CLINICAL INVESTIGATIONS

MITRAL REGURGITATION

Color Doppler Splay: A Clue to the Presence

of Significant Mitral Regurgitation
Philip C. Wiener, DO, Evan J. Friend, BS, Ruchika Bhargav, MD, Kirthi Radhakrishnan, PhD, Lyes Kadem, PhD,
and Gregg S. Pressman, MD, Philadelphia, Pennsylvania; Andover, Massachusetts; and Montreal, Quebec, Canada

Background: The authors describe a previously unreported Doppler signal associated with mitral regurgitation
(MR) as imaged using transthoracic echocardiography. Horizontal ‘‘splay’’ of the color Doppler signal along
the atrial surface of the valve may indicate significant regurgitation when the MR jet otherwise appears benign.

Methods: Splay was defined as a nonphysiologic arc of color centered at the point at which the MR jet emerges
into the left atrium. The authors present a series of 10 cases of clinically significant MR (moderately severe or
severe as defined by transesophageal echocardiography) that were misclassified on transthoracic echocar-
diography as less than moderate. The splay signal was present on at least one standard transthoracic view
in each case. To better characterize the splay signal, two groups were created from existing clinically driven
transthoracic echocardiograms: 100 consecutive patients with severe MR and 100 with mild MR.

Results: Splay was present in the majority of severe MR cases (81%) regardless of vendor machine, ejection frac-
tion, or MR etiology. Splay was particularly prevalent among patients with wall-hugging jets (28 of 30 [93%]). In
patients with mild MR, splay was present less often (16%), on fewer frames per clip, and had smaller dimensions
compared with severe MR. Color scale did not differ between subjects with and those without splay, but color
gain was higher when splay was present (P = .04). Machine settings were further explored in a single subject
with prominent splay: increasing transducer frequency reduced splay, while increasing color gain increased it.

Conclusions: The authors describe a new transthoracic echocardiographic sign of MR. Horizontal splay may
be a clue to the presence of severe MR when the main body of the jet is out of the imaging plane. Splay is likely
generated as a side-lobe artifact due to a high-flux regurgitant jet. (J Am Soc Echocardiogr 2020;33:1212-9.)

Keywords: Color Doppler splay, Mitral regurgitation, Valvular disease, Echocardiography, Side-lobe artifact

Mitral regurgitation (MR) is a common valvular abnormality with repair improves outcomes, in both primary8 and secondary9 MR.
increasing prevalence in older age groups1,2 and is an important cause Transthoracic echocardiography (TTE) with Doppler imaging is the
of morbidity and mortality.3-6 Among symptomatic patients, and modality of choice for detection and evaluation of MR.3-5 It allows
even asymptomatic individuals, surgical correction of severe MR quantitative grading, which can predict clinical outcomes4: increasing
reduces mortality.2,7 In patients with moderately severe or severe size of the regurgitant orifice is associated with greater risk for death
MR who are poor surgical candidates, endovascular mitral valve and cardiac events. However, there are limitations to this
technology,1,10-12 and accurate assessment of MR relies on the
presence of a discrete, well-visualized jet.3-5
We have observed cases of benign-appearing MR (reported as less
From the Division of Cardiology, Heart and Vascular Institute (P.C.W., E.J.F.,
than moderate) that displayed abnormal color Doppler signal tracking
G.S.P.), the Department of Medicine (R.B.), Einstein Medical Center,
Philadelphia, Pennsylvania; Philips North America Corporation, Andover,
along the atrial surface of the valve in a nonphysiologic fashion that we
Massachusetts (K.R.); and the Department of Mechanical, Industrial and describe as ‘‘splay.’’ On further evaluation with transesophageal echo-
Aerospace Engineering, Concordia University, Montreal, Quebec, Canada (L.K.). cardiography (TEE), the severity of MR was more significant than orig-
Dr. Radhakrishnan is an employee of Philips Healthcare but did not have any input inally suspected (Figure 1). We believe that this horizontal splay of the
into the design and conduct of the study, and no financial support was provided by regurgitant jet represents a unique signal that may be a clue to the pres-
Philips Healthcare. ence of moderately severe or severe (‘‘actionable’’) MR.
Conflicts of Interest: None. In this report, we present a series of 10 patients with benign-
Reprint requests: Gregg S. Pressman, MD, Einstein Medical Center, 5501 Old York appearing MR on TTE who demonstrated this splay signal and were
Road, 3230 Levy Building, Philadelphia, PA 19141 (E-mail: pressmang@einstein. later shown to have moderately severe or severe MR on TEE. To better
edu). understand the prevalence of this signal and its relationship to severity
0894-7317/$36.00 of MR, we also characterized its presence, dimensions, and duration in
Copyright 2020 by the American Society of Echocardiography. a series of patients in whom TTE revealed severe MR and compared
https://doi.org/10.1016/j.echo.2020.05.002
them with patients in whom TTE revealed mild MR.
1212
Journal of the American Society of Echocardiography Wiener et al 1213
Volume 33 Number 10

