GUIDELINES AND STANDARDS

Guidelines for the Evaluation of Valvular
Regurgitation After Percutaneous Valve
Repair or Replacement
A Report from the American Society of Echocardiography Developed in
Collaboration with the Society for Cardiovascular Angiography andInterventions, Japanese Society of Echocardiography, and Society for
Cardiovascular Magnetic Resonance
William A. Zoghbi, MD, FASE, (Chair), Federico M. Asch, MD, FASE, Charles Bruce, MBChB, FASE,
Linda D. Gillam, MD, MPH, FASE, Paul A. Grayburn, MD, FASE, Rebecca T. Hahn, MD, FASE,
Ignacio Inglessis, MD, Ashequl M. Islam, MD, MPH, FSCAI, Stamatios Lerakis, MD, FASE,
Stephen H. Little, MD, FASE, Robert J. Siegel, MD, FASE, Nikolaos Skubas, MD, DSc, FASE,
Timothy C. Slesnick, MD, FASE, William J. Stewart, MD, FASE, Paaladinesh Thavendiranathan, MD, MSc, FASE,
Neil J. Weissman, MD, FASE, Satoshi Yasukochi, MD, JCC, SJSUM, and Karen G. Zimmerman, BS, ACS, RDCS,
RVT, FASE, Houston and Dallas, Texas; Washington, District of Columbia; Rochester, Minnesota; Morristown, New
Jersey; New York, New York; Boston and Springfield, Massachusetts; Los Angeles, California; Cleveland, Ohio;
Atlanta, Georgia; Toronto, Ontario, Canada; Nagano, Japan; and Morgantown, West Virginia
Keywords: Doppler echocardiography, Valve disease, Transaortic valve replacement, Magnetic resonanceimaging, Aortic regurgitation, Mitral regurgitation

In addition to the collaborating societies listed in the title, this document is endorsed by the following American
Society of Echocardiography International Alliance Partners: Argentine Society of Cardiology, Argentinian
Federation of Cardiology, Asian-Pacific Association of Echocardiography, Australasian Sonographers Association,
Cardiovascular Imaging Department of the Brazilian Society of Cardiology, Canadian Society of Echocardiography,
Chinese Society of Echocardiography, Echocardiography Section of the Cuban Society of Cardiology, Indian
Academy of Echocardiography, Indian Association of Cardiovascular Thoracic Anaesthesiologists, Indonesian Societyof Echocardiography, InterAmerican Association of Echocardiography, Iranian Society of Echocardiography, Israeli
Working Group on Echocardiography, Italian Association of CardioThoracic and Vascular Anaesthesia and Intensive
Care, Mexican Society of Echocardiography and Cardiovascular Imaging, National Association of Cardiologists of
Mexico, National Society of Echocardiography of Mexico, Saudi Arabian Society of Echocardiography, Thai Society of
Echocardiography, and Venezuelan Society of Cardiology.

From Houston Methodist Hospital, Houston, Texas (W.A.Z. and S.H.L.); MedStar HealthResearch Institute, Washington, District of Columbia (F.M.A. and N.J.W.); Mayo Clinic,
Rochester, Minnesota (C.B.); Morristown Medical Center, Morristown, New Jersey(L.D.G.); Baylor University Medical Center, Dallas, Texas (P.A.G.); Columbia University
Medical Center, New York, New York (R.T.H.); Massachusetts General Hospital, Boston,
Massachusetts (I.I.); Baystate Medical Center, Springfield, Massachusetts (A.M.I.); Icahn
School of Medicine at Mount Sinai, New York, New York (S.L.); Emory University School of
Medicine, Atlanta, Georgia (T.C.S.); Cedars-Sinai Medical Center, Los Angeles, California(R.J.S.); Cleveland Clinic, Cleveland, Ohio (N.S. and W.J.S.); University of Toronto,
Toronto, Ontario, Canada (P.T.); Nagano Children’s Hospital, Nagano, Japan (S.Y.); West
Virginia University Heart & Vascular Institute, Morgantown, West Virginia (K.G.Z.).
The following authors reported no actual or potential conflicts of interest in relation to thisdocument: Ignacio Inglessis, MD; Nikolaos Skubas, MD, FASE, DSc; Timothy Slesnick,
MD, FASE; William J. Stewart, MD, FASE; Paaladinesh Thavendiranathan, MD; Satoshi Yasukochi, MD, JCC, SJSUM; Karen G. Zimmerman, BS, ACS, RDCS, RVT, FASE. The
following authors reported relationships with one or more commercial interests: Federico
M. Asch, MD, FASE and Neil J. Weissman, MD, FASE have been directors of an academiccore lab providing services for Edwards Lifesciences, Medtronic, Boston Scientific/Symetis, Abbott/St Jude Medical, Neovasc, Mitralign, GDS, Caisson/Livanova, Biotronik, andDirectFlow. Charles Bruce, MBChB, FASE, consulted for Edwards Lifesciences; Linda
D. Gillam, MD, MPH, FASE provided core lab services for Edwards Lifesciences and Medtronic; Paul A. Grayburn, MD, FASE, consulted for Abbott Vascular, Neochord, and Tendyne and received research support from Abbott Vascular, Tendyne, Valtech, Edwards,
Medtronic, Neochord, and Boston Scientific; Rebecca T. Hahn, MD, FASE, consulted

for Abbott Vascular, Edwards Lifesciences, Medtronic, Philips Healthcare, Siemens
Healthineers and Gore and Associates, serves on the speaker’s bureau for Abbott
Vascular, Boston Scientific, Edwards Lifesciences, Philips Healthcare, Siemens Healthineers; Ashequl M. Islam, MD, MPH, FSCAI, consulted for Edwards and Medtronic; Stamatios Lerakis, MD, FASE, consulted for Edwards Lifesciences; Stephen H. Little, MD, FASE,
received research support from Medtronic and Abbott Vascular, and consulted for Abbott
Vascular. Robert J. Siegel, MD, FASE, served on the speaker’s bureau for Abbott Vascularand Philips; William A. Zoghbi, MD, FASE, has a licensing agreement with GE Healthcare
and is on the advisory board for Abbott Vascular, GE Healthcare, and Siemens Healthineers.
Reprint requests: American Society of Echocardiography, 2530 Meridian Parkway, Suite
450, Durham, NC 27713 (Email: ase@asecho.org).

Attention ASE Members:
Visit www.aseuniversity.org to earn free continuing medical education credit
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Copyright 2019 by the American Society of Echocardiography.
https://doi.org/10.1016/j.echo.2019.01.003

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Abbreviations

TABLE OF CONTENTS

2D = Two-dimensional
3D = Three-dimensional
AR = Aortic regurgitation
AV = Aortic valve
CD = Color Doppler
CMR = Cardiac magnetic resonance
CS = Coronary sinus
CWD = Continuous-wave Doppler
EROA = Effective regurgitant orifice area
LA = Left atrium
LV = Left ventricle
LVEDP = Left ventricular end-diastolic pressure
LVOT = Left ventricular outflow tract
MDCT = Multi-detector computed tomography
MR = Mitral regurgitation
MV = Mitral valve
MVA = Mitral valve area
PA = Pulmonary artery
PASP = Pulmonary artery systolic pressure
PR = Pulmonic regurgitation
PVR = Paravalvular regurgitation
PWD = Pulsed-wave Doppler
RF = Regurgitant fraction
RV = Right ventricle
RVol = Regurgitant volume
RVOT = Right ventricular outflow tract
SAVR = Surgical aortic valve replacement
SSFP = Steady-state free precession
TAVR = Transcatheter aortic valve replacement
TMVR = Transcatheter mitral valve replacement

I. Introduction 433
II. General Principles 433
III. Percutaneous Aortic Valve Interventions 434
A. Balloon-Expandable vs. Self-Expanding Valves 434
B. Pre-procedural Planning for TAVR and Valve-In-Surgical
Valve 435
C. Implantation Technique for Routine TAVR 435
D. TTE vs. TEE in the Catheterization Laboratory 435
E. Evaluation of Valvular Regurgitation after TAVR 436
1. Aortography436
2. Hemodynamic Assessment in the Catheterization Laboratory436

3. Doppler Echocardiographic Assessment of AR after TAVR

440

a. Color Doppler Jet Features

440

b. Continuous-Wave and Pulsed-Wave Doppler

2. Evaluation of Residual MR with CD Immediately after Edge-to-Edge
Repair 451
3. Interaction of Mean Transvalvular Gradient and Residual MR afterEdge-to-Edge Repair 452
C. Transcatheter Mitral Valve Replacement 452
1. TMVR Implantation 452
2. Evaluation of Residual MR Immediately after TMVR 453
3. Other Considerations in TMVR 454
D. Percutaneous Mitral Annuloplasty 454
1. Percutaneous MV Annuloplasty Devices

2. Evaluation of Residual MR after Repair of Paravalvular MR
455
F. Evaluation of Residual MR Outside the Catheterization Laboratory
after all MV Procedures
455
1. Color Doppler Imaging
456
2. CW Doppler of MR Jet 458
3. Mitral Inflow Pattern and Pressure Gradient
4. Pulmonary Vein Flow Pattern

THV = Transcatheter heart valve

5. Pulmonary Artery Systolic Pressure

TR = Tricuspid regurgitation
TTE = Transthoracic echocardiography
TV = Tricuspid valve
VCA = Vena contracta area
VCW = Vena contracta width
VTI = Velocity-time integral

454

2. Evaluation of MR after Percutaneous Annuloplasty
455
E. Transcatheter Repair of Paravalvular Prosthetic MR
455
1. Repair of Paravalvular MR
455

TPVR = Transcatheter pulmonary valve replacement

TEE = Transesophageal echocardiography444

c. Quantitative Doppler Assessment of PVR Severity 444
F. Assessing Residual AR after Percutaneous Repair of Prosthetic Paravalvular Regurgitation 446
G. Integrative Approach to Assessment of AR 446
H. Role of Cardiovascular Magnetic Resonance in Evaluating AR 447
IV. Percutaneous Mitral Valve Interventions 449
A. General Considerations in Evaluating Residual MR during MV Interventions 449
B. Mitral Leaflet Repair 450
1. Edge-to-Edge MV Repair 450

459

459

6. Regurgitant Volume and Fraction

459
459

7. An Integrative Approach to Assessing Residual MR

460

8. Role of CMR in the Evaluation of Residual MR after Percutaneous
MV Interventions 460
a. Evaluation of Residual MR 460
b. LV and LA Reverse Remodeling462
c. When is CMR Indicated?
462
V. Percutaneous Pulmonary Valve Replacement 462
A. Description of TPVR and Assessment of Acute Results 463
B. Evaluation of Residual Regurgitation Outside the Catheterization
Laboratory 463

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1. Assessment of Pulmonary Regurgitation after TPVR with Echocardiography 463
2. Role of Computed Tomography in Pulmonic Regurgitation after
TPVR 463
3. Role of CMR in Pulmonary Regurgitation after TPVR 465
C. Integrative Approach to Assessing Residual Pulmonic Regurgitation
after TPVR 465
VI. Percutaneous Tricuspid Valve Interventions 466
A. Tricuspid Valve Repair and Annuloplasty
466
B. Assessment of Residual TR after Tricuspid Valve Interventions
466
C. Role of CMR in Assessing Residual TR after Tricuspid Valve Interventions 467
D. Integrative Approach in the Evaluation of Residual TR
468
VII. Conclusions and Future Directions

469

I. INTRODUCTION
Valvular disease remains a major cause of cardiovascular morbidity
and mortality worldwide.1 Over the past decade, catheter-based interventions in valvular disease have evolved from balloon dilationof native stenotic valves to repair of paravalvular regurgitation(PVR) with vascular plugs and more recently to valve replacement
and repair. Currently-approved interventions include transcatheter
aortic valve replacement (TAVR), pulmonic valve replacement, andmitral valve repair, targeted to specific populations. Rapid technological advancements in device design are likely to improve acute andlong-term results and expand current indications.
Hemodynamics of percutaneous valves have been very favorable.2-5
However, a challenging area has been the new or residual valve
regurgitation that may occur either after transcatheter valve
implantation or repair of a native or prosthetic valve. This condition
presents a diagnostic and therapeutic challenge to the interventional
and imaging cardiology team in the catheterization laboratory and tothe clinician and imager in the outpatient setting. The current
document addresses the challenges of assessing residual regurgitation
after percutaneous valve replacement or repair and provides a guide to
the cardiac team on how best to approach this condition, based on theavailable data and a consensus of a panel of experts. This document
supplements the previous American Society of Echocardiography(ASE) guideline on the assessment of surgically implanted prosthetic
valves.6 It does not address flow dynamics through the percutaneous
prosthetic valves since, in general, the evaluation is similar to surgically implanted valves,6 but focuses mostly on new or residual valvular regurgitation. In addition to the use of echocardiography and hemodynamic
assessment in the acute setting, the document incorporates the role of cardiac magnetic resonance (CMR) imaging. This guideline is accompanied
by a number of tutorials and illustrative case-studies on evaluation of
valvular regurgitation after catheter-based interventions as well as native
valve regurgitation, posted on the following website (www.asecho.org/
vrcases), which will build gradually over time.

II. GENERAL PRINCIPLESIn the catheterization laboratory, members of the heart team should
be well versed with how to assess valve regurgitation, the language
used to describe valve structure and position, as well as a clear, coor-

Zoghbi et al 433

dinated nomenclature as to the site of regurgitation, using a clock
depiction or anterior/posterior, medial and lateral sites in relation to
the annulus. General principles for evaluating native valve regurgitation with echocardiography, Doppler, and CMR have recently been
updated.7 The methodology of assessing regurgitation qualitatively
and quantitatively with these techniques will not be reiterated indetail but summarized, with emphasis on how these parameters
may be affected in the setting of transcatheter valve replacement or
repair. The committee concurs with recent ASE guidelines7 and thoseof the American College of Cardiology (ACC) and American Heart
Association (AHA) on valvular heart disease8 that valvular regurgitation should be classified as mild, moderate, or severe.
There are four main principles to the evaluation of valvular regurgitation with echocardiography: comprehensive imaging, integrationof multiple parameters, individualization to the patient, and precise
language to describe the findings. Comprehensive imaging by transthoracic echocardiography (TTE) incorporates two dimensional/
three-dimensional (2D/3D) structural evaluation of the implanted device and surrounding structures, cardiac chamber size and function,
flow interrogation with pulsed-wave Doppler (PWD), continuouswave Doppler (CWD), and color Doppler (CD), and volumetricquantitation as well as assessment of additional hemodynamic parameters such as pulmonary artery (PA) pressures. Each of these methods
has particular technical considerations, strengths, and limitations,which have been described in detail.7 Unfortunately, many of theseparameters may not be available during intra-procedural transesophageal echocardiography (TEE) or TTE due to limited windows, inability
to align Doppler interrogation with blood flow, and foreshortening of
the apex, which may preclude accurate volumetric quantitation. Thus,
intra-procedural echocardiography often relies heavily on CD jet
characteristics, evaluating when possible its three components offlow convergence, vena contracta, and jet area. CD imaging of thejet in this setting can be impacted by hemodynamics, effects of sedation/anesthesia, technical factors, and attenuation by the implanted
device. Because CD area is mainly determined by jet momentum(area  velocity2), the pressure gradient and therefore velocity driving
the jet can greatly influence jet size. For example, mitral regurgitation(MR) jets after mitral repair or transcatheter mitral valve replacement(TMVR) can be large despite a small orifice if left ventricular (LV) pressure is high (e.g., hypertension or aortic stenosis). Conversely, a low
aortic diastolic pressure after TAVR might result in a small aortic regurgitation (AR) jet with CD despite hemodynamically significant AR. To
compensate for hemodynamically mediated variation inherent in CDcharacterization, it is common practice for the implanting physician or
anesthesia team to ‘‘normalize’’ post-implant hemodynamics (increaseor decrease heart rate and systemic blood pressure) pharmacologically prior to assessing intraoperative valvular regurgitation in the procedure room. Moreover, valve regurgitation after percutaneous
procedures, in contrast to native or surgical prosthetic valves,
frequently arises from multiple sites with variable severity, making
CD assessment of regurgitation more difficult. All the above issues
highlight the need to integrate CD information with other echocardiographic findings to determine overall severity of regurgitation.
This comprehensive evaluation may be more feasible to perform after
completion of the procedure, out of the catheterization laboratory
setting. Intra-procedurally, the findings by echo-Doppler are complemented with invasive hemodynamic assessment to gauge the overall
results of the intervention, and cineangiography may be needed in situations where the residual regurgitation is difficult to assess, inconclusive, or suspected to be more than mild (Figure 1). In the setting

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Figure 1 Tools for the intra-procedural assessment of paravalvular regurgitation following TAVR: color Doppler (2D/3D), pulsed-wave
Doppler of aortic flow, aortic & LV diastolic pressures and aortography. All panels are from the same patient. The valve is a selfexpanding valve. (A) Mid-esophageal TEE long-axis view showing paravalvular AR (white arrows). Off-axis imaging is frequently helpful. (B) Deep transgastric view showing the paravalvular jet seen in panel A. Multiple views are essential to avoid missing jets. (C)Mid-esophageal short-axis view showing a paravalvular jet (red arrow), and a pinhole jet (arrow head). It is important to scan the valve
and image at the lower end of the valve stent to ensure that the measured jet reaches the LV. The circumferential extent of the larger jet
here is 14% but the jet is relatively wide. The pinhole jet is too small to planimeter. (D) 3D planimetry of the same paravalvular jet yields
an area of 0.22 cm2. 3D echocardiography makes it possible to precisely identify the vena contracta, something that may be challenging with 2D imaging alone. (E) Mid-esophageal TEE images of the descending thoracic aorta showing non-holodiastolic flow
reversal by pulsed-wave Doppler. Some flow reversal, usually non-holodiastolic, may be present in patients undergoing TAVR
even in the absence of aortic regurgitation; Hence it is important to establish the baseline aortic flow pattern. (F) Simultaneous LV
and aortic (Ao) pressure tracings that form the basis for the AR index. In this case, the AR index is 28%. Indices of <25% havebeen reported to have increased 1-year mortality. However, this value is very dependent on aortic and ventricular compliances aswell as the severity of paravalvular regurgitation. Red arrow denotes diastolic BP – LVEDP. (G) Diastolic still frame from postimplantation aortogram showing 2+ paravalvular AR (outlined area). Ao, Aortic pressure tracing; EDP, end-diastolic pressure; LV,
left ventricular pressure tracing; S, systole.
outside the catheterization laboratory, uncertainty regarding severityof regurgitation by echocardiography due to poor-quality data or discrepancies among parameters that cannot be resolved should bestated in the report to alert the clinician to consider other imaging modalities such as TEE, CMR or multi-detector computed tomography(MDCT), if clinically indicated, to better assess lesion severity andmechanism, particularly if it could mean the difference between
another intervention and medical therapy.

III. PERCUTANEOUS AORTIC VALVE INTERVENTIONSTAVR is an accepted alternative to surgical aortic valve replacement(SAVR) in high- and intermediate-risk as well as inoperable patients.2-5,9-11 Evaluation of the use of TAVR in patients with low
surgical risk is ongoing. Multiple studies have shown a higher
incidence of PVR in patients undergoing TAVR compared to

SAVR.12-14 Residual AR is an important predictor of mortality15-18
and was a major impetus for recent improvements in TAVR design,
such as cuffs, skirts and repositionable valves. Although earlystudies suggested that even mild PVR might impact outcomes,19
more recent observations in the intermediate-risk population suggestthat only moderate or severe PVR increase mortality.2,10 Several
factors may account for the varying incidence of PVR and its
prognostic outcome, including prosthetic valve design, valve
calcification, physiologic considerations, and difficulty in grading
PVR severity.20 Newer valve iterations or designs however, show
very low rates of PVR (0-2%), which will likely reduce the impactof this complication on outcomes.10,21,22
A. Balloon-Expandable vs. Self-Expanding Valves
While transcatheter aortic valve designs continue to evolve, devices
that have the largest world-wide experience fall into two general

Journal of the American Society of Echocardiography
Volume 32 Number 4

categories: those deployed with balloon-assisted expansion and thosethat spontaneously expand on release from the delivery system, theso-called self-expanding valves. Within these categories, the mostwidely used valves have been the Edwards SAPIENÔ family ofballoon-expandable valves and the Medtronic CorevalveÒ/EvolutÔ self-expanding valves. Within these families of valves, improvements in design have reduced the incidence and severity of
PVR. The construct of these valves has been reviewed recently.23
Although other valves have received the CE (conformiteEuropeenne) mark in Europe and are in varying phases of clinical trials
in North America, they will not be further discussed.
B. Pre-procedural Planning for TAVR and Valve-InSurgical Valve
Pre-procedural planning for TAVR can be useful for predicting PVR
following valve implantation and allows the heart team to plan for
the appropriate treatment of intra-procedural PVR. Numerous studies
have shown that significant under-sizing of the transcatheter heart
valve (THV) will result in greater degrees of PVR.12,24 MDCT
reconstruction-based measurements of the aortic annulus has beenshown to reduce the incidence of greater than mild paravalvular AR
compared to 2D TEE measurements.25 The accuracy of 3D TEE for
annular sizing and prediction of PVR severity has also been demonstrated.26 MDCT determination of calcium location and burden isanother important predictor of PVR.27,28 For valve-in-surgical-valve
procedures, knowledge of the manufacturer’s reported internal diameter of the bioprosthetic surgical valve is essential for appropriate
sizing. In the absence of this information, TEE or MDCT may be
used to determine the internal diameter of the valve; however, regurgitation following this procedure is rarely more than mild.29
C. Implantation Technique for Routine TAVR
Although not required, the balloon-expandable THV may be predilated using balloon aortic valvuloplasty, which is intended to
improve the positioning process but may also decrease the numberof cerebral ischemic lesions.30 The SAPIEN 3 delivery system has a
middle marker and two other markers to facilitate trans-annular positioning of the valve before deployment; because of stent cell design,
the valve shortens from the ventricular end, engaging the surrounding
tissue early in the deployment process. After obtaining a suitable coplanar angle, the Edwards SAPIEN 3 valve is deployed using rapid
ventricular pacing to reduce valve motion just before balloon expansion. Medtronic’s CoreValve Evolut R and Evolut Pro have acontrolled and slow-release self-expanding delivery system. They do
not require rapid pacing, although some interventionalists may use
pacing to stabilize the valve during deployment. The valve can also
be repositioned and recaptured up to a point in the unsheathing process. In addition to adequate sizing of the annulus, accurate positioning of all valves is essential to reduce post-implantation PVR
and reduce post-procedural pacemaker rates.31 Valve positioning
can be imaged by TTE and TEE as well as fluoroscopy.23,32 The
amount and location of calcium within the landing zone of thevalve also plays a major role in the incidence and severity of PVR
following TAVR.12,28,33
D. TTE vs. TEE in the Catheterization Laboratory
Echocardiography remains the primary imaging modality for assessing
PVR immediately following TAVR. Initially, the procedure was performed under general anesthesia with TEE monitoring. Performing
TAVR under local anesthesia with conscious sedation or with moni-

Zoghbi et al 435

tored anesthesia care has been reported recently and is increasingly
used.34-36 However, the conscious sedation approach is notuniversal, and conversion to general anesthesia in 10-17% ofcases37,38 has been reported, with a more recent lower rate ofconversion (5.9%) published from the National Cardiovascular
Data Registry (NCDR).39 TEE guidance has been associated withless contrast use,40 lower incidence of PVR,41 and greater procedural
success.39 A recent study from a high-volume site performing primarily conscious sedation with TTE guidance showed that there was ahigher incidence of second valve implantation (7% vs. 2%;
P = .026) and post-TAVR balloon dilation (38% vs 17%; P < .001)
intra-procedurally compared to the TEE approach.42
Studies evaluating the clinical outcome of patients undergoing
TAVR with either TEE/general anesthesia or TTE/moderate sedation
have not shown consistent results favoring one or the other approach.
In the Brazilian Registry,43 the use of TEE to monitor the procedurecompared to TTE was associated with less overall mortality (HR:0.57) and late mortality (HR: 0.47). Recent observational studies support the safety of the ‘‘minimalist’’ anesthetic approach36,44 and theEuropean Society of Cardiology’s Transcatheter Valve Treatment(TCVT) Registry found that survival at 1 year was similar between
groups.35 Lastly, the observational NCDR study reported that while
the conscious sedation approach had lower procedural success, it
was associated with a reduced rate of in-hospital mortality (1.5%versus 2.4%, P < .001) and 30-day mortality after TAVR (2.3% versus
4.0%, P < .001), warranting formal study.39 This is particularly important as the field begins to address TAVR in the lower-risk patient population who are also at lower risk for complications during generalanesthesia, and whose expected outcomes are significantly better
than patients treated in these registries.10,45
Advantages and disadvantages of TTE and TEE as they pertain toassessing valvular regurgitation after TAVR are listed in Table 1. Using
TTE, imaging from the parasternal windows requires direct placement of the probe within the fluoroscopic imaging plane withhigh exposure of the imager to radiation. The patient’s supine position and operator avoidance of the sterile field may prohibit optimaltransducer placement. The usual sources of ultrasound interference
still apply, such as chest wall deformities, emphysema, obesity, etc.
Intra-procedural TTE can evaluate the causes of acute hemodynamic compromise such as pericardial effusion, under-filled or
dysfunctional ventricles, and severe valvular regurgitation. The
assessment of PVR may be challenging unless imaging windows
are ideal. On the other hand, a major advantage of intraprocedural TEE guidance is continuous imaging throughout the
TAVR procedure with rapid and accurate diagnosis of complications,
including PVR.32,46,47 Studies have shown that TEE can be safely
performed in the setting of monitored anesthetic care.48 Since CD
is essential in localizing and assessing PVR severity, it is importantto recognize that shadowing of the prosthetic valve may affect detection of paravalvular regurgitation by either TTE or TEE (TTE may not
optimally display posterior paravalvular regurgitation whereas TEE
may not optimally display anteriorly located defects; Figure 2). A
combination of both techniques may be needed in situations wherean AR jet is detected in the left ventricular outflow tract (LVOT) or
LV and the source cannot be localized by one approach. TEE must
include standard and deep transgastric views to assess both
valvular/LVOT hemodynamics and detect paravalvular regurgitation that may be missed in esophageal views (Figure 2). Overall,qualitative and quantitative echo-Doppler parameters can be obtained with TTE or TEE imaging and applied to assess the severityof PVR either during or after the procedure.

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Table 1 Advantages and disadvantages of TTE versus TEE imaging for assessment of aortic regurgitation during and after TAVR
Parameter

TTE

TEE

Advantages
General Standard windows for assessing valvular/cardiac
structure & function
 Imaging anterior paravalvular regurgitation withCD Ease of CWD interrogation of AR jet Ease of PWD interrogation of flow in the LVOT
 Can provide volumetric quantitation
 Less resource intensive

 Higher resolution with high frame rates for 2D and
3D imaging, and quantitation of VCA
 Imaging posterior paravalvular regurgitation with
CD

Advantages
During TAVR Does not require intubation or general anesthesia
 Superior viewing of anterior paravalvular
regurgitation
 May still convert to TEE approach, if needed Continuous imaging throughout procedure,irrespective of TAVR access route Intra-procedural imaging may help avoid
complications (e.g., imaging during balloon
valvuloplasty to assess risks of calcium
displacement)
 Immediate intra-procedural diagnosis ofcomplications
 Lower contrast use for procedure Ability to hold respiration during generalanesthesia for better 3D assessment of PVR, andaortic annular measurement (if needed)

Disadvantages
General Image quality dependent on patient factors (e.g.,chest morphology, lung hyperinflation,
suboptimal positioning, valve calcific acoustic
shadowing) Difficulty imaging posterior paravalvular
regurgitation with CD Lower resolution of 2D and 3D imaging

 Image quality dependent on patient factors (e.g.,valve calcific acoustic shadowing, cardiac
position relative to esophagus and stomach) Difficulty imaging anterior paravalvular
regurgitation with CD in esophageal views
 Challenge in optimizing CWD recording of AR jet
and CD display of AR from deep transgastric view

Disadvantages
During TAVR

 Procedural delay during image acquisition (tominimize radiation exposure to imager) Non-continuous imaging during procedure may
delay diagnosis of complications (e.g., valve malpositioning, annular rupture, coronary occlusion)
 Limited imaging windows for non-transfemoral
TAVR access routes
 Difficult to perform volumetric quantitation

 Requires conscious sedation or monitored
anesthesia care
 More resource intensive; may prolong
hospitalization if requires intubation & there isdifficulty extubating patient Probe interference with fluoroscopic imaging(minimized by articulation of probe)

E. Evaluation of Valvular Regurgitation after TAVR
Assessment of the presence and severity of AR after TAVR is complex,
requiring imaging and Doppler evaluation of the valve and annulus.
Central valve regurgitation is far less common than paravalvular
regurgitation. Evaluation and grading of PVR is complicated by thecomplex nature of AR jets after valve implantation and the differences in jet characteristics between valve designs. Regurgitant jets
around a stented valve are due to mal-apposition of the stent andthe native surrounding structures. Mal-apposition may occur for anumber of reasons: 1) THV collapsible frames have empty cells between metal struts; 2) metallic stents have limited deformability, preventing complete closure of small gaps created by irregularly-calcified
leaflets, protruding dystrophic calcium in the annulus or LVOT, or
triangular commissural gaps; 3) mal-positioning of the THV (toohigh or low in the annulus); and 4) under-sizing of the THV for thenative annular size.
Assessment of PVR relies heavily on CD imaging both during theprocedure and in the outpatient setting, as conventional spectral
Doppler parameters may have limitations.20 CD evaluation has outcomes data from 2 separate trials using 2 different core laboratories.2,10 Spectral Doppler evaluation is particularly hampered in
evaluating PVR during the TAVR procedure because of limited

windows of interrogation of flow, for either TEE or TTE. Thus,
during the acute setting, hemodynamics and aortography are
frequently used to complement CD imaging for a comprehensive
evaluation of residual PVR (Figure 1). The current document will
therefore address aortography, hemodynamic assessment, andDoppler methods that can be used in the interventional arena during
TAVR (qualitative/semi-quantitative parameters) and will detail also
other Doppler quantitative methods and CMR methods that canbe applied outside the interventional laboratory for a more comprehensive evaluation of PVR with non-invasive techniques.
1. Aortography. Conventional cineangiography with an aortic root
injection of radiographic contrast can be used for intra-procedural
determination of AR severity.49 This is usually performed during
the TAVR procedure in the catheterization laboratory when AR is detected by CD and its severity needs further evaluation. This approach,however, is rarely indicated in the chronic setting or for serial followup. Angiographic grading, while helpful in extremes, may not correlate well with quantitative assessment of AR severity, and cannot reliably distinguish central from paravalvular regurgitation.20,50,51
2. Hemodynamic Assessment in the Catheterization
Laboratory. A number of investigators have attempted to use theZoghbi et al 437

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Figure 2 Demonstration of paravalvular leaks after TAVR assessed by TTE and TEE in two different patients, demonstrating ultrasound attenuation of the valve ring and adjacent structures by the prosthetic valve, and the importance of comprehensive color
Doppler imaging from the apical views (apical in TTE and transgastric in TEE). Panels A to C demonstrate an anterior paravalvularleak that is identified from a parasternal long-axis view (A), short-axis view (B), and modified apical five-chamber view (C). Thereis posterior attenuation (yellow arrows). Panels D-F demonstrate posterior paravalvular leak on mid-esophageal 120 degrees (D)and short-axis views (E); the transgastric view (F) demonstrates two jets of paravalvular regurgitation, one jet is anterior and the otheris posterior. Without careful comprehensive interrogation, the anterior leak would have been potentially missed on just midesophageal views because of attenuation (yellow arrows).

Table 2 Invasive hemodynamic indexes for assessing severity of AR immediately After TAVR
Author

Index

FormulaCutoff for significanceSinning et al.52

AR index([DBP– LVEDP] O SBP) x 100

AR index <25 predicted higher mortality

Sinning et al.54

ARI ratio

Ratio of post-procedural to pre-procedural AR
index

ARI ratio <0.60 improved 1-year mortality
prediction of post TAVR AR Index <25

Jilaihawi et al.53

CHAI score([DBP – LVEDP] O HR) x 80

<25 (denoting $ moderate PVR), predicted
higher mortality

Bugan et al.55

TIAR index(LV-Ao diastolic pressure time integral)/(LVsystolic pressure time integral) x 100

TIAR index <80 was associated with a sensitivityof 86% and a specificity of 83% for $mild AR.

AR, Aortic regurgitation; ARI, AR index; CHAI, composite heart-rate-adjusted hemodynamic-echocardiographic aortic insufficiency; DBP, diastolicblood pressure; HR, heart rate; LVEDP, left ventricular end-diastolic pressure, SBP, systolic blood pressure; TIAR, Time-integrated aortic regurgitation.

hemodynamic tracings obtained during the TAVR procedure to assess
the severity of AR acutely. Several indices have been proposed, mostof which use a combination of differences between aortic pressureand LV diastolic pressure (Table 2).52-55 The premise of these
indices is that the difference between aortic and LV diastolicpressures decreases with increasing severity of acute AR (higher LV
diastolic pressure, lower aortic diastolic pressure, or a combinationof the two). Despite multiple limitations of these indices, including
heart rate dependence and inability to distinguish valvular fromparavalvular regurgitation, they remain a helpful adjunctive tool

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Table 3 Echocardiographic parameters (TEE/TTE) and respective comments in determining AR severity after TAVR
Parameter

Comments

Stent shape andposition

Not accurate in predicting presence/severity of
AR

Color Doppler
Jet number,
location,
direction, andeccentricity- Needs meticulous scanning of whole valve to
identify sites of regurgitation, which arefrequently multiple and eccentric- Essential to identify origin of jets, which may
not all be at the same level- Short-axis imaging below the valve may
overestimate AR severity in eccentric jets
- Attenuation of ultrasound by prosthesis in far
field may hinder visualization of regurgitation(anterior with TEE and posterior with TTE)
- Deep transgastric views during TEE areessential for assessment of regurgitant jets (jetarea and length are not used to assess
regurgitation severity)

Vena contracta
width (VCW)

VCW >0.6 cm specific for severe AR; severity ofmultiple smaller jets more difficult to evaluate

Vena contracta
area (VCA)- May allow addition of multiple jets
- Prone to blooming artifacts- Accuracy limited by spatial resolution for small
jets(Continued )Zoghbi et al 439

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Table 3 (Continued )Parameter

Comments

Circumferential
extent (%)- Continuous circumferential extent of AR of>30% indicative of severe AR- Circumferential extent of few, smaller discrete
jets more difficult to assess

Flowconvergence

Large flow convergence in aorta indicative ofsevere AR

Spectral Doppler
Flow reversal indescending
aorta (PWD)- Useful if new (relative to baseline) andholodiastolic, consistent with at least
moderate AR; lesser aortic flow reversal isnon-diagnostic- Holodiastolic flow reversal in abdominal aorta
more specific for significant AR(Continued )440 Zoghbi et al

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Table 3 (Continued )Parameter

CW Doppler
profile of AR jet(velocity
waveform
density,pressure halftime)

Quantitative
parameters:
RVol, RF, andEROA

Comments- Dense velocity waveform consistent withmore than mild AR- Pressure half-time in extremes (>500 or<200 ms) may be helpful acutely; influenced
by LV compliance and other factors- Not feasible during TAVR procedure- Stroke volume by PWD in LVOT: particularattention must be paid to site of measurementof LVOT diameter and velocity depending ontype of TAVR valve- 3D echo or contrast echo is recommended for
LV volumetric quantitation of stroke volume to
avoid underestimation of RVol and RF- Mitral valve annulus for calculation ofsystemic stroke volume has limitations inpresence of mitral annular calcification; RVOT
site can used in the absence of significant
pulmonic regurgitation- EROA determination (RVol/VTIAR) is rarely
used clinically

AR, Aortic regurgitation; EROA, effective regurgitant orifice area; LV, left ventricle; LVOT, LV outflow tract; RF, regurgitant fraction; RVol, regurgitantvolume; RVOT, RV outflow tract; VTI, velocity-time integral.

immediately following TAVR to assess the acute hemodynamic
severity of AR and its prognostic impact.52-55
3. Doppler Echocardiographic Assessment of AR after
TAVR. Similar to any assessment of regurgitation, evaluation of
PVR should be an integrative approach using a number of qualitative
parameters as well as semi-quantitative and quantitative measurements. These Doppler parameters are, in principle, similar to thoseused in evaluating native or prosthetic valve AR.7 However, there
are particular considerations related to TAVR and the TAVR population that may modulate the approach to imaging PVR, and the feasibility, applicability, and accuracy of standard Doppler parameters inassessing regurgitation severity. Table 3 details the echocardiographic
parameters that may be used in the evaluation of severity of PVR after
TAVR and offers technical and interpretive comments and caveats.
Table 4 details the overall comprehensive evaluation of aortic regurgitation after valve implantation.
A few comments for assessing PVR severity post-TAVR should be
mentioned (Table 3). First, stent shape and position may support
AR Doppler findings but lack sensitivity and specificity for AR
severity. Second, PVR post-TAVR frequently arises at multiple sites

in the paravalvular space, with jets having irregular shapes and trajectories, thus challenging standard CD measures of AR severity. Third,
limitations of imaging AR are similar to those observed with surgicalprostheses,6 such as acoustic shadowing of the far field (posterior paravalvular region for TTE and anterior paravalvular region for TEE;
Figure 2), requiring an extensive search for jets, using multiple imaging
windows (Figure 3). It is essential to use windows that not only avoid
the acoustic shadowing but also image the regurgitant jets parallel tothe insonation beam: in general, apical and subcostal windows for
TTE, and mid-esophageal and deep transgastric for TEE. In very
eccentric jets directed anteriorly or posteriorly, the parasternal window may be best for TTE. Fourth, the paravalvular jet path and number of jets are significantly affected by native calcium and leaflets, andby the discontinuous nature of the metallic stent. This is particularly
important to understand when assessing the circumferential extent
of the PVR. Jet length or area should not be used to grade severity,
but rather to confirm the presence and location of the AR jet(s).
a. Color Doppler Jet Features.–The assessment of PVR following
TAVR relies heavily on CD. It is by far the most essential Doppler
modality during the TAVR intervention. A number of jet

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Table 4 Evaluation of severity of prosthetic aortic regurgitation after TAVR
PVR severity

Mild

Aortography

Moderate

Contrast does not fillentire LV and clears
with each cycle

Intermediate

SevereContrast fills LV on
first beat, ending
with greater density
than in ascending
aorta

Invasive Hemodynamic Parameters
AR index*

$25

<25

<25

Dicrotic notch

Present

Present

Effaced or absent

Echocardiography: TTE and/or TEE
Structural parameters
Position of prosthesis

Usually normal

Variable

Frequently abnormal

Stent and leaflet morphology

Usually normal

Variable

Frequently abnormal

Proximal flow convergence (CD)

AbsentMay be present

Often present

AR velocity waveform density (CWD)

Soft

Dense

Dense

Diastolic flow reversal (PWD) in- Proximal descending aorta†‡- Brief, early diastolic- May be holodiastolic- Absent- Absent- Holodiastolic (enddiastolic velocity$20 cm/s)- Present<0.3

0.3-0.6

Doppler Parameters
Qualitative- Abdominal aorta
Semi-quantitative
Vena contracta width (cm) (CD)>0.6

Vena contracta area (cm ) (2D/3D CD)<0.10

0.10-0.29$0.30

Circumferential extent of PVR (%) (CD)k{

<10

10-29

$30

Jet deceleration rate (PHT, ms)# (CWD)

Variable
Usually >500

Variable200-500

Steep
Usually <200**

Regurgitant volume (mL)<30

30-59††>60†† (May be lower
in low flow states)

Regurgitant fraction (%)

<30

30-49

$50

EROA (cm2)‡‡<0.10

0.10-0.29††$0.30††

2§§

Quantitative

2D, Two-dimensional; 3D, three dimensional; AR, aortic regurgitation; CD, color flow Doppler; CWD, continuous-wave Doppler; EROA, effective
regurgitant orifice area; LVOT, left ventricular outflow tract; PVR, paravalvular regurgitation; PHT, pressure half-time; PWD, pulsed wave Doppler;
TTE, transthoracic echocardiography; TEE, transesophageal echocardiography.
*One of the hemodynamic parameters (Table 1) used in the catheterization laboratory after TAVR.
†
More specific in peri-procedural or early post-procedural assessment. Holodiastolic flow reversal may not be seen in severe bradycardia.
‡
Dependent on aortic compliance; limits its utility in the elderly population; influenced by heart rate.
§
The vena contracta area is measured by planimetry of the vena contracta of the jet(s) on 2D or 3D color Doppler images in the short-axis view.
kMeasured as the sum of the circumferential lengths of each regurgitant jet vena contracta (not including the non-regurgitant space between theseparate jets) divided by the circumference of the outer edge of the valve.
{
Circumferential extent of PVR best not to be used alone, but in combination with vena contracta width and/or area.
#
Influenced by LV and aortic compliance, particularly in this population.
**May not be specific for severe aortic regurgitation in the setting of abnormal aortic or ventricular compliance.
††
May be functionally important at lower values depending on the acuteness of PVR, and size and function of the LV. When total stroke volume iscalculated from LV volumes, use of 3D echocardiography and preferably contrast echocardiography is recommended to avoid underestimationof LV volumes, RVol, and RF.
‡‡
EROA is infrequently used in AR. It is derived using the volumetric approach, not PISA.

characteristics are important to assess: jet width at its origin, thenumber of jets, whether there is visible proximal flow convergence(usually a sign of more than mild PVR), jet path/direction, andcircumferential extent of the jet. Although PVR jets may not be
as wide as with surgical PVR, a single jet VC width at its originof >6 mm is specific for severe AR. If the jet path can be imaged

tracking around the stented valve and into the LV, there is usuallysignificant mal-apposition of the stent and more than mild PVR.56
Because PVR jets may be re-directed by bulky calcium, it is important to note the direction of the AR; not infrequently these jets may
be eccentric, going across the short-axis plane of the LV outflow
tract (Figure 4). The severity of these AR jets is prone to442 Zoghbi et al

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Figure 3 Standard 2D echocardiographic views depicting the detection of TAVR-related paravalvular regurgitation. Color coding delineates the regions around the prosthetic valve that can be visualized from the parasternal and apical views. With ultrasound planerotation, tilting upward or sideways, a more complete interrogation of the valve can be accomplished. Although these unconventional
planes may foreshorten cardiac structures, they are essential in detecting and localizing the residual regurgitation. The importance ofapical views lies in the fact that some jets may not be detected in the parasternal views because of either shadowing from the prosthesis in parasternal short axis (PSAX; lateral, medial and posterior surfaces; see Figure 2) or are located medially or laterally to be
seen in the parasternal long-axis (PLAX) view.
overestimation if assessment of the circumferential extent of the jet
origin mistakenly includes this single short-axis view displaying jet
eccentricity. Because the number of jets also reflects severity, an
extensive search for all jets should be performed, using multiple imaging windows, biplane imaging, and subtle manipulation of thetransducer within each window.
The circumferential extent of the jet is a useful parameter for assessing PVR severity; however, as with all parameters, it should not
be used in isolation (Figure 5). The updated Valve Academic
Research Consortium (VARC-2) criteria57 used in the PARTNER I
trial58 recommended the following with respect to the circumferential extent of paravalvular AR in short axis: trace (pinpoint jet), mild(<10%), moderate (10-30%), and severe (>30%). Recent studies using the VARC-2 criteria, including this parameter, have shown
increased mortality associated with worse PVR severity.10,45,59
To assess residual AR with CD after TAVR, the following caveats
should be considered:
1. The whole transcatheter valve should be scanned, from the distal (aortic) tothe proximal (ventricular) end of the THV, to identify the number, location(s), and direction(s) of the AR jet(s).
2. The entire short axis of the valve should be imaged in a single view, if
possible, so that the valve level imaged is the same in the far field as it isin the near field, and laterally as well as medially.
3. Central prosthetic AR jets will occur at the level of leaflet coaptation
whereas PVR will be seen at the proximal (ventricular) edge of the valve.

Importantly, the jet must enter the LV to be considered true regurgitation,
thus imaging just below the edge of the stent will confirm the presence oftrue PVR; however, the vena contracta of the jet should be measured at its
narrowest region.
4. Color flow around the THV within the sinuses of Valsalva but above the annularvalve skirt should not be mistaken for PVR. Flow in the sinuses has low velocity
and does not connect with the LVOT in diastole. Scanning through the long axisof the valve is useful in distinguishing color flow in the sinuses from PVR.
5. Small jets of regurgitation are typically isolated to the open stent cells andnot at the ‘‘nodes’’ of the stent frame. It is important not to include thestented frame in the measurement of the circumferential extent of the
regurgitation but to integrate only the regurgitant jets when determining
the circumferential extent (Figure 5).
6. In contrast to native valve AR, the ratio of jet width to LVoutflow tract widthor jet cross-sectional area to cross-sectional area of the valve or LV outflow
tract should not be used to assess the severity of AR since regurgitant jets are
frequently eccentric, constrained by and entrained within the LVOT, leading to rapid jet broadening (Figure 4).
7. Using a clock face to represent the short-axis view (placing the tricuspid
valve at 9 o’clock) may be helpful for recording the jet location and number,and useful for follow-up comparisons (Figure 3).
8. Echo assessment of valve implant depth is important to assist the implanterin assessing the mechanism and potential mediation (i.e post dilatation,
valve repositioning, placement of a second valve or even possible plug
placement) of significant AR when present.

Three-dimensional echocardiography with CD can be used toplanimeter the vena contracta, an estimate of the regurgitant orificeJournal of the American Society of Echocardiography
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Zoghbi et al 443

Figure 4 Effect of AR eccentricity on color Doppler jet recording in assessing PVR severity after TAVR. Scanning of the whole stented
valve in short axis is needed to identify the vena contracta of the jet(s). Proper plane selection of the short axis is critical. In the case ofan eccentric jet in the LVOT (A; curved arrow), the plane below the valve ring (B; dashed red) shows a large color jet as it spreads in the
LVOT (C), overestimating AR severity. By selecting the proper short axis at the aortic annulus (D), the regurgitant orifice is best depicted (small red arrow), more consistent with mild PVR. Similarly, a high short-axis view at the aortic root level (not shown) could be
misinterpreted due to normal diastolic flow in the sinuses of Valsalva or coronary arteries; flows in these locations, however, are oflower velocity and are not aliased.

Figure 5 Examples of paravalvular regurgitation of different degrees of severity using short-axis color Doppler depicting two criteria:
vena contracta area (VCA), and % circumferential (Circ) extent of the jet in relation to the total circumference of the prosthetic valve
ring. % Circ is calculated as the length of the jet along the valve curvature (‘‘a’’ in Panel A) divided by the total perimeter (‘‘c’’ in panel A)
as: (a/c)*100. In the case of two jets (D), % Circ would be [(a + b)/c]*100. As the VCA and circumferential extent of the jet increase, AR
severity is more significant. However, VCA in TAVR is affected by both circumferential extent and thickness of the PVR, i.e., separation of the valve from the aortic wall. As shown in Panels A and B, the circumferential extent may at times be similar to those of mild
regurgitation but the thickness of the PVR is large, leading to a larger VCA (B). Similarly, Panels B and C depict two lesions of similar
moderate severity by VCA but different circumferential extent. These considerations are very important in assessing mild and moderate AR severity and multiple jets (A-D). Once circumferential extent exceeds 30%, PVR is usually severe.

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Figure 6 Quantitative Doppler for assessing regurgitant volume (RVol) and regurgitant fraction (RF) in a patient with AR after TAVR.
Stroke volume (SV) is calculated at the LVOT and RVOT in this patient with mitral annular calcification. Flow quantitation complements
other assessments of AR severity.

area.60-62 Studies have shown the feasibility of measuring AR 3D
vena contracta area (VCA) in native valves61,63-65 as well as postTAVR.62 The primary pitfalls of this technique at this time are low
frame rates and color blooming artifacts, which may be resolved
with more advanced 3D technology.
b. Continuous-Wave and Pulsed-Wave Doppler.–Classically, twoparameters from CWD recordings have been used in the evaluationof AR: velocity waveform density and the deceleration rate (pressurehalf-time). These may have limited applicability in the TAVR population. The common occurrence of multiple PVR jets limits the utility of
CWD spectral density from a single jet; however, a very dense velocity waveform recording may signal at least moderate AR. In the current elderly patient population undergoing TAVR, ventricular andaortic compliance abnormalities may limit the use of pressure halftime for assessing the severity of PVR. A recent computationalmodeling study confirmed that increasing LV and/or aortic stiffness
led to faster decay of the transvalvular pressure gradient and, therefore, to a faster decrease of diastolic flow velocity across the aortic
valve compared with normal stiffness with the same regurgitantorifice. This faster decay led to both a shorter pressure half-time (simulating greater AR severity) and a lower regurgitant fraction (indicating
less AR severity).66
Flow reversal in the descending aorta recorded with pulsed-wave
Doppler may similarly be of limited value in the setting of abnormal
aortic or ventricular compliance. A number of studies in patients withhypertension have shown some flow reversal in the descending aorta
in the absence of AR.67,68 Thus, in order to use this parameter forassessing post-TAVR regurgitation severity, a pre-TAVR assessmentof descending aortic flow is essential. In the absence of baseline
flow reversal, a new holodiastolic reversal of flow in the descending
thoracic aorta is consistent with at least moderate AR,56 and likely severe if the end-diastolic velocity is >20 cm/s at a normal heart rate.69
In severe bradycardia, holodiastolic flow reversal may not be seen,
despite the presence of severe AR. Flow reversal in the abdominal
aorta is a more specific indication of significant regurgitation.70

c. Quantitative Doppler Assessment of PVR Severity.–
Quantitation of prosthetic AR involves the calculation of regurgitantvolume (RVol), regurgitation fraction (RF), and less often, effective regurgitant orifice area (EROA; Figure 6). The methods for calculatingthese parameters are well described in prior guidelines.6 However,
it is important to highlight a few issues that may be encountered in
the TAVR population that can modulate the approach to quantitation,
the accuracy of the derived parameters, and their clinical implicationsin assessing PVR severity.
Methodology: RVol in aortic regurgitation is derived as total LV
stroke volume minus systemic stroke volume. LV stroke volume isquantitated with either pulsed-wave Doppler at the LVOT site orwith a volumetric approach (the difference between LV enddiastolic and LV end-systolic volumes). There are challenges to calculation of LV stroke volume in the LVOT by PWD in the TAVR population. This stems from the measurement of LVOT diameter in thepresence of the prosthetic valve as it protrudes into the LVOT (incontrast to a sutured surgical valve at the aortic annulus). The corelab methods for calculating LVOT stroke volume and aortic valve
area following implantation of the balloon-expandable and selfexpanding valve have been recently published.71 It is important tomatch the location of the PWD sample volume with the location ofdiameter measurement of the THV for accurate stroke volume calculations (Figure 7). The preferred approach is to measure the LVOT
diameter from the outer-to-outer border of the stented valve at its
ventricular tip, with the corresponding PWD sample volume just apical to the valve stent (Figure 7, upper panels). In the case where theprosthesis is positioned too deep into the LVOT, encroaching on
the anterior leaflet of the mitral valve, an in-stent diameter measurement is performed at the mid-stent level (level of leaflets), with the
PWD sample volume positioned into the stent but proximal to thevalve (Figure 7, lower panels).71 In cases of technical difficulty, theLV volumetric method is used, provided there is no significant mitral
regurgitation.
For LV volumes measurements to derive SV, avoidance of LV foreshortening is essential. In general, 3D volumes are preferred to 2D

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Zoghbi et al 445

Figure 7 Calculation of stroke volume in the LVOT in transcatheter aortic valves. The default approach is to measure the LVOT diameter using the outer edge-to-outer edge diameter at the lower (ventricular) end of the valve stent (A, arrow). The pulsed-wave Doppler(PWD) sample volume is placed immediately proximal to the site of flow acceleration at the inlet to the stent (B). Stroke volume is thencalculated as usual, assuming a circular LVOT geometry as: 0.785*d2*VTI. In instances where a self-expanding valve is placed low in
the LV, particularly if the lower end of the stent is not in close proximity to the anterior mitral leaflet and interventricular septum, analternative approach is to measure the inner edge-to-inner edge diameter of the valve stent immediately proximal to the cusps (D).
The PWD sample volume should be placed just inside the stent but proximal to the site of flow acceleration at the cusps (E). Note thatwith transcatheter valves there is flow acceleration at the inlet to the stent and again at the cusps. Red arrows point to the lower end of
the stent. Panels C and F show the respective PWD recordings in the LVOT.
determinations. In studies with suboptimal endocardial definition,
contrast-echo enhancement is recommended to avoid underestimation of ventricular size and thus underestimation of all measurementsof total SV, RVol, and RF. Lastly, for determination of systemic strokevolume, the usual mitral valve (MV) site with PWD used for mitral
inflow volume may be problematic in this population, as the mitralannulus is frequently calcified, hindering the measurement of mitralannular diameter and derivation of accurate annular area. The mitralannulus site may also be problematic in the presence of more thanmild mitral regurgitation. In these circumstances, the pulmonic annulus
is an alternative site to calculate systemic stroke volume (Figure 6).
Lastly, EROA can be derived from the ratio of RVol to the velocity
time integral of the AR jet, obtained by CWD. This is rarely performedin clinical laboratories. EROA using the proximal isovelocity surface
area (PISA) method is usually not feasible because the flow convergence from the apical window is shadowed frequently by the prosthesis and its shape is typically non-hemispheric.
Severity of PVR using quantitative criteria: Whereas quantitative
grading schemes have been advocated for the evaluation of prosthetic
valve regurgitation, there is little data to support the use of these quantitative parameters in the context of acute PVR, shortly after TAVR.
The PARTNER IA study reported a mean LVOT Doppler stroke volume in patients with $mild AR following TAVR of 68 6 20 mL,14

which has been supported by larger studies.72 The usual cut-off for severe chronic native AR (RVol of >60 mL) seems inappropriate early
after TAVR in this population with LV hypertrophy, smaller LV cavity
size, and abnormal ventricular compliance. The effect of relatively
small RVols on patients with abnormal ventricular and aortic compliances could explain why even mild regurgitation may have a significant impact on clinical outcomes post-TAVR.12,19
Regurgitant fraction may be a more physiologically importantparameter that normalizes for the lower stroke volumes seen in thispopulation. In fact, CMR grading of PVR relies on RF and is discussed
below. According to ASE guidelines, mild AR has a RF <30%, moderate AR, a RF of 30-50%, and severe AR a RF of >50%.6,7 Data in
the TAVR population using CMR measures of PVR severity showed areduced survival with a regurgitant fraction of 30%,73 supporting theuse of this cutoff for moderate AR post-TAVR. Harmonizing grading
schemes between imaging modalities may minimize discordance between the two techniques.
Continued follow-up of patients following TAVR is recommended, particularly in the setting of recent data suggesting PVR may
improve over time74,75 and because of the unclear long-term
durability of these valves. Patients with uncomplicated THV implantation should undergo a comprehensive TTE soon after implantation to establish baseline valvular function, and subsequently at446 Zoghbi et al

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Figure 8 Repair for bioprosthetic aortic paravalvular regurgitation. At baseline: 2D color Doppler depicts very eccentric paravalvular
AR evident in both short-axis (left) and long-axis (right) TEE views (arrows). An occluder device is deployed with reduction of color
Doppler intensity but with significant residual PVR noted medial to device #1 (white arrows in center image, bottom). Occluder device#2 was deployed medial to occluder device #1 with immediate reduction in PVR severity to trace (white arrow).
1-3 months and 1 year. Studies should also be performed if unexpected clinical deterioration or new murmurs occur after THV.
TTE is used to identify complications of the procedure, especially
PVR, and changes in LV or RV function, assess aortic root structure
and valvular function, and measure PA pressure. The baseline postTAVR TTE is integral to accurate follow-up, since changes in baseline hemodynamics (increase in mean gradient of $10 mm Hg or
1 grade in AR) are an indication of possible valve deterioration orcomplication.76
F. Assessing Residual AR after Percutaneous Repair of
Prosthetic Paravalvular Regurgitation
The recently published Paravalvular Leak Academic ResearchConsortium Expert Statement reviews the technical aspects of performing PVR closure after SAVR or TAVR.77 The document also defines the clinical endpoints reflecting safety and effectiveness oftranscatheter devices, as well as the single and composite clinical endpoints for clinical trials. The therapeutic endpoint should be understood prior to the procedure. If the procedure is being performed
to address heart failure, any reduction in RVol is desirable. If, on theother hand, the procedure is to address hemolysis, then completeor near obliteration of the leak should be the objective. In deciding
when and how to address PVR after SAVR or TAVR, it is important
for the imaging physician to understand the underlying mechanismof the paravalvular regurgitation; this should guide the treatment
approach and may also predict whether a transcatheter closure device
will be successful in treating the regurgitation.
Localization and grading of residual AR after repair is assessed primarily with TEE or TTE as described for acute intra-procedural TAVR
assessment (Figure 8). In addition to grading of the regurgitation, an
assessment of the effects of regurgitation in the chronic setting should
include an evaluation of change in LV size and function, PA pressures,and the effect of high pulmonary pressures on right ventricular sizeand function.
G. Integrative Approach to Assessment of AR
The evaluation of AR by Doppler echocardiography after percutaneous interventions on the aortic valve should be a comprehensive
and integrative process, based on all the information collected during
the examination, since each of the parameters used in this evaluation
has advantages and limitations. In all cases, one should routinely
perform a comprehensive sweep of the implanted valve by 2D and
CD echocardiography, which includes an assessment of LV size andfunction, as well as velocity recordings in the LV outflow tract, mitraland pulmonic valve annuli, and in the proximal descending aorta
and/or abdominal aorta. CW Doppler of the AR jet should also be
routinely recorded but only utilized if a complete signal is obtained.
Recordings of CD and pulsed-wave Doppler of prosthetic valve AR
are more challenging compared to native AR due to the valve structure and mechanism of residual AR after aortic valve interventions.
Based on data in the literature and a consensus of the committee
members, the Writing Group proposes a scheme for evaluation of patients with AR (Figure 9). It is in a similar format to the scheme
recently proposed for native valve AR, but differs in the incorporationof VCA and % circumferential extent of VC, the removal of the conventional AR jet width/LVOT diameter ratio because of AR jet eccentricity, and the consideration of LV size and function.7 In applying thisscheme, it is the consensus of the committee members that the process of grading AR should be comprehensive, using a combinationof signs and measurements obtained by Doppler echocardiography.
If the AR is definitely determined as mild or severe using these specificsigns, no further measurement is required, particularly for mild lesions. If there are only a few parameters consistent with mild or severe
AR, and the quality of the primary data lends itself to quantitation, it isZoghbi et al 447

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Aortic Regurgitation After TAVR or Percutaneous Prosthetic Valve Repair
Yes, mild*
Specific Criteria for Mild AR• VC width < 0.3 cm• VCA < 0.10 cm2• Circumferential extent <10%
• Small or no flow convergence• PHT > 500 ms• No or brief diastolic flow
reversal in the descending aorta≥ 4 criteria
Definitively mild
(quantitation not needed)

Yes, severe

Does AR meet specific criteria ofmild or severe AR?
Intermediate values:
AR probably moderate

2-3 criteria

RVol < 30 mL
RF < 30%
EROA <0.1 cm2

2-3 criteria

Perform quantitative methods whenever possible torefine assessment

Specific Criteria for Severe AR• VC width > 0.6 cm• VCA ≥ 0.30 cm2• Circumferential VC extent ≥ 30%• Large flow convergence• PHT < 200 ms• Prominent holodiastolic flow
reversal in the descending aorta

RVol ≥ 60 mL¶
RF ≥ 50%EROA ≥ 0.3 cm2

RVol 30 - 59 mL
RF 30 - 49%
EROA 0.10 - 0.29 cm2*≥ 4 criteria
Definitively severe(may still quantitate)

3 specific criteria
for severe AR

Mild
AR
•
•

Moderate
AR

Poor TTE quality or low confidence in measured Doppler parameters
Discordant quantitative and qualitative parameters and/or clinical data

SevereAR
Indeterminate AR
Consider further testing:

TEE or CMR for quantitation*

AR after TAVR is frequently eccentric, involving more than one jet; an integrative approach is essential¶

Regurgitant volume for severe AR may be lower in low flow conditions.

§

EROA is infrequently used in AR. It is derived using the volumetric approach, not PISA.

Figure 9 Suggested algorithm to guide implementation of integration of multiple parameters of AR severity after TAVR or prosthetic
aortic valve repair. Good-quality echocardiographic imaging and complete data acquisition are assumed. If imaging is technicallydifficult, consider TEE or CMR. AR severity may be indeterminate due to poor image quality, technical issues with data, internal inconsistency among echo findings, or discordance with clinical findings.

desirable for echocardiographers with experience in quantitative
methods to measure quantitatively the degree of AR, including the regurgitant volume and fraction as descriptors of volume overload. The
effective regurgitant orifice area, a descriptor of lesion severity, is lessfrequently used after aortic valve interventions. As previously
mentioned, quantification of EROA via PISA is limited in TAVR;
hence quantification via the volumetric approach is recommended.
Grading of AR in this population is more challenging than in native
AR and for this reason and the errors involved in quantitation, athree-grade system is proposed (mild, moderate, and severe). Whenthe evidence from the different parameters is congruent, it is easierto grade AR severity. When parameters are contradictory, one must
look carefully for technical and physiologic reasons to explain these
discrepancies and rely on the components that have the best qualityof the primary data and that are the most accurate considering the underlying clinical condition. In situations where the assessment is difficult and indeterminate, provides contradicting echo/Doppler datathat cannot be resolved or conflicts with the clinical presentation,
further testing is advised with either TEE or CMR. TEE in this scenario
can provide the mechanism of AR and quantitation of VC area andcircumferential extent. CMR, on the other hand, can provide quantitation of RVol and RF (see below).

H. Role of Cardiovascular Magnetic Resonance in
Evaluating AR
A few studies have demonstrated the feasibility of CMR for evaluation of PVR after TAVR.78-81 There are a number of advantages of
CMR for assessing PVR in this setting, including the ability tomeasure RVol irrespective of the number of regurgitant jets or theirmorphology,82 the high reproducibility of measurements,83 and theability to measure RVol for multiple valve lesions.80,81,84 LV
volumes and function can also be assessed using standard cine
CMR sequences. Few pitfalls of the technique exist, and the cost,
access to scanners, and expertise with valve disease continue to bebarriers to widespread use.
The direct measurement of forward and reverse flow volumes in
the aortic root by CMR facilitates the calculation of aortic RF forassessment of PVR severity (Figure 10). PVR can be visualized in
the cine CMR three-chamber view using the steady-state free precession (SSFP) technique. Due to intra-voxel spin dephasing, a regurgitant jet causes a signal change that is either bright or dark
depending on the direction of phase encoding. However, due to susceptibility artifact from the valve frame, identification of regurgitant
flow can often be challenging (Figure 10). Alternatively, phasecontrast imaging in a CMR three-chamber view using in-plane phase448 Zoghbi et al

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Figure 10 CMR for evaluation of PVR after TAVR and subsequent valve-in-valve (ViV) implantation for treating residual AR. Threechamber cine view showing the PVR jet (red arrow) after TAVR (A). (B) shows the decreased severity of PVR after ViV placement.
Phase-contrast imaging of the flow through the prosthetic valve (C and D) shows the PVR jet, which has decreased significantly after
ViV. The right panels show the flow-volume curves through the aortic valve (plane of acquisition in A & B) before and after ViV placement. Significant backward flow was seen due to PVR with a RF of 36% (moderate severity). After ViV placement, regurgitation was
reduced and the RF decreased to 12% (mild severity).

encoding can be used to more reliably visualize the jet. Given the 2D
nature of both SSFP and phase-contrast imaging, eccentric regurgitantjets may be missed. The major advantage of CMR in the characterization of PVR is the ability to quantify regurgitant flow regardless ofwhether a regurgitant jet has been visually identified. This is accomplished via through-plane phase-contrast imaging acquired at the levelof the aortic root immediately above the transcatheter heart valve.
This allows the direct measurement of forward stroke volume andRVol, and subsequent calculation of regurgitant fraction (Figure 10).
Contrary to TTE, this technique is not affected by potential variability
in the shape of the regurgitant orifice during the cardiac cycle.
Furthermore, the quantitative approach by CMR has very low
observer variability compared to either 2D or 3D TEE.82,85,86
Preliminary data have shown that paravalvular AR severity gradingwith TTE may be underestimated compared to quantitative
CMR.79 Limitations of the phase-contrast technique include signal
loss due to complex flow, velocity encoding choices in stenosis/regurgitation, temporal and spatial resolution, and that reverse flow by
CMR includes coronary flow in addition to AR,87 partially explaining
the variable cutoffs for mild AR in previous studies. Alternatively, theindirect method can be used to calculate RVol and RF. This involves
comparison of total LV stroke volume derived in the aorta with phase
contrast or from LV volumes, to stroke volume in the pulmonary artery or from the right ventricle (in the absence of significant tricuspid
or pulmonic regurgitation), which reflect systemic stroke volume.7
Similar to native valve disease, when the clinical presentation and
TTE results do not concur, CMR at centers with appropriate expertiseshould be considered for further evaluation of PVR, especially when atherapeutic intervention is under consideration.7 CMR-based phasecontrast imaging provides direct, accurate, and reproducible quantification of valvular regurgitation.88-90 AR quantification is more
reproducible by CMR compared to echocardiography in native
valve disease.83,91,92 CMR-derived quantitative findings also havebeen shown to have prognostic value in native AR93 as well as inpost-TAVR patients.78
A number of different cutoffs for defining severity of aortic regurgitation after TAVR have been used, adding to the confusion in theliterature. RF cut-offs for severe AR after TAVR in small populations
ranged between >30% and >40%,85 and quantitative RF values ofAR severity obtained by phase-contrast imaging were lower thanthose obtained by echocardiography.94,95 However, strong
outcomes evidence from recent trials using TTE grading suggeststhat this may not be the case and that TTE can accurately assess
severity.2,10 Gelfand et al.95 have shown that the CMR cutoffs that
optimized the correlation with integrative echocardiographic grades
were similar to those recommended for both native and surgical prosthetic AR in guidelines published by the American Society of
Echocardiography: mild <30%, moderate 30-50%, and severe>50%.6,7 Developing a unified grading scheme would help
determine the true differences between imaging techniques, sinceobtaining a routine CMR in this elderly population with highprevalence of pacemakers is frequently not possible.

Key Points
Assessment of paravalvular regurgitation after
aortic valve interventions
 Paravalvular regurgitation (PVR) is a complication of transcatheter aortic valve replacement (TAVR). Recent observations with newer valve designs suggest that the incidence of
PVR is low (0-2%) and that mild or lesser PVR does not affectoutcomes.
 Imaging prior to TAVR (echocardiography and multi-detector
computed tomography) and intra-procedural imaging (echocardiography and fusion imaging) can predict and reduce therisk of PVR following TAVR. The predictors of PVR include:Journal of the American Society of Echocardiography
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under-sizing the transcatheter heart valve (THV), severe
valve/annular calcification and inappropriate positioning of
the valve.
 Intra-procedural echocardiography may be performed usingtransesophageal (TEE) or transthoracic (TTE) imaging; eachapproach has its advantages and limitations in assessing
TAVR results and severity of PVR. Because echocardiographic
views and availability of Doppler parameters are limited during the procedure (color Doppler and flow pattern in descending aorta), confirming the severity of PVR withaortography and invasive hemodynamics may be needed if
echocardiographic imaging is non-diagnostic.
 Color Doppler is the first-line method for detecting and assessing severity of aortic regurgitation (AR) after TAVR. However, the limitations of echocardiography and characteristics
of PVR jets both introduce challenges: 1) From parasternalor esophageal views, there is ultrasound attenuation fromthe valve in the far field, necessitating the use of multiple imaging windows to detect all AR jets, including apical views (forTTE) and deep transgastric views (for TEE); 2) AR after TAVR
frequently arises from multiple jets that are often eccentric; 3)
In the setting of stent frame non-conformability, intact calcified leaflets, and open THV cells, there are frequently multiple small PVR jets traveling in atypical directions; 4)
Conventional AR jet width/LVOT diameter ratio cannot be
used to assess AR severity because of jet eccentricity.
 Evaluation of residual AR after TAVR should be comprehensive and include assessment of: 1) THV shape and position; 2)The number and location of the regurgitant jets; 3) Vena contracta width and area; 4) Circumferential extent of the regurgitant jets (with careful consideration of non-contiguous,
small, discrete jets); 4) Duration of diastolic flow reversal by
PWD in the descending and/or abdominal aorta; 5)Continuous-wave Doppler velocity waveform density andpressure half-time; 6) Methods for quantifying regurgitantvolume, regurgitant fraction, and, less often, effective regurgitant orifice area.
 When more than mild AR is suspected but the data are equivocal, CMR should be performed (at centers with appropriate
expertise) to quantitate aortic regurgitant volume and fraction, as well as LV chamber volumes.

IV. PERCUTANEOUS MITRAL VALVE INTERVENTIONSThere are 4 major categories of percutaneous mitral valve interventions aimed at reducing MR: mitral valve leaflet repair (edge-toedge clip, and placement of artificial chords), transcatheter mitralvalve replacement, mitral annuloplasty, and catheter-based plugging
of paravalvular leaks. Among these, edge-to-edge repair is the only
catheter-based MV intervention approved by the United States
Food and Drug Administration (USFDA) for commercial use andthus will be detailed in this document. Each intervention has uniqueissues regarding both intra-procedural and post-procedural assessment of residual MR. However, the general principles of assessing residual MR with Doppler echocardiography after percutaneous mitralinterventions are similar to those recently published in detail fornative and prosthetic valves.7 The current document will focus on

Zoghbi et al 449

the 4 categories of percutaneous MV interventions with comments
and caveats for assessing residual MR during the procedure, followedby an overall evaluation of MR outside the catheterization laboratorycommon to these interventions. TEE (2D & 3D) is the main imaging
modality for guiding the procedures and evaluating their immediate
success, while TTE is the main initial modality outside the catheterization laboratory. Similar to all regurgitant lesions, an integrative
approach using various parameters is essential in the overall evaluation of the severity of residual MR.
A. General Considerations in Evaluating Residual MR
during MV Interventions
Unlike PVR after TAVR for aortic stenosis, which represents a newlesion, residual MR after most mitral interventions involves assessment of the reduction in MR severity from baseline, as most current
MV interventions are aimed at reducing MR. An assessment ofchanges in both hemodynamics and Doppler echocardiographic parameters is important in the overall evaluation of acute changes in
MR severity during MV repair or replacement. Table 5 depicts the hemodynamic and Doppler parameters that can be evaluated with TEE
during the procedure and their implications for severity of MR. CD is
the main Doppler modality for assessing MR (site, number of jets, eccentricity, vena contracta, and flow convergence) prior to and during
the procedure, with special considerations and limitations dependingon the type of MV intervention (see text below and Table 5). The pulmonary vein flow pattern is used together with other findings in an
integrated fashion to assess residual MR; it should be meticulouslyinterrogated in all patients before and during the procedure.
Patients with severe MR have either systolic blunting or systolic
flow reversal in one or more pulmonary veins. Normalization of pulmonary vein flow after MV interventions strongly suggests that MR
has been reduced to mild, with normalization of left atrial (LA) pressure (Table 5). Failure of pulmonary vein velocity pattern to improvesuggests insufficient MR reduction. Recently, these intra-proceduralchanges in pulmonary vein flow patterns have been shown topredict re-hospitalization and mortality after the procedure.96
Appearance of spontaneous contrast in the LA after MV intervention
also suggests significant reduction in MR severity. The mitral inflow
velocity pattern [(decrease in mitral E velocity and velocity time integral (VTI)] may be helpful in assessing reduction of MR, particularly inprocedures that do not change actual MV structure (annuloplasty andrepair of PVR). A change from an E-wave-dominant to an A-wavedominant pattern suggests mild residual MR. Furthermore, measurement of velocity in the LVOT with TEE from deep transgastric views,
while challenging, may be helpful in demonstrating an increase in velocity and thus systemic flow. Lastly, a decline in LV ejection fraction
after MV intervention suggests significant MR reduction because ofincreased afterload, absent other causes (ischemia, pacemakerrelated, etc.).
Hemodynamically, the resolution of a regurgitant v wave andreduction of left atrial or pulmonary pressures provide important
clues to improvement in MR severity that might be particularly helpful when residual MR severity is difficult to assess with color Doppler.
It is also common to observe a 10-15 mm Hg increase in systolic bloodpressure immediately after a successful reduction in severe MR, reflecting an increase in forward stroke volume. On the other hand, it
is important to note that MV interventions are performed under general anesthesia, which may alter hemodynamics in a way that can
reduce the severity of MR. Consequently, assessment of MR severity
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Table 5 Hemodynamics and TEE parameters useful in determining residual MR severity during MV interventions in thecatheterization laboratory
Parameter

Invasive hemodynamics

Assessing severity of residual MR

Decrease in regurgitant v wave, LA pressure, and pulmonary pressures are
specific signs of reduction in MR severity; Consider effects of generalanesthesia on MR severity

General echocardiographic findings
Spontaneous echo contrast in LA

Appearance of spontaneous contrast after MV intervention suggests significant
reduction in MR severity

LVEF

Decline in LVEF after MV intervention suggests significant MR reduction in theabsence of other causes (ischemia, pacemaker-related, etc.)

