Basic valvular lesions on 2D and color
Why examiners ask this
The outline limits valve disease to what I can see on 2D and color flow; there is no pulsed or continuous-wave Doppler on the exam.1 So the station asks whether I can recognize a stenotic or regurgitant valve from its structure and its color jet, grade it roughly, and say how it changes my hemodynamic goals. It tests application of knowledge and judgment.
The 60-second answer
For any valve loop I go in the same order. The view, so the grader knows which valve I am looking at. The leaflets on 2D: thin and mobile, or thickened, calcified, restricted, prolapsing or flail. The chamber that pays for the lesion: a hypertrophied LV for aortic stenosis, a dilated LV for chronic regurgitation, a big left atrium for mitral disease. Then color, with the Nyquist limit set at 50–70 cm/s and the gain just below speckle:2 a mosaic jet going the wrong way in diastole or systole, and its width at the narrowest point, the vena contracta. I name the lesion, give a severity of mild, moderate or severe, and finish with the hemodynamic goals. A stenotic valve wants a slow rate and preserved afterload; a regurgitant valve wants a normal-to-fast rate and lower afterload.
Decision points and the "why"
| Lesion | Best view | 2D and color findings | Severe when |
|---|---|---|---|
| Aortic stenosis | ME AV short-axis, ME long-axis | Calcified cusps, restricted opening, concentric LVH, turbulent flow above the valve | Planimetered area <1.0 cm²3 |
| Aortic regurgitation | ME long-axis | Diastolic jet into the LVOT from the cusps, dilated LV in chronic disease | Central jet width ≥65% of LVOT; vena contracta >6 mm2 |
| Mitral regurgitation | ME four-chamber, two-chamber, long-axis | Systolic jet into the LA; prolapse or flail leaflet; eccentric jets hug the wall | Vena contracta ≥7 mm; central jet >50% of LA area, or an eccentric wall-impinging jet2 |
| Mitral stenosis | ME four-chamber, long-axis | Thickened leaflets, "hockey-stick" anterior leaflet doming, big LA, spontaneous contrast | Severe restriction with marked LA enlargement |
| Tricuspid regurgitation | ME four-chamber, RV inflow-outflow | Systolic jet into the RA, dilated RV and annulus | Vena contracta >7 mm; central jet >50% of RA; flail or no coaptation2 |
- Vena contracta over jet area — jet area depends on gain, the Nyquist limit and loading; the narrowest neck is far less load-dependent. I use it as my main severity grade.
- Eccentric jets are underestimated — a jet that hugs the atrial wall loses momentum against it and looks smaller than a central jet of the same severity. The prolapsing or flail leaflet is usually the one opposite the jet direction, which tells the surgeon which leaflet to repair.2
- Aortic stenosis goals — sinus rhythm, rate 60–80, normal-to-high systemic pressure with phenylephrine, and full preload, because a stiff ventricle needs atrial kick and diastolic time, and a fall in diastolic pressure starves the hypertrophied subendocardium.
- Regurgitant lesions — rate 80–100 and lower afterload shorten the time and lower the pressure gradient driving backward flow. I avoid bradycardia and pure vasoconstrictors.
- Mitral stenosis goals — a slow rate to lengthen diastolic filling across the narrow valve, rate control of atrial fibrillation, and no hypoxia, hypercarbia or acidosis, which raise pulmonary pressure on an RV that is already working hard.
The complication they will inject
After a mitral repair, or in an underfilled patient with a septal bulge, the clip shows a mosaic color jet in the LV outflow tract in systole and a posteriorly directed mitral regurgitant jet. The anterior leaflet swings toward the septum. This is systolic anterior motion of the mitral valve with dynamic LV outflow obstruction, and the hypotension that comes with it gets worse with the instinctive treatment. I say the finding and the mechanism, then act: stop inotropes, give volume, raise afterload with phenylephrine, slow the rate with esmolol, and lighten the dilators. If the obstruction persists after the repair, the surgeon has to revise it. The other variant is acute severe mitral regurgitation from papillary muscle rupture after an infarct: a flail leaflet with a wide jet and a hyperdynamic LV; I lower afterload, support with an inotrope, and call for an intra-aortic balloon pump and surgery.
Pitfalls that cost points
- Grading regurgitation on jet area with the Nyquist limit set too low.
- Calling a stenosis severe from color turbulence alone without looking at leaflet opening.
- Offering a Doppler gradient the exam does not ask for and cannot show.
- Treating hypotension from systolic anterior motion with epinephrine.
- Forgetting the hemodynamic goals after naming the lesion.
Rapid-why
Q: Why does color mosaic appear? A: Velocities above the Nyquist limit alias, so high-speed turbulent flow shows as a mix of colors.
Q: Why are eccentric jets underestimated? A: The Coanda effect pulls the jet along the atrial wall, so its visible area shrinks while the regurgitant volume does not.
Q: Why does an empty, fast heart worsen systolic anterior motion? A: A small LV cavity and high outflow velocity drag the anterior leaflet into the outflow tract by flow drag and Venturi forces.
Q: Which view shows the aortic valve as three cusps? A: The ME aortic valve short-axis at about 25–45°.4
Numbers to know
| Item | Value |
|---|---|
| Color Nyquist limit | 50–70 cm/s2 |
| Severe AS area | <1.0 cm²3 |
| Severe AR vena contracta | >6 mm2 |
| Severe MR vena contracta | ≥7 mm2 |
| AS heart-rate goal | 60–80 bpm |
| Regurgitant heart-rate goal | 80–100 bpm |
Links
- The 11 TEE views, Aortic stenosis, Mitral regurgitation and mitral stenosis (coming), Hypertrophic obstructive cardiomyopathy (coming)
- Atlas: The 11 TEE views
- 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease; ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)
Sources
- 1.APPLIED Exam Objective Structured Clinical Examination (OSCE) Content Outline · ABA · theaba.org
- 2.Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation · ASE/SCMR, 2017 · asecho.orgNyquist 50-70 cm/s; severity tables for MR, AR, TR.
- 3.Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice · EAE/ASE, 2009 · asecho.orgASE note: use ACC/AHA staging for mitral stenosis instead of the 2009 values.
- 4.Guidelines for Performing a Comprehensive Transesophageal Echocardiography Examination · ASE/SCA, 2013 · asecho.org
Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.