Pi Is 0894731723005333

GUIDELINES AND STANDARDS
Guidelines for the Evaluation of Prosthetic

Valve Function With Cardiovascular Imaging:
A Report From the American Society of
Echocardiography Developed in
Collaboration With the Society for
Cardiovascular Magnetic Resonance and
the Society of Cardiovascular Computed
Tomography
William A. Zoghbi, MD (Chair), Pei-Ni Jone, MD (Co-Chair), Mohammed A. Chamsi-Pasha, MD,
Tiffany Chen, MD, Keith A. Collins, MS, RDCS, Milind Y. Desai, MD, MBA, Paul Grayburn, MD,
Daniel W. Groves, MD, Rebecca T. Hahn, MD, Stephen H. Little, MD, Eric Kruse, RDCS, Danita Sanborn, MD,
Sangeeta B. Shah, MD, Lissa Sugeng, MD, Madhav Swaminathan, MD, MBBS, Jeremy Thaden, MD,
Paaladinesh Thavendiranathan, MD, SM, Wendy Tsang, MD, SM, Jonathan R. Weir-McCall, MD, MBChB, PhD,
and Edward Gill, MD, Houston and Dallas, Texas; Chicago, Illinois; Philadelphia, Pennsylvania; Cleveland, Ohio;
Aurora, Colorado; New York and Manhasset, New York; Boston, Massachusetts; Richmond, Virginia; Durham, North
Carolina; Rochester, Minnesota; Toronto, Ontario, Canada; and Cambridge, United Kingdom
In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement
may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgita-
tion, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to
assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation
of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-
dimensional transesophageal echocardiography for further refinement of valve morphology and function
when needed. More recently, advances in computed tomography and cardiac magnetic resonance have
enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardio-
graphic techniques used and provides recommendations and general guidelines for evaluation of prosthetic
From the Houston Methodist Hospital, DeBakey Heart & Vascular Center, Houston, Danita Sanborn, MD, Sangeeta B. Shah, MD, Madhav Swaminathan, MD, MBBS,
Texas (W.A.Z., M.C.-P., S.H.L.); Ann & Robert H. Lurie Children’s Hospital of Paaladinesh Thavendiranathan, MD, SM, Jonathan R. Weir-McCall, MD,
Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois MBChB, PhD, and Edward Gill, MD, FASE.
(P.-N.J.); Hospital of the University of Pennsylvania, Perelman Center for Advanced The following authors reported relationships with one or more commercial inter-
Medicine, Philadelphia, Pennsylvania (T.C.); Northwestern Medicine Healthcare, ests: Rebecca T. Hahn, MD, has participated on speakers bureaus for Edwards
Chicago, Illinois (K.A.C.); Heart and Vascular Institute, Cleveland Clinic, Cleveland, Lifesciences, Philips Healthcare, and Abbott Vascular and on advisory boards for
Ohio (M.Y.D.); Baylor Scott & White Health, University of Texas Southwestern, Abbott Vascular, Boston Scientific, and Edwards Lifesciences. Lissa Sugeng,
Dallas, Texas (P.G.); UC Health Heart and Vascular Center, University of Colorado MD, has participated on speakers bureaus for Siemens Healthineers and Philips
Anschutz Medical Campus, Aurora, Colorado (D.W.G.); Columbia Structural Heart & Healthcare. Paul Grayburn, MD, has participated on advisory boards for Abbott
Valve Center, Columbia University Irving Medical Center, New York, New York Vascular and Edwards Lifesciences. Wendy Tsang, MD, SM, has participated in
(R.T.H.); Heart & Vascular Imaging Services, University of Chicago Medical Center, equipment research for Philips Healthcare. Jeremy Thaden, MD, has participated
Chicago, Illinois (E.K.); Massachusetts General Hospital, Boston, Massachusetts in Medtronic trials for assessing valves.
(D.S.); VCU Pauley Heart Center, Virginia Commonwealth University, Richmond,
Reprint requests: American Society of Echocardiography, Meridian Corporate Center,
Virginia (S.B.S.); Northwell Health Physician Partners Cardiology, North Shore
2530 Meridian Parkway, Suite 450, Durham, NC 27713 (E-mail: ase@asecho.org).
University Hospital, Manhasset, New York (L.S.); Cardiothoracic Anesthesiology
and Critical Care Medicine, Duke University, Durham, North Carolina (M.S.);
Attention ASE Members:
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.T.);
Login at www.ASELearningHub.org to earn continuing medical education
Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
credit through an online activity related to this article. Certificates are available
(P.T.); Toronto General Hospital Research Institute, University of Toronto, Toronto,
for immediate access upon successful completion of the activity and post-
Ontario, Canada (W.T.); Department of Radiology, University of Cambridge School
work. This activity is free for ASE Members, and $40 for nonmembers.
of Clinical Medicine, Cambridge, United Kingdom (J.R.W.-M.); and Anschutz
Medical Campus, University of Colorado School of Medicine, Aurora, Colorado (E.G.).
0894-7317/$36.00
The following authors reported no actual or potential conflicts of interest in rela-
Copyright 2023 Published by Elsevier Inc. on behalf of the American Society of
tion to this document: William A. Zoghbi, MD, Pei-Ni Jone, MD, Mohammed A.
Echocardiography.
Chamsi-Pasha, MD, Tiffany Chen, MD, Keith A. Collins, MS, RDCS, Milind Y. De-
sai, MD, MBA, Daniel W. Groves, MD, Stephen H. Little, MD, Eric Kruse, RDCS, https://doi.org/10.1016/j.echo.2023.10.004
2
Journal of the American Society of Echocardiography Zoghbi et al 3
Volume 37 Number 1
valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline dis-
cusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomogra-
phy, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It
replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements
the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.
(J Am Soc Echocardiogr 2024;37:2-63.)
Keywords: Echocardiography, Doppler echocardiography, Prosthetic valves, Cardiac valves, Magnetic

resonance imaging, Computed tomography
This document is endorsed by the following ASE International Alliance Partners: Argentine Federation of
Cardiology; Argentine Society of Cardiology; ASEAN Society of Echocardiography; Australasian Society for
Ultrasound in Medicine; Australasian Sonographers Association; British Heart Valve Society; British Society of
Echocardiography; Canadian Society of Echocardiography; Cardiovascular Imaging Society of the Inter-American
Society of Cardiology; Chinese Society of Echocardiography; Echocardiography Section of the Venezuelan
Society of Cardiology; Indian Academy of Echocardiography; Indonesian Society of Echocardiography;
Interventional Imaging Group of the Saudi Arabian Cardiac Interventional Society; Iranian Society of
Echocardiography; Italian Society of Cardio-Thoracic Anesthesia and Intensive Care; Japanese Society of
Echocardiography; Korean Society of Echocardiography; National Association of Cardiologists of Mexico, AC;
Philippine Society of Echocardiography, Inc.; Vietnamese Society of Echocardiography.
TABLE OF CONTENTS J. Other Techniques for Assessing PHVs 13

i. Cine fluoroscopy 13
I. General Considerations With Prosthetic Valves 4
ii. Cardiac catheterization 13
A. Types of Prosthetic Valves 4
B. PHV Dysfunction 5 iii. CT 13
i. SVD 6 iv. CMR 13
ii. Nonstructural valve dysfunction 6 v. Cardiac positron emission tomography (PET) 14
II. Evaluation of Prosthetic Aortic Valves 16
a. Prosthesis-patient mismatch 6
A. Echocardiographic and Doppler Evaluation of Prosthetic Aortic
b. Paravalvular leak 6 Valve Function 16
c. Other nonstructural causes of dysfunction 6 i. TTE 16
iii. Endocarditis 6 ii. TEE 17
iv. Thrombus 6 iii. Doppler echocardiography 17
C. Evaluation of Prosthetic Valves 6
iv. Considerations for TAVI and ViV 18
i. Clinical information 7 B. Echocardiographic and Doppler Evaluation of Prosthetic Aortic
ii. Echocardiographic imaging 7 Valve Regurgitation 18
iii. Doppler echocardiography 7 i. TTE and TEE 18
a. Determination of gradients across prosthetic valves 7 ii. Doppler echocardiography 20
b. Effective orifice area 7 C. Role of CT in the Evaluation of Prosthetic Aortic Valves 20
c. Doppler velocity index 9 i. Stenosis 21
D. Pressure Recovery: Hemodynamic Conditions and Clinical Implica- ii. Regurgitation 21
tions 9 D. Role of CMR in the Evaluation of Prosthetic Aortic Valves 21
E. Prosthesis-Patient Mismatch 10 i. Prosthetic aortic valve stenosis 21
F. Physiologic Regurgitation 10
a. Anatomic valve area 21
G. Pathologic Prosthetic Regurgitation 10
H. Changes During Stress 11 b. Phase-contrast imaging 21
I. Considerations for Intraoperative and Intraprocedural Guid- ii. Prosthetic aortic valve regurgitation 22
ance 11 a. Phase-contrast imaging 22
i. Intraoperative echocardiography during prosthetic valve place- III. Evaluation of Prosthetic Mitral Valves 23
ment 11 A. Types of Prosthetic Valves in the Mitral Position 23
ii. Image guidance during percutaneous prosthetic valve replace- B. Echocardiographic Evaluation of Prosthetic Mitral Valves 24
ment 11 i. Evaluation of prosthetic mitral valve function 24
a. Two-dimensional and 3D TEE 11 ii. Evaluation of prosthetic MR 25
b. TAVI 11 iii. Role of TEE 25
c. Mitral valve repair or replacement 12 C. Role of CT in the Evaluation of Prosthetic Mitral Valves 25
d. Tricuspid valve repair or replacement for native tricuspid regurgi- i. Valve stenosis 25
tation (TR) 13 ii. Valve regurgitation 26
4 Zoghbi et al Journal of the American Society of Echocardiography
January 2024
Abbreviations
D. Role of CMR in the Evalu- ment is often required. Despite
ation of Prosthetic Mitral TAVI = Transcatheter aortic
advances in valve repair, valve
Valves 26 valve implantation
2D = Two-dimensional replacement remains common,
i. Valve stenosis 26 TEE = Transesophageal particularly in adults. The first
3D = Three-dimensional
ii. Valve regurgitation 28 echocardiography American Society of
4D = Four-dimensional IV. Evaluation of Prosthetic Pul- Echocardiography (ASE) guide-
TTE = Transthoracic
monary Valves 30 line for the evaluation of pros-
AR = Aortic regurgitation echocardiography
A. Surgical and Transcatheter thetic heart valves (PHVs) was
ASE = American Society of PVR 30 TR = Tricuspid regurgitation published in 2009.1
Echocardiography B. Evaluation of Prosthetic
TV = Tricuspid valve Subsequently, there has been a
Pulmonary Valve Steno-
CHD = Congenital heart sis 30 European Association of
TVR = Tricuspid valve
disease
i. Echocardiographic and
Cardiovascular Imaging guideline
replacement
CMR = Cardiac magnetic Doppler evaluation 30 on prosthetic valves in 20162
resonance
VC = Vena contracta and an ASE guideline in 2019 on
ii. Role of TEE and 3D 31
ViV = Valve-in-valve the evaluation of valvular regurgi-
CT = Computed tomography iii. Role of CMR 31
tation after percutaneous valve
iv. Role of CT 32 VTI = Velocity-time integral
CW = Continuous-wave repair or replacement.3 Although
C. Evaluation of Prosthetic
Pulmonary Valve Regurgi- VTIPrMV = Prosthetic mitral many principles and recommen-
DVI = Doppler velocity index dations detailed in the 2009 ASE
tation 34 valve velocity-time integral
EOA = Effective orifice area i. Echocardiographic and guideline are still current and
Doppler evaluation 34 valid, it lacks several important de-
EROA = Effective regurgitant
ii. Role of TEE and 3D 35 velopments: function of percuta-
orifice area
iii. Role of CT 35
neous valves, the use of three-dimensional (3D) echocardiography,
FDA = US Food and Drug and the role of computed tomography (CT) and cardiac magnetic reso-
iv. Role of CMR 35
Administration nance (CMR) in the evaluation of PHVs. With the evolution of structural
V. Evaluation of Prosthetic
ICE = Intracardiac TVs 36 heart disease interventions and imaging of valvular heart disease, a
echocardiography A. Echocardiographic Assess- comprehensive update is necessary. The present document replaces
ment of Prosthetic TV the 2009 ASE guideline and complements the 2019 guideline on
LV = Left ventricular Function 37 valvular regurgitation after percutaneous valve repair or replacement.1,3
LVOT = Left ventricular B. Evaluation of Prosthetic
outflow tract TV Stenosis 37
i. Echocardiographic evalua-
MR = Mitral regurgitation I. GENERAL CONSIDERATIONS WITH PROSTHETIC VALVES
tion 37
PA = Pulmonary artery ii. Role of CT 40
iii. Role of CMR 40
PET = Positron emission A. Types of Prosthetic Valves
C. Evaluation of Prosthetic
tomography
TV Regurgitation 40 A wide variety of PHV types and sizes are available, with selection
PHT = Pressure half-time i. Echocardiographic evalua- dependent upon implantation location, underlying valvular pathology,
PHV = Prosthetic heart valve
tion 40 implantation technique, and patient-specific factors. Although percuta-
ii. Role of CMR 40 neous valves are bioprosthetic, surgically implanted prosthetic valves
PPM = Prosthesis-patient iii. Role of CT 40 can be either bioprosthetic or mechanical, with the latter associated
mismatch VI. Evaluation of Prosthetic with greater durability4 but necessitating chronic anticoagulation.
PR = Pulmonary regurgitation Valves in CHD 41 The shared decision-making surrounding valve choice and implanta-
A. Prosthetic Valves in tion technique must integrate patient anatomy, procedural risk, ex-
PVL = Paravalvular leak CHD 41 pected patient longevity, the expected PHV durability, and patient
B. Echocardiography in the preferences and lifestyle.5
PVR = Pulmonary valve
Evaluation of PHVs Asso-
replacement The prevalence of mechanical valve implantation has declined over
ciated With CHD 42
the past 10 years for several reasons, including patient preference.
PW = Pulsed-wave i. TTE 42
Transcatheter valve repair and replacement have changed the demo-
RA = Right atrial ii. Stress echocardiography 42
graphics and clinical characteristics of patients undergoing surgical valve
iii. TEE 42 replacements.6,7 The need for concurrent procedures such as aortic
RV = Right ventricular
iv. Three-dimensional echo- root and ascending aorta modification, as well as left ventricular outflow
RVOT = Right ventricular cardiography 42 tract (LVOT) or right ventricular outflow tract (RVOT) alteration may
outflow tract C. Role of Cardiac CT 42
also affect PHV choice. The most common type of mechanical valve
D. Role of CMR 43
SAVR = Surgical aortic valve is the bileaflet tilting disk valve (e.g., St. Jude Medical, Carbomedics,
VII. Conclusions and Future Di-
replacement On-X), which offers the best hemodynamics of currently available me-
rections 43
chanical valves.8 Single tilting disk valves with low thrombogenicity
SSFP = Steady-state free VIII. Appendix 51
(e.g., Medtronic-Hall) are infrequently used in contemporary practice.
precession
In patients with significant Last, the Starr-Edwards ball-in-cage valve is no longer implanted; how-
SVD = Structural valve valvular disease, intervention ever, given its durability, some of these valves continue to function satis-
dysfunction with either valve repair or replace- factorily and may be encountered in clinical practice. Examples of
Volume 37 Number 1
Figure 1 Mechanical valves: (A) bileaflet, (B) single-leaflet, and (C) caged-ball valves and their 2D and 3D transesophageal echocar-
diographic characteristics taken in the mitral position in diastole and systole (second and third panels from left). The arrows in diastole
point to the open occluder mechanism of the valve and in systole to the characteristic physiologic regurgitation observed with each
valve. Three-dimensional transesophageal echocardiography images (fourth panel) from a midesophageal window are displayed
from a left atrial view. LA, Left atrium; LV, left ventricle.
mechanical prosthetic valves are depicted in Figure 1 and examples of several mitral and tricuspid transcatheter valves are currently under
stented and percutaneous bioprosthetic valves in Figure 2. clinical investigation. These feature a wide variety of designs and
Surgical bioprosthetic valves may be xenografts comprising porcine anchoring mechanisms, including radial force, leaflet capture, annular
or bovine pericardial tissue, homografts from cadaveric donors, or au- engagement, and apical tethering. In addition, a ViV transcatheter
tografts (such as in the Ross procedure). Stented xenografts are most mitral valve implantation with a balloon-expandable TAVI prosthesis
frequently used; the pericardial leaflets are mounted onto either the in- is feasible and has US Food and Drug Administration (FDA) approval.
side or outside of a stent frame. Externally mounted leaflets and stent- The SAPIEN valve has also been approved for implantation in the pul-
less bioprostheses have the advantage of larger valve areas and lower monary position. Last, the self-expanding Harmony valve (Medtronic)
transvalvular gradients but recent studies show high rates of early struc- recently received breakthrough device designation from the FDA and
tural valve dysfunction (SVD), particularly in younger patients.9 In the is also available for treatment of pediatric or adult patients with severe
setting of SVD, transcatheter valve-in-valve (ViV) procedures offer pa- pulmonary regurgitation (PR).
tients an alternative to surgical reoperation.10 Although the risk for cor- From an imaging standpoint, the type, position, and size of a prosthetic
onary obstruction with externally mounted leaflets as well as stentless valve influence its hemodynamic profile and rate of complications.
valves following a ViV procedure is greater than for internally mounted Normal transvalvular velocities and gradients are flow dependent but
bioprosthetic valves, percutaneous leaflet laceration procedures may can vary depending on the particular valve size and type.11,12 The valve
mitigate this risk. Different bioprosthetic valves can often be identified type also affects the amount of artifact seen with echocardiography,
by the fluoroscopic and computed tomographic appearance of the CT, and CMR, which may affect the evaluation of PHV function.
stent posts’ configuration and sewing ring. Normal echocardiographic parameters of valve function for various
Transcatheter heart valve technology has continued to evolve with prosthetic valve types and sizes in the aortic, mitral, pulmonary, and
expanding indications.5 Transcatheter aortic valve implantation (TAVI) tricuspid positions are detailed in Appendix Tables A1-A9.
prostheses in commercial use include balloon-expandable intra-
annular devices (e.g., SAPIEN valves; Edwards Lifesciences), self- B. PHV Dysfunction
expanding supra-annular valves (e.g., Evolut valves; Medtronic), and Prosthetic valve dysfunction can be divided into the following cate-
intra-annular valves (Navitor valves; Abbott Structural Heart). Other gories: SVD, nonstructural valve dysfunction, endocarditis, and
TAVI prostheses are in trials or early human use. On the other hand, thrombus.13 Regardless of etiology, the hemodynamic consequences
January 2024
Figure 2 Biological valves: stented (top row) and percutaneous valves with their echocardiographic features and 3D transesophageal
echocardiographic images. The self-expanding percutaneous valve is in the middle row, and the balloon-expandable valve is in the
bottom row. Mild paravalvular regurgitation is highlighted by the arrows in the middle panels. LA, Left atrium; LV, left ventricle.
of dysfunction must be quantified. The following definitions are valve embolization. Pannus is fibrous tissue that grows in the periannular
derived from the Valve Academic Research Consortium 313: region and can cause PHV dysfunction.16 Pannus has a prevalence of
0.2% to 4.5% and occurs equally in mechanical and bioprosthetic valves,
i. SVD: intrinsic permanent changes to the prosthetic valve. Examples include
with three times higher risk in the mitral position.17 Pannus may coexist
wear and tear, leaflet disruption, leaflet fibrosis or calcification, and stent or
with thrombus formation in PHVs.
strut fracture or deformation. Structural failure is more common in bio-
iii. Endocarditis has a prevalence of 1% to 6% and can occur any time after
prosthetic than mechanical prostheses. Valve calcification is the most com-
surgery. In mechanical valves, the infection almost always spreads from the
mon cause of bioprosthesis degeneration, seen in 50% of porcine valves
sewing ring and results in complications such as PVL, abscess, and exten-
at 5 years and in 75% at 8 years.14 Failure rates at 10 to 15 years are 10%
sion to adjacent structures. Bioprosthetic valve infections originate in the
to 20% in homografts and 30% in heterografts.15 The leaflets and stents
leaflet cusps and may involve the sewing ring or paravalvular region. Para-
are the primary sites with calcification and leaflet tear or rupture.
valvular abscess is more common in PHVs (56%-100%) than in native
ii. Nonstructural valve dysfunction: any abnormality of the prosthesis
valves (10%-40%), especially in the aortic position.18,19 Pseudoaneurysms
not related to the valve itself but still resulting in valve dysfunction.
are commonly seen in the aortic position, with a prevalence of 7% to 25%
a. Prosthesis-patient mismatch (PPM) occurs when a normally functioning
of prosthetic valve endocarditis.18-20 An infected pseudoaneurysm in
PHV is small relative to the patient’s size, causing a high gradient and
relation to a PHV refers to drainage of a paravalvular abscess into an
functional stenosis. Outcomes have been related to the severity of PPM.
adjacent cardiac chamber. An abnormal communication such as a fistula
b. Paravalvular leak (PVL) may occur in surgical valves from dehiscence of
can occur between two neighboring cavities through a perforation from
the sewing ring and for transcatheter valves from malapposition of the
the infection that extends beyond the valve.18,19 Last, endocarditis after
stent frame with native tissue. Dehiscence is a serious complication,
TAVI is an increasingly important consideration in the appropriate clinical
with 4.9% of aortic PHVs requiring reoperation or catheter-based inter-
setting, given the increasing number of TAVI prostheses implanted.21
vention compared with 2.0% of mitral PHVs. Risk factors for dehiscence
iv. Thrombus is seen in 0.3% to 8% of PHVs.2 Mechanical valves are more
include bacterial endocarditis, surgical technique, ascending aortic aneu-
thrombogenic than bioprosthetic valves, although the risk for thrombus for
rysm, degenerative regurgitation, and severe calcification of the native
a mechanical valve with appropriate anticoagulation therapy is similar to
valve. Transcatheter PVL is related to multiple factors, including mis-
that of a bioprosthetic valve. Right-sided valves are more vulnerable to throm-
sizing of the device, bulky calcification of leaflet or annulus, underdeploy-
bosis than left-sided valves, with the tricuspid valve (TV) affected 12 to 20
ment of the transcatheter valve, or improper implantation depth.13
times more frequently than left-sided valves.22 Thrombus is seen on echocar-
c. Other nonstructural causes of dysfunction: Other causes of dysfunction
diography as a mass on the valve with a soft echodensity that can be associated
include leaflet entrapment or dysfunction from pannus, inappropriate
with intracardiac thrombus16; in bioprosthetic valves, it may appear as valve
position or sizing, dilatation of the cardiac chambers after implantation
thickening.23 On CT, thrombus on bioprosthetic valves may manifest as hypo-
(e.g., aortic root dilatation, mitral annular or left atrial) dilatation), and
attenuated leaflet thickening, characterized by thickened and hypoattenuating
Volume 37 Number 1
available. This allows comparison of the study measurements with the expected
Table 1 Essential clinical and echocardiographic parameters
normal PHV hemodynamics. Similarly, blood pressure, heart rate, height,
in the comprehensive evaluation of prosthetic valve function weight, and body surface area should be included. Heart rate affects the dura-
tion of diastolic filling and therefore mean gradients in the mitral valve and TV;
Parameters
body surface area is helpful in assessing the presence of PPM and chamber size.
Clinical information Date of valve replacement ii. Echocardiographic imaging: Standardized measurements of cardiac
Type and size of the prosthetic valve chambers, systolic and diastolic function, aortic root, and ascending aorta
per ASE guidelines are recommended in patients with PHVs. Zoom imaging
Height/weight/body surface area
with multiple views should be used to evaluate all components of the pros-
Symptoms and related clinical findings thetic valve (Table 1). Because of acoustic reverberation by prosthetic material,
Blood pressure and heart rate visualizing the central occluder or leaflets may require off-axis imaging. Biplane
Echocardiography Opening and closing of leaflets or occluder imaging allows simultaneous assessment of the valve structure in real time and
localization of paravalvular regurgitation with color Doppler. Mild thickening is
Presence of leaflet thickening,
often the first sign of primary failure of a biologic valve and is a signal to reduce
calcifications, or abnormal echo
the interval between follow-up studies. Independent or rocking motion of a
density(ies) on the various components of
replacement valve is a sign of dehiscence and may be more diagnostic for
the prosthesis or adjacent to prosthesis
valves in the aortic position.25 In the mitral position, normal increased mobility
Valve sewing ring or stent integrity and of a valve may be due to annular motion, atrial or annular reconstruction, or
stability location of the sewing ring (i.e., within the left atrium); it needs to be differen-
Position of sewing ring or stent frame tiated from dehiscence by the absence of a PVL. Thickening of the aortic root
Doppler Contour of the jet velocity signal due to hematoma and edema after insertion of a stentless valve usually re-
echocardiography of solves in 3 to 6 months but can be mistaken for an aortic root abscess. Review-
the valve ing the postoperative or intraoperative study is useful to corroborate this
finding. Note that careful attention to the possibility of abscess formation is
Peak velocity and gradient
needed at the level of the annulus or sewing ring.25
Mean pressure gradient When using 3D echocardiography, the prosthesis should be assessed via 3D
VTI of the jet volume data sets, with and without color Doppler, from the imaging view
DVI that best visualizes the valve or paravalvular structures. The en face view of pros-
thetic valves allows easier localization of PVL and guidance of percutaneous in-
Acceleration time, acceleration time/
terventions. When acquiring 3D data sets, the two-dimensional (2D)
ejection time for AV
multiplanar images should be used to optimize line density and frame rate, al-
PHT in MV and TV lowing an accurate assessment of spatial and temporal changes. This may be
EOA* achieved with single-beat narrow volumes using live 3D modes or multibeat
Presence, location, and severity of acquisition using live 3D, zoom, or full-volume modes, preferably with volume
regurgitation† rates surpassing 20 Hz. If measurements are performed using 3D volumes,
high–volume rate single-beat acquisitions are preferred. However, if 3D color
Other LV and RV size, function, and
Doppler is required to quantify the vena contracta (VC) area, then a multibeat
echocardiographic hypertrophy
acquisition may be necessary to improve line density and volume rate. Optimal
data
3D acquisitions will include surrounding tissue and valvular landmarks so that
Left atrial and RA size and function the location of the lesion may be referenced and displayed in accordance with
Concomitant valvular disease the ASE and European Association of Echocardiography guidelines.26
Estimation of PA pressure iii. Doppler echocardiography: The principles of interrogation and
recording flow velocity through prosthetic valves using pulsed-wave (PW),
Venous inflow pattern (i.e., pulmonary
continuous-wave (CW), and color Doppler are similar to those used in assess-
vein for MV and hepatic vein for TV)
ing native valve function.
Previous postoperative Comparison of above parameters is a. Determination of gradients across prosthetic valves: Velocity across a
study(ies), when particularly helpful in suspected prosthetic prosthetic valve is dependent on flow, valve size, and valve type. The
available valvular dysfunction simplified Bernoulli equation (DP = 4V2) is key to the noninvasive calcu-
lation of pressure gradients. In patients with aortic prostheses and high
AV, Aortic valve; MV, mitral valve. cardiac output or narrow LVOT in whom the proximal velocity (V1) is
*EOA using the continuity equation; must be compared with normal >1.5 m/sec, the proximal velocity can no longer be ignored, and estima-
Doppler values of the valve type and size. tion of the pressure gradient is DP = 4(V22 V12). In bileaflet prostheses
†
Transthoracic Doppler is less sensitive for detection of valvular and caged-ball valves, however, overestimation of the gradient may
regurgitation in mitral and tricuspid prosthesis; TEE is frequently occur more than in bioprosthetic valves, particularly with smaller valves
needed for a more definitive assessment. and high cardiac output (see ‘‘Pressure Recovery: Hemodynamic Con-
ditions and Clinical Implications’’; Figure 3).27,28
PHV leaflets and reduced valve motion (hypoattenuation affecting motion). b. Effective orifice area (EOA): The prosthetic valve EOA derived using
The reported prevalence is 3.6% to 40%.24 the continuity equation is a better index of valve function than gradient
alone as it is less dependent on flow through the valve:
C. Evaluation of Prosthetic Valves
A comprehensive assessment of prosthetic valve function includes EOA = stroke volume/prosthetic valve velocity-time integral (VTI).
clinical information, echocardiography, and Doppler evaluation.
Comparison with a baseline study or serial postoperative studies is For stroke volume calculation using the LVOT, the LVOT diameter mea-
key to determining whether valve function has changed (Table 1). surement and the corresponding position of the PW Doppler sample vol-
ume introduce the largest errors in estimating EOA.1,2 The diameter used
i. Clinical information: Study indications, patient symptoms, size and type of should always be the largest diameter measured perpendicular to the
valve replacement, and date of surgery should be included in the report when LVOT direction, not an average determination, as the error is in
January 2024
Figure 3 Pressure recovery in prosthetic valves. Schematics of changes in velocity and pressure in prosthetic aortic valves. Velocities
are lower and systolic arterial pressure (SAP) is higher at the distal aorta than at the level of the VC. The left figure represents changes
in velocity and pressure from the LV outflow to the ascending aorta (AA) in a stented bioprosthetic valve. As flow expands into the
wider lumen beyond a valve, velocity and kinetic energy decrease and pressure recovers. The magnitude of this phenomenon is
small, except in patients with aortas <3 cm in diameter. On the right, in mechanical bileaflet prostheses, the velocity is higher in
the central orifice (CO) compared with the lateral orifices (LOs); hence the pressure drop is higher at this level. This is not seen in
a single tilting disk or bioprosthetic valve. The smaller CO gives rise to a higher velocity jet that corresponds to a localized pressure
drop that then recovers once the central flow reunites with flows from the two LOs. Doppler-estimated velocity and gradients usually
cannot differentiate between the lower and maximal velocities, leading to overestimation compared with the invasive standard.
LVSP, LV systolic pressure; SV, stroke volume in LV outflow.
Figure 4 Calculation of flow in the left ventricular outflow in transcatheter aortic valves. The default approach is to measure LVOT
diameter using the outer edge–to–outer edge diameter at the lower (ventricular) end of the valve stent (A, arrow). The PW sample vol-
ume from the apical view is placed immediately proximal to the site of flow acceleration at the inlet to the stent (B). Stroke volume is
then calculated as usual, assuming a circular LVOT geometry as 0.785 d2 VTI. In instances in which a self-expanding valve is
placed low in the left ventricular outflow, particularly if the lower end of the stent is not in close proximity to the anterior mitral leaflet
and interventricular septum, an alternative approach is to measure the inner edge–to–inner edge diameter of the valve stent imme-
diately proximal to the cusps (D). Then, the Doppler sample volume should be placed just inside the stent but proximal to the site of
flow acceleration at the valve cusps (E). Velocity and VTI would be larger if the PW Doppler sample volume is placed just inside the
stent (F vs C). Note that with transcatheter valves, there is flow acceleration at the inlet to the stent and again at the valve cusps. Red
arrows point to the lower end of the stent. Ao, Aorta; LV, left ventricle.
Volume 37 Number 1
Figure 5 DVI, an index of valve performance, is derived for the prosthetic aortic valve (PrAV) and for the prosthetic mitral valve (PrMV).
The VTI in the LV outflow (LVO) is by PW Doppler, and that of the jet is by CW Doppler. The same concept can also be applied to the
pulmonary valve and TV. DVI use in prosthetic mitral, tricuspid and pulmonary valves is valid in the absence of significant AR.
underestimating LVOT diameter. In surgical aortic valve replacement (2) within some prosthetic valves, typically bileaflet or caged-ball
(SAVR), the diameter is measured just below the valve plane. For valves.27,34-36
TAVI, the LVOT diameter preferentially is the outer-to-outer diameter In the first scenario (Figure 3, left), as flow expands into the wider
of the stented valve.3,11 The PW Doppler sample volume should also be lumen beyond a valve, velocity and kinetic energy decrease and pres-
placed apical to the stent frame at peak systole. The inner-to-inner stent
sure recovers. Several factors influence the magnitude of pressure re-
diameter may be used, but the matched PW Doppler sample volume
covery and the accuracy of Doppler-derived gradients, including flow
within the stent may record flow acceleration, overestimating stroke
volume (Figure 4). Using the label size of the prosthetic valve to calcu- profile, flow rate, size of the downstream chamber, and simplification
late the annular cross-sectional area is not recommended.29 The of the Bernoulli equation, which may lead to higher gradients with
biplane method of disks for left ventricular (LV) volume calculation Doppler compared with invasive measurements.37 The magnitude of
(modified Simpson method) and 3D LV volumes are alternative this discordance is usually small, except in patients with aortas <3 cm
methods to calculate total LV stroke volume and EOA, particularly in in diameter.
the presence of flow acceleration in the LVOT. However, avoidance In the second scenario (Figure 3, right), the design of the mechanical
of LV foreshortening and the use of ultrasound-enhancing agents are bileaflet and caged-ball prosthetic valves creates a separate pressure re-
strongly recommended to prevent underestimation of LV stroke vol- covery at the level of the valve not seen in monoleaflet or bioprosthetic
ume, which is known to occur with echocardiography compared
valves.38 In bileaflet valves, the smaller central orifice gives rise to a
with CMR.30,31 In prosthetic mitral valves, stroke volume calculated
high-velocity jet that corresponds to a localized pressure drop that nor-
at the aortic annulus or pulmonary annulus may be used, provided
no significant mitral, aortic, or PR exists. malizes once the central flow reunites with flows originating from the
c. Doppler velocity index (DVI): In prosthetic aortic valves, DVI—the ratio two larger lateral orifices.34,38 CW Doppler recording often includes
of VTI proximal to the valve to that through the valve—can be used to this high-velocity jet, which leads to overestimation of gradients and un-
assess aortic valve function.29,32 A DVI #0.35 is associated with adverse derestimation of EOA compared with the invasive hemodynamic mea-
outcomes for SAVR but not TAVI.32 The inverse of this ratio is used for sures, particularly in small prostheses and high-flow states.
prosthetic mitral valves (Figure 5).33 For mitral valves, this ratio is also Differentiation of central from lateral orifice jets is possible in prosthetic
helpful in detecting significant mitral regurgitation (MR), as flow velocity mitral valves with transesophageal echocardiography (TEE; in the near
increases through the mitral valve and decreases in the LVOT with sig- field) but not with transthoracic echocardiography (TTE). The effect of
nificant MR. The DVI parameter may also be applied to prosthetic pul-
pressure recovery usually does not interfere with assessment of PHV
monary valves and TV, but more validation is needed.
function, as it is already incorporated in the normal values of
Doppler velocities, gradients, and DVIs of various valves (Appendix
D. Pressure Recovery: Hemodynamic Conditions and Tables A1-A9). However, in patients with small bileaflet aortic valves
Clinical Implications (e.g., 19 mm) accompanied by high flow, differentiation of abnormal
In prosthetic valves, the phenomenon of pressure recovery can occur function may require further evaluation of valve motion and
in two regions (Figure 3): (1) downstream from a prosthetic valve and structure with fluoroscopy, CT, or TEE. Last and most important, as
January 2024
the valve (bioprosthetic or mechanical) becomes stenotic, the displacement of blood caused by the motion of the occluder) and true
echocardiographic and invasive measures of valvular hemodynamics trivial or mild regurgitation at the hinges of the occluder. For the Starr-
become concordant and associated with outcomes.27,28,37 Edwards valve, there is typically a small closing volume and little or no
true transvalvular regurgitation (Figure 1). The single tilting disk valves
E. Prosthesis-Patient Mismatch have both types of regurgitation, but the pattern may vary: the Bjork-
Shiley valve has small jets located just inside the sewing ring where the
PPM occurs when the prosthetic EOA is too small relative to the body
closed disk meets the housing, while the Medtronic-Hall valve has
size and resting blood flow needs of the patient.39 EOA as well as leaflet
these same jets plus a single large jet through a central hole in the
morphology and mobility are all normal; however, the indexed EOA is
disk where it pivots (Figure 1). The now commonly used bileaflet
small for body size.40 Although PPM may be one cause for high trans-
valves typically have multiple jets located just inside the sewing ring
valvular gradients, gradients may be normal in the setting of PPM with
where the closed leaflets meet the housing and centrally where the
low flow, an entity that is associated with poor outcomes.41
closed leaflets meet each other (Figure 1). These ‘‘washing jets’’ are
The diagnosis of aortic PPM relies on measurement of EOA using
thought to prevent the formation of thrombi at sites of stasis within
the continuity equation indexed to the patient’s body surface area.
the sewing ring. The regurgitant fraction is usually no larger than
CT may provide additional diagnostic information, including confirma-
10% to 15%; the associated color jet can appear large, up to 5 cm
tion of normal leaflet mobility, prosthesis size, and stent frame inlet
long (especially in Medtronic-Hall valves) but narrow at its origin. In
area. It also allows the identification of valve obstruction (reduced
the case of bileaflet valves, the washing jets are usually found in for-
mobility from thrombus, calcifications, or pannus).2 Gradients have
mation, two from each pivot point; sometimes these single pivotal
been shown to increase exponentially when the indexed EOA is
washing jets divide into two or three separate ‘‘plumes’’ (Figure 1).
<0.8 to 0.9 cm2/m2.39,42 Importantly, indexed EOA can overestimate
The jets are invariably low in momentum so that they are homoge-
PPM severity in the setting of obesity (body mass index > 30 kg/m2),
neous in color, with aliasing confined mostly to the base of the jet.
and thus different PPM thresholds are suggested for these patients.
Regurgitation is increasingly reported in normal biologic valves,
The impact of aortic PPM on clinical outcomes increases with
mainly because of improved Doppler sensitivity of current ultrasound
severity.43,44 The reported incidence of moderate aortic PPM in
machines. Stentless valves, including homografts and autografts, are
SAVR varies between 20% and 70%, whereas that of severe PPM is
more likely than stented valves to have minor regurgitant jets.
between 2% and 20%.40 The incidence of severe PPM in TAVI is lower
Percutaneous aortic valves rarely have small central regurgitation.
than that for SAVR.45,46 It should be emphasized that the indexed
More often, the regurgitation is paravalvular at the apposition of the
EOA (rather than the size or geometric specifications of the prosthesis)
valve stent to the calcified native valve (Figure 2).3 The incidence of
is the only parameter that is consistently related to postoperative gra-
paravalvular regurgitation has significantly decreased with improve-
dients and/or adverse clinical outcomes. SAVR PPM is associated with
ments in valve skirt design.
decreased exercise capacity and lower functional class. The main
adverse clinical outcome of PPM is reduced short-term and long-
term survival but higher rates of heart failure and hospitalization, less G. Pathologic Prosthetic Regurgitation
regression of LV hypertrophy, and faster development of SVD have
Pathologic regurgitation can be either central or paravalvular.
also been reported.40 Worse outcomes have also been described in
Pathologic central valvular regurgitation is most often seen with bio-
specific patient subsets, such as in individuals <65 to 70 years old
logic valves, whereas paravalvular regurgitation can be seen with
and those with coexisting LV dysfunction, significant hypertrophy,
either valve type but is more frequent in mechanical and percuta-
low-flow, low-gradient aortic stenosis, and MR.47,48 Aortic PPM can
neous valves (Figure 2). Localization of paravalvular regurgitation
usually be avoided47,49,50 with calculation of the projected indexed
may be challenging but is possible if the jet can be visualized origi-
EOA of the prosthesis before implantation. If PPM is anticipated,
nating and traveling outside the sewing ring. This may require the
choosing an alternative prosthesis, opting for TAVI, or considering
use of multiple transducer positions and off-axis views.3 Multiplanar
aortic root enlargement surgery is recommended.40
and/or 3D TEE may be helpful, particularly in the mitral valve and
PPM can also occur with mitral prostheses, but the correlation be-
TV. Although paravalvular regurgitation is abnormal, small jets are
tween indexed EOA and transvalvular gradients is not as strong as in
not uncommon, especially during perioperative examination early af-
aortic prostheses.51 Calculation of indexed EOA for mitral prostheses
ter surgery. Immediately following implantation, the prevalence of
is best done using the continuity equation; it should be emphasized
paravalvular regurgitation ranges between 5% and 20%57; the major-
that calculation of EOA using the pressure half-time (PHT) method
ity of these leaks, however, are clinically and hemodynamically insig-
is frequently inaccurate and leads to overestimation of EOA, particu-
nificant and, in the absence of endocarditis, have a benign course.
larly in normal valves.52,53 The threshold values for mitral PPM are
In general, the same methods used for quantitation of native valvular
higher than for aortic valves, with an ideal indexed EOA of
regurgitation58 can be used for prosthetic valves, but application of
>1.2 cm2/m2 to avoid abnormally high postoperative gradients.53
these methods can be more challenging. Because of acoustic reverber-
Moderate mitral PPM is defined as <1.2 cm2/m2, and severe mitral
ation and shadowing from the prosthesis, detection of regurgitation
PPM is defined as #0.9 cm2/m2.2,54 The reported prevalence of
with TTE is more difficult for valves in the mitral and tricuspid positions,
mitral PPM varies between 39% and 71%. It is associated with persis-
particularly in mechanical valves (Figure 6). Indirect clues from various
tent pulmonary hypertension and decreased perioperative and long-
Doppler parameters can suggest the presence of significant regurgita-
term survival.55,56 Mitral PPM can be prevented or minimized by im-
tion. However, TEE is frequently needed for the diagnosis of prosthetic
planting a prosthesis with a larger projected EOA when possible.54
MR. The frequent eccentricity of regurgitant jets, particularly in me-
chanical valves, renders the quantitation and assessment of regurgita-
F. Physiologic Regurgitation tion in general more difficult or limited. Multiple small normal
Mechanical valves typically have minor regurgitant jets. Two types of transprosthetic jets cannot be quantified accurately, but these are typi-
‘‘physiologic’’ regurgitation may be seen: a closing volume (retrograde cally not clinically relevant. For paravalvular jets, the proportion of the
Volume 37 Number 1
Figure 6 Effect of mechanical prosthetic valve position and echocardiographic imaging view on ultrasound attenuation and masking
of a color Doppler regurgitant jet. A higher effect from transthoracic imaging is seen on prostheses in the mitral position compared
with the aortic position.
circumference of the sewing ring occupied by the jet gives an approx- In addition, intracardiac echocardiography (ICE), including 3D ICE
imate guide to severity.3 Comparative flow measurements for the and image fusion, is becoming more important for image guidance
determination of regurgitant volume or fraction, which frequently during structural procedures. Other approaches such as epicardial
rely on the determination of stroke volume at annular sites, can be and epiaortic echocardiography, are used infrequently in the oper-
used for prosthetic aortic regurgitation (AR) and PR but not for pros- ating room, according to local expertise.62
thetic MR, as mitral inflow cannot be measured using Doppler because
i. Intraoperative echocardiography during prosthetic valve place-
of the mitral prosthesis. The use of 3D TEE with Doppler improves the
ment: Apart from evaluating dysfunctional prosthetic valves or newly
assessment and quantitation of prosthetic regurgitation.59
seated prostheses, TEE can identify previously undetected pathology for
appropriate surgical planning and guide placement of cannulas to facilitate
H. Changes During Stress cardiopulmonary bypass, especially in minimally invasive and robotic valve
surgery. A fundamental goal of intraoperative evaluation of newly seated
Stress echocardiography can be useful to evaluate symptoms in patients
valves is to diagnose any pathology that requires resumption of cardiopul-
with prosthetic valves,60 especially when there is discrepancy between
monary bypass and immediate surgical correction. These include significant
the resting valve hemodynamics and the patient’s symptoms. Normally paravalvular regurgitation, dehisced prostheses, and complications in adja-
and abnormally functioning prosthetic valves can have similar trans- cent structures, such as coronary ostial obstruction or stuck prosthetic valve
valvular gradients at rest.61 Symptoms can develop from prosthetic ste- leaflets. Three-dimensional TEE has had a major impact in assessing PHVs in
nosis or regurgitation, PPM, coronary stenoses, or pulmonary diseases, the mitral position compared with other positions because of the proximity
and these can be assessed during stress echocardiography. As hemody- of the mitral valve to the left atrium and the en face view of the entire mitral
namics can return rapidly to baseline following treadmill stress, supine valve. Three-dimensional TEE is particularly helpful for detecting and char-
bicycle and pharmacologic stress with dobutamine are preferable mo- acterizing paravalvular regurgitation. A more comprehensive approach to in-
dalities; both allow the assessment of valvular hemodynamics during traoperative imaging of prosthetic valves is discussed in the ASE guidelines
on the use of TEE to assist surgical decision-making.62
stress and at peak stress. Exercise is generally preferred over pharmaco-
ii. Image guidance during percutaneous prosthetic valve replace-
logic stress because of its physiologic response, important in these clin-
ment
ical circumstances. In general, the assessment for valve obstruction a. Two-dimensional and 3D TEE: TEE is an important tool for image guid-
should be similar to that of native valve stenosis, and details regarding ance for percutaneous PHV replacement, particularly for prosthetic
stress protocols have been previously described.60 mitral valves, and for repair of paravalvular regurgitation.63 TEE for
TAVI has also been extensively reviewed. Pulmonary valve replacement
I. Considerations for Intraoperative and Intraprocedural (PVR) is often guided by ICE. TV intervention is still experimental but is
guided using TEE, supplemented with ICE when needed.
Guidance
b. TAVI: Image guidance during TAVI is performed using both transtho-
TEE with the use of both 2D and 3D imaging remains the mainstay racic and transesophageal echocardiographic approaches.3,64 The key
for intraoperative and intraprocedural guidance for PHV deployment. focus is detecting paravalvular regurgitation while remaining cognizant
January 2024
Table 2 Multimodality imaging of prosthetic valves after initial transthoracic echocardiographic evaluation: advantages and
limitations
Advantages Limitations
TEE High spatial and temporal resolution in real time Optimal valve visualization and assessment
of valvular structure and function depends on valve and probe position
Doppler quantitative hemodynamic assessment Reverberation/shadowing from near field
of valve function prosthetic valve structures prevent visualization
Best visualization and assessment for mitral of far-field structures; changing acoustic
valves (en face) followed by aortic, tricuspid, and windows may allow imaging of previously
pulmonary valves: shadowed structures.
Valve and occluder/leaflet motion, etiology of Less able to assess pulmonary valve structure
dysfunction, gradient; localization and severity and function; special views needed
assessment of regurgitation (trans- or
paravalvular)
3D TEE, using en face views and/or MPR, may
offer more definitive assessment of valve
structure, leaflet/occluder motion, localization of
PVL, and baseline assessment prior to structural
intervention.
Detection of valvular vegetations (small, mobile)
Identification of paravalvular complications
(dehiscence, abscess, pseudoaneurysm)
Portable, feasible to use in ICU/emergency
department setting and intubated patients
No contraindications in renal dysfunction
ICE Best modality to evaluate the pulmonary valve Narrow sector width of 3D ICE volume-rendered
and TV and anterior structures of the heart images with limited temporal and spatial
3D ICE can show en face views of the pulmonary resolution
valve and TV as well as the mitral valve (when Color Doppler in 3D ICE has low spatial and
performed from the left atrium) temporal resolution with current systems
Simultaneous biplane imaging using 3D ICE has
higher temporal and spatial resolution compared
with 3D volume-rendered images
CT Excellent spatial resolution Lack of hemodynamic evaluation
Good visualization of occluder/leaflet motion, Valve regurgitation severity is inferred from
pannus, and leaflet calcification/thickening anatomic defect; mild regurgitation or shunt may
irrespective of valve position not be detected.
Identification of paravalvular complications Beam-hardening artifact, particularly in
(dehiscence, abscess, pseudoaneurysm) mechanical valves, may interfere with identifying
Useful in the context of multiple prosthetic valves vegetations, thrombus, pannus, small
where artifact may affect TEE quality dehiscence
Nephrotoxic contrast agents needed for
angiography (noncontrast CT can be used for
mechanical valve motion)
Full R-R acquisitions contribute to higher
radiation doses
Temporal resolution may be limited
CMR Quantitation of peak velocity and gradients (in Limited spatial and temporal resolution
bioprosthetic valves), irrespective of valve Artifact from prosthesis interferes with evaluation
position of mechanical valves and some bioprosthetic
Quantitation of regurgitant volume and fraction in valves
regurgitant valves Inability to detect small, highly mobile
Identification of anatomic valve area and leaflet vegetations
pathologies in bioprosthetic valves (thickening, Irregular rhythm and atrial fibrillation effect on
flail) valve visualization (potential to overcome with
Identification of large paravalvular complications real-time cines) and flow quantitation
(e.g., dehiscence, pseudoaneurysm)
ICU, Intensive care unit; MPR, multiplanar reconstruction.
of major complications that can occur after TAVI, such as aortic annular setting and corroborate with invasive hemodynamics and aortography
rupture, ventricular septal defect, periaortic hematoma, LVOT obstruc- when needed.
tion, and interference with mitral valve function.64,65 Most laboratories c. Mitral valve repair or replacement. Three-dimensional TEE has been
apply a semiquantitative approach using color Doppler only in this revolutionary with regard to guidance of transcatheter edge-to-edge
Volume 37 Number 1
mitral valve repair and device deployment.66,67 Three-dimensional TEE

