Goals of Reporting. Background of the STS/ACC TVT Registry. TVT Registry TAVR and MitraClip 10/11/ /11/2016 9:10 9:30 AM

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1 10/11/2016 9:10 9:30 AM Rebecca T. Hahn, MD Director of Interventional Echocardiography Columbia University Medical College Background of the STS/ACC TVT Registry The STS/ACC TVT Registry is a benchmarking tool developed to track patient safety and real world outcomes related to transcatheter valve replacement and repair procedures and emerging treatments for valve disease patients. Created by The Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC), the TVT Registry is designed to monitor the safety and efficacy of these new technologies for the treatment of valve disease.* Goals of Reporting *Carroll JD, Edwards FH, Marinac Dabic D, Brindis RG, Grover FL, Peterson ED, et al. The STS ACC transcatheter valve therapy national registry: a new partnership and infrastructure for the introduction and surveillance of medical devices and therapies. J Am Coll Cardiol. 2013;62(11): The strength of the database is not only to monitor real world outcomes and appropriate use, but also to serve as a powerful research tool that may significantly change our current clinical practice. Quality of Life parameters as important and procedural and device parameters A large portion of the STS/ACC TVT Registry database includes post procedure echocardiographic parameters. Note: Participation in the Registry is mandated by CMS (for reimbursement) for all sites participating in transcatheter procedures. 1

2 The intent of this webinar is: To discuss some of the components of the echocardiogram report that have been difficult to collect To answer questions about specific echocardiographic parameters Why we should measure Suggestion on how to measure MitraClip EOA cm 2 EOA is the orifice area of valve: for the mitral valve, this is the opening in DIASTOLE EROA is the effective regurgitant orifice area: for the mitral valve, this is the regurgitation seen in SYSTOLE Linear dimensions Volumes by Biplane Simpson s Method of Discs Area length Method Ejection fraction Biplane Simpson s Visual EF is NOT recommended Compromise: experience-based partition values only for LV EF and LA volume, while suggesting partition values for additional parameters of LV size and mass Lang RM et al. J Am Soc Echocardiogr 2015;28:1 39 2

3 Linear Measurements Volumetric Measurements ASE Interactive Webinar February 11, 2015 EYE BALL assessment is NOT recommended 1. From parasternal long-axis view. 2. Values should be carefully obtained perpendicular to the LV long axis 3. Electronic Calipers at the interface between myocardial wall and cavity, and between wall and pericardium 4. Measured at or immediately below the level of the mitral valve leaflet tips 5. Linear measurements obtained from 2D echocardiographic images are preferred to 2D-guided M-mode to avoid oblique sections of the ventricle Case: LV Function Geometric assumptions are NOT recommended for calculating volume OR ejection fraction LVIDd = 5.6 cm LVIDs = 4.4 cm Looking at multiple SAX levels helps determine regional wall motion abnormalities which should be confirmed in the apical views. LV VOLUME BY METHOD OF DISCS (MODIFIED SIMPSON S RULE) 1. Apical four- and two-chamber views. 2. Trace the interface between the compacted myocardium and the LV cavity. 3. At the mitral valve level, the contour is closed by connecting the two opposite sections of the mitral ring with a straight line. 4. LV length is defined as the distance between the bisector of this line and the apical point of the LV contour, which is most distant to it. 5. The use of the longer LV length between the apical two- and fourchamber views is recommended for the Area/length method. A4CV A2CV LV EDD LV ESD Lang RM et al. J Am Soc Echocardiogr 2005;18:

4 Endocardium is well imaged >90% of ventricle 4Ch and 2Ch long axis <20% difference Not foreshortened: apical motion appropriate YES NO End-diastole is preferably defined as the first frame after mitral valve closure or the frame in the cardiac cycle in which the respective LV dimension or volume measurement is the largest. End-systole is best defined as the frame after aortic valve closure or the frame in which the cardiac dimension or volume is smallest. Acquire LV views at a reduced depth Reduces the likelihood of foreshortening and minimize errors in endocardial border tracings Include the entire ventricle in your sector throughout the entire cardiac cycle To enhance border detection: B mode color Contrast To trace: Exclude papillary muscles Exclude trabeculations (trace the inner edge) If apex not in sector, end the trace at the edge of the sector Always begin and end the trace at the MV annulus 1. Contrast agents should be used when needed to improve endocardial delineation when two or more contiguous LV endocardial segments are poorly visualized in apical views 2. Avoid basal acoustic shadowing 3. Volumes typically larger (and comparable to CMR) Normative data lacking Lang RM et al. J Am Soc Echocardiogr 2015;28:1 39 Biplane Simpson s EF = 48% Biplane Simpson s Stroke Volume = 90 cc 3D Stroke Volume = 98 cc LVOT stroke volume = 68 cc Regurgitant volume = 30 cc EROA = 12 mm2 Sex specific Criteria Normal Mildly Moderately Severely Male LV diastolicvolume/bsa >100 LV systolicvolume/bsa >45 Female LV diastolicvolume/bsa >80 LV Systolic Volume/BSA >40 Lang RM et al. J Am Soc Echocardiogr 2015;28:1 39 4

5 2D EDV Biplane Simpson s MOD 150 ml for men 106 ml for women ESV: 61 ml/m 2 for men 42 ml/m 2 for women Average male BSA = 2.03 m 2 Average female BSA = 1.74 m 2 LV size should be routinely assessed on 2DE by calculating volumes using the biplane method of disks summation technique. In laboratories with experience in 3DE, 3D measurement and reporting of LV volumes is recommended when feasible depending on image quality. When reporting LV linear dimensions, the recommended method is 2D guided measurements. LV size and volume measurements should be reported indexed to BSA. Lang RM et al. Am Soc Echocardiogr 2015;28:1 39. Male (ml/m 2 ) Normal Mildly Moderately Severely LV Diastolic >100 Volume/BSA LV Systolic Volume/BSA >45 Female (ml/m 2 ) Normal Mildly Moderately Severely LV Diastolic >80 Volume/BSA LV Systolic Volume/BSA >40 2D Biplane Simpson s MOD EDV 74 ml/m 2 for men 61 ml/m 2 for women ESV: 31 ml/m 2 for men 24 ml/m 2 for women 3D Volumes EDV 79 ml/m 2 for men 71 ml/m 2 for women ESV: 32 ml/m 2 for men 28 ml/m 2 for women Lang RM et al. Am Soc Echocardiogr 2015;28:1 39. Average male BSA = 2.03 m 2 Average female BSA = 1.74 m 2 Lang RM et al. Am Soc Echocardiogr 2015;28:1 39. Average male BSA = 2.03 m 2 Average female BSA = 1.74 m 2 Case: LA and MV Linear AP dimension is NOT recommended LA Volume by Biplane Simpson s Method of Discs Area Length Method 5

6 LEFT ATRIAL ANTERO-POSTERIOR DIMENSION LA in the AP dimension assumes that when the left atrium enlarges, all its dimensions change similarly which is often not the case. Expansion of the LA in the AP dimension may be constrained by the thoracic cavity between the sternum and the spine. Lang RM et al. J Am Soc Echocardiogr 2015;28:1 39 AP linear dimension should not be used as the sole measure of LA size LA VOLUME: BIPLANE AREA-LENGTH L L When LA size is measured in clinical practice, volume determinations are preferred over linear dimensions because they allow accurate assessment of the asymmetric remodeling of the LA chamber. A 1 A 2 A4C A2C Left Atrial Volume = 8/3π[(A 1 )(A 2 )/(L)]. On axis Pulmonary veins should be imaged but will be excluded from measurement Exclude left atrial appendage Trace from annulus to annulus in end systole (maximum LA volume) Preferred Method of LA Volume: Biplane MOD Trace from annulus to annulus in end systole (maximum LA volume) Exclude pulmonary veins and LAA The inferior border = MV annulus Left Atrial Volume = π/4(h) (D 1 )(D 2 ). A4C A2C LA Volume Normal Mildly Moderately Severely Index (ml/m 2 ) Male/Female >48 6

