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. 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.

2 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. 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. Quantitative Approaches to Valvular Regurgitation 311a.

3 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, ( ); 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 ( ).

4 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. 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. Hahn, MD, FASE, is aspeaker for Philips Healthcare, St.

5 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. 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.

6 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. 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. Mitral Regurgitation 318A. Anatomy of the Mitral Valve and General Imaging Consider-ations 318B.

7 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. Regurgitant jet area 324b. Vena contracta (width and area) 328c. Flow convergence (PISA) 3282. Continuous Wave Doppler 3303. Pulsed Doppler 3304. Pulmonary Vein Flow 330E. Assessment of LV and LAVolumes 330F. Role of Exercise Testing 330G. Role of TEE in Assessing Mechanism and Severity of MR 330H. Role of CMR in the Assessment of MR 3311. Mechanism of MR 3312.

8 Methods of MR Quantitation 3313. LV and LAVolumes and Function 3314. When Is CMR Indicated? 331I. Concordance between Echocardiography and CMR 331J. Integrative Approach to Assessment of MR 3321. Considerations in Primary MR 3342. Considerations in Secondary MR 334IV. Aortic Regurgitation 334A. Anatomy of the Aortic Valve and Etiology of Aortic Regurgita-tion 334B. Classification and Mechanisms of AR 335C. Assessment of AR Severity 3361. Echocardiographic Imaging 3362. Doppler Methods 336a. Color flow Doppler 336b. Pulsed wave Doppler 336c. Continuous wave Doppler 336D. Role of TEE 340E. Role of CMR in the Assessment of AR 3401. Mechanism 3402. Quantifying AR with CMR 3403. LV Remodeling 3424. Aortopathy 3425. When Is CMR Indicated? 342F. Integrative Approach to Assessment of AR 343V. Tricuspid Regurgitation 345A.

9 Anatomy of the Tricuspid Valve 345 Abbreviations2D= Two-dimensional3D= Three-dimensionalACC/AHA= American College of Cardiology/American HeartAssociationARO= Anatomic regurgitant orificeAR= Aortic regurgitationASE= American Society of EchocardiographyCMR= Cardiovascular magnetic resonanceCSA= Cross-sectional areaCWD= Continuous wave DopplerEROA= Effective regurgitant orifice areaLA= Left atrium, atrialLV= Left ventricle, ventricularLVEF= Left ventricular ejection fractionLVOT= Left ventricular outflow tractMR= Mitral regurgitationMV= Mitral valveMVP= Mitral valve prolapsePA= Pulmonary arteryPISA= Proximal isovelocity surface areaPR= Pulmonary regurgitationPRF= Pulse repetition frequencyPV= Pulmonary valveRF= Regurgitant fractionRV= Right ventricle, ventricularRVol= Regurgitant volumeRVOT= Right ventricular outflow tractSSFP= Steady-state free precessionSV= Stroke volumeTEE= Transesophageal echocardiographyTR= Tricuspid regurgitationTTE= Transthoracic echocardiographyTV= Tricuspid valveVa= Aliasing velocityVC= Vena contractaVCA= Vena contracta areaVCW= Vena contracta widthVTI= Velocity time integral304 Zoghbi et alJournal of the American Society of EchocardiographyApril 2017B.

10 Etiology and Pathology of Tricuspid Regurgitation 345C. Role of Imaging in Tricuspid Regurgitation 3451. Evaluation of the Tricuspid Valve 345a. Echocardiographic imaging 345b. CMR imaging 3452. Evaluating Right Heart Chambers 345D. Echocardiographic Evaluation of TR Severity 3501. Color Flow Imaging 350a. Jet area 350b. Vena contracta 350c. Flow convergence 3502. Regurgitant Volume 3523. Pulsed and Continuous Wave Doppler 352E. CMR Evaluation of TR Severity 353F. Integrative Approach in the Evaluation of TR 353VI. Pulmonary Regurgitation 353A. Anatomy and General Imaging Considerations 353B. Etiology and Pathology 355C. Right Ventricular Remodeling 355D. Echocardiographic Evaluation of PR Severity 3551. Color Flow Doppler 3552. Pulsed and Continuous Wave Doppler 3563. Quantitative Doppler 356E.