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Conversely, in patients with small cavities prior to the onset of regurgitation, an increase in cavity size may be underestimated if preregurgitation cavity size is unknown. Anatomic variability and technical issues may limit the ability to detect cavity dilatation. Measuring cavity diameters rather than volumes has inherent limitations as the diameter-volume relationship is nonlinear. Patch the pirate s. Furthermore, the proposed range of normal values currently available is based on a limited number of subjects, so that for patients with small or very large body size, normalcy is difficult to define. The small body size limitation is of particular concern in evaluating valve regurgitation in females, where normalizing ventricular and regurgitant measurements to body size may provide a more accurate assessment of outcomes. Nevertheless, in a patient with regurgitation, an enlarged ventricle is consistent with significant regurgitation in the chronic setting and in the absence of other modulating factors, particularly when ventricular function is normal. Once a diagnosis of significant regurgitation is established, serial echocardiography with TTE is currently the method of choice to assess the progression of the impact of regurgitation on cardiac chamber structure and function. Careful attention to consistency of measurements and individualized interpretation of results are critical to the assessment of cardiac remodeling as a sign of regurgitation severity. Contrast echocardiography should be used in technically difficult studies for better endocardial visualization, as it enhances overall accuracy of ventricular volume measurements. Three-dimensional TTE can also be used for an overall more accurate assessment of volumes and ejection fraction, as it avoids foreshortening of the left ventricle (LV).

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Gabriel RS, Kerr AJ, Raffel OC, Stewart FA, Cowan BR, Occleshaw CJ. Mapping of mitral regurgitant defects by cardiovascular magnetic resonance in moderate or severe mitral regurgitation secondary to mitral valve prolapse. J Cardiovasc Magn Reson 2008;10:16.

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Yosefy C, Levine RA, Solis J, Vaturi M, Handschumacher MD, Hung J. Proximal flow convergence region as assessed by real-time 3-dimensional echocardiography: Challenging the hemispheric assumption. J Am Soc Echocardiogr 2007;20:389-96.

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Søndergaard L, Thomsen C, Ståhlberg F, Gymoese E, Lindvig K, Hildebrandt P, et al. Mitral and aortic valvular flow: Quantification with MR phase mapping. J Magn Reson Imaging 1992;2:295-302.

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As the clinical management of patients with severe MR or AR continues to evolve toward early surgical intervention, it is important that early preemptive surgery be performed only in those with truly severe regurgitation. Similarly, surgery in symptomatic patients is recommended only when AR or MR is considered severe enough to be the cause of symptoms. Thus, quantifying severity of regurgitation with echocardiography or CMR is of paramount importance in determining whether asymptomatic or symptomatic patients are candidates for surgical or percutaneous intervention. In such cases, however, patient symptoms and all of the skills of the clinician such as meticulous physical examination and history taking are of equal importance to the results of the imaging itself to identify those with truly severe disease.

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Leung DY, Griffin BP, Stewart WJ, Cosgrove DM 3rd, Thomas JD, Marwick TH. Left ventricular function after valve repair for chronic mitral regurgitation: Predictive value of preoperative assessment of contractile reserve by exercise echocardiography. J Am Coll Cardiol 1996;28:1198-205.

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Sievers HH, Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg 2007;133:1226-33.

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Chatzimavroudis GP, Oshinski JN, Franch RH, Pettigrew RI, Walker PG, Yoganathan AP. Quantification of the aortic regurgitant volume with magnetic resonance phase velocity mapping: A clinical investigation of the importance of imaging slice location. J Heart Valve Dis 1998;7:94-101.

Movsowitz HD, Levine RA, Hilgenberg AD, Isselbacher EM. Transesophageal echocardiographic description of the mechanisms of aortic regurgitation in acute type A aortic dissection: Implications for aortic valve repair. J Am Coll Cardiol 2000;36:884-90.

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Lang RM, Tsang W, Weinert L, Mor-Avi V, Chandra S. Valvular heart disease. The value of 3-dimensional echocardiography. J Am Coll Cardiol 2021;58:1933-44.

Maceira AM, Cosín-Sales J, Roughton M, Prasad SK, Pennell DJ. Reference left atrial dimensions and volumes by steady state free precession cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2021;12:65.

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Gelfand EV, Hughes S, Hauser TH, Yeon SB, Goepfert L, Kissinger KV, et al. Severity of mitral and aortic regurgitation as assessed by cardiovascular magnetic resonance: Optimizing correlation with Doppler echocardiography. J Cardiovasc Magn Reson 2006;8:503-7.

