Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice.

AR = aortic regurgitation AS = aortic stenosis AVA = aortic valve area CSA = cross sectional area CWD = continuous wave Doppler D = diameter HOCM = hypertrophic obstructive cardiomyopathy LV = left ventricle LVOT = left ventricular outflow tract MR = mitral regurgitation MS = mitral stenosis MVA = mitral valve area ΔP = pressure gradient RV = right ventricle RVOT = right ventricular outflow tract SV = stroke volume TEE = transesophageal echocardiography T 1/2 = pressure half-time TR = tricuspid regurgitation TS = tricuspid stenosis V = velocity VSD = ventricular septal defect VTI =velocity time integral Valve stenosis is a common heart disorder and an important cause of cardiovascular morbidity and mortality. Echocardiography has become the key tool for the diagnosis and evaluation of valve disease, and is the primary non-invasive imaging method for valve stenosis assessment. Clinical decision-making is based on echocardiographic assessment of the severity of valve stenosis, so it is essential that standards be adopted to maintain accuracy and consistency across echocardiographic laboratories when assessing and reporting valve stenosis. The aim of this paper was to detail the recommended approach to the echocardiographic evaluation of valve stenosis, including recommendations for specific measures of stenosis severity, details of data acquisition and measurement, and grading of severity. These recommendations are based on the scientific literature and on the consensus of a panel of experts. This document discusses a number of proposed methods for evaluation of stenosis severity. On the basis of a comprehensive literature review and expert consensus, these methods were categorized for clinical practice as:

[1]  A. Weyman,et al.  Echocardiographic differentiation of infundibular from valvular pulmonary stenosis. , 1975, The American journal of cardiology.

[2]  A. Weyman,et al.  Cross‐Sectional Echocardiographic Visualization of the Stenotic Pulmonary Valve , 1977, Circulation.

[3]  H. Katsume,et al.  Echocardiographic Measurement of Right Ventricular Wall Thickness A New Application of Subxiphoid Echocardiography , 1977, Circulation.

[4]  S. Goldberg,et al.  Noninvasive Prediction of Transvalvular Pressure Gradient in Patients with Pulmonary Stenosis by Quantitative Iwo‐dimensional Echocardiographic Doppler Studies , 1983, Circulation.

[5]  L. Hatle Noninvasive assessment of valve lesions with Doppler ultrasound. , 1984, Herz.

[6]  J. Ross,et al.  Detection by Doppler echocardiography of acquired pulmonic stenosis due to extrinsic tumor compression. , 1984, The American journal of cardiology.

[7]  O. L. Kwan,et al.  Accuracy of combined two-dimensional echocardiography and continuous wave Doppler recordings in the estimation of pressure gradient in right ventricular outlet obstruction. , 1984, Journal of the American College of Cardiology.

[8]  G. Cherian,et al.  Tricuspid stenosis and regurgitation in rheumatic heart disease: a prospective cardiac catheterization study in 525 patients. , 1985, American heart journal.

[9]  J. Seward,et al.  Continuous-wave Doppler echocardiographic assessment of severity of calcific aortic stenosis: a simultaneous Doppler-catheter correlative study in 100 adult patients. , 1985, Circulation.

[10]  M. Quiñones,et al.  Accurate noninvasive quantification of stenotic aortic valve area by Doppler echocardiography. , 1986, Circulation.

[11]  O. L. Kwan,et al.  Value and limitations of continuous-wave Doppler echocardiography in estimating severity of valvular stenosis. , 1986, JAMA.

[12]  W. Mckenna,et al.  Echocardiographic measurement of the normal adult right ventricle , 1986 .

[13]  L L Huntsman,et al.  Determination of the stenotic aortic valve area in adults using Doppler echocardiography. , 1986, Journal of the American College of Cardiology.

[14]  A. Weyman,et al.  Doppler mitral pressure half-time: a clinical tool in search of theoretical justification. , 1987, Journal of the American College of Cardiology.

[15]  R. S. Mitchell,et al.  When should Doppler-determined valve area be better than the Gorlin formula?: Variation in hydraulic constants in low flow states. , 1987, Journal of the American College of Cardiology.

[16]  J. Krivokapich,et al.  Comparison of two-dimensional and Doppler echocardiography and intracardiac hemodynamics for quantification of mitral stenosis. , 1987, The American journal of cardiology.

[17]  S. Nakatani,et al.  Value and Limitations of Doppler Echocardiography in the Quantification of Stenotic Mitral Valve Area: Comparison of the Pressure Half-time and the Continuity Equation Methods , 1988, Circulation.

[18]  Value and Limitations of Doppler Echocardiography in the Quantification of Stenotic Mitral Valve Area: Comparison of the Pressure Half-time and the Continuity Equation Methods , 1988 .

[19]  I. Palacios,et al.  Inaccuracy of mitral pressure half-time immediately after percutaneous mitral valvotomy. Dependence on transmitral gradient and left atrial and ventricular compliance. , 1988, Circulation.

[20]  C. Otto,et al.  Doppler echocardiography in adults with symptomatic aortic stenosis. Diagnostic utility and cost-effectiveness. , 1988, Archives of internal medicine.

[21]  A J Tajik,et al.  Prediction of the severity of aortic stenosis by Doppler aortic valve area determination: prospective Doppler-catheterization correlation in 100 patients. , 1988, Journal of the American College of Cardiology.

[22]  N. Silverman,et al.  Doppler ultrasound evaluation of valvar pulmonary stenosis from multiple transducer positions in children requiring pulmonary valvuloplasty. , 1988, The American journal of cardiology.

[23]  I. Palacios,et al.  Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. , 1988, British heart journal.

[24]  P. Eriksson,et al.  Doppler echocardiographic assessment of the valve area in patients with atrioventricular valve stenosis by application of the continuity equation , 1989, Journal of internal medicine.

[25]  J. V. Nixon,et al.  Pacemaker lead-induced tricuspid stenosis: diagnosis by Doppler echocardiography. , 1989, American heart journal.

[26]  P. Eriksson,et al.  Reassessment of valve area determinations in mitral stenosis by the pressure half-time method: impact of left ventricular stiffness and peak diastolic pressure difference. , 1989, Journal of the American College of Cardiology.

[27]  A. Weyman,et al.  Fluid dynamics model of mitral valve flow: description with in vitro validation. , 1989, Journal of the American College of Cardiology.

[28]  M. Fawzy,et al.  Doppler echocardiography in the evaluation of tricuspid stenosis. , 1989, European heart journal.

[29]  C. Keirns,et al.  Echocardiographic diagnosis of rheumatic cardiopathy affecting all four cardiac valves. , 1990, American heart journal.

[30]  H. Baumgartner,et al.  Determination of aortic valve area by Doppler echocardiography using the continuity equation: a critical evaluation. , 1990, Cardiology.

[31]  T. Spray,et al.  Congenital tricuspid valve stenosis with atrial septal defect and left anterior fascicular block , 1990, Clinical cardiology.

[32]  A. Weyman,et al.  Physical and physiological determinants of transmitral velocity: numerical analysis. , 1991, The American journal of physiology.

[33]  A. Pearlman Role of echocardiography in the diagnosis and evaluation of severity of mitral and tricuspid stenosis. , 1991, Circulation.

[34]  W. Walsh,et al.  Left atrial spontaneous echo contrast: a clinical and echocardiographic analysis. , 1991, Journal of the American College of Cardiology.

[35]  G. Hughes,et al.  Systemic lupus erythematosus complicated by tricuspid stenosis and regurgitation: successful treatment by valve transplantation. , 1992, Annals of the rheumatic diseases.

[36]  A. Weyman,et al.  Calculation of atrioventricular compliance from the mitral flow profile: analytic and in vitro study. , 1992, Journal of the American College of Cardiology.

[37]  C. Otto,et al.  Echocardiographic volume flow and stenosis severity measures with changing flow rate in aortic stenosis. , 1993, The American journal of physiology.

[38]  Physiologic Changes with Maximal Exercise in Asymptomatic Valvular Aortic Stenosis Assessed by Doppler Echocardiography , 1993 .

[39]  E D Verrier,et al.  Dependence of Gorlin Formula and Continuit Equation Valve Areas on Transvalvular Volume Flow Rate in Valvular Aortic Stenosis , 1994, Circulation.

[40]  Accurate Measurement of the Transmitral Gradient in Patients with Mitral Stenosis: A Simultaneous Catheterization and Doppler Echocardiographic Study , 1994 .

[41]  T. Folliguet,et al.  Valved conduit bypass for extensively calcified tricuspid valve stenosis. , 1995, The Annals of thoracic surgery.

[42]  B. Waller,et al.  Pathology of pulmonic valve stenosis and pure regurgitation , 1995, Clinical cardiology.

[43]  A. Evangelista,et al.  Cardiac index quantification by Doppler ultrasound in patients without left ventricular outflow tract abnormalities. , 1995, Journal of the American College of Cardiology.

[44]  T. Cheng,et al.  Percutaneous balloon valvuloplasty for pulmonic stenosis in adolescents and adults. , 1996, The New England journal of medicine.

[45]  A. Pezzano,et al.  Measurement of mitral valve area in mitral stenosis: four echocardiographic methods compared with direct measurement of anatomic orifices. , 1996, Journal of the American College of Cardiology.

[46]  J. Bermejo,et al.  Effects of dobutamine on Doppler echocardiographic indexes of aortic stenosis. , 1996, Journal of the American College of Cardiology.

[47]  B Cormier,et al.  Immediate results of percutaneous mitral commissurotomy. A predictive model on a series of 1514 patients. , 1996, Circulation.

[48]  B. Iung,et al.  Value of multiplane transesophageal echocardiography in determining aortic valve area in aortic stenosis. , 1996, The American journal of cardiology.

[49]  H. Baumgartner,et al.  Importance of pressure recovery for the assessment of aortic stenosis by Doppler ultrasound. Role of aortic size, aortic valve area, and direction of the stenotic jet in vitro. , 1996, Circulation.

[50]  R. O'rourke,et al.  Comparison of exercise and dobutamine stress echocardiography in assessing mitral stenosis. , 1997, The American journal of cardiology.

[51]  C M Otto,et al.  Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. , 1997, Circulation.

[52]  T. Akasaka,et al.  Planimetry and transthoracic two-dimensional echocardiography in noninvasive assessment of aortic valve area in patients with valvular aortic stenosis. , 1997, Journal of the American College of Cardiology.

[53]  G Maurer,et al.  "Overestimation" of catheter gradients by Doppler ultrasound in patients with aortic stenosis: a predictable manifestation of pressure recovery. , 1999, Journal of the American College of Cardiology.

[54]  J. Chambers,et al.  The relation between transaortic pressure difference and flow during dobutamine stress echocardiography in patients with aortic stenosis , 1999, Heart.

[55]  J. de Mey,et al.  Pulmonary stenosis caused by extrinsic compression of an aortic pseudoaneurysm of a composite aortic graft. , 1999, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[56]  B. Iung,et al.  Late results of percutaneous mitral commissurotomy in a series of 1024 patients. Analysis of late clinical deterioration: frequency, anatomic findings, and predictive factors. , 1999, Circulation.

[57]  G. Thiene,et al.  Aortic root dilatation in young men with normally functioning bicuspid aortic valves , 1999, Heart.

[58]  E. Schwammenthal,et al.  Impact of Atrioventricular Compliance on Pulmonary Artery Pressure in Mitral Stenosis: An Exercise Echocardiographic Study , 2000, Circulation.

[59]  J. Dubois-Randé,et al.  Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients: risk stratification by low-dose dobutamine echocardiography. , 2001, Journal of the American College of Cardiology.

[60]  G. Porenta,et al.  Predictors of outcome in severe, asymptomatic aortic stenosis , 2001 .

[61]  S. Hammami,et al.  Predictors of long-term event-free survival and of freedom from restenosis after percutaneous balloon mitral commissurotomy. , 2001, American heart journal.

[62]  Robert A Levine,et al.  Effect of three-dimensional valve shape on the hemodynamics of aortic stenosis: three-dimensional echocardiographic stereolithography and patient studies. , 2002, Journal of the American College of Cardiology.

[63]  S. Rahimtoola,et al.  Current evaluation and management of patients with mitral stenosis. , 2002, Circulation.

[64]  H. Schaff,et al.  Low-Output, Low-Gradient Aortic Stenosis in Patients With Depressed Left Ventricular Systolic Function: The Clinical Utility of the Dobutamine Challenge in the Catheterization Laboratory , 2002, Circulation.

[65]  K. Tsukuda,et al.  Congenital Heart Disease with Hypereosinophilic Syndrome , 2003, Pediatric Cardiology.

[66]  I. Palacios,et al.  Which Patients Benefit From Percutaneous Mitral Balloon Valvuloplasty?: Prevalvuloplasty and Postvalvuloplasty Variables That Predict Long-Term Outcome , 2002, Circulation.

[67]  C. Otto,et al.  Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. , 2002, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[68]  R. Levine,et al.  Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. , 2003, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[69]  J. Bermejo,et al.  Clinical efficacy of Doppler-echocardiographic indices of aortic valve stenosis: a comparative test-based analysis of outcome. , 2003, Journal of the American College of Cardiology.

[70]  Isolated tricuspid stenosis and heart failure: a focus on carcinoid heart disease. , 2003, Congestive heart failure.

[71]  C. Tribouilloy,et al.  Low‐Gradient Aortic Stenosis Operative Risk Stratification and Predictors for Long‐Term Outcome: A Multicenter Study Using Dobutamine Stress Hemodynamics , 2003, Circulation.

[72]  Huge Right Atrial Myxoma Causing Fixed Tricuspid Stenosis with Constitutional Symptoms , 2003, Journal of cardiac surgery.

[73]  Congenital tricuspid stenosis and membranous right ventricular outflow tract obstruction in an adult. , 2003, Annals of cardiac anaesthesia.

[74]  M. Enriquez-Sarano,et al.  Sequential assessment of mitral valve area during diastole using colour M-mode flow convergence analysis: new insights into mitral stenosis physiology. , 2003, European heart journal.

[75]  Philippe Ravaud,et al.  A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. , 2003, European heart journal.

[76]  B. Prendergast,et al.  Anomalous origin of the pulmonary artery from the left coronary artery , 2003, Heart.

[77]  T. Kamoshida,et al.  Isolated tricuspid valve stenosis caused by infective endocarditis in an adult: Report of a case , 2004, Surgery Today.

[78]  M. S. Motta,et al.  Dobutamine stress echocardiography for noninvasive assessment and risk stratification of patients with rheumatic mitral stenosis. , 2004, Journal of the American College of Cardiology.

[79]  J. Zamorano,et al.  Real-time three-dimensional echocardiography for rheumatic mitral valve stenosis evaluation: an accurate and novel approach. , 2004, Journal of the American College of Cardiology.

[80]  Mild and moderate aortic stenosis. Natural history and risk stratification by echocardiography. , 2004, European heart journal.

[81]  J. Chambers,et al.  Crossing the aortic valve in severe aortic stenosis: no longer acceptable? , 2004, The Journal of heart valve disease.

[82]  Alec Vahanian,et al.  Percutaneous Approaches to Valvular Disease , 2004, Circulation.

[83]  R. Voces,et al.  Reversible tricuspid valve stenosis due to a metastatic dissemination of a noncardiac sarcoma. , 2005, The Annals of thoracic surgery.

[84]  Damien Garcia,et al.  Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment. , 2005, Journal of the American College of Cardiology.

[85]  D. Hagler,et al.  Echocardiographic assessment of isolated pulmonary valve stenosis: which outpatient Doppler gradient has the most clinical validity? , 2005, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[86]  R. K. Grooters,et al.  Metastatic right atrial tumor in colon cancer with superior vena cava syndrome and tricuspid obstruction , 2005, Heart and Vessels.