Table 3 Comparative strength of imaging modalities in
is similarly important for the placement of ViV in the mitral position for a
degenerated bioprosthetic valve, a failed mitral valve repair with surgical
evaluating prosthetic valve structure, function, and
ring, or for a valve–in–mitral annular calcification procedure.63 complications
d. Tricuspid valve repair or replacement for native tricuspid regurgitation
TTE TEE CT CMR
(TR): TV repair or replacement is typically guided by 2D and 3D
TEE. In this more challenging and relatively new procedure, additional Valve function/stenosis
imaging from a deep esophageal position is recommended to avoid
acoustic noise from the left heart. From this level, the inflow-outflow Valve structure, ++ ++++ ++++ +++
view with orthogonal 140 and 40 to 60 deep esophageal views anatomic area
are the most helpful.68 The 140 TEE view is helpful because of the (bioprosthetic)
lack of adjacent structures to impede the ultrasound beam.68-70 Valve structure, motion + ++ (MV 4+) ++++ +
(mechanical)
Gradient, EOA* +++ ++ (MV 3+) ++
J. Other Techniques for Assessing PHVs
Thrombus, pannus + +++ ++++ +
(mechanical)
i. Cine fluoroscopy: Cine fluoroscopy was the initial noninvasive modality
to evaluate mechanical valves.71 Because of the radiopaque base and disk Valve regurgitation
occluder, abnormal tilting of the base ring and impaired disk occluder Localization ++ ++++ ++ +
mobility can be assessed. Abnormal tilting of the base ring is representative
Valve dehiscence ++ ++++ ++++ ++
of significant valve dehiscence and paravalvular regurgitation. Impaired disk
occluder mobility can be evaluated by calculating the opening and closing Endocarditis† ++ +++ ++ +
angles and is suggestive of prosthetic valve dysfunction.71 Cine fluoroscopy Quantitation ++ ++++ ++ ++++
has limited value in bioprosthetic valves. Calcifications on bioprosthetic
MV, Mitral valve.
tissue valve leaflets are suggestive of valvular degeneration, although its he-
On a scale of none to 4+.
modynamic impact cannot be assessed. With TEE and the increasing use of
*Gradients may be higher in prosthetic valves, particularly in me-
cardiac CT, cine fluoroscopy is now primarily a complementary tool in eval-
chanical bileaflet valves.
uating mechanical valve mobility. †
For abscess detection, computed tomographic angiography is +++.
ii. Cardiac catheterization: The widespread availability of echocardiogra-
phy limits the need for invasive hemodynamic evaluation for prosthetic valve
dysfunction. The Gorlin formula is used to calculate EOA of a valve inva- Comparison of noncontrast images and correlation with echocardiography
sively.72 Ideally, a dual-catheter approach should be used to measure the pres- is essential for accurate identification of PVLs. On the other hand, small
sures upstream and downstream from the valve simultaneously. Catheter PVLs can be obscured by metallic artifacts from the prosthetic ring or disk
crossing of a mechanical valve for pressure gradient measurement should occluders. Calcification of bioprosthetic valve leaflets is a marker of degen-
be avoided because of potential complications.73 In prosthetic mitral stenosis, eration; however, there is currently no quantitation or scoring strategy to
the pulmonary artery (PA) wedge pressure for measurement of transmitral allow its use in a diagnostic capacity.80 CT may also play a complementary
pressure gradient frequently results in an overestimation of the true gradient role in the workup of prosthetic valve endocarditis, with TEE providing a
resulting in underestimation of valve area; direct measurement of the left atrial more accurate assessment of leaflet vegetations and perforations, while
pressure with a transseptal technique is recommended in circumstances CT provides a more accurate assessment for the presence of root abscess.81
where invasive mitral stenosis assessment is required.74,75 Contrast injection iv. CMR: CMR has a complementary role in the assessment of PHV func-
may be used to evaluate prosthetic transvalvular or paravalvular regurgitation tion (Table 2). PHVs can be safely imaged using 1.5- and 3-T magnets,
and other complications including fistulas and pseudoaneurysm. which are the most common field strengths used in clinical practice.82-
iii. CT: Electrocardiographically gated CT provides high–spatial resolution 84
The various techniques used in CMR and their applications in the
volumetric imaging of the prosthetic valve and cardiac chambers that can assessment of prosthetic valves are detailed in Figure 8. The presence of
be combined with full cardiac cycle imaging to provide functional and prosthetic valve stenosis or regurgitation may first be recognized on cine
anatomic assessment. In patients with arrhythmias, retrospective gating is images. However, steady-state free precession (SSFP) cines are susceptible
often beneficial, further aided by the use of absolute delay (in milliseconds) to artifacts and are less sensitive to flow. Fast-gradient echo sequences can
reconstructions rather than relative delay (as a percentage) reconstruc- help reduce flow-related artifacts,85,86 and spin-echo sequences can be
tions.76 CT is of greatest utility when dysfunction of a valve is detected on used to reduce prosthetic valve artifacts.83 The degree of artifact is related
TTE but its etiology is not clear or structural intervention is planned. Advan- to the type of valve (i.e., mechanical vs bioprosthetic, bileaflet vs single
tages and limitations of advanced imaging modalities after an initial transtho- leaflet, stented vs nonstented) and can be minor or severe, the latter pre-
racic echocardiographic examination of prosthetic valves are detailed in cluding diagnostic assessment. When there are minimal artifacts, cine im-
Table 2. The relative strengths of TTE, TEE, CT, and CMR in assessing pros- ages may help visualize excursion of bioprosthetic valve leaflets or
thetic valve structure, function, and complications are shown in Table 3. CT mechanical PHV occluders, allow planimetry of bioprosthetic valve
has a limited role in the routine surveillance or quantification of hemody- area,85,86 and enable the identification of exaggerated motion of the pros-
namic severity. Noncontrast images can be used to assess mechanical valve thesis in the context of valve dehiscence. Phase-contrast acquisitions using
mobility where the degree of leaflet opening can be accurately measured. in-plane phase encoding can help improve visualization of flow turbulence
The addition of intravenous contrast allows the detection and potential dif- through stenotic prosthetic valves or both valvular and paravalvular regur-
ferentiation between thrombus and pannus as the underlying cause of any gitation. For assessment of PHV stenosis, phase-contrast images using
restricted motion (Figure 7).77 The accuracy of CT with contrast is on par through-plane phase encoding enables direct quantification of peak veloc-
with 3D TEE for PHV and may be superior in aortic mechanical valves ities/gradients through PHVs.87 However, this is usually not feasible for
and pulmonary valves.77 In bioprosthetic valves, routine use of intravenous mechanical prostheses in the mitral and tricuspid positions because of arti-
contrast is beneficial, as it allows the assessment of leaflet thickening and fact and is often challenging with bioprosthetic valves because of annular
restricted motion, as well as the detection and localization of significant translation. For assessment of valvular or paravalvular regurgitation,
PVLs.78,79 Of note is that felt or pledgets may have slightly higher or similar through-plane phase-contrast images can provide quantification of total
Hounsfield units as contrast and thus can be mistaken for small PVLs. stroke volume, regurgitant volume, and regurgitant fraction for PHVs at
January 2024
Figure 7 Two cases of bileaflet mechanical aortic valves imaged with cardiac computed tomographic angiography. Case 1 of a pa-
tient after the Bentall procedure (top panels) shows the aortic valve in diastole (A) and systole (B) with normal closure and opening
angles. However, there is an anterior paravalvular dehiscence (red arrows). In case 2 (bottom panels), three-chamber and short-axis
views show a frozen disk of the mechanical aortic valve (asterisk) imaged in systole (C). Pannus is seen over the left coronary cusp
(arrow) in long-axis (C) and short-axis (D) views, with Hounsfield units of 150. Ao, Aorta; LA, left atrium; LV, left ventricle.
the aortic and pulmonary positions (Figure 9, Table 2).58,88 For the mitral Key Points for Assessing PHVs
valve and TV, an indirect approach using a combination of ventricular
stroke volume and through-plane phase-contrast images at the aortic or 1. The different types of PHVs must be understood before assessing the hemodynamics
of PHV function. Knowledge of the type and size of the valve in a particular patient is
pulmonary valve position is required.58,88 Specific techniques are important.
described in the respective valvular sections below and in previous ASE 2. Bioprosthetic valve dysfunction can be divided into the following categories: SVD,
guidelines.3,58 nonstructural valve dysfunction, thrombosis, and endocarditis.
v. Cardiac positron emission tomography (PET): The principal role of 3. A comprehensive assessment of prosthetic valve function includes echocardio-
graphic imaging (2D and 3D), Doppler evaluation, and pertinent clinical informa-
cardiac PET is in the workup of suspected prosthetic valve endocarditis. Flu- tion.
orodeoxyglucose PET will show an intense increase in uptake in the adja- 4. Stress echocardiography can be useful to evaluate symptoms in patients with pros-
cent annular tissue in the presence of prosthetic valve endocarditis thetic valves.
(Figure 10),89 although this should be interpreted with caution as low to in- 5. Two-dimensional TEE and 3D TEE remain the mainstay for intraoperative and intra-
procedural guidance for PHV deployment.
termediate paravalvular uptake is a normal finding even up to 1 year post- 6. CT and CMR provide complementary and valuable information to a transthoracic
operatively.90,91 Fluorine-18 fluoride may be of benefit in identifying valves echocardiographic evaluation of PHV. CT is particularly helpful in assessing valvular
at risk for structural degeneration; however, results in this field are limited, anatomy, while CMR can provide hemodynamic evaluation.
and further work is required.80
Volume 37 Number 1
Cardiac Magne c Resonance of Prosthe c Valves, Homogra s & Conduits

1.5T and 3T both suitable
Anatomy & Flow visualiza on Quan fica on Flow/Velocity 3D anatomy Fibrosis
SSFP
• Standard cine 2D Phase Contrast 3D MRA Tissue Characteriza on
• Mul ple planes – Ventricles and valves • Measure Flow and Velocity • Assessment of aorta and
• Place 0.25 to 0.44 mm downstream from PHV • Assessment of myocardial fibrosis
• Quan fy chamber volumes pulmonary arteries
• May be challenging in MV/TV due to through • Evalua on for conduit
• Assess leaflet mo on/thickening in • Assessment of Conduit
plane mo on; Indirect quan fica on using fibrosis/inflamma on
bioprosthe c valves and conduits size and stenosis
• Valvular planimetry ventricular SV and Aor c/pulmonary flow may
• Challenging with large signal void PHV improve assessment in these situa ons
• 3D phase contrast may be er characterise
eccentric steno c jets
Gradient Echo
• Decreases flow ar fact
• Mul ple planes
• Challenging with large signal void PHV 4D Phase Contrast
• Measure Flow and Velocity in 3 planes
simultaneous of en re heart and vasculature
Spin Echo • Flow visualiza on, Flow quan fica on, and
• S ll images only advance hemodynamics
• Mul ple planes • Feasible in low signal void PHV
• Not affected by signal void of PHV
Figure 8 Cardiac magnetic resonance methodology and respective applications in the evaluation of prosthetic aortic valves, homo-
grafts, and conduits. MRA, Magnetic resonance angiography; MV, mitral valve; SSFP, steady-state free precession; SV, stroke
volume.
Figure 9 Cardiac magnetic resonance imaging of a case with severe bioprosthetic AR. (A) Three-chamber long-axis view on steady-
state free precession cine CMR showing spin dephasing in diastole across the valve, suggestive of turbulence from AR (red arrow).
(B, C) Short-axis views of the bioprosthetic valve in systole showing normal systolic excursion (B, three arrows) and leaflet malcoap-
tation in diastole (C, arrow). (D-F) Magnitude and phase-contrast CMR sequence with region of interest at the level of sinotubular
junction. Flow-vs-time curve (F) shows forward (red arrow) and backward (yellow arrow) flow for direct assessment of AR (regurgitant
volume = 55 mL).
January 2024
Figure 10 Example of endocarditis affecting a mechanical aortic valve and ascending aortic graft (G), detected on fluorodeoxyglu-
cose (FDG) PET. The patient presented with malaise and dyspnea. Dehiscence of the bileaflet valve and severe AR were detected by
TTE. FDG PET performed after prolonged fasting showed intense uptake around the aortic valve in the area of suggested abscess
(A, arrows) and, importantly, also in the aortic graft (B, upper arrow). Computed tomographic angiography confirmed the possible
abscess anterior to the aortic valve (C, arrow) and dehiscence of the aortic valve prosthesis (PrAV) with a 10-mm PVL (D, arrows).
II. EVALUATION OF PROSTHETIC AORTIC VALVES

Table 4 Echocardiographic evaluation of prosthetic aortic
valves
A. Echocardiographic and Doppler Evaluation of Parameter
Prosthetic Aortic Valve Function
Doppler echocardiography of Peak velocity/gradient
The application of imaging tools to evaluate prosthetic aortic valve the aortic valve
function should begin with the identification of the implanted pros-
Mean gradient
thetic valve size and type, followed by a comprehensive echocardio-
graphic study (Table 4). Although surgical valve types and techniques Contour of the jet velocity;
acceleration time
have remained stable over the years, the introduction of sutureless
valves along with TAVI in native valves and in degenerated bio- DVI (DVI = VTILVOT/VTIPrAV)
prostheses has increased the scope and complexity of evaluating pros- EOA
thetic valves. Presence, location, and severity of
regurgitation
i. TTE: TTE is the initial imaging modality used to assess patients with SAVR or Pertinent cardiac chambers LV size, function, and hypertrophy
TAVI. The parameters for evaluation of PHVs in the aortic position are Previous postoperative Comparison of above parameters is
detailed in Table 4. Standard views required to evaluate valve function study(ies), when available particularly helpful in suspected
have been summarized previously (Figure 11).1,3 Although TTE assessments prosthetic valvular dysfunction
of bioprosthetic SAVR and TAVI are similar, special consideration should be
given to percutaneous valves. A full assessment of percutaneous valves VTIPrAV, VTI through the prosthetic aortic valve.
Volume 37 Number 1
Figure 11 Doppler echocardiographic findings in a normal and a stenotic mechanical aortic valve showing the difference in velocity
and its contour, and acceleration time (AT). Normal valve: LVOT diameter 2 cm, VTILVOT 19 cm, VTIPrAV 31 cm, DVI 0.6, and EOA
1.92 cm2. The calculated ratio of AT to ejection time (ET) is normal at 0.24. Stenotic valve: LVOT diameter 2 cm, VTILVOT 24 cm, VTIPrAV
98 cm, DVI 0.24, EOA 0.77 cm2, and calculated AT/ET ratio 0.4. PrAV, Prosthetic aortic valve.
should include valve position in the aortic root, the short-axis valve shape, struts, or annulus. For these reasons, the precise motion and excursion of
apposition of the valve stent to native aortic tissue, and the presence of aortic metallic leaflets may not be well delineated; if this is clinically needed,
annular injury or ventricular septal defects. Furthermore, sweeping the imag- such as when there is a question of valve obstruction or PPM, radiologic im-
ing plane through the valve is necessary to detect valve regurgitation as re- aging (CT or fluoroscopy; Tables 2 and 3) is advised. Details regarding the
gurgitant jets may not be seen adequately in a single valve plane (refer to acquisition and presentation of a 3D rendering of the aortic valve are pro-
the recent guideline for further details3). Low deployment of a TAVI vided in previous European Association of Echocardiography and ASE
prosthesis can limit anchoring and result in protrusion of the native valve recommendations.26
leaflets above the aortic edge of the frame. This increases the risk for delayed iii. Doppler echocardiography: The assessment of prosthetic aortic valve
migration of the valve into the LVOT or left ventricle. In addition to valve function includes peak velocity through the valve, mean gradient, and the
regurgitation, low deployment can affect mitral valve function, causing EOA, in addition to other criteria such as DVI, the contour of the jet and
MR. Incomplete expansion of the TAVI valve because of calcium can result acceleration time (Tables 4 and 5, Figures 11 and 12). A Doppler algorithm
in paravalvular and valvular regurgitation and higher valve gradient.3 that helps facilitate assessment of prosthetic aortic valve function in patients
ii. TEE: TEE plays an important role in the assessment of prosthetic aortic with elevated maximal velocity through the prosthesis is shown in
valve function.3,92 One limitation of the transthoracic echocardiographic Figure 13. Similar to native aortic valve disease, Doppler insonation should
assessment of a prosthetic aortic valve is aortic prosthesis–related reverber- be acquired from all possible windows. A small nonimaging probe should
ation and shadowing, precluding complete interrogation of the posterior also be used for better access between rib spaces and for optimal supraster-
annulus and root (Figure 12). Conversely, although TEE allows excellent nal notch angulation. Normal Doppler echocardiographic parameters for
visualization of the posterior aortic root, its assessment of the anterior various types and sizes of percutaneous and surgical valves in the aortic po-
root may be limited because of the same artifact. This may be addressed sition are detailed in Appendix Tables A1-A4.1,11,93 Recommended criteria
by adjusting the imaging angle or the depth of the transesophageal probe for assessing possible or significant stenosis, SVD, and PPM are provided in
to ‘‘shift’’ the artifact and allow partial visualization of other prosthetic valve Tables 5-7, respectively. The recommendations for SVD differ slightly from
segments. The presence of a mechanical mitral valve will also affect assess- other published criteria.13,94,95
ment of the LVOT using TEE. Thus, transgastric images play a valuable role The diagnosis of prosthetic valve stenosis should not rely on the
in patients with prosthetic aortic valves, allowing assessment of prosthetic measurement of a single parameter, as fluctuations in blood flow can
valve leaflet motion, gradient, and regurgitation. However, one must be affect Doppler measurements.13 Diagnosis should incorporate assessments
cognizant that Doppler angulation from the transgastric approach may from two or more serial echocardiograms when available. Baseline postpro-
not be optimal. Three-dimensional TEE imaging of prosthetic aortic valve cedural echocardiograms are crucial to establish if PPM is present after im-
cusps or a mechanical occluder can be challenging. The orientation of the plantation and to permit comparison of valve performance over time.
prosthetic aortic valve coaxial to the insonation beam can result in leaflet Other causes of elevated Doppler gradients such as high-flow states, supra-
body dropout with tissue prosthetic valves, especially if the leaflets are or subvalvular obstruction, and pressure recovery should be excluded. Inte-
thin and noncalcified. Conversely, mechanical valves and tissue valves gration of Doppler hemodynamic data with dedicated imaging to visualize
that are heavily calcified also pose a challenge because of artifacts caused the prosthetic leaflets, often by TEE or CT (especially in mechanical valves
by attenuation and/or reverberation from the leaflet calcium, disks, valve [Table 3], as discussed below), is important as it improves diagnostic
January 2024
Figure 12 A case of bioprosthetic aortic valve thrombus. (A) Transthoracic echocardiographic parasternal short-axis image of the
aortic valve during systole demonstrates shadowing of the posterior structure (white arrow). Note that there is failure of the left cor-
onary cusp to open because of a mass (red arrow). (B) The administration of ultrasound-enhancing agent reveals that this mass is
likely a thrombus. (C) CW Doppler in the apical five-chamber view demonstrating a normal peak systolic gradient of 9 mm Hg. (D)
TEE performed a few days later allows clear visualization of the posterior annulus. However, there is artifact obscuring the anterior
annulus (white arrow). It also shows in the long-axis view that the right coronary cusp is now thickened (left), and in the short-axis
view obtained through biplane, it does not open fully during systole (right). (E) Three-dimensional transesophageal echocardiographic
rendering of the aortic valve in the short-axis view during diastole (top) and systole (bottom) demonstrating prosthesis-related shad-
owing (white arrow) and fixation of the left and right coronary cusps. (F) CW Doppler in the transgastric view demonstrates a higher
peak systolic gradient of 18 mm Hg. Ao, Aorta; AV, aortic valve; IAS, interatrial septum; LA, left atrium; maxPG, maximal pressure
gradient; MPA, main PA; PG, pressure gradient; Vel, velocity; Vmax, maximal velocity.
performance and frequently identifies a specific etiology for elevated trans- Clinically significant elevated gradients should be confirmed with cardiac
valvular gradient.96 Note that in patients with poor LV function or elevated catheterization as echocardiographic gradients may be higher compared
systemic blood pressures, high gradients may not be present despite signif- with invasive measurements because of the pressure recovery phenome-
icant valve stenosis. non and limitations of the simplified Bernoulli equation.102-104 The
iv. Considerations for TAVI and ViV: For TAVI in native valves, in-stent degree of discordance is greater with self-expandable valves than with
flow acceleration occurs at two locations, below the valve and at the level balloon-expandable valves.104-106 Significant PPM has also been
of the cusps.97 Thus, LVOT diameter and flow measurements should be ob- observed after ViV, with moderate or greater PPM in 60% of patients
tained immediately proximal to the stent to prevent overestimation of the and severe PPM in 25%.102 However, the presence of moderate or greater
EOA by flow acceleration within the stent (Figure 4). It is recommended PPM does not affect 1- or 3-year mortality or clinical outcomes.102,107,108
that one highly flow-dependent (e.g., peak velocity, mean gradient) and Finally, long-term follow-up studies have reported that echocardiographic
one less flow-dependent (e.g., EOA) measurement be used to assess pros- findings remain stable up to 5 years after the procedure, and rates of valve
thetic aortic valve stenosis.13 Studies have demonstrated that compared deterioration are approximately 6.6% at 5 years.109
with patients with SAVR patients, TAVI patients have similar or lower valve
gradients, higher indexed EOA, and lower rates of PPM.98,99 However,
although the percentage of patients with moderate or severe AR was B. Echocardiographic and Doppler Evaluation of
similar between SAVR and third-generation TAVI valves, the prevalence Prosthetic Aortic Valve Regurgitation
of postprocedural mild AR is higher in TAVI patients.99
For TAVI ViV, echocardiographic parameters are affected by the type and i. TTE and TEE: TTE is used to identify both prosthetic aortic intravalvular
size of both the original implanted surgical or TAVI valve and the second and paravalvular regurgitation. In addition to assessing the location and
implanted valve.100,101 Appendix Table A3 summarizes echocardiographic mechanism of AR, TTE can identify associated complications such as endo-
findings after ViV at 1 year. Echocardiographic findings on the basis of the carditis, abscess formation, masses, and thrombus (Figure 14). Sweeps in
original implanted valve and the secondary TAVI valve are limited in the both the parasternal long- and short-axis views are often needed to ensure
literature. Overall, supra-annular valves compared with intra-annular valves that all jets are identified. Off-axis views may be needed to determine jet
tend to have larger EOAs, lower mean gradients, and lower incidence of origin. Because of reverberation and shadowing from the prosthesis, poste-
moderate or greater AR. Elevated echocardiographic ViV gradients rior paravalvular AR may be obscured with TTE, while anterior regurgitation
(mean gradient > 20 mm Hg) are found in 28% of patients after ViV. can be masked during TEE.3 Thus, TTE and TEE are complementary in this
Volume 37 Number 1
Table 5 Doppler parameters of prosthetic valves in the aortic valve position
Normal Possible stenosis Suggests significant stenosis
Appropriate for all prosthetic aortic valves

Jet velocity contour* Triangular, early peaking Triangular to intermediate Rounded, symmetric
Acceleration time, msec* <80 80-100 >100
Acceleration time/LV <0.32 0.32-0.37 >0.37
ejection time ratio
Peak velocity, m/sec†‡ <3 3-4 $4
Specific AVR considerations
SAVR
Mean gradient, mm <20 20-34 $35
Hg†
DVI§{ >0.35 0.25-0.35 <0.25
EOA §
Reference EOA 6 1 SD 1 SD smaller than reference 2 SDs smaller than
EOA reference EOA
TAVI (change from baseline)
Mean gradient† Change <10 mm Hg from Increase of 10-19 mm Hg Increase $20 mm Hg from
baseline† from baseline baseline
DVI§{ Change <0.1 or 20% from Decrease 0.1-0.19 or 20%- Decrease $0.2 or $40%
baselinek 39% from baselinek from baselinek
EOA§ Change <0.3 cm2 or 25% Decrease of 0.3-0.59 cm2 Decrease $0.6 cm2 or
from baselinek or 25%-49% from $50% from baselinek
baselinek
AVR, Aortic valve replacement.
Significant stenosis should meet at least one flow-dependent (i.e., velocity and mean gradient) and one flow-independent (i.e., EOA or DVI)
parameter.
*This can be affected by LV function and heart rate.
†
Flow dependent.
‡
Valid with normal stroke volume (50-90 mL) and flow rates (200-300 mL).
§
Flow independent.
{
DVI calculated using VTI as in Table 4.
k
Baseline defined as TTE performed under stable hemodynamic conditions.
Figure 13 Algorithm for initial evaluation of elevated peak prosthetic aortic jet velocity incorporating DVI, jet contour, and measures of
acceleration time (AT) and the ratio of AT to ejection time (ET). Improper PW Doppler sample volume influences both DVI and EOA
calculations: too close to the valve will increase DVI and EOA, while too far (apical) will decrease them. AVR, Aortic valve replacement.
January 2024
Note that for stroke volume calculation, care should be taken not to place
Table 6 Hemodynamic criteria for structural valve
the sample volume too close to the prosthesis, which would result in over-
deterioration*† estimation of stroke volume because of proximal acceleration. Methods for
quantitation of regurgitant volume and fraction after SAVR and TAVI have
Possible structural valve Significant structural valve
deterioration deterioration been described previously.1,3
Classification of intra- and paravalvular prosthetic AR severity is similar to
Increase in mean transvalvular Increase in mean gradient that suggested for native valves in that assessment requires integration of
gradient $10 mm Hg resulting $20 mm Hg resulting in a qualitative and semiquantitative parameters (Table 8).3,58 However, deter-
in a mean gradient $ 20 mm mean gradient $ 30 mm Hg mination of prosthetic valve AR severity may be more complicated because
Hg with concomitant with concomitant decrease in of the presence of combined valvular and paravalvular regurgitant jets, mul-
decrease in EOA $0.3 cm2 or EOA $0.6 cm2 or $50% and/ tiple regurgitant jets, or eccentric jets. Figure 16 shows a proposed algorithm
$25% and/or decrease in or decrease in DVI $0.2 or for the evaluation of severity of prosthetic valve AR with echocardiography,
DVI $0.1 or $20% compared $40% compared with the similar to a recently proposed algorithm.3 Generally, if the qualitative and
with the baseline (1-3 months) baseline (1-3 months) semiqualitative parameters are consistent with mild regurgitation, then
postprocedural assessment postprocedural assessment assessment is complete. If there is a discrepancy or inconsistency among pa-
New occurrence or increase New occurrence or increase rameters, then explanations from image quality, technical, and physiologic
of at least one grade of of at least two grades of factors should be identified. For patients in whom a consensus grading
intraprosthetic AR resulting in intraprosthetic AR resulting in cannot be determined and there is a need to identify the mechanism
moderate or greater AR moderate or greater to severe and/or quantify the severity of AR, TEE, CMR, or CT is likely required.
AR Each of these modalities has its advantages and limitations (Tables 2 and
3). Note that ASE guidelines describing the assessment of AR after percuta-
In the setting of concomitant stenosis and regurgitation, the criteria neous aortic valve replacement have been published.3
for significant structural valve deterioration may be present at lower
thresholds.
*Criteria assume stable LV function and blood pressure. C. Role of CT in the Evaluation of Prosthetic Aortic Valves
†
Morphologic adverse changes to the prosthesis should be evident. CT is a common adjunct imaging modality in patients with PHV
dysfunction suspected on echocardiography. CT allows the evalua-
regard to detect all sites of paravalvular AR. Last, technical limitations and tion of valve morphology, structural abnormalities, stenotic orifices,
prosthesis-related artifacts with TTE can limit assessment of structural abnor- regurgitant orifices, sewing ring complications, and paravalvular com-
malities related to the mechanism of AR, necessitating the use of other implications. Prospective electrocardiographic triggering is adequate for
aging modalities such as TEE or CT (Tables 2 and 3, Figure 15). assessing morphology, but retrospective gating is essential for dy-
ii. Doppler echocardiography: Color Doppler evaluation of the AR jet re- namic 3D evaluation of the valve and functional quantification. A
quires visualization of the flow convergence, VC, and proximal jet exten-
nonenhanced acquisition is useful for detecting calcifications and
sion into the LVOT and left ventricle. Limitations of this method include
acoustic reverberation and shadowing from the prosthesis that may impair
postsurgical changes, while a delayed phase (60-90 sec) helps in eval-
visualization of the flow convergence and VC regions or assessment of the uating abscess cavities with rim enhancement and thrombus.
jet width in the LVOT. In this situation, the VC width, area, and circumfer- CT has emerged as a useful complementary imaging modality in
ential extent could be assessed from a carefully obtained short-axis view.3 the follow-up evaluation of transcatheter heart valves.110 A more
Similar to native valves, measuring the width of an eccentric jet in the recent application of CT (similar to its use in primary TAVI) is for plan-
outflow tract may overestimate regurgitation severity. Also, entrainment ning of ViV aortic valve implantation. CT is advantageous in prepro-
of the regurgitant jet in the LVOT may result in overestimation because cedural planning as it is less affected by metal-induced artifacts.
of rapid widening of the jet. Conversely, a wall-impinging aortic paravalvu- Displacement of the native aortic valve leaflets during deployment
lar jet may lead to underestimation because of an unimpressive color of the transcatheter valve is associated with a minimal but important
Doppler jet area.
risk for subsequent occlusion of the coronary ostia, with a reported
Semiquantitative and quantitative spectral Doppler methods for grading AR
severity are not affected by the prosthetic aortic valve. The presence of a
incidence of 0.6% to 4.1%.111 Patients with large and heavily calcified
PHT <200 msec or holodiastolic flow reversal in the abdominal aorta sug- valve leaflets and a short distance between the annular plane and the
gests the presence of severe regurgitation (Figure 14). Quantitative param- ostia of the coronary arteries are at greater risk. Hence, it is important
eters such as regurgitant volume are calculated using 2D or 3D methods. to report the distance of coronary ostia from the annular plane.112
Table 7 Doppler parameter criteria of aortic valve and mitral valve PPM
Normal Moderate Severe
Aortic EOA* >0.85 cm /m if

2 2
0.85-0.66 cm /m if
2 2
#0.65 cm2/m2 if
BMI < 30 kg/m2 BMI < 30 kg/m2 BMI < 30 kg/m2
>0.70 cm2/m2 if 0.70-0.56 cm2/m2 if #0.55 cm2/m2 if
BMI $ 30 kg/m2 BMI $ 30 kg/m2 BMI $ 30 kg/m2
Mitral EOA* >1.2 cm2/m2 if BMI 1.2-0.91 cm2/m2 if #0.90 cm2/m2 if
< 30 kg/m2 BMI < 30 kg/m2 BMI < 30 kg/m2
>1.0 cm2/m2 if BMI 1.0-0.76 cm2/m2 if #0.75 cm2/m2 if
$ 30 kg/m2 BMI $ 30 kg/m2 BMI $ 30 kg/m2
BMI, Body mass index.