Abbreviations METHODS All transesophageal and transthoracic echocardiographic studies

were performed for clinical indications and stored as digital images
MR = Mitral regurgitation We first performed a retro- in the hospital picture archiving and communication system; no study
TEE = Transesophageal spective review of all transeso- was obtained as part of a research protocol. Studies were performed
echocardiography phageal echocardiographic using Philips (iE33, Sonos 5500, HD15, and Epiq 7; Philips Medical
examinations performed at Systems, Andover, MA), GE (Vivid E9, Vivid E95, and Vivid 7; GE
TTE = Transthoracic Einstein Medical Center from Healthcare, Boston, MA), and Siemens (Acuson SC2000; Siemens
echocardiography
January 2013 through Medical Solutions USA, Mountain View, CA) echocardiographic
December 2017. These included machines.
inpatients and outpatients. Our aim was to identify patients with In the second part of the study, consecutive transthoracic echocar-
regurgitation severe enough to require possible intervention (action- diograms were reviewed to obtain 100 patients with reported severe
able MR) in whom TTE demonstrated less than moderate MR. We MR and 100 patients with reported mild MR. All echocardiograms
excluded subjects with endocarditis, prosthetic mitral valves, or were reviewed, and the severity of MR was confirmed by a single
previous mitral valve repair. There were 182 transesophageal studies reader (G.S.P.). The presence or absence of splay was recorded.
reporting moderately severe or severe MR. Of these, 120 patients When present, the splay signal dimensions (width and depth) were
underwent TTE within 14 days of TEE. After excluding those in noted, along with the number of frames per cycle in which it was
whom TTE showed moderate or greater MR, 32 subjects remained. seen. Color scale, color gain, and transducer frequency were also
These 32 transthoracic echocardiograms were reviewed in detail to recorded. Initial detection of the splay signal was made on review
determine the presence or absence of the splay signal. of digital video images played at normal speed. Frame-by-frame

Figure 1 Demonstration of the splay signal in a select patient from the series (subject 2 from Table 1). (A) Apical two-chamber view,
(B) apical three-chamber view, (C) apical four-chamber view, (D) parasternal long-axis view, (E) zoomed-in apical four-chamber view,
and (F) severe primary MR with an anteriorly directed jet on TEE at 120
. The red arrows denote the splay arc.
1214 Wiener et al Journal of the American Society of Echocardiography
October 2020

Table 2 Splay prevalence and dimensions

HIGHLIGHTS
Parameter Mild MR Severe MR P
 Splay represents a nonphysiologic color Doppler signal.
Splay present 16% 81% <.0001
 Splay is often seen with significant MR.
Number of frames with 2 6 1.6 3.6 6 1.3 <.0001
 Splay is likely due to side-lobe artifact with high flow through a splay present
small orifice. Width of splay, cm 2.2 6 0.5 3.2 6 0.9 <.0001
 Splay is a clue to actionable MR in poorly defined jets. Depth of splay, cm 0.36 6 0.11 0.47 6 0.16 .01
Data (mean 6 SD) demonstrate percentage of patients in whom
review was then performed to determine where in systole splay splay was present, number of frames in which splay was present
occurred; measurements of the splay signal were made on the frame during cycle, width of splay as measured during TTE, and depth of
with the largest splay signal detected. the splay as measured during TTE from the validation cohorts.
Finally, we studied different machine settings (using a Philips Epiq 7
echocardiograph) in a single subject who had marked splay in multi-
ple transthoracic views. Three subjects had anteriorly directed jets, five had posteriorly
Categorical variables are presented as number and percentage and directed jets, and two had central jets.
continuous variables as mean 6 SD. Comparisons between categor- In our review of consecutive transthoracic echocardiograms from
ical variables were done using either the c2 test or the Fisher exact test, 100 patients with severe MR and 100 patients with mild MR, splay
as appropriate. For continuous variables, Student’s t test or the was present in the majority (81%) of severe MR cases (Table 2,
Wilcoxon test, when values were not normally distributed, was Figure 2) but less frequently in patients with mild MR (16%;
used. A two-tailed P value <.05 was considered to indicate statistical Figure 3). In addition, when present, splay was seen on fewer frames
significance. Statistical analyses were performed using JMP version and had smaller dimensions in the mild MR group compared with
14.0 (SAS Institute, Cary, NC). those with severe MR (Table 2). Splay was particularly prevalent in pa-
tients with severe MR who had ‘‘wall-hugging’’ jets (28 of 30 [93%]).
Looking more closely at the 100 patients in whom TTE demon-
RESULTS strated severe MR, we made the following additional observations:
(1) splay was present in mid-systole in 72 subjects, in early systole
Thirty-two patients were identified as having moderately severe or in 50 subjects, and in late systole in 35 subjects, and splay could be
severe MR on TEE in whom standard TTE revealed less than seen in a portion of systole or could be holosystolic (16 subjects),
moderate MR. Independent review of these cases identified 10 trans- and (2) splay could also occur on the ventricular side of the valve
thoracic studies in which the splay signal was present in at least one (proximal isovelocity surface area splay), noted in 26 subjects
standard view (apical four-chamber, three-chamber, two-chamber, (example in Figure 1E).
or parasternal long- or short-axis). Demographic and echocardio- The splay signal was seen across three vendors’ machines, irrespec-
graphic data for these patients are displayed in Table 1. tive of left ventricular ejection fraction or etiology of MR. It was most
Representative echocardiographic images from these cases are pre- commonly seen in the apical views but was occasionally present in the
sented as a photo montage (Supplemental Figure 1). Age ranged parasternal long-axis and short-axis views. Examples of splay are
from 51 to 90 years; half of the subjects were men. The mechanism demonstrated in each standard transthoracic view along with a corre-
of MR involved in these cases included prolapse or flail, secondary sponding transesophageal view in Supplemental Videos 1 to 10
MR due to left ventricular cardiomyopathy, and rheumatic disease. (available at www.onlinejase.com). Effects of machine settings were

Table 1 Demographics and comorbidities

BMI, Type Jet direction

Subject Rhythm Age, y Sex kg/m2 BSA, m2 HTN HLD DM MI LVEF, % of MR on TEE Etiology

1 AF 59 M 39.6 2.6 Yes Yes Yes Yes 20 Secondary Posterior DCM, A2 override
2 SR 54 M 37.8 2.5 Yes Yes Yes No 55 Primary Anterior P2 flail
3 SR 71 F 32.7 1.9 Yes Yes Yes No 75 Primary Posterior P3 flail and P2 cleft-like indentation
4 SR 62 M 39.9 2.4 Yes Yes Yes No 20 Secondary Posterior DCM
5 SR 90 F 28.6 2.1 No No No No 55 Primary Anterior P2 prolapse and calcified posterior annulus
6 ST 51 F 33.5 1.6 Yes No No No 75 Primary Posterior Rheumatic
7 SR 51 M 28.0 1.9 Yes No No No 50 Primary Posterior A2 prolapse and posterior calcified annulus
8 AF 85 F 22.7 1.6 Yes Yes No No 50 Primary Anterior A3, P3 prolapse
9 SR 67 F 31.6 1.8 Yes Yes Yes No 35 Primary Central Rheumatic
10 AF 61 M 35.8 2.5 Yes Yes No No 35 Secondary Central DCM
AF, Atrial fibrillation; BMI, body mass index; BSA, body surface area; DM, diabetes mellitus; DCM, dilated cardiomyopathy; HLD, hyperlipidemia;
HTN, hypertension; LVEF, left ventricular ejection fraction; MI, myocardial infarction; SR, sinus rhythm; ST, sinus tachycardia.
Journal of the American Society of Echocardiography Wiener et al 1215
Volume 33 Number 10

Figure 2 Presence of splay demonstrated in the severe MR validation cohort group. (A) Apical two-chamber, (B) apical three-
chamber, (C) apical four-chamber, (D) parasternal long-axis, and (E) parasternal short-axis views. The red arrows denote the splay
arc.

explored in subjects studied with Philips equipment (the largest We further studied various machine settings in a single subject with
subset). Color scale did not differ according to the presence or a prominent splay signal (using a Philips Epiq 7 echocardiograph)
absence of splay, but color gain was higher when splay was present and observed the following: (1) reducing transmission frequency
(57.5 6 6.8% vs 55.2 6 6.1%, P = .04). In addition, changing the from 2.5 to 2.0 MHz increased the splay signal somewhat, while
Nyquist limit could occasionally produce splay when it was not increasing the frequency to 3.3 MHz greatly reduced splay; (2)
present at baseline (Figure 4). harmonic imaging had little effect on splay; and (3) increasing
1216 Wiener et al Journal of the American Society of Echocardiography
October 2020

Figure 3 Presence of splay demonstrated in the mild MR validation cohort group. (A) Apical two-chamber, (B) apical three-chamber,
and (C) apical four-chamber views. No examples of splay were found in parasternal views. The red arrows denote the splay arc.

the color gain increased the splay signal. These findings are while those with mild MR had splay less often and of lesser dimen-
illustrated in Supplemental Videos 11 to 13 (available at www. sions when it was present. Splay could occur at any point in systole
onlinejase.com). (mid-systole was most common) or could be holosystolic. In addi-
tion, it was occasionally seen on the ventricular side of the valve
(proximal isovelocity surface area splay). Etiology of MR did not
DISCUSSION appear to play a role in generation of the splay signal. Nor was
splay specific to a particular machine or vendor. It did vary with
MR is a common valvular lesion that carries a significant risk for changes in transducer frequency (more prominent at lower trans-
morbidity and mortality.2-6 Current recommendations emphasize mission frequencies) and color gain settings (more prominent at
the importance of MR quantitation,3,4 particularly if intervention is higher color gain). Occasionally, shifting the Nyquist limit could
being considered. However, quantitative measurement of MR can bring out splay when it was not present at baseline. Using harmonic
be problematic in the presence of a highly eccentric jet or when the imaging had little effect compared with fundamental imaging; this
jet is not well visualized.3,4,13,14 In this study, we describe a horizontal was expected, as harmonic imaging only affects the B-mode image
color Doppler signal we have termed ‘‘splay,’’ which is frequently asso- and not color.
ciated with severe MR. On occasion, when standard transthoracic We believe that the splay signal occurs as a side-lobe artifact. These
views do not adequately image the regurgitant signal, splay may be artifacts are due to reflected or back-scattered signals that are detected
an important clue to the presence of actionable MR. In a review of by side lobes that accompany the main beam of the phased-array
patients over a 5-year period, who had moderately severe or severe transducer.12 Side lobes are generated because of the finite aperture
MR on TEE, we identified 32 cases in which TTE misclassified the size of the transducer. For rectangular apertures (such as the trans-
regurgitation as less than moderate. Of these 32, splay was present ducers used in echocardiography) the point-spread function, or focal
in 10 subjects. zone, consists of a main lobe and several side lobes that are mathemat-
We also examined patients with severe MR, as reported on TTE, ically represented as a sinc function during signal processing. Each of
and compared them with patients in whom TTE revealed mild MR. the peaks in the sinc function indicates the side lobes of decreasing
The splay signal was more common in patients with severe MR, strength on either side of the main lobe.15 Typically, the first side lobes
Journal of the American Society of Echocardiography Wiener et al 1217
Volume 33 Number 10

Figure 4 The left panel shows a systolic frame displaying a large mitral regurgitant jet but no splay; the right panel shows the same
view with the Nyquist limit shifted. Note the appearance of splay (red arrows).

Figure 5 The illustration depicts the formation of a side-lobe artifact. (A) Ultrasound waves (dashed lines) from the side lobe (SL) of the
echo beam reflecting off an ‘‘echo-bright’’ object (solid red circle) and returning to the transducer; the machine interprets this signal as
coming from the main lobe (ML) and depicts the object in the location of the dashed circle. (B) What happens as the beam is swept
across the ‘‘echo-bright’’ object: the side lobes will each image the object, leading to creation of an arc-like artifact extending to either
side of the object.

are of interest because of their higher strength and proximity to the The strength of the first side lobes for rectangular aperture is
main lobe. 13 dB relative to the main lobe.16
The location of the side lobes is dependent on the aperture size Side-lobe artifacts present as an arc-like image that follows the
(i.e., the size of the transducer when the full aperture is being used, curvilinear path of the echo beam (Figure 5).12 Such artifacts are
typically at depths > 4 cm on TTE). It is given by the following equa- often seen on two-dimensional TTE when imaging highly echo-
tion: genic structures such as calcium or prosthetic material; these
can be detected by the side lobes of the echo beam as well as
sinðaÞ ¼ mlD; the main lobe. Reflected signals returning from the side lobes
will be plotted in the location of the main beam at that instant.
where a is the angular location of the side lobe with reference to the Thus, as the beam sweeps through the object, dots will be plotted
main lobe location, m is the number of the side lobe, l is the wave- on the screen in the location of the structure and on either side,
length, and D is the transducer/aperture footprint (lateral size). resulting in an arc-like image whose points are all equidistant from
1218 Wiener et al Journal of the American Society of Echocardiography
October 2020

Figure 6 Two examples in which the main-lobe and side-lobe imaging of the emerging regurgitant jet can possibly be distinguished.
In both cases, the color of the splay ‘‘wings’’ is different from the center of the splay; the center also tends to be thicker.

the transducer. In the case of color Doppler splay, we believe that with the side lobes having a wing-like appearance; on occasion these
the phenomenon is related to volumetric flux (rate of volume wings can be a different color than the main lobe (Figure 6). We would
flow per unit area), and thus flux of echo scatterers, through a also note that both splay and a truncated jet can be present in the
small orifice. In cases of severe MR, a prominent and intense same image (Supplemental Video 14 available at www.onlinejase.
splay signal is often present, whereas in cases of mild MR, there com).
is a less prominent signal or none at all. Quantitative measurement improves the accuracy of MR assess-
Of note, side-lobe artifacts are less frequent on TEE. On the basis of ment.3,4 However, accurate quantitation requires optimal imaging
the above equation, they are dependent on the transducer size and of regurgitant flow. There are many potential reasons such jets may
wavelength (determined by transducer frequency), both of which be suboptimally imaged: misalignment of the Doppler cursor, poor
are different for TEE compared with TTE. visualization of the jet within the left atrium, poor visualization of
Although splay can be a tip-off to the presence of clinically signif- the area of proximal flow acceleration, and inaccurate measurement
icant MR, it should not be the sole criterion in making this determina- of the vena contracta. In such cases, we must rely on other clues to
tion. All other parameters usually used to assess MR severity should detect the presence of actionable MR. Splay can be helpful in such
be considered, including jet density on CW Doppler, forward veloc- settings. As observed in our patient series, discrepant readings of
ities and mean gradient across the mitral valve, vena contracta width, MR severity on TTE and TEE are not rare. Finally, we have also noted
and elevation of pulmonary pressure. Even so, there will be occasional the splay signal in cases of other high-flux jets, such as aortic stenosis
studies in which the regurgitation appears benign but for the presence and regurgitation, suggesting that this may be a more generalized
of splay. Most of these patients will have narrow, highly eccentric MR phenomenon.
jets. In such cases, repeat TTE should be considered, with a careful This was a retrospective study, subject to the usual limitations
search for eccentric jets, including off-axis views. Alternatively, TEE of such studies. We could not define the true prevalence of splay,
can be performed. as we considered only patients who underwent both TTE and
It is important to differentiate MR splay from an eccentric out-of- TEE within 2 weeks of each other; suspicion that MR was
plane jet that appears truncated (though in both cases, the MR may more severe than demonstrated by TTE may have driven
be more significant than it would appear on first impression). The ordering of TEE. In addition, splay could not completely distin-
key feature of splay is that it occurs in an arc that precisely maintains guish between mild and severe MR, being present in both
the distance from the echocardiographic probe; this can be readily groups. However, it was more common and of greater dimen-
appreciated on careful inspection of Supplemental Videos 7 and 9. sions and duration in the severe group. Splay also did not identify
In addition, splay does not respect anatomic boundaries; in all subjects with underestimation of MR severity on standard
Supplemental Video 9, the color arc crosses the lateral aspect of the transthoracic views. But it was able to provide a clue to the pres-
anterior leaflet. Finally, the main lobe (the point at which the MR ence of actionable MR in 10 of 32 subjects with discrepant find-
jet emerges into the atrium) is usually a bit rounder and thicker, ings between TTE and TEE.
Journal of the American Society of Echocardiography Wiener et al 1219
Volume 33 Number 10

CONCLUSION heart disease: a report of the American College of Cardiology/Amer-

ican Heart Association Task Force on Clinical Practice Guidelines. J
We describe the presence of a novel echocardiographic sign of signif- Am Coll Cardiol 2017;70:252-89.
icant MR that appears as a splay of color across the mitral valve. 5. O’Gara PT, Grayburn PA, Badhwar V, Afonso LC, Carroll JD, Elmariah S,
et al. 2017 ACC expert consensus decision pathway on the management
Identification of MR splay may be clinically useful in two scenarios:
of mitral regurgitation: a report of the American College of Cardiology
(1) when the regurgitant jet appearance is otherwise benign, the pres- Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol
ence of MR splay may be a clue that the regurgitation is greater than it 2017;70:2421-49.
appears, and (2) a prominent and bright splay signal can support the 6. Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E,
degree of MR as being severe when other indicators are equivocal. Grayburn PA, et al. Recommendations for noninvasive evaluation of
The splay signal likely originates as a side-lobe artifact, at the point native valvular regurgitation: a report from the American Society of
at which an MR jet emerges into the left atrium. Echocardiography developed in collaboration with the Society for
Cardiovascular Magnetic Resonance. J Am Soc Echocardiog 2017;30:
303-71.
7. Ling LH, Enriquez-Sarano M, Seward JB, Orszulak TA, Schaff HV,
ACKNOWLEDGMENTS Bailey KR, et al. Early surgery in patients with mitral regurgitation due to
flail leaflets. Circulation 1997;96:1819-25.
We thank Dr. Raphael Bonita for review of the manuscript and Rachel 8. Feldman T, Foster E, Glower DD, Glower DG, Kar S, Rinaldi MJ, et al.
Murphy, BS, for help with project coordination. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med
2011;364:1395-406.
9. Stone GW, Lindenfeld J, Abraham WT, Kar S, Lim SD, Mishell JM, et al.
Transcatheter mitral-valve repair in patients with heart failure. N Engl J
SUPPLEMENTARY DATA Med 2018;379:2307-18.
10. Omoto R, Yokote Y, Takamoto S, Kyo S, Ueda K, Asano H, et al. The devel-
Supplementary data related to this article can be found at https://doi. opment of real-time two-dimensional doppler echocardiography and its
org/10.1016/j.echo.2020.05.002. clinical significance in acquired valvular diseases. Jpn Heart J 1984;25:
325-40.
11. Helmcke F, Nanda N, Hsiung M, Soto B, Adey C, Goyal R, et al. Color
REFERENCES Doppler assessment of mitral regurgitation with orthogonal planes. Circu-
lation 2018;75:175-83.
1. Singh JP, Evans JC, Levy D, Larson MG, Freed LA, Fuller DL, et al. Preva- 12. Bertrand PB, Levine RA, Isselbacher EM, Vandervoort PM. Fact or artifact
lence and clinical determinants of mitral, tricuspid, and aortic regurgitation in two-dimensional echocardiography: avoiding misdiagnosis and missed
(the Framingham Heart Study). Am J Cardiol 1999;83:897-902. diagnosis. J Am Soc Echocardiog 2016;29:381-91.
2. Enriquez-Sarano M, Avierinos J-F, Messika-Zeitoun D, Detaint D, 13. El-Tallawi K, Messika-Zeitoun D, Zoghbi WA. Assessment of the
Capps M, Nkomo V, et al. Quantitative determinants of the outcome of severity of native mitral valve regurgitation. Prog Cardiovasc Dis 2017;
asymptomatic mitral regurgitation. N Engl J Med 2005;352:875-83. 60:322-33.
3. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, 14. Enriquez-Sarano M, Tajik A, Bailey K, Seward J. Color flow imaging
Guyton RA, et al. 2014 AHA/ACC guideline for the management of pa- compared with quantitative Doppler assessment of severity of mitral
tients with valvular heart disease: a report of the American College of Car- regurgitation: influence of eccentricity of jet and mechanism of regurgita-
diology/American Heart Association Task Force on Practice Guidelines. tion. J Am Coll Cardiol 1993;21:1211-9.
Circulation 2014;129:e521-643. 15. Ilovitsh A, Ilovitsh T, Ferrara KW. Multiplexed ultrasound beam summa-
4. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, tion for side lobe reduction. Sci Rep 2019;9:13961.
Fleisher LA, et al. 2017 AHA/ACC focused update of the 2014 16. Szabo TL. Beamforming. In: Diagnostic ultrasound imaging: inside out.
AHA/ACC guideline for the management of patients with valvular Oxford, United Kingdom: Elsevier; 2014. pp. 167-207.
1219.e1 Wiener et al Journal of the American Society of Echocardiography
October 2020

