Appropriate Use Criteria for Clinical Decision-Making
This guideline evaluates 92 clinical scenarios for the use of multimodality imaging in valvular heart disease. Each scenario receives one of three appropriateness ratings:
The following modalities are evaluated across all clinical scenarios in this guideline:
Transthoracic Echocardiography — First-line imaging for most VHD scenarios; non-invasive, real-time assessment of valve anatomy and hemodynamics.
Transesophageal Echocardiography — Higher resolution, posterior structures; indicated when TTE inadequate or for procedural guidance (TAVR, mitral repair).
3-Dimensional Transthoracic Echo — Enhanced spatial anatomy; useful for prosthetic valve assessment and complex morphology.
Cardiovascular Magnetic Resonance — No ionizing radiation; excellent for quantifying regurgitation and assessing myocardial fibrosis.
Cardiac Computed Tomography — High-resolution anatomy; aortic root assessment, coronary assessment, pre-TAVR evaluation.
Stress Testing (Ex-SE, DSE, RVG) — Assessment of ischemic burden, LV function during stress; less common in VHD but used selectively.
Indications for screening echocardiography in asymptomatic patients with known or suspected valvular disease:
| Indication | TTE | TEE (3D) | 3D TTE | CMR | CCT |
|---|---|---|---|---|---|
| Unexamined murmur or abnormal heart sounds | A | R | R | R | R |
| Reasonable suspicion of VHD | A | R | M | R | R |
| History of rheumatic heart disease | A | R | M | R | R |
| Exposure to medications that could result in VHD development (e.g., fenfluramine, anorexigens) | A | R | M | R | R |
| First-degree family history of a bicuspid aortic valve | A | R | M | R | R |
Note: TTE is Appropriate for all six asymptomatic screening indications. Additional modalities (3D TTE, TEE, CMR, CCT) are not recommended for initial screening; they are reserved for diagnostic clarification in subsequent scenarios.
Indications for imaging in patients presenting with clinical signs and/or symptoms of VHD:
| Clinical Presentation | TTE | TEE (3D) | 3D TTE | CMR | CCT | Stress Echo |
|---|---|---|---|---|---|---|
| ARRHYTHMIAS | ||||||
| Palpitations AND no other symptoms of cardiovascular disease | M | R | R | R | R | R |
| Syncope AND no other symptoms of cardiovascular disease | A | R | M | R | R | M |
| HYPERTENSION / HEMODYNAMIC INSTABILITY | ||||||
| Hypertension or hemodynamic instability AND uncertain or suspected cardiac etiology | A | R | R | R | R | R |
| Assessment of volume status in a critically ill patient | M | R | R | R | R | R |
| Suspected acute mitral or aortic regurgitation | A | M | R | R | R | R |
| RESPIRATORY FAILURE | ||||||
| Respiratory failure or pulmonary edema of uncertain etiology | A | M | R | R | R | M |
| Respiratory failure with noncardiac etiology established | M | R | R | R | R | R |
| HEART FAILURE | ||||||
| Initial evaluation in patients with heart failure to exclude primary or secondary valve disease | A | R | R | R | R | R |
| BACTEREMIA / ENDOCARDITIS | ||||||
| Suspected IE with positive blood cultures or clinical signs/symptoms | A | A | M | R | R | R |
| CARDIAC MASS / SOURCE OF EMBOLUS | ||||||
| Suspected cardiac mass, tumor, thrombosis, or potential cardiac source of embolus | A | A | M | R | M | M |
When initial TTE imaging is inadequate or equivocal, additional modalities may be needed:
| Clinical Scenario | TEE | 3D TTE | 3D TEE | CMR | CCT |
|---|---|---|---|---|---|
| AORTIC STENOSIS | |||||
| Symptomatic, severe AS by valve area AND low flow/low gradient AND low LVEF | R | M | R | R | M |
| Severe AS AND low flow/low gradient AND preserved LVEF for exercise or dobutamine stress measurement | R | R | A | R | M |
| Discordance between clinical assessment and TTE about AR severity | R | A | R | M | R |
| MITRAL STENOSIS | |||||
| Discrepancy between TTE findings and clinical symptoms to evaluate mean mitral gradient and mitral area | R | M | A | R | R |
| MITRAL REGURGITATION | |||||
| Severe MR suspected clinically AND inadequately estimated on TTE AND better imaging of MR jet needed | R | R | A | M | R |
| ENDOCARDITIS | |||||
| Suspected IE with moderate to high pretest probability | R | A | M | R | R |
Timing and modality for re-evaluation in patients with known, stable VHD:
| Clinical Scenario | Interval | TTE | TEE | 3D | CMR |
|---|---|---|---|---|---|
| STAGE A VHD — AT RISK | |||||
| Routine surveillance for stage A (bicuspid AV or aortic sclerosis) | 3–5 years | A | R | R | R |
| MILD–MODERATE VHD (STAGE B) | |||||
| Re-evaluation of mild (stage B) valvular regurgitation | 3–5 years | A | R | R | R |
| Re-evaluation of mild (stage B) VHD without clinical change | 1–2 years | M | R | R | R |
| Re-evaluation of moderate (stage B) VHD | 1–2 years | A | R | R | R |
| SEVERE VHD (STAGE C) | |||||
| Re-evaluation of asymptomatic severe (stage C) AS without clinical change | 6–12 months | M | R | R | R |
| Re-evaluation for asymptomatic (stage C) AS | 1 year | A | R | M | R |
| BICUSPID AORTIC VALVE WITH DILATED AORTA | |||||
| Re-evaluation of aortic sinuses and ascending aorta in bicuspid AV <4 cm with risk factors (rapid change, family history) | Annually | A | R | R | A |
When patients with known VHD develop new or worsening symptoms, re-evaluation is warranted:
| Indication | TTE | TEE (3D) | 3D TTE / CMR |
|---|---|---|---|
| Re-evaluation of IE when clinical status changes or to guide therapy | A | A | M |
Endocarditis is the primary scenario in this table. Both TTE and TEE are Appropriate when patients with known or suspected endocarditis develop clinical changes indicating disease progression or complications requiring intervention.
Imaging protocols for patients undergoing surgical valve intervention:
| Scenario | Timing | TTE | TEE | 3D TTE | CMR |
|---|---|---|---|---|---|
| SURGICAL VALVE REPLACEMENT (NO DYSFUNCTION) | |||||
| Initial evaluation of bioprosthetic or mechanical valve for baseline (6 w to 3 m) | 6–12 weeks | A | R | R | R |
| Re-evaluation (<3 y) of bioprosthetic or mechanical valve if no dysfunction | <3 years | M | R | R | R |
| Re-evaluation (≥3 y) of bioprosthetic or mechanical valve if no dysfunction | ≥3 years | A | R | R | R |
| SURGICAL VALVE REPLACEMENT (SUSPICION OF DYSFUNCTION) | |||||
| Characterization of mechanical prosthetic valve if clinical signs suggesting dysfunction | As needed | A | A | M | R |
| Characterization of bioprosthetic valve if clinical signs suggesting dysfunction | As needed | A | A | M | R |
| SURGICAL VALVE REPAIR | |||||
| Initial postoperative assessment of valve repair (6 w to 3 m) | 6–12 weeks | A | R | M | R |
| Re-evaluation (<3 y) without suspected dysfunction | <3 years | R | R | R | R |
| Re-evaluation (–3 y) for suspected repaired valve dysfunction | As needed | A | M | M | R |
Multimodality imaging is essential for TAVR patient selection, procedural guidance, and postprocedural assessment:
| Assessment | TTE | TEE | 3D TTE | CMR | CCT |
|---|---|---|---|---|---|
| Assessment for concomitant coronary artery disease | R | R | R | M | A |
| Accurate assessment of annulus size and shape of calcification | R | A | M | R | A |
| Assessment of number of aortic cusps and degree of calcification | A | A | M | R | A |
| Measurement of the distance between annulus and the coronary ostia | R | M | R | R | A |
| Precise coaxial alignment of the implant within the centerline | R | R | R | R | A |
| Assessment of aortic dimensions | R | M | R | R | A |
| Procedural Guidance | TTE | TEE | 3D TTE | Angio | Fluoro |
|---|---|---|---|---|---|
| Guidewire placement into the LV | A | A | M | M | A |
| Valve placement | A | A | M | A | A |
| Postdeployment assessment (position, function, regurgitation) | A | A | A | A | A |
| Evaluate immediate complications | A | A | A | A | A |
| Postprocedural Assessment | TTE | 3D TTE | CMR | CCT | Brain MRI |
|---|---|---|---|---|---|
| Assessment of aortic regurgitation (including paravalvular) | A | A | M | R | R |
| Assessment of stroke with suspicion of aortic dysfunction | A | M | R | R | A |
Imaging for MitraClip patient selection, procedural guidance, and follow-up:
| Assessment | TTE | TEE (3D) | 3D TTE | Exercise | CMR |
|---|---|---|---|---|---|
| Determine patient eligibility | A | A | A | A | M |
| Exclude intracardiac mass, thrombus, or vegetation | M | A | M | R | R |
| Intraprocedural Guidance | TTE | TEE (3D) | 3D TTE | Angio/Fluoro |
|---|---|---|---|---|
| Alignment of the device over the regurgitant jet origin and advance to LV | R | A | A | A |
| Guidance for grasping the mitral valve leaflets and device closure | R | A | A | A |
| Assess adequacy in the reduction of the MR | M | A | M | A |
| Assess for presence of mitral stenosis | M | A | M | R |
| Postprocedural Assessment | TTE | TEE (3D) | 3D TTE | Exercise | CMR |
|---|---|---|---|---|---|
| Reassessment of MR and left ventricular function (predischarge, 1, 6, 12 m, annually to 5 y) | A | R | M | M | M |
Use these calculators to quantify valve lesions and assess severity in the context of the imaging scenarios above:
Calculate AS severity by valve area, mean gradient, and peak velocity. Compare continuity equation and planimetry methods.
Estimate mitral valve area in stenosis using the pressure half-time method from Doppler echocardiography.
Index aortic or mitral valve area to body surface area for prognostic assessment.
Calculate tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP).
Calculate E/e' ratio to estimate left ventricular filling pressures. Useful in VHD with concurrent diastolic dysfunction.
Assess aortic valve calcium burden on CT and integrate with echo findings for AS risk stratification.
These calculators support the imaging-based assessment described throughout this guideline. Use them to: