Foster, MD, FASE, receivedgrant support from Abbott Vascular Structural Heart and consulted for Gilead; PaulA. Grayburn, MD, FASE, consulted for Abbott Vascular, Neochord, and Tendyneand received research support from Abbott Vascular, Tendyne, Valtech, Edwards,Medtronic, Neochord, and Boston Scientific; Rebecca T.

7 Hahn, MD, FASE, is aspeaker for Philips Healthcare, St. Jude s Medical, and Boston Scientific; YuchiHan, MD, MMSc, received research support from Gilead and GE; Roberto , MD, FASE, is on the advisory board of and received grant support from Phil-lips Medical Systems; Dipan Shah, MD, MMSc, received research grant supportfrom Abbott Vascular and Guerbet; Stanton Shernan, MD, FASE, is an educatorfor Philips Healthcare, Inc.; James D. Thomas, MD, FASE, received honorariafrom Edwards and GE, and honoraria, research grant, and consultation fee fromAbbott; and William A.

8 Zoghbi, MD, FASE, has a licensing agreement with GEHealthcare and is on the advisory board for Abbott requests: American Society of Echocardiography, 2100 Gateway CentreBoulevard, Suite 310, Morrisville, NC 27560 ASE Members:The ASE has gone green! earn free continuingmedical education credit through an online activity related to this are available for immediate access upon successful completionof the activity. Nonmembers will need to join the ASE to access this greatmember benefit!*Society for Cardiovascular Magnetic Resonance $ 2017 by the American Society of Evaluating Valvular Regurgitation with Cardiac Magnetic Reso-nance 3141.

9 Cardiac Morphology, Function, and Valvular Anatomy 314a. Ventricular volumes 314b. Correct placement of the basal ventricular short-axis slice iscritical 314c. Planimetry of LVepicardial contour 315d. Left atrial volume 3152. Assessing Severity of Regurgitation with CMR 315a. Phase-contrast CMR 315b. Quantitative methods 315c. Technical considerations 317d. Thresholds for regurgitation severity 3173. Strengths and Limitations of CMR 3174. When Is CMR Indicated? 317D. Grading the Severity of Valvular Regurgitation 318 III.

10 Mitral Regurgitation 318A. Anatomy of the Mitral Valve and General Imaging Consider-ations 318B. Identifying the Mechanism of MR: Primary and SecondaryMR 3191. Primary MR 3192. Secondary MR 3203. Mixed Etiology 321C. Hemodynamic Considerations in Assessing MR Severity 3231. Acute MR 3232. Dynamic Nature of MR 323a. Temporal variation of MR during systole 323b. Effect of loading conditions 323c. Systolic anterior MV motion 3243. Pacing and Dysrhythmias 324D. Doppler Methods of Evaluating MR Severity 3241. Color Flow Doppler 324a.