[87]  W. Roberts,et al.  Frequency by Decades of Unicuspid, Bicuspid, and Tricuspid Aortic Valves in Adults Having Isolated Aortic Valve Replacement for Aortic Stenosis, With or Without Associated Aortic Regurgitation , 2005, Circulation.

[88]  Usefulness of three-dimensionally guided assessment of mitral stenosis using matrix-array ultrasound. , 2005, The American journal of cardiology.

[89]  T. Disessa,et al.  Doppler estimation of pressure gradient in pulmonary stenosis: Maximal instantaneous vs peak-to-peak, vs mean catheter gradient , 2005, Pediatric Cardiology.

[90]  G. Dreyfus,et al.  Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? , 2005, The Annals of thoracic surgery.

[91]  M. Simon,et al.  Prognostic Importance of Quantitative Exercise Doppler Echocardiography in Asymptomatic Valvular Aortic Stenosis , 2005, Circulation.

[92]  Damien Garcia,et al.  Impact of systemic hypertension on the assessment of aortic stenosis , 2005, Heart.

[93]  B. Iung,et al.  Echocardiographic evaluation of the mitral valve area before and after percutaneous mitral commissurotomy: the pressure half-time method revisited. , 2005, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[94]  K. Bailey,et al.  Outcome of 622 Adults With Asymptomatic, Hemodynamically Significant Aortic Stenosis During Prolonged Follow-Up , 2005, Circulation.

[95]  K. Ashikawa,et al.  Tricuspid valve stenosis related to subvalvular adhesion of pacemaker lead: a case report. , 2006, Journal of cardiology.

[96]  William Stewart,et al.  Recommendations for chamber quantification. , 2006, European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology.

[97]  C. Otto,et al.  Valvular aortic stenosis: disease severity and timing of intervention. , 2006, Journal of the American College of Cardiology.

[98]  Projected Valve Area at Normal Flow Rate Improves the Assessment of Stenosis Severity in Patients With Low-Flow, Low-Gradient Aortic Stenosis: The Multicenter TOPAS (Truly or Pseudo-Severe Aortic Stenosis) Study , 2006 .

[99]  P. Byers,et al.  Usefulness of bicuspid aortic valve phenotype to predict elastic properties of the ascending aorta. , 2007, The American journal of cardiology.

[100]  J. Serfaty,et al.  Three-dimensional evaluation of the mitral valve area and commissural opening before and after percutaneous mitral commissurotomy in patients with mitral stenosis. , 2006, European Heart Journal.

[101]  Helmut Baumgartner,et al.  Guidelines on the management of valvular heart disease The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology , 2007 .

[102]  M. Shoukri,et al.  Seventeen years' clinical and echocardiographic follow up of mitral balloon valvuloplasty in 520 patients, and predictors of long-term outcome. , 2007, The Journal of heart valve disease.

[103]  Kiyoshi Iida,et al.  Assessment of aortic stenosis by three-dimensional echocardiography: an accurate and novel approach , 2007, Heart.

[104]  C. Izgi,et al.  Mitral valve resistance as a determinant of resting and stress pulmonary artery pressure in patients with mitral stenosis: a dobutamine stress study. , 2007, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[105]  Manjula V. Burri,et al.  Live/Real Time Three‐Dimensional Transthoracic Echocardiographic Assessment of Tricuspid Valve Pathology: Incremental Value over the Two‐Dimensional Technique , 2007, Echocardiography.

[106]  Phalla Ou,et al.  Prevalence of rheumatic heart disease detected by echocardiographic screening. , 2007, The New England journal of medicine.

[107]  K. Linhartová,et al.  Impact of blood pressure on the Doppler echocardiographic assessment of severity of aortic stenosis. , 2008, Heart.

[108]  H. Baumgartner,et al.  Systemic pressure does not directly affect pressure gradient and valve area estimates in aortic stenosis in vitro. , 2008, European heart journal.

[109]  I. Kallikazaros,et al.  Multiple cardiac metastases from a malignant melanoma. , 2007, European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology.