Echo Info
🫀

Prosthetic Valve Function

ASE Guidelines — Echocardiographic & Multimodality Assessment

JASE 2024 · Zoghbi et al. · DOI 10.1016/j.echo.2023.10.004

Prosthetic Heart Valve Assessment — Overview

Echocardiography is the first-line modality. Know valve type and size before interpreting hemodynamics. Always compare with baseline post-implantation study.

PHV Dysfunction Categories

① Structural Valve Dysfunction (SVD)

  • Intrinsic permanent changes — wear, leaflet fibrosis/calcification, stent fracture
  • More common in bioprosthetic valves
  • Calcification in 50% of porcine valves at 5 yr; 75% at 8 yr
  • Failure rates 10–20% at 10–15 yr (homografts); 30% (heterografts)

② Nonstructural Dysfunction

  • PPM — normally functioning PHV too small for patient body size
  • Paravalvular leak (PVL) — dehiscence (surgical) or malapposition (transcatheter)
  • Pannus — fibrous ingrowth (0.2–4.5% prevalence; 3× more common mitral)
  • Inappropriate sizing, chamber dilation, valve embolization

③ Endocarditis

  • Prevalence 1–6%; can occur any time post-surgery
  • Mechanical: spreads from sewing ring → PVL, abscess, fistula
  • Bioprosthetic: originates in leaflet cusps
  • Paravalvular abscess: 56–100% of PHV endocarditis (vs 10–40% native)

④ Thrombus

  • Prevalence 0.3–8% of PHVs
  • Right-sided valves 12–20× more vulnerable than left-sided
  • Echo: soft echodensity mass; CT: hypoattenuated leaflet thickening (HALT)
  • CT HU <145 = thrombus; >200 = pannus (87.5% sensitivity, 96% specificity)
Essential Assessment Parameters
📖 Always document valve type and size — hemodynamic thresholds differ by valve design. Compare with prior baseline study to detect change.
Doppler Parameters — All Valves
Peak velocity & gradientFlow-dependent
Mean pressure gradientPrimary criterion
EOA (continuity equation)Flow-independent
Doppler Velocity Index (DVI)Flow-independent
Jet contour / acceleration timeAortic position
PHT (pressure half-time)Mitral & tricuspid
Regurgitation severityTrans- + paravalvular
Key Principles
Use ≥1 flow-dependent and ≥1 flow-independent parameter to diagnose stenosis — never rely on a single value
Doppler insonation from all available windows; use small non-imaging probe at suprasternal notch for aortic valves
Bileaflet mechanical valves: pressure recovery overestimates gradient by Doppler, especially in small valves + high-flow states
EOA via continuity equation — measure LVOT at largest diameter perpendicular to flow (underestimating diameter is the main error source)
Significant stenosis should meet ≥1 flow-dependent criterion and ≥1 flow-independent criterion simultaneously
Prosthesis-Patient Mismatch (PPM)
⚠️ PPM = indexed EOA too small for patient body size, despite normally functioning valve. Indexed EOA overestimates PPM severity in obesity (BMI >30).
PositionNormalModerate PPMSevere PPM
Aortic (BMI <30)>0.85 cm²/m²0.66–0.85≤0.65
Aortic (BMI ≥30)>0.70 cm²/m²0.56–0.70≤0.55
Mitral (BMI <30)>1.2 cm²/m²0.91–1.2≤0.90
Mitral (BMI ≥30)>1.0 cm²/m²0.76–1.0≤0.75
Structural Valve Deterioration (SVD) Criteria
ParameterPossible SVDSignificant SVD
↑ Mean gradient≥10 mm Hg → ≥20 mm Hg≥20 mm Hg → ≥30 mm Hg
↓ EOA≥0.3 cm² or ≥25%≥0.6 cm² or ≥50%
↓ DVI≥0.1 or ≥20%≥0.2 or ≥40%
New intraprosthetic AR↑ ≥1 grade → mod+↑ ≥2 grades → sev
All changes measured from baseline 1–3 month post-procedural assessment under stable hemodynamics and LV function.

Prosthetic Aortic Valve Assessment

Use at least one flow-dependent and one flow-independent parameter. Acquire Doppler from all windows. Always compare with baseline.

Algorithm — Elevated Prosthetic Aortic Jet Velocity >3 m/s (Figure 13)
📖 Evaluate jet contour first (early vs late peak), then DVI to reach a diagnosis.
Figure 13 — Prosthetic aortic jet velocity algorithm Algorithm for evaluation of elevated peak prosthetic aortic jet velocity. Zoghbi et al. JASE 2024. Prosthetic aortic jet velocity > 3 m/s Jet Contour Early Peak AT < 100 ms · AT/ET < 0.37 Late Peak AT > 100 ms · AT/ET > 0.37 DVI ≥ 0.30 0.29 – 0.25 < 0.25 Normal AVR § Possible stenosis* § Stenosis* § Indexed EOA (cm²/m²): > 0.85: High flow state < 0.85: Patient-prosthesis mismatch Consider: – Valve stenosis with small LVOT – Improper LVOT PW Doppler position – Underestimation of jet velocity Consider: – Valvular stenosis incl. thrombosis – Sub-valvular stenosis * Valve stenosis further substantiated by EOA vs reference values for same valve type and size. § Mechanical valve motion: fluoroscopy & CT > TEE. Etiology of stenosis: CT angiography & TEE > CMR.
Doppler Stenosis Criteria — Aortic Position
📖 Significant stenosis = meets ≥1 flow-dependent (velocity/gradient) AND ≥1 flow-independent (EOA or DVI) criterion. Exclude high-flow states, supra/subvalvular obstruction, and pressure recovery before diagnosing stenosis.
ParameterNormalPossible StenosisSignificant Stenosis
Appropriate for ALL prosthetic aortic valves
Jet velocity contourTriangular, early peakingTriangular to intermediateRounded, symmetric
Acceleration time (AT)<80 ms80–100 ms>100 ms
AT / LV ejection time ratio<0.320.32–0.37>0.37
Peak velocity<3 m/s3–4 m/s≥4 m/s
SAVR-specific
Mean gradient<20 mm Hg20–34 mm Hg≥35 mm Hg
DVI (VTILVOT / VTIPrAV)>0.350.25–0.35<0.25
EOAReference ± 1 SD1 SD below reference2 SDs below reference
TAVI — change from baseline
Mean gradient change<10 mm Hg ↑ from baseline10–19 mm Hg ↑≥20 mm Hg ↑
DVI change<0.1 or <20% ↓0.1–0.19 or 20–39% ↓≥0.2 or ≥40% ↓
EOA change<0.3 cm² or <25% ↓0.3–0.59 cm² or 25–49% ↓≥0.6 cm² or ≥50% ↓
Prosthetic AR Severity — Grading Parameters
ParameterMildModerateSevere
Jet width / LVOT diameter (central jets)≤25%26–64%≥65%
VC width<0.3 cm0.3–0.6 cm>0.6 cm
VC area (2D/3D color)<0.10 cm²0.10–0.29 cm²≥0.30 cm²
Circumferential PVL extent<10%10–29%≥30%
PHT>500 ms200–500 ms<200 ms
Holodiastolic flow reversal (descending Ao)Absent / brief earlyIntermediateProminent, holodiastolic
Regurgitant volume<30 mL/beat30–59 mL≥60 mL
Regurgitant fraction<30%30–50%≥50%
TAVI & Valve-in-Valve Considerations
In-stent flow acceleration: occurs at 2 locations — at stent inlet AND at valve cusps. Measure LVOT diameter and PW Doppler proximal to the stent to avoid EOA overestimation.
LVOT diameter (TAVI): Use outer-to-outer diameter of the stented valve at its lower (ventricular) end. Inner-to-inner may be used if PW sample placed inside stent proximal to cusps.
ViV elevated gradients: Mean gradient >20 mm Hg in 28% of ViV cases. Confirm with catheterization — echo overestimates vs invasive due to pressure recovery (greater with self-expandable than balloon-expandable valves).
ViV PPM: Moderate or greater PPM in 60% of ViV; severe in 25%. However, moderate/severe PPM does not independently affect 1- or 3-year mortality.
TAVI vs SAVR: TAVI has similar or lower gradients, higher indexed EOA, lower PPM rates. Mild paravalvular AR more common in TAVI than SAVR despite improved skirt designs.

Prosthetic Mitral Valve Assessment

TEE often essential — TTE detection of MR jets is limited by acoustic reverberation and shadowing from mitral prostheses. Always report heart rate at time of Doppler measurement.

Doppler Criteria — Prosthetic Mitral Stenosis
⚠️ EOA via PHT method frequently inaccurate and leads to overestimation — use continuity equation instead.
ParameterNormalPossibleSignificant
Peak velocity<1.9 m/s1.9–2.5 m/s≥2.5 m/s
Mean gradient≤5 mm Hg6–10 mm Hg>10 mm Hg
DVI (VTIPrMV / VTILVOT)<2.22.2–2.5>2.5
EOA (continuity equation)≥2.0 cm²1–2 cm²<1 cm²
PHT<130 ms130–200 ms>200 ms
📖 DVI (VTIPrMV/VTILVOT) is the most specific and sensitive single Doppler parameter for mitral prosthetic stenosis in published studies. Note that elevated DVI can also reflect significant MR (high flow through valve).
Indirect Signs of Significant Prosthetic MR
⚠️ TTE color Doppler frequently limited by acoustic shadowing from mitral prosthesis — look for these spectral Doppler clues.
Peak mitral E velocity ≥1.9 m/s (mechanical valves) — sensitivity 90%, specificity 89%
VTIPrMV / VTILVOT ≥2.5 — sensitivity 89%, specificity 91% (when both elevated with normal PHT → specificity ~100%)
Mean gradient ≥5 mm Hg — sensitivity 90%, specificity 70%
Maximal TR jet velocity >3 m/s — sensitivity 80%, specificity 71%
Hyperdynamic LV with low VTILVOT (<16 cm) — suggests MR despite preserved function
Systolic flow convergence on LV side of prosthesis — low sensitivity, high specificity
If significant MR suspected → TEE indicated. The parasternal window often gives best color Doppler view of prosthetic MR on TTE.
Prosthetic MR Severity Grading — TTE + TEE
ParameterMildModerateSevere
Color jet area (central)<4 cm² or <20% LAVariable>8 cm² or >50% LA (or wall-impinging)
Vena contracta width<0.3 cm0.3–0.69 cm≥0.7 cm
PISA radius (Nyquist 40 cm/s)≤0.5 cm0.6–0.9 cm>0.9 cm
Pulmonary vein flowSystolic dominanceSystolic bluntingSystolic flow reversal
Regurgitant volume<30 mL/beat30–59 mL≥60 mL
Regurgitant fraction<30%30–49%≥50%
EROA<0.20 cm²0.20–0.39 cm²≥0.40 cm²
📖 For paravalvular jets: circumferential extent of sewing ring occupied by jet guides severity — <10% mild, 10–29% moderate, ≥30% severe.

Prosthetic Tricuspid & Pulmonary Valve Assessment

Off-axis views often required. Heart rate and respiration significantly affect tricuspid gradients — average ≥5 cycles or measure at mid-expiratory apnea.

Prosthetic Pulmonary Valve Stenosis
ParameterNormalPossible Obstruction
Peak velocity — bioprosthesis<3.2 m/s≥3.2 m/s
Peak velocity — homograft<2.5 m/s≥2.5 m/s
Mean gradient — bioprosthesis<20 mm Hg≥20 mm Hg
Mean gradient — homograft<15 mm Hg≥15 mm Hg
RV systolic pressureStableIncreased from baseline
RV size and functionStableIncreased size / ↓ function
DVIStableDecreased from baseline
⚠️ Use PW Doppler to localize obstruction — may occur at valve, conduit edge, or branch PA. RVSP in PVR stenosis = RV systolic pressure minus gradient across obstructed valve.
Prosthetic Pulmonary Regurgitation Severity
ParameterMildModerateSevere
Jet width / annulus≤25%26–50%>50%
Jet density (CW)Incomplete/faintDenseDense
Jet decelerationSlowVariableSteep; early termination
Diastolic flow reversal (distal main PA)NonePresentPresent
RV sizeNormalNormal or dilatedDilated / progressive
Regurgitant fraction (Echo)<30%30–50%>50%
Regurgitant fraction (CMR)<26%26–35%>35%
📖 PHT <95 ms or slope >4.9 m/s² indicates need for intervention. CMR is superior for PR quantification — preferred for serial assessment.
Prosthetic TV Stenosis Criteria
⚠️ PHT-derived EOA overestimates TV area in bioprostheses — use continuity equation (EOA = stroke volume / VTIPrTV). If significant AR, measure stroke volume from RVOT.
ParameterBioprostheticMechanical
Peak E velocity≥2.1 m/s≥1.9 m/s
Mean gradient≥9 mm Hg≥6 mm Hg
PHT≥200 ms≥130 ms
EOA (continuity eq.)<1.5 cm²<2.0 cm²
DVI (VTIPrTV / VTILVOT)≥3.3≥2.1
For ViV or valve-in-ring: post-implantation mean gradient >10 mm Hg = evidence of stenosis. Normal bioprosthetic gradients <6–9 mm Hg across valve sizes.
Prosthetic TR Severity Grading
ParameterMildModerateSevere
Color jet areaSmall, narrow, centralModerate centralLarge central or wall-impinging
Vena contracta width<0.3 cm0.3–0.69 cm≥0.7 cm
PISA radius≤0.5 cm0.6–0.9 cm>0.9 cm
Hepatic vein flowSystolic dominanceSystolic bluntingSystolic flow reversal
EROA<0.20 cm²0.20–0.39 cm²≥0.40 cm²
Regurgitant volume<30 mL30–44 mL≥45 mL
CW Doppler contourFaint, parabolicDense, parabolicDense, triangular
📖 Modified RV inflow and subcostal views are essential to compensate for acoustic shadowing. 3D color planimetry of VC area may be the most accurate method but requires further validation.

Hemodynamic Calculators

All calculated values are estimates. EOA via continuity equation is preferred — less flow-dependent than gradient alone. Compare with reference values for specific valve type and size.

Calculator
EOA — Continuity Equation
EOA = (LVOT area × VTILVOT) / VTIvalve
LVOT area = 0.785 × LVOT diameter²
For TAVI: use outer-to-outer stent diameter
cm
cm
cm
EOA / DVI
Calculator
PPM — Indexed EOA
iEOA = EOA (cm²) / BSA (m²)
BSA = 0.007184 × height0.725 × weight0.425 (Dubois)
cm²
cm
kg
Indexed EOA / PPM Grade
Calculator
Aortic DVI Interpreter
DVIPrAV = VTILVOT / VTIPrAV
Normal SAVR: >0.35 · Significant stenosis: <0.25
DVI ≤0.35 associated with adverse outcomes in SAVR (not TAVI)
cm
cm
DVI
Calculator
Regurgitant Volume & Fraction (Aortic/Pulmonary)
RVol = SVprox − SVdistal
RF (%) = RVol / SVtotal × 100
For MR/TR: indirect method using LV total SV − aortic forward SV
mL
mL
Regurgitant Volume / Fraction

Multimodality Imaging of Prosthetic Valves

CT and CMR complement TTE/TEE — choice depends on valve type, position, and suspected pathology.

Comparative Strengths by Modality
ApplicationTTETEECTCMR
Valve structure / anatomic area (bioprosthetic)+++++++++++++
Valve structure / motion (mechanical)+++ (MV 4+)+++++
Gradient / EOA+++++ (MV 3+)—++
Thrombus / pannus (mechanical)+++++++++
Regurgitation — localization+++++++++
Regurgitation — quantitation++++++++++++
Valve dehiscence++++++++++++
Endocarditis / vegetations+++++++ (abscess +++)+
CT — Key Indications & Findings
Mechanical valve motion: Opening/closing angles without contrast. Normal opening angle 73–90° (bileaflet), 60–80° (monoleaflet). Noncontrast CT sufficient.
Thrombus vs pannus: CT HU <145 = thrombus (87.5% sens, 96% spec vs pannus). Thrombus: early post-op, aortic side, HU <200. Pannus: late, ventricular side, HU >200.
HALT (hypoattenuated leaflet thickening): Prevalence 3.6–40% of TAVI. Responds to anticoagulation. Monitor with serial CT.
Paravalvular leak: Contrast-filled channel connecting upstream and downstream lumina. Distinguish from pledgets (felt HU 383–494 vs contrast 202–367).
Endocarditis workup: CT superior for paravalvular extension, root abscess; TEE superior for small vegetations (<4 mm) and perforations (<2 mm).
Limitations: No hemodynamic evaluation; beam-hardening artifact from metallic prostheses; nephrotoxic contrast; higher radiation with retrospective gating.
CMR — Key Indications & Methods
Regurgitation quantitation: Through-plane phase contrast at aortic/pulmonary level. Regurgitant volume = forward − net flow. Not affected by jet number or eccentricity.
Bioprosthetic valve area: Stack of 4–5 mm slices perpendicular to valve. Planimetry at leaflet tips during maximal systolic opening. Anatomic area = ~10–20% larger than effective area.
Prosthetic MR (indirect method): LV total stroke volume (SSFP cines) − aortic forward stroke volume (phase contrast at proximal ascending aorta) = MR volume.
LV remodeling: Late gadolinium enhancement detects replacement fibrosis. Focal fibrosis in 30–50% of AS patients; predicts perioperative risk and post-TAVI/SAVR survival.
Limitations: Mechanical valves create large artifact; arrhythmias reduce accuracy; lower temporal resolution vs echo; limited for small vegetations. Safe at 1.5T and 3T.
Indications for CMR after TTE: Discrepant clinical and echo findings; area-gradient mismatch; AR/PR quantitation; paravalvular complications; LV remodeling assessment.
When to Use Advanced Imaging
Clinical QuestionPreferred Next StepRationale
Elevated aortic gradient — mechanism unclearCT or TEEVisualize leaflets; distinguish thrombus, pannus, SVD, PPM
Mechanical valve — occluder motion cannot be assessedCT or fluoroscopyEcho artifact from metal; CT/fluoro directly measures opening angles
Suspected prosthetic MR (mitral or tricuspid)TEE (2D + 3D)TTE limited by shadowing; TEE provides en face view and jet localization
Quantify AR or PR severityCMRPhase-contrast provides absolute regurgitant volumes irrespective of jet eccentricity
Endocarditis — paravalvular extensionCT angiographyBetter than TEE for abscess, pseudoaneurysm, fistula extent
Pre-TAVI planning / ViV sizingCTCoronary ostial distances; annular sizing; leaflet calcification
Pulmonary valve / conduit (poor echo windows)CMR then CTCMR quantifies PR; CT useful when stent artifact limits CMR
Thrombus vs pannus (mechanical)CT with contrastHU thresholds differentiate with high specificity; guides thrombolysis decision

Normal Doppler Reference Values — Appendix Tables A1–A9

Mean ± SD unless noted. Values are flow-dependent — compare with patient-specific baseline when available. Refer to original guidelines for full dataset.

Table A1 — SAPIEN Percutaneous Aortic Valves (Native AS, Mean ± SD)
📖 All data from Hahn et al., JACC Cardiovasc Imaging 2019. Values at 30 days post-implant.
Valve / SizeEOA (cm²)Mean Gradient (mm Hg)DVI
SAPIEN (1st gen)
23 mm1.56 ± 0.439.92 ± 4.270.53 ± 0.13
26 mm1.84 ± 0.528.76 ± 3.890.53 ± 0.13
All sizes1.70 ± 0.499.36 ± 4.130.53 ± 0.13
SAPIEN XT
23 mm1.41 ± 0.3010.41 ± 3.740.52 ± 0.10
26 mm1.74 ± 0.429.24 ± 3.570.54 ± 0.11
29 mm2.06 ± 0.528.36 ± 3.140.53 ± 0.11
All sizes1.67 ± 0.469.52 ± 3.640.53 ± 0.11
SAPIEN 3
20 mm1.22 ± 0.2216.23 ± 5.010.42 ± 0.07
23 mm1.45 ± 0.2612.79 ± 4.650.43 ± 0.08
26 mm1.74 ± 0.3510.59 ± 3.880.43 ± 0.09
29 mm1.89 ± 0.379.28 ± 3.160.40 ± 0.09
All sizes1.66 ± 0.3811.18 ± 4.350.43 ± 0.09
Table A2 — CoreValve & Evolut R Percutaneous Aortic Valves (Native AS, Mean ± SD)
Valve / SizeEOA (cm²)Mean Gradient (mm Hg)DVI
CoreValve
23 mm1.12 ± 0.3614.43 ± 5.720.44 ± 0.09
26 mm1.74 ± 0.498.27 ± 3.820.59 ± 0.15
29 mm1.97 ± 0.538.85 ± 4.170.54 ± 0.12
31 mm2.15 ± 0.729.55 ± 3.440.49 ± 0.12
All sizes1.88 ± 0.568.85 ± 4.140.55 ± 0.13
Evolut R (30 days)
23 mm1.09 ± 0.2614.97 ± 7.150.42 ± 0.04
26 mm1.69 ± 0.407.53 ± 2.650.61 ± 0.13
29 mm1.97 ± 0.547.85 ± 3.080.59 ± 0.14
34 mm2.60 ± 0.756.30 ± 3.230.58 ± 0.15
All sizes2.01 ± 0.657.52 ± 3.190.59 ± 0.14
Table A3 — Aortic Valve-in-Valve at 1 Year (Mean ± SD)
⚠️ ViV gradients are generally higher than native TAVI — elevated gradients (mean >20 mm Hg) in 28% of cases. Confirm with invasive catheterization if clinically significant.
TAVI ViV ValvePeak Gradient (mm Hg)Mean Gradient (mm Hg)EOA (cm²)
CoreValve (all)23.48 ± 12.1012.89 ± 0.201.62 ± 0.14
Evolut (all)22.43 ± 5.7214.70 ± 9.111.36 ± 0.07
SAPIEN 3 (all)33.93 ± 10.1127.00 ± 10.201.07 ± 0.32
SAPIEN XT (all)31.31 ± 3.7518.02 ± 4.221.31 ± 0.25
Table A4 — Surgical Prosthetic Aortic Valves (Mean ± SD)
📖 Use valve-type and size-specific reference to assess EOA. "—" indicates data not reported in source. Modified from Rajani et al., J Heart Valve Dis 2007.
Valve (Type)Size (mm)Peak Grad (mm Hg)Mean Grad (mm Hg)EOA (cm²)
Abbott Epic (stented porcine)21—19.1 ± 8.21.0 ± 0.3
23—13.9 ± 6.01.4 ± 0.5
25—12.1 ± 5.11.5 ± 0.5
27—11.4 ± 4.11.6 ± 0.4
29—7.5 ± 3.32.4 ± 1.1
Abbott Trifecta (stented pericardial)19—10.7 ± 4.61.41 ± 0.24
21—8.1 ± 3.51.63 ± 0.29
23—7.2 ± 2.81.81 ± 0.30
25—6.2 ± 2.72.02 ± 0.32
27—4.8 ± 2.02.20 ± 0.20
29—4.7 ± 1.62.35 ± 0.22
ATS Bileaflet (mechanical)1947.0 ± 12.625.3 ± 8.01.1 ± 0.3
2123.7 ± 6.815.9 ± 5.01.4 ± 0.5
23—14.4 ± 4.91.7 ± 0.5
25—11.3 ± 3.72.1 ± 0.7
27—8.4 ± 3.72.5 ± 0.1
29—8.0 ± 3.03.1 ± 0.8
ATS AP Bileaflet (mechanical)2021.4 ± 4.211.1 ± 3.51.3 ± 0.3
2218.7 ± 8.310.5 ± 4.51.7 ± 0.4
2415.1 ± 5.67.5 ± 3.12.0 ± 0.6
26—6.0 ± 2.02.1 ± 0.4
18—21.0 ± 1.81.2 ± 0.3
Baxter Perimount (stented bovine pericardial)1932.5 ± 8.519.5 ± 5.51.3 ± 0.2
2124.9 ± 7.713.8 ± 4.01.3 ± 0.3
2319.9 ± 7.411.5 ± 3.91.6 ± 0.3
2516.5 ± 7.810.7 ± 3.81.6 ± 0.4
2712.8 ± 5.44.8 ± 2.22.0 ± 0.4
Carbomedics Standard (bileaflet mechanical)1938.0 ± 12.818.9 ± 8.31.0 ± 0.3
2126.8 ± 10.112.9 ± 5.41.5 ± 0.4
2322.5 ± 7.411.0 ± 4.61.4 ± 0.3
2519.6 ± 7.89.1 ± 3.51.8 ± 0.4
Carpentier-Edwards Pericardial (stented bovine pericardial)1932.1 ± 3.424.2 ± 8.61.2 ± 0.3
2125.7 ± 9.920.3 ± 9.11.5 ± 0.4
2321.7 ± 8.613.0 ± 5.31.8 ± 0.3
2516.5 ± 5.49.0 ± 2.3—
Carpentier-Edwards Standard (stented porcine)1943.5 ± 12.725.6 ± 8.00.9 ± 0.2
2127.7 ± 7.617.3 ± 6.21.5 ± 0.3
2328.9 ± 7.516.1 ± 6.21.7 ± 0.5
2524.0 ± 7.112.9 ± 4.61.9 ± 0.5
2722.1 ± 8.212.1 ± 5.52.3 ± 0.6
Edwards Inspiris Resilia (stented pericardial)19—17.6 ± 7.81.1 ± 0.2
21—12.6 ± 4.71.3 ± 0.3
23—10.1 ± 3.81.6 ± 0.4
25—9.6 ± 5.21.8 ± 0.5
Edwards Intuity (sutureless)19—13.9 ± 3.91.1 ± 0.1
21—11.6 ± 3.61.3 ± 0.1
23—10.4 ± 3.51.7 ± 0.2
25—9.1 ± 3.21.9 ± 0.2
27—8.3 ± 3.72.2 ± 0.2
Hancock II (stented porcine)21—14.8 ± 4.11.3 ± 0.4
2334.0 ± 13.016.6 ± 8.51.3 ± 0.4
2522.0 ± 5.310.8 ± 2.81.6 ± 0.4
2916.2 ± 1.58.2 ± 1.71.6 ± 0.2
Medtronic Freestyle (stentless)21—9.1 ± 5.11.4 ± 0.3
2311.0 ± 4.08.1 ± 4.61.7 ± 0.5
25—5.3 ± 3.12.1 ± 0.5
27—4.6 ± 3.12.5 ± 0.1
Medtronic Mosaic (stented porcine)21—14.2 ± 5.01.4 ± 0.4
2323.8 ± 11.013.7 ± 4.81.5 ± 0.4
2522.5 ± 10.011.7 ± 5.11.8 ± 0.5
27—10.4 ± 4.31.9 ± 0.1
Medtronic Avalus (stented pericardial)19—17.1 ± 5.01.11 ± 0.25
21—14.5 ± 4.31.25 ± 0.25
23—12.1 ± 3.81.47 ± 0.32
25—11.7 ± 4.01.57 ± 0.31
MCRI On-X (bileaflet mechanical)1921.3 ± 10.811.8 ± 3.41.5 ± 0.2
2116.4 ± 5.99.9 ± 3.61.7 ± 0.4
2315.9 ± 6.48.6 ± 3.41.9 ± 0.6
2516.5 ± 10.26.9 ± 4.32.4 ± 0.6
St. Jude Medical Regent (bileaflet mechanical)1920.6 ± 1211.0 ± 4.91.6 ± 0.4
2115.6 ± 9.48.0 ± 4.82.0 ± 0.7
2312.8 ± 6.86.9 ± 3.52.3 ± 0.9
2511.7 ± 6.85.6 ± 3.22.5 ± 0.8
277.9 ± 5.53.5 ± 1.73.6 ± 0.5
St. Jude Medical Standard (bileaflet mechanical)1942.0 ± 10.024.5 ± 5.81.5 ± 0.1
2125.7 ± 9.515.2 ± 5.01.4 ± 0.4
2321.8 ± 7.513.4 ± 5.61.6 ± 0.4
2518.9 ± 7.311.0 ± 5.31.9 ± 0.5
2713.7 ± 4.28.4 ± 3.42.5 ± 0.4
2913.5 ± 5.87.0 ± 1.72.8 ± 0.5
Sorin Perceval (sutureless)S (21)—10.1 ± 4.21.3 ± 0.3
M (23)—9.4 ± 5.51.5 ± 0.4
L (25)—8.5 ± 4.61.5 ± 0.4
XL (27)—9.7 ± 4.71.6 ± 0.4
Starr-Edwards (caged ball)2332.6 ± 12.822.0 ± 9.01.1 ± 0.2
2631.8 ± 9.019.7 ± 6.1—
2929.0 ± 9.316.3 ± 5.5—
Homograft20–227.2 ± 3.03.5 ± 1.5—
24–276.2 ± 2.62.8 ± 1.1—
Showing selected valves. See full guidelines Appendix Table A4 for all 35+ valve types.
Table A5 — Surgical Prosthetic Mitral Valves (Mean ± SD)
📖 Always report heart rate at time of measurement. Modified from Rosenhek et al., J Am Soc Echocardiogr 2003.
Valve (Type)Size (mm)Peak Grad (mm Hg)Mean Grad (mm Hg)Peak Vel (m/s)PHT (ms)EOA (cm²)
Abbott Epic27—6.1 ± 2.9——1.4 ± 0.7
29—5.5 ± 1.7——1.5 ± 0.5
31—4.8 ± 1.4——1.6 ± 0.3
33—4.1 ± 1.6——1.5 ± 0.3
Bjork-Shiley (single tilting disk)2512 ± 46 ± 21.75 ± 0.3899 ± 271.72 ± 0.6
2710 ± 45 ± 21.6 ± 0.4989 ± 281.81 ± 0.54
297.83 ± 2.932.83 ± 1.271.37 ± 0.2579 ± 172.1 ± 0.43
316 ± 32 ± 1.91.41 ± 0.2670 ± 142.2 ± 0.3
23——1.7115—
Carbomedics (bileaflet mechanical)2510.3 ± 2.33.6 ± 0.61.3 ± 0.193 ± 82.9 ± 0.8
278.79 ± 3.463.46 ± 1.031.61 ± 0.389 ± 202.9 ± 0.75
298.78 ± 2.93.39 ± 0.971.52 ± 0.388 ± 172.3 ± 0.4
318.87 ± 2.343.32 ± 0.871.61 ± 0.2992 ± 242.8 ± 1.14
Carpentier-Edwards Pericardial (stented)27—6 ± 21.7 ± 0.398 ± 28—
29—4.7 ± 21.76 ± 0.2792 ± 14—
31—4.4 ± 21.54 ± 0.1592 ± 19—
33—6 ± 3—93 ± 12—
27—3.61.6100—
Carpentier-Edwards Perimount (stented pericardial)25—4.0 ± 1.01.7 ± 0.1067 ± 21.51.75 ± 0.53
27—6.3 ± 1.651.7 ± 0.2774 ± 20.61.88 ± 0.52
29—6.0 ± 1.411.8 ± 0.1976 ± 17.92.02 ± 0.57
31—5.5 ± 1.061.8 ± 0.2080 ± 21.82.09 ± 0.48
33—6.1 ± 1.861.7 ± 0.2377 ± 13.22.24 ± 0.97
Hancock II (stented porcine)25—8.3 ± 1.712.1 ± 0.2876 ± 19.81.42 ± 0.29
27—6.1 ± 1.332.0 ± 0.2881 ± 18.91.62 ± 0.47
29—6.7 ± 2.202.0 ± 0.3177 ± 15.11.83 ± 0.68
31—6.0 ± 1.582.0 ± 0.3276 ± 12.11.70 ± 0.41
33—5.5 ± 1.641.9 ± 0.5065 ± 8.72.71 ± 0.77
Medtronic Mosaic (stented porcine)25—8.3 ± 1.712.1 ± 0.2876 ± 19.81.42 ± 0.29
27—6.1 ± 1.332.0 ± 0.2881 ± 18.91.62 ± 0.47
29—6.7 ± 2.202.0 ± 0.3177 ± 15.11.83 ± 0.68
31—6.0 ± 1.582.0 ± 0.3276 ± 12.11.70 ± 0.41
On-X (bileaflet mechanical)2511.5 ± 3.25.3 ± 2.1——1.9 ± 1.1
27–2910.3 ± 4.54.5 ± 1.6——2.2 ± 0.5
31–339.8 ± 3.84.8 ± 2.4——2.5 ± 1.1
——————
St. Jude Medical (bileaflet mechanical)25—2.5 ± 11.34 ± 1.1275 ± 41.35 ± 0.17
2711 ± 45 ± 1.821.61 ± 0.2975 ± 101.67 ± 0.17
2910 ± 34.15 ± 1.81.57 ± 0.2985 ± 101.75 ± 0.24
3112 ± 64.46 ± 2.221.59 ± 0.3374 ± 132.03 ± 0.32
23—4.01.51601.0
33—————
Starr-Edwards (caged ball)28—7 ± 2.751.9 ± 0.57——
3012.2 ± 4.66.99 ± 2.51.7 ± 0.3125 ± 251.65 ± 0.4
3211.5 ± 4.25.08 ± 2.51.7 ± 0.3110 ± 251.98 ± 0.4
34—5.02.6——
26—10.0——1.4
Edwards Mitris (stented pericardial)25—4.9 ± 1.2——1.1 ± 0.4
27—4.1 ± 1.4——1.2 ± 0.3
29—4.1 ± 1.5——1.5 ± 0.6
31—3.9 ± 2.0——1.4 ± 0.5
33—3.3 ± 1.4——1.5 ± 0.7
Table A6 — SAPIEN Valve in Mitral Position (ViV / ViR / ViMAC)
⚠️ None of the SAPIEN valves in these studies had >2+ MR. Data expressed as median (IQR) or mean ± SD.
Reference / SizeViVViRViMACAll (Mean Gradient, mm Hg)
Guerrero et al. (all sizes)7 (6–9)7 (6–9)6 (4–8)7 (5–9)
Whisenant et al. (all)7.3 ± 2.73NANANA
Eleid et al. — 23 mm6.4 ± 2.45 ± 28*6.25 ± 2.2
Eleid et al. — 26 mm7.0 ± 2.66 ± 1.44*6.5 ± 2.4
Eleid et al. — 29 mm4.9 ± 2.16 ± 32.5 ± 0.54.8 ± 2.3
Eleid et al. — all sizes5.7 ± 2.55.7 ± 2.24.3 ± 2.35.5 ± 2.4
*Limited data, no SD reported. ViMAC = valve-in-mitral annular calcification.
Table A7 — Normal Doppler Values for Prosthetic Pulmonary Valves
📖 Accurate CW Doppler may be challenging due to valve position — use off-axis parasternal and suprasternal views. AT = acceleration time.
Valve Type / SizePeak Grad (mm Hg)Mean Grad (mm Hg)Peak Vel (m/s)EOA (cm²)
Homograft—<15<2.5—
Valved conduits (Contegra, Shelhigh, Medtronic)—<15<2.2—
Bioprosthetic valves (general)—<15<2.2—
Percutaneous — Melody
16 mm (≤20 mm conduit)——<2.4—
18 mm (≤22 mm conduit)——<2.4—
Percutaneous — SAPIEN
20 mm16 ± 5——1.22 ± 0.2
23 mm11 (8–17)——1.47 (1.1–2.0)
26 mm9.5 (4.9–14.5)——1.77 (1.3–2.4)
29 mm10.4 (5.9–15.5)——2.0 (1.5–2.6)
Mechanical — St. Jude (pulmonary position)
21 mm20 (19–21)12 (11–13)2.21.73
23 mm20 (7–35)11 (4–20)2.0 (1.2–2.9)2.5 (1–3.8)
25 mm18 ± 7.511 ± 62.02.9 ± 1
27 mm15 (6–30)6 (3–18)1.8 (1.2–2.7)4.2 (3–4.8)
Mechanical — Carbomedics (pulmonary)
23 mm19 (17–20)122.0 (1.8–2.2)1.7 (1.3–2.1)
25 mm20 (11–30)11 (5–33)2.0 (1.6–2.7)3.3 (1.5–4.4)
27 mm19 (10–28)10 (6–14)1.9 (1.4–2.4)4.1 (4.0–4.1)
Mechanical — On-X (pulmonary)
23 mm20 (7–36)12 (4–22)2.2 (1.1–2.7)2.4 (1.9–2.9)
25 mm17 (7–24)10 (3–13)1.8 (1.3–2.4)1.5 (0.9–2.2)
29 mm20 (18–22)12 ± 12.1 (1.9–2.3)2.02 (1.8–2.2)
Table A8 — Transcatheter Tricuspid ViV and ViR
📖 Data from McElhinney et al., J Am Coll Cardiol 2019 (n=306). ViV = 93%, ViR = 7%.
nViV / ViRAge (yrs)Mean Gradient (mm Hg)PVL
306 ViV 284 (93%) / ViR 22 (7%) 40 (1–86) 3.8 ± 2.0
≥29 mm: 3.6 ± 1.8 · <29 mm: 4.2 ± 2.3		 Trivial or none in 83%
Table A9 — Surgical Prosthetic Tricuspid Valves (Mean ± SD)
⚠️ PHT not recommended when Doppler contour is rounded. DVI = VTIPrTV / VTILVOT. iEOA = EOA indexed to BSA. Modified from Blauwet et al., J Am Soc Echocardiogr 2010 & 2011.
Valve (Size)PHT (ms)Mean Grad (mm Hg)E Vel (m/s)VTIPrTV (cm)DVIEOA (cm²)iEOA (cm²/m²)
Mechanical — St. Jude Medical Standard
27 mm77 ± 14.62.4 ± 1.271.1 ± 0.3225 ± 7.01.2 ± 0.332.54 ± 0.641.52 ± 0.34
29 mm100 ± 35.22.6 ± 1.131.2 ± 0.2131 ± 6.51.4 ± 0.302.20 ± 0.331.21 ± 0.13
31 mm81 ± 13.53.3 ± 1.211.4 ± 0.3130 ± 5.11.4 ± 0.232.49 ± 0.451.38 ± 0.29
33 mm82 ± 18.83.2 ± 1.241.3 ± 0.2230 ± 7.81.5 ± 0.332.46 ± 0.591.36 ± 0.36
Mechanical — Carbomedics Standard
31 mm784.0 ± 1.631.4 ± 0.1940 ± 11.41.9 ± 0.532.01 ± 0.511.04 ± 0.18
33 mm98 ± 9.73.4 ± 1.191.2 ± 0.1634 ± 7.31.6 ± 0.332.33 ± 0.431.25 ± 0.35
Mechanical — Starr-Edwards (caged ball)
30 mm13251.5411.52.071.51
32 mmNA4.0 ± 1.01.5 ± 0.4439 ± 14.22.0 ± 0.681.87 ± 0.330.96 ± 0.18
34 mm118 ± 32.95.7 ± 1.631.8 ± 0.2844 ± 7.81.9 ± 0.321.81 ± 0.481.08 ± 0.29
Bioprosthetic — Medtronic Mosaic
25 mm804.01.6353.21.370.93
27 mmNA5.5 ± 0.531.6 ± 0.1751 ± 6.82.2 ± 0.41.53 ± 0.160.86 ± 0.18
29 mm115 ± 13.46.0 ± 2.01.5 ± 0.2637 ± 0.971.8 ± 0.391.96 ± 0.391.12 ± 0.21
31 mm144 ± 28.65.2 ± 1.431.5 ± 0.2146 ± 9.52.2 ± 0.61.74 ± 0.520.95 ± 0.29
33 mm139 ± 56.54.3 ± 1.31.4 ± 0.1940 ± 8.62.1 ± 0.32.0 ± 0.531.01 ± 0.26
Bioprosthetic — Carpentier-Edwards Perimount
29 mm94 ± 2.82.0 ± 1.411.1 ± 0.2129 ± 7.11.6 ± 0.202.16 ± 0.431.39 ± 0.42
31 mm74 ± 26.23.7 ± 1.531.2 ± 0.2037 ± 9.11.7 ± 0.352.12 ± 0.531.20 ± 0.29
33 mm137 ± 533.9 ± 1.071.4 ± 0.2138 ± 7.91.9 ± 0.281.93 ± 0.431.03 ± 0.19
Bioprosthetic — Carpentier-Edwards Duraflex
27 mm130 ± 45.45.2 ± 1.691.5 ± 0.2646 ± 8.02.4 ± 0.401.34 ± 0.220.78 ± 0.15
29 mm102 ± 26.56.0 ± 1.951.7 ± 0.2747 ± 9.62.3 ± 0.601.54 ± 0.380.88 ± 0.19
31 mm115 ± 40.85.7 ± 1.671.5 ± 0.2748 ± 9.02.3 ± 0.531.57 ± 0.390.88 ± 0.22
33 mm116 ± 39.75.6 ± 2.101.5 ± 0.2647 ± 10.22.3 ± 0.541.69 ± 0.440.92 ± 0.24
35 mm83 ± 26.55.3 ± 1.611.5 ± 0.2546 ± 10.52.3 ± 0.541.63 ± 0.380.88 ± 0.22
Bioprosthetic — Medtronic Hancock II
31 mmNA5.7 ± 1.371.6 ± 0.1949 ± 8.72.3 ± 0.361.4 ± 0.210.77 ± 0.19
33 mmNA5.5 ± 3.541.4 ± 0.2850 ± 16.32.9 ± 0.481.4 ± 0.590.71 ± 0.24
35 mmNA5.3 ± 0.581.3 ± 0.3241 ± 2.51.8 ± 0.122.11 ± 0.231.01 ± 0.22
Bioprosthetic — St. Jude Biocor
29 mmNA61.6431.72.841.54
31 mm106 ± 48.55.1 ± 1.361.5 ± 0.3446 ± 12.52.2 ± 0.571.92 ± 0.530.99 ± 0.19
33 mm125 ± 45.73.9 ± 1.201.3 ± 0.2339 ± 101.9 ± 0.561.88 ± 0.491.07 ± 0.29
⚠️ Clinical Disclaimer: This tool is for educational and clinical reference only, based on Zoghbi et al., JASE 2024;37:2–63. All hemodynamic thresholds must be interpreted with knowledge of specific valve type, size, and flow state. Normal reference ranges vary by prosthesis — consult Appendix Tables A1–A9 of the guidelines for type- and size-specific values. Not a substitute for individual clinical judgment.
Citation: Zoghbi WA, Jone P-N, Chamsi-Pasha MA, et al. Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging. J Am Soc Echocardiogr. 2024;37:2–63.

📄 Download full guidelines from ASE website  |  DOI: 10.1016/j.echo.2023.10.004

For educational and clinical reference purposes only. Normal reference values vary by specific valve type and size — refer to original guideline Appendix Tables A1–A9 for complete normative data. Content © 2024 American Society of Echocardiography.