7 Mitral valve area (EOA) Mean gradient Why do you need BOTH? Velocity and Gradient ignore the influence of cardiac output High cardiac output (stroke volume index >58 cc/m 2 ) high gradient Mitral Regurgitation Hyperdynamic function Low cardiac output (stroke volume index < 35 cc/m 2 ) low gradient Reduced RV stroke volume Right ventricular systolic function Severe tricuspid regurgitation Severe pulmonary hypertension Reduced LV stroke volume Reduced LVEF Severe aortic regurgitation Mitral Valve: Double Orifice Mitral Valve area = cm2 = 3.7 cm2 Total MV Area = 3.53 cm2 The primary method for assessing post MitraClip effective orifice area (EOA) is to planimeter the 2 orifices from the short axis views (at the TIPS of the leaflets). Planimetry of the EOA can be done from the short axis view on 3D images Case: Pressure Halftime Case: Peak and Mean Gradient PHT Caveats: 1. Take the DOMINANT slope 2. Extrapolate back to the beginning of the flow profile Mean Gradient Caveats: 1. Start at the beginning of diastole 2. End and the end of diastole 3. DO NOT extend the tracing into systole Why is the PHT calculation wrong? 1. Difficult measuring PHT (multiple slopes). 2. Presence of MR 3. Diastolic function Note: the mean gradient just prior to clip release may be different than the gradient after clip release. Both should be reported. 7

8 PHT values lower than planimetry Planimetry is the method of choice in the EVEREST Trial In the absence of significant mitral regurgitation. The hemodynamic behavior of a double orifice mitral valve does not differ from that of a physiological valve of same total area: pressure drops and flow velocity across the valve are not influenced by the configuration of the valve Echo Doppler estimation of the maximum velocities is a reliable method for the calculation of pressure gradients across the repaired valve. Central gradients are lower than gradients lateral within the orifice Maisano, F. et al. European Journal of Cardiothoracic Surgery 15 (1999) Continuity Equation utilizes the conservation of mass theory Mass can be neither created nor destroyed Stroke Volume 1 = Stroke Volume 2 (Area x TVI) 1 = (Area x TVI) 2 V 2 Continuity Equation utilizes the conservation of mass theory Mass can be neither created nor destroyed Stroke Volume 1 = Stroke Volume 2 (Area x TVI) 1 = (Area x TVI) 2 Area LVOT VTI LVOT = Area LVOT x VTI LVOT V 1 A 2 A 1 = x VTI AV V 1 A 1 VTI AV The continuity equation for the mitral valve may be used to calculate valve area if the aortic regurgitation and the mitral regurgitation are mild Stroke Volume 1 = Stroke Volume 2 Mitral Valve Area x Mitral VTI = LVOT Area x LVOT VTI Mitral Valve Area = LVOT Area x LVOT VTI Mitral VTI Note: for a nonstenotic aortic valve, the ANNULUS diameter is used to calculate stroke volume D 2 x0.785 Note: for a nonstenotic aortic valve, the PW sample volume is placed on the annulus = 1.2 cm 2 Stroke Volume 1 = Stroke Volume 2 Mitral Valve Area x Mitral VTI = PV Area x PV VTI Mitral Valve Area = PV Area x PV VTI In the setting of >mild Mitral VTI aortic regurgitation, the right ventricular stroke D 2 x0.785 volume may be used (assuming pulmonic regurgitation is mild) = 1.3 cm 2 Using Aortic Stroke Volume Using Pulmonic Stroke Volume 8

9 Qualitative Assessment PISA Quantitative Doppler 3D Planimetry Other Doppler Parameter Mitral Inflow (tips) MR jet density A wave dominant Incomplete /faint Mild Moderate Severe Variable Dense E wave dominant (>1.2m/s) Dense Zoghbi et al J Am Soc Echocardiogr 2003;16: Doppler Parameter MR jet contour Mild Moderate Severe Parabolic Usually parabolic Earlypeaking, triangular Doppler Parameter Pulmonary Vein Mild Moderate Severe Systolic dominant Systolic blunting Systolic flow reversal * S D * Specific Sign Zoghbi et al J Am Soc Echocardiogr 2003;16: Zoghbi et al J Am Soc Echocardiogr 2003;16: Three components of the regurgitant jet: Proximal flow convergence Vena contract Jet Area Proximal Convergence Vena Contracta Jet Area Caveats: measure from Parasternal LAX Must measure the jet at its narrowest portion Zoom on mitral valve to distinguish proximal convergence and expanding distal jet from the vena contracta Maximize color frame rate by narrowing sector Optimize gain settings Vena Contracta = 0.4 cm 9

10 Case: LA and MV Doppler Parameter Vena Contracta Mild Moderate Severe < 0.3 cm* > 0.7 cm* * Specific Sign Indirect measure of ERO Mitral Regurgitation Doppler Parameter Jet Area Mild Moderate Severe Small Central Variable jet (<4 cm2, <20% LA) * Large central jet (>10 cm2, >40% LA) or variable walljet swirling in LA* Qualitative assessment of mitral regurgitation severity is difficult following MitraClip! * Specific Sign Zoghbi et al J Am Soc Echocardiogr 2003;16: Case: Mitral Regurgitation MV diameter 1 = 3.3 cm MV diameter 2 = 3.5 cm MV area = 9.07 cm 2 Estimated Stroke volume = 100 cc Regurgitant volume 25 cc EROA= 11 mm 2 LIMITATION: 1. Flow acceleration prior to a stenotic orifice 2. Accurate measurement of annular area 3. Accurate placement of Sample Volume 10

11 Caveats: The largest jet in any plane is used and assumed to represent the jet throughout systole When multiple jets exist, the areas must be added Typical regurgitant jet areas reach their peak in midsystole when gradient is maximal Jets confined to a portion of systole (ie: mitral prolapse) will not have same area:regurgitant volume relationship Normalize for LA area when comparing patients of different size or measuring constrained jets Use absolute area for unconstrained jets (into a large LA) Jet size influenced by equipment settings: Pulse repetition frequency (inversely proportional to jet area) Color gain (slight speckle in far field) Nyquist setting usually cm/sec Jet size influenced by physics Far field beam widening Far field attenuation Jet size influenced by hemodynamic factors: Eccentric, wall impinging jets appear significantly smaller than centrally located jets Wall jets are only 40% of the size of free jets with the same regurgitant fraction Jet area influenced by flow momentum (rate x velocity) so jet area larger with greater driving pressure (BP) but may be same volume Central jets entrain red blood cells on all sides of jet (appearing larger) Doppler Parameter Regurgitant Volume Regurgitant Fraction Regurgitant Orifice Area Mild Moderate Severe < 30 cc cc > 60 cc < 30% % > 50 % % < 20 mm mm 2 > 40 mm mm 2 Zoghbi et al J Am Soc Echocardiogr 2003;16: Case: Quantitative Doppler RVOT diameter = 2.5 cm LVOT diameter 22 mm PISA: Flow thru any isovelocity shell = the instantaneous orifice flow Volumetric Stroke volume in diastole = stroke volume in systole Diastole Systole LVOT VTI = 17.8 cm Calculates the ERO Derives the RVol Calculates RVol Derives the ERO Regurg LVOT Vol SV RVOT stroke volume = 67 cc RVol = ERO x VTI MR LVOT stroke volume = 68 cc 11

12 LVOT diameter 22 mm LVOT VTI = 17.8 cm Biplane Simpson s EF = 48% Biplane Simpson s Stroke Volume = 90 cc LVOT stroke volume = 68 cc Regurgitant volume = 22 cc EROA = 9 mm2 Biplane MOD stroke volume = 90 cc LVOT stroke volume = 68 cc PISA PISA Native Valve Disease MitraClip Pitfalls: Multiple jets Constrained PISA (by MitraClip) PISA: Dynamic Jet PISA 1 + PISA 2 = 0.84 cm2 EROA = [6.282 x (0.84)2 x 31.3]/605 EROA= 23 mm2 Regurgitant volume = 52 Limited accuracy in eccentric jets Difficult to judge precise location of mitral valve orifice Errors in measurement are squared, resulting in large variance in effective regurgitant orifice area Must be angle corrected in nonplanar flow convergence geometry Assumes hemispheric flow convergence geometry, which is rarely the case in secondary mitral regurgitation Regurgitant flow changes during systole Assumes that measured proximal isovelocity surface area radius corresponds temporally to peak velocity of the mitral regurgitation jet by continuous Doppler Not validated for multiple jets Shape is affected by aliasing velocity and adjacent structures Interobserver variability and poor agreement among experienced observers 12

13 3D Vena Contracta: single point in time 3D EROA: single point in time MR Vena contracta = 19 mm and 2 mm Total EROA = 21 mm 2 = 0.21 cm 2 Regurgitant volume = 51 cc Method Regurgitant Volume by 2D/Doppler Method Doppler Relative Stroke Volumes PISA Method 3D Vena contracta Pitfall 2D method underestimates LV volume: Use of 3D may be superior Mitral stroke volume inaccurate PISA Assumptions Non hemispheric PISA Dynamic orifice 3D Pitfalls Dynamic orifice Resolution limitations TAVR 13

14 Post deployment (TEE) vs discharge vs 30 day echo 1. TEE (intra procedural): general anesthesia and Intraprocedural hemodynamics may be significantly different than post procedural hemodynamics 2. Discharge TTE may be done in office (within 7 days of the procedure): may be more comfortable for SAVR and TA TAVR day TTE is most important baseline study Are there changes to the valve over a short period of time? Paravalvular Regurgitation TCT 2013 LBCT Extreme Risk Study Iliofemoral Pivotal 85 Measurement of Follow-up LVOT Diameter and In-stent Diameter LVOT Annulus LVOT In stent 1. For the LVOT, attempt to clarify what is true LV endocardium from side-lobe artifacts from the calcified AV 2. Avoid measuring the focal calcification of the anterior mitral leaflet: this will underestimate LVOT area 3. Annular measurements are at the leaflet HINGE POINTS 1. Measure LVOT diameter apical to stent, from septal endocardium to anterior mitral leaflet 2. In stent measurement at the mid stent (level of leaflets) 14

15 LVOT Diameter (systole) In stent Diameter Post TAVR (systole) AoV Annulus Diameter (systole) Should diameters be measured from Parasternal LAX or SAX LAX Post TAVR views? Should diameters be measured in systole vs diastole? The scalloped configuration of the hingelines of the leaflets leave fibrous interleaflet triangles or trigones between the sinuses The virtual annulus marks the hinge points of the cusps (Blue Line) The maximum diameter of the annulus bisects a trigone on one side, and a cusp on the other side (Yellow arrow) When equal cusps are imaged in LAX view the LVOT and annular diameters may be underestimated (Red arrow) N R L The annulus is approximately perpendicular to the long-axis of the aorta Because the trigone between the L and N coronary cusps is imaged, be careful NOT to measure the calcification of the trigone (red arrow). Use of biplane imaging to align the annulus In a trileaflet AV, the maximum diameter of the annulus is in the plane the images the RCC (anterior) and the commissure between the LCC and NCC If 2 cusps are well imaged in the LAX view, this may not yield the largest annular diameter 1. Use the pattern of calcification and valve opening 2. Color Doppler jets (systolic and diastolic) may help align the LAX view The Hinge point is best defined in the LONG AXIS VIEW Why Measure in Systole? 1. Stroke volume calculations measure SYSTOLIC forward flow 2. In systole, the annulus becomes less elliptical 3. In systole, the sagittal dimension is the largest LVOT Pulsed Wave Doppler Location Flow acceleration occurs prior to a stenotic orifice (native disease) Flow acceleration occurs WITHIN the stent of the transcatheter valve Hahn RT et al. J Am Soc Echocardiogr 2013;26:

16 LVOT velocity Measurement at two locations: Pre and In Stent Preferred location of the sample volume is JUST AT THE APICAL EDGE of the THV in SYSTOLE Position of Sample Volume in SYSTOLE LVOT PW Sample volume placed just apical to the annulus Trace Modal Velocity Not the maximum velocities of a few blood cells Rather the most frequent value in a distribution Lower gain and/or increase reject VTI=21 VTI=32 1. The annulus is oval or elliptical 2. The sagittal plane (long axis imaging plane) is the minimum diameter and the coronal plane is the maximum diameter 3. In systole, the annulus becomes less elliptical (with larger sagittal dimension in systole) 4. Three D measurements(ct, MRI and 3D Echo) of mean diameter, perimeter or area, correlate well Koos R, et al. Int J Cardiol (2011), doi: /j.ijcard Hamdan A et al. J. Am. Coll. Cardiol., January 10, 2012; 59: Altiok E. et al. Heart 2011;97: Measured PW: LVOT Peak Velocity LVOT TVI AoV Stent TVI Measured CW: AoV Peak Velocity AoV Peak Gradient AoV Mean Gradient AoV TVI Calculated Doppler Stroke Volume Doppler Cardiac Output Doppler Cardiac Index AoV EOA Area AoV Area Index AoV Doppler Index LVOT TVI/AoV TVI Only trace the sharpest border Do not trace the feathery spectral signals Be aware of the cardiac cycles Only trace a systolic jet in systole Only trace a diastolic jet in diastole DO NOT TRACE the post extrasystolic higher velocity jet if in sinus rhythm With irregularly irregular rhythms, average 5 10 sequential beats Structural Valve Dysfunction Non structural Valve Dysfunction Thrombosis Endocarditis Akins CW, Miller DC, Turina MI et al. Guidelines for reporting mortality and morbidity after cardiac valve interventions. J Thorac Cardiovasc Surg 2008;135:

17 Bioprosthetic Valve Dysfunction Structural Dysfunction: Anatomic imaging or autopsy findings demonstrate nonreversible/persiste nt intrinsic bioprosthetic valve pathology which may result in stenosis or regurgitation of the prosthesis Sub classification Types of SVD Description Morphologic Structural Valve Dysfunction Isolated Hemodynamic Dysfunction (HD) Leaflet Integrity Leaflet Structure Leaflet Function Leaflet tears or defects (Non central intraframe AR) including flail Leaflet thickening Calcification Strut/frame Fracture or failure Loss of Mobility (> 50% reduction) resulting in Stenosis and/or central AR Mild HD > 50% increase in mean AV gradient from discharge baseline*, and/or mild intraprosthetic AR and/or moderate intraprosthetic AR (new or progressive). Moderate HD Mean gradient > 20mmHg and/or a of > 10mmHg, and/or moderate intra prosthetic AR (new or progressive). In the absence of a change in AR, a reduction in valve area and/or DVI may be seen. Severe HD Mean gradient 40 mmhg, and/or a change from baseline of > 20mmHg, and/or severe intra prosthetic AR (new or progressive). In the absence of a change in AR, a reduction in valve area and/or DVI is expected. Bioprosthetic Valve Dysfunction Non structural Dysfunction: Anatomic imaging or autopsy findings demonstrating nonreversible/persistent abnormality not intrinsic to the valve itself which may result in stenosis or regurgitation of the prosthesis Types of Non SVD Description Para valvular regurgitation Aortic Regurgitation (AR) located outside the prosthetic valve frame which may be a result of inappropriate sizing or suture dehiscence. May result in heart failure or hemolysis Intra prosthetic regurgitation AR within the surgical or stent frame in the absence of disruption of the valve components Entrapment of leaflets Reduced mobility of the prosthetic leaflet by tissue (i.e. native retained leaflet), suture or pannus Mal position of the prosthesis Inappropriate positioning of the prosthesis requiring corrective procedures Patient prosthetic mismatch (PPM)* *Grading of PPM based on gradients is not recommended in the setting the variable normal hemodynamic performance of different prosthetic valves and the complex relationship between gradients and flow. Primary Classification defined by Indexed Effective Orifice Area adjusted for BSA at discharge. Normal valve and leaflet function/mobility should be seen on imaging Structural Valve Dysfunction and Thrombosis TTE AVA = 0.54 cm 2 TEE 17

18 Peak/Mean gradient = 40/21 mmhg Peak/Mean gradient = 62/30 mmhg J Am Coll Cardiol 2012;60: Abnormal Finding on Follow-up: Peak/Mean gradient = 49/25 mmhg An increase in the mean gradient >10 mm Hg, a decrease in the EOA > cm2, or a reduction in the DVI > Isolated Hemodynamic Dysfunction (Isolated HD): In the absence of significant imaging findings of leaflet pathology on transthoracic echocardiography (TTE), hemodynamic changes in valve function may be identified (i.e. with transthoracic Doppler echocardiography). 18

19 Normal Reduced Motion Normal Reduced Motion NSVD: Paravalvular Regurgitation Pibarot et al. J Am Coll Cardiol Img 2015;8: ASE: Qualitative and quantitative parameters useful in grading aortic regurgitation severity in prosthetic valves Parameter Mild Moderate Severe Qualitative Jet density (CW Doppler) Incomplete/faint Dense Dense Jet deceleration (PHT by CW)) Slow > 500 Medium Steep < 200 Reversal of PW flow in the aorta Brief, early diastolic reversal Intermediate Prominent holodiastolic Rev (>20 cm/s)* Semi quantitative Vena contracta < >0.60 Jet width/lvot Width (%) < Jet area/lvot CSA (%) < Circum Extent/LVOT Circum (%) < Quantitative Regurgitant Volume (ml/beat) < Regurgitant Fraction (%) < EROA (cm 2 ) < Zoghbi et al J Am Soc Echocardiogr 2003;16: Color Doppler is influenced by jet shape and hemodynamics: jet area or length are *Lancellotti et al. Eur J Echocardiogr 2010;11;: NOT recommended methods of Kappetein assessing severity et al. J Am of prosthetic Coll Cardiol valve 2012;60: regurgitation A C B D Aorta to LV sweep of the Transcatheter Heart Valve 19

20 A B CAVEATS: 1. PVR is typically at the native commissures OR where the stent ASE Guidelines fails to & make PARTNER contact with Mild native PVL LVOT structures PARTNER 1 TRIAL: 2. PVR is discontinuous 2: because of the frame design (cells/nodes) 3. From SAX view, one MUST integrate the individual Mild PVL jets to assess circumferential Mild PVL extent <10% of the sewing ring <10% of the sewing ring Moderate PVL C D Moderate PVL 10 20% of the sewing ring Moderate PVL 10 30% of the sewing ring Severe PVL >20% of the sewing ring Zoghbi WA et al. J Am Soc Echocardiography 2009;22(9): Severe PVL Severe PVL >30% of the sewing ring Douglas PS et al. J Am Soc Echocardiography 2013;26(4): Strengths of New Grading Scheme: 1. Unifying Scheme which will allow us to understand prior grading schemes 2. Clinically relevant and familiar to clinical echocardiographers 3. Can be collapsed easily into simpler grading schemes Pibarot et al. J Am Coll Cardiol Img 2015;8: Parameters are inherently hierarchical: Parameters that are most frequently used to grade PVR severity by Doppler echocardiography. Parameters that are less often applicable due to pitfalls in the feasibility/accuracy of the measurements or to the interaction with other factors. Pibarot et al. J Am Coll Cardiol Img 2015;8: Courtesy of Dr. Oh, unpublished data Regurgitant volume using standard criteria should probably NOT be used since in hypertrophied, small ventricles, forward stroke volume on average (PARTNER Trial), was cc After Pibarot et al. J Am Coll Cardiol Img 2015;8:

21 Assess Color Doppler from ALL views Use integrative approach Apical 5Ch Apical 3Ch Using the TV septal leaflet insertion as 9 o clock, locate the position of the paravalvular jets Most common sites are at the commissures of the native valve: 1 2 o clock 5 6 o clock 9 10 o clock 6 Parasternal LAX Parasternal SAX A FIGURE B A FIGURE 4 B Ao The most useful view is the SAX, assuming acoustic shadowing can be avoided C D C LV D LV LA CAVEAT: If a previously unseen jet is identified from apical views, repeat imaging of the SAX view to clearly identify the origin of the jet should be performed LA LA After Pibarot et al. J Am Coll Cardiol Img 2015;8: After Pibarot et al. J Am Coll Cardiol Img 2015;8: FIGURE 4 (Cont d) FIGURE 4 (Cont d) Apical 5-Ch View E F I F E Apical 3-Ch View H After Pibarot et al. J Am Coll Cardiol Img 2015;8: G G H Angle of Imaging plays a large role in the jet imaged Distinguish Mitral inflow (blue arrow) Paravalvular Aortic regurgitation (yellow arrow) Central aortic regurgitation (red arrow) After Pibarot et al. J Am Coll Cardiol Img 2015;8:

22 FIGURE 5 FIGURE 5 (Cont d) Level of Imaging and Differences in Flow Sinus Lumen Native valve THV E F G RC LC NC LVOT Lumen Only flow seen just below the stented valve represents true regurgitation G E F Level of left main coronary artery (red arrow) The size of the jet is dependent on the level of imaging After Pibarot et al. J Am Coll Cardiol Img 2015;8: Level of the transcatheter valve leaflets (blue arrow) Lower level, near the ventricular edge of the transcatheter valve and the aortic regurgitant jet is much larger FIGURE 6: Examples of paravalvular regurgitation Trace Mild Mild moderate A B C G FIGURE 6 (Cont d) H D E F Wrap around jets Moderate Moderate Severe Severe After Pibarot et al. J Am Coll Cardiol Img 2015;8: After Pibarot et al. J Am Coll Cardiol Img 2015;8: The STS/ACC TVT Registry is a benchmarking tool for transcatheter valve replacement and repair procedures and emerging treatments for valve disease patients Tracks patient safety Monitors real world outcomes. Serves as a powerful research tool that may significantly change our current clinical practice The strength of the database depends on you for accurate and comprehensive data entry! 22