Color Doppler
Color Doppler jet (size, number, location, eccentricity)- Easy to obtain with a comprehensive, systematic approach- Difficult to assess multiple and eccentric jets
- Jet area affected by eccentricity, technical and hemodynamic factors(especially driving velocity)

Flow convergence- Large flow convergence denotes significant residual MR whereas a small orno flow convergence suggests mild MR- Difficult to use in presence of multiple jets or very eccentric jets, or may bemasked by the device

Vena contracta width- VCW $0.7 cm specific for severe MR- Difficult to use in presence of multiple small jets or very eccentric jets forwhich orifice shape is not well delineated

Vena contracta area (3D planimetry)- Allows better delineation of eccentric orifice shape and possibly the addition
of VCA of multiple jets
- Prone to blooming artifacts

Spectral Doppler
Pulmonary vein flow pattern- Systolic flow reversal in >1 vein specific for severe MR- Increase in forward systolic velocity after MV intervention helps confirm MR
reduction

MR jet profile by CWD (contour, density, peak velocity)- Dense, triangular pattern suggests severe MR- May be hard to line up CWD properly in flail leaflet or very eccentric jet after
intervention

Mitral inflow pattern- In sinus rhythm, mitral A-wave-dominant flow excludes severe MR- Decrease in mitral E velocity and VTI suggests reduction in MR severity

Pulsed Doppler of LVOT (deep transgastric view)

Increase in LVOT velocity and VTI after procedure suggests MR reduction

Quantitative parameters

In general, more difficult to perform; some procedure-specific limitations inquantitation

EROA by PISA

- Not recommended after edge-to-edge repair because assumption ofhemispheric proximal flow convergence is violated by the device.
- PISA often underestimates MR severity in the presence of multiple jets ormarkedly eccentric jets.
- Not feasible in PVR of mechanical prosthetic MV or possibly TMVR (flowmasking in LV by TEE)

Regurgitant volume- Difficult to perform volumetric RVol with pulsed Doppler by TEE

CWD, Continuous-wave Doppler; EROA, effective regurgitant orifice area; LA, left atrium; LVEF, left ventricular ejection fraction; LVOT, left ventricular outflow tract; PISA, proximal isovelocity surface area; PVR, paravalvular regurgitation; TEE, transesophageal echocardiography; TMVR,
transcatheter mitral valve replacement; VCW, vena contracta width; VCA, vena contracta area; VTI, velocity-time integral.

performed under similar loading conditions. Phenylephrine or intravascular volume expansion may be given to adjust systolic blood pressure or filling pressures to physiologic levels prior to final assessmentof MR severity during the procedure.
B. Mitral Leaflet Repair
Edge-to-edge mitral leaflet repair is the only USFDA-approved percutaneous therapy and will be discussed in detail. Artificial chords are in

early feasibility trials and will not be discussed separately. It is expected that residual MR assessment after the latter procedure will
be similar to surgical MV repair with valve preservation techniques.
1. Edge-to-Edge MV Repair. The MitraClip (Abbott Vascular
Structural Heart, Santa Clara, CA) is a chromium cobalt device withtwo polyester-covered clip arms designed to grasp both MV leafletsin a similar fashion as edge-to-edge surgical repair. A similar device(PASCAL, Edwards Lifesciences, Irvine, CA) is in early feasibility

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Figure 11 Illustrative echocardiographic parameters of reduction of MR severity to mild after edge-to-edge mitral valve repair.
trials.97 These devices are implanted via a transcatheter delivery system that is inserted into the LA from the femoral vein via transseptal
puncture. TEE (2D and 3D) is used to guide the transseptal puncture
and to steer the device to the appropriate MV pathology. A key part ofthe procedure is to visualize the stable capture and insertion of bothleaflets into the clip arms. Once anterior and posterior leaflet insertionis verified, the clip is then closed more fully while TEE color flow imaging is used to assess MR reduction. This is typically done in thecommissural view (mid-esophageal between 60-90 degrees) because
it allows imaging of MR jets on both sides of the clip and across theentire coaptation plane of the MV. After confirmation of leaflet insertion, demonstration of MR reduction and a non-significant mitralpressure gradient post-clip implant, the clip is detached from the delivery system and permanently deployed. If needed, a second, or lessfrequently a third clip can be placed for further MR reduction. The
decision to proceed with a second clip is complex and based on
the degree of reduction of MR with the first clip, residual MR,
mean mitral gradient and valve area, improvement in hemodynamics,
and the technical feasibility of placing a second clip. Regardless ofwhether 1 or more clips are deployed, evaluation of the degree ofMR reduction, the severity of residual MR, and the trans-mitralmean gradient are key components of the decision-making process
and are predominantly guided by intra-procedural TEE. Table 5 andFigure 11 detail the echocardiographic parameters that are assessed

during edge-to-edge device deployment to evaluate the severity of residual MR. CD evaluation pertaining to edge-to-edge repair is further
discussed below.
2. Evaluation of Residual MR with CD Immediately afterEdge-to-Edge Repair. CD allows rapid assessment of the presence or absence of MR. Despite its limitations,7 CD is the mainstay
of intra-procedural TEE because of its simplicity. It is important tomaintain the same ultrasound settings pre- and post-procedure.
In vitro experiments have shown that when there are two or more
MR jets, they tend to merge together and overestimate the severityof MR.98 MR jets after clip deployment can be multiple, in different
planes, of different severity, and may crisscross and merge, thus adding to the complexity of assessment of residual MR severity(Figure 12). Two or three small, thin jets emanating after deploymentof a single clip resemble the washing jets from a bi-leaflet mechanical
MV and are usually no more than mild MR. Factors indicative of atleast moderate MR after edge-to-edge repair include a wide vena contracta or a prominent proximal convergence zone on the LV side.
Because proximal convergence is constrained by the presence ofthe clip itself, angle correction would be required for the calculationof EROA by PISA.7 However, the requirement for angle correction
and the frequent presence of 2 or more jets makes PISA less reliable
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Figure 12 Challenges of multiple MR jets after edge-to-edge mitral valve repair. Transesophageal echocardiographic images from a
mid-esophageal level. (A) Three separate, small jets are seen. (B) A large jet with a wide orifice is seen medial to the device with a verysmall jet laterally. (C) Two separate large jets, crisscrossing with a confluence close to the valve. (D) Five different residual jets of variable severity seen after deployment of a single clip.
derivation of EROA. 3D imaging of the vena contracta area(s) of the
MR jet(s) after valve repair shows promise because of its quantitative
nature and good correlation with CMR.99-101 Each jet that is deemedsignificant would need to be analyzed separately for VCA, since they
are often in different planes and with different orientations, and their
VCAs are added (Figure 13). Further experience and validation isneeded with this approach. Multiplying the velocity time integral of
the CWD jet of MR by the total VCA provides, in principle, theRVol; however this has not been validated.7 3D color can help identify, assess, and localize residual eccentric or wall-hugging MR jets notseen by 2D color flow imaging.
3. Interaction of Mean Transvalvular Gradient and Residual
MR after Edge-to-Edge Repair. Mitral valve edge-to-edge repair
causes a reduction in MV area (MVA). Reduction in MR after a firstclip may reduce mitral E velocity but narrowing of the MV orifice
may have an opposing effect. In the EVEREST I and II trials, an initialmaximal MVA in early diastole was empirically chosen to ensure thatclip placement did not cause mitral stenosis. Lubos et al.102 showedthat a baseline MVA #3.0 cm2 and a mean gradient $4 mm Hg
were associated with a high risk of an aborted procedure due to potential mitral stenosis. Altiok et al.99 found that mitral stenosis is unlikely to occur if the MVA is at least 4.1 cm2 by 3D TEE. Further, apost-procedure mean gradient of $5 mm Hg is predictive of elevatedmean gradient at discharge.103 Thus, the MV gradient is always
measured after clip implantation and is considered along with the re-sidual MR grade in determining the need for and advisability of a second clip. On the other hand, residual moderate or greater MR canaugment the diastolic gradient across the MV when a clip is present,
which should also be taken into account when considering placementof an additional clip. In such a setting, an additional clip may reduce
the transmitral diastolic gradient if the MR is effectively reduced.
C. Transcatheter Mitral Valve Replacement
1. TMVR Implantation. A few TMVR designs have been developed and successfully implanted in patients.104-108 None of thesevalves are currently US FDA-approved for commercial use. At thistime, the Edwards SAPIEN 3 is US FDA-approved only in the settingof valve-in-bioprosthetic mitral valve. The valves specifically designed
for TMVR share common requirements, including a proper seal at themitral annulus, an anchor to the native structures, and avoidance of
LVOTobstruction. The approach to implantation has initially been primarily trans-apical. However, transvenous transseptal implantation
has also been successfully performed and will likely be the primary
implant approach in the future.
Fluoroscopic imaging planes for the MV are well-defined,109 andpre-procedural imaging planes for TMVR can be determined bymulti-detector computed tomography.110,111 MDCT is particularly
useful to comprehensively evaluate the entire MV landing zone,
choose the appropriate device size, and evaluate the predicted neo-Journal of the American Society of Echocardiography
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Figure 13 3D vena contracta area measurements by TEE during MitraClip implantation. (A) Baseline 3D en face view from the left
atrium. Both leaflets were restricted with coaptation defects (arrows). (B) 3D quad images showing vena contracta width (yellow arrows) that is wider in bi-commissural view (top left) than long-axis view (top right). 3D vena contracta area (VCA, bottom left) is elliptical, seen in magnified view in (C), measuring 0.57 cm2. (D) 3D en face view from left atrium after placement of two MitraClips(arrows). (E) 3D vena contracta measurements after placement of two MitraClips orienting cut planes to lateral jet with VCA of
0.10 cm2. (F) 3D vena contracta measurements orienting cut planes to medial jet with VCA of 0.04 cm2. The combined VCA is
0.14 cm2, consistent with mild MR.

LVOT after valve deployment.111 For trans-apical implantation, thelocation of the apical puncture can be determined pre-procedurally
by MDCT and confirmed during the procedure by TEE. Each device
has unique aspects to implantation, but they all require TEE guidance
to ensure that the guide wire and subsequent device delivery system
are centrally located in the chord-free space between the middle segments of the valve (A2 and P2 segments) to avoid chordal rupture.
During the TMVR procedure, the device can interfere with anterior
leaflet closure and create transient acute severe MR. Prompt recognition of this problem by TEE and redirection of the delivery system isimportant. After deployment of the device, 2D and 3D imaging areused to confirm appropriate device seating, stability, orientation,and function (transvalvular gradient and the determination of centralor paravalvular regurgitation). LVOT obstruction after TMVR may
occur either due to the MV prosthesis itself or displacement of theanterior mitral leaflet into the LVOT. In addition to TMVR per se, implantation of TAVR valves in the mitral position in patients with native
mitral annular calcification, complete annuloplasty rings, or prior bioprosthetic valves has been reported in large registries.112,113 The same
principles of evaluating MR severity after such procedures isapplicable.

2. Evaluation of Residual MR Immediately after
TMVR. Because the TMVR orifice is smaller than that of the native
mitral valve, devices typically rely on skirts or flanges to seal off thenative valve lines of coaptation to both competitive antegrade flow
and PVR. As with all bioprostheses, there is a risk of central MR
due to cusp malfunction, which is readily identified by CD. Acute central valvular regurgitation is uncommon, and may occur due to inadequate initial cusp motion, theoretically as a result of collapsing thevalve or damaging the leaflets during delivery.
Early feasibility trials indicate that PVR occurs infrequently after
TMVR.114,115 However, identification and localization of PVR after
TMVR may be difficult, in contrast to central MR (Table 5). The valve
flange or skirt causes acoustic shadowing, which may make it difficult
to discern if the color jets that are seen moving across the annularplane are contained within the flange/skirt or enter the LA, causing
MR. PVR may occur at any point along the perimeter of the valve;
it is essential therefore to interrogate the valve systematically withmultiple views and imaging angles and is best performed with 3D
TEE. PVR following TMVR may result from suboptimal valve sizingthat may leave native commissures/lines of coaptation exposed,
which then can interfere with the seating of the valve and flange.

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Figure 14 Plug repair for mechanical MV paravalvular regurgitation. At baseline: 2D color Doppler depicts paravalvular MR with avena contracta diameter of 7 mm. A large paravalvular defect is noted at the 10 o’clock location (arrow). 3D color Doppler depicts
a large paravalvular MR jet. The left upper pulmonary vein demonstrates systolic flow reversal (S). After deployment of an occluder:
2D color Doppler depicts two very small MR jets on either side of the repair device. The device is appropriately deployed within theparavalvular defect (arrow). 3D color Doppler depicts a very small residual paravalvular MR jet at the superior margin of the occluder
device. Left upper pulmonary vein flow demonstrates systolic blunting but no reversal of flow.

This may also be exacerbated because of native annular or valvular
calcification. Even with appropriate sizing, there may be inadequate
seating due to insufficient capture of the native valve elements towhich the prosthetic valve is anchored. This may be associated withexcessive systolic movement of the valve, which may result in permanent or intermittent displacement of the valve flange/skirt into the
LA. In extreme cases, complete valve dislodgement will result in severe MR.
Since experience with TMVR is limited, the approach to evaluating
the severity of MR is extrapolated from that used for surgical mitralprostheses6 or native MR.7 CD is used to identify and localize thejet(s). Although jet dimensions may provide semi-quantitative information as to the degree of regurgitation, it should be noted that there
has been no validation of jet dimensions in the setting of TMVR.
Theoretically, measurement of VCW or VCA for discrete jets may
be helpful but lacks validation after TMVR. Application of the PISA
approach to PVR with TEE has significant limitations, as the PISA
shells are rarely hemispheric, are usually truncated by adjacent walls,
and are frequently shadowed by the prosthetic valve (Table 5). Nonholosystolic MR jets that typically are not associated with severe MR
may be encountered post TMVR. Therefore, it is important to verify
MR jet duration with CWD and/or color M-mode.
3. Other Considerations in TMVR. Many of the current TMVR
prostheses have structural elements that may project toward the interventricular septum and predispose to LVOT obstruction. The orientation of valvular elements relative to the septum should be carefully
assessed and LVOT pressure gradients recorded from the transgastricapproach during TEE. While the relationship between LVOT gradients and MR is uncertain, there is a theoretical possibility that interac-tion of the valve with the septum may interfere with the stability of theimplanted valve.
D. Percutaneous Mitral Annuloplasty
1. Percutaneous MV Annuloplasty Devices. Mitral annuloplasty is a critical component of most surgical MV repairs for both primary and secondary MR with annular dilatation. Accordingly, there isa significant interest in the development of percutaneous mitral annuloplasty. Indirect annuloplasty refers to the deployment of a device
within the coronary sinus, taking advantage of the vicinity of the coronary sinus to the posterior and lateral aspects of the mitralannulus.116,117 None of the devices listed below are approved forclinical use in the US. The Carillon device (Cardiac Dimensions
Inc., Kirkland, WA) is currently approved in Europe and works bypulling together the distal and proximal coronary sinus to reducethe mitral valve orifice area.118,119 The role of intra-procedural echocardiography is to evaluate MR severity before and after deployment,
and to detect complications such as pericardial effusion (due to coronary sinus laceration or perforation) and LV lateral wall ischemia fromacute compression of the left circumflex coronary artery. Direct annuloplasty consists of the re-shaping of the mitral annulus by cinching it
through different mechanisms that approach the annulus itself rather
than the coronary sinus. Mitralign (Mitralign Inc., Tewksbury, MA)
consists of 2 pairs of pledgets deployed in the posterior annulus.120
Each pledget of the pair is implanted by perforation of the annulus
with radiofrequency wires from the LV to the LA. Cinching and locking the pledgets together reduces the annular dimension. As this procedure is performed in the P1 (lateral) and P3 (medial) segments, theantero-posterior dimension is reduced, therefore improving leaflet

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coaptation. This procedure requires TEE guidance for precise positioning of the guiding catheters near the commissures and for subsequent safe crossing of the radio frequency wires into the LA. The
Cardioband system (Edwards Lifesciences, Irvine, CA) uses TEE
and fluoroscopic guidance to anchor a band directly to the annulus
from the lateral to the medial trigones.121,122 The band is thenadjusted in the beating heart to cinch the annulus until maximal
MR reduction is obtained. 3D TEE has demonstrated acute
reduction of annular dimensions with associated MR reduction.123
2. Evaluation of MR after Percutaneous Annuloplasty. The
evaluation of MR after any of the annuloplasty procedures is the least
challenging of all MV percutaneous interventions, as the MV still consists of a single orifice, with an anatomy predictably similar to a native
valve. Evaluation of MR severity should be performed according to
the recent ASE recommendations for native MR.7 Importantly, all
Doppler measurements pre-intervention can be compared after theprocedure (CD, PWD, CWD) for a comprehensive assessment ofchanges in MR severity. If the anchors detach, the shape of theannulus may be altered, allowing for unusual MR jet location posterior to the annuloplasty device, possibly resulting in worse MR
severity. In general, the expected result of all these annuloplasty procedures is that mitral annular dimensions and tenting area decrease,and coaptation length increases, resulting in a decrease in MR
severity, and subsequently in LV dimensions and volumes over time.

E. Transcatheter Repair of Paravalvular Prosthetic MR
1. Repair of Paravalvular MR. TEE with 3D imaging and CD is
the imaging technique of choice for the localization and anatomic
analysis of prosthetic paravalvular MR and for guidance during theprocedure (Figure 14). There is, however, an increasing interest in
integrating and co-registering MDCT imaging with real-time fluoroscopy in the catheterization laboratory. The localization and image
display of the PVR jets should be done to facilitate the communication between the echocardiographer and the interventionalist. The
standard approach is to use the ‘‘surgeon’s view’’ from the LA,
whereby the aortic valve is at the top (12 o’clock), the medial commissure/annulus is to the right (3 o’clock), and the lateral commissure/annulus and neighboring LA appendage are to the left (9 o’clock).
Most para-prosthetic MR defects are in the anteromedial or posterolateral locations. Evaluation of the size and shape of the defect(s) is
important for procedural planning. In the rare cases of PVR repairof TMVR, the skirts/flanges of the prosthesis pose challenges to transcatheter approaches of valve repair not encountered with surgical MV
replacement; 3D TEE imaging is an essential component of preprocedural planning and intra-procedural monitoring.
Knowledge of the 2D echocardiographic appearance of the
expanded occluder device is important for proper positioning, stability, and potential for impacting prosthetic valve function and leaflet
motion. 3D echocardiography of the MV from the LA provides excellent visualization of the occluder device, extent of overlap (if any), andthe need for repositioning or deployment of additional occluders to
successfully obliterate the defect. Assessment should be performed
from both an LA and LV perspective. CD is used to identify andconfirm defects and differentiate them from dropout or artifact secondary to acoustic shadowing from the mitral prosthesis. Doppler
assessment of antegrade mitral flow and calculation of the mean
mitral valve pressure gradient should be undertaken to screen forpossible prosthetic valve obstruction. Occluder devices may alsointerfere with the prosthetic valve leaflets during systole, preventing
proper closure. This complication can be more difficult to recognize,
and frequently the only sign is an abrupt increase in valvular regurgitation that is greater than the normal closing volume.124 Other potential complications include device embolization, thrombus formation,and compromise of the circumflex coronary artery (typically withposterolateral defect targets) manifesting as a new lateral regional
wall motion abnormality.
2. Evaluation of Residual MR after Repair of Paravalvular
MR. In assessing residual MR by TEE, a remaining defect versus anecho dropout around the occluder(s) should be confirmed by thepresence of a PVR jet. Multiplane TEE imaging with CD (oftenwith off-axis views) is used to visualize the PVR defect. CD is used
to localize the PVR jet as well as assess its severity. Visualization of
the post-repair residual PVR jet and its area in the receiving chamber
can provide a rapid screening of the presence and direction of the jet
and a semi-quantitative assessment of its severity (Figure 14). Larger
jet areas represent more significant residual PVR. However, eccentric,wall-impinging jets appear smaller than centrally directed jets ofsimilar hemodynamic severity, leading to underestimation of PVR
by CD.

Key Points
TEE guidance of mitral valve interventions
 Most mitral valve interventions are designed to reduce MR
severity, so comparison of baseline to peri-interventional
measures are paramount.
 Each device has unique characteristics that require devicespecific imaging protocols for successful and safe deployment,
as well as for evaluating residual MR severity.
 Color Doppler is a convenient first-line method for detecting
the presence of residual MR, determining the number, location, and direction of MR jets, and for estimating MR severity
using jet characteristics of flow convergence, vena contracta,
and jet area. However, determinations of severity of MR using
color Doppler alone can be misleading, so integration withother parameters is necessary.
 A change in pattern from systolic flow reversal in more than
one pulmonary vein to a normal pattern is strongly suggestiveof mild residual MR.
 A change from an E-wave-dominant mitral inflow pattern toan A-wave-dominant pattern is consistent with mild residualMR.
 3D TEE measurement of MR vena contracta area(s) may be
useful in determining residual MR severity but requires
further validation.
 Integration of echo/Doppler measures with invasive hemodynamics can help determine residual MR severity.
 In addition to assessment of residual MR severity, trans-mitralpressure gradient, mitral valve area, and potential LVOT
obstruction should be evaluated.

F. Evaluation of Residual MR Outside the Catheterization
Laboratory after all MV Procedures
Follow-up echocardiographic evaluation after MV interventions
should be a comprehensive study that includes qualitative, semiquantitative, and quantitative analysis when possible, using color

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Table 6 Echocardiographic parameters and related comments in the assessment of MR severity with TTE after transcatheter MV
interventions
Parameter

Assessing residual MR after MV interventions

Color Doppler
Color Doppler MR jet(s) Multiple jets can lead to overestimation of MR severity
 MV device artifacts/shadowing may mask MR jet (TTE) or flow convergence (TEE).
 PVR often difficult to identify, localize and quantify by TTE; TEE often needed Eccentric jets difficult to evaluate and harder to detect (out of imaging plane)

Flow convergence Small, suggests mild MR; large suggests significant MR

Vena contracta width Often better defined with TEE Not validated for multiple jets or various interventions

Vena contracta area (3D) Better defined with TEE May be useful after edge-to-edge repair; likely a preferred method for CD quantitation but limited studies
available

Spectral Doppler
CW Doppler of MR jet

 Parabolic contour and soft density suggest mild MR Dense and triangular velocity waveform suggests significant MR

Pulmonary vein flow pattern

 Systolic flow reversal specific for severe MR
 Flow pattern influenced by multiple factors: LA pressure, LV filling pressure, atrial fibrillation
 Difficult to record with prosthetic mitral valves

Mitral inflow pattern Mitral E-wave dominance affected by multiple factors: increased MR severity, LV filling pressure, andrelative MV obstruction from implanted MV devices
 Mitral A-wave dominance suggests mild MR

Quantitative parameters
EROA and RVol by PISA

 Not recommended in the presence of MV devices, including edge-to-edge repair (not validated for multiple
jets, double orifice MV, or eccentric jets)

Volumetric RVol and RF

 Requires excellent LV endocardial definition to quantitate LV stroke volume; best used with 3D echo orcontrast echo so as not to underestimate LV stroke volume and hence RVol/RF Cannot use mitral annulus site for flow because of MV devices (except MV annuloplasty)
 Multiple measurements may compound errors
 Not accurate if >mild aortic regurgitation or VSD present

VSD, Ventricular septal defect.
Other abbreviations as stated earlier.

and spectral Doppler. Patients who have undergone a transcatheter
MV intervention should typically receive TTE one day, 30 days,and 6-12 months after the procedure. Additional TTE studies shouldbe performed sooner if clinically indicated. Echocardiograms on day 1
and 30 are primarily for assessing complications and acute results. The
study at 6-12 months is performed to determine primary effectivenessof the device, including favorable reverse remodeling of the LV and
LA (important indicators of MR reduction), and possible decreasein elevated pulmonary artery pressure. The post-procedure TTE is
more informative if comprehensive echocardiograms are performed
before, during, and immediately after the procedure and are available
for comparison. At the time of the follow-up TTE, it is important todocument any changes in medical therapy or clinical condition, measure blood pressure and heart rate, and assess cardiac rhythm to determine if the pre- and post-procedure studies are performed undersimilar clinical and hemodynamic conditions. Following reductionof MR, the precise timing of LV reverse remodeling is unclear, but it
appears that at 6 months, assessment with TTE is reasonable to determine if there has been a reduction in LV size; changes in LA size areless prominent.125,126
More data is available regarding MR assessment after edge-to-edge
repair than for the other MV procedures. With little information on
the assessment of MR severity after TMVR, most investigators haveassumed that evaluation of residual MR should be similar to thatused for surgical mitral prostheses.6 There is little data validating
MR assessment after any of the annuloplasty procedures. However,since these procedures result in a valve similar to a native MV witha surgical ring annuloplasty, assessment of residual MR would be
similar to native MR.7 Lastly, evaluation of residual MR after PVR
closure has similar complexities and limitations as after TMVR
because of the presence of the prosthetic MV and shadowing of the
Doppler signal. Defining PVR often requires TEE, especially if the regurgitant orifice is small or eccentric. Thus, if there is clinical suspicionof PVR because of a systolic murmur, hemolysis, or congestive heart
failure, a TEE, preferably with 3D capability, should be performed.
The following details all echocardiographic parameters used in theevaluation of residual MR severity after MV interventions, along withpertinent issues with the TTE approach (Table 6). Table 7 summarizes
all Doppler and echocardiographic parameters used in assessing
severity of residual MR with either TTE or TEE, as these approaches
are complementary in evaluating post-procedural MR.
1. Color Doppler Imaging. General consideration: CD is essential
in detecting residual MR after MV interventions and identifying
several characteristics of the regurgitation (number of jets, site, direction, eccentricity). It is important to identify the three components of
the MR jet (flow convergence, vena contracta, and jet area in the LA),
using traditional parasternal long-axis, apical, and off-angle views;

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Table 7 Echocardiographic and Doppler parameters for grading MR severity by TEE or TTE after transcatheter MV interventions*Parameter

Mild

Moderate

SevereStructural
Morphology

Device appropriately
positioned/expected or
normal valve motion

No specific criteria

Abnormal device position/flailvalve (single leaflet
detachment, dehiscence,
incomplete TMVR
expansion etc.)

LA and LV volumes

Reduction in size frombaseline or normalization

Minimal change

Enlarged with no change/
worsening from baseline,
particularly in primary MR

Color Doppler jet (size,
number, eccentricity)

One or two small, narrow jets

More than mild but does notmeet severe criteria

Large central jet/multiple jets/
eccentric jet(s) of any size
wrapping around LA

Flow convergence size†

None or smallIntermediate

Large

Mitral inflow pattern

A-wave dominant

No specific criteria

No specific criteria

Pulmonary vein flow
pattern‡

NormalBlunted systolic flow

Systolic flow reversal

CW Doppler of MR jet(density, contour)

Faint, parabolic contour

No specific criteria

Dense, triangular contour

Single jet with VCW #0.3

Single jet with VCW 0.4-0.6

Any jet with VCW $0.7 or $2
moderate jets

Vena contracta area by 3D
planimetry (cm2)§

Single jet with VCA <0.2

Single jet with VCA 0.2-0.39

Any jet with VCA $0.4 or $2
moderate jets

EROA by PISA (cm2)<0.2
Not recommended after edge
to- edge repair or in PVR

0.2-0.39
Not recommended after edgeto-edge repair or in PVR$0.4
Not recommended after edgeto-edge repair or in PVR

Regurgitant volume (mL)<30

30-59k$60k (May be lower in low flow
states)Regurgitant fraction (%)

<30%

30-49

$50%

Qualitative

Semi-quantitative
Vena contracta width (cm)
Quantitative

CW, continuous-wave; EROA, effective regurgitant orifice area; LA, left atrium; LV, left ventricle; MR, mitral regurgitation; PISA, proximal isovelocity
surface area; PVR, paravalvular regurgitation; TMVR, transcatheter mitral valve replacement; VCA, vena contracta area; VCW, vena contracta
width.
*All parameters have limitations and an integrated approach must be used that weighs the strength of each echocardiographic measurement. Allsigns and measures should be interpreted in an individualized manner that accounts for body size, hemodynamics, and other patient characteristics.
†
Flow convergence is usually small with a PISA radius #0.3 cm and large with a radius $1 cm at a Nyquist limit 25-40 cm/s.
‡
Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure).
§by Color Doppler; further validation is needed.
k
Total stroke volume (inclusive of the RVol) is calculated from LV volumes. Use of 3D echocardiography and preferably contrast echocardiography
is recommended to avoid underestimation of LV volumes, RVol, and RF.

parasternal short-axis views at the level of the valve may identify the
number of residual jets. Despite all these manipulations, the 3 components may not be seen in the same plane. It is also important toacknowledge three areas of challenge for CD in assessing MR severity
after MV interventions:1) There is frequently more than one MR jet;2) MR jets are often eccentric and wall-hugging, and may crisscross;3) A variable degree of shadowing of MR jets occurs, depending on the procedure/MV structure, is worse in the presence of a prosthetic MV (e.g., TMVR
and repair of PVR), and occurs to the least extent with MV annuloplasty.

Nonetheless, CD is useful as a first-line approach to identify andlocalize the site or origin of MR jet(s). In general, small thin jets withno or little flow convergence denote mild MR (Figure 15); large jets
or eccentric jets that track along the LA wall to the pulmonary veinswith a large VC or proximal flow convergence are typically severe.
CD should always be coupled with other supportive PWD and
CWD parameters of MR, using an integrative approach, particularly
when limitations with CD are suspected (Figure 16).7 If there is suspicion for significant residual MR, further evaluation is needed withother parameters and/or TEE with 3D capabilities. The utility of 3D
CD to assess MR severity has been reported but is not yet fully validated.99
Vena contracta: There is a paucity of data on vena contracta widthand area in evaluating severity of residual MR after MV interventions.
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Figure 15 Echocardiographic features of mild residual MR after edge-to-edge mitral valve repair. The MR jet is narrow, small, and of
low velocity (minimal aliasing), with a small VC and no flow convergence. Pulmonary venous flow shows normal systolic dominance.
There is A-wave dominance of mitral inflow and the CWD recording of the MR jet has a faint spectral display with a parabolic profile.
within the native valve after annuloplasty, provided that the origin of
the MR jet is well identified in a zoomed view and preferably in an
imaging plane in the axial resolution of ultrasound, thus optimizing
resultant measurement accuracy.6 There is controversy as to whether
to add VCW of multiple jets, or ignore the very small ones (VCW
#2 mm). MR is severe in the presence of a single jet with a VCW$0.7 cm, as well as two or more moderate (VCW 0.4-0.6 cm) jets.
3D TEE allows measurement of VCA, although data with thisparameter is still scant. Altiok et al.99 measured VCA with 3D TEEafter MitraClip placement and found that patients with improved
NYHA functional class at 6 months had a greater reduction in
VCA when compared to patients without improvement.
Moreover, they found that the reduction in LA and LV volumes
were significantly greater in patients who had more than a 50%
reduction in VCA after repair. 3D TEE has the unique advantage
of allowing for the analysis of MR severity from each orifice of the
double-orifice mitral valve after edge-to-edge repair. There is lessexperience with VCA in other residual MR conditions, but it is expected that such measurements would also be applicable, given
good quality of the acquired data. The proposed thresholds for
MR severity using VCA are detailed in Table 7; with increasing experience in mitral interventions and 3D TEE, further validation andrefinement will be forthcoming.
Flow convergence: PISA has been traditionally used to assess theseverity of native or prosthetic MR in conjunction with TTE and

TEE. These same parameters should in principle also apply to other
MV procedures. For central jets and at a Nyquist limit of 3040 cm/s, mild MR is associated with a minimal flow-convergenceradius of #0.3 cm, and severe MR is characterized by a large flowconvergence radius of $ 1 cm. After edge-to-edge device implantation, flow convergence can be used qualitatively, however PISA is
unsuitable for MR quantification due to multiple MR jets or because
the clip may obscure the flow-convergence zone or truncate it, making angle correction necessary and difficult. Similar limitations may bepresent with the other prosthetic MV repair devices/replacement, andthere are little data on these newer devices.
2. CW Doppler of MR Jet. Density of the spectral display of the
MR jet relates to the severity of MR. A soft parabolic MR waveform
is consistent with mild MR (Figure 15). However, a dense velocity
waveform is associated with greater severity, but cannot differentiate
moderate from severe MR (Figure 16). An early peaking, triangular
waveform contour denotes a large regurgitant pressure wave in the
LA and significant MR. If early-peaking of the MR jet is present prior
to the procedure, the contour of the MR velocity waveform changes
from early-peaking to parabolic, with reduction in MR severity.
Occasionally a bimodal, early and late systolic flow pattern of MR isseen. When severe MR persists after the procedure, the MR CWD
signal is holosystolic, dense, with similar density to the mitral inflow
Doppler signal.

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Zoghbi et al 459

Figure 16 An example of significant residual MR after edge-to-edge mitral valve repair. The severity from the above views is likely
moderate but would need to be substantiated further with either quantitative LV volumes/Doppler (see example in Figure 17), TEE
or CMR. The color Doppler jet is aliased and large in the left atrium; however’ flow convergence is not prominent. There is aliased
systolic flow reversal in the pulmonary vein but this may be contaminated with the MR jet being directed into the interrogated pulmonary vein. Mitral E wave-dominance is sensitive but not specific for significant MR as it is load dependent and also related to the residual valve area after repair. The CWD velocity waveform is of moderate density and still parabolic.
3. Mitral Inflow Pattern and Pressure Gradient. After edge-toedge MV repair, TMVR, annuloplasty ring insertion, or catheter-based
plugging of paravalvular leaks, the mitral inflow velocity pattern is assessed using CWD to determine the peak mitral E velocity, its deceleration rate, and the mean mitral pressure gradient. The heart rateshould be noted. Anatomic assessment of mitral valve openings afteredge-to-edge repair or residual paravalvular leaks is best assessed with
3D TEE.124 After edge-to-edge repair, a mean mitral valve gradient of<5 mm Hg at a normal heart rate is considered acceptable. An
elevated pressure gradient in the presence of a large valve opening
may be an important clue to the presence of significant MR. A change
from an E-wave-dominant mitral inflow pattern at baseline to an
A-wave-dominant pattern after the intervention is indicative of significant reduction in MR and non-severe residual MR, provided the patient is in sinus rhythm. In contrast, a mitral E-dominant inflow pattern
is not diagnostic of significant MR, as it is influenced by many factors,
including the new relative valve stenosis after the MV intervention,and LV filling pressures (Figures 15 and 16). On the other hand, anincrease in mitral E velocity and velocity-time integral with a decrease
in LVOT velocity over time may indicate worsening severity of MR.
4. Pulmonary Vein Flow Pattern. Pulmonary venous flow velocities can be a useful indicator of LA pressure and MR severity.
Improvement in or normalization of systolic pulmonary vein flow

strongly suggests that MR has been reduced (Figures 11 and 14).
Diastolic dominance may persist if MR is still significant, or in thepresence of elevated LV diastolic pressure or atrial fibrillation.127
With worsening of MR, pulmonary vein systolic flow reversal may
develop.
5. Pulmonary Artery Systolic Pressure. Pulmonary artery systolic pressure (PASP) is an adjunctive measurement because it may
be normal or elevated at rest in patients with moderate-to-severe
MR; elevated PASP may also be due to intrinsic pulmonary vasculardisease rather than MR. In one study, the PASP fell from 36 6 4 to
29 6 7 mm Hg after MitraClip placement.128 The fall in PASP wasprimarily seen in patients with elevated values at baseline.123
6. Regurgitant Volume and Fraction. Evaluation of RVol and RF
by volumetric echo/Doppler is a useful method to assess MR postintervention. This is feasible unless more than mild AR or a significant
ventricular septal defect is present. Because MV anatomy is usuallyabnormal after MV percutaneous interventions (edge-to-edge repair,
prosthetic valve), determination of stroke volume with PWD at the
MV annulus is not feasible. Thus, total LV stroke volume is determinedfrom the difference between LV end-diastolic and end-systolic volumes from TTE apical images. It is preferable to use 3D or contrast
echo so as not to underestimate LV volumes and thus stroke volume

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Figure 17 Quantification of mitral regurgitation using a combination of total LV stroke volume (from contrast-enhanced bi-plane LV
volume measurements) and LVOT stroke volume (from diameter and velocity measurements). (A) Apical two-chamber view shows
two jets of MR and the MitraClip; (B) Apical four-chamber contrast-enhanced image; (C) Apical two-chamber contrast-enhanced image; (D) LVOT diameter measurement, (E) LVOT pulsed-wave Doppler velocity waveform.
and RVol (Figure 17).6 Systemic stroke volume is most often estimated with PWD at the LVOT.6 Foster et al.127 analyzed the RVol
and RF before and after MitraClip placement and demonstrated
that RVol fell from 50.3 6 21.5 mL at baseline to 27.5 6 18.6 mL(P < .0001). RF also fell from 44.6 6 13.6 % to 28.9 6 15.3 %(P < .0001) at 6 months. Hamilton-Craig et al.129 compared
Doppler echocardiography and CMR grading of MR severity in patients after MitraClip placement. RF by Doppler quantification exhibited significantly better reproducibility than expert readers’subjective assessment. CMR quantitation demonstrated excellent
reproducibility. Altiok et al.99 showed that during TEE, 3D quantitation of mitral RVol before and after MitraClip placement have lower
intra-and inter-observer variability as compared to 2D techniques.
Lastly, the ratio of velocity-time integral of mitral inflow to LV
outflow (VTIMV/VTILVOT) has been used in prosthetic mitral valves
to assess function of the prosthesis and detect MR.6 An elevated
VTIMV/VTILVOT ratio (>2.2 in mechanical bileaflet valves; > 2.3 inbioprosthetic pericardial; > 2.6 in porcine valves) suggests significant
MR in the presence of a normal pressure half-time.6,130 Conceptually,
this ratio could be used after TMVR and catheter-based plugging of
PVR of prosthetic mitral valves. However, a cut-off value has notbeen validated for TMVR and requires further study.
7. An Integrative Approach to Assessing Residual
MR. Similar to all valvular regurgitation, an integrative approachis needed in the overall evaluation of residual MR after interventions on the MV. Table 7 lists the various parameters that may be
helpful in this evaluation and Figure 18 provides an algorithm using
these parameters to help facilitate the overall assessment of residual
MR. These suggestions are based on clinical expert opinion, available data, and a consensus of the Writing Group members. All patients should have blood pressure, heart rhythm and rate, andmedications (e.g., pressors, inotropes, vasodilators) recorded at
the time of study, as these may influence MR severity. These parameters are predominantly based on recent guidelines pertaining

to native valve regurgitation7 but with several modifications. These
recommendations have not been extensively validated and further
studies are needed to test and refine these criteria singularly and incombination.
As stated, MR grading may be difficult due to the complexity of its
mechanisms after MV repair or replacement, the frequent multiple
eccentric jets of variable size, shadowing from devices, mitral annular
calcium, or the hemodynamic conditions that may affect some ofthese parameters. For these reasons and because of the errors
involved in quantitation, a three-grade system is proposed (mild,moderate, and severe). Nevertheless, if the preponderance of thedata favors mild or severe regurgitation, the assessment is most likely
accurate and further quantitation may not be needed, at least for themild lesions. However, if the data are of suboptimal quality andpossibly conflicting, quantitation is advised; if not possible, additional
evaluation with TEE or CMR should be undertaken.
8. Role of CMR in the Evaluation of Residual MR after Percutaneous MV Interventions. CMR has a role in the evaluation andquantitation of residual or paravalvular MR after MV interventions.
However, since there are currently no published data on the use of
CMR in this clinical setting, potential approaches for quantification
are extrapolated from the literature of native MR or surgical prosthesis.131,132 Furthermore, it is essential to first ensure that the
implanted device is CMR-safe prior to performing the study.
a. Evaluation of Residual MR.–Qualitative assessment of regurgitation based on SSFP cine images may not be reliable in the presence of
implanted valves, clips, or annuloplasty rings due to susceptibility artifacts from the valve frame, ring, or clip itself (Figure 19). In addition,
the atypical regurgitant patterns due to valve flange/skirt from TMVR
may make visual assessment of regurgitation challenging. The use ofphase-contrast imaging with through-plane phase-encoding may provide better visual assessment of the regurgitation as opposed to SSFP
cine images; this however remains to be studied.

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Residual Mitral Regurgitation after Percutaneous MV Repair or Replacement

Yes, mild*

Does MR meet specific criteria for
mild or severe MR?

Yes, severe**

Specific Criteria for Mild MR• Small, narrow central jet• VCW ≤ 0.3 cm• VCA < 0.2 cm• No or small flow convergence• Mitral A wave dominant inflow• Soft or incomplete jet by CW Doppler

Intermediate values:
MR probably moderate
2-3
criteria**
Perform quantitative methods whenever possible≥4 Criteria
Definitely mild
RVol < 30 mL
RF < 30%**EROA < 0.2 cm2

2-3
criteria

Specific Criteria for Severe MR• Abnormal device morphology/flail leaflet• VCW ≥ 0.7 cm or ≥ 2 moderate jets
• VCA ≥ 0.4 cm or ≥ 2 moderate jets
• Large flow convergence• Central large jet > 50% of LA area
• Pulmonary vein systolic flow reversal

RVol ≥ 60 mL¶
RF ≥ 50%**EROA ≥ 0.4 cm 2

RVol 30-59 mL
RF 30-49%**EROA 0.2-0.39 cm2≥4 Criteria
Definitely severe

3 specific criteria
for severe MR

Mild
MR

•
•

Moderate
MR

Poor TTE quality or low confidence in measured Doppler parameters
Discordant quantitative and qualitative parameters and/or clinical data

SevereMR

Indeterminate MR
Consider further testing:

TEE or CMR for quantitation*

Beware of underesƟmaƟon of MR severity in eccentric, wall impinging jets**

EROA by PISA: not recommended aŌer edge-to-edge valve repair or in PVR; assumes holosystolic MR; single frame EROA by PISA,
VCW, and VCA overesƟmate non-holosystolic MR¶

Regurgitant volume cut-offs for severe MR may be lower in low flow conditions.

Figure 18 Suggested algorithm to guide implementation of integration of multiple parameters of MR severity after mitral valve percutaneous interventions. Good-quality echocardiographic imaging and complete data acquisition are assumed. If imaging is technicallydifficult, consider TEE or CMR. MR severity may be indeterminate due to poor image quality, technical issues with data, internal
inconsistency among echo findings, or discordance with clinical findings.

Figure 19 Quantitation of mitral regurgitant volume and regurgitant fraction with CMR in a patient after edge-to-edge mitral valve
repair. The ‘‘indirect’’ method is used: total LV stroke volume is calculated from LV end-diastolic volume (LVEDV) and end-systolicvolume (LVESV) using a short axis stack of the LV (A and B). The susceptibility artifact from the MitraClip is shown by the arrow inpanel A. Forward stroke volume is derived from phase-contrast flow through the aortic valve (C: flow curve; D and E depict in red
the regions of anatomic and phase-contrast flow in the aorta, respectively).

462 Zoghbi et al

Quantitative assessment of residual mitral RVol and RF133-141 may be
useful in the context of percutaneous MV interventions.129 Available
CMR techniques can be divided into direct and indirect methods, whichhave been discussed in detail.7 The direct method uses short-axis phasecontrast imaging with through-plane velocity encoding to measure RVol
directly.133 The use of this direct technique is less feasible in the case of
percutaneous annuloplasty ring implantation and edge-to-edge
repair,129 and is limited in the setting of TMVR or post-paravalvularleak closure due to significant susceptibility artifacts. Indirect techniques
are likely more appropriate for the quantification of MR. This includes
calculation of RVol using: (1) the difference between LV stroke volumeusing planimetry of short-axis cine images and aortic stroke volume obtained by phase-contrast images (Figure 19)135-137; and (2) the
difference in left and right ventricular stroke volumes by endocardial
contouring of left and right ventricular cine images.133,138-140 The
regurgitant fraction can be calculated by dividing the RVol by the LV
stroke volume. Careful attention to the basal LV slice is important incalculating LV volumes as this slice is most likely to be affected bysusceptibility artifact from the implanted device (Figure 19). If susceptibility artifact significantly affects the delineation of endocardial borders,then LV volume, RVol, and RF measurements will be less reliable, andthis should be stated in the report.
Currently there are no published data validating partition values of
RVol or RF by CMR to classify patients into degrees of MR severity inthe context of percutaneous MV intervention. Previous data suggested grading MR using the following RF values: Mild #15%, moderate 16-25%, moderate-to-severe 26-48%, and severe >48%;95
clinical outcome was differentiated at a cut-off of 40%.142 Morerecently, the partition values used with echocardiography were suggested as appropriate thresholds with CMR to grade MR severity.7,143
It is the consensus of the Writing Group that these partitions for MR
severity also be used for both echocardiography and CMR after
percutaneous MV interventions, until further data are available
specific to the population of percutaneous MV interventions (Table 7).
b. LV and LA Reverse Remodeling.–CMR can also have a role in assessing reverse remodeling of the LVor LA after percutaneous MV interventions.144,145 LV volumes and function are measured using a stack of
SSFP short-axis cine images based on existing recommendations.146,147
As stated earlier, careful attention to the basal slice is important as it is
the most affected by susceptibility artifact, which would affectmeasurements of LV volumes and LVEF. All measurements should beindexed to body surface area.143,148-151 Similarly, accurate
measurement of LA volumes would require acquisition of multiple
cine planes through the LA, allowing quantification withoutgeometrical assumptions.152 Since this will require additional dedicatedimaging and analysis, it can be time intensive. Left atrial area and dimension based on standard two- and four-chamber cine images indexed tobody surface area can also be used to assess atrial remodeling.151,152
c. When is CMR Indicated?.–The primary indication for CMR in theassessment of residual MR or paravalvular MR after percutaneous MV
intervention is when Doppler echocardiographic assessment is unsatisfactory or inconsistent with the clinical findings. Another potential roleof CMR is in determining the physiologic consequences of MR on the
LVand LA, with more accurate and reproducible measurements of volumes and ejection fraction. The major limitations in using CMR for
regurgitation quantification include: 1) CMR compatibility of the implanted device, 2) susceptibility artifacts, 3) underlying arrhythmia inpatients undergoing these procedures and, 4) lack of validated partition
values specific for CMR to grade severity of the regurgitation. It is

Journal of the American Society of Echocardiography
April 2019

important to note that while the use of gadolinium contrast is contraindicated in patients with significant renal dysfunction, quantitation ofvalve regurgitation can still be performed in these patients as phasecontrast and SSFP cine images do not need contrast administration.

Key Points
Assessment of residual MR after percutaneous MV
interventions
 Imaging after MV interventions includes careful evaluation ofdevice integrity, position, stability, and interaction with adjacent structures.
 Color Doppler is the first-line method to assess residual MR
with TTE. It is reliable for excluding or detecting mild MR.
For more severe lesions, color Doppler assessment of MR
severity with TTE is challenging due to interaction of the device or adjacent structures with the MR jets, and the frequent
presence of multiple MR jets, often crisscrossing and indifferent planes.
 Evaluation of residual MR requires careful integration of multiple parameters, as no single parameter is sufficiently accurate to assess MR severity. These parameters include
assessment of color Doppler components of MR jets (flowconvergence, VC, jet area and direction), regurgitant volume
by volumetric methods, mitral inflow pattern, pulmonary vein
flow pattern, CWD jet density and contour, and forward
stroke volume [(LVOT or right ventricular outflow tract(RVOT)]. The PISA method for MR quantitation is notadvised after edge-to-edge MV repair or in paravalvular regurgitation.
 It is important to compare post-procedural parameters to preprocedural baseline images, which can help evaluate thechange in MR severity and reverse remodeling of the LV orLA.
 When more than mild MR is suspected, but the data areuncertain, this should be communicated so that further
imaging with either TEE or CMR is performed.
 CMR offers the advantage of quantitation of mitral regurgitant volume and fraction, comparing total LV stroke volume
to systemic stroke volume in the aorta by phase contrast orderived from the right heart. Depending on the MV device,a variable amount of artifact around the device is seen.

V. PERCUTANEOUS PULMONARY VALVE REPLACEMENT
Initial repair of tetralogy of Fallot often involves surgical disruption of
the pulmonary valve with resultant pulmonary regurgitation (PR). In
addition to patients with tetralogy, several other forms of congenital
heart disease require placement of a right ventricle-to-pulmonary artery (RV-PA) conduit to establish reliable pulmonary blood flow, suchas truncus arteriosus, pulmonary atresia with ventricular septal defect,and some forms of double-outlet right ventricle (RV). Over time,
dysfunction of the native RVOTor RV-PA conduit leads to varying degrees of stenosis and regurgitation. Progressive pulmonary insufficiency with resultant RV dilation and dysfunction has been shownto lead to decreased exercise tolerance, increased arrhythmia burden,and sudden cardiac death.153,154 In these patients, specific criteria for
re-intervention are used to guide placement of a competent pulmonary valve including moderate to severe pulmonary valve/RV-PAJournal of the American Society of Echocardiography
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conduit regurgitation in combination with clinical symptoms, severe
RV dilatation, and depressed RV function.155-160 Traditionally,
surgical pulmonary valve replacement was undertaken, but overthe last 15 years, transcatheter techniques for pulmonary valve
replacement have become widely available.
The Melody valve (Medtronic Inc., Minneapolis, MN) and the
Edwards SAPIEN XT valve (Edwards Lifesciences, Irvine, CA) are
the only FDA-approved valves for transcatheter pulmonary valve
replacement (TPVR) in the United States.161-163 To date, more than6000 patients worldwide have received TPVR for a variety ofunderlying congenital heart abnormalities.164 Currently, TPVR isonly USFDA-approved for placement of a competent valve within
an RV-PA conduit, although trials are now underway assessing devices
designed for native outflow tracts in these patients.165,166 As an
adjunct to this therapy, some centers also perform bare-metal stentingof a native outflow tract to serve as a conduit, and then implant atranscatheter pulmonary valve within the stent.167
A. Description of TPVR and Assessment of Acute Results
Prior to implantation, CMR or MDCT imaging allows 3D multiplanarreconstruction and provides accurate delineation of anatomy, size,and geometry of the RVOT and pulmonary arteries (with orwithout an existing RV-PA conduit or bioprosthetic valve).168 This information is crucial in pre-procedural assessment for TPVR, as certain
anatomic criteria must be met before valve implantation.162,163,169
Ensuring that the outflow tract/conduit is of an appropriate size toaccept a TPVR valve (not too small or too large) and that there isan appropriate ‘‘landing zone’’ to seat the valve are both critical.
Delineation of the coronary artery course is also essential prior to
any RVOT intervention, as a subset of these patients have acoronary branch crossing the RVOT, which may complicate theinterventions.170-173 Additionally, for some patients the left anterior
descending coronary artery and conal branches arise normally, but
lie directly posterior/inferior to the RVOT in the area of proposed
valve deployment. In these cases, coronary compression from valve
expansion is a rare but potentially catastrophic complication.
TPVR is performed via femoral or jugular venous access. The
currently available valve platforms require large delivery systems(up to 22 French in size), which are relatively rigid, making navigation
through the right-sided heart chambers occasionally challenging,particularly in smaller children. Presently, there are two available platforms that can be used for TPVR in the United States. In addition to
the Melody valve, the Edwards SAPIEN valve has been successfully
used in the pulmonary position during the multicenter
COMPASSION trial,174 and also received FDA approval. As opposed
to aortic and mitral valve interventions, TPVR is primarily guided byfluoroscopy rather than echocardiographic imaging. Due to the anterior location of the pulmonary valve, both TEE and TTE guidance
have proven less helpful than in TAVR. Recently, rotational angiography with acquisition of MDCT-like 3D volume imaging or fusion
with pre-existing MDCT images is gaining popularity for intraprocedure guidance and may improve accuracy in sizing and positioning. Acute valve performance is primarily evaluated by cathetermeasured pressure gradients and pulmonary angiography, althoughsome operators use intracardiac echocardiography as well.175,176
B. Evaluation of Residual Regurgitation Outside theCatheterization Laboratory
To date, TPVR has proven to be very successful at reducing PR acutely
and over the medium term. In the most recent update for the US

Zoghbi et al 463

Melody Valve Investigational Device Exemption Trial, among the
113 patients who were alive and free from re-intervention at
medium-term follow up (average 4.5 years), 97 had no or minimal
PR, 15 had mild, and only 1 had moderate PR.161
1. Assessment of Pulmonary Regurgitation after TPVR with
Echocardiography. Compared to the evaluation of percutaneous aortic and MV interventions, there is a paucity of consensus
and recommendations regarding the echocardiographic evaluationof patients after TPVR.126 Evaluation of PR by TTE most commonly
utilizes a combination of techniques, including color and spectral
Doppler interrogation of the RVOT/conduit and the main andbranch pulmonary arteries, extrapolating traditional assessment of
PR in native valves.7,177 In the US Melody Valve Investigational
Device Exemption Trial,178 PR was graded via a composite scale
based on the width of the regurgitant jet by CD in relation to either
the conduit or pulmonary annulus diameter (Figure 20) as well as
the extent of diastolic flow reversal in the pulmonary artery(Table 8). For this trial, both pre- and post-TPVR studies were assigned a PR value corresponding with the greater value between
PR jet width and extent of diastolic flow reversal. This technique,however, yielded only modest correlation with CMR-derived pulmonary RF,178 suggesting that TTE evaluation of PR in this patient
population remains challenging. It is important to note that in severe
PR with normal pulmonary artery pressures, the color jet can bedifficult to detect as the PR jet velocities are low and brief in duration due to rapid equalization of pulmonary and RV diastolic pressures. Though not validated in patients who have undergone TPVR,
additional Doppler indices have been reported for assessment ofseverity of PR. Rapid deceleration of the PR CW Doppler velocity
waveform with a pressure half-time of <100 ms has been shownto have good sensitivity and specificity for predicting severe PR(Figure 20).179,180 Pressure half-time, however, is also influenced
by the diastolic pressures in both the pulmonary arteries and theRV, such that a non-compliant RV with restrictive physiology will
demonstrate a shorter pressure half-time. Similarly, a period oftime in late diastole with no regurgitation indicates rapid equilibration of the RV and PA diastolic pressures, and in cases with severe
PR and poor RV compliance, there may in fact be antegrade flowin late diastole into the main PA.181 The density of the CWD signal
relates to severity of regurgitation but does not differentiate moderate from severe PR (Figure 20). Finally, flow convergence quantitative methods such as PISA, though theoretically applicable topulmonary valve assessment, are difficult to record in the presenceof prosthetic material and have not been validated for either native
or transcatheter pulmonary valves to date.182 However, flow
convergence can be used qualitatively in the evaluation of PR(Figure 20). The use of TEE in TPVR patients is not widely employed to assess severity of PR, as visualization of the RVOT andpulmonary valve replacement is limited.
2. Role of Computed Tomography in Pulmonic Regurgitation after TPVR. MDCT offers excellent spatial resolution andrapid acquisition times. However, the lack of flow data limits its utility
in assessing patients who have undergone TPVR for residual valve
regurgitation. MDCT can provide excellent assessment for stent fracture as well as delineation of the valve orientation and eccentricity index, which may be helpful in predicting valve dysfunction (Figure 21)
since stent and valve distortion have been shown to impact valvefunction.183-185 These factors may be important in TPVR,
particularly in patients with post-operative pectus deformities, as the464 Zoghbi et al

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Figure 20 Examples of patients with mild (left panels) and severe (right panels) pulmonary regurgitation (PR) after TPVR are shown.
The width of the color jet is depicted by the yellow arrows. Note also the difference in flow convergence (white arrows). Lower panels
show examples of CWD recordings of mild and severe PR. The density of the spectral Doppler waveform (faint versus dense, particularly in relation to systolic flow) and the slope of the decrease in velocity in diastole (long vs. short pressure half-time) are apparent.

Table 8 Echocardiographic and Doppler parameters useful in grading pulmonary regurgitation severity after TPVR
Parameter

Mild

Moderate

SevereJet width in relation to pulmonary
annulus or conduit (CD)*<20%

20-40%>40%

Site of diastolic flow reversal in
PA/conduit (PWD)

Proximal half of the main PA/
conduitDistal main PA/conduit

Extends into PA branches

PR velocity waveform density andcontour (CWD)

Soft

Dense; early termination ofdiastolic flow possible(depending on RV compliance)

Dense; early termination ofdiastolic flow<100 ms†

PR pressure half-time (CWD)‡

Regurgitant fraction<20%

20-40%>40%

CD, Color Doppler; CWD, continuous-wave Doppler; PA, pulmonary artery; PR, pulmonary regurgitation; PWD, pulsed wave Doppler; RV, rightventricle.
*At a Nyquist limit of 50-60 cm/s.
†
Not reliable in the presence of high RV end-diastolic pressure.
‡
Regurgitant fraction data primarily derived from CMR with limited application with echocardiography.

position of the RVOT often lies directly posterior to the sternum.
Additionally, with retrospective electrocardiographic gating, multiphase MDCT imaging can provide functional imaging to calculate
ventricular volumes. In the absence of other concomitant valve regurgitation, comparison of the right and left ventricular stroke volumes

can provide an estimate of pulmonary RVol and RF with reasonable
correlation to values obtained by CMR.186 This, however, comes atthe cost of increased radiation exposure and may only be indicatedin the context of non-diagnostic echocardiography and contraindications to CMR.

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Zoghbi et al 465

Figure 21 Value of CT angiography in evaluating the mechanism of significant PR after TPVR. Longitudinal and cross-sectional images of a fractured RVOT stent are depicted, showing discontinuity of the stent circumference (red dotted line) and collapse of thefractured stent into the vessel lumen.

Figure 22 CMR phase-contrast analysis of a patient with severe pulmonary regurgitation, as demonstrated on the flow curve. Quantitation shows a regurgitant fraction of 63%. The left panel shows the stent artifact usually seen with CMR. The dashed lines depict theplane where phase-contrast data are obtained for flow quantitation, to avoid the artifact.
3. Role of CMR in Pulmonary Regurgitation after
TPVR. CMR imaging allows quantification of PR and assessment of
its hemodynamic effects. The methods have been described in detailfor native valves.7 For patients who have undergone TPVR, this canbe done similarly, either directly through flow quantitation in themain PA (Figure 22) or indirectly by several methods, including calculating the differences between right and left ventricular stroke volumes,
as described earlier and for native PR.187 With isolated PR (assuming noother valve regurgitation and no intracardiac shunts), the difference instroke volumes between the ventricles reflects the RVol.
As is the case for other valve replacement, a significant challenge inthis patient population are the imaging artifacts imposed by pre-stenting
the RV-PA conduit prior to insertion of the valve. These stents create
susceptibility artifacts throughout their length, limiting CMR’s ability
to fully visualize the RVOTand measure phase-contrast stroke volumes
within the conduit itself (Figure 22). In the COMPASSION Trial, only
50% of the initial cohort had complete, interpretable ventricular volumes and phase-contrast data on post-intervention CMR,174 althoughother centers have reported more consistent results with placement of
the phase-contrast imaging plane more distal (or proximal) to the stentartifact (Figure 22).187 In the context of stent artifacts, indirect techniques may be of greater value to quantify regurgitation.
C. Integrative Approach to Assessing Residual Pulmonic
Regurgitation after TPVR
TTE is the first-line imaging modality after TPVR to assess prosthetic
valve function, the presence and severity of any residual PR, changes
in right heart size and function, and PA pressure. If color and spectral
Doppler demonstrate no evidence of PR or mild PR, no further imaging is needed. If PR is suspected to be moderate, severe, or indeterminate, CMR is indicated for further quantitation of the regurgitation,and right heart size and function. MDCT, TEE, and catheterization
are reserved for patient-specific situations to assess the mechanismof valve dysfunction and/or associated hemodynamics.
There are presently no consensus guidelines for the timing ofroutine follow-up of patients after TPVR. The trials to date have

466 Zoghbi et al

performed TTE evaluations at discharge, 1 month, 3 or 6 months,
1 year, and then annually thereafter, with a follow-up CMR at
6 months.174 In clinical practice many centers roughly follow theseearly imaging recommendations, but often forego the 3-month TTE
and perform the first post-implant CMR either 6 months or one
year after TPVR. Follow-up after 1 year post-implant is based predominantly on TTE, but most centers apply the more generalized multimodality imaging guidelines for tetralogy of Fallot,155-160 which
encompass the majority of patients with TPVR, for mid- and longterm follow up. Routine follow-up for asymptomatic patients usually
includes TTE every 1-2 years and CMR every 3 years.

Key Points
Assessment of residual PR after pulmonic valve
interventions
 Pulmonary regurgitation (PR), when greater than mild inseverity, occurs most frequently in patients with palliated or
repaired congenital heart disease.
 Experience with grading and, in particular, with quantificationof PR after transcatheter pulmonary valve replacement(TPVR) is limited.
 Similar to recommendations for native PR, a combination of
Doppler and 2D echocardiographic parameters are needed
to grade PR severity. When multiple parameters agree, PR
grade can be determined with a high degree of certainty(occurring most often with mild or severe regurgitation).
 Jet width, extent of diastolic flow reversal, pressure half-time,
PR duration, and regurgitant velocity waveform density alllend insight into the severity of regurgitation.
 Reverse remodeling of RV volume after intervention should
be considered over time as it does not occur immediately after TPVR.
 MDCT plays a role, particularly in assessing valve positionand orientation, as well as in evaluating stent fracture. Cardiac
CT can be used to quantify pulmonary insufficiency by comparison of ventricular stroke volumes with retrospective
gating; this comes at the cost of increased radiation dose.
 CMR provides good quantification of RV volumes and regurgitant fraction. CMR imaging in this patient group is impaired,however, by susceptibility artifact from the TPVR, as well asfrom any bare metal stents that may be in the RVOT.

VI. PERCUTANEOUS TRICUSPID VALVE INTERVENTIONSInterest in the tricuspid valve (TV) has increased in recent years withthe recognition of the impact of secondary TR on outcomes.188-191 A
number of approaches and devices to address symptomatic severe TR
are in early development stage or trials.192 None however, as of thedate of this publication, have received FDA approval for this clinicalindication. Tricuspid repair devices currently under investigation canbe generally divided into those targeting coaptation of the leafletswith edge-to-edge repair and those treating annular dilatation.
Individualized valve-in-valve and valve-in-ring procedures are also
performed, off-label, in patients who previously underwent TV surgery. TV replacement devices are still in very early stages of development. Since catheter-based intervention on the TV is still an evolving
field, a brief overview is presented along with challenges and proposals to the assessment of residual TR.

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A. Tricuspid Valve Repair and Annuloplasty
TV repair with the edge-to-edge approach has been recently used totreat severe TR. As stated, this technique is not approved in the US fortreatment of TR. A recent registry of 64 cases performed in Europe
showed feasibility, an effective reduction in various parameters of
TR severity, and an improvement in functional status.192 Vismara
et al. developed an ex vivo model of functional TR and showedthat grasping the septal and anterior leaflets allowed for the best
post-procedural outcome.193 In the registry, the most common location of implanted clips was anteroseptal (78%). Although technicalsuccess was high (97%) and reduction in at least 1 grade of TR wasseen in 91% of patients, 13% of patients had residual severe TR.
In the setting of functional TR, the annulus dilates laterally. The
most common surgical tricuspid repair is a ring annuloplasty.194
Numerous transcatheter tricuspid annular repair devices are currently
being investigated, attempting either to reduce the size of the annulus
or to replicate the results of the Kay bicuspidization surgical procedure.195 Practically, all these interventions rely significantly on echocardiography for device placement and assessment of results.196
B. Assessment of Residual TR after Tricuspid Valve
Interventions
The assessment of native TR with echocardiography relies predominantly on TTE, using an integration of information from qualitativeand semi-quantitative parameters of color and spectral Doppler.7
These include CD evaluation of flow convergence, VC size, and jet
behavior/extent in the right atrium, spectral density and contour of
the regurgitant velocity waveform by CWD, and assessment of hepatic flow pattern by PWD. Patients undergoing TV interventions to
reduce severe TR present particular challenges, at least at thisjuncture:
1- Lack of well-validated quantitative parameters of TR severity.
Evaluation of TR has been traditionally less quantitative than otherregurgitant lesions. EROA, RVol, and RF by echocardiography are
rarely performed, partly because of technical challenges of quantitation of EROA, RV volumes, or Doppler flow through the TV
annulus.
2- Wide range of severe TR. Patients with severe TR are intervened
upon currently late in their course, usually when edema and ascites become unresponsive to diuretics. Thus, patients undergoing
percutaneous procedures frequently have a markedly dilated
valve annulus, right atrium, RV, as well as RV dysfunction. In thesepatients, the regurgitant orifice can be exceedingly large, 3-4 times
the cut-off for severe TR, with obvious non-coaptation of the valve
leaflets. In contrast to MR, this wide-open TR is compatible withlife. Thus the range within the severe TR category can be very
wide, prompting a proposal to extend the current ASE guidelines
severity scheme7 to include grades of ‘‘massive’’ and ‘‘torrential’’TR using both semi-quantitative and quantitative methods.197
This is for the purpose of recording the change in TR following device therapy, as patients may benefit from reduction in TR severity,
although residual TR may still be in the moderate or severe range.
The clinical significance of this approach and its impact on
outcome however, still needs to be evaluated.
3- The type of intervention on the TV may complicate the assessment of residual TR. Challenges of CD evaluation are more likely
after edge-to-edge repair, similar to the mitral valve, where multiple jets can be seen, going in different directions. The flowconvergence method in these situations is difficult to apply

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Table 9 Proposed grading of the severity of residual tricuspid regurgitation by echocardiography after tricuspid valve
interventions
Parameters

Mild

Moderate

SevereQualitative
Color jet area*

Small, narrow, central

Moderate central

Large central jet or eccentric wallimpinging jet(s) of variable size
swirling in RA

Flow-convergence zone†

Not visible or smallIntermediate in size

Large

TR CW Doppler velocity waveform(density and shape)

Faint/partial/parabolic

Dense, parabolic or triangular

Dense, often triangular

Tricuspid inflow

A-wave dominantVariable

E-wave dominant‡§

Semi-quantitative
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

EROA (cm2)k<0.20

0.20-0.39$0.40

RVol (mL)k

<30

30-44

$45

Quantitative

CW, Continuous-wave; EROA, effective regurgitant orifice area; RA, right atrium; RVol, regurgitant volume; TR, tricuspid regurgitation; VC, vena
contracta.
*With Nyquist limit >50-60 cm/s.
†
Not well-validated for quantitation; best used after interventions that leave the valve intact; baseline Nyquist limit shift to 25-35 cm/s.
‡
Non-specific, influenced by other factors (RV diastolic function, atrial fibrillation, RA pressure).
§
Not suitable in procedures intervening with valve leaflets (e.g., edge-to-edge repair).
k
EROA from 2D PISA is not suitable in patients with edge-to-edge valve repair because of multiplicity of jets and non-hemispheric shape of flow
convergence. Needs further validation of cut-offs by either PISA or volumetric methods.

quantitatively; the VCA method using 3D CD would be likely
more appropriate for quantitation, although is not yet well-validated.
There is scant data on how to evaluate residual TR after TV interventions. In the registry of tricuspid edge-to-edge repair,192 a numberof methods to assess regurgitation were used. The vena contracta and
PISA-derived EROA and RVol were calculated and summed from themultiple jets. These methods require further validation in view of previous studies showing the limitations of both CD jet characteristics andquantitative methods in assessing MR after edge-to-edge repair.129
In the early experience with tricuspid annuloplasty,192 residual TR
was assessed using multiple quantitative methods, including PISA and
RVol. Systemic stroke volume was measured using LVOT or RVOT
forward flow, and stroke volume across the TV was calculated using
annular diameters from orthogonal planes (ellipse formula for annulararea), and velocity-time integral (PWD at the annulus). A reduction in
tricuspid EROA by quantitative Doppler from 0.9 6 0.2 to
0.6 6 0.3 cm2 was associated with an increase in LVOT stroke volume, and improvement in functional status. Although the PISA
method is simple and easy to perform,198 the complex relationshipof the isovelocity shell to the often elliptical199,200 shape and large
size of the TR EROA resulted in significant underestimation of
volumetric EROA.201 Importantly, the SCOUT trial showed thatPISA EROA underestimates the quantitative EROA by >50%.202
Other possible novel quantitative methods have been recently reviewed196 and include quantitative Doppler (using either biplane or
3D annular area) and 3D color Doppler VCA; further validation,
however, is needed.
Against this backdrop, and with the current knowledge of assessing
TR severity, the Writing Group proposes a few parameters in evalu-

ating TR after interventions on the TV apparatus (Table 9), modified
from those previously published for native TR.7 These proposed recommendations take into consideration variables that are no longer
applicable in assessing TR severity such as right heart chamber sizeand function, or are less accurate because of the intervention(EROA by 2D PISA after edge-to-edge valve repair). Examples ofchanges in parameters of TR severity after edge-to-edge repair are
shown in Figure 23. The Writing Group acknowledges that the fieldis evolving and there is a need for further validation of proposed
quantitative parameters against independent standards. Irrespective,
and as is the case for all valvular regurgitation, an integrative approachto overall evaluation of TR severity is needed to complement any
quantitative parameter of residual valve regurgitation.
C. Role of CMR in Assessing Residual TR after Tricuspid
Valve Interventions
CMR assessment of TR is less established compared to other regurgitant valvular lesions. A few indirect quantitative techniques have been
used, since direct measurement of tricuspid inflow is of limited
value.7,203 Regurgitant volume can be calculated by subtracting thepulmonic forward stroke volume from the RV stroke volume, fromwhich regurgitant fraction can be derived. Alternatively, in theabsence of AR, aortic forward stroke volume can be subtracted
from RV stroke volume. Lastly, in the absence of other regurgitantlesions, LV stroke volume can also be subtracted from RV strokevolume to obtain tricuspid regurgitant volume. These methods havesignificant limitations since the shape of the RV and RVOT present
significant problems for short-axis planimetry. A recent study evaluating methods of assessing TR with CMR and comparing them toechocardiographic CD showed that the standard velocity-encoded468 Zoghbi et al

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Figure 23 Illustrative echocardiographic parameters of reduction in severe TR after percutaneous tricuspid repair.
methods had only moderate agreement with echocardiography.204
These issues may be magnified after catheter-based TR interventions,as susceptibility artifacts may invariably occur in the RV base depending on the type of device, hindering visualization of the basal shortaxis slice and interfering with RV volumetric measurements. As thefield advances, both the methods of quantitation and the grading
schemes will require validation.
D. Integrative Approach in the Evaluation of Residual TR
The approach to the evaluation of TR severity is to integrate multiple parameters rather than emphasize or depend on a single measurement; this helps mitigate the effects of technical ormeasurement errors inherent to each method discussed earlier.
Evaluating reduction in TR after catheter-based interventions is an
evolving field. While research is progressing, and further validationof quantitative methods are needed, the Writing Group proposes
an approach to TR evaluation that would assess first whether there
are a majority of signs that would point toward severe regurgitation—the underlying indication for TR interventions (Table 9). A significant reduction in CD jet parameters (flow convergence, VC, andjet area), an improvement in TR jet CWD features toward mild, andnormalization of the hepatic venous flow pattern would point to asignificant reduction in TR severity to mild (Table 9 and Figure 23).
In less impressive scenarios, one needs to evaluate whether minimalor moderate improvement in parameters has occurred, with more
confidence achieved if most of the signs and indices are concordant.
While quantitation may be feasible, it is more challenging at thistime as the various methods proposed by echocardiography and
CMR need further validation and experience.

Key Points
Assessment of residual TR after tricuspid valve
interventions
 Tricuspid regurgitation (TR) is most often secondary (functional) due to lateral dilation of the annulus. Primary causessuch as flail leaflet are less common.
 Currently, there are no catheter-based devices approved for
TV repair. Early experience has been with edge-to-edge repair
in the setting of secondary TR; alternative catheter-based approaches are being developed.
 As is the case for native TR, an integrated approach is used toassess severity of residual TR. However, the presence ofZoghbi et al 469

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multiple jets as commonly seen after edge-to-edge repair, andthe limited experience and validation of quantitative parameters complicate this assessment.
 Key elements of evaluating residual TR severity include color
jet characteristics, flow convergence, 2D vena contracta,
CWD jet waveform density/shape, and hepatic venous
flow. 3D VCA may be helpful but needs further experienceand validation.
 PISA-derived EROA and regurgitant volume have been used
but are less helpful following edge-to-edge repair.
 Quantitative pulsed-wave Doppler approaches are limited after repair.
 While devices may reduce TR and favorably affect clinical status, residual TR with current attempts is frequently moderateor severe using the conventional scoring system. Expanding
the grading scheme to include categories of ‘‘massive’’ and‘‘torrential’’ TR has been suggested to capture the impact ofdevices. However, this approach and its clinical outcome
need further evaluation.
 The use of CMR for quantitation of residual TR after catheterbased interventions is feasible using the indirect method.
However, this approach needs further validation as TV devices may create artifacts that can interfere with accuracy ofvolume calculations.
 As devices evolve, so will approaches to quantitation.

VII. CONCLUSIONS AND FUTURE DIRECTIONSCatheter-based interventions to repair or replace heart valves haveprogressed exponentially over the past few years. From early applications in high-risk patients with aortic valve stenosis, catheter-based
technology has evolved to address the pulmonic, mitral, and more
recently the tricuspid valve. Issues with valve stenosis early after
deployment are rare, except after edge-to-edge MV repair with multiple devices, hence the emphasis of the current document on new orresidual valve regurgitation. Such an evaluation after valve repair or
replacement is important for both guidance of the intervention in
the catheterization laboratory and for the overall outcome of patients
after the procedure. Thus, the imager is an integral member of theheart valve team. In general, these regurgitant lesions present a challenge to the imager as their mechanism, number, direction, hemodynamics, and underlying cardiac physiology is frequently different fromregurgitant native valves. The assessment of regurgitation acutely inthe catheterization laboratory frequently requires evaluation of echocardiographic, angiographic, and/or hemodynamic parameters, depending on the valve position. In the outpatient setting, anintegrative transthoracic echocardiographic approach is always
needed as a first-line assessment. Further imaging with TEE, CMR,
and occasionally MDCT may be needed, depending on the initialstudy and remaining question(s). As more clinical experience is acquired with these interventions, further data on validation, comparative accuracy, and prognostic impact are needed in echocardiography
as well as CMR to identify the most optimal quantitative approachand enhance the accuracy and confidence of evaluation of valve
regurgitation after catheter-based interventions.
NOTICE AND DISCLAIMER: This report is made available by ASE
as a courtesy reference source for members. This report contains rec-ommendations only and should not be used as the sole basis to makemedical practice decisions or for disciplinary action against any
employee. The statements and recommendations contained in thisreport are primarily based on the opinions of experts, rather thanon scientifically-verified data. ASE makes no express or implied warranties regarding the completeness or accuracy of the information inthis report, including the warranty of merchantability or fitness for aparticular purpose. In no event shall ASE be liable to you, your patients, or any other third parties for any decision made or action takenby 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 andyour patients or anyone else.
Reviewers: This document was reviewed by members of the
2018–2019 ASE Guidelines and Standards Committee, ASE Boardof Directors, ASE Executive Committee, and designated representatives from the Japanese Society of Echocardiography, Society for
Cardiovascular Angiography and Interventions, and Society for
Cardiovascular Magnetic Resonance. Reviewers included Bonita
Anderson, MAPPLSC, DMU, AMS, FASE, ACS, Alicia Armour, BS,
MA, RDCS, FASE, Azin Alizadehasl, MD, FASE, Scott D. Choyce,
RDCS, RVT, RDMS, FASE, Craig Fleishman, MD, FASE, Benjamin
Freed, MD, FASE, Mark K. Friedberg, MD, FASE, Edward Gill, MD,
FASE, Suzanne Golz, MS, RDCS, FASE, Yuchi Han, MD, MMSc,
FASE, FSCMR, Renuka Jain, MD, FASE, Pei-Ni Jone, MD, FASE,James N. Kirkpatrick, MD, FASE, Judy Mangion, MD, FASE, Anuj
Mediratta, MD, FASE, Satoshi Nakatani, MD, PhD, Andy Pellett,
PhD, RCS, RDCS, FASE, Dermot Phelan, MD, PhD, FASE,
Geoffrey A. Rose, MD, FASE, Michael H. Salinger, MD, FSCAI,
Stanton Shernan, MD, FASE, Mark Taylor, MD, FASE, David H.
Wiener, MD, FASE, and Megan Yamat, RDCS, RCS, FASE.

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