| Valve structure and motion |
|---|
| Mechanical or bioprosthetic |
| Mild: Usually normal Moderate: Abnormal** Severe: Abnormal** |
| Structural parameters |
| LV size |
| Mild: Normal* Moderate: Normal or mildly dilated Severe: Usually dilated*** |
| Prosthetic valve***** |
| Mild: Usually normal Moderate: Abnormal****** Severe: Abnormal****** |
| Doppler parameters |
| Color flow jet area***** # |
| Mild: Small, central jet (usually <4 cm2 or <20% of LA area) Moderate: Variable Severe: Large central jet (usually >8 cm2 or >40% of LA area) or variable size wall-impinging jet swirling in left atrium |
| Flow convergence## |
| Mild: None or minimal Moderate: Intermediate Severe: Large |
| Jet density: CW Doppler***** |
| Mild: Incomplete or faint Moderate: Dense Severe: Dense |
| Jet contour: CW Doppler***** |
| Mild: Parabolic Moderate: Usually parabolic Severe: Early peaking, triangular |
| Pulmonary venous flow***** |
| Mild: Systolic dominance**** Moderate: Systolic blunting**** Severe: Systolic flow reversal** |
| Quantitative parameters### |
| VC width (cm) |
| Mild: <0.3 Moderate: 0.3-0.59 Severe: ≥0.6 |
| R vol (mL/beat) |
| Mild: <30 Moderate: 30-59 Severe: ≥60 |
| RF (%) |
| Mild: <30 Moderate: 30-49 Severe: ≥50 |
| EROA (cm2) |
| Mild: <0.20 Moderate: 0.20-0.49 Severe: ≥0.50 |
EROA, Effective regurgitant orifice
*LV size applied only to chronic lesions.
**Pulmonary venous systolic flow reversal is specific but not sensitive for severe MR.
***In the absence of other etiologies of LV enlargement and acute MR.
****Unless other reasons for systolic blunting (eg, atrial fibrillation, elevated LA pressure).
*****Parameter may be best evaluated or obtained with TEE, particularly in mechanical valves.
******Abnormal mechanical valves, for example, immobile occluder (valvular regurgitation), dehiscence or rocking (paravalvular regurgitation); abnormal biologic valves, for example, leaflet thickening or prolapse (valvular), dehiscence or rocking (paravalvular regurgitation).
#At a Nyquist limit of 50 to 60 cm/s.
##Minimal and large flow convergence defined as a flow convergence radius <0.4 and ≥0.9 cm for central jets, respectively, with a baseline shift at a Nyquist limit of 40 cm/s; cutoffs for eccentric jets may be higher.
###These quantitative parameters are less well validated than in native MR.