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ACC/AHA Guidelines for the Clinical Application of Echocardiography

1997; Lippincott Williams & Wilkins; Volume: 95; Issue: 6 Linguagem: Inglês

10.1161/01.cir.95.6.1686

1524-4539

Melvin D. Cheitlin, Joseph S. Alpert, William F. Armstrong, Gerard P. Aurigemma, George Beller, Fredrick Z. Bierman, Thomas Davidson, J. Davis, Pamela S. Douglas, Linda D. Gillam, Richard P. Lewis, Alan S. Pearlman, John T. Philbrick, Pravin M. Shah, Roberta G. Williams, James L. Ritchie, Melvin D. Cheitlin, Kim A. Eagle, Timothy J. Gardner, Arthur Garson, Raymond J. Gibbons, Richard P. Lewis, Robert A. O’Rourke, Thomas J. Ryan,

Cardiac Valve Diseases and Treatments

HomeCirculationVol. 95, No. 6ACC/AHA Guidelines for the Clinical Application of Echocardiography Free AccessResearch ArticleDownload EPUBAboutView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticleDownload EPUBACC/AHA Guidelines for the Clinical Application of Echocardiography A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography) Developed in Collaboration With the American Society of Echocardiography Melvin D. Cheitlin, Joseph S. Alpert, William F. Armstrong, Gerard P. Aurigemma, George A. Beller, Fredrick Z. Bierman, Thomas W. Davidson, Jack L. Davis, Pamela S. Douglas, Linda D. Gillam, Richard P. Lewis, Alan S. Pearlman, John T. Philbrick, Pravin M. Shah and Roberta G. Williams James L. Ritchie, Melvin D. Cheitlin, Kim A. Eagle, Timothy J. Gardner, Arthur GarsonJr, Raymond J. Gibbons, Richard P. Lewis, Robert A. O'Rourke and Thomas J. Ryan Melvin D. CheitlinMelvin D. Cheitlin , Joseph S. AlpertJoseph S. Alpert , William F. ArmstrongWilliam F. Armstrong , Gerard P. AurigemmaGerard P. Aurigemma , George A. BellerGeorge A. Beller , Fredrick Z. BiermanFredrick Z. Bierman , Thomas W. DavidsonThomas W. Davidson , Jack L. DavisJack L. Davis , Pamela S. DouglasPamela