American Society of Echocardiography Rec

Eur J Echocardiography (2003) 4, 237e261
doi:10.1016/j.euje.2003.07.001
GUIDELINES
American Society of Echocardiography:

Recommendations for Evaluation of the Severity
of Native Valvular Regurgitation with
Two-dimensional and Doppler Echocardiography
A Report from the American Society of Echocardiography’s
Nomenclature and Standards Committee and The Task Force
on Valvular Regurgitation, Developed in Conjunction with the
American College of Cardiology Echocardiography Committee,
The Cardiac Imaging Committee, Council on Clinical Cardiology,
The American Heart Association, and the European Society of
Cardiology Working Group on Echocardiography, Represented by:
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W. A. Zoghbi, M. Enriquez-Sarano, E. Foster, P. A. Grayburn, C. D. Kraft,
R. A. Levine, P. Nihoyannopoulos, C. M. Otto, M. A. Quinones, H. Rakowski,
W. J. Stewart, A. Waggoner and N. J. Weissman
American Society of Echocardiography, 1500 Sunday Drive, Suite 102, Raleigh, NC 27607, USA
Introduction overload state. Echocardiography with Doppler has

recently emerged as the method of choice for the
Valvular regurgitation has long been recognized as an noninvasive detection and evaluation of the severity
important cause of morbidity and mortality. Al- and etiology of valvular regurgitation. This article
though the physical examination can alert the offers a critical review of echocardiographic and
clinician to the presence of significant regurgitation, Doppler techniques used in the evaluation of valvular
diagnostic methods are often needed to assess the regurgitation in the adult patient, and provides
severity of valvular regurgitation and remodeling of recommendations for the assessment of severity of
the cardiac chambers in response to the volume valvular regurgitation based on the scientific litera-
ture and a consensus of a panel of experts. Issues of
medical management and timing of surgical inter-
vention will not be addressed in this article, as these
Reprinted from the Journal of the American Society of Echo- have been recently published[1].
cardiography, July 2003, Vol. 16, No. 7, pp. 777e802.
These recommendations are endorsed by the American College of
Cardiology (ACC), the American Heart Association (AHA), and Two-dimensional and Doppler
the European Society of Cardiology (ESC). Representative from
the ACC Echocardiography Committee: Elyse Foster, MD; Echocardiography in Valvular
representative from the Cardiac Imaging Committee, Council on Regurgitation: General Considerations
Clinical Cardiology, AHA: Miguel A. Quinones, MD; representa-
tive from the ESC Working Group on Echocardiography: Petros
Nihoyannopoulos, MD.
Valvular regurgitation or incompetence results from
various etiologies including valvular degeneration,
Address document reprint requests to the American Society of calcification, fibrosis or infection, alteration of the
Echocardiography, 1500 Sunday Drive, Suite 102, Raleigh, NC valvular support apparatus or dilatation of the valve
27607, USA. Tel: +1 919 787-5181. annulus. These conditions cause poor apposition of
Received 17 June 2003; accepted 24 July 2003. the valvular leaflets or cusps, and may lead to
1525-2167/03/ $30.00/0 Ó 2003 The American Society of Echocardiography. Published by Elsevier Ltd. All rights reserved.
238 W. A. Zoghbi et al.
prolapse, flail, restricted leaflet motion or valvular remodeling. While cardiac chamber remodeling is not
perforation. With the advent of Doppler techniques specific for the degree of regurgitation (i.e. occurs in
that are sensitive to detection of regurgitation, trivial coronary artery disease, congestive cardiomyopathy
and physiologic valvular regurgitation, even in etc.), its absence in the face of chronic regurgitation
a structurally normal valve, is now well recognized should imply a milder degree of valvular insufficiency.
and is noted to occur frequently in right-sided valves. Once a diagnosis of significant regurgitation is
The following sections describe general considera- established, serial 2D echocardiography is currently
tions of the role of echocardiographic and Doppler the method of choice for assessing the progression of
techniques in the evaluation of regurgitant lesions. the mechanical impact of regurgitation on cardiac
chamber structure and function. Recommendations
for determination of ventricular volumes and ejection
Role of Two-Dimensional fraction have been previously published[2]. These,
Echocardiography along with clinical evaluation are needed for ade-
quate timing of surgical intervention.
Two-dimensional (2D) echocardiography allows an
evaluation of the valvular structure as well as the
impact of the volume overload on the cardiac
Doppler Methods for Evaluation of
chambers. Calcifications, tethering, flail motion or Valvular Regurgitation
vegetations can be readily assessed, which can give
Doppler echocardiography is the most common
indirect clues as to the severity of regurgitation.
technique used for the detection and evaluation of
While prolapse, vegetations or calcifications are not
severity of valvular regurgitation. Several indices have
necessarily associated with significant regurgitation,
been developed to assess the severity of regurgitation
a flail leaflet almost always is. In the cases of non-
using color Doppler, pulsed wave (PW) and contin-
diagnostic transthoracic studies, transesophageal
echocardiography (TEE) improves the visualization uous wave (CW) Doppler. Details of the Doppler
techniques and the methods involved in obtaining
of the valvular structure and delineates the mecha-
these parameters are described in a recently published
nism and severity of regurgitation.

article from the American Society of Echocardiogra-
The duration (acute or chronic) and severity of
phy on quantification of Doppler Echocardiogra-
valvular regurgitation are among the most important
phy[3]. The following sections summarize the salient
determinants of the adaptive changes that occur in the
features of these techniques for the purposes of
cardiac chambers in response to the regurgitant
evaluation and quantitation of valvular regurgitation.
volume. Thus, a chronic significant regurgitation is
usually accompanied by an increase in size and hyper-
Color Doppler
trophy of the involved cardiac chambers whereas
significant regurgitation of acute onset from a condi- Color flow Doppler is widely used for the detection of
tion such as endocarditis may not result acutely in this regurgitant valve lesions. This technique provides
Figure 1. Color flow recording of a mitral regurgitation jet obtained from a zoomed view in the parasternal long axis
depicting the three components of the regurgitant jet: flow convergence, vena contracta (VC), and jet area in the left
atrium. Measurement of the vena contracta is shown between the red arrows.
Eur J Echocardiography, Vol. 4, issue 4, December 2003

Recommendations for Assessing Valvular Regurgitation 239
visualization of the origin of the regurgitation jet and velocity, laminar flow and is slightly smaller than the
its width (vena contracta), the spatial orientation of anatomic regurgitant orifice due to boundary effects.
the regurgitant jet area in the receiving chamber and, Thus, the cross-sectional area of the vena contracta
in cases of significant regurgitation, flow convergence represents a measure of the effective regurgitant
into the regurgitant orifice (Fig. 1). Experience has orifice area (EROA), which is the narrowest area of
shown that attention to these three components actual flow. The size of the vena contracta is
of the regurgitation lesion by color Doppler d as independent of flow rate and driving pressure for
opposed to the traditional regurgitant jet area a fixed orifice[5]. However, if the regurgitant orifice is
alone d significantly improves the overall accuracy dynamic, the vena contracta may change with hemo-
of estimation and quantitation of the severity of dynamics or during the cardiac cycle[6]. Comprised of
regurgitation with color Doppler techniques. The size high velocities, the vena contracta is considerably less
of the regurgitation jet by color Doppler and its sensitive to technical factors such as PRF compared
temporal resolution, however, are significantly affect- to the jet in the receiving chamber. To specifically
ed by transducer frequency and instrument settings image the vena contracta, it is often necessary to
such as gain, output power, Nyquist limit, size and angulate the transducer out of the normal echocar-
depth of the image sector[4]. Thus, full knowledge by diographic imaging planes such that the area of
the sonographer and interpreting echocardiographer proximal flow acceleration, the vena contracta, and
of these issues is necessary for optimal image the downstream expansion of the jet can be distin-
acquisition and accuracy of interpretation. guished. It is preferable to use a zoom mode to
optimize visualization of the vena contracta and
facilitate its measurement. The color flow sector
Jet area Visualization of the regurgitant jet area in
should also be as narrow as possible, with the least
the receiving chamber can provide a rapid screening
depth, to maximize lateral and temporal resolution.
of the presence and direction of the regurgitant jet Because of the small values of the width of the vena
and a semi-quantitative assessment of its severity. In-
contracta (usually !1 cm), small errors in its
general, a larger area may translate into a more
measurement may lead to a large percent error and
significant regurgitation. However, the sole reliance

misclassification of the severity of regurgitation,
on this parameter can be quite misleading. Numerous
hence the importance of accurate acquisition of the
technical, physiologic and anatomic factors affect the
primary data and measurement.
size of the regurgitant area and therefore alter its
accuracy as an index of regurgitation severity[4]. Jet Proximal isovelocity surface area (PISA) or flow
size is affected by instrument factors, especially pulse convergence The PISA method is derived from the
repetition frequency (PRF) and color gain. Standard hydrodynamic principle stating that, as blood ap-
technique is to use a Nyquist limit (aliasing velocity) proaches a regurgitant orifice, its velocity increases
of 50e60 cm/s, and a color gain that just eliminates forming concentric, roughly hemispheric shells of
random color speckle from non-moving regions. Jet increasing velocity and decreasing surface area[7].
area is inversely proportional to PRF, and substantial Color flow mapping offers the ability to image one of
error can be introduced with the use of higher or these hemispheres that corresponds to the Nyquist
lower settings than the nominal settings to which limit of the instrument. If a Nyquist limit can be
echocardiographers have become accustomed. Re- chosen at which the flow convergence has a hemi-
garding hemodynamic factors, eccentric, wall-im- spheric shape, flow rate (ml/s) through the regurgi-
pinging jets appear significantly smaller than tant orifice is calculated as the product of the surface
centrally directed jets of similar hemodynamic area of the hemisphere (2pr2) and the aliasing velocity
severity, mainly because they flatten out on the wall (Va) as 2pr2 )Va (Fig. 2). Assuming that the maximal
of the receiving chamber. Their presence, however, PISA radius occurs at the time of peak regurgitant
should also alert to the possibility of structural flow and peak regurgitant velocity, the maximal
abnormalities of the valve (e.g. prolapse, flail, or EROA is derived as:
perforation), frequently in the leaflet or cusp opposite
to the direction of the jet. Lastly, color flow area is EROA ¼ ð6:28r2 )VaÞ=PkVReg
also influenced by flow momentum d the product of
where PkVReg is the peak velocity of the regurgitant
flow rate and velocity. Thus a jet may appear larger jet by CW Doppler. The regurgitant volume can be
by increasing the driving pressure across the valve;
estimated as EROA multiplied by the velocity time
hence the importance of measuring blood pressure
integral of the regurgitant jet. Since the PISA
for left heart lesions at the time of the echocardio- calculation provides an instantaneous peak flow rate,
graphic examination, particularly in the intraoper-
EROA by this approach is the maximal EROA and
ative setting.
may be slightly larger than EROA calculated by
other methods.
Vena contracta The vena contracta is the narrowest Measurement of PISA by color flow mapping
portion of a jet that occurs at or just downstream requires adjustment of the aliasing velocity such that
from the orifice (Fig. 1). It is characterized by high a well-defined hemisphere is shown. This is generally

Figure 2. Schematic depiction of the flow convergence or proximal isovelocity surface area (PISA) method for quantitating
valvular regurgitation. Va is the velocity at which aliasing occurs in the flow convergence towards the regurgitant orifice.

PkVReg Z peak velocity of the regurgitant jet, determined by continuous wave Doppler. Reg flow Z regurgitant flow;
EROA Z effective regurgitant orifice area; Reg jet Z regurgitation jet.
done by shifting the baseline toward the direction of severity. Criteria for these maximum instantaneous
flow, or by lowering the Nyquist limit, or both (the measurements corresponding to the severity of each
latter reduces the wall filter, whereas the former does lesion assume a pan-systolic (or pan-diastolic) dura-
not)[8]. If the base of the hemisphere is not a flat tion. However, in some circumstances, such as mitral
surface (180(), then correction for wall constraint valve prolapse, the duration of regurgitation may be
should be performed, multiplying by the ratio of the brief[12] and can be suspected from real-time, 2D
angle formed by the walls adjacent to the regurgitant color Doppler. A time-based graphic, such as CW
orifice and 180(. This has been shown to improve the Doppler or color M mode, can better ascertain this
reliability of the measurement[9]. finding. Although graphing the actual duration of
The limitations of PISA have been reviewed in such flow patterns has not been systematically
detail[10]. It is more accurate for central jets than for studied, a correction of color flow indices of regurgi-
eccentric jets, and for regurgitation with a circular tation for the duration of regurgitation is advised.
orifice. If the image resolution allows the flow
convergence to be seen well, and a Nyquist limit
can be chosen at which the flow convergence has
Pulsed Doppler Quantitative Flow Methods
a hemispheric shape, it is easy to identify the aliasing
line of the hemisphere. However, it can be difficult to PW Doppler recordings of flow velocity can be
judge the precise location of the orifice and the flow combined with 2D measurements to derive flow rates
convergence shape. Any error introduced is then and stroke volume[13]. The technical details involved
squared, which can markedly affect the resulting flow in making these measurements and their sources of
rate and EROA. Recent modifications of the de- error are described in the article on Quantitation of
scribed PISA method use the distance between two Doppler Echocardiography[3]. This method is simple
aliasing contours to circumvent the errors from in theory but accurate results require individual
imprecise location of the orifice in the standard PISA training (e.g. practice in normal patients where the
formula, and automate localizing the most hemi- stroke volumes at different sites are equal). Briefly,
spheric shape[11]. Although promising, further expe- stroke volume (SV) at any valve annulus d the least
rience is needed with these methods. variable anatomic area of a valve apparatus d is
All the color Doppler parameters discussed above derived as the product of cross-sectional area (CSA)
provide instantaneous measures of regurgitation and the velocity time integral (VTI) of flow at the

annulus. Assumption of a circular geometry has based on M-mode echocardiography has important
worked well clinically for most valves with the limitations and is not recommended.
exception of the tricuspid annulus. Thus,
Other Pulsed and Continuous
SV ¼ CSA!VTI ¼ pd2 =4!VTI ¼ 0:785d2 !VTI Wave Doppler Methods
where d is the diameter of the annulus. Calculations There are several pulsed and CW Doppler methods
of stroke volume can be made at two or more that give indirect clues to the significance of valvular
different sites d left ventricular outflow tract regurgitation. In general, the density of the spectral
(LVOT), mitral annulus, and pulmonic annulus. In display of a regurgitant jet is proportional to the
the absence of regurgitation, stroke volume determi- number of red cells exhibiting regurgitation and is a
nations at these sites are equal. In the presence of qualitative index of severity. Other parameters result
regurgitation of one valve, without any intracardiac from the hemodynamic consequences of the severity
shunt, the flow through the affected valve is larger of regurgitation and are more valve specific (atrio-
than through other competent valves. The difference ventricular valve vs aortic or pulmonic valve). For
between the two represents the regurgitant vol- atrio-ventricular valves, these parameters include the
ume[14,15]. Regurgitant fraction is then derived as magnitude of the early inflow velocity (E), the
the regurgitant volume divided by the forward stroke pulmonary or hepatic venous inflow pattern, and
volume through the regurgitant valve. Thus, the contour or shape of the regurgitant jet by CW
Doppler. For aortic and pulmonic valve insufficiency,
Regurgitant Volume ¼ SVRegValv SVCompValv the parameter used is the rate of deceleration of the
regurgitant jet velocity (pressure half-time), which
Regurgitant Fraction reflects the rapidity of equilibration of diastolic
¼ ðSVRegValv SVCompValv Þ=SVRegValv arterial and ventricular pressures. Another index of
severity of aortic insufficiency is the magnitude of
where SVRegValv is stroke volume derived at the diastolic flow reversal in the aorta. Although helpful
annulus of the regurgitant valve and SVCompValv is the in the overall evaluation of regurgitation, these

stroke volume at the competent valve. EROA can be parameters are in general sensitive but less specific
calculated similar to the PISA method as regurgitant for the severity of regurgitation, as they are in-
volume divided by the velocity time integral of the fluenced by other hemodynamic and clinical condi-
regurgitant jet velocity (VTIRegJet) recorded by CW tions. These methods will be discussed in detail for
Doppler as: each valve (see below).
EROA ¼ Regurgitant Volume=VTIRegJet
Doppler Methods in Acute vs
The most common errors encountered in determining Chronic Regurgitation
these parameters are (1) failure to measure the valve
annulus properly (error is squared in the formula), (2) Color Doppler measures are particularly deceptive in
failure to trace the modal velocity (brightest signal acute regurgitation, leading to the clinical paradox of
representing laminar flow) of the pulsed Doppler apparently small jet size in a critically ill patient,
tracing and (3) failure to position the sample volume especially from the transthoracic echocardio-
correctly, and with minimal angulation, at the level of gram[18,19]. This is related in part to technical factors,
the annulus. Furthermore, in the case of significant particularly insufficient color Doppler temporal
calcifications of the mitral annulus and valve, quan- resolution in the tachycardic patient; practically,
titation of flow at the mitral site is less accurate and frame rate should therefore be maximized[20]. TEE
more prone to errors. has been felt to provide a more sensitive view, and the
In left sided regurgitant lesions, SVRegValv or total decreased depth also maximizes frame rate particu-
stroke volume of the ventricle can also be measured larly for mitral regurgitation[18,19]. More fundamen-
using left ventricular volume calculations by 2D tally, however, the short duration of regurgitation
echocardiography as end-diastolic volume minus and small receiving chambers limit the maximal
end-systolic volume. Methods for calculation of left development of jet area, and the rapid equalization
ventricular volumes have been previously detailed[2]. of pressures diminishes orifice velocity, jet momen-
Measurement of left ventricular volumes by echocar- tum, and therefore jet area[21,22]. The proximal jet or
diography has the potential pitfall of underestimating vena contracta remains reliable in this setting, as does
true left ventricular volume and therefore under- pulsed Doppler quantitation. Doppler hemodynamic
estimating regurgitation severity. Recently, the use of signs of elevated receiving chamber pressures, such as
intravenous contrast agents that cross the pulmonary short aortic insufficiency pressure half-time, early
circulation has shown promise in facilitating the truncation of mitral regurgitant velocities, and pul-
tracing of the ventricular endocardium and improv- monary venous flow reversal, are particularly inform-
ing the accuracy and reproducibility of volume mea- ative in this setting, and may provide the only clues to
surements[16,17]. Assessment of ventricular volumes significant regurgitation. In this clinical scenario of

suspected acute valvular regurgitation, TEE is en- Finally, the echocardiographic and Doppler exam-
couraged for a more definite diagnosis and improved ination in a patient with valvular regurgitation is best
patient management[19,23]. interpreted within the clinical context at the time of
the examination. It has been clearly demonstrated
Grading the Severity of Valvular Regurgitation
that the severity of regurgitation may be influenced
by hemodynamic conditions. Therefore, it is essential
Characterization of the severity of regurgitant lesions to record the patient’s blood pressure at the time of
is among the most difficult problems in valvular heart the study and note the patient’s medications when-
disease. Such a determination is important since mild ever possible. When following a patient with serial
regurgitation does not lead to remodeling of cardiac examinations, these factors need to be considered in
chambers and has a benign clinical course, whereas comparing the severity of regurgitation and its
severe regurgitation is associated with significant hemodynamic consequences.
remodeling, morbidity and mortality[1]. Contributing The following sections detail the use of 2D and
to the difficulty of assessment of regurgitation is the Doppler echocardiographic methods for the evalua-
lack of a true gold standard, and the dependence of tion of each valvular lesion and provide suggested
regurgitation severity on the hemodynamic condi- criteria and approach for the assessment of the
tions at the time of evaluation. Although angiography severity of regurgitation.
has been used historically to define the degree of re-
gurgitation based on opacification of the receiving
chamber, it is also dependent on several technical Mitral Regurgitation
factors and hemodynamics[24e27]. For example, an in-
crease in blood pressure will increase all parameters of Role of Two-Dimensional
aortic or mitral regurgitation, be it assessed as regur- Echocardiography
gitant fraction or angiographic grade. Furthermore,
the angiographic severity grades, which have ranged Evaluation of the anatomy of the mitral valve
between 3 and 5, have only modest correlations with apparatus by 2D echocardiography is critically impor-
quantitative indices of regurgitation[14,24e28]. tant in the assessment of severity of mitral regurgita-

Doppler methods for valvular regurgitation have tion (MR). The mitral apparatus includes the leaflets,
been validated in vitro and in animal models against chordae tendineae, annulus, and the papillary muscles
independent flow parameters, and clinically, mostly with their supporting left ventricular (LV) walls.
in adults, against the angiographic standard. The Careful evaluation of these structures should be able
majority of these validation studies have involved left to define the mechanism of MR and yield clues to its
sided cardiac valves. As already discussed, there are severity. For example, a prominent flail leaflet is
several qualitative and quantitative echocardiographic usually associated with severe MR. On the other hand,
parameters that can provide assessment of valvular severe MR rarely occurs in the setting of an anatom-
regurgitation. The availability of these different ically normal mitral valve and support apparatus.
parameters provides an internal verification and Defining the mechanism of MR may determine
corroboration of the severity of the lesion, particu- whether valve repair is feasible instead of valve
larly when technical or physiologic conditions pre- replacement[29,30]. In patients with MR in the setting
clude the use of one or the other of these indices. This of LV dilatation and/or systolic dysfunction, it is
multi-faceted approach is essential. If there are signs important to determine whether MR is functional (i.e.
suggesting that the regurgitation is significant and the due to LV dilatation) or primary (i.e. due to an
quality of the data lends itself to quantitation, it is abnormality of the valve apparatus). In functional
desirable for echocardiographers with experience in MR, the leaflets are usually tethered by outward dis-
quantitative methods to determine quantitatively the placement of the LV walls and papillary muscles, with
degree of regurgitation, particularly for left sided or without annular dilation[31]. Underlying wall motion
lesions. Ultimately, the interpreter must integrate the abnormalities in patients with coronary artery disease
information and disregard ‘outlying’ data (because of may also lead to functional MR. Finally, evaluation of
poor quality or a physiologic condition that alters left atrial (LA) size and LV size and function provides
accuracy of a certain parameter), making a best clues to the severity of MR, its acuteness or chronicity,
estimate of regurgitation severity. and is important in determining the necessity and
The consensus of the Task Force is to classify timing of surgery[1,32]. Normal 2D-derived values for
grading of severity of regurgitation into mild, left ventricular size and function have been previously
moderate, and severe. In cases of overlap or in- reported[2]. Briefly, the end-diastolic minor axis di-
termediate severity, the terms ‘mild-to-moderate’ or mension of the LV obtained from the parasternal
‘moderate-to-severe’ can be used. ‘Trace’ regurgita- window by 2D is normally %2.8 cm/m2 while the
tion is also used in the event that regurgitation is normal end-diastolic LV volume is !82 ml/m2
barely detected. Usually this can be physiologic, (reference [2]). For the left atrium, a normal antero-
particularly in right heart valves and mitral valve, posterior diameter is %2 cm/m2 (reference [33]). Re-
and may not produce an audible murmur. cent studies, however, have shown that determination

of LA volumes with 2D echocardiography from the area[37]. Finally, color flow jets that are directed
apical views is generally more accurate in assessing centrally into the LA generally appear larger because
LA size than the traditional antero-posterior dimen- they entrain red blood cells on all sides of the jet. In
sion[34]. A normal maximal LA volume is %36 ml/m2 contrast, eccentric jets that hug the LA wall cannot
(reference [35]). entrain blood on all sides and tend to appear smaller
than central jets of similar or lesser severity (Fig.
3)[38e40]. Because of these considerations, deter-
Doppler Methods mination of the severity of MR by ‘eyeballing’ or
planimetry of the MR color flow jet area only, is not
Color Flow Doppler
recommended. Nevertheless, small, non-eccentric jets
Color Doppler flow mapping is widely used to screen with an area !4.0 cm2 or !20% of LA area are
for the presence of mitral regurgitation. Importantly, usually trace or mild MR (Table 1). Conversely, large
small color flow jets are seen in roughly 40% of jets that penetrate into the pulmonary veins are more
healthy normal volunteers and therefore are consid- likely to be hemodynamically significant. However,
ered a normal variant[36]. The incidence of mild the detection of eccentric, wall-impinging jets should
regurgitation tends to increase with age. The terms alert the observer to avoid the use of jet area as an
trace MR or MR closing volume have been applied to index of severity and use other, more appropriate
these jets. There are three methods of quantifying methods described below.
MR severity by color flow Doppler mapping: re-
gurgitant jet area, vena contracta, and flow conver- Vena contracta The vena contracta should be ima-
gence (PISA). Although jet area was the first method ged in high-resolution, zoom views for the largest
used for assessing MR severity, its sole use is less obtainable proximal jet size for measurements. The
accurate than the latter two methods. examiner must search in multiple planes perpendic-
ular to the commissural line (such as the parasternal
Regurgitant jet area As a general rule, large jets that long-axis view), whenever possible (Fig. 1). The width
extend deep into the LA represent more MR than of the neck or narrowest portion of the jet is then

small thin jets that appear just beyond the mitral measured. The regurgitant orifice in MR may not be
leaflets. However, the correlation between jet area circular, and is often elongated along the mitral
and MR severity is poor due to a variety of technical coaptation line. The two-chamber view, which is
and hemodynamic limitations as noted earlier[4]. oriented parallel to the line of leaflet coaptation,
Patients with acute severe MR, in whom blood generally shows a wide vena contracta even in mild
pressure is low and LA pressure is elevated, may have MR, and should not be used to measure the vena
a small eccentric color flow jet area, whereas contracta. Although the size of the vena contracta is
hypertensive patients with mild MR may have a large independent of flow rate and driving pressure for
jet area. Furthermore, the same regurgitant flow will a fixed orifice[5], the regurgitant orifice in MR is often
produce larger or smaller jets depending on the size of dynamic and therefore the vena contracta may
the atrium, which has led to indexing for atrial change with hemodynamics or during systole[6].
Figure 3. Examples of color flow recordings of different mitral regurgitation (MR) lesions from the apical window. The
case of mild regurgitation has no flow convergence and a small regurgitant jet area, in contrast to that of severe central
MR, which shows a prominent flow convergence and a large regurgitant jet area. The example with severe eccentric MR
has a small jet area impinging on the wall of the left atrium but a large flow convergence and a wide vena contracta.

Table 1. Qualitative and quantitative parameters useful in grading mitral regurgitation severity.
Parameter Mild Moderate Severe
Structural parameters
LA size Normal* Normal or dilated Usually dilatedy
LV size Normal* Normal or dilated Usually dilatedy
Mitral leaflets or support Normal or abnormal Normal or abnormal Abnormal/flail leaflet/ruptured papillary
apparatus muscle
Doppler parameters
Color flow jet areaz Small, central jet (usually Variable Large central jet (usually O10 cm2 or
!4 cm2 or !20% O40% of LA area) or variable size
of LA area) wall-impinging jet swirling in LA
Mitral inflow d PW A-wave dominantx Variable E-wave dominantx (E usually R1.2 m/s)
Jet density d CW Incomplete or faint Dense Dense
Jet contour d CW Parabolic Usually parabolic Early peaking d triangular
Pulmonary vein flow Systolic dominance{ Systolic blunting{ Systolic flow reversalk
Quantitative parameters**
VC width (cm) !0.3 0.3e0.69 R0.7
R Vol (ml/beat) !30 30e44 45e59 R60
RF (%) !30 30e39 40e49 R50
EROA (cm2) !0.20 0.20e0.29 0.30e0.39 R0.40
VC Z vena contracta; R Vol Z regurgitant volume; RF Z regurgitant fraction; EROA Z effective regurgitant orifice area; PW Z pulsed
wave Doppler; CW Z continuous wave Doppler; LA Z left atrium; LV Z left ventricle.
*Unless there are 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 antero-posterior diameter %2 cm/m2, maximal LA volume %36 ml/m2 (references [2,33,35]).
yException: acute mitral regurgitation.
zAt a Nyquist limit of 50e60 cm/s.
xUsually above 50 years of age or in conditions of impaired relaxation, in the absence of mitral stenosis or other causes of elevated LA

pressure.
{Unless other reasons for systolic blunting (e.g. atrial fibrillation, elevated left atrial pressure).
kPulmonary venous systolic flow reversal is specific but not sensitive for severe MR.
**Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe.
Several studies have shown that the width of the 50e60 cm/s) should alert to the presence of signifi-
vena contracta is accurate in assessing the severity of cant MR. Several clinical studies have validated
MR, either by transthoracic echocardiography or PISA measurements of regurgitant flow rate and
TEE[41e45]. The width of the vena contracta in long- EROA[12,46,47]. As mentioned earlier, there are many
axis views and its cross-sectional area in short-axis technical considerations related to optimal acquisi-
views can be standardized from the parasternal tion of flow convergence images and to quantitation
views[44]. A vena contracta !0.3 cm usually denotes of mitral regurgitant orifice area by PISA. This
mild MR whereas the cut-off for severe MR has methodology is more accurate for central regurgitant
ranged between 0.6 cm and 0.8 cm[43e45]. Although jets than eccentric jets, and for a circular orifice than
intermediate values tend to correlate well with a non-circular orifice. Flow convergence should be
moderate MR, there is enough overlap that another optimized from the apical view, usually the four-
method should be used for confirmation. A particular chamber view, using a zoom mode. Combining data
strength of the vena contracta method is that it works from two views through the major and minor axes of
equally well for central and eccentric jets. In fact, in a non-circular orifice (apical two- and four-chamber
eccentric jets of severe MR, the width of the vena views) provides greater accuracy, but adds more
contracta along with flow convergence alerts the complexity[8,44,48]. The size of the PISA has meaning
echocardiographer to the severity of regurgitation by only in terms of the aliasing velocity that defines the
color Doppler (Fig. 3). In patients with multiple MR color surface. Results vary widely for calculations at
jets, the respective widths of the vena contracta are different aliasing velocities, and care must be taken to
not additive, but their cross-sectional areas can be[44]. use the velocity at which the hemispheric formula
In the future, three-dimensional imaging of the vena applies best[49,50]. Furthermore, for determination of
contracta should improve the accuracy of measuring EROA, it is essential that the CW Doppler signal be
EROA by this technique. well aligned with the regurgitant jet. Poor alignment
with an eccentric jet will lead to an underestimation
Flow convergence or PISA Most of the experience of velocity and an overestimation of the EROA.
with the PISA method for quantitation of regurgi- Generally, an EROA R0.4 cm2 is consistent with
tation is with MR. Qualitatively, the presence of severe MR, 0.20e0.39 cm2 with moderate, and !0.20
PISA on a routine examination (at Nyquist limit of cm2 with mild MR.

Figure 4. Example of findings of continuous wave Doppler recordings and pulmonary vein flow by pulsed Doppler in a case
with mild and another with severe mitral regurgitation (MR). In mild MR, spectral recording of the jet has a soft density
with a parabolic, rounded contour of the regurgitant velocity whereas in severe MR, the jet is dense with a triangular, early
peaking of the velocity (arrow). Pulmonary vein flow is normal in mild MR with predominance of systolic flow (S). In

contrast, the case with severe MR displays systolic flow reversal. D Z diastolic flow velocity.
Continuous Wave Doppler Pulsed Doppler

In most patients, maximum MR velocity is 4e6 m/s Pulsed Doppler tracings at the mitral leaflet tips are
due to the high systolic pressure gradient between the commonly used to evaluate LV diastolic function.
LV and LA. The velocity itself does not provide Patients with severe MR often demonstrate a mitral
useful information about the severity of MR. inflow pattern with a dominant early filling (increased
However, the contour of the velocity profile and its E velocity) due to increased diastolic flow across the
density are useful. A truncated, triangular jet contour mitral valve, with or without an increase in LA
with early peaking of the maximal velocity indicates pressure[52]. In severe mitral regurgitation without
elevated LA pressure or a prominent regurgitant stenosis, the mitral E velocity is higher than the
pressure wave in the LA (Fig. 4). velocity during atrial contraction (A velocity), and
The density of the CW Doppler signal is a qualita- usually greater than 1.2 m/s. For these reasons,
tive index of MR severity. A dense signal that a mitral inflow pattern with an A-wave dominance
approaches the density of antegrade flow suggests virtually excludes severe MR. Because of the effect of
significant MR, whereas a faint signal, with or without relaxation on mitral inflow indices, these observa-
an incomplete envelope represents mild or trace MR, tions are more applicable in individuals older than 50
presuming the recording is made through the vena years of age or in conditions of impaired myocardial
contracta (Fig. 4). In eccentric significant MR, it may relaxation.
be difficult to record the full envelope of the jet In contrast to ventricular filling dynamics, calcula-
because of its eccentricity, while the signal intensity tion of flow and stroke volume through the mitral
shows dense features. Recently, the returning power of valve with pulsed Doppler is performed at the mitral
the regurgitant velocity signal, which is proportional annulus level. Several studies have shown the validity
to the area of the vena contracta, has been used to and clinical utility of quantitative Doppler measure-
obtain instantaneous regurgitant orifice area and flow ments of MR severity[14,15,53e55]. The values for
rate[51]. This method offers considerable promise. regurgitant volumes, regurgitant fraction and EROA
Using CW Doppler, the tricuspid regurgitation jet by quantitative Doppler for various degrees of MR
should be interrogated in order to estimate pulmo- are shown in Table 1. It should be remembered,
nary artery systolic pressure. The presence of pul- however, that in individual patients, these values
monary hypertension provides another indirect clue might vary. For example, a patient with severe MR
as to MR severity and compensation to the volume and a small LV may have a low regurgitant volume
overload. but a high regurgitant fraction and EROA. There are

no data regarding indexing these measurements to Interrogation of all pulmonary veins is generally
body surface area. Quantitative Doppler measure- feasible with TEE.
ments may be more applicable to patients with
a single regurgitant valve. For example, in the
presence of combined MR and significant aortic Integrative Approach to Assessment of
regurgitation, the calculated regurgitant volume will Mitral Regurgitation Severity
be erroneous if the LV outflow site is used for
comparison. In this case, systemic flow could be The approach to the evaluation of MR severity
calculated at the pulmonic annulus. Lastly, the ideally integrates multiple parameters rather than
quantitative PW Doppler method offers an advantage depending on a single measurement. This helps
in the case of eccentric or multiple regurgitant MR minimize the effects of technical or measurement
jets, where PISA is not as accurate and vena errors that are inherent to each method previously
contracta is not applicable in the latter situation. discussed. It is also important to distinguish between
the amount of MR and its hemodynamic consequen-
Pulmonary Vein Flow ces. For example, a modest regurgitant volume that
develops acutely into a small, noncompliant LA may
Pulsed Doppler evaluation of pulmonary venous flow cause severe pulmonary congestion and systemic
is a useful adjunct to evaluating the hemodynamic hypotension. Conversely, some patients with chronic
consequences of MR. Normal pulmonary venous severe MR remain asymptomatic due to compensa-
flow is characterized by a velocity during ventricular tory mechanisms and a dilated, compliant LA.
systole that is higher than during ventricular diastole. Parameters that describe the amount of MR
With increasing severity of MR, there is a diminution include vena contracta width, regurgitant volume
of the systolic velocity. In many patients with severe and fraction, and EROA calculated either by PISA or
MR, the flow in the pulmonary veins becomes quantitative pulsed Doppler. Because regurgitant
reversed in systole (Fig. 4). Since the mitral regur- flows may be holosystolic or brief, as in valve pro-
gitant jet may selectively enter one or the other of the lapse[12], color Doppler techniques should be adjusted
pulmonary veins, sampling through all pulmonary

for duration of MR: for example, a wide vena
veins is recommended, especially during TEE. One contracta occurring briefly conveys only mild MR.
limitation of pulmonary venous pattern in the On the other hand, the hemodynamic consequences
assessment of severity of MR is that elevation in of MR are reflected in several parameters including
LA pressure of any etiology, and atrial fibrillation LA and LV volumes, the contour of the CW Doppler
also result in a blunted systolic forward flow[56]. As profile, and pulmonary venous flow pattern. Advan-
a result, the use of pulmonary venous flow pattern tages and limitations of the various echo/Doppler
should be used adjunctively with other parameters. parameters used in assessing severity of MR are
Nevertheless, the finding of systolic flow reversal in detailed in Table 2. An MR index has been devised
more than one pulmonary vein is specific but not that assigns different weights to six different indica-
sensitive for severe mitral regurgitation. tors of MR[57], using a score of 0e3 for jet
penetration into the LA, PISA radius, CW jet
intensity, pulmonary artery pressure, pulmonary
Role of TEE in Assessing Mitral venous flow pattern, and LA size. A score of 1.7 or
Regurgitation Severity less reliably separated mild MR from severe MR;
a considerable overlap, however, was observed be-
TEE is indicated to evaluate MR severity in patients tween moderate and severe MR. Although it may be
in whom transthoracic echocardiography is incon- impractical for routine clinical use, this scoring sys-
clusive or technically difficult. In addition, TEE is tem emphasizes the need to evaluate multiple echo-
particularly well suited to identify the underlying cardiographic parameters.
mechanism of MR and for planning mitral valve Based on data in the literature and a consensus of
surgery. All of the above methods of quantifying MR the committee members, the Task Force proposes
can also be used during TEE. In particular, the higher a scheme of specific signs (R90% specificity), along
resolution of TEE, multiplane capabilities, and with supportive signs and quantitative parameters to
proximity to the mitral valve make vena contracta help grade the severity of MR (Table 3). In applying
imaging and PISA easier and probably more accu- this scheme, the Task Force also wishes to recognize
rate. On the other hand, since jet size is affected by the following. The specific signs have inherently a high
transducer frequency, PRF, and signal strength, the positive predictive value for the severity of regurgi-
same jet may appear larger on TEE compared to tation. On the other hand, the supportive signs or
transthoracic images. Quantitative pulsed Doppler by clues may be helpful in consolidating the impression
TEE works well provided that a deep transgastric of the degree of MR, although their predictive value
view is obtained to properly align the PW Doppler is more modest, since they are influenced by several
beam to the LV outflow tract. The latter, however, is factors (Table 2). It is the consensus of the committee
more difficult than with the transthoracic approach. members that the process of grading MR should be

Table 2. Echocardiographic and Doppler parameters used in the evaluation of mitral regurgitation severity:
utility, advantages and limitations.
Parameter Utility/advantages Limitations
LA and LV size Enlargement sensitive for chronic significant MR, Enlargement seen in other conditions. May be
important for outcomes. Normal size virtually normal in acute significant MR
excludes significant chronic MR
MV leaflet/support Flail valve and ruptured papillary muscle specific for Other abnormalities do not imply significant MR
apparatus significant MR
Doppler parameters
Jet area d color flow Simple, quick screen for mild or severe central MR; Subject to technical, hemodynamic variation;
evaluates spatial orientation of jet significantly underestimates severity in wall-
impinging jets
Vena contracta width Simple, quantitative, good at identifying mild or Not useful for multiple MR jets; intermediate values
severe MR require confirmation. Small values; thus small error
leads to large % error
PISA method Quantitative; presence of flow convergence at Less accurate in eccentric jets; not valid in multiple
Nyquist limit of 50e60 cm/s alerts to significant MR. jets. Provides peak flow and maximal EROA
Provides both, lesion severity (EROA) and volume
overload (R Vol)
Flow quantitation d PW Quantitative, valid in multiple jets and eccentric jets. Measurement of flow at MV annulus less reliable in
Provides both lesion severity (EROA, RF) and calcific MV and/or annulus. Not valid with
volume overload (R Vol) concomitant significant aortic regurgitation unless
pulmonic site is used
Jet profile d CW Simple, readily available Qualitative; complementary data
Peak mitral E velocity Simple, readily available. A-wave dominance Influenced by LA pressure, LV relaxation, MV area,
excludes severe MR and atrial fibrillation. Complementary data only, do
not quantify MR severity
Pulmonary vein flow Simple. Systolic flow reversal is specific for severe Influenced by LA pressure, atrial fibrillation. Not

MR accurate if MR jet directed into the sampled vein
CW Z continuous wave Doppler; EROA Z effective orifice regurgitant area; LA Z left atrium; PISA Z proximal isovelocity surface
area; LV Z left ventricle; PW Z pulsed wave Doppler; MV Z mitral valve; MR Z mitral regurgitation; R Vol Z regurgitant volume.
comprehensive, using a combination of clues, signs Aortic Regurgitation

and measurements obtained by Doppler echocardi-
ography. If the MR is definitely determined as mild The assessment of aortic regurgitation (AR) is based
or less using these signs, no further measurement is on a comprehensive utilization of 2D echocardiogra-
required. If there are signs suggesting that the MR is phy, color-flow imaging, pulsed and CW Doppler
more than mild and the quality of the data lends itself techniques and is essential in the clinical evaluation of
to quantitation, it is desirable for echocardiographers aortic valvular disease[1]. The echocardiographic and
with experience in quantitative methods to determine Doppler evaluation of AR uses qualitative and
quantitatively the degree of MR, including the quantitative measures that can be derived in a single
regurgitant volume and fraction as descriptors of examination. While qualitative or semi-quantitative
volume overload and the effective regurgitant orifice measures are used uniformly, quantitative measures
as a descriptor of the lesion severity. It is also the are often more time consuming and are used more
consensus of the Task Force that the wording chosen selectively.
for expressing the degree of MR, which is a continuum
best defined by quantitative measurements, can
include qualifiers such as mild-to-moderate to des- Role of Two-Dimensional
cribe the lowest end of the moderate range and Echocardiography
moderate-to-severe to describe the upper end of the
moderate range. Finally, it is important to stress that 2D echocardiography provides important informa-
when the evidence from the different parameters is tion regarding valve anatomy and structural deform-
congruent, it is easy to grade MR severity with con- ities, presence and severity of aortic root dilatation
fidence. When different parameters are contradictory, and adaptation of the LV to the volume overload
one must look carefully for technical and physiologic state. While mild degrees of AR are associated in
reasons to explain any discrepancies and rely on the general with mild pathology of the valve and aortic
components that have the best inherent quality of the root and do not result in LV remodeling, severe
primary data and are the most accurate considering chronic AR is usually observed in the setting of
the underlying physiologic condition. significant structural abnormalities of the valve or

Table 3. Application of specific and supportive signs, and quantitative parameters in the grading of mitral
regurgitation severity.
Mild Moderate Severe
Specific signs Small central jet !4 cm2 or Signs of MR Omild present, Vena contracta width R0.7 cm with
of severity !20% of LA area* but no criteria for severe MR large central MR jet (area O40% of
LA) or with a wall-impinging jet of
any size, swirling in LA*
Vena contracta width !0.3 cm Large flow convergencey
No or minimal flow convergencey Systolic reversal in pulmonary veins
Prominent flail MV leaflet or
ruptured papillary muscle
Supportive signs Systolic dominant flow in Intermediate signs/findings Dense, triangular CW Doppler MR
pulmonary veins jet
A-wave dominant mitral inflowz E-wave dominant mitral inflow
(EO1:2 m=s)z
Soft density, parabolic CW Doppler Enlarged LV and LA sizex
MR signal (particularly when normal LV
function is present)
Normal LV size{
Quantitative parametersk
R Vol (ml/beat) !30 30e44 45e59 R60
RF (%) !30 30e39 40e49 R50
2
EROA (cm ) !0.20 0.20e0.29 0.30e0.39 R0.40
CW Z continuous wave; EROA Z effective regurgitant orifice area; LA Z left atrium; LV Z left ventricle; MV Z mitral valve; MR Z
mitral regurgitation; R Vol Z regurgitant volume; RF Z regurgitant fraction.
*At a Nyquist limit of 50e60 cm/s.
yMinimal and large flow convergence defined as a flow convergence radius !0.4 cm and R0.9 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).
zUsually above 50 years of age or in conditions of impaired relaxation, in the absence of mitral stenosis or other causes of elevated LA
pressure.
xIn the absence of other etiologies of LV and LA dilatation and acute MR.
{LV size applied only to chronic lesions. Normal 2D measurements: LV minor axis %2.8 cm/m2, LV end-diastolic volume %82 ml/m2,
maximal LA antero-posterior diameter %2 cm/m2, maximal LA volume %36 ml/m2 (references [2,33,35]).
kQuantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe as shown.
aortic root, and results in LV enlargement in the apical views because of better axial resolution. The
chronic state. Importantly, evaluation of LV size and recommended measurements are those of maximal
function in significant AR provides clues as to the proximal jet width obtained from the long-axis views
acuteness or chronicity of the regurgitation and helps and its ratio to the LV outflow tract diameter[59].
determine management strategies and timing of sur- Similarly, the cross-sectional area of the jet from the
gical intervention. parasternal short-axis view and its ratio to the LV
outflow tract area can also be used[59]. The criteria to
define severe AR are ratios of R65% for jet width
Doppler Methods and R60% for jet area (Table 4) (Fig. 6). Although
Color Flow Doppler small jets reliably reflect small degrees of AR, there
are important limitations to color-flow imaging of re-
Color-flow imaging directly shows the regurgitant gurgitant jet, similar to mitral regurgitation[38,40]. Jet
flow through the aortic valve during diastole. The shape may affect the measurements. If the proximal
regurgitant flow has three components that can be jet does not have a shape with parallel borders in the
visualized: the flow convergence region in the aorta, LV outflow, it is difficult to know where to measure
the vena contracta through the regurgitant orifice, and it. Jet direction is also a confounding variable.
the jet direction and size in the left ventricle (Fig. 5). Eccentric jets that are directed predominantly to the
anterior leaflet of the mitral valve (Fig. 5) or the
Regurgitant jet size Imaging of the regurgitant jet septum tend to occupy a small portion of the
is used in all patients with AR because of its simpli- proximal outflow tract and may thus appear narrow
city and real-time availability[58]. The length of jet and underestimate the severity of regurgitation[38].
penetration into the left ventricle is an unsatisfactory Conversely, central jets tend to expand fully in the
indicator of AR severity[59]. The preferred assessment outflow tract and may be overestimated. Further-
is based on the proximal jet width or cross-sectional more, the severity of AR in diffuse jets arising from
area immediately below the aortic valve, within 1 cm of the entire coaptation line is also poorly evaluated by
the valve[59,60]. The parasternal views are preferred to color-flow imaging. This can be suspected from short

Figure 5. Examples of central and eccentric aortic regurgitation (AR) jets recorded by TEE. The components of AR by
color Doppler are highlighted by arrows in the example of central AR: flow convergence, vena contracta (VC) and jet
width in the left ventricular outflow tract. Note the smaller size and location of the vena contracta compared to the jet
width in the LV outflow tract. The eccentric AR jet is directed towards the mitral valve (arrow) with a prominent flow
convergence. Jet width in the left ventricular outflow in this eccentric jet cannot be used for evaluation of AR severity.
LA Z left atrium; LV Z left ventricle.
axis imaging at the aortic valve. In practice, the Vena contracta The vena contracta is defined as the
assessment of AR based on jet size in the LV outflow smallest neck of the flow region at the level of the
is most often based on visual estimation rather than aortic valve, immediately below the flow convergence

direct quantitative measurement and is used as a gross region. It is different from the jet width discussed
indicator of the degree of AR. above, which is measured in the LVOT, below the
Table 4. Qualitative and quantitative parameters useful in grading aortic regurgitation severity.
LV size Normal* Normal or dilated Usually dilatedy
Aortic leaflets Normal or abnormal Normal or abnormal Abnormal/flail, or wide
coaptation defect
Doppler parameters
Jet width in LVOT d color flowz Small in central jets Intermediate Large in central jets; variable in
eccentric jets
Jet density d CW Incomplete or faint Dense Dense
Jet deceleration rate d CW (PHT, ms)x Slow O500 Medium 500e200 Steep !200
Diastolic flow reversal in Brief, early diastolic Intermediate Prominent holodiastolic reversal
descending aorta d PW reversal
Quantitative parameters{
VC width, cmz !0.3 0.3e0.60 O0.6
Jet width/LVOT width, %z !25 25e45 46e64 R65
Jet CSA/LVOT CSA, %z !5 5e20 21e59 R60
R Vol, ml/beat !30 30e44 45e59 R60
RF, % !30 30e39 40e49 R50
EROA, cm2 !0.10 0.10e0.19 0.20e0.29 R0.30
AR Z aortic regurgitation; CSA Z cross-sectional area; CW Z continuous wave Doppler; EROA Z effective regurgitant orifice area;
LV Z left ventricle; LVOT Z left ventricular outflow tract; PHT Z pressure half-time; PW Z pulsed wave Doppler; R Vol Z regurgitant
volume; RF Z regurgitant fraction; VC Z vena contracta.
*Unless there are other reasons for LV dilation. Normal 2D measurements: LV minor axis %2.8 cm/m2, LV end-diastolic volume %82 ml/
m2 (reference [2]).
yException would be acute AR, in which chambers have not had time to dilate.
xPHT is shortened with increasing LV diastolic pressure and vasodilator therapy, and may be lengthened in chronic adaptation to severe
AR.
{Quantitative parameters can sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe regurgitation
as shown.

Figure 6. Color Doppler and continuous wave (CW) Doppler recordings of the regurgitant jet as well as pulsed wave (PW)
Doppler recording of flow in the descending thoracic aorta in examples of mild and severe aortic regurgitation (AR).
Compared to the mild AR, the case of severe AR has a large jet width in the left ventricular outflow, a steep deceleration
rate of the AR velocity by CW Doppler, and a holodiastolic flow reversal in the descending (desc) aorta (arrows).

aortic valve (Fig. 5). The measurement of vena measurable flow convergence zone and the aliasing
contracta width is significantly smaller than that of radius is measured from the stop frame with the
jet width in the LVOT because the jet expands largest observable PISA. CW Doppler recording of
immediately after the vena contracta. Imaging of the the regurgitant peak velocity and velocity time
vena contracta is obtained similarly from parasternal integral allows calculation of the EROA and regur-
long-axis views[61]. The vena contracta provides an gitant volume. This method has been shown to
estimate of the size of the EROA. To appropriately provide accurate quantitation of AR[63]. However, it
visualize the vena contracta, it is essential to see all is feasible in a lower percentage of patients compared
three components of the regurgitant flow, i.e. the flow to MR due to interposition of valve tissue (apical
convergence, the vena contracta and the jet[61]. Mea- views) and difficulty in obtaining high quality images
surement of vena contracta is simple and has a high of the flow convergence region. Another pitfall is
feasibility both by transthoracic echocardiography related to the timing of measurement of the flow
and TEE. Furthermore, it appears to be more robust convergence radius, which should be in early diastole,
than jet width and area in the LVOT for the closest to the peak regurgitant velocity. Furthermore,
assessment of AR severity[61]. Limitations of this ascending aortic aneurysms, which deform the valvu-
parameter occur in the presence of multiple jets or lar plane, may lead to underestimation of AR by this
jets with irregular shapes, where one diameter may method[63]. The thresholds for severe AR are an
not be reflective of the severity of the AR; a short-axis EROA R0.30 cm2 and a regurgitant volume R60 ml.
view, however, will provide a better appreciation of
the regurgitation[62]. The thresholds of vena contracta Pulsed Wave Doppler
width associated with severe AR are 0.5 cm as Aortic diastolic flow reversal It is normal to observe
a highly sensitive threshold, 0.7 cm as a highly specific a brief diastolic flow reversal in the aorta. The flow
threshold and 0.6 cm as the threshold with the best reversal is best recorded in the upper descending
combination of specificity and sensitivity[61]. aorta at the aortic isthmus level using a suprasternal
view, or in the lower descending aorta using a longi-
Flow convergence or PISA Considerably less expe- tudinal subcostal view. With increasing aortic re-
rience exists with PISA for the assessment of AR gurgitation both the duration and the velocity of the
compared to MR. Imaging of the proximal flow reversal increase[64]. Therefore, a holodiastolic re-
convergence region by transthoracic echocardiogra- versal is usually a sign of at least moderate aortic
phy is performed from the apical, para-apical views, regurgitation (Fig. 6) and appears to be more specific
or the upper right-sternal border, with images zoomed if recorded from the thoraco-abdominal aorta. The
on the valvular and supra-valvular region. The velocity of flow reversal at end-diastole, the velocity
Nyquist limit is adjusted to obtain a rounded and time integral of the reversal, and the ratio of reversal

to forward velocity time integrals in the descending Role of TEE

aorta have all been proposed as semi-quantitative in-
dices of AR severity[64,65]. A prominent holodiasto TEE is seldom needed to evaluate severity of AR due
lic reversal with a diastolic time integral similar to the to the proximity of the aortic valve to the chest from
systolic time integral is a reliable qualitative sign of the parasternal window. However, TEE may be
severe AR. However, reduced compliance of the aorta needed in patients with poor acoustic windows, in
seen with advancing age may also prolong the normal whom transthoracic echocardiography cannot pro-
diastolic reversal in the absence of significant AR. vide adequate delineation of anatomy or accurate
Doppler recordings. Color Doppler criteria on jet
width and the size of the vena contracta apply equally
Flow calculations Quantitation of flow with pulsed
to TEE and may show improved image quality in
Doppler for the assessment of AR is based on
some patients. However, due to more difficulty with
comparison of measurement of aortic stroke volume
TEE in obtaining views where the jet direction is
at the LVOT with mitral or pulmonic stroke
parallel to the ultrasound beam, measurements of
volume[14,15]. Total stroke volume (aortic stroke
regurgitant fraction by PW Doppler and recording of
volume) can also be derived from quantitative 2D
the AR velocity with CW Doppler are more difficult
measurements of LV end-diastolic and end-systolic
to obtain reliably. With proper angulation, the
volumes. EROA can be calculated from the regurgi-
magnitude of the proximal flow convergence can be
tant stroke volume and the regurgitant jet velo-
measured. In addition, one can record the diastolic
city time integral by CW Doppler [15,53]. As with the
flow reversal in the ascending aorta with PW Doppler
PISA method, a regurgitant volume R60 ml and
from the upper esophageal views, which also show
EROA R0.30 cm2 are consistent with severe AR. The
the aortic arch.
quantitative Doppler method cannot be used if there
is more than mild mitral regurgitation, unless the
pulmonic site is used for systemic flow calculation. Integrative Approach to Assessment
of AR

Continuous Wave Doppler
Signal density The density of the CW Doppler spec- The assessment of AR by Doppler echocardiography
is an integrative and comprehensive process based on
tral display of the AR jet reflects the volume of re-
all information collected during the examination. The
gurgitation, especially in comparison to the antegrade
spectral density. However, the AR jet density is also advantages and limitations of the 2D and Doppler
parameters in evaluating AR severity are shown in
determined by the respective directions of initial and
Table 5. In all cases one should routinely perform an
distal jet within the beam of ultrasound and also
possibly by the ability of the jet to expand and mobilize evaluation of the aortic valve, LV size and function,
an assessment by color-flow imaging of the proximal
adjoining red blood cells. While a faint spectral display
jet width and, if possible, the vena contracta. The LV
is compatible with trace or mild AR, significant over-
lap between moderate and severe regurgitation exists outflow velocity and the velocity in the proximal
descending aorta and/or abdominal aorta should be
in more dense jet recordings. Therefore, CW Doppler
recorded by pulsed Doppler. CW Doppler of the AR
jet density is an imperfect indicator of severity of AR.
jet should also be routinely recorded but only utilized
if a complete signal is obtained.
Diastolic jet deceleration The rate of deceleration Based on data in the literature and a consensus of
of the diastolic regurgitant jet and the derived the committee members, the Task Force proposes
pressure half-time reflect the rate of equalization of a scheme of specific signs (R90% specificity), along
aortic and LV diastolic pressures. With increasing with supportive signs in which predictive accuracy is
severity of AR, aortic diastolic pressure decreases more modest, and quantitative parameters for AR
more rapidly. The late diastolic jet velocity is lower severity (Table 6). In applying this scheme, it is the
and hence pressure half-time is shorter[66]. Pressure consensus of the committee members that the process
half-time is easily measured if the peak diastolic of grading AR should be comprehensive using
velocity is appropriately recorded. A pressure half- a combination of these signs, clues and measurements
time O500 ms is usually compatible with mild AR obtained by Doppler echocardiography. If the AR is
whereas a value !200 ms is considered consistent definitely determined as mild or less using these signs,
with severe AR (Fig. 6). However, the diastolic AR no further measurement is required. If there are
velocity is also determined by LV diastolic compli- parameters suggestive of more than mild AR and the
ance and pressure. For a given severity of AR, quality of the primary data lends itself to quantita-
pressure half-time can be further shortened by an tion, it is desirable for echocardiographers with
elevated LV diastolic pressure or by vasodilator experience in quantitative methods to measure quan-
therapy that reduces AR[66,67]. On the other hand, titatively the degree of AR, including the regurgitant
pressure half-time can be lengthened or normalized volume and fraction as descriptors of volume over-
with chronic LV adaptation to severe AR[68]. load and the effective regurgitant orifice as a descriptor

Table 5. Echocardiographic and Doppler parameters used in the evaluation of aortic regurgitation severity:
LV size Enlargement sensitive for chronic significant Enlargement seen in other conditions. May
AR, important for outcomes. Normal size be normal in acute significant AR
virtually excludes significant chronic AR
Aortic leaflets alterations Simple, usually abnormal in severe AR; flail Poor accuracy, may grossly underestimate or
valve denotes severe AR overestimate the defect
Doppler parameters
Jet width or jet cross-sectional Simple, very sensitive, quick screen for AR Expands unpredictably below the orifice.
area in LVOT d color flow Inaccurate for eccentric jets
Vena contracta width Simple, quantitative, good at identifying mild Not useful for multiple AR jets. Small values;
or severe AR thus small error leads to large % error
PISA method Quantitative. Provides both lesion severity Feasibility is limited by aortic valve
(EROA) and volume overload (R Vol) calcifications. Not valid for multiple jets, less
accurate in eccentric jets. Provides peak flow
and maximal EROA. Underestimation is
possible with aortic aneurysms. Limited
experience
Flow quantitation d PW Quantitative, valid with multiple jets and Not valid for combined MR and AR, unless
eccentric jets. Provides both lesion severity pulmonic site is used
(EROA, RF) and volume overload (R Vol)
Jet density d CW Simple. Faint or incomplete jet compatible Qualitative. Overlap between moderate and
with mild AR severe AR. Complementary data only
Jet deceleration rate (PHT) d CW Simple Qualitative; affected by changes in LV and
aortic diastolic pressures
Diastolic flow reversal in descending Simple Depends on rigidity of aorta. Brief velocity
aorta d PW reversal is normal

AR Z aortic regurgitation; CW Z continuous wave Doppler; EROA Z effective regurgitant orifice area; LV Z left ventricle; LVOT Z
left ventricular outflow tract; MR Z mitral regurgitation; PHT Z pressure half-time; PW Z pulsed wave Doppler; R Vol Z regurgitant
volume; RF Z regurgitant fraction; VC Z vena contracta width.
Table 6. Application of specific and supportive signs, and quantitative parameters in the grading of aortic
regurgitation severity.
Mild Moderate Severe
Specific signs for Central jet, width !25% of LVOT* Signs of AR Omild present Central jet, width R65% of LVOT*
AR severity but no criteria for severe AR
Vena contracta !0.3 cm* Vena contracta O0.6 cm*
No or brief early diastolic flow
reversal in descending aorta
Supportive signs Pressure half-time O500 ms Intermediate values Pressure half-time !200 ms
Normal LV sizey Holodiastolic aortic flow reversal in
descending aorta
Moderate or greater LV
enlargementz
Quantitative parametersx
R Vol, ml/beat !30 30e44 45e59 R60
RF, % !30 30e39 40e49 R50
2
EROA, cm !0.10 0.10e0.19 0.20e0.29 R0.30
AR Z aortic regurgitation; EROA Z effective regurgitant orifice area; LV Z left ventricle; LVOT Z left ventricular outflow tract;
R Vol Z regurgitant volume; RF Z regurgitant fraction.
*At a Nyquist limit of 50e60 cm/s.
yLV size applied only to chronic lesions. Normal 2D measurements: LV minor axis %2.8 cm/m2, LV end-diastolic volume %82 ml/m2
(reference [2]).
zIn the absence of other etiologies of LV dilatation.
xQuantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe
regurgitation as shown.

of the lesion severity. The wording chosen for of severity. The various parameters used in this
expressing the degree of AR, which is a continuum evaluation are detailed in Table 7. More quantitative
best defined by quantitative measurements, can in- measures of TR severity are rarely needed. During
clude qualifiers such as mild-to-moderate to describe the examination, it is important to measure the TR
the lowest end of the moderate range and moderate- velocity with CW Doppler, which provides an
to-severe to describe the upper end of the moderate estimation of RV systolic pressure.
range. Similar to MR, when the evidence from the
different parameters is congruent, it is easy to grade
AR severity. When different parameters are contra- Role of Two-Dimensional
dictory, one must look carefully for technical and Echocardiography
physiologic reasons to explain these discrepancies and
rely on the components that have the best quality of Evaluation of the tricuspid valve apparatus with 2D
the primary data and that are the most accurate echocardiography is important in determining the
considering the underlying clinical condition. etiology of TR. Secondary findings like right atrial
and RV enlargement often accompany significant
chronic TR. Such an evaluation is usually qualitative.
Tricuspid Regurgitation Although enlargement of right-sided chambers is not
specific for significant regurgitation, its absence
A small degree of tricuspid regurgitation (TR) is suggests milder degree of TR. Paradoxical ventricular
present in about 70% of normal individuals[69e71]. septal motion may occur with the RV volume
Pathologic regurgitation is often due to right ven- overload due to severe TR. However, this sign is
tricular (RV) and tricuspid annular dilation second- not specific for TR, as it is affected by many
ary to pulmonary hypertension or RV dysfunction. factors[75e77]. Lastly, imaging of the inferior vena
Primary causes of TR include endocarditis, carcinoid cava in the subcostal view for size and respiratory
heart disease, Ebstein’s anomaly, and rheumatic variation provides an evaluation of right atrial
disease[72e74]. pressure[78e80].
Evaluation of TR severity has been hampered by

the lack of a quantitative standard for severity.
Furthermore, in contrast to left sided lesions, surgical Doppler Methods
intervention for severe TR alone is uncommon. More
Color Flow Doppler
often, tricuspid annuloplasty is performed as an
adjunct to other cardiac surgery when TR is The simplest approach to evaluate TR severity is
significant. The echocardiographic examination color-flow imaging in several views to establish the
therefore seeks to determine the etiology of re- characteristics, direction and the size of the regur-
gurgitation and provides a semi-quantitative estimate gitant jet. Since the RV is situated in the anterior
Table 7. Echocardiographic and Doppler parameters used in the evaluation of tricuspid regurgitation severity:
RV/RA/IVC size Enlargement sensitive for chronic significant TR. Enlargement seen in other conditions. May be
Normal size virtually excludes significant normal in acute significant TR
chronic TR
TV leaflet alterations Flail valve specific for significant TR Other abnormalities do not imply significant TR
Paradoxical septal motion Simple sign of severe TR Not specific for TR
(volume overload pattern)
Jet area d color flow Simple, quick screen for TR Subject to technical and hemodynamic factors.
Underestimates severity in eccentric jets
Vena contracta width Simple, quantitative, separates mild from Intermediate values require further confirmation
severe TR
PISA method Quantitative Validated in only a few studies
Flow quantitation d PW Quantitative Not validated for determining TR regurgitant
fraction
Jet profile d CW Simple, readily available Qualitative, complementary data
Peak tricuspid E velocity Simple, usually increased in severe TR Depends on RA pressure and RV relaxation,
TV area, and atrial fibrillation; complementary
data only
Hepatic vein flow Simple; systolic flow reversal is sensitive for Influenced by RA pressure, atrial fibrillation
severe TR
CW Z continuous wave Doppler; EROA Z effective orifice regurgitant area; IVC Z inferior vena cava; PISA Z proximal isovelocity
surface area; PW Z pulsed wave Doppler; RA Z right atrium; RV Z right ventricle; TV Z tricuspid valve; TR Z tricuspid regurgitation.

Figure 7. Examples of jet recordings by color Doppler, continuous wave Doppler, and hepatic vein flow by pulsed Doppler
in a case of mild tricuspid regurgitation (TR) and another with severe TR. The case of mild TR shows a small central color
jet with minimal flow convergence in contrast to the severe TR with a very large flow convergence and jet area in the right
atrium. CW Doppler recording shows a parabolic spectral display in mild TR whereas in severe TR, early peaking and
triangular shape of the velocity is seen (arrow). Hepatic vein flow pattern in mild TR is normal whereas in severe TR,

hepatic venous flow reversal in systole (S) is seen. D Z diastolic hepatic venous flow.
chest, transthoracic images usually are adequate and appear to be more accurate than jet area. However,
should include the parasternal RV inflow view, the there can be overlap in values of jet width between
parasternal short-axis view, the apical four-chamber mild and moderate TR. Underestimation of severe
view and the subcostal four-chamber view. As TR can also occur in 20e30% of patients using jet
a general rule, jets that extend deep into the right area or PISA[81].
atrium represent more TR than small central jets that
appear just superior to the tricuspid leaflets (Fig. 7).
Overall, color Doppler flow mapping of TR severity
using jet area correlates well with angiographic Recording of TR jet velocity provides a useful
evaluation[81] and clinical measures of regurgitant method for noninvasive measurement of RV or
severity[82,83]. However, there can be considerable pulmonary artery systolic pressure. It is important
overlap of jet areas in patients with mild vs moderate to note that TR jet velocity, similar to velocity of
TR[83]. Furthermore, and similar to MR, flow jets other regurgitant lesions, is not related to the volume
that are directed centrally into the right atrium of regurgitant flow. In fact, massive TR is often
generally appear larger by color Doppler than associated with a low jet velocity (!2 m/s), as there is
eccentric, wall-impinging jets with similar or worse near equalization of RV and right atrial pressures
severity. (Fig. 7). Conversely, mild regurgitation may have
Color-flow imaging also may be used to determine a very high jet velocity when pulmonary hypertension
TR severity by the PISA method. Visualization of a is present.
measurable contour of the flow convergence zone is Similar to MR, the features of the TR jet by CW
more challenging than with MR. Quantitation of TR Doppler that help in evaluating severity of regurgi-
using the PISA method has been validated in small tation, are the signal intensity and the contour of the
studies but is rarely needed clinically[81,84]. On velocity curve (Fig. 7). With severe TR, a dense
the other hand, visualization of the vena contracta spectral recording is seen along with a triangular,
width is technically less demanding and can be uti- early peaking of the velocity because of a prominent
lized either quantitatively or qualitatively[82,85,86]. A regurgitant pressure wave. With severe tricuspid
jet width O0.7 cm identifies severe TR with a sen- regurgitation and normal RV pressures, the ante-
sitivity of 89% and a specificity of 93% and correlates grade and retrograde CW flow signals across the
well with EROA[85,86]. Both the PISA and vena cont- valve are almost mirror images of each other, cor-
racta methods are more accurate for determining TR responding to the ‘to-and-fro’ flow across the severely
severity in central jets compared to eccentric jets, and incompetence valve orifice[87].

Pulsed Doppler chamber and RV inflow views. Similar to MR, jet

area may appear larger with TEE than with trans-
The severity of TR will affect the early diastolic tri-
thoracic imaging.
cuspid E velocity, similar to MR. Values above 1.0 m/s
CW Doppler signals can be recorded from high
are often recorded in patients with severe regurgi-
esophageal or transgastric views. However, obtaining
tation even without valve stenosis. In theory, tricuspid
a parallel intercept angle can be problematic. Hepatic
regurgitant volume can be calculated by subtracting
vein flow can be recorded by starting in a parasternal
the flow across a non-regurgitant valve from the
long-axis view of the right atrium and then following
antegrade flow across the tricuspid valve annulus. In
the inferior vena cava caudally until the hepatic veins
contrast to MR and AR, this approach is rarely
are visualized. The goals of the TEE examination are
utilized for TR, partly because of errors in measuring
identical to those of the surface examination so that
the tricuspid valve annulus.
standard image planes and multiple approaches to
Similar to the use of pulmonary vein flow pattern
evaluation of regurgitant severity should be per-
in MR, PW Doppler examination of the hepatic veins
formed when pathologic tricuspid valve disease is
helps corroborate the assessment of TR severity.
suspected.
With increasing severity of TR, the normally
dominant systolic wave is blunted. With severe
tricuspid regurgitation, systolic flow reversal occurs
(Fig. 7). However, hepatic vein flow patterns are also Integrative Approach to Assessment
affected by abnormalities in right atrial and RV of Tricuspid Regurgitation Severity
relaxation and compliance, the phase of the re-
spiratory cycle, preload, and atrial fibrillation[88]. The Similar to the assessment of other regurgitant lesions,
sensitivity of flow reversal for severe TR is 80%[83]. an integrative approach is recommended for evalua-
While the specificity of systolic flow reversal is not tion of TR (Table 8). This includes evaluation of the
well defined, experience has shown that it is also size of right-sided chambers, septal motion and
a specific sign of severe TR, provided that the various Doppler parameters. Color Doppler flow
modulating conditions mentioned above are ac- mapping in at least two orthogonal planes should be

counted for during interpretation. performed, with particular attention to the vena
contracta, flow convergence and the direction and
size of the jet. CW Doppler recording of the TR jet
Role of TEE should be recorded to evaluate the signal intensity
and contour of the jet, and estimate pulmonary artery
Most often, TR can be adequately evaluated on systolic pressure. Moreover, the size of the inferior
transthoracic imaging. Even when parasternal and vena cava and response to respiration as well as
apical views are suboptimal, subcostal views allow hepatic vein flow pattern help evaluate right atrial
color flow mapping, and recording of hepatic vein pressure and adaptation to the volume overload.
flow pattern. When transthoracic images are poor, With the lack of extensive data on quantitation of
TEE may be helpful. Color flow mapping can be TR, the Task Force recommends integration of
performed using the high esophageal four-chamber information from all available parameters discussed
and short-axis views as well as the transgastric four- (Table 8). The more congruent the findings are
Table 8. Echocardiographic and Doppler parameters useful in grading tricuspid regurgitation severity.
Tricuspid valve Usually normal Normal or abnormal Abnormal/flail leaflet/poor coaptation

RV/RA/IVC size Normal* Normal or dilated Usually dilatedy
Jet area d central jets (cm2)z !5 5e10 O10
VC width (cm)x Not defined Not defined, but !0.7 O0.7
PISA radius (cm){ !0.5 0.6e0.9 O0.9
Jet density and contour d CW Soft and parabolic Dense, variable contour Dense, triangular with early peaking
Hepatic vein flowk Systolic dominance Systolic blunting Systolic reversal
CW Z continuous wave Doppler; IVC Z inferior vena cava; RA Z right atrium; RV Z right ventricle; VC Z vena contracta.
*Unless there are other reasons for RA or RV dilation. Normal 2D measurements from the apical four-chamber view: RV medio-lateral
end-diastolic dimension %4.3 cm, RV end-diastolic area %35.5 cm2, maximal RA medio-lateral and supero-inferior dimensions %4.6 cm
and 4.9 cm, respectively, and maximal RA volume %33 ml/m2 (references [35,89]).
yException: acute TR.
zAt a Nyquist limit of 50e60 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.
xAt a Nyquist limit of 50e60 cm/s.
{Baseline shift with Nyquist limit of 28 cm/s.
kOther conditions may cause systolic blunting (e.g. atrial fibrillation, elevated RA pressure).

regarding severity, the more confident the diagnosis. structure (hypoplasia, dysplasia or absence of the
Inherent to this process is the particular attention to pulmonary valve) may help define the mechanism of
the quality of the data obtained, and to the regurgitation and yield clues to its severity. Visuali-
physiologic conditions that can alter the accuracy of zation of the entire pulmonary valve is more difficult
these parameters as indices of regurgitation severity. than the mitral, aortic and tricuspid valves. However,
dilatation of the pulmonary artery, frequently ob-
served in pulmonary hypertension, allows easier
Pulmonary Regurgitation visualization of the valve. Inability to fully visualize
the pulmonary valve may limit the quantitation of
Minor degrees of pulmonary regurgitation (PR) pulmonary regurgitation. Lastly, evaluation of the
have been reported in 40e78% of patients with size and function of the RV in the absence of
morphologically normal pulmonary valves and no pulmonary hypertension provides an indirect in-
other evidence of structural heart disease[90e92]. dicator to the significance of PR and adaptation of
Pathologic regurgitation is infrequent, and should the RV to the volume overload state.
be diagnosed mainly in the presence of significant
structural abnormalities of the right heart. In the
adult, acquired PR is most often seen in patients with Doppler Methods
pulmonary hypertension, which is often associated Color Flow Doppler
with dilatation of the pulmonary artery, right
ventricle, right atrium and hepatic veins. PR in this Color Doppler flow mapping is the most widely used
condition, however, is rarely severe. Severe PR is method to identify PR. A diastolic jet in the RV
usually observed in patients with anatomic abnor- outflow tract, beginning at the line of leaflet co-
malities of the valve or after valvotomy. Because of aptation and directed toward the right ventricle is
the difficulties in imaging the pulmonary valve and diagnostic of PR (Fig. 8). Although color Doppler is
the low prevalence of severe, life-threatening PR, few ideally suited to determine the jet size and spatial
validation studies have been conducted. Further- orientation, many of the factors used to evaluate the
more, validation of echo/Doppler methods measuring severity of regurgitation (jet size, extent and duration)

PR is limited by the uncommon use of angiography will be determined by a combination of the regur-
or other methods to diagnose this condition. Echo- gitant volume and the driving pressure (gradient
cardiographic and Doppler parameters that are between the pulmonary artery and the RV). Regur-
useful in the evaluation of PR are listed in Table 9. gitant jets seen in normal pulmonary valves, consid-
ered a variation of normal, are usually very small,
‘spindle-shaped’ and originate centrally from the
pulmonary leaflet coaptation site (Fig. 8)[91]. Initial
Role of Two-Dimensional studies attempted to quantify pulmonary regurgitation
Echocardiography by measuring jet length[91]. Jets !10 mm in length were
trivial while larger jets were associated with heart
Evaluation of the RV outflow tract and pulmonary disease. However, jet length is highly dependent on
valve by 2D echocardiography is possible from the the driving pressure gradient between the pulmonary
parasternal and subcostal views. Identification of artery and the RV, and is therefore not a reliable
anatomic abnormalities associated with PR, such index of severity. Assessing the entire jet area by
as abnormalities of cusp number (quadricuspid or planimetry should, theoretically, fare better than the
bicuspid valves), motion (doming or prolapse) or jet length alone. Planimetered jet areas, indexed for
Table 9. Echocardiographic and Doppler parameters used in the evaluation of pulmonary regurgitation
severity: utility, advantages and limitations.
Parameter Utility/advantages Disadvantages
RV size RV enlargement sensitive for chronic significant Enlargement seen in other conditions
PR. Normal size virtually excludes significant PR
Paradoxical septal motion Simple sign of severe PR Not specific for PR
(volume overload pattern)
Jet length d color flow Simple Poor correlation with severity of PR
Vena contracta width Simple quantitative method that works More difficult to perform; requires good images
well for other valves of pulmonary valve; lacks published validation
Jet deceleration rate d CW Simple Steep deceleration not specific for severe PR
Flow quantitation d PW Quantitates regurgitant flow and fraction Subject to significant errors due to difficulties of
measurement of pulmonic annulus and a dynamic
RVOT; not well validated
CW Z continuous wave; RV Z right ventricle; PR Z pulmonic regurgitation; RVOT Z right ventricular outflow tract.

Figure 8. Example of color flow and continuous wave Doppler recording in a case with mild pulmonary regurgitation (PR)
and another with severe PR. In the mild PR, color Doppler shows a small spindle-shaped PR jet in the right ventricular
outflow tract. CW recording of the jet shows a slow deceleration of the PR velocity. In the case with severe PR, a large and
wide PR jet is seen by color Doppler (arrow). Continuous wave Doppler recording shows a steep deceleration of the

diastolic PR velocity, with early termination of PR flow (arrow). LA Z left atrium; RV Z right ventricle.
body surface area, correlated well with PR severity density of the CW signal provides a qualitative
compared to angiography. However, a high degree measure of regurgitation[51]. A rapid deceleration
of variability and overlap among different grades of rate, while consistent with more severe regurgitation,
regurgitation was observed[92]. In cases of severe is influenced by several factors including RV diastolic
pulmonary regurgitation, the full extent of the properties and filling pressures. In severe PR, a rapid
regurgitant jet may not be appreciated from the equalization of RV and pulmonary artery pressures
parasternal position; subcostal imaging may be can occur before the end of diastole. Thus, an intense
necessary to fully appreciate its full extent. signal of ‘to and fro’ flow in the shape of a ‘sine
Although not systematically validated for the wave’, with termination of flow in mid to late diastole
pulmonary valve, the vena contracta width is can be seen (Fig. 8). This finding, however, is not
probably a more accurate method to evaluate the specific for severe PR, as early and rapid equilibra-
severity of PR by color Doppler, similar to other tion of diastolic pressures is also seen in patients with
regurgitant lesions. Some investigators have used the low pulmonary artery end-diastolic pressure and/or
PR jet width in the serial assessment of pulmonary elevated RV diastolic pressure (e.g. RV infarction).
homografts, but standards for pulmonary vena However, the intensity of the PR signal, color
contracta width have not been established[93]. It is Doppler characteristics of the jet and pulmonic flow
important to note that in cases of severe PR, where quantitation in the RV outflow tract by PW Doppler
equalization of diastolic pulmonary artery and RV help differentiate these entities.
pressures occurs early in diastole, the color jet area
can be brief and misleading at first glance. In this Pulsed Doppler
case, the large width of the vena contracta and
findings by PW and CW Doppler (see below) alert the In the evaluation of PR, pulsed Doppler interrogation
observer to the severity of regurgitation (Fig. 8). of velocity can be useful at the level of the pulmonic
annulus and in the pulmonary artery[94e96]. If the
velocity of the PR jet is not aliased by PW Doppler,
its contour and timing can be evaluated similar to
CW Doppler (above), with identical implications[97].
CW Doppler is frequently used to measure the end- Pulsed Doppler assessment of the forward and
diastolic velocity of PR and thus estimate pulmonary reverse flows in the pulmonary artery has been used
artery end-diastolic pressure. However, there is no to calculate regurgitant volume and regurgitant
clinically accepted method of quantifying pulmonary fraction[95,96]. If the diameter of the pulmonary artery
regurgitation using CW Doppler. Similar to AR, the is assumed to be constant, then the ratio of the

reverse to forward velocity time integral can be used regurgitation. Since there is insufficient data on
to estimate the percent of regurgitant flow[95]. quantitation of PR to recommend a clinically vali-
Although differences in regurgitation fraction were dated quantitative approach, the evaluation is gener-
observed among groups with various severity of PR, ally qualitative and should include the various
a considerable overlap was seen and standards for parameters discussed above (Table 10). Color Dopp-
pulmonary artery regurgitant fraction have not been ler is the best screening modality and accurately
established[96]. Furthermore, this method is not valid identifies trivial and mild pulmonary regurgitation as
in patients with pulmonic stenosis because of post- thin, small jets with a ‘pin-point’ origin. These lesions
stenotic turbulent flow. are readily differentiated from more severe degrees of
As previously discussed, pulsed Doppler can be PR. In addition to color Doppler, an evaluation of
used to calculate stroke volume at different annular the pulmonic valve, RV size and function helps
sites. The pulmonic annulus, however, is probably the elucidate the etiology of the regurgitation and the
most difficult site to measure because of its poor adaptation to the volume overload. CW Doppler of
visualization and the changing size of the RV outflow the PR jet and TR jet, if available, should be
tract during the cardiac cycle. It is recommended to routinely recorded to provide supportive evidence
measure the pulmonic annulus during early ejection for the degree of regurgitation and estimation of
(two to three frames after the R wave on the ECG), pulmonary pressure. Quantitation of the vena con-
just below the pulmonic valve[98,99]. Although not tracta by color Doppler and regurgitant fraction with
validated for quantitation of PR, flows at the pulsed Doppler, although helpful, needs further
pulmonic annulus can be compared to other sites to validation. Despite these limitations, clinically useful
derive quantitative parameters of regurgitation (re- qualitative estimates of PR regurgitation are feasible
gurgitant volume and fraction). Clinically, this is in the majority of cases.
feasible provided that particular attention is taken to
image well the area of the pulmonic annulus and thus
minimize errors of its measurement. Conclusions
Role of TEE Echocardiography with Doppler has become the first

line approach to the evaluation and management of
The main pulmonary artery is an anterior structure valvular heart disease. While 2D echocardiography
and is often imaged as well or even better with provides an assessment of valvular structure, mech-
transthoracic echocardiography compared to the anism of regurgitation and adaptation to the volume
transesophageal approach. The role of TEE is overload state, Doppler allows in the same setting,
therefore limited in assessing severity of PR. a comprehensive evaluation of the severity of re-
gurgitation using qualitative and quantitative meth-
ods from color flow and spectral Doppler. In general,
Integrative Approach to Assessment of regurgitation may present a challenge for most
Pulmonary Regurgitation Severity diagnostic techniques because of the dynamic nature
of lesion and its dependence on various hemodynam-
A comprehensive approach to the evaluation of PR ic and physiologic conditions. For all valvular
severity is recommended, similar to other valvular regurgitation, an integrative approach of 2D and
Table 10. Echocardiographic and Doppler parameters useful in grading pulmonary regurgitation severity.
Pulmonic valve Normal Normal or abnormal Abnormal

RV size Normal* Normal or dilated Dilatedy
Jet size by color Dopplerz Thin (usually !10 mm in length) Intermediate Usually large, with a wide origin;
with a narrow origin may be brief in duration
Jet density and deceleration Soft; slow deceleration Dense; variable Dense; steep deceleration, early
rate d CWx deceleration termination of diastolic flow
Pulmonic systolic flow compared Slightly increased Intermediate Greatly increased
to systemic flow d PW{
CW Z continuous wave Doppler; PR Z pulmonic regurgitation; PW Z pulsed wave Doppler; RA Z right atrium; RF Z regurgitant
fraction; RV Z right ventricle.
*Unless there are other reasons for RV enlargement. Normal 2D measurements from the apical four-chamber view: RV medio-lateral end-
diastolic dimension %4.3 cm, RV end-diastolic area %35.5 cm2 (reference [89]).
yException: acute PR.
xSteep deceleration is not specific for severe PR.
{Cut-off values for regurgitant volume and fraction are not well validated.

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Eur J Echocardiography (2003) 4, 237e261

American Society of Echocardiography:

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Introduction overload state. Echocardiography with Doppler has

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Eur J Echocardiography, Vol. 4, issue 4, December 2003

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Eur J Echocardiography, Vol. 4, issue 4, December 2003

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Eur J Echocardiography, Vol. 4, issue 4, December 2003

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Eur J Echocardiography, Vol. 4, issue 4, December 2003

Parameter Mild Moderate Severe

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Eur J Echocardiography, Vol. 4, issue 4, December 2003

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Continuous Wave Doppler Pulsed Doppler

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Parameter Utility/advantages Limitations

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comprehensive, using a combination of clues, signs Aortic Regurgitation

Eur J Echocardiography, Vol. 4, issue 4, December 2003

Mild Moderate Severe

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Eur J Echocardiography, Vol. 4, issue 4, December 2003

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Parameter Mild Moderate Severe

Eur J Echocardiography, Vol. 4, issue 4, December 2003

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Eur J Echocardiography, Vol. 4, issue 4, December 2003

to forward velocity time integrals in the descending Role of TEE

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Parameter Utility/advantages Limitations

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Mild Moderate Severe

Eur J Echocardiography, Vol. 4, issue 4, December 2003

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Parameter Utility/advantages Limitations

Eur J Echocardiography, Vol. 4, issue 4, December 2003

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Eur J Echocardiography, Vol. 4, issue 4, December 2003

Pulsed Doppler chamber and RV inﬂow views. Similar to MR, jet

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Parameter Mild Moderate Severe

Tricuspid valve Usually normal Normal or abnormal Abnormal/ﬂail leaﬂet/poor coaptation

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Parameter Utility/advantages Disadvantages

Eur J Echocardiography, Vol. 4, issue 4, December 2003

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Eur J Echocardiography, Vol. 4, issue 4, December 2003

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Parameter Mild Moderate Severe