*Valve structure and motion are normal; measured EOA is within 1 SD of the reference EOA.
Volume 37 Number 1
Figure 14 An example of combined AR and stenosis in a patient with a tissue prosthetic aortic valve (AV). (A) TTE in the apical five-
chamber view during diastole demonstrates a vegetation on the tissue prosthetic AV. (B) The corresponding color Doppler image
demonstrates severe regurgitation. (C) On the CW Doppler image, the PHT is <200 msec, which is consistent with severe regurgita-
tion. (D) A high systolic gradient across the valve is evident. (E) PW Doppler in the proximal descending thoracic aorta demonstrates
flow reversal (arrow). (F) Flow reversal is also seen in the abdominal aorta (arrow). LA, Left atrium; LV, left ventricle; Max, maximal; PG,
pressure gradient; Vmax, maximal velocity; Vmean, mean velocity.
The Role of CT in the evaluation of complications is as follows: referenced lines), anatomic valve area can be planimetered via en
i. Stenosis: CT can help determine whether pathologic causes of face tracing of the largest systolic orifice opening (Figure 18).124 Proper
elevated valve pressure gradient exist. These may be difficult to discern alignment at the leaflet tips is crucial for reproducible and accurate mea-
on TTE and TEE, particularly in mechanical valves. Possible causes surement. This can be done on bioprosthetic valves (in the absence of
include stenosis from structural failure, calcification, obstruction by pan- metal struts), but metallic artifact from mechanical valves precludes
nus or thrombus, or hypoattenuated leaflet thickening with or without the assessment of disk motion.85 Both in vivo and in vitro studies
restricted motion (Figures 7, 15, and 17). have shown strong agreement between CMR and echocardiography,
ii. Regurgitation: Structural failure of a bioprosthetic valve is the most with superior inter- and intraobserver variability of CMR.125 One study
common cause of central pathologic regurgitation and often occurs evaluating 65 bioprosthetic aortic valves showed a strong correlation be-
close to the commissure at the site of a tear in the leaflet. CT permits tween CMR-derived anatomic area and echocardiographic effective
the identification and quantification of a sufficiently large regurgitant area measurements (mean differences, 0.02 6 0.24 cm2 by TTE and
orifice, along with evaluation of its secondary consequences. Measure- 0.05 6 0.15 cm2 by TEE).85 It is imperative to know that the anatomic
ment of regurgitant and stenotic orifice areas with CT shows good accu- valve area is 10% to 20% larger than the effective valve area because of
racy, comparable with that of TTE.113,114 Computed tomographic the flow contraction phenomenon.2
angiography can also identify significant valve dehiscence and complica- b. Phase-contrast imaging: In stenosis, flow turbulence creates signal voids
tions such as pseudoaneurysm formation (Figure 15). Table 9 describes because of proton dephasing.126,127 CMR has the advantage of assess-
the potential role of CT in evaluating various complications of PHVs, re- ing flow in an in-plane phase (like Doppler echocardiography) and
sulting in either stenosis or regurgitation or both. Comparative advan- through-plane phase (perpendicular to the maximal velocity across
tages, limitations, and strengths of CT in relation to TTE and CMR the prosthetic valve). Using two orthogonal in-plane phase-encoding
are detailed in Tables 2 and 3. views (derived from cine three-chamber and aorta coronal views to
see the site of the jet aliasing), a through-plane image is created perpen-
dicular to the aortic stenosis jet and the highest pixel velocity can be
D. Role of CMR in the Evaluation of Prosthetic Aortic measured (Figure 18). A novel CMR-derived EOA was compared
Valves with valve area derived using Doppler echocardiography in native
and prosthetic aortic valves.128,129 Using phase-contrast imaging to
i. Prosthetic aortic valve stenosis assess transvalvular forward flow volume and dividing that by VTI to
a. Anatomic valve area: Using a stack of thin slices (4-5 mm) perpendic- obtain phase-contrast effective regurgitant orifice area (EROA), this
ular to the prosthetic valve in two orthogonal planes (using cross- measurement compared favorably and showed excellent agreement
with the clinical classification of prosthetic aortic valve stenosis
January 2024
Figure 15 A case of a bioprosthetic aortic valve (AV) complicated by a large aortic root pseudoaneurysm imaged with TEE and
computed tomographic angiography. Midesophageal long-axis views (A, B) and short-axis view (C) show a large pseudoaneurysm
(arrows). The valve has evidence of calcification but no discrete vegetations. (B) Same view with color Doppler showing eccentric
paravalvular regurgitation in diastole. (D) Cardiac computed tomographic angiographic sagittal view shows dehiscence below the
left cusp with a large pseudoaneurysm (two red arrows). (E) Modified sagittal view shows circumferential hypodensity on the aortic
root suggestive of root abscess (white arrows). There is mild thickening and calcification of the bioprosthetic AV (visualized in systole).
The pseudoaneurysm is seen over the left sinus (red arrow). Ao, Aorta; LA, left atrium; LV, left ventricle; PrV, prosthetic valve; RA, right
atrium.
severity.129 A novel technique using time-resolved 3D flow mapping volume and hence the fraction (regurgitant volume/forward volume)
(four-dimensional [4D] flow) can visualize turbulent flow with vortex can then be calculated (Figure 9).126,133 An alternative method using
formation pattern and measure pressure-drop estimation in a 3D plane. the difference between forward aortic and net pulmonary flow can
This technique is not widely used and is time consuming.125,130 In gen- be used.133 In addition, the presence of holodiastolic flow reversal in
eral, as data in CMR are averaged over multiple cardiac cycles, arrhyth- the descending aorta has shown excellent sensitivity and specificity
mias and rapid irregular heart rates can introduce measurement errors. for severe regurgitation.134,135
Because of the limited temporal resolution of CMR (from partial vol- Studies comparing echocardiography with CMR in assessing paravalvular
ume effect of high jet velocities), there is an underestimation of regurgitation have yielded different results, with underestimation of regur-
velocities using phase-contrast CMR sequences compared with gitant volumes using TTE and TEE.88 In a recent meta-analysis assessing
Doppler echocardiography.124 AR after TAVI, significant discordance was noted between TTE and
Adverse cardiac effects of chronic LV pressure overload (LV hypertro- CMR; however, TTE was able to discriminate moderate or severe AR
phy, replacement fibrosis) can be accurately assessed with CMR. Focal from mild or none.136 These studies used different cutoff values for
replacement or infarct-like fibrosis (detected by late gadolinium CMR, which could have contributed to the major discrepancies between
enhancement on CMR) has been seen in 30% to 50% of patients both imaging modalities. Limitations of the phase-contrast technique
with aortic stenosis and has been shown to predict worse perioperative include metal-related artifact or nonlaminar flow creating a signal void, ar-
risk and cardiovascular disease–related survival in patients undergoing rhythmias reducing the accuracy of measurements, and lower temporal
TAVI or SAVR.131,132 resolution. In addition, the coronary artery diastolic flow is included in
ii. Prosthetic aortic valve regurgitation: CMR provides an advantage the total regurgitant volume. In the future, evolving techniques such as
over echocardiography in providing absolute regurgitant volumes and frac- 4D flow may provide direct flow assessment in regurgitant lesions.127
tions irrespective of regurgitant jet numbers, eccentricity, or prosthetic valve
type.3,58 In addition, aortic root and aorta anatomy can be simultaneously Overall, suggested indications for CMR in prosthetic aortic valve
assessed in patients with aneurysms and/or aortopathy. Cine SSFP se- assessment are as follows:
quences along with phase-contrast imaging can help delineate trans- or 1. Discrepancy in clinical history and echocardiographic findings or when
paravalvular regurgitant jets, the former causing spin dephasing. Depending imaging quality from TTE or TEE is suboptimal
on the ferromagnetic material in the surgical strut or frame, artifact preclud- 2. Cases in which valve area–gradient mismatch is seen on TTE; CMR is
ing accurate assessment of the origin of regurgitation can be encountered. additive in assessing anatomic bioprosthetic valve area and ensuring
a. Phase-contrast imaging: In-plane phase-contrast imaging can help delin- highest velocity captured across the valve
eate trans- or paravalvular regurgitation using three-chamber and aorta 3. Assessment of aortic root in complicated endocarditis (paravalvular
coronal views. Using through-plane phase-contrast imaging perpendic- extension of disease, pseudoaneurysm or root abscess)
ular to the aortic wall immediately above the prosthetic valve, both an- 4. Quantitation of AR severity
tegrade and retrograde flow can be measured directly. The regurgitant 5. Assessing adverse LV remodeling
Volume 37 Number 1
Table 8 Parameters for evaluation of the severity of prosthetic aortic valve regurgitation
Parameters Mild Moderate Severe
Valve structure and motion

Mechanical or bioprosthetic Usually normal Abnormal* Abnormal*
Structural parameters
LV size Normal† Normal or mildly dilated† Dilated†
Doppler parameters (qualitative or
semiquantitative)
Jet width in central jets, % LVOT Narrow (#25%) Intermediate (26%-64%) Large ($65%)
diameter, (CD)‡
VC width, cm (CD) <0.3 0.3-0.6 >0.6
VC area, cm2 (2D/3D CD)§ <0.10 0.10-0.29 $0.30
Circumferential extent of PVL, % <10 10-29 $30
(CD){k
Jet density (CW) Incomplete or faint Dense Dense
Jet deceleration rate (PHT), msec Slow (>500) Variable (200-500) Steep (<200)
(CW)#
Diastolic flow reversal in the Absent or brief early diastolic Intermediate Prominent, holodiastolic
descending aorta (PW)
Doppler parameters (quantitative)
Regurgitant volume, mL/beat <30 30-59 $60
Regurgitant fraction, % <30 30-50 $50
CD, Color Doppler.
*Abnormal mechanical valves: for example, immobile occluder (valvular regurgitation), dehiscence or rocking (paravalvular regurgitation); abnormal
biological valves: for example, leaflet thickening or prolapse (valvular regurgitation), dehiscence or rocking (paravalvular regurgitation).
†
Applies to chronic, late postoperative AR in the absence of other etiologies.
‡
Parameter applicable to central jets and less accurate in eccentric jets; Nyquist limit of 50 to 60 cm/sec.
§
The VC area is measured by planimetry of the VC of the jet(s) on 2D or 3D CD images in the short-axis view.
{
Measured as the sum of the circumferential lengths of each regurgitant jet VC (not including the nonregurgitant space between the separate jets)
divided by the circumference of the outer edge of the valve.
k
Circumferential extent of PVL best not to be used alone but in combination with VC width and/or area.
#
Influenced by LV compliance.
Key Points and Recommendations for Prosthetic III. EVALUATION OF PROSTHETIC MITRAL VALVES
Aortic Valves
1. Transthoracic echocardiographic assessment of prosthetic valves in the aortic posi-
As with prosthetic aortic valves, the initial assessment of prosthetic
tion can be limited by reverberation and shadowing of the posterior annulus/root. mitral valve function begins with knowledge of the type and size of
TEE is recommended to improve visualization of the posterior annulus/root when the prosthetic valve implanted.
poorly imaged with TTE or if there is concern for posterior annulus/root pathology.
CMR and CT can offer additional information in these situations.
2. Dedicated imaging of mechanical prosthetic aortic valve leaflets is recommended us-
ing radiologic imaging with CT or fluoroscopy when the range of motion cannot be A. Types of Prosthetic Valves in the Mitral Position
determined with echocardiography and there is clinical concern for prosthetic aortic The principal mechanical valve used in the mitral position is a bileaf-
valve obstruction.
3. In assessing prosthetic aortic valve stenosis, it is recommended that Doppler insona- let valve. Bileaflet mechanical valves are prone to pressure recovery
tion be acquired from all possible windows and a small nonimaging probe should be from the small orifice between the two tilting disks, which may
used when possible.
4. In patients with elevated prosthetic aortic valve Doppler gradients, it is recommen-
result in a slight overestimation of the gradient by Doppler and un-
ded that causes such as high-flow states, PPM, supra- or subvalvular obstruction, derestimation of EOA with the continuity equation (Figure 3).
and pressure recovery be excluded. Three-dimensional planimetry of the orifice has been shown to
5. It is recommended to use at least one highly flow-dependent measurement (e.g., peak
velocity, mean gradient) and one less flow-dependent measurement (e.g., EOA, DVI)
correlate well with manufacturer-predicted EOA.137 The EOA of
to assess prosthetic aortic valve stenosis. mechanical mitral valves is in the 2- to 3-cm2 range and the mean
6. For TAVI valves, in-stent flow acceleration occurs below the valve and at the level of gradient ranges from 2 to 3 mm Hg, with some smaller valves hav-
the cusps. It is recommended that the LVOT diameter and velocity measurements be
obtained immediately proximal to the stent to prevent overestimation of the EOA by ing a gradient of up to 5 to 6 mm Hg at physiologic heart rates
flow acceleration within the stent. (Appendix Table A5).
7. Classification of intra- and paravalvular prosthetic aortic valve regurgitation severity
is like that in native valves. If there is a discrepancy between echocardiographic qual-
Mitral bioprosthetic valves are stented only. The classic mitral bio-
itative and semiqualitative AR severity parameters that cannot be explained by image prosthetic valve is a stented heterograft consisting of three biological
quality, technical, or physiologic factors and prevents consensus grading, then TEE, leaflets reconstructed from either porcine aortic valve or bovine peri-
CMR, or CT is required. These additional imaging modalities can also provide infor-
mation on the etiology of the PHV dysfunction.
cardium. The hemodynamics of these surgical valves are similar and
dependent on implant size but have an expected EOA of 2.2 to
January 2024
Figure 16 Suggested algorithm to guide integration of multiple parameters of AR severity after aortic valve replacement. Good-
quality echocardiographic imaging and complete data acquisition are assumed. If imaging is technically difficult, consider TEE or
CMR for evaluation of severity. Regurgitation severity may be indeterminate because of poor image quality, technical issues with
data, internal inconsistency among echocardiographic findings, or discordance with clinical findings. RF, Regurgitant fraction;
Rvol, regurgitant volume; VCA, VC area.
3.5 cm2 and a mean gradient of 3 to 5 mm Hg at physiologic heart pressure gradient; PHT; a statement on the presence or absence of signifi-
rates (Table A5). cant regurgitation, LV, right ventricular (RV), and left atrial size; and, if
Only one prosthesis is currently approved for percutaneous place- possible, estimation of PA pressure and right atrial (RA) pressure. EOA
ment in the mitral position. The Edwards SAPIEN 3 valve is FDA and DVI are particularly important for evaluation of stenosis but can also
provide a clue to the presence of significant MR, which may increase the
approved for percutaneous placement in the mitral position for ViV
gradient and DVI because of high flow through the valve and lower systemic
and valve-in-ring (as of July 2021) implantation. At the time of these
output through the LVOT.
guidelines, it remains off label for valve–in–mitral annular calcifica- Diagnostic criteria of prosthetic mitral stenosis by Doppler
tion. The hemodynamics of the SAPIEN 3 valve in the mitral posi- echocardiography remain similar to the 2009 guidelines
tion138-140 are similar to those of bioprosthetic valves listed above (Table 11). An example of severe prosthetic mitral stenosis is
and are summarized in Appendix Table A6. At the time of writing, shown in Figure 19. Reporting the heart rate at which Doppler
there are several investigational percutaneous mitral valve replace- measurements are performed is important. The main criteria for
ments as well as systems for mitral valve repair. One of these has the diagnosis of significant mitral stenosis are a mean gradient
recently published excellent 2-year outcomes141; however, long- >10 mm Hg at a normal heart rate, a PHT >200 msec, a
term durability has not been established, and none of these valves DVI >2.5, and an EOA <1 cm2.33,52,142,143 The, DVI derived
are currently approved by the FDA. Therefore, for percutaneous as VTI PrMV/VTI LVOT has been shown to be the most specific
mitral valves, we will focus our discussion on the SAPIEN 3 valve and sensitive Doppler parameter for stenosis in one study.143
(Appendix Table A6). Derivation of EOA is covered earlier in the general section on
Doppler. For the mitral valve,
B. Echocardiographic Evaluation of Prosthetic Mitral
Valves EOA = stroke volume/VTI PrMV,
i. Evaluation of prosthetic mitral valve function: Comprehensive eval-
uation of prosthetic mitral valves with echocardiography is summarized in where VTI PrMV is the VTI through the prosthetic mitral valve,
Table 10 and includes the following: heart rate; peak early velocity; mean and stroke volume is measured through the LVOT when there
Volume 37 Number 1
Figure 17 (Panel A) Increased mean gradient (28 mm Hg) and peak velocity of 3.6 m/sec across a 23-mm SAPIEN 3 valve were noted
approximately 4 months following TAVI. Cardiac CT demonstrated hypoattenuated leaflet thickening (HALT; red arrows) with 50% to
75% leaflet involvement (B, C) and hypoattenuation affecting motion (D). After initiation of anticoagulation, mean gradient decreased
to 14 mm Hg (E). Repeat cardiac CT demonstrated resolution of HALT (F, G) with normal leaflet mobility (H).
is no significant AR. Causes of prosthetic mitral stenosis are 3. Low systemic output and VTILVOT despite a hyperdynamic left ventricle
valve degeneration, valve thrombosis, pannus formation, and 4. An elevated VTIPrMV/VTILVOT ratio (>2.5)
5. A large zone of systolic flow convergence seen on the LV side of the
large vegetations. Although Doppler echocardiography is the
mitral prosthesis
mainstay of the diagnosis of stenosis and obstruction, TEE pro- 6. A significant rise in the PA pressure compared with a previous study
vides an en face view of the mitral valve, which is essential for When significant prosthetic or paravalvular MR is suspected on the basis
confirming the diagnosis and evaluating the mechanism of of these parameters, TEE is often helpful to definitively visualize pros-
dysfunction (Figure 19). Other multimodal imaging plays a com- thetic leaflet morphology and leaflet or disk mobility and to quantify
MR severity (Figure 20). Combined transthoracic and transesophageal
plementary role (see below).77,144
echocardiographic parameters and criteria for assessing MR severity are
PPM is significantly less common in the mitral compared with the detailed in Table 13. A suggested algorithm for evaluation of MR
aortic position. However, it may be underdiagnosed. Criteria for severity with echocardiography is shown in Figure 21.
PPM are detailed in Table 7. The clinical outcomes may actually iii. Role of TEE: TEE has a very important role in the evaluation of prosthetic
be worse when present in the mitral position as opposed to the mitral valves. The prosthetic mitral valve can be visualized en face, allowing
aortic, particularly in patients <70 years of age.145 thorough assessment of its structure, mobility of the leaflets or the occluder
ii. Evaluation of prosthetic MR: TTE is indicated for routine surveillance of mechanical valves, and identification of any dehiscence or regurgitation.
and may be the initial test of choice when mitral prosthetic valve dysfunc- TEE is crucial in assessing prosthetic valve regurgitation, particularly in me-
tion is suspected, but visualization of MR jets by TTE is frequently limited by chanical valves where acoustic reverberation and shadowing on TTE is the
acoustic reverberation or shadowing from the mitral prosthesis (Figure 6). rule. Three-dimensional TEE has a pivotal role for diagnosing prosthetic
The parasternal window is often the optimal view for evaluation of pros- mitral valve pathology by providing a full view of the valve, its annulus,
thetic MR jets, although apical views may be helpful to identify a suspected and adjacent structures (Figures 19, 20, and 22). The comparative advantages
eccentric regurgitant jet or paravalvular regurgitation.146 Apical views may and limitations of TEE and other modalities are detailed in Tables 2 and 3.
also provide better visualization of the prosthetic valve leaflets for identifica-
tion of vegetation, thrombus, pannus, or leaflet degenerative changes. C. Role of CT in the Evaluation of Prosthetic Mitral Valves
Given that transthoracic echocardiographic visualization of prosthetic or
paravalvular MR is often limited, it is particularly important to look for indi- i. Valve stenosis: Cardiac CT is a valuable complementary tool for the eval-
rect spectral Doppler evidence of severe MR. Criteria suggesting significant uation of prosthetic mitral valve stenosis given the high spatial resolution and
MR are detailed in Table 12 and include the following: 3D volume acquisition. Retrospective electrocardiographically gated acqui-
sition is typically performed for prosthetic valve evaluation to allow optimal
1. A dense CW MR jet visualization of the prosthetic valve throughout the cardiac cycle; however,
2. An elevation of the mitral E velocity (>1.9 m/sec in mechanical valves)1 the radiation dose is higher than with prospective electrocardiographically
January 2024
Table 9 Potential role of CT in various complications of prosthetic aortic valves
Complication Potential role of MDCT
Mechanical leaflet dysfunction Can evaluate motion and opening angle of mechanical leaflet(s) and compare it with manufacturer’s
specifications
Normal opening angle is 73 -90 for bileaflet valves and 60 -80 for monoleaflet valves
PPM Small EOA, normal leaflet motion, lack of masses, and a small geometric orifice area115
Structural failure Detects valvular calcification despite normal gradients116
Prosthesis dehiscence Identifies a gap between the annulus and prosthesis sewing ring
For the aortic valve prosthesis, excessive sewing ring motion with rocking >15 implies significant
paravalvular regurgitation1
PVL Contrast material–filled channel in the paravalvular region that connects the lumina proximal and distal to the
valve (e.g., for the aortic valve, aorta, and LVOT)
Helps distinguish from pseudoaneurysm and abscess117
Helps distinguish from pledget material (the HU of a pledget are significantly higher than those of contrast
material [383-494 vs 202-367 HU]118)
Endocarditis Large vegetations (>1 cm) seen on the valve leaflet or sewing ring, usually on the ventricular side of the aortic
valve119; generally inferior to TEE for small vegetations (<4 mm) and perforations (<2 mm) but superior in
evaluating paravalvular and extracardiac extension120
CT may show other manifestations of infection such as aortic wall thickening, mediastinal gas, fat stranding,
collections119,120
Pseudoaneurysm Contrast material–filled saccular or fusiform outpouchings arising from the annulus, which may contain
thrombus
With infection, adjacent soft tissue inflammatory changes may be seen
Thrombus Irregular mass commonly mobile, without enhancement, attached to a PHV
Distinguishing from pannus is important
Thrombus is seen more commonly early after surgery, adherent usually to the aortic side of an aortic valve
prosthesis, and has lower attenuation (<200 HU)
Pannus is seen late after surgery, is usually located on the ventricular side, and has higher attenuation (>200
HU)121
A cutoff of 145 HU is useful in distinguishing thrombus from pannus, with 87.5% sensitivity and 96%
specificity121
CT allows prediction of response to thrombolysis. Complete lysis is more common in thrombi with
attenuation less than 90 HU vs 90-145 HU121
HALT and HAM Helps identify HALT, with or without restricted motion, which benefits from anticoagulation122
Aortic dissection Intimal flap with true and false lumina, internal displacement of intimal calcification, delayed enhancement of
the false lumen, widening of the aorta and mediastinum, ulcer-like contrast material projections, and
compression of the true lumen123
HALT, Hypoattenuated leaflet thickening; HAM, hypoattenuation affecting motion; HU, Hounsfield unit; MDCT, multidetector CT.
triggered acquisitions.147-149 If there are no contraindications, b-blockers can ii. Valve regurgitation: Excessive rocking of the mitral valve prosthesis
be administered to decrease the heart rate to a goal of 60 beats/min to during the cardiac cycle is seen in valvular dehiscence. The size of PVL
decrease motion artifacts. Images are reconstructed at 5% to 10% on CT correlated with regurgitant grade on echocardiography in early ob-
increments of the R-R interval to allow evaluation of the prosthetic valve servations, most of which involved significant regurgitation.78 Small PVLs
throughout the cardiac cycle. can be obscured because of metallic artifacts from the prosthetic ring or
Mechanical valve opening and closing angles can be evaluated on non- disk occluders or confused with a pledget. In these situations, confirmation
contrast-enhanced acquisitions such as cine fluoroscopy, but the etiology or exclusion of regurgitation with Doppler echocardiography would be
of limited valve opening cannot be determined.147 Contrast-enhanced ac- important. Pledgets can be identified also with the addition of a noncon-
quisitions can assess bioprosthetic leaflet degeneration (thickening and calci- trast acquisition or careful inspection of the attenuation on the contrast-
fication), leaflet or disk occluder mobility, calcification of the bioprosthetic enhanced acquisition, as a felt pledget may have a higher attenuation
ring, thrombus, pannus, or vegetation.150 The geometric orifice area of the than contrast-enhanced blood.153 Regurgitant orifice area can be
prosthetic mitral valve can be measured using multiplanar reconstruction.151 measured in a systolic phase, with good agreement with TEE and surgical
In mechanical valves, the opening and closing angles in addition to the geo- findings reported.154
metric orifice area can be measured.152 TEE and CT are more accurate in
identifying the etiology of prosthetic mitral stenosis compared with TTE;
CT is more sensitive in the identification of pannus as the cause of valve D. Role of CMR in the Evaluation of Prosthetic Mitral
obstruction.77 There are technical limitations to CT as blooming and Valves
beam-hardening artifacts from the valve ring or disk occluders can impair
evaluation. These metallic artifacts can be reduced by the use of a higher i. Valve stenosis: Assessment of mitral valve stenosis by CMR can be per-
tube voltage and iterative reconstruction.153 formed by three methods: visual assessment of bioprosthetic cusps or occluder
excursion, direct planimetry of the valve orifice of a bioprosthetic valve, or
Volume 37 Number 1
Figure 18 A case of bioprosthetic aortic stenosis evaluated using CMR. (A) Aortic long-axis view on steady-state free precession cine
CMR shows spin dephasing in systole consistent with high velocities from the stenosis. Note the lack of significant metallic artifact.
(B) Double orthogonal view at the valve leaflet tips during maximal systolic opening shows a corresponding short-axis view of the
prosthetic aortic valve and evidence of stenosis with an anatomic valve area of 0.9 cm2. (C, D) Phase-contrast imaging shows de-
phasing at the aortic valve level. Magnitude and phase contrast using a double orthogonal plane at the aortic valve level with a
velocity-encoded CMR velocity of 450 cm/sec shows no aliasing and a peak transvalvular velocity of 4.1 m/sec (white arrow on
the flow graph).
measurement of peak velocity through the prosthesis using phase-contrast im- primary limitation remains susceptibility artifact, especially with mechanical
aging. A combination of three long-axis and short-axis stack images should be valves. For quantification of stenosis severity, the anatomic orifice area can
used for visual assessment. This may identify impaired excursion of the me- be measured on bioprosthetic valves.86,87 If artifact is present that limits assess-
chanical PHVoccluders or leaflets of a bioprosthesis and demonstrate a poten- ment of the leaflets, fast-gradient echo sequences could be considered. The
tial cause of stenosis including pannus, thrombosis, or endocarditis. The
Table 11 Doppler findings suggestive of prosthetic mitral

Table 10 Echocardiographic parameters to evaluate valve stenosis
prosthetic mitral valve function (stenosis or regurgitation)
Suggests
Doppler echocardiography Peak early velocity Possible significant
of the mitral valve Normal* stenosis† stenosis*†
Mean pressure gradient Peak velocity, m/sec ‡§
<1.9 1.9-2.5 $2.5
Heart rate at the time of Doppler Mean gradient, mm Hg‡§ #5 6-10 >10
PHT VTIPrMv/VTI LVOT‡§ <2.2 2.2-2.5 >2.5
DVI (VTIPrMV/VTILVOT) EOA, cm2 $2.0 1-2 <1
EOA* PHT, msec <130 130-200 >200
Presence, location, and severity of
VTIPrMV, VTI through the prosthetic mitral valve.
regurgitation
*For either mechanical or bioprosthetic valves; diagnostic accuracy
Other pertinent LV size and function is best if most of the parameters listed are normal or abnormal, respec-
echocardiographic tively.
parameters †
Values of the parameters should prompt a closer evaluation of valve
Left atrial size function and/or other considerations such as increased flow,
RV size and function increased heart rate, or PPM.
‡
These parameters are also abnormal in the presence of significant
Estimation of PA pressure
prosthetic MR.
§
VTIPrMV, VTI through the prosthetic mitral valve. Slightly higher cutoff values than shown may be seen in some bio-
*Using the continuity equation. prosthetic valves.
January 2024
Figure 19 A case of severe mechanical mitral valve stenosis secondary to thrombus formation. (A) Two-dimensional TEE, mideso-
phageal view in diastole, shows restricted disk motion (yellow arrow) with high inflow color aliasing (B) and severe prosthetic stenosis
(mean gradient, 29 mm Hg at a heart rate of 86 beats/min) on CW Doppler (C). (D) Real-time 3D TEE of the mechanical mitral valve (en
face view) showing restricted disk motion in diastole (red arrow) and two immobile masses (circles) along the hinge points of the me-
chanical valve.
major limitation with this technique is the assumption that the narrowest area is the ability to measure VTI and to calculate mitral valve area.87 The major chal-
in a single plane, which often is not the case. However, prior small studies have lenge with this approach is the through-plane motion of the annulus, making it
shown high feasibility, good interobserver variability, and agreement with challenging to measure velocity at the same location over the cardiac cycle.
CMR mitral valve planimetry and echocardiography-measured mitral valve Furthermore, this approach is limited with mechanical valves because of sus-
area using PHT.86 Another potential method to assess bioprosthetic valve ste- ceptibility artifacts. Overall clinical validation of methods to assess prosthetic
nosis is to obtain through-plane phase-contrast images perpendicular to the mitral stenosis remains limited.
transprosthetic inflow jet at the level of the valve tips. The Nyquist limit should ii. Valve regurgitation: Prosthetic valve regurgitation can be visually assessed
be carefully chosen to ensure lack of aliasing. Planimetry of the flow area will by the presence of CMR-induced intervoxel dephasing in the left atrium on
provide measurement of peak velocity, with recent in vitro data demonstrating SSFP cines.155 The jet size can be graded in relation to the area of the left
Table 12 Transthoracic echocardiographic findings suggestive of significant prosthetic MR in mechanical valves with normal PHT
Finding Sensitivity Specificity Comments
Peak mitral velocity $1.9 m/sec* 90% 89% Also consider high flow, PPM
VTIPrMV/VTILVOT $ 2.5* 89% 91% Measurement errors increase in atrial fibrillation because of
difficulty in matching cardiac cycles; also consider PPM
Mean gradient $ 5 mm Hg* 90% 70% At physiologic heart rates; Also consider high flow, PPM
Maximal TR jet velocity >3 m/sec* 80% 71% Consider residual postoperative pulmonary hypertension or other
causes
LV stroke volume derived by 2D or 3D Moderate sensitivity Specific Validation lacking; significant MR is suspected when LV function
echocardiography is >30% higher than is normal or hyperdynamic and VTILVOT is small (<16 cm)
systemic stroke volume by Doppler
Systolic flow convergence seen in the left Low sensitivity Specific Validation lacking; technically challenging to detect readily
ventricle toward the prosthesis
VTIPrMV, VTI through the prosthetic mitral valve.
*Data from Olmos et al.33 When both peak velocity and VTI ratio are elevated with a normal PHT, specificity is close to 100%.
Volume 37 Number 1
Figure 20 A case of paravalvular MR in a mechanical valve. (A) Apical four-chamber view shows acoustic reverberation behind the
mechanical mitral valve (MV) in systole (arrow). (B) Color Doppler shows eccentric MR (arrow); artifact makes its origin and extent
difficult to ascertain. (C) Spectral Doppler shows elevated velocities and gradient across the valve (mean gradient, 9 mm Hg at a heart
rate of 87 beats/min) with VTIMV of 52 cm. (D) Spectral PW Doppler in the LVOT shows reduced velocity and VTI of 17 cm. A ratio of
prosthetic MV VTI to VTILVOT of 3 alerts to the presence of concomitant regurgitation in the absence of mitral stenosis inferred from a
normal PHT. (E) Midesophageal TEE shows two paravalvular regurgitant jets (arrows). (F) Three-dimensional TEE shows a wide-open
valve in diastole. (G) Three-dimensional TEE with color shows two PVLs, one at 11 o’clock and the other at 5 o’clock (circles). The third
more central jet is a washing jet, as seen in (E). LA, Left atrium; LV, left ventricle
atrium (mild, less than one third; moderate, one third to two thirds; severe, Key Points for Assessing Prosthetic Mitral Valves
more than two thirds) and has good agreement with echocardiography, espe- 1. Assessment of prosthetic mitral valve function begins with knowledge of the type
cially for more than moderate MR.155 Although intervoxel dephasing may be and size of the prosthetic valve implanted.
the first sign of bioprosthetic MR, it may not be reliably identified, because of 2. Structural and hemodynamic evaluation with TTE and TEE provides key understand-
ing of the function of the prosthetic mitral valve.
susceptibility artifacts from the PHV. The cine images may also help identify
3. From the Doppler interrogation of prosthetic mitral valves, peak velocity, mean
mechanisms of regurgitation such as dehiscence, vegetation, or abscess. How- gradient, PHT, EOA or DVI, and heart rate should be measured whenever feasible
ever, the strength of CMR is in quantitative assessment of MR by measure- and reported.
ment of regurgitant volume and fraction. This is best achieved using an 4. Because of shadowing and flow masking in the left atrium, particularly in mechanical
mitral valves, significant prosthetic MR may be missed with color Doppler on TTE.
indirect method. Ideally this should include planimetry of the left ventricle us-
Clues for significant MR from spectral Doppler include increased mitral peak early ve-
ing SSFP cines to measure LV total stroke volume; aortic forward stroke vol- locity, mean gradient, DVI, and a relatively low systemic stroke volume in relation to
ume is calculated using through-plane phase-contrast images at the level of total LV stroke volume. TEE is indicated in suspected cases of significant MR.
the proximal ascending aorta. The difference between LV total stroke volume 5. TEE (2D and 3D) provides an en face view of the prosthetic mitral valve which allows
the evaluation of valve structure, occluder motion, and the presence, location, and
and aortic forward stroke volume is the MR volume.88 Dividing the regurgi-
extent of valvular regurgitation; the latter are crucial in guiding interventional pro-
tant volume by total LV stroke volume provides the regurgitant fraction. If cedures.
aortic phase-contrast data are not available, through-plane phase-contrast im- 6. CT and CMR provide complementary evaluation of prosthetic mitral valves, particu-
ages at the pulmonary valve can also be used. A potential limitation of this larly when further information is needed regarding prosthetic structure, function, or
associated complications. CT allows the evaluation of valve structure and mechanical
strategy is the risk for susceptibility artifact at the basal short-axis cine images
valve occluder motion, as well as the localization of significant paravalvular regurgi-
from the PHV, reducing the accuracy of the LV total stroke volume quantifi- tation and identification of associated complications. CMR allows the evaluation of
cation. Finally, in the absence of phase-contrast data and tricuspid, pulmonary, valvular structure of bioprosthetic valves and is particularly helpful in quantitation
or aortic regurgitation, the difference between LVand RV total stroke volumes of prosthetic MR and LV remodeling.
can be used to quantify regurgitant volume and fraction.88
January 2024
Table 13 Echocardiographic criteria for severity of prosthetic mitral valve regurgitation using findings from TTE and TEE
Mild Moderate Severe
Structural parameters
LV size Normal* Normal or dilated Usually dilated†
‡ §
Prosthetic valve Usually normal Abnormal Abnormal§
Doppler parameters
Color flow jet area‡{ Small, central jet (usually <4 cm2 or Variable Large central jet (usually >8 cm2 or >50%
<20% of LA area) of LA area) or variable size wall-
impinging jet swirling in left atrium
Flow convergencek None or minimal Intermediate Large
Jet density (CW)‡ Incomplete or faint Dense Dense
Jet contour (CW)‡ Parabolic Usually parabolic Early peaking: triangular
‡ # #
Pulmonary venous flow Systolic dominance Systolic blunting Systolic flow reversal**
Quantitative parameters††
VC width (cm)‡ <0.3 0.3-0.69 $0.7
RVol, mL/beat <30 30-59‡‡ $60‡‡
RF, % <30 30-49 $50
EROA, cm2 <0.20 0.20-0.39 $0.40
MV, Mitral valve; RF, regurgitant fraction; RVol, regurgitant volume.
*LV size applied only to chronic lesions with progressive enlargement.
†
In the absence of other etiologies of LV enlargement and acute MR.
‡
Parameter may be best evaluated or obtained with TEE, particularly in mechanical valves.
§
Abnormal mechanical valves: for example, immobile occluder (valvular regurgitation), dehiscence or rocking (paravalvular regurgitation);
abnormal biological valves: for example, leaflet thickening or prolapse (valvular), dehiscence or rocking (paravalvular regurgitation).
{
At a Nyquist limit of 50-60 cm/sec.
k
Minimal and large flow convergence defined as a flow convergence radius <0.4 and $0.9 cm for central jets, respectively, with a baseline shift at a
Nyquist limit of 40 cm/sec; cutoffs for eccentric jets may be higher.
#
Unless other reasons for systolic blunting (e.g., atrial fibrillation, elevated left atrial pressure).
**Pulmonary venous systolic flow reversal is specific but not sensitive for severe MR.
††
These quantitative parameters are less well validated than in native MR.
‡‡
Regurgitant volume cutoffs may be lower in low-flow conditions.
IV. EVALUATION OF PROSTHETIC PULMONARY VALVES a biologic tissue (e.g., homograft, xenograft). Stented biologic prosthe-
ses are generally implanted for pulmonary valve regurgitation, which
The native pulmonary valve is located anterior and superior to the most commonly occurs in patients who have previously undergone
aortic valve and is best visualized with TTE using the RVOT view RVOT reconstruction.156
from the parasternal window (modified from the parasternal short- Transcatheter PVR was first reported in 2000 and has since
axis view at the aortic valve level) or subcostal window. The prosthetic become a viable alternative to surgical PVR in select patients.157
valve is not always in the same position as the native pulmonary valve, Outcomes for both types of interventions are favorable and compara-
especially when a conduit is involved. It is important to understand ble, with transcatheter PVR associated with shorter hospital stays and
that off-axis views may be necessary when using echocardiography. periprocedural complications but higher rates of endocarditis.158 The
CT and CMR provide improved spatial resolution and should be number of PVR procedures has increased over the years, with a
used to complement the echocardiographic findings. When assessing consistently increasing trend in surgical PVR.159 Additionally, the
the pulmonary valve prosthesis, additional information on anatomy age at PVR is markedly heterogeneous among centers across the
of the RVOT and PA as well as RV size, function, and pressures are United States, with administrative data indicating an overall increase
important to include. in younger patients receiving a PVR over time.160 Trends suggest
that more absolute numbers of adult patients are likely to present
A. Surgical and Transcatheter PVR for evaluation of pathologic complications of replaced prostheses. It
is important to understand the types of surgical and transcatheter re-
The native diseased pulmonary valve may be replaced either by a
placements to better understand the risk for complications.
valved conduit for complete repair of a congenital defect or by a pros-
thetic valve without a conduit in isolated valve pathology. The most
common indication for a valved conduit is tetralogy of Fallot. Other B. Evaluation of Prosthetic Pulmonary Valve Stenosis
indications include the Rastelli procedure (transposition of the great
i. Echocardiographic and Doppler evaluation: When characterizing
arteries with ventricular septal defect) or as part of a Ross procedure
the severity of prosthetic stenosis, it is important to remember that high
(congenital aortic valve stenosis) or Yasui repair (interrupted aortic flow velocities may be encountered in locations other than the prosthetic
arch with diminutive ascending aorta). The valved conduit is generally valve. Branch vessel stenosis or conduit edge stenosis may also be present
Volume 37 Number 1
Figure 21 Suggested algorithm to guide integration of multiple parameters of MR severity after mitral valve replacement. Good-
quality echocardiographic imaging and complete data acquisition are assumed. If imaging is technically difficult, consider TEE or
CMR for evaluation of severity. MR severity may be indeterminate because of poor image quality, technical issues with data, internal
inconsistency among echocardiographic findings, or discordance with clinical findings. LA, Left atrial; PISA, proximal isovelocity sur-
face area; RF, regurgitant fraction; Rvol, regurgitant volume; VCA, VC area; VCW, VC width.
and confound CW Doppler interrogation of velocities across the prosthetic impact on the right ventricle are also indicators of an obstructive lesion.
valve. Previous ASE guidelines have described the general imaging consider- Quantitative parameters are generally limited to peak velocity and mean
ations and challenges of evaluating PVR, including the unconventional gradient (Figure 23). Interestingly, there are data to suggest that normally
shape of the RVOT, the location of the prosthesis, and association with sur- functioning mechanical prostheses are more likely to have lower peak veloc-
gically placed conduits.1 Echocardiographic assessment of valve obstruction ity and mean gradient compared with biologic valves in the pulmonary po-
should include (1) characterization of the type and size of prosthesis as noted sition.163 Indicators of prosthetic stenosis are provided in Table 15.
in Table 14, (2) observation of qualitative indicators of obstruction ii. Role of TEE and 3D: TEE can be challenging when evaluating a PVR, as
(e.g., thrombus, pannus), (3) quantitation of severity of stenosis, and (4) the pulmonary valve is an anterior structure and if there is a conduit, the
any changes from previous assessments in serial examinations. In addition, location is atypical. Classically, TEE of the pulmonary valve is in the mide-
RV systolic pressure should be determined using the jet of TR, if present. sophageal view with the transducer angle at 50 to 70 or from the deep
Of note, PA systolic pressure in the presence of PVR stenosis is the difference transgastric view with transducer angle approximately 50 to 90 .164 It is
between RV systolic pressure and the gradient across the obstructed valve. helpful to use color Doppler to locate the prosthesis and to pan from
Biologic prostheses remain the most common type of PVR. However, these 0 to 90 to find the best angle, especially in congenital heart disease
valves are likely to eventually fail and require replacement. Mechanical pros- (CHD). PW and CW Doppler are important to evaluate for valve or conduit
theses are infrequently implanted in this position, thus data on pathology stenosis. Live 3D or 3D zoom using the midesophageal view with the trans-
affecting these valves is sparse. Given that a younger age at PVR is prognostic ducer angle at 50 to 70 can be used to display the en face view of the pul-
of prosthetic valve failure and that more PVR procedures are being per- monary valve from the PA side or the RVOTside with rotation to display the
formed in younger individuals, prosthetic pulmonary valve stenosis will anterior leaflet at the 12 o’clock position.26 Multiplane reconstruction of the
become more common.161 Prosthetic valve failure or dysfunction predom- 3D data set can quickly be used to evaluate the commissures of the three
inantly manifests as stenosis rather than regurgitation, with an approximately leaflets for calcification or fusion in addition to tracing the valve orifice.165
80% incidence within 10 years of initial implantation.161 When endocarditis For percutaneous pulmonary valve reimplantation, ICE provides better
occurs in PVR or conduits, obstruction at the time of diagnosis is more com- visualization of the homograft or conduit and may identify infective endo-
mon than severe regurgitation: 53% vs 29%, respectively.162 Identifying the carditis associated with the prosthetic valve.166,167
location of stenosis is important, as the obstruction may occur further along a iii. Role of CMR: Cine imaging with SSFP or gradient echo allows visualiza-
conduit or in the PA rather than at the valve. PW Doppler is helpful in deter- tion of the pulmonary prosthesis, the right ventricle, and the PA with its
mining the precise location of obstruction. Narrowing of the conduit and bifurcation. Black blood imaging or gated turbo (fast) spin-echo can be
January 2024
Figure 22 Transesophageal echocardiographic images of a bioprosthetic mitral valve (PrMV) stenosis at baseline and after trans-
catheter ViV insertion. Baseline 3D transesophageal views (A) show thickened leaflets with severely restricted opening in diastole
and a mean diastolic gradient (Gr) of 8 mm Hg. (C) After transcatheter ViV deployment, the transcatheter valve is well seated with
normal leaflet opening in diastole, no significant prosthetic or paravalvular regurgitation, and a mean transvalvular Gr of 4 mm Hg
(D). Max, Maximal; PG, pressure gradient; Vmax, maximal velocity; Vmean, mean velocity.
used if there is stent artifact and allows assessment of the vessel, as it has obtains a 3D data set that can be used to further identify the areas of ste-
decreased sensitivity to metal artifacts, with the limitation of being a static nosis. Late gadolinium enhancement with long T1 times can be used to
image.168 Through-plane phase-contrast imaging through the prosthesis al- identify thrombus as a cause of stenosis.127,170 CMR cannot be used to
lows assessment of the peak velocity through the valve, conduit, and/or the accurately assess calcification of the prosthesis or conduit.
main PA or PAs separately. If there is a stent artifact, phase contrast can be iv. Role of CT: When significant stent-related artifact prevents adequate assess-
placed just proximal and distal to the stent artifact.169 The peak velocity ment on CMR, CT can be used to evaluate the pulmonary valve or conduit
generally is slightly lower than that obtained by Doppler echocardiography (Figure 24).171 This can be helpful when the etiology of stenosis is not clear or
at an optimal angle. Contrast-enhanced magnetic resonance angiography for evaluation for percutaneous structural intervention.
Table 14 Most common types of PVR
Type of valve/conduit Manufacturer; size (valve or conduit diameter)
Surgical Homograft (cryopreserved aortic or pulmonary) Variety of sizes

Xenograft conduits Medtronic Contegra; 12-22 mm
Shelhigh; 10-24 mm
Medtronic Freestyle; 19-29 mm
Composite synthetic conduits with Carpentier-Edwards Porcine valve; 12-30 mm
bioprosthetic/mechanical valves
Medtronic Hancock; 12-26 mm
Manually constructed; various sizes
Bioprosthetic or mechanical valves Variety of types and sizes
Transcatheter Within conduits or bioprosthetic valves Medtronic Melody; 18 mm
Edwards SAPIEN; 23-29 mm
In native outflow tract Medtronic Harmony; 22 and 25 mm
Volume 37 Number 1
Figure 23 Examples of a normally functioning prosthetic pulmonary valve (A, B) and another with significant stenosis (C, D).
PkV, Peak velocity through the pulmonary valve.
Electrocardiographically gated contrast-enhanced whole–cardiac cycle im- for other causes of stenosis.172 Cardiac CT may be used to determine the size
aging is recommended, particularly where percutaneous intervention is of the valve or conduit using the effective diameter derived from area or
required. The presence of calcification is indicative of structural valvular perimeter measurement if previous surgical notes are not available. However
degeneration but cannot be used for quantitation of the degree of stenosis. it should be noted that these measurements are less accurate in conduits,
The presence of cusp thickening, pannus, or thrombus can also be assessed where postoperative calcification can lead to alterations in size and shape.173
Table 15 Parameters for prosthetic pulmonary valve stenosis
Normal Possible obstruction
Qualitative Normal valve structure and motion Abnormal valve structure and motion
Laminar flow Use PW Doppler to determine the location of stenosis
Increased turbulence by color Doppler with a narrow flow jet
Quantitative* Peak velocity Peak velocity
<3.2 m/sec for bioprosthesis $3.2 m/sec for bioprosthesis
<2.5 m/sec for homograft $2.5 m/sec for homograft
Mean gradient Mean gradient
<20 mm Hg for bioprosthesis $20 mm Hg for bioprosthesis
<15 mm Hg for homograft $15 mm Hg for homograft
Serial comparison with baseline Stable peak/mean gradient and peak velocity Increased peak/mean gradient and peak velocity
No change in RV systolic pressures Increased RV systolic pressure
No change in RV size and systolic function Increased RV size and decreased systolic function
No change in DVI Decrease in DVI
*Measurements assume normal RV stroke volume. Accurate CW Doppler may be challenging because of the position of the homograft or bio-
prosthetic valve; important to use off-axis parasternal and suprasternal views. Normal values for various prosthetic PVs are shown in Appendix Table
A7.
January 2024
Figure 24 A case of tetralogy of Fallot with a 20-mm homograft placed 25 years earlier. CMR phase contrast systolic and diastolic
flow (left) shows significant stenosis and regurgitation (4.1 m/sec, with a regurgitation fraction of 41%). Computed tomographic angi-
ography with multiplanar reconstruction (panels) shows stenosis of the homograft (14 15 mm) secondary to calcification. The yellow
arrows point to the pulmonary homograft. Ao, Aorta; RV, right ventricle.
C. Evaluation of Prosthetic Pulmonary Valve Regurgitation Echocardiographic assessment of PR should include (1) characterization of
the type and size of prosthesis; (2) the presence of relevant anatomic abnor-
i. Echocardiographic and Doppler evaluation: There is a paucity of data malities, such as degeneration or vegetations; (3) quantitation of severity of
specifically evaluating PR in prosthetic valves; therefore, the information regurgitation; and (4) any changes from previous assessments in serial exam-
available is extrapolated from assessment of PR in native valves. Table 16 de- inations. Additionally, assessment of the RV size and interventricular septal
tails the echocardiographic findings in various degrees of prosthetic PR position and motion during diastole is needed.
severity, and Table 17 shows the pros and cons of each imaging modality in As discussed previously, prosthetic pulmonary stenosis occurs more
assessing PR. frequently than regurgitation in both degeneration and endocarditis.
Table 16 Echocardiographic evaluation of severity of prosthetic pulmonary valve regurgitation
Valve structure Usually normal Abnormal or valve dehiscence Abnormal or valve dehiscence
RV size Normal* Normal or dilated* Dilated or progressive dilation†
Jet size by color Doppler Thin with a narrow origin; jet Intermediate; jet width 26%- Usually large, with a wide
(central jets)‡ width #25% of pulmonary 50% of pulmonary annulus origin; jet width >50% of
annulus pulmonary annulus; may be
brief in duration
Jet density by CW Doppler Incomplete or faint Dense Dense
Jet deceleration rate by CW Slow deceleration Variable deceleration Steep deceleration,§ early
Doppler termination of diastolic flow
Pulmonary systolic flow Slightly increased Intermediate Greatly increased
compared with systemic
flow by PW Doppler{
Diastolic flow reversal in the None Present Present
distal main PA
Adapted from Zoghbi et al.1
*Unless other cause of RV dilatation exists, including residual postsurgical dilatation.
†
Unless there are other reasons for baseline RV enlargement. Acute PR is an exception. RV volume overload is usually accompanied with typical
paradoxical septal motion.
‡
At a Nyquist limit of 50-60 cm/sec; parameter applies to central jets and not eccentric jets.
§
Steep deceleration is not specific for severe PR, as it may occur with severe RV diastolic dysfunction.
{
Cutoff values for regurgitant volume and fraction are not well validated.
Volume 37 Number 1
Table 17 Prosthetic pulmonary valve assessment and multimodality imaging: advantages and limitations
Echocardiography CMR CT
Primary valve Advantages Advantages Advantages

failure Qualitative assessment of Spatial resolution Spatial resolution
regurgitation/stenosis Quantification of stenosis/ Visualization of leaflets for stenosis
Assessment of peak/mean regurgitation Assessment of calcification of
gradients Quantification of RV volume/ valve/conduit
Assessment of RV hemodynamics function Anatomic visualization of PA/
Limitations Anatomic visualization of PA/ bifurcation
Challenging to be coaxial to PVR bifurcation Limitations
Challenging to evaluate PA Limitations Assessment of regurgitation
stenosis Some valves can create artifacts No hemodynamic assessment
Radiation/contrast use
Thrombosis Advantages Not ideal for assessment Advantages
/Pannus Qualitative assessment Good visualization and spatial
regurgitation/stenosis resolution
Assessment of peak/mean Differentiates between thrombus
gradients and pannus
Assessment of RV hemodynamics Limitations
Limitations Radiation/contrast
Difficult to visualize valve structure
Endocarditis Advantages Not ideal for assessment of small Not ideal for assessment of small
Temporal resolution vegetations vegetations
Qualitative assessment of
regurgitation/stenosis
Limitations
Dependent on acoustic windows
However, when a valved conduit is present, both stenosis of the conduit and Table 18 Echocardiographic parameters required for
regurgitation of the valve can occur (Figure 23). Color, PW, and CW Doppler comprehensive prosthetic TV assessment
are used to assist with the evaluation (Table 16). Color Doppler demonstrates
Size and type of prosthesis,
diastolic flow into the RVOT, and jet duration and jet width assist in deter-
Standard parameters and implantation date
mining the severity. Severe PR has a short jet duration, as the PA and RV dia-
stolic pressures equalize quickly, making it challenging to visually appreciate 2D or 3D imaging Heart rate and blood pressure
the PR. A color jet width >50% of the prosthesis annulus suggests severe PR.
Leaflet thickening/mobility
These parameters are less reliable in eccentric and paravalvular regurgitation.
Reversal of flow in the distal main PA by PW Doppler is suggestive of at least Mechanical occluder mobility
moderate PR. A brief diastolic deceleration time is also suggestive of severe Presence of thrombus, vegetation,
PR, but this is also dependent on the compliance of the right ventricle. In a or pannus
study comparing CMR with echocardiography, a PHT <95 msec and a slope Prosthesis stability/dehiscence
>4.9 m/sec2 indicated a need for pulmonary valve intervention.174 There are
Color Doppler Regurgitant jet location (central,
limited methods for quantification of PR that can be extrapolated to pros-
eccentric, or paravalvular)
thetic valves. A comparison of stroke volume obtained just below the PVR
and stroke volume obtained at the aortic or mitral valve can provide a mea- Proximal flow convergence location,
surement of regurgitant volume and fraction (in the absence of AR or MR, radius
respectively). A regurgitant fraction <30% is considered mild, and >50% is Regurgitant jet VC
considered severe.1 Regurgitant jet area
ii. Role of TEE and 3D: The use of TEE described previously in the section
CW Doppler Peak and mean diastolic gradient
on pulmonary stenosis can help evaluate the severity of PR (Table 17).3
Prosthetic valves can have calcification and thrombus, which are better visu- PHT
alized using TEE. The evaluation of PR using 3D TEE can also be achieved DVI (VTIPrTV/SVLVOT)
with live 3D, 3D zoom, or multiplanar reconstruction. The added value of EOA
3D TEE is to see the valve en face with the regurgitant orifice.26 ICE may be
Peak TR velocity
a consideration in evaluating a PVR when TEE is inconclusive.166,167
iii. Role of CT: Although CT can be used to detect leaflet mobility and the TR contour and density
presence of prolapse, its temporal resolution is limited. Furthermore, Related cardiac chambers RA, RV size and function
although the anatomic regurgitant orifice area has been demonstrated as a Size and respiratory variation of IVC
useful tool for the quantification of AR, no studies are available for PR. How-
Hepatic vein flow profile
ever, CT may be useful for the precise localization and sizing of PVLs.78
iv. Role of CMR: The benefit of CMR for assessment of regurgitation is IVC, Inferior vena cava; SV, stroke volume; VTIPrTV, VTI through the
quantification using phase-contrast imaging (Figure 24).169 CMR is prosthetic TV.
January 2024
Figure 25 Transthoracic (A, B) and transesophageal (C, D) imaging of a patient with severe bioprosthetic TV stenosis. (A) Color-
compare diastolic image showing the calcified and restricted leaflets (yellow arrow) with turbulent diastolic flow. CW Doppler
(B) shows a peak velocity of 3.0 m/sec, with a mean gradient of 20 mm Hg. The transesophageal systolic image shows concomitant
TR (red arrows) in the setting of markedly restricted bioprosthetic leaflet mobility. Three-dimensional imaging confirms severe
restriction of all three leaflets with a small diastolic orifice (blue arrow). RA, Right atrium; RV, right ventricle.
Table 19 Doppler parameters suggestive of prosthetic TV Key Points for Assessing Prosthetic Pulmonary
stenosis Valves and Conduits
1. Assessment of a prosthetic pulmonary valve requires an understanding of the
Bioprosthetic Mechanical different types of valves and valved conduits that are placed.
2. Evaluation with echocardiography may require off-axis, unconventional views.
Peak E velocity, m/sec) $2.1 $1.9 3. Doppler-derived peak velocity and mean gradient (and possibly DVI) where feasible
should be measured and reported.
Mean gradient, mm Hg $9 $6 4. For valve regurgitation, color Doppler interrogation, spectral Doppler recording of
PHT, msec $200 $130 the jet with attention to its intensity and slope are necessary.
5. CT and CMR offer better delineation of prosthetic pulmonary valves regarding
EOA, cm2 <1.5 <2.0 thrombus and calcification. CMR is particularly helpful in quantitation of PR.
DVI (VTIPrTV/VTILVOT)* $3.3 $2.1 6. There is a paucity of data evaluating PR in prosthetic valves; the information available
is mostly extrapolated from assessment of native valves.
VTIPrTV, VTI through the prosthetic TV.
*Assessed in the absence of AR or TR. Upper limits of normal DVI
vary by valve size and type.
V. EVALUATION OF PROSTHETIC TRICUSPID VALVES

superior to echocardiography for quantification of PR.168 On the basis of
measured regurgitant fraction, the severity of PR is mild when <26%, mod- Evaluation of the TV is in evolution, as the once ‘‘forgotten’’ valve has
erate when 26% to 35%, and severe when >35%.175 Other investigators
received greater attention following natural history studies showing
consider a regurgitant fraction >40% as severe.176 Phase-contrast CMR is
poor outcomes associated with progressively worse disease.177,178
not affected by multiple or eccentric jets. The through plane can be placed
outside of the valvular artifact if need. Newer sequences such as 4D flow Given the current guideline recommendations,5 the majority of TV
can be used to better understand the direction of the flow and quantitate repairs or TV replacements (TVRs) are performed at the time of left
the regurgitation, however its reliability has not been proven at this time. heart surgery, most commonly mitral valve surgery alone.179
Additionally, quantification of RV volumes is important in the assessment Almost 90% of TV procedures in the United States are repairs, with
of PR and is best evaluated using CMR. a decline in the number of replacements over the past decades. For
Volume 37 Number 1
Figure 26 Example of bioprosthetic TV with severe regurgitation. TEE shows multiple vegetations (red arrows, A and B) on the bio-
prosthetic TV, resulting in severe regurgitation (C). CW Doppler (D) shows a low-velocity dense and early systolic peaking profile. PW
Doppler of the hepatic vein (E) shows systolic flow reversal (arrows) consistent with severe regurgitation. RA, Right atrium; RV, right
ventricle.
isolated TV procedures, however, replacements continue to predom- Doppler, a minimum of five cardiac cycles should be averaged in atrial
inate, likely related to the late presentation of isolated disease.180 fibrillation and sinus rhythm, or measurements can be performed in
Although the majority of TVRs are bioprosthetic, meta-analyses midexpiratory apnea.1 PHT is influenced by heart rate, chamber
suggest that there is an equal risk for 30-day and late mortality, reop- compliance, and loading conditions and thus should be interpreted
eration, and 5-year valve failure in patients with mechanical vs biolog- with caution when used as a stand-alone indicator of TV function.
ical TVR.181 Some investigators have shown that bioprosthetic In addition, the PHT-derived EOA calculation overestimates TV
degeneration rate is steeper after 7 years.182 area for bioprosthetic valves compared with continuity equation–
Prosthetic valves and prosthetic rings have different presentations derived methods and is not recommended.192
and modes of failure. Surgical bioprostheses can fail because of pros- The new ASE guidelines for performance of a comprehensive TEE
thetic stenosis or regurgitation. The mean time period between before structural valve intervention suggest strategies for complete
tricuspid bioprosthesis implantation and dysfunction requiring ViV visualization of the native TV.193 In general, these same strategies
implantation was 12 years (range, 3-32 years).183 Longitudinal studies should be used to assess prosthetic TVs. Guidelines have suggested
of TV repairs have shown that significant recurrent regurgitation oc- standardized imaging display for the en face view of the native TV
curs within 5 to 7 years of repair.184,185 and the same standards should be used for en face display of TV pros-
In the setting of inpatient mortality of 10% to 13% associated with thetic valves.26,194 Imaging the TV with TEE may be more difficult
both isolated and redo TV surgery,180,186 transcatheter options have than with TTE because of the position of the valve relative to the
become more common to address both native TV and prosthetic de- esophagus (anterior and medial). Acoustic noise from the fibrous
vice failure.183,185,187,188 The assessment of prosthetic TV function body of the heart, as well as left heart prosthetic material, makes
thus involves the evaluation of surgical and transcatheter TV repair TEE from the midesophageal views particularly problematic.
and replacement, as well as ViV and valve-in-ring procedures. Imaging from deep esophageal or transgastric transducer positions
places the probe closer to the TV and can therefore eliminate both
A. Echocardiographic Assessment of Prosthetic TV shadowing caused by left heart structures and far-field attenua-
Function tion.92,194 Understanding these limitations can help determine the
optimal image plane for detection of specific abnormalities.68,195,196
The comprehensive evaluation of TVR requires multiple imaging
planes where both 2D and 3D echocardiography are used B. Evaluation of Prosthetic TV Stenosis
(Table 18). TTE of the TVR is particularly useful because of the ante-
rior position of the valve. All standard imaging planes for native TV i. Echocardiographic evaluation: TVR may fail early or late after implan-
assessment should be performed.189 Native and prosthetic TV veloc- tation. Echocardiographic evaluation of prosthetic TV function includes
ity varies with cycle length and respiration and therefore multiple car- assessment of the parameters listed in Table 18. Two-dimensional or 3D im-
diac cycles should be obtained by Doppler.190,191 For PW and CW ages demonstrating thickened and/or restricted motion of bioprosthetic
January 2024
Table 20 Echocardiographic parameters for determining prosthetic TV regurgitation: advantages and limitations
Parameter Advantages Limitations
TV morphology (e.g., flail leaflet, Abnormalities should be seen if severe Influenced by machine settings and
perforation, dehiscence) TR is present physics of ultrasound (e.g., depth,
acoustic artifact by prosthetic material)
RA and RV size and function Dilatation of both right atrium and right Underlying pathology of left and right
ventricle is typically seen in significant heart as well as pulmonary
TR hypertension may also cause right
Absence of RA and RV dilatation heart chamber dilatation
argues against severe chronic TR
IVC and hepatic vein flow In the setting of significant TR, Changes in RA compliance are
dilatation of the IVC and holosystolic frequently seen following TVR,
flow reversal in the hepatic vein are resulting in blunting of hepatic vein
seen flow and/or late systolic reversal.
Dilatation of IVC may be seen in other
conditions with high RA/RV diastolic
pressure
CW Doppler Dense systolic spectral recording with Jet alignment is required
triangular, early peaking velocity are Diastolic peak and mean gradients are
suggestive of severe TR influenced not only by TR but also by
RV/LV function and prosthetic
stenosis.
Color Doppler jet (size, number of jets, Real time and rapid Influenced by machine settings and
location, eccentricity) Large central jet (area > 10 cm2) physics of ultrasound (e.g., depth,
suggestive of severe TR acoustic artifact by prosthetic
material), and hemodynamics
Multiple and eccentric jets are more
difficult to interpret
VCW Real time and rapid Difficult to assess in jets with temporal
VCW $ 0.7 cm suggestive of severe TR variability
Limited validation for multiple jets
Limited validation for noncircular
orifice shape
PISA radius and EROA* Large flow convergence (>0.9 cm) May underestimate TR severity in
suggests severe presence of multiple jets, temporal
EROA < 0.2 cm2 usually mild TR; variability or markedly asymmetric
$0.4 cm2 usually severe TR orifice shape
Device interference with flow
convergence zone limits accuracy
VC area by 3D planimetry May be the most accurate assessment Limitations of resolution (axial, lateral,
of TR; however, poorly validated and temporal) as well as blooming
artifacts
Accuracy in nonplanar orifices may be
limited
3D reconstruction of each orifice is
time consuming
Temporal averaging may be necessary
IVC, Inferior vena cava; PISA, proximal isovelocity surface area; VCW, VC width.
*Not well validated for quantitation in TVR; for PISA, baseline Nyquist limit shift to 25-35 cm/sec.
leaflets or reduced excursion of one or more mechanical disks are obvious Similarly, a mean gradient <6 mm Hg was found to be a marker of normal me-
signs of prosthetic stenosis. Stenosis should also be suspected when there is a chanical TV function.202 It should be emphasized, however, that there are
narrowed, aliased high-velocity color Doppler TV inflow pattern (Figure 25). several factors that can significantly affect mean gradient in the absence of pros-
Degeneration of TV bioprostheses is not uncommon and occurs in 0.4% to thetic valve dysfunction, including a smaller valve and high output states. In pa-
2.2% patients/year.197,198 The rate of freedom from TV bioprosthetic tients undergoing ViV or valve-in-ring procedures, a postimplantation mean
dysfunction has been estimated at 66% at 5 years.199 Mechanical prostheses gradient of >10 mm Hg is considered evidence of stenosis.203
typically become obstructed by thrombosis, pannus, or vegetation with re- In the absence of tachycardia, bioprosthetic TV obstruction is suspected when
ported thrombosis rates of 0.5% to 3.3% patients/year.197,200,201 CW Doppler E-wave velocity is $2.1 m/sec, whereas mechanical prosthetic
Normal Doppler values for various prosthetic TVs are detailed in Appendix obstruction is suggested when E-wave velocity is $1.9 m/sec
Tables A8 and A9. Mean gradient values <6 to 9 mm Hg have been associated (Table 19).191,192,204 Previous guidelines recommended that a
with normal bioprosthetic function across a wide variety of bioprosthesis.192 PHT<230 msec is consistent with absence of prosthetic stenosis.1 In a series
Volume 37 Number 1
Table 21 Echocardiographic grading of TR after TVR or TV repair
Qualitative
Color jet area* Small, narrow, central Moderate central Large central jet or eccentric wall-
impinging jet(s) of variable size swirling in
right atrium
Flow convergence zone† Not visible or small Intermediate in size Large
TR CW Doppler velocity waveform Faint/partial/parabolic Dense, parabolic or triangular Dense, often triangular
(density and shape)
Tricuspid inflow A-wave dominant Variable E-wave dominant‡
Semiquantitative
VC width, cm* <0.3 0.3-0.69 $0.7 or $2 moderate jets
PISA radius, cm† #0.5 0.6-0.9 >0.9
Hepatic vein flow§ Systolic dominance Systolic blunting Systolic flow reversal
Quantitative
EROA, cm2§ <0.20 0.20-0.39 $0.40
RVol, mL§ <30 30-44 $45
PISA, Proximal isovelocity surface area; RVol, regurgitant volume.
*With Nyquist limit > 50-60 cm/sec.
†
Not well validated for quantitation in TVR; baseline Nyquist limit shift to 25-35 cm/sec.
‡
Nonspecific, influenced by other factors (RV diastolic function, atrial fibrillation, RA pressure).
§
EROA and RVol from 2D PISA need further validation of cutoffs by either PISA or volumetric methods.
of 285 bioprostheses, Blauwet et al.202 found that a PHT <200 msec was repre- and EOA have more recently been included as part of a comprehensive Doppler
sentative of normal bioprosthetic function early after implantation. Mechanical assessment of TVR. The DVI associated with normal bioprosthetic TV function
bileaflet TV prostheses, in contrast, have a lower normal cut point for PHT varies significantly by valve type and size, with upper values ranging from 2.4 to
(<130 msec). PHT is not recommended in the presence of rounded spectral 3.6.192 Likewise, the DVI associated with normal mechanical TV function varies
Doppler contours, as measurement of PHT cannot be performed reliably in significantly by valve type and size, with upper limits ranging from 2.3 to 2.8.202
these circumstances.205 It should also be noted that PHT is influenced by EOA can be calculated by dividing the stroke volume in the LVOT by the dia-
both heart rate and right-sided chamber compliance. stolic tricuspid prosthetic VTI.192,202 This method is most accurate if there is
Although prior guidelines have suggested the use of prosthetic gradients mild or less TR and AR, though there is a dearth of normative data. If there is sig-
and PHT to evaluate prosthetic function, the DVI (DVI = VTIPrTV/VTILVOT) nificant AR, the forward stroke volume can be measured from the RVOT.206
Table 22 List of CHD anatomies likely to require a prosthetic heart valve after primary surgery
CHD anatomy Surgical interventions Percutaneous valve interventions
Aortic valve Severe aortic stenosis Ross procedure Balloon valvuloplasty

Shone complex Ross-Konno procedure ViV TAVI
Interrupted aortic arch with small aortic Yasui procedure
annulus Aortic valve replacement
Bicuspid aortic valve
Unicuspid aortic valve
Mitral valve Congenital mitral valve stenosis Mitral valve repair Balloon valvuloplasty
Parachute mitral valve AVSD repair ViV (Melody or Edwards SAPIEN valve)
Arcade mitral valve Mechanical mitral valve replacement
Shone complex
AVSD
TV AVSD TV repair ViV (Melody valve)
Ebstein anomaly Cone reconstruction
TV dysplasia Mechanical TVR
Tricuspid atresia Bjork procedure
Pulmonary valve Truncus arteriosus RV-to-PA conduit Balloon valvuloplasty
Transposition with LVOT obstruction Rastelli operation Melody valve
TOF/pulmonary atresia Homograft Edwards SAPIEN valve
Congenital pulmonary valve stenosis Harmony transcatheter pulmonary
valve
AVSD, Atrioventricular septal defect; TOF, tetralogy of Fallot.

January 2024
of the jet—flow convergence, VC, and jet direction—as well as jet effects
Table 23 Challenges to prosthetic valve evaluation in
on the right atrium. To compensate for acoustic shadowing from the pros-
patients with CHD thetic valve stent or disk occluders, it is important to acquire modified RV
Poor echocardiographic windows due to inflow and subcostal views. Numerous studies have suggested significant pit-
◦ Previous surgery falls of color Doppler jet area alone for the assessment of TR severity.1,210
◦ Chest deformities Quantitative measurements should be performed whenever possible. How-
◦ Artifacts from prosthetic materials ever, proximal isovelocity surface area quantitation of both native and pros-
◦ Body size thetic valve TR has several pitfalls (e.g., low flow, irregular orifice shape,
temporal variability), and few studies have validated the methodology in
Underestimation of prosthetic valve/conduit gradients due to
native or prosthetic valve disease.211,212 Progressive dilatation of cardiac
◦ The presence of associated shunts
chambers or alterations in hepatic vein size and flow at follow-up may
◦ Serial stenoses
also be indications of a change in prosthetic valve function.
◦ Eccentric jets
Echocardiographic criteria for assessing TR severity are shown in Table 21.
EOA calculation may be limited by On color Doppler imaging, a large flow convergence, increased VC width
◦ Serial stenoses, which affect use of the continuity equation (>0.7 cm), EROA > 0.4 cm2, and regurgitant volume > 45 mL all suggest
◦ Noncircular LVOT or RVOT shape affecting calculation of pre- severe TR. A dense CW Doppler tracing with a triangular, early peaking ve-
prosthesis flow locity as well as increased transvalvular diastolic peak velocity and mean
◦ Inaccurate VTI in patients with subaortic or subpulmonary ste- gradient also suggests severe TR. A DVI of >3.3 in the context of increased
nosis when the preobstruction flow velocity pattern is not laminar transvalvular gradient and normal PHT help confirm the presence of signif-
Long tubular narrowing in conduits will affect the pressure icant TR. Few studies have shown the feasibility of 3D color Doppler planim-
gradient calculated by the modified Bernoulli equation using peak etry of the VC area by both TTE211 and TEE in native valve disease.213
flow velocity Compared with the multiparametric assessment of severe TR, the 3D VC
area cutoff211,213 and Doppler EROA cutoff are nearly double the proximal
isovelocity surface area EROA.211 Whether these methods can be used to
assess prosthetic valves requires further study.
The Doppler parameters suggestive of prosthetic TV stenosis are listed in ii. Role of CMR: CMR is able to evaluate the status of the right ventricle in
Table 19. the setting of TR because of its ability to quantify RV volumes and ejection
Although high pressure gradients can be indicative of prosthetic stenosis, high fraction without geometric assumptions.5 Although there are currently no
transprosthetic gradients can also reflect PPM. Proposed values of EOA for published data on prosthetic TR, the approaches used are analogous to
TV PPM have ranged from <0.9 to 1.19 cm2/m2.192,207 At present, data are lack- those for native TR. Typically, quantitation of regurgitant volumes by
ing regarding the impact of these indexed EOA thresholds on outcomes in lon- CMR relies on velocity-encoded phase-contrast images to measure forward
gitudinal cohorts. flow across the pulmonary valve, then subtract this from the total RV stroke
ii. Role of CT: CT can aid in the evaluation of TVR stenosis by measurement volume measured using short-axis planimetry of multiple disks. This quan-
of the geometric orifice area and determination of the etiology of stenosis. It titative approach demonstrated modest agreement with a multiparametric
shows etiologies such as leaflet degeneration, abnormal leaflet or disk oc- echocardiographic approach in native TR.214 A recent study that used CMR
cluder mobility, calcification of the bioprosthetic ring, thrombus, pannus, to assess outcomes in native functional TR showed that both regurgitant vol-
or vegetation.150 Adequate RA and RV opacification with limited mixing ume and regurgitant fraction are associated with increased mortality after
artifact is required for CT evaluation of the prosthetic TV. This can be adjustment for clinical and imaging covariates, including RV ejection frac-
achieved with a triphasic contrast injection protocol and timing of acquisition.215 Although the risk was progressive with increasing TR volume and
tion for right heart opacification rather than the left heart.208 The maximal regurgitant fraction, a TR volume of $45 mL or regurgitant fraction of
geometric orifice area of the prosthetic TV can be measured in diastole us- $50% identified patients in the highest risk stratum for mortality. Specific
ing multiplanar reconstruction in short axis at the bioprosthetic leaflet tip.151 CMR thresholds for intervention in prosthetic TR are not established.
In mechanical valves, the opening and closing angles in addition to the geo- iii. Role of CT: The role of CT in prosthetic TV regurgitation is similar to that
metric orifice area can be measured.152 Careful consideration of these mea- in prosthetic MR. Excessive rocking of the prosthesis during the cardiac cy-
surements is required as the geometric orifice area by CT is larger than the cle is seen in valvular dehiscence and significant PVLs can be identified and
EOA by TTE, as expected.151 localized. Small PVLs can be obscured because of metallic artifacts from the
iii. Role of CMR: Prosthetic tricuspid stenosis can be quantified on CMR prosthetic ring or disk occluders. The role of CT is currently primarily to
with planimetry of the geometric orifice area on cine imaging or peak ve- help in planning transcatheter TV interventions.216
locity and gradient on through-plane contrast-velocity mapping. Suscepti-
bility artifact from a metal ring and disk occluder can limit visualization
of the valve opening but can be minimized with a gradient-echo sequence Key Points for Assessing Prosthetic TVs
rather than SSFP sequence.209 The use of through-plane velocity mapping 1. A comprehensive evaluation of TVR requires multiple imaging planes in which 2D
may be limited because of the susceptibility artifact from the valve ring or and 3D and Doppler echocardiography are used to assess valvular structure and func-
disk occluder and the annular motion in the TV position. tion, as well as right heart chamber size and function. Because of shadowing and flow
masking in the right atrium, particularly in mechanical TVs, screening for TR should
include modified RV inflow and subcostal views as well as PW Doppler interrogation
of hepatic vein flow, where feasible.
C. Evaluation of Prosthetic TV Regurgitation 2. From the Doppler recordings of prosthetic TVs, peak velocity, mean gradient, PHT,
and heart rate should be measured and reported whenever feasible. There is less expe-
rience with EOA and DVI of TVR.
i. Echocardiographic evaluation: TR may be either transvalvular or para- 3. Several factors can affect mean TV gradient in the absence of prosthetic valve
valvular in origin, and careful assessment of the prosthetic TV from all avail- dysfunction, including heart rate, flow, prosthesis size and type; considering these
able windows is necessary. Regurgitation after use of a transcatheter device confounders, we suggest use of prosthesis type-specific cutoffs for determination of
in native TV disease has been addressed in recent guidelines3 and is not prosthetic TV stenosis.
4. A multiparametric echocardiographic approach for assessing prosthetic TV regurgita-
covered here. As for all valvular regurgitation assessments by echocardiogra- tion is required, as validation of quantitative methods is lacking.
phy, an integrative approach using color, PW, and CW Doppler is needed in 5. CMR may be useful for quantifying regurgitant volume and fraction; however, vali-
the overall evaluation of TR (Figure 26, Tables 20 and 21). Color Doppler dation of its use in prosthetic valve function is lacking.
should be performed from multiple transthoracic echocardiographic views 6. CT is helpful in identifying mechanisms of valve dysfunction, localization of signif-
icant PVLs and is essential in planning percutaneous interventions on the TV.
for the assessment of TR severity with attention to the three components
Volume 37 Number 1
Figure 27 Transesophageal echocardiographic image from a deep transgastric window at about 60 , in a patient who underwent a
Ross procedure for infective endocarditis, demonstrating the cardiac structures surrounding the pulmonary homograft (A). The
zoomed deep transgastric images with color Doppler demonstrate flow acceleration in the homograft (B). A high esophageal view
at about 130 provides a clear view of the homograft leaflets (red arrows, C), with restricted motion (D) and flow acceleration across
the leaflets by color Doppler (E). CW Doppler (F) measures peak and mean systolic gradients of 52 and 30 mm Hg, respectively. The
patient underwent surgical replacement of the pulmonary valve with a Sorin prosthesis; a 3D image of the valve is shown (G).
congenital valvular stenosis and some patients receive ViV implanta-

VI. EVALUATION OF PROSTHETIC VALVES IN CHD
tion in the respective atrioventricular or semilunar valve position us-
ing a percutaneous approach before valve replacement.217 This
allows patients to grow before they receive mechanical valves after
A. Prosthetic Valves in CHD failed repair.218,219 The evaluation of PHV in CHD using the
The advent of interventional transcatheter approaches to deploying described approach in adults in this document generally works,
PHV has benefited many patients with CHD. In children with valve though there are some limitations and differences as described below.
disease, repair is preferred over replacement, as PPM is inevitable as Table 22 lists all the CHD lesions that may require surgical and/or
children grow. Balloon valvuloplasty is the first line of treatment for percutaneous interventions for PHV. Use of 2D and 3D
Table 24 Use of 3D echocardiography in patients with CHD*
Region of interest 3D modality Information Feasibility
Aortic valve GS/color Doppler Prosthetic valve leaflet appearance/ Moderate

TTE: PLAX, PSAX, apical motion
TEE: ME 60 , 120 Regurgitation origin
Improved LVOT area measurement
Mitral valve GS/color Doppler Prosthetic valve leaflet appearance/ High
TTE: PLAX, PSAX, apical motion
TEE: ME 0 , 90 , 120 Regurgitation origin
TV GS/color Doppler Prosthetic valve leaflet appearance/ Moderate
TTE: apical, RV inflow, subcostal motion
TEE: ME 0 , 40 -60 , transgastric Regurgitation origin
Pulmonary valve/pulmonary homografts GS/color Doppler Prosthetic valve leaflet appearance/ Low
TTE: PSAX motion
TEE: high esophageal 0 -40 , Regurgitation origin
transgastric Improves RVOT area measurement
GS, Grayscale; ME, midesophageal; PLAX, parasternal long-axis view; PSAX, parasternal short-axis view.
*Edited from Simpson et al.224
January 2024
echocardiography, CMR, and CT is delineated in the evaluation of iii. TEE: TEE is predominantly used when transthoracic imaging is inadequate
PHV in adolescents and adults with CHD. to assess prosthetic valve function. However, it is also indicated when there
are concerns regarding prosthetic valve infective endocarditis, a need to
reevaluate the valve after treatment for thrombosis or infection, or to guide
B. Echocardiography in the Evaluation of PHVs Associated surgical or percutaneous valve interventions. The ASE has published guide-
With CHD lines for the performance of TEE in patients with CHD.164 Similar to TTE,
Echocardiography is the primary noninvasive imaging modality used some transesophageal echocardiographic views need to be modified to
to assess prosthetic valves in patients with CHD. It allows both thoroughly assess the prosthetic valve/conduit in patients with CHD
appraisal of valve function and hemodynamic impact of valve (Figure 27).
iv. Three-dimensional echocardiography: In patients with good acoustic
dysfunction on the left and/or right ventricles. Comprehensive echo-
windows, 3D echocardiography can provide valuable anatomic informa-
cardiographic assessment includes 2D and 3D transthoracic or trans-
tion. It can also improve assessment of valve dysfunction severity and quan-
esophageal imaging with the use of color, CW, and PW Doppler.164 It tification of LV, RV, and stroke volumes.224 An expert consensus statement
can also include agitated saline, ultrasound-enhancing agents, and on the use of 3D echocardiography in patients with CHD was published in
stress echocardiography. One of the most important steps before im- 2017.224 Table 24 summarizes its feasibility in patients with CHD. Of note,
aging the patient with moderate or great complexity CHD is to under- patients with complex anatomy will likely need multibeat acquisition to
stand the flow of blood through the heart to determine which images obtain a data set that encompasses the prosthetic valve and conduit and
are needed. This requires an appreciation of the original cardiac anat- adjacent structures needed for orientation with adequate spatial and tempo-
omy and the changes introduced with surgical repairs or percuta- ral resolution. It may also be necessary for high quality 3D color images.
neous interventions. Information regarding CHD classification is
available in the American College of Cardiology and American
Heart Association adult CHD guidelines.217 C. Role of Cardiac CT
CT with 4D imaging is a useful complementary method for the eval-
i. TTE: Several guidelines and recommendations have been published uation of PHVs in patients with CHD. CT may be particularly useful
regarding TTE in patients with CHD. These include a general transthoracic in patients with CHD for the following reasons: (1) the position of the
echocardiographic protocol from the International Society for Adult
PHV may not always lend itself to assessment with traditional echo-
Congenital Heart Disease.220 Also, the ASE has published guidelines for
multimodality imaging for patients with tetralogy of Fallot and transposition
cardiographic windows given multiple prior surgical procedures, atyp-
of the great arteries.170,221 Challenges in imaging and assessing prosthetic ical anatomy, or unusual locations (e.g., RA-to-RV conduit in Bjork
valves in patients with CHD are summarized in Table 23. procedure); (2) valves can be placed within conduits in patients
Transthoracic echocardiographic images from patients with CHD may be with CHD (e.g., RV-to-PA conduit), making assessment challenging
suboptimal because of body size, chest wall deformities, and multiple surgical because of the location and artifacts related to the conduit; and (3)
procedures. The artifacts from prosthetic materials and valves are additional the potential presence of multiple sequential obstructions, making
obstacles to obtaining interpretable echocardiographic images. Off-axis and Doppler assessment difficult.
nonconventional imaging windows are frequently required. In particular, Potential causes of PHV dysfunction in patients with CHD are
right heart structures can be challenging to image because of their location. similar to those without CHD. Once an increased gradient or valvular
For example, right-sided conduits (e.g., RV-PA or RA-RV) are anteriorly
regurgitation is identified by echocardiography or is clinically sus-
located and can be situated behind the sternum. Significant gradients in these
conduits can be missed if the image is not optimized. Color flow mapping can
pected, CT can be considered. To assess the cause of increased gradi-
be used to identify their location.220 Views that are not often acquired, such ents across a mechanical prosthetic valve, noncontrast CT (especially
as an anteriorly tilted image in the apical window, could be attempted to in the context of renal dysfunction) with retrospective gating may be
improve visualization of RA-RV conduits or pulmonary valves. The higher sufficient to assess the motion of the occluders. Noncontrast CT can
heart rate of pediatric patients may cause low-frame-rate images that can also identify the presence of valve stent fracture (e.g., from transcuta-
be addressed by using M-mode echocardiography. If images are inadequate, neous pulmonary valves) and perivalvular calcification, as well as help
TEE should be considered (see the following section). Furthermore, use of differentiate pledgets from potential PVL that may be contributing to
ultrasound-enhancing agent is recommended to improve assessment of car- increased transvalvular gradients. If there is suspicion of valve throm-
diac chamber size and function. Changes could indicate possible prosthetic bosis, pannus formation, vegetations, or dysfunction of a bio-
valve/conduit dysfunction and necessitate further imaging with CMR or CT.
prosthetic valve, retrospectively gated CT with contrast should be
Beyond echocardiographic image quality, evaluation of prosthetic valves in
patients with CHD may be complicated by the coexistence of multiple levels
performed. The site of contrast injection (right arm, left arm, leg)
of obstruction and the presence of additional shunts. Serial stenoses will should be carefully determined on the basis of knowledge of the
affect the application of the continuity equation to determine EOA. For known venous anatomy.
instance, pressure gradient measurements across the valve in a RV-PA Specific scenarios in which cardiac CT is useful in patients with
conduit will be affected by the presence of a stenosis extending to the right CHD to assess PHV beyond their usual location include assessment
or left PA. The presence of additional shunts, either untreated or residual after of valved conduits (e.g., tetralogy of Fallot) or percutaneous valve
treatment, will affect flow and pressure gradients and therefore the EOA within an RV-to-PA conduit (e.g., Melody valve172), a valve within
calculation. an RA-to-RV conduit (Bjork procedure), to differentiate conduit
ii. Stress echocardiography: The use of stress echocardiography in native edge stenosis from valvular dysfunction, and to identify the presence
and prosthetic valves is well established.60 Current European Association of
of concomitant sub- or supravalvular stenosis (e.g., branch PA steno-
Cardiovascular Imaging and ASE recommendations on the clinical use of
stress echocardiography in nonischemic heart disease include a description
sis; Figure 24). For these specific indications, given the right-sided loca-
of its application in patients with CHD.60 Patients with CHD with pros- tion of these abnormalities, the timing of image acquisition in relation
thetic valves or valved conduits can undergo stress echocardiography to to contrast administration should maximize the presence of contrast
assess symptoms, exercise capacity, ventricular dysfunction and contractile in the right-sided structures. Triphasic injections may be useful for
reserve, and pulmonary vascular response.217,222,223 Importantly, exercise this purpose.172 A retrospectively gated study should be performed
testing can be used to increase early diagnosis and intervention. to assess the dynamic nature of the prosthetic valve and mobility of
Volume 37 Number 1
the valved stent if applicable. Assessing valve regurgitation is not Key Points for the Evaluation of Prosthetic Valves
directly possible because of the lack of flow data, however, retrospec- in CHD
tive gated acquisition can identify the presence of valve rocking. If
1. Evaluation of prosthetic valves in CHD may require modifications to standard trans-
dehiscence is clearly present, CT can characterize its location, length, thoracic and transesophageal echocardiographic views.
and width to allow planning for potential percutaneous procedures. 2. An understanding of different CHD anatomy, conduits, and hemodynamics is
In addition, in the context of single valve disease, RV and LV stroke required in the evaluation of PHV in CHD.
3. Three-dimensional echocardiography can provide valuable anatomic information
volumes could be measured to quantify regurgitant volume and frac- and en face views of the PHV in CHD.
tion. 4. CT and CMR provide additional means of imaging PHVs in CHD.
An important limitation of CT is the potential for beam hardening
or blooming artifacts that affect diagnostic accuracy, especially in the
context of multiple valves, stents, coils, and pacemaker leads. These
VII. CONCLUSIONS AND FUTURE DIRECTIONS
must be carefully avoided whenever possible using techniques
described above.
Echocardiography is the imaging modality of choice for the initial
evaluation and management of PHVs. A comprehensive approach
D. Role of CMR is needed to assess valve structure and function in addition to the
extent of reverse remodeling of cardiac chambers after percutaneous
CMR is widely used in both the preoperative and postoperative
or surgical valve replacement. Color and spectral Doppler play a cen-
assessment of simple to complex CHD. CMR’s strength in CHD is
tral role in evaluating prosthetic valve function and related complica-
its ability to (1) image the valve in planes that may be challenging
tions. In general, assessment of prosthetic valve function is more
for echocardiography, such as behind the sternum; (2) provide cham-
challenging than native valves because of suboptimal visualization
ber quantification; (3) assess great vessel and conduit anatomy by 3D
of prosthetic valve structure and occluder devices with TTE and the
contrast-enhanced magnetic resonance angiography; and (4) charac-
inherent variability of valve hemodynamics and orifice areas observed
terize tissue for a comprehensive evaluation of valvular function.225
with the wide range of prosthetic valve types and sizes. Thus, docu-
In a prospective evaluation of cases, the most common PHV for
mentation of the type and size of the inserted valve or conduit is para-
CHD was PVR, followed by aortic valve replacement and homograft
mount in assessment of prosthetic valves. Furthermore, serial
or autograft.226 Currently, there is a paucity of published literature
comparison with a baseline postoperative study is essential in facili-
focused specifically on PHVs in CHD. The use of CMR in this popu-
tating accurate evaluation of valve function.
lation is extrapolated from literature primarily involving native valves
In patients with suspected prosthetic valvular dysfunction,
that are similar to homografts or autografts and with data from surgi-
advanced imaging is frequently needed to identify the mechanism
cal prostheses as discussed above.124
of dysfunction or severity of regurgitation, particularly in mechanical
The use of both 1.5- and 3-T CMR magnets is safe in patients with
valves. In addition to the traditional role of 2D and 3D TEE in assess-
all types of PHVs. When evaluating which magnet strength to use in
ing valve dysfunction, CT and CMR have emerged as powerful imag-
CHD, it is important to consider other interventions the patient may
ing modalities that complement echocardiography. CT offers high-
have had, such as vascular plugs, coils, or pacemakers or defibrillators,
resolution imaging with particular advantage in mechanical valves,
which may require a 1.5-T magnet or be contraindicated for CMR.
while CMR’s main strength is quantitation of regurgitation severity.
Various sequences can be used, as described earlier (Figure 8) to eval-
Thus, the role of imaging has significantly expanded since the initial
uate leaflet morphology and motion and delineate prosthetic vs peri-
ASE document on prosthetic valves in 2009. The choice of advanced
prosthetic regurgitation complementary to echocardiography. Phase-
imaging modality, if needed after an initial TTE, should be carefully
contrast velocity mapping can measure velocity and flow through a
decided, as each modality has advantages and limitations. This choice
specific plane slice (Figure 24).124 When performing phase contrast,
is best tailored to the patient’s clinical condition, the type and position
depending on the signal void that occurs with PHV, the assessment
of prosthetic valve, and the suspected underlying condition of
may be placed 0.25 to 0.4 mm downstream from the PHV.
obstruction and/or regurgitation. Goals of future research will include
Additionally, contrast-enhanced tissue characterization of pulmonary
enhancing automated quantitation of regurgitation severity with color
conduits is noted with stenosis and correlated with inflammation and
and spectral Doppler, increasing temporal resolution with CT and
fibrosis of the conduit.
CMR, and decreasing artifacts emanating from metallic structures,
Four-dimensional flow CMR is a newer modality that allows
thus improving valve visualization.
comprehensive study of flow in the heart and thoracic vessels in all
three spatial directions. This technique allows flow visualization,
flow quantification, and advanced hemodynamic parameters
including wall shear stress and kinetic energy evaluation. In CHD, NOTICE AND DISCLAIMER
4D flows have been studied in patients with d-transposition of the
great arteries with arterial switch, who can develop neo-AR and supra- This report is made available by ASE as a courtesy reference source for
valvular pulmonary or aortic stenosis at the anastomotic site. Studies members. This report contains recommendations only and should not
show increased asymmetric flow in the anterior main PA, better visu- be used as the sole basis to make medical practice decisions or for
alization of the supravalvular pulmonary stenosis, and asymmetrical disciplinary action against any employee. The statements and recom-
wall stress in the distal ascending aorta.227 Calkoen et al.228 studied mendations contained in this report are primarily based on the opin-
atrioventricular septal defect patients after correction, which can ions of experts, rather than on scientifically-verified data. ASE makes
involve mitral valve surgery, and showed the ability of 4D flow to no express or implied warranties regarding the completeness or accu-
accurately quantitate and visualize eccentric left atrioventricular valve racy of the information in this report, including the warranty of
regurgitation. These findings can help understand complications that merchantability or fitness for a particular purpose. In no event shall
these patients may encounter in the long term.228 ASE be liable to you, your patients, or any other third parties for
January 2024
any decision made or action taken by you or such other parties in reli- 8. Halkos ME, Puskas JD. Are all bileaflet mechanical valves equal? Curr
ance on this information. Nor does your use of this information consti- Opin Cardiol 2009;24:136-41.
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Volume 37 Number 1
Table A1 Normal Doppler echocardiographic values for percutaneous SAPIEN valves in native aortic stenosis by valve size
Valve iteration Normal values
SAPIEN 20 mm 23 mm 26 mm 29 mm All sizes
EOA, cm 2
NA 1.56 6 0.43 1.84 6 0.52 NA 1.70 6 0.49
Mean gradient, mm Hg NA 9.92 6 4.27 8.76 6 3.89 NA 9.36 6 4.13
DVI NA 0.53 6 0.13 0.53 6 0.13 NA 0.53 6 0.13
SAPIEN XT 20 mm 23 mm 26 mm 29 mm All sizes
EOA, cm 2
NA 1.41 6 0.30 1.74 6 0.42 2.06 6 0.52 1.67 6 0.46
Mean gradient, mm Hg NA 10.41 6 3.74 9.24 6 3.57 8.36 6 3.14 9.52 6 3.64
DVI NA 0.52 6 0.10 0.54 6 0.11 0.53 6 0.11 0.53 6 0.11
SAPIEN 3 20 mm 23 mm 26 mm 29 mm All sizes
EOA, cm 2
1.22 6 0.22 1.45 6 0.26 1.74 6 0.35 1.89 6 0.37 1.66 6 0.38
Mean gradient, mm Hg 16.23 6 5.01 12.79 6 4.65 10.59 6 3.88 9.28 6 3.16 11.18 6 4.35
DVI 0.42 6 0.07 0.43 6 0.08 0.43 6 0.09 0.40 6 0.09 0.43 6 0.09
NA, Not applicable.
Data are expressed as mean 6 SD. Data are modified from Hahn et al.11 with permission.
Table A2 Normal Doppler echocardiographic values for percutaneous CoreValve and Evolut R valves by valve size in native aortic
stenosis
Valve iteration Normal values
CoreValve 23 mm 26 mm 29 mm 31 mm All sizes
EOA, cm 2
1.12 6 0.36 1.74 6 0.49 1.97 6 0.53 2.15 6 0.72 1.88 6 0.56
DVI 0.44 6 0.09 0.59 6 0.15 0.54 6 0.12 0.49 6 0.12 0.55 6 0.13
Evolut R (30 d) 23 mm 26 mm 29 mm 34 mm All sizes
EOA, cm 2
1.09 6 0.26 1.69 6 0.40 1.97 6 0.54 2.60 6 0.75 2.01 6 0.65
DVI 0.42 6 0.04 0.61 6 0.13 0.59 6 0.14 0.58 6 0.15 0.59 6 0.14
Data are expressed as mean 6 SD. Data are modified from Hahn et al. 11
with permission.
January 2024
Table A3 Doppler echocardiographic parameters for percutaneous aortic ViV at 1 year after the procedure
TAVI ViV THV size Peak gradient, mm Hg Mean gradient, mm Hg EOA, cm2
CoreValve100 All 23.48 6 12.10 12.89 6 0.20 1.62 6 0.14

Evolut141,229 All 22.43 6 5.72 14.70 6 9.11 1.36 6 0.07
SAPIEN 3100 All 33.93 610.11 27.00 610.20 1.07 6 0.32
SAPIEN XT100,230 All 31.316 3.75 18.02 6 4.22 1.31 6 0.25
THV, Transcatheter heart valve.
Data are expressed as mean 6 SD. Data are derived from the respective publications.
Volume 37 Number 1
Table A4 Normal Doppler echocardiographic values for surgical prosthetic aortic valves
Valve Size, mm Peak gradient, mm Hg Mean gradient, mm Hg EOA, cm2
Abbott Epic 21 19.1 6 8.2 1.0 6 0.3

23 13.9 6 6.0 1.4 6 0.5
25 12.1 6 5.1 1.5 6 0.5
27 11.4 6 4.1 1.6 6 0.4
29 7.5 6 3.3 2.4 6 1.1
Abbott 19 10.7 6 4.6 1.41 6 0.24
Trifecta
21 8.1 6 3.5 1.63 6 0.29
23 7.2 6 2.8 1.81 6 0.30
25 6.2 6 2.7 2.02 6 0.32
27 4.8 6 2.0 2.20 6 0.20
29 4.7 6 1.6 2.35 6 0.22
Arbor Surgical Trilogy 21 21 6 8 11 6 6 1.9 6 0.2
23 15 6 7 864 2.0 6 0.3
ATS 19 47.0 6 12.6 25.3 6 8.0 1.1 6 0.3
Bileaflet
21 23.7 6 6.8 15.9 6 5.0 1.4 6 0.5
23 14.4 6 4.9 1.7 6 0.5
25 11.3 6 3.7 2.1 6 0.7
27 8.4 6 3.7 2.5 6 0.1
29 8.0 6 3.0 3.1 6 0.8
ATS AP 18 21.0 6 1.8 1.2 6 0.3
Bileaflet
20 21.46 4.2 11.1 6 3.5 1.3 6 0.3
22 18.76 8.3 10.5 6 4.5 1.7 6 0.4
24 15.16 5.6 7.5 6 3.1 2.0 6 0.6
26 6.0 6 2.0 2.1 6 0.4
ATS 21 27.0 6 8.4 15.0 6 4.6 1.1 6 0.4
3F Enable
22 25.7 6 10.8 14.5 6 6.0 1.4 6 0.4
25 20.3 6 7.4 11.4 6 4.0 1.6 6 0.5
27 16.8 6 6.3 9.4 6 3.3 1.9 6 0.5
29 14.3 6 6.7 7.8 6 3.8 2.4 6 0.8
Baxter Perimount 19 32.5 6 8.5 19.5 6 5.5 1.3 6 0.2
Stented bovine pericardial
21 24.9 6 7.7 13.8 6 4.0 1.3 6 0.3
23 19.9 6 7.4 11.5 6 3.9 1.6 6 0.3
25 16.5 6 7.8 10.7 6 3.8 1.6 6 0.4
27 12.8 6 5.4 4.8 6 2.2 2.0 6 0.4
Biocor 23 30.0 6 10.7 20 6 6.6 1.3 6 0.3
Stented porcine
25 23.0 6 7.9 16 6 5.1 1.7 6 0.4
27 22.0 6 6.5 15.0 6 3.7 2.2 6 0.4
Extended Biocor 19-21 17.5 6 6.5 9.6 6 3.6 1.4 6 0.4
Stentless
23 14.7 6 7.3 7.7 6 3.8 1.7 6 0.4
25 14.0 6 4.3 7.4 6 2.5 1.8 6 0.4
(Continued )
January 2024
Table A4 (Continued )
Bioflo 19 37.2 6 8.8 26.4 6 5.5 0.7 6 0.1

21 28.7 6 6.2 18.7 6 5.5 1.1 6 0.1
Bjork-Shiley 21 38.9 6 11.9 21.8 6 3.4 1.1 6 0.3
Single tilting disk
23 28.8 6 11.2 15.7 6 5.3 1.3 6 0.3
25 23.7 6 8.2 13.0 6 5.0 1.5 6 0.4
27 10.0 6 2.0 1.6 6 0.3
Carbomedics reduced 19 43.4 6 1.2 24.4 6 1.2 1.2 6 0.1
Bileaflet
Carbomedics Standard 19 38.0 6 12.8 18.9 6 8.3 1.0 6 0.3
Bileaflet
21 26.8 6 10.1 12.9 6 5.4 1.5 6 0.4
23 22.5 6 7.4 11.0 6 4.6 1.4 6 0.3
25 19.6 6 7.8 9.1 6 3.5 1.8 6 0.4
27 17.5 6 7.1 7.9 6 3.2 2.2 6 0.2
29 9.1 6 4.7 5.6 6 3.0 3.2 6 1.6
Carbomedics Tophat 21 30.2 6 10.9 14.9 6 5.4 1.2 6 0.3
Bileaflet
23 24.2 6 7.6 12.5 6 4.4 1.4 6 0.4
25 9.5 6 2.9 1.6 6 0.32
Carpentier Edwards Pericardial 19 32.1 6 3.4 24.2 6 8.6 1.2 6 0.3
21 25.7 6 9.9 20.3 6 9.1 1.5 6 0.4
23 21.7 6 8.6 13.0 6 5.3 1.8 6 0.3
25 16.5 6 5.4 9.0 6 2.3
Carpentier Edwards Standard 19 43.5 6 12.7 25.6 6 8.0 0.9 6 0.2
Stented porcine
21 27.7 6 7.6 17.3 6 6.2 1.5 6 0.3
23 28.9 6 7.5 16.1 6 6.2 1.7 6 0.5
25 24.0 6 7.1 12.9 6 4.6 1.9 6 0.5
27 22.1 6 8.2 12.1 6 5.5 2.3 6 0.6
29 9.9 6 2.9 2.8 6 0.5
Carpentier Supra-Annular 19 34.1 6 2.7 1.1 6 0.1
Stented porcine
21 28.0 6 10.5 17.5 6 3.8 1.4 6 0.9
23 25.3 6 10.5 13.4 6 4.5 1.6 6 0.6
25 24.4 6 7.6 13.2 6 4.8 1.8 6 0.4
27 16.7 6 4.7 8.8 6 2.8 1.9 6 0.7
Cryolife 19 9.0 6 2.0 1.5 6 0.3
Stentless
21 6.6 6 2.9 1.7 6 0.4
23 6.0 6 2.3 2.3 6 0.2
25 6.1 6 2.6 2.6 6 0.2
27 4.0 6 2.4 2.8 6 0.3
Edwards Duromedics 21 39.0 6 13
Bileaflet
23 32.0 6 8.0
25 26.0 6 10.0
27 24.0 6 10.0
(Continued )
Volume 37 Number 1
Edwards 19 17.6 6 7.8 1.1 6 0.2

Inspiris Resilia
21 12.6 6 4.7 1.3 6 0.3
23 10.1 6 3.8 1.6 6 0.4
25 9.6 6 5.2 1.8 6 0.5
27 8.2 6 3.5 2.2 6 0.6
Edwards 19 13.9 6 3.9 1.1 6 0.1
Intuity
21 11.6 6 3.6 1.3 6 0.1
23 10.4 6 3.5 1.7 6 0.2
25 9.1 6 3.2 1.9 6 0.2
27 8.3 6 3.7 2.2 6 0.2
Edwards Mira 19 18.2 6 5.3 1.2 6 0.4
Bileaflet
21 13.3 6 4.3 1.6 6 0.4
23 14.7 6 2.8 1.6 6 0.6
25 13.1 6 3.8 1.9
Edwards Mosaic 21 13.3 6 5.3 1.4 6 0.4
23 11.8 6 4.9 1.6 6 0.5
25 10.6 6 4.4 1.8 6 0.5
27 9.1 6 4.0 2.0 6 0.5
29 8.6 6 2.9 2.3 6 0.6
Hancock 21 18.0 6 6.0 12.0 6 2.0
Stented porcine
23 16.0 6 2.0 11.0 6 2.0
25 15.0 6 3.0 10.0 6 3.0
Hancock II 21 14.8 6 4.1 1.3 6 0.4
Stented porcine
23 34.0 6 13.0 16.6 6 8.5 1.3 6 0.4
25 22.0 6 5.3 10.8 6 2.8 1.6 6 0.4
29 16.2 6 1.5 8.2 6 1.7 1.6 6 0.2
Homograft 17-19 9.7 6 4.2 4.2 6 1.8
Homograft valves
19-21 5.4 6 0.9
20-21 7.9 6 4.0 3.6 6 2.0
20-22 7.2 6 3.0 3.5 6 1.5
22 1.7 6 0.3 5.8 6 3.2
22-23 5.6 6 3.1 2.6 6 1.4
22-24 5.6 6 1.7
24-27 6.2 6 2.6 2.8 6 1.1
26 1.4 6 0.6 6.8 6 2.9
25-28 6.2 6 2.5
Intact 19 40.4 6 15.4 24.5 6 9.3
Stented porcine
21 40.9 6 15.6 19.6 6 8.1 1.6 6 0.4
23 32.7 6 9.6 19.0 6 6.1 1.6 6 0.4
25 29.7 6 15.0 17.7 6 7.9 1.7 6 0.3
27 25.0 6 7.6 15.0 6 4.5
(Continued )
January 2024
Ionescu-Shiley 17 23.8 6 3.4 0.9 6 0.1

19 19.7 6 5.9 13.3 6 3.9 1.1 6 0.1
21 26.6 6 9.0
23 15.6 6 4.4
Labcor Santiago 19 18.6 6 5.0 11.8 6 3.3 1.2 6 0.1
21 17.5 6 6.6 8.2 6 4.5 1.3 6 0.1
23 14.8 6 5.2 7.8 6 2.9 1.8 6 0.2
25 12.3 6 3.4 6.8 6 2.0 2.1 6 0.3
Labcor Synergy 21 24.3 6 8.1 13.3 6 4.2 1.1 6 0.3
Stented porcine
23 27.3 6 13.7 15.3 6 6.9 1.4 6 0.4
25 22.5 6 11.9 13.2 6 6.4 1.5 6 0.4
27 17.8 6 7.0 10.6 6 4.6 1.8 6 0.5
MCRI On-X 19 21.3 6 10.8 11.8 6 3.4 1.5 6 0.2
Bileaflet
21 16.4 6 5.9 9.9 6 3.6 1.7 6 0.4
23 15.9 6 6.4 8.6 6 3.4 1.9 6 0.6
25 16.5 6 10.2 6.9 6 4.3 2.4 6 0.6
Medtronic Advantage 23 10.4 6 3.1 2.2 6 0.3
Bileaflet
25 9.0 6 3.7 2.8 6 0.6
Medtronic Advantage 27 7.6 6 3.6 3.3 6 0.7
Bileaflet
29 6.1 6 3.8 3.9 6 0.7
Medtronic 19 17.1 6 5.0 1.11 6 0.25
Avalus
21 14.5 6 4.3 1.25 6 0.25
23 12.1 6 3.8 1.47 6 0.32
25 11.7 6 4.0 1.57 6 0.31
27 10.3 6 4.2 1.77 6 0.41
Medtronic Freestyle 19 13.0 6 3.9
Stentless
21 9.1 6 5.1 1.4 6 0.3
23 11.0 6 4.0 8.1 6 4.6 1.7 6 0.5
25 5.3 6 3.1 2.1 6 0.5
27 4.6 6 3.1 2.5 6 0.1
Medtronic-Hall 21 26.9 6 10.5 14.1 6 5.9 1.1 6 0.2
Single tilting disk
23 26.9 6 8.9 13.5 6 4.8 1.4 6 0.4
25 17.1 6 7.0 9.5 6 4.3 1.5 6 0.5
27 18.9 6 9.7 8.7 6 5.6 1.9 6 0.2
Medtronic-Hall 20 34.4 6 13.1 17.1 6 5.3 1.2 6 0.5
Single tilting disk
Medtronic Mosaic 21 14.2 6 5.0 1.4 6 0.4
Stented porcine
23 23.8 6 11.0 13.7 6 4.8 1.5 6 0.4
25 22.5 6 10.0 11.7 6 5.1 1.8 6 0.5
27 10.4 6 4.3 1.9 6 0.1
29 11.1 6 4.3 2.1 6 0.2
(Continued )
Volume 37 Number 1
Mitroflow 19 18.6 6 5.3 13.1 6 3.3 1.1 6 0.2

Monostrut Bjork-Shiley 19 27.4 6 8.8
Single tilting disk
21 27.5 6 3.1 20.5 6 6.2
23 20.3 6 0.7 17.4 6 6.4
25 16.1 6 4.9
27 11.4 6 3.8
Prima 21 28.8 6 6.0 13.7 6 1.9 1.4 6 0.7
Stentless
23 21.5 6 7.5 11.5 6 4.9 1.5 6 0.3
25 22.1 6 12.5 11.6 6 7.2 1.8 6 0.5
Omnicarbon 21 37.4 6 12.8 20.4 6 5.4 1.3 6 0.5
Single tilting disk
23 28.8 6 9.1 17.4 6 4.9 1.5 6 0.3
25 23.7 6 8.1 13.2 6 4.6 1.9 6 0.5
27 20.1 6 4.2 12.4 6 2.9 2.1 6 0.4
Omniscience 21 50.8 6 2.8 28.2 6 2.2 0.9 6 0.1
Single tilting disk
23 39.8 6 8.7 20.1 6 5.1 1.0 6 0.1
Starr-Edwards 23 32.6 6 12.8 22.0 6 9.0 1.1 6 0.2
Caged ball
24 34.1 6 10.3 22.1 6 7.5 1.1 6 0.3
26 31.8 6 9.0 19.7 6 6.1
27 30.8 6 6.3 18.5 6 3.7
29 29.0 6 9.3 16.3 6 5.5
Sorin Bicarbon 19 30.1 6 4.5 16.7 6 2.0 1.4 6 0.1
Bileaflet
21 22.0 6 7.1 10.0 6 3.3 1.2 6 0.4
23 16.8 6 6.1 7.7 6 3.3 1.5 6 0.2
25 11.2 6 3.1 5.6 6 1.6 2.4 6 0.3
Sorin Pericarbon Stentless 19 36.5 6 9.0 28.9 6 7.3 1.2 6 0.5
21 28.0 6 13.3 23.8 6 11.1 1.3 6 0.6
23 27.5 6 11.5 23.2 6 7.6 1.5 6 0.5
Sorin Perceval Sutureless S (21) 10.1 6 4.2 1.3 6 0.3
M (23) 9.4 6 5.5 1.5 6 0.4
L (25) 8.5 6 4.6 1.5 6 0.4
XL (27) 9.7 6 4.7 1.6 6 0.4
St. Jude Medical 19 28.5 6 10.7 17.0 6 7.8 1.9 6 0.1
Haem Plus Bileaflet
21 16.3 6 17.0 10.6 6 5.1) 1.8 6 0.5
23 16.8 6 7.3 12.1 6 4.2 1.7 6 0.5
St. Jude Medical Regent 19 20.6 6 12 11.0 6 4.9 1.6 6 0.4
Bileaflet
21 15.6 6 9.4 8.0 6 4.8 2.0 6 0.7
23 12.8 6 6.8 6.9 6 3.5 2.3 6 0.9
25 11.7 6 6.8 5.6 6 3.2 2.5 6 0.8
27 7.9 6 5.5 3.5 6 1.7 3.6 6 0.5
(Continued )
January 2024
St. Jude Medical Standard 19 42.0 6 10.0 24.5 6 5.8 1.5 6 0.1
Bileaflet
21 25.7 6 9.5 15.2 6 5.0 1.4 6 0.4
23 21.8 6 7.5 13.4 6 5.6 1.6 6 0.4
25 18.9 6 7.3 11.0 6 5.3 1.9 6 0.5
27 13.7 6 4.2 8.4 6 3.4 2.5 6 0.4
29 13.5 6 5.8 7.0 6 1.7 2.8 6 0.5
St. Jude Medical 21 22.6 6 14.5 10.7 6 7.2 1.3 6 0.6
Stentless
23 16.2 6 9.0 8.2 6 4.7 1.6 6 0.6
25 12.7 6 8.2 6.3 6 4.1 1.8 6 0.5
27 10.1 6 5.8 5.0 6 2.9 2.0 6 0.3
29 7.7 6 4.4 4.1 6 2.4 2.4 6 0.6
Data are expressed as mean 6 SD.
Modified from Rajani et al.231
Table A5 Normal Doppler echocardiographic values for surgical prosthetic mitral valves
Peak gradient, Mean gradient, Peak velocity,

Valve Size, mm mm Hg mm Hg m/sec PHT, msec EOA, cm2
Abbott Epic 27 6.1 6 2.9 1.4 6 0.7

29 5.5 6 1.7 1.5 6 0.5
31 4.8 6 1.4 1.6 6 0.3
33 4.1 6 1.6 1.5 6 0.3
Biocor 27 13 6 1
Stentless bioprosthesis
29 14 6 2.5
31 11.5 6 0.5
33 12 6 0.5
Bioflo pericardial 25 10 6 2 6.3 6 1.5 2 6 0.1
Stented bioprosthesis
27 9.5 6 2.6 5.4 6 1.2 2 6 0.3
29 5 6 2.8 3.6 6 1 2.4 6 0.2
31 4.0 2.0 2.3
Bjork-Shiley 23 1.7 115
Tilting disk
25 12 6 4 662 1.75 6 0.38 99 6 27 1.72 6 0.6
27 10 6 4 562 1.6 6 0.49 89 6 28 1.81 6 0.54
29 7.83 6 2.93 2.83 6 1.27 1.37 6 0.25 79 6 17 2.1 6 0.43
31 663 2 6 1.9 1.41 6 0.26 70 6 14 2.2 6 0.3
Bjork-Shiley monostrut 23 5.0 1.9
Tilting disk
25 13 6 2.5 5.57 6 2.3 1.8 6 0.3
27 12 6 2.5 4.53 6 2.2 1.7 60.4
29 13 6 3 4.26 6 1.6 1.6 6 0.3
31 14 6 4.5 4.9 6 1.6 1.7 6 0.3
Carbomedics 23 1.9 6 0.1 126 6 7
Bileaflet
25 10.3 6 2.3 3.6 6 0.6 1.3 6 0.1 93 6 8 2.9 6 0.8
(Continued )
Volume 37 Number 1
27 8.79 6 3.46 3.46 6 1.03 1.61 6 0.3 89 6 20 2.9 6 0.75

29 8.78 6 2.9 3.39 6 0.97 1.52 6 0.3 88 6 17 2.3 6 0.4
31 8.87 6 2.34 3.32 6 0.87 1.61 6 0.29 92 6 24 2.8 6 1.14
33 8.8 6 2.2 4.8 6 2.5 1.5 6 0.2 93 6 12
Carpentier-Edwards 27 662 1.7 6 0.3 98 6 28
29 4.7 6 2 1.76 6 0.27 92 614
31 4.4 6 2 1.54 6 0.15 92 6 19
33 663 93 6 12
Carpentier-Edwards pericardial 27 3.6 1.6 100
Stented Bioprosthesis
29 5.25 6 2.36 1.67 6 0.3 110 6 15
31 4.05 6 0.83 1.53 6 0.1 90 6 11
33 1.0 0.8 80
Carpentier-Edwards 25 4.0 6 1.0 1.7 6 0.10 67 6 21.5 1.75 6 0.53
Perimount
Stented pericardial
27 6.3 6 1.65 1.7 6 0.27 74 6 20.6 1.88 6 0.52
29 6.0 6 1.41 1.8 6 0.19 76 6 17.9 2.02 6 0.57
31 5.5 6 1.06 1.8 6 0.20 80 6 21.8 2.09 6 0.48
33 6.1 6 1.86 1.7 6 0.23 77 6 13.2 2.24 6 0.97
Duromedics 27 13 6 6 563 1.61 6 0.4 75 6 12
Bileaflet
29 10 6 4 361 1.40 6 0.25 85 6 22
31 10.5 6 4.33 3.3 6 1.36 1.38 6 0.27 81 6 12
33 11.2 2.5 85
Edwards 25 4.9 6 1.2 1.1 6 0.4
Mitris
27 4.1 6 1.4 1.2 6 0.3
29 4.1 6 1.5 1.5 6 0.6
31 3.9 6 2.0 1.4 6 0.5
33 3.3 6 1.4 1.5 6 0.7
Hancock I or not specified 27 10 6 4 562 1.3 6 0.8
29 763 2.46 6 0.79 115 6 20 1.5 6 0.2
31 4 6 0.86 4.86 6 1.69 95 6 17 1.6 6 0.2
33 362 3.87 6 2 90 6 12 1.9 6 0.2
Hancock II 25 8.3 6 1.71 2.1 6 0.28 76 6 19.8 1.42 6 0.29
27 6.1 6 1.33 2 6 0.28 81 6 18.9 1.62 6 0.47
29 6.7 6 2.20 2.0 6 0.31 77 6 15.1 1.83 6 0.68
31 6.0 6 1.58 2.0 6 0.32 76 6 12.1 1.70 6 0.41
33 5.5 6 1.64 1.9 6 0.50 65 6 8.7 2.71 6 0.77
Hancock pericardial 29 2.61 6 1.39 1.42 6 0.14 105 6 36
31 3.57 6 1.02 1.51 6 0.27 81 6 23
Ionescu-Shiley 25 4.87 6 1.08 1.43 6 0.15 93 6 11
27 3.21 6 0.82 1.31 6 0.24 100 6 28
(Continued )
January 2024
29 3.22 6 0.57 1.38 6 0.2 85 6 8

31 3.63 6 0.9 1.45 6 0.06 100 6 36
Ionescu-Shiley low profile 29 3.31 6 0.96 1.36 6 0.25 80 6 30
31 2.74 6 0.37 1.33 6 0.14 79 6 15
Labcor-Santiago pericardial 25 8.7 4.5 97 2.2
27 5.6 6 2.3 2.8 6 1.5 85 6 18 2.12 6 0.48
29 6.2 6 2.1 3 6 1.3 80 6 34 2.11 6 0.73
Lillehei-Kaster 18 1.7 140
Tilting disk
20 1.7 67
22 1.56 6 0.09 94 6 22
25 1.38 6 0.27 124 6 46
Medtronic-Hall 27 1.4 78
Tilting disk
29 1.57 6 0.1 69 6 15
31 1.45 6 0.12 77 6 17
Medtronic Intact Porcine 29 3.5 6 0.51 1.6 6 0.22
31 4.2 6 1.44 1.6 6 0.26
33 4 6 1.3 1.4 6 0.24
35 3.2 6 1.77 1.3 6 0.5
Medtronic Mosaic 25 8.3 6 1.71 2.1 6 0.28 76 6 19.8 1.42 6 0.29
27 6.1 6 1.33 2 6 0.28 81 6 18.9 1.62 6 0.47
29 6.7 6 2.20 2.0 6 0.31 77 6 15.1 1.83 6 0.68
31 6.0 6 1.58 2.0 6 0.32 76 6 12.1 1.70 6 0.41
33 5.5 6 1.64 1.9 6 0.50 65 6 8.7 2.71 6 0.77
Mitroflow 25 6.9 2.0 90
27 3.07 6 0.91 1.5 90 6 20
29 3.5 6 1.65 1.43 6 0.29 102 6 21
31 3.85 6 0.81 1.32 6 0.26 91 6 22
Omnicarbon 23 8.0
Tilting disk
25 6.05 6 1.81 1.77 6 0.24 102 6 16
27 4.89 6 2.05 1.63 6 0.36 105 6 33
29 4.93 6 2.16 1.56 6 0.27 120 6 40
31 4.18 6 1.4 1.3 6 0.23 134 6 31
33 462
On-X 25 11.5 6 3.2 5.3 6 2.1 1.9 6 1.1
Bileaflet
27-29 10.3 6 4.5 4.5 6 1.6 2.2 6 0.5
31-33 9.8 6 3.8 4.8 6 2.4 2.5 6 1.1
Sorin Allcarbon 25 15 6 3 561 2 6 0.2 105 6 29 2.2 6 0.6
Tilting disk
27 13 6 2 461 1.8 6 0.1 89 6 14 2.5 6 0.5
29 10 6 2 461 1.6 6 0.2 85 6 23 2.8 6 0.7
(Continued )
Volume 37 Number 1
31 961 461 1.6 6 0.1 88 6 27 2.8 6 0.9

Sorin Bicarbon 25 15 6 0.25 4 6 0.5 1.95 6 0.02 70 6 1
Bileaflet
27 11 6 2.75 4 6 0.5 1.65 6 0.21 82 6 20
29 12 6 3 4 6 1.25 1.73 6 0.22 80 6 14
31 10 6 1.5 461 1.66 6 0.11 83 6 14
St. Jude Medical 23 4.0 1.5 160 1.0
Bileaflet
25 2.5 6 1 1.34 6 1.12 75 6 4 1.35 6 0.17
27 11 6 4 5 6 1.82 1.61 6 0.29 75 6 10 1.67 6 0.17
29 10 6 3 4.15 6 1.8 1.57 6 0.29 85 6 10 1.75 6 0.24
31 12 6 6 4.46 6 2.22 1.59 6 0.33 74 6 13 2.03 6 0.32
Starr-Edwards 26 10.0 1.4
Caged ball
28 7 6 2.75 1.9 6 0.57
30 12.2 6 4.6 6.99 6 2.5 1.7 6 0.3 125 6 25 1.65 6 0.4
32 11.5 6 4.2 5.08 6 2.5 1.7 6 0.3 110 6 25 1.98 6 0.4
34 5.0 2.6
Stentless quadrileaflet bovine pericardial 26 2.2 6 1.7 1.6 103 6 31 1.7
Stentless bioprosthesis
28 1.58 6 0.25 1.7 6 0.6
30 1.42 6 0.32 2.3 6 0.4
Wessex 29 3.69 6 0.61 1.66 6 0.17 83 6 19
31 3.31 6 0.83 1.41 6 0.25 80 6 21
Data are expressed as mean 6 SD.
Modified from Rosenhek et al.232
Table A6 Mean Doppler echocardiographic gradients for normal SAPIEN Valves placed percutaneously in the mitral position
Reference and valve size ViV ViR ViMAC All
Guerrero et al.139 7 (6-9) 7 (6-9) 6 (4-8) 7 (5-9)

Whisenant et al.138 7.3 6 2.73 NA NA NA
Eleid et al.140 5.7 6 2.5 5.7 6 2.2 4.3 6 2.3 5.5 6 2.4
23 mm 6.4 6 2.4 562 8* 6.25 6 2.2
26 mm 7.0 6 2.6 6 6 1.4 4* 6.5 6 2.4
29 mm 4.9 6 2.1 663 2.5 6 0.5 4.8 6 2.3
NA, Not applicable; ViMAC, valve–in–mitral annular calcification.
Data are expressed as median (IQR) or as mean 6 SD. Data are in millimeters of mercury from each publication. Data for individual valve size are
computed from Eleid et al.140 None of the SAPIEN valves had >2+ MR.
*Limited data, no SD reported.
January 2024
Table A7 Normal Doppler echocardiographic values for prosthetic pulmonary valves

Valve Size, mm mm Hg mm Hg m/sec AT, msec EOA, cm2
Homograft233 <25 <15 <2.5

233
Valved conduits
Contegra 12-22
Shelhigh 10-24 <15 <2.2
Medtronic 19-29
233
Bioprosthetic valves <15 <2.2
Percutaneous pulmonary valves 16 (#20) <2.4
(Melody)234
18 (#22) <2.4
Percutaneous pulmonary valves 20 16 6 5 1.22 6 0.2
(SAPIEN)11
23 11 (8-17) 1.47 (1.1-2)
26 9.5 (4.9-14.5) 1.77 (1.3-2.4)
29 10.4 (5.9-15.5) 2 (1.5-2.6)
Percutaneous pulmonary valve native No data
outflow (Alterra Stent with SAPIEN)
Percutaneous pulmonary valve native No data
outflow (Harmony)
Mechanical valves (St. Jude)235 21 20 (19-21) 12 (11-13) 2.2 98 (85-110) 1.73
23 20 (7-35) 11 (4-20) 2 (1.2-2.9) 87 (52-118) 2.5 (1-3.8)
25 18 6 7.5 11 6 6 2 83 6 11 2.9 6 1
27 15 (6-30) 6 (3-18) 1.8 (1.2-2.7) 90 (72-116) 4.2 (3-4.8)
31 14 7 1.6 93 5.73
235
Mechanical valves (Carbomedics) 23 19 (17-20) 12 2 (1.8-2.2) 78 (70-85) 1.7 (1.3-2.1)
25 20 (11-30) 11 (5-33) 2 (1.6-2.7) 89 (64-108) 3.3 (1.5-4.4)
27 19 (10-28) 10 (6-14) 1.9 (1.4-2.4) 78 (75-80) 4.1 (4-4.1)
29 14 7 1.7 76 2.6
Mechanical valve 23 20 (7-36) 12 (4-22) 2.2 (1.1-2.7) 112 (106-118) 2.4 (1.9-2.9)
On-X235
25 17 (7-24) 10 (3-13) 1.8 (1.3-2.4) 100 (55-118) 1.5 (0.9-2.2)
27 23 13 2.2 113 1.9
29 20 (18-22) 12 6 1 2.1 (1.9-2.3) 103 (95-110) 2.02 (1.8-2.2)
AT, Acceleration time of the prosthetic valve.
Data are expressed as mean 6 SD or as median (IQR).
Table A8 Transcatheter tricuspid ViV and ViR
Mean gradient, Peak velocity,

n ViV/ViR Age, y mm Hg (mean 6 SD) EOA, cm2 m/sec PVL
McElhinney et al. 203

306 ViV, n = 284 (93%) 40 (1-86) 3.8 6 2.0 NR NR Trivial or none in 83%
ViR, n = 22 (7%)
$29 mm, 3.6 6 1.8
<29 mm, 4.2 6 2.3
NR, Not reported.

Volume 37 Number 1
Table A9 Normal Doppler echocardiographic values for prosthetic TVs
Mechanical St. Jude Medical Standard Carbomedics Standard Starr-Edwards
Size, mm 27 29 31 33 31 33 30 32 34
PHT, msec 77 6 14.6 100 6 35.2 81 6 13.5 82 6 18.8 78 98 6 9.7 132 NA 118 6 32.9
MG, mm Hg 2.4 6 1.27 2.6 6 1.13 3.3 6 1.21 3.2 6 1.24 4.0 6 1.63 3.4 6 1.19 5 4.0 6 1.0 5.7 6 1.63
E velocity, m/sec 1.1 6 0.32 1.2 6 0.21 1.4 6 0.31 1.3 6 0.22 1.4 6 0.19 1.2 6 0.16 1.5 1.5 6 0.44 1.8 6 0.28
VTITVP, cm 25 6 7.0 31 6 6.5 30 6 5.1 30 6 7.8 40 6 11.4 34 6 7.3 41 39 6 14.2 44 6 7.8
VTITVP/VTILVOT 1.2 6 0.33 1.4 6 0.30 1.4 6 0.23 1.5 6 0.33 1.9 6 0.53 1.6 6 0.33 1.5 2.0 6 0.68 1.9 6 0.32
EOA CON, cm2 2.54 6 0.64 2.20 6 0.33 2.49 6 0.45 2.46 6 0.59 2.01 6 0.51 2.33 6 0.43 2.07 1.87 6 0.33 1.81 6 0.48
iEOA CON, cm2/m2 1.52 6 0.34 1.21 6 0.13 1.38 6 0.29 1.36 6 0.36 1.04 6 0.18 1.25 6 0.35 1.51 0.96 6 0.18 1.08 6 0.29
Bioprosthesis Medtronic Mosaic Carpentier Edwards Perimount
Size, mm 25 27 29 31 33 29 31 33
PHT, msec 80 NA 115 6 13.4 144 6 28.6 139 6 56.5 94 6 2.8 74 6 26.2 137 653
MG, mm Hg 4.0 5.5 6 0.53 6.0 6 2.0 5.2 6 1.43 4.3 6 1.3 2.0 6 1.41 3.7 6 1.53 3.9 6 1.07
E velocity, m/sec 1.6 1.6 6 0.17 1.5 6 0.26 1.5 6 0.21 1.4 6 0.19 1.1 6 0.21 1.2 6 0.20 1.4 6 0.21
VTITVP, cm 35 51 6 6.8 37 6 0.97 46 6 9.5 40 6 8.6 29 6 7.1 37 6 9.1 38 6 7.9
VTITVP/VTILVOT 3.2 2.2 6 0.4 1.8 6 0.39 2.2 6 0.6 2.1 6 0.3 1.6 6 0.20 1.7 6 0.35 1.9 6 0.28
EOA CON, cm2 1.37 1.53 6 0.16 1.96 6 0.39 1.74 6 0.52 2.0 6 0.53 2.16 6 0.43 2.12 6 0.53 1.93 6 0.43
iEOA CON, cm2/m2 0.93 0.86 6 0.18 1.12 6 0.21 0.95 6 0.29 1.01 6 0.26 1.39 6 0.42 1.20 6 0.29 1.03 6 0.19
Bioprosthesis Carpentier Edwards Duraflex St. Jude Biocor
Size, mm 27 29 31 33 35 29 31 33
PHT, msec 130 6 45.4 102 6 26.5 115 6 40.8 116 6 39.7 83 6 26.5 NA 106 6 48.5 125 6 45.7
MG, mm Hg 5.2 6 1.69 6.0 6 1.95 5.7 6 1.67 5.6 6 2.10 5.3 6 1.61 6 5.1 6 1.36 3.9 6 1.20
E velocity, m/sec 1.5 6 0.26 1.7 6 0.27 1.5 6 0.27 1.5 6 0.26 1.5 6 0.25 1.6 1.5 6 0.34 1.3 6 0.23
VTITVP, cm 46 6 8.0 47 6 9.6 48 6 9.0 47 6 10.2 46 6 10.5 43 46 6 12.5 39 6 10
VTITVP/VTILVOT 2.4 6 0.40 2.3 6 0.60 2.3 6 0.53 2.3 6 0.54 2.3 6 0.54 1.7 2.2 6 0.57 1.9 6 0.56
EOA CON, cm2 1.34 6 0.22 1.54 6 0.38 1.57 6 0.39 1.69 6 0.44 1.63 6 0.38 2.84 1.92 6 0.53 1.88 6 0.49
iEOA CON, cm2/m2 0.78 6 0.15 0.88 6 0.19 0.88 6 0.22 0.92 6 0.24 0.88 6 0.22 1.54 0.99 6 0.19 1.07 6 0.29
Bioprosthesis Medtronic Hancock II
Size, mm 31 33 35
PHT, msec NA NA NA
MG, mm Hg 5.7 6 1.37 5.5 6 3.54 5.3 6 0.58
E velocity, m/sec 1.6 6 0.19 1.4 6 0.28 1.3 6 0.32
VTITVP, cm 49 6 8.7 50 6 16.3 41 6 2.5
VTITVP/VTILVOT 2.3 6 0.36 2.9 6 0.48 1.8 6 0.12
EOA CON, cm2 1.4 6 0.21 1.4 6 0.59 2.11 6 0.23
iEOA CON, cm2/m2 0.77 6 0.19 0.71 6 0.24 1.01 6 0.22
CON, Continuity equation; iEOA, indexed EOA; MG, mean gradient; VTI, velocity-time integral; TVP, TV prosthesis.
Data are mean 6 SD. Data for mechanical and bioprosthetic TVs are from Blauwet et al.192,202

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GUIDELINES AND STANDARDS

Guidelines for the Evaluation of Prosthetic

Keywords: Echocardiography, Doppler echocardiography, Prosthetic valves, Cardiac valves, Magnetic

TABLE OF CONTENTS J. Other Techniques for Assessing PHVs 13

mitral valve repair and device deployment.66,67 Three-dimensional TEE

Cardiac Magne c Resonance of Prosthe c Valves, Homogra s & Conduits

Anatomy & Flow visualiza on Quan ﬁca on Flow/Velocity 3D anatomy Fibrosis

II. EVALUATION OF PROSTHETIC AORTIC VALVES

Table 5 Doppler parameters of prosthetic valves in the aortic valve position

Normal Possible stenosis Suggests significant stenosis

Appropriate for all prosthetic aortic valves

Normal Moderate Severe

Aortic EOA* >0.85 cm /m if

BMI, Body mass index.

Parameters Mild Moderate Severe

Valve structure and motion

Table 9 Potential role of CT in various complications of prosthetic aortic valves

Complication Potential role of MDCT

Table 11 Doppler findings suggestive of prosthetic mitral

Finding Sensitivity Specificity Comments

Mild Moderate Severe

Table 14 Most common types of PVR

Type of valve/conduit Manufacturer; size (valve or conduit diameter)

Surgical Homograft (cryopreserved aortic or pulmonary) Variety of sizes

Table 15 Parameters for prosthetic pulmonary valve stenosis

Normal Possible obstruction

Table 16 Echocardiographic evaluation of severity of prosthetic pulmonary valve regurgitation

Parameters Mild Moderate Severe

Primary valve Advantages Advantages Advantages

V. EVALUATION OF PROSTHETIC TRICUSPID VALVES

Parameter Advantages Limitations

Table 21 Echocardiographic grading of TR after TVR or TV repair

Parameters Mild Moderate Severe

CHD anatomy Surgical interventions Percutaneous valve interventions

Aortic valve Severe aortic stenosis Ross procedure Balloon valvuloplasty

AVSD, Atrioventricular septal defect; TOF, tetralogy of Fallot.

congenital valvular stenosis and some patients receive ViV implanta-

Table 24 Use of 3D echocardiography in patients with CHD*

Region of interest 3D modality Information Feasibility

Aortic valve GS/color Doppler Prosthetic valve leaflet appearance/ Moderate

Valve iteration Normal values

SAPIEN 20 mm 23 mm 26 mm 29 mm All sizes

SAPIEN XT 20 mm 23 mm 26 mm 29 mm All sizes

SAPIEN 3 20 mm 23 mm 26 mm 29 mm All sizes

Valve iteration Normal values

CoreValve 23 mm 26 mm 29 mm 31 mm All sizes

Evolut R (30 d) 23 mm 26 mm 29 mm 34 mm All sizes

CoreValve100 All 23.48 6 12.10 12.89 6 0.20 1.62 6 0.14

Valve Size, mm Peak gradient, mm Hg Mean gradient, mm Hg EOA, cm2

Abbott Epic 21 19.1 6 8.2 1.0 6 0.3

Bioflo 19 37.2 6 8.8 26.4 6 5.5 0.7 6 0.1

Edwards 19 17.6 6 7.8 1.1 6 0.2

Ionescu-Shiley 17 23.8 6 3.4 0.9 6 0.1

Mitroflow 19 18.6 6 5.3 13.1 6 3.3 1.1 6 0.2

Peak gradient, Mean gradient, Peak velocity,

Abbott Epic 27 6.1 6 2.9 1.4 6 0.7

27 8.79 6 3.46 3.46 6 1.03 1.61 6 0.3 89 6 20 2.9 6 0.75

29 3.22 6 0.57 1.38 6 0.2 85 6 8