Maceira AM, Prasad SK, Khan M, Pennell DJ. Normalized left ventricular systolic and diastolic function by steady state free precession cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2006;8:417-26.

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Hundley WG, Li HF, Willard JE, Landau C, Lange RA, Meshack BM, et al. Magnetic resonance imaging assessment of the severity of mitral regurgitation. Comparison with invasive techniques.

Stewart WJ, Currie PJ, Salcedo EE, Lytle BW, Gill CC, Schiavone WA, et al. Intraoperative Doppler color flow mapping for decision-making in valve repair for mitral regurgitation. Technique and results in 100 patients.

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Vanoverschelde JL, van Dyck M, Gerber B, Vancraeynest D, Melchior J, de Meester C, et al. The role of echocardiography in aortic valve repair. Ann Cardiothorac Surg 2021;2:65-72.

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Panidis IP, Ross J, Munley B, Nestico P, Mintz GS. Diastolic mitral regurgitation in patients with atrioventricular conduction abnormalities: A common finding by Doppler echocardiography. J Am Coll Cardiol 1986;7:768-74.

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Carpentier A. Cardiac valve surgery-the “French correction”. J Thorac Cardiovasc Surg 1983;86:323-37.

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The RV is usually dilated in the presence of hemodynamically significant TR. The position of the septum produces a D-shaped LV predominantly in diastole (RV volume overload pattern). When TR is due to pulmonary hypertension, septal flattening is present throughout the cardiac cycle, reflecting the diastolic and systolic overload of the RV (RV pressure overload pattern).

Exercise echocardiography can be useful in evaluating patients with both primary MR and ischemic functional MR. Exercise may unmask the presence of symptoms and establish functional capacity in patients who are sedentary or have equivocal symptoms. Failure of LVEF to increase normally with exercise predicts worse postoperative LV function in primary MR. Color Doppler inclusive of changes in EROA derived with PISA during exercise can be technically difficult to capture due to tachypnea and tachycardia and may be best performed during supine bicycle exercise.

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AR in most patients is easily seen with color flow Doppler as a mosaic blend of colors originating from the aortic valve during diastole. Although the apical approach is the most sensitive for detection, the parasternal long and short axis are essential in evaluating the origin of the jet and its semiquantitative characteristics. It is important to visualize the three components of the color jet (flow convergence, VC, and jet area) for a better assessment of the origin and direction of the jet and its overall severity [Figure 20]. Because the length of the AR jet into the LV chamber is so dependent on the driving pressure (diastolic blood pressure), it is not a reliable parameter of AR severity. Lastly, AR usually lasts throughout diastole except in acute AR, where it may be brief and of lower velocity, making detection and assessment with color Doppler more difficult.

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Shah PM, Raney AA. Tricuspid valve disease. Curr Probl Cardiol 2008;33:47-84.

There are several methods for quantifying AR by CMR, broadly categorized as direct and indirect methods (see Section II, General Considerations). The direct method involves performing phase-contrast velocity mapping in a plane perpendicular to the aorta; most operators recommend positioning in the aortic root (just above the aortic valve),,[Figure 7] and [Figure 24].

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There is a paucity of data on specific CMR thresholds of RVol or fraction that define severe regurgitation based on outcomes. An earlier study suggested using a RF threshold of 48% by CMR to define severe regurgitation of the aortic or MVs, based on achieving the best correlation with limited echocardiographic assessment.

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Thorsgard ME, Morrissette GJ, Sun B, Eales F, Kshettry V, Flavin T, et al. Impact of intraoperative transesophageal echocardiography on acute type-A aortic dissection. J Cardiothorac Vasc Anesth 2021;28:1203-7.

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There is a paucity of data regarding the quantification of PR. This stems partly from the difficulty in visualizing PR, the fact that minor degrees of PR are common and have no clinical impact, and the low incidence of clinically significant PR in the adult. Most of the concepts for quantifying AR are applied to PR. The various parameters used and their advantages and limitations are listed in [Table 15].

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Emine BS, Murat A, Mehmet B, Mustafa K, Gokturk I. Flail mitral and tricuspid valves due to myxomatous disease. Eur J Echocardiogr 2008;9:304-5.

The intensity (amplitude) of the returned Doppler signal is proportional to the number of red blood cells reflecting the signal. Hence, the signal density of the CWD of the regurgitant jet should reflect the regurgitant flow. Thus a faint, incomplete, or soft signal is indicative of trace or mild regurgitation. A dense signal may not be able to differentiate moderate from severe regurgitation. Signal density also depends on spectral recording of the jet throughout the relevant portion of the cardiac cycle. Therefore, a central jet well aligned with the ultrasound beam may appear denser than an eccentric jet of much higher severity, if not well aligned.

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Pennell DJ. Ventricular volume and mass by CMR. J Cardiovasc Magn Reson 2002;4:507-13.

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Signal density: the density of the CWD signal reflects the volume of regurgitation, particularly when compared to the density of the forward flow. A faint or incomplete jet indicates mild or trace regurgitation, while a dense jet may be compatible with more significant regurgitation but cannot differentiate between moderate and severe AR.

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Isolated PR in adults is usually innocuous and rarely severe. A high-pitched murmur of PR, however, may be an important clinical marker of primary or secondary pulmonary hypertension. In addition, PR following repair of tetralogy of Fallot is a common late complication of previous surgical repair with important clinical implications.

Hahn RT, Roman MJ, Mogtader AH, Devereux RB. Association of aortic dilation with regurgitant, stenotic and functionally normal bicuspid aortic valves. J Am Coll Cardiol 1992;19:283-8.

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Quantitative pulsed Doppler methods can be used to measure PR RVol and fraction. The RVOT, however, is probably the most difficult site to measure SV because of its poor visualization and the changing size of the RVOT during the cardiac cycle. The RVOT is measured during early ejection (two to three frames after the R wave on the electrocardiogram) just below the PV in the parasternal short-axis view. Although not validated for quantitation of PR, flows in the RVOT can be compared to other sites to derive RVol and fraction.

Puchalski MD, Askovich B, Sower CT, Williams RV, Minich LL, Tani LY. Pulmonary regurgitation: Determining severity by echocardiography and magnetic resonance imaging. Congenit Heart Dis 2008;3:168-75.

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Mor-Avi V, Jenkins C, Kühl HP, Nesser HJ, Marwick T, Franke A, et al. Real-time 3-dimensional echocardiographic quantification of left ventricular volumes: Multicenter study for validation with magnetic resonance imaging and investigation of sources of error. JACC Cardiovasc Imaging 2008;1:413-23.

Witkowski TG, Thomas JD, Debonnaire PJ, Delgado V, Hoke U, Ewe SH, et al. Global longitudinal strain predicts left ventricular dysfunction after mitral valve repair. Eur Heart J Cardiovasc Imaging 2021;14:69-76.

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Shanks M, Siebelink HM, Delgado V, van de Veire NR, Ng AC, Sieders A, et al. Quantitative assessment of mitral regurgitation: Comparison between three-dimensional transesophageal echocardiography and magnetic resonance imaging. Circ Cardiovasc Imaging 2021;3:694-700.

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Quantitation of regurgitation can further subclassify regurgitation into four grades, with grade III having some overlap with characteristics of severe MR [Figure 18] and [Table 8], hence the need for an integrative approach. Finally, it is important to stress that when there is congruent evidence from different parameters, it is easy to grade MR severity with confidence. When different parameters are contradictory, one must look carefully for technical and physiologic reasons to explain the discrepancies and rely on components with the highest quality of the primary data that are the most accurate, considering the underlying physiologic condition. There will be times when MR severity and/or mechanism is uncertain by TTE and further testing is needed with TEE or CMR.

Levine HJ, Gaasch WH. Vasoactive drugs in chronic regurgitant lesions of the mitral and aortic valves. J Am Coll Cardiol 1996;28:1083-91.

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Seiffert M, Bader R, Kappert U, Rastan A, Krapf S, Bleiziffer S, et al. Initial German experience with transapical implantation of a second-generation transcatheter heart valve for the treatment of aortic regurgitation. JACC Cardiovasc Interv 2021;7:1168-74.

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Thavendiranathan P, Liu S, Datta S, Walls M, Calleja A, Nitinunu A, et al. Automated 3D quantification of mitral regurgitation by real-time volume color flow Doppler: Comparison with cardiac magnetic resonance imaging. J Am Soc Echocardiogr 2021;24:B3.

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If the majority or all criteria point to either mild or severe PR, the evaluation of the severity of PR is confident. If intermediate criteria or an overlap among them is present, the severity of PR is likely moderate. Although quantitation may be feasible, it is more challenging than in MR and AR; echocardiographers may quantitate RVols and fractions to further refine assessment of intermediate lesions; however, clinical experience with these measurements is far less than with MR and AR and likely better obtained with CMR. Furthermore, in contrast to MR and AR, further subclassifying PR severity into four grades according to quantitative criteria has not been validated in the literature.

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Krombach GA, Kühl H, Bücker A, Mahnken AH, Spüntrup E, Lipke C, et al. Cine MR imaging of heart valve dysfunction with segmented true fast imaging with steady state free precession. J Magn Reson Imaging 2004;19:59-67.

Lancellotti P, Moura L, Pierard LA, Agricola E, Popescu BA, Tribouilloy C, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: Mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr 2021;11:307-32.

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To understand how large a jet will appear in color Doppler, one needs to know the minimum velocity that can be detected by the instrument. This is not specifically defined on the echocardiogram but typically is a fraction (around 10%) of the full Nyquist velocity. The jet will appear anywhere the jet velocity is greater than this minimally detectible velocity. The situation is somewhat more complicated in that no jets inside the heart are completely free but are constrained by the chamber walls, causing the velocity to fall off earlier than it would otherwise.

Hundley WG, Kizilbash AM, Afridi I, Franco F, Peshock RM, Grayburn PA. Administration of an intravenous perfluorocarbon contrast agent improves echocardiographic determination of left ventricular volumes and ejection fraction: Comparison with cine magnetic resonance imaging. J Am Coll Cardiol 1998;32:1426-32.

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La Canna G, Maisano F, de Michele L, Grimaldi A, Grassi F, Capritti E, et al. Determinants of the degree of functional aortic regurgitation in patients with anatomically normal aortic valve and ascending thoracic aorta aneurysm. Transoesophageal Doppler echocardiography study.

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In asymptomatic patients with known valvular disease who are being followed serially, the timing of imaging studies changes when there are changes in the clinical situation. Exercise stress testing is used to assess functional capacity and equivocal symptoms. The onset of possible or definite symptoms or changes in the timing or intensity of the murmur should trigger repeat echocardiography or CMR. In patients with bicuspid aortic valves, a new murmur of AR could reflect an increase in severity or dilatation of the aortic sinuses or ascending aorta and is an indication for comprehensive imaging with echocardiography, CMR or both.

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A short-axis view is useful in defining the exact location of pathology because it allows imaging of both leaflets and the commissures. The four-chamber view can cut through the leaflets at different locations. A cross-commissural view (typically by TEE but approximated by the transthoracic apical two-chamber view) is good at identifying the lateral (P1) and medial (P3) scallops of the posterior leaflet and the middle (A2) anterior leaflet. The optimal view of the coaptation line is a 3D en face view by either TTE or TEE.

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In addition to peak velocity, the contour of the velocity profile and its density are useful. A truncated, triangular jet contour with early peaking of the maximal velocity indicates elevated LA pressure or a prominent regurgitant pressure wave [Figure 12]. The density of the CWD signal is a qualitative index of MR severity; a dense signal suggests significant MR, whereas a faint signal is likely to be mild or trace MR. CWD should also be used to interrogate the TR jet to estimate PA systolic pressure, another indirect clue as to MR severity and compensation for the volume overload.

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Visualization of the VCW is technically less demanding than the PISA method and can be utilized either semi-quantitatively or qualitatively. When acquired from the apical four-chamber and RV inflow parasternal views, a TR VCW >0/7 cm identifies severe TR and is a marker of worse prognosis. Three-dimensional color Doppler methods can be used to measure VCA and VCW; however, it is important to note that the imaging planes acquired by 2D and those displayed by 3D may not be identical. In comparing 2D and 3D color Doppler measures of the VC, maximal VC diameter is often larger by 3D Doppler imaging. The 3D VCA correlates well with EROA, moderately well with VC diameter, and weakly with jet area/right atrial area ratio and was best for organic TR and in patients in sinus rhythm. From current available data,, a VCA >0/4 cm2 is a reasonable cutoff value for severe TR.

Mascherbauer J, Rosenhek R, Bittner B, Binder J, Simon P, Maurer G, et al. Doppler echocardiographic assessment of valvular regurgitation severity by measurement of the vena contracta: An in vitro validation study. J Am Soc Echocardiogr 2005;18:999-1006.

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Tribouilloy CM, Enriquez-Sarano M, Bailey KR, Tajik AJ, Seward JB. Quantification of tricuspid regurgitation by measuring the width of the vena contracta with Doppler color flow imaging: A clinical study. J Am Coll Cardiol 2000;36:472-8.

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Muzzarelli S, Monney P, O'Brien K, Faletra F, Moccetti T, Vogt P, et al. Quantification of aortic flow by phase-contrast magnetic resonance in patients with bicuspid aortic valve. Eur Heart J Cardiovasc Imaging 2021;15:77-84.

Globits S, Mayr H, Frank H, Neuhold A, Glogar D. Quantification of regurgitant lesions by MRI. Int J Card Imaging 1990;6:109-16.

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Mercer-Rosa L, Yang W, Kutty S, Rychik J, Fogel M, Goldmuntz E. Quantifying pulmonary regurgitation and right ventricular function in surgically repaired tetralogy of Fallot: A comparative analysis of echocardiography and magnetic resonance imaging. Circ Cardiovasc Imaging 2021;5:637-43.

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A lesion or condition that results in a higher pressure gradient will affect color jet area as detailed earlier under general considerations. For example, the addition of aortic stenosis to MR will increase the RVol in proportion to the square root of the rise in LV pressure, assuming that the EROA remains the same (since jet velocity is related to the square root of the driving pressure gradient). The jet area, however, will be expected to increase more than this, since jet momentum is proportional to regurgitant orifice area × Δp and thus is increased above and beyond the increase in flow. Similarly, any lesion that increases pulmonary arterial pressure will worsen TR by similar amounts, with an exaggerated impact on jet area.

Pu M, Prior DL, Fan X, Asher CR, Vasquez C, Griffin BP, et al. Calculation of mitral regurgitant orifice area with use of a simplified proximal convergence method: Initial clinical application. J Am Soc Echocardiogr 2001;14:180-5.

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Sugeng L, Weinert L, Lang RM. Real-time 3-dimensional color Doppler flow of mitral and tricuspid regurgitation: Feasibility and initial quantitative comparison with 2-dimensional methods. J Am Soc Echocardiogr 2007;20:1050-7.

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Figure 5: Schematic representation of the flow convergence method (proximal isovelocity surface area). The example on the right shows the measurement of the proximal isovelocity surface area radius and the timing of the selection of the color frame for measurement (solid yellow arrow), corresponding to the maximal jet velocity by continuous wave Doppler (dashed arrow).

This report is made available by ASE as a courtesy reference source for members. This report contains recommendations only and should not be used as the sole basis to make medical practice decisions or for disciplinary action against any employee. The statements and recommendations contained in this report are primarily based on the opinions of experts, rather than on scientifically verified data. ASE makes no express or implied warranties regarding the completeness or accuracy of the information in this report, including the warranty of merchantability or fitness for a particular purpose. In no event shall ASE be liable to you, your patients, or any other third parties for any decision made or action taken by you or such other parties in reliance on this information. Nor does your use of this information constitute the offering of medical advice by ASE or create any physician-patient relationship between ASE and your patients or anyone else.

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The regurgitant orifice area in MR is often a variable quantity during the cardiac cycle, whether holosystolic or not. The measured EROA as described earlier differs from the dynamic regurgitant orifice area in that it is usually derived from static, maximal values from single systolic frames. Although MR is classically holosystolic, patients with MVP often have no MR in early systole, with a relatively large EROA limited to mid- or late systole. Compared with patients with holosystolic MR, those with late systolic MR yield lower RVols, despite similar EROA and jet areas. In such patients, RVol has been shown to be superior to EROA in predicting cardiac death, admission for congestive heart failure, or new-onset atrial fibrillation.

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Grigioni F, Detaint D, Avierinos JF, Scott C, Tajik J, Enriquez-Sarano M. Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction. J Am Coll Cardiol 2005;45:260-7.

Kizilbash AM, Willett DL, Brickner ME, Heinle SK, Grayburn PA. Effects of afterload reduction on vena contracta width in mitral regurgitation. J Am Coll Cardiol 1998;32:427-31.

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Reddy ST, Shah M, Doyle M, Thompson DV, Williams RB, Yamrozik J, et al. Evaluation of cardiac valvular regurgitant lesions by cardiac MRI sequences: Comparison of a four-valve semi-quantitative versus quantitative approach. J Heart Valve Dis 2021;22:491-9.

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A jet may appear larger by increasing the driving pressure across the valve (higher momentum); hence the importance of measuring blood pressure for left heart lesions at the time of the study, particularly in the intraoperative setting or in a sedated patient. Lastly, it is important to note that in cases of very large regurgitant orifice areas, such as in cases of massive TR with a wide, noncoapting valve, a distinct jet may not be seen with color Doppler because of laminar flow and very low blood velocity.

Nordmeyer S, Riesenkampff E, Messroghli D, Kropf S, Nordmeyer J, Berger F, et al. Four-dimensional velocity-encoded magnetic resonance imaging improves blood flow quantification in patients with complex accelerated flow. J Magn Reson Imaging 2021;37:208-16.

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Chinitz JS, Chen D, Goyal P, Wilson S, Islam F, Nguyen T, et al. Mitral apparatus assessment by delayed enhancement CMR: Relative impact of infarct distribution on mitral regurgitation. JACC Cardiovasc Imaging 2021;6:220-34.

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Grayburn PA, Carabello B, Hung J, Gillam LD, Liang D, Mack MJ, et al. Defining “severe” secondary mitral regurgitation: Emphasizing an integrated approach. J Am Coll Cardiol 2021;64:2792-801.

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Kramer CM, Barkhausen J, Flamm SD, Kim RJ, Nagel E; Society for Cardiovascular Magnetic Resonance Board of Trustees Task Force on Standardized Protocols. Standardized cardiovascular magnetic resonance (CMR) protocols 2021 update. J Cardiovasc Magn Reson 2021;15:91.

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Tribouilloy CM, Enriquez-Sarano M, Capps MA, Bailey KR, Tajik AJ. Contrasting effect of similar effective regurgitant orifice area in mitral and tricuspid regurgitation: A quantitative Doppler echocardiographic study. J Am Soc Echocardiogr 2002;15:958-65.

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TEE is indicated to evaluate MR severity in patients in whom TTE is inconclusive or technically difficult. In addition, TEE is particularly well suited to identify the underlying mechanism of MR and for planning MV surgery or percutaneous valve procedures and provides overall a better accuracy in localizing MV pathology. The majority of the above methods of quantifying MR can be used during TEE. In particular, the higher resolution of TEE, multiplane and 3D capabilities, and proximity to the MV makes VC imaging and PISA easier and probably more accurate. Furthermore, interrogation of all pulmonary veins is generally feasible and better than with TTE. A few cautionary points are worth mentioning regarding TEE. Since jet size is affected by transducer frequency, PRF, and signal strength, the same jet may appear larger on TEE compared with on TTE. Because sedatives are used, careful attention to blood pressure is important; secondary MR may appear less severe if the blood pressure is significantly lowered. Quantitative pulsed Doppler is more challenging and is the most affected quantitative MR parameter with TEE: acquisition of pulsed Doppler in the LVOT is usually hampered by angulation issues, leading to underestimation of systemic output.

In MR, PISA is more accurate for central regurgitant jets than eccentric jets and for circular orifices than noncircular orifices. It is usually easy to identify the aliasing line of the hemisphere; however, it can be difficult to judge the exact location of the orifice. Optimization of acquisition and measurement of PISA are essential and have been discussed earlier, as any error in radius is subsequently squared in the derivation of EROA. Errors of 10%-25% are common even among expert readers and are the smallest for central jets; therefore, PISA should always be considered in the context of the other echo/Doppler findings. The dynamic nature of the orifice in MR can also lead to errors with the PISA formula.

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Marsan NA, Westenberg JJ, Ypenburg C, Delgado V, van Bommel RJ, Roes SD, et al. Quantification of functional mitral regurgitation by real-time 3D echocardiography: Comparison with 3D velocity-encoded cardiac magnetic resonance. JACC Cardiovasc Imaging 2009;2:1245-52.

Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2021;28:1-3/9E+15.

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Mahmood F, Kim H, Chaudary B, Bergman R, Matyal R, Gerstle J, etal. Tricuspid annular geometry: A three-dimensional transesophageal echocardiographic study. J Cardiothorac Vasc Anesth 2021;27:639-46.

Lancellotti P, Cosyns B, Zacharakis D, Attena E, van Camp G, Gach O, et al. Importance of left ventricular longitudinal function and functional reserve in patients with degenerative mitral regurgitation: Assessment by two-dimensional speckle tracking. J Am Soc Echocardiogr 2008;21:1331-6.

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The spectral velocity profile of a regurgitant jet is determined by the pressure difference between the upstream and downstream chambers,, with a general parabolic shape during systole for atrioventricular valves and a trapezoid shape during diastole for semilunar valves. For atrioventricular valves, an early peaking or cutoff sign denotes a large regurgitant wave in the respective atrium and significant regurgitation. A rapid decay of the diastolic slope in semilunar valve regurgitation also can denote significant regurgitation but is exaggerated in cases of poor ventricular compliance and thus may not be specific. Pulmonic regurgitation (PR) may end prior to end diastole and may be related to poor ventricular compliance and/or severe regurgitation. Premature termination of diastolic flow is rarely seen in AR and usually denotes acute severe regurgitation.

Figure 4: Echo-Doppler calculations of stroke volume at the left ventricular outflow tract and mitral valve annulus sites. In this example of severe mitral regurgitation, SVMV was 183 mL (d = 3/5 cm, velocity time integral =19 cm) and SVLVOT was 58 mL (d = 2/3 cm, velocity time integral =14 cm).

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Schwammenthal E, Chen C, Benning F, Block M, Breithardt G, Levine RA. Dynamics of mitral regurgitant flow and orifice area. Physiologic application of the proximal flow convergence method: Clinical data and experimental testing.

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Thavendiranathan P, Liu S, Datta S, Rajagopalan S, Ryan T, Igo SR, et al. Quantification of chronic functional mitral regurgitation by automated 3-dimensional peak and integrated proximal isovelocity surface area and stroke volume techniques using real-time 3-dimensional volume color Doppler echocardiography: In vitro and clinical validation. Circ Cardiovasc Imaging 2021;6:125-33.

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Beigel R, Siegel RJ. Should the guidelines for the assessment of the severity of functional mitral regurgitation be redefined? JACC Cardiovasc Imaging 2021;7:313-4.

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Baumgartner H, Schima H, Kühn P. Value and limitations of proximal jet dimensions for the quantitation of valvular regurgitation: An in vitro study using Doppler flow imaging. J Am Soc Echocardiogr 1991;4:57-66.

In patients with secondary TR associated with MV disease, surgical repair of severe TR is indicated at the time of MV surgery whether or not there are clinical signs of severe TR. In such situations, the decision for concomitant TV repair is driven principally by imaging evidence of severe TR or severe dilation of the tricuspid annulus. In contrast, in patients with primary TR, the clinical presentation is also of great importance, as the indications for surgical tricuspid repair or replacement are strongest in those with symptoms, declining exercise tolerance, or evidence of RV failure. However, TV surgery may also be considered in asymptomatic patients when there is evidence of severe TR associated with progressive RV dilation or systolic dysfunction. Diagnosing the etiology of primary TR is often challenging. Expert imaging with echocardiography or CMR is the key to reduce misdiagnoses.

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Since color Doppler visualization of regurgitant jets plays such a significant role in the assessment of valvular regurgitation, it is useful to discuss the underlying basis of color jet formation and display and factors that affect it. A more detailed exposition on color jet formation has been described elsewhere. First, it is important to understand that simply knowing the orifice flow rate is not enough to predict jet size, since the jet will entrain additional flow as it propagates into the receiving chamber and this entrainment strongly depends on the orifice velocity (which in turn is affected by the orifice driving pressure). Psp sid meiers pirates patch. Rather, jet flow is governed mainly by conservation of momentum. Cardiologists are likely less familiar with momentum as opposed to the other two conserved quantities in fluid flow: mass (manifest in the continuity equation) and energy (found in the Bernoulli equation); but momentum is a critical concept for understanding regurgitant jets.

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Grayburn PA, Appleton CP, DeMaria AN, Greenberg B, Lowes B, Oh J, et al. Echocardiographic predictors of morbidity and mortality in patients with advanced heart failure: The Beta-blocker Evaluation of Survival Trial (BEST). J Am Coll Cardiol 2005;45:1064-71.

Martinez RM, O'Leary PW, Anderson RH. Anatomy and echocardiography of the normal and abnormal tricuspid valve. Cardiol Young 2006;16 Suppl 3:4-11.

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Rarely blunt chest trauma can lead to leaflet disruption and prolapse. Secondary PR is most common in patients with elevated PA pressure, although the volume of regurgitation is usually small. By definition, the PV leaflets are normal with secondary PR.

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Pulsed wave Doppler examination of the hepatic veins helps corroborate the assessment of TR severity. With increasing severity of TR, the normally dominant systolic wave is blunted. With severe TR, systolic flow reversal occurs [Figure 30]. However, hepatic vein flow patterns are also affected by right atrial and RV compliance, respiration, preload, pacemaker rhythms, complete heart block, and atrial fibrillation and flutter. Systolic flow reversal is a specific sign of severe TR, provided that the modulating conditions mentioned above are accounted for during interpretation.

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Cawley PJ, Hamilton-Craig C, Owens DS, Krieger EV, Strugnell WE, Mitsumori L, et al. Prospective comparison of valve regurgitation quantitation by cardiac magnetic resonance imaging and transthoracic echocardiography. Circ Cardiovasc Imaging 2021;6:48-57.

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Figure 30: Measurement of effective regurgitant orifice area and regurgitant volume in a patient with severe tricuspid regurgitation associated with pulmonary hypertension. Severe right atrial enlargement and atrial septal deviation to the left is seen in addition to systolic reversal of hepatic vein flow. D: Diastolic velocity, S: Systolic velocity.

Mielniczuk L, Haddad H, Davies RA, Veinot JP. Tricuspid valve chordal tissue in endomyocardial biopsy specimens of patients with significant tricuspid regurgitation. J Heart Lung Transplant 2005;24:1586-90.

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Locating the flow convergence proximal to the regurgitant orifice provides qualitative information on both the location of the lesion causing the regurgitation and the magnitude of the regurgitant flow. A well-defined small flow convergence combined with a small jet is specific for mild regurgitation, while a large flow convergence recorded at the minimum 50-70 cm/sec range, persisting throughout the duration of flow is specific for severe regurgitation. Flow convergence is amenable to quantitation of regurgitant flow (see below).

Valve regurgitation implies that the forward stroke volume (SV) across the affected valve during the cardiac cycle is increased. For atrioventricular valves, increased forward flow is characterized by increased early E velocity and E/A ratio, generally associated with a short E deceleration time in the absence of stenosis.

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Characterization of the severity of regurgitant lesions is among the most difficult problems in valvular heart disease. Such a determination is important since mild regurgitation does not lead to remodeling of cardiac chambers and has a benign clinical course, whereas severe regurgitation is associated with significant remodeling, morbidity and mortality. Contributing to the difficulty of assessment of regurgitation is the lack of a true gold standard and the dependence of regurgitation severity on the hemodynamic conditions at the time of evaluation.

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Nyquist limit (velocity scale): reducing the velocity scale emphasizes lower velocities and makes the jet appear larger. In addition, blood cells within the receiving chamber that move in response to or are entrained by the regurgitant jet may reach the minimal velocity and thus appear part of the regurgitant jet.

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Ben Zekry S, Nagueh SF, Little SH, Quinones MA, McCulloch ML, Karanbir S, et al. Comparative accuracy of two- and three-dimensional transthoracic and transesophageal echocardiography in identifying mitral valve pathology in patients undergoing mitral valve repair: Initial observations. J Am Soc Echocardiogr 2021;24:1079-85.

Choi J, Hong GR, Kim M, Cho IJ, Shim CY, Chang HJ, et al. Automatic quantification of aortic regurgitation using 3D full volume color doppler echocardiography: A validation study with cardiac magnetic resonance imaging. Int J Cardiovasc Imaging 2021;31:1379-89.

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Thus, systolic blunting is less valuable in secondary MR than in primary MR. As a result, the pulmonary venous flow pattern should be used adjunctively with other parameters. Nevertheless, the finding of systolic flow reversal in more than one pulmonary vein is specific for severe MR. If the MR is confined to late systole, flow reversal may be present only during late systole. It is also important to distinguish true systolic flow reversal from contamination by the MR jet itself, a more difficult task during TTE compared with during TEE.

Schlamowitz RA, Gross S, Keating E, Pitt W, Mazur J. Tricuspid valve prolapse: A common occurrence in the click-murmur syndrome. J Clin Ultrasound 1982;10:435-9.

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Cardiovascular imaging has had a major impact in the diagnosis, prognosis, and management of patients with valvular heart disease. In general, regurgitation may present a challenge for most diagnostic techniques because of the dynamic nature of the lesion and its dependence on various hemodynamic and physiologic conditions. For all valvular regurgitation, irrespective of the modality, an integrative approach is recommended to achieve an accurate evaluation of the severity of the lesion and its clinical significance. This takes into account physiologic conditions that could alter the accuracy of certain parameters, emphasizes the quality of the primary data, and allows internal verification of the interpretation. Future developments should aim for advances in ultrasound and CMR techniques, more automation in quantitation to reduce variability, and more data on quantitation and grading of right heart lesions in relation to outcomes. In real-time 3D imaging, improvements in temporal and spatial resolution to enhance display of valve regurgitation and improve automation of flow convergence, VC, and the regurgitant jet would be welcome.

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Gatehouse PD, Rolf MP, Graves MJ, Hofman MB, Totman J, Werner B, et al. Flow measurement by cardiovascular magnetic resonance: A multi-centre multi-vendor study of background phase offset errors that can compromise the accuracy of derived regurgitant or shunt flow measurements. J Cardiovasc Magn Reson 2021;12:5.

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Unlike the MV, there is no fibrous continuity with the corresponding semilunar valve. Three-dimensional echocardiography has been integral in our understanding of TV anatomy. A normal annulus is triangular as well as saddle shaped [Figure 26]. When functional dilatation occurs, the annulus becomes more circular and planar, dilating in the septal to lateral direction.

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Simpson IA, Shiota T, Gharib M, Sahn DJ. Current status of flow convergence for clinical applications: Is it a leaning tower of “PISA”? J Am Coll Cardiol 1996;27:504-9.