Supplemental Figure 1 Clinical vignettes and representative echocardiographic images (‘‘splay’’ on TTE designated by red arrows).
Demographic information is presented in Table 1. Subject 1 was a 59-year-old man presenting with a 1-month history of progressive
dyspnea with (A) an apical four-chamber view showing mild MR on TTE and (B) moderate to severe secondary MR with a posteriorly
directed jet on TEE at 92
. Subject 2 was a 54-year-old man presenting with a 2-week history of progressive dyspnea with (C) an
apical four-chamber view showing mild MR due to a flail P2 scallop on TTE and (D) moderate to severe primary MR with an anteriorly
directed jet on TEE at 120
. Subject 3 was a 71-year-old woman presenting with syncope with (E) a parasternal long-axis view
showing mild MR due to flail P3 and P2 cleft on TTE and (F) severe primary MR with a posteriorly directed jet on TEE at 58
. Subject
4 was a 62-year-old man admitted for a 1-month history of worsening fatigue and nausea with (G) an apical two-chamber view
showing mild to moderate on TTE and (H) severe secondary MR with a posteriorly directed jet on TEE at 90
. Subject 5 was a 90-
year-old man presenting with 6 weeks of dyspnea with (I) an apical four-chamber view showing mild to moderate MR on TTE and
(J) severe primary MR with an anteriorly directed jet due to prolapse of P2 and a calcified posterior annulus on TEE at 119
. Subject
6 was a 51-year-old woman presenting with cough, dyspnea, and chest pain for 3 days with (K) an apical four-chamber view showing
trace MR on TTE and (L) moderate to severe primary MR with rheumatic changes with a posteriorly directed jet on TEE at 32
. Subject
7 was a 51-year-old man referred for outpatient imaging with (M) an apical four-chamber view showing mild to moderate MR on TTE
and (N) moderate to severe primary MR with a posteriorly directed jet due to prolapse of A2 on TEE at 0
. Subject 8 was an 85-year-old
woman admitted for chest pain and shortness of breath with (O) an apical four-chamber view showing mild to moderate MR on TTE
and (P) severe eccentric anteriorly directed primary MR due to A3 and P3 prolapse on TEE at 90
. Subject 9 was a 67-year-old woman
admitted for shortness of breath for 3 days with (Q) an apical four-chamber view showing mild MR on TTE and (R) moderate to severe
primary MR with a central jet and rheumatic changes on TEE at 120
. Subject 10 was a 61-year-old man admitted with shortness of
breath with (S) an apical four-chamber view showing mild to moderate MR on TTE and (T) moderate to severe secondary MR with a
central jet on TEE at 61
.