Mitral valve guideline published

The British Society of Echocardiography (BSE) is delighted to announce the publication of a new mitral valve guideline, updating previous guidance to reflect contemporary practice.

The new mitral valve (MV) guideline outlines a structured and comprehensive protocol for the echocardiographic assessment of MV anatomy and disease. Where previous BSE guidance for echocardiography of the MV focussed on assessment prior to repair and prior to balloon valvuloplasty, the current guideline updates all previous BSE guidance and is the first to incorporate both mitral regurgitation (MR) and mitral stenosis (MS) assessment. In addition to extensive guidance for 2D, 3D and Doppler TTE, the guide also includes detailed protocols for 2D and 3D transoesophageal and stress echocardiography, with the addition of novel and emerging techniques for the assessment of MR severity. 

Key features include:

  • Comprehensive guide for the assessment of MV anatomy by 2D and 3D imaging during both TTE and TOE procedures
  • Description in detail of the benefits and limitations of each echocardiographic method of assessing MR and MS severity, thus helping the echocardiographer choose the most appropriate method when mixed and multi-valve disease is present
  • Structured guide for the assessment of MR severity and mechanism by TTE and TOE, including: 2D, 3D and Doppler modalities. Clear guidance for when calculations should and shouldn’t be applied
  • Structured guide for the assessment of MS severity by TTE and TOE, including: 2D, 3D and Doppler modalities. Clear guidance for when calculations should and shouldn’t be applied
  • Echo assessment prior to MV repair surgery and indicators of reparability
  • Guide to performing stress-echocardiography for the assessment of MR and MS
  • Description of novel and emerging concepts in the assessment of MR

The quantitative parameter cut-offs for confirming severe primary MR are well established across international guidance for the diagnosis and management of MV disease. It is also well established that the elliptic regurgitant orifice associated with secondary MR results in quantitative parameters that are underestimated for the true degree of regurgitation. For this reason, previous BSE guidance recommended that the cut-off parameters for identifying severe secondary MR were half of that for primary MR. However, the new MV guideline recognises that although quantitative parameters for secondary MR are lower than those for primary MR, albeit not by half, additional haemodynamic indicators are required to confirm that MR is severe.

Although the change to the cut-offs for indicating severe secondary MR will lead to the reclassification of severity for some patients, the new guidance improves the diagnostic accuracy of echocardiography and will help ensure that appropriate management decisions are made. 

The recommendations within this guideline are based upon well-established clinical practice and supported by the latest empirical research. The new recommendations for grading secondary mitral regurgitation are also in line with contemporary guidance from the American Society of Echocardiography. 

Mr Shaun Robinson, first author and Consultant Clinical Scientist at North West Anglia NHS Foundation Trust, said “We are excited for the publication of the new MV guideline that provides a comprehensive overview of echocardiography in mitral valve disease. With descriptions of two and three-dimensional trans-thoracic, transoesophageal and exercise stress echocardiography, alongside novel and emerging concepts, this guideline pulls together recommendations for well-established imaging practice, findings from the latest research and looks to the future directions of mitral valve imaging to provide our members with a comprehensive resource that is applicable in both daily practice and advanced complex echocardiography.”

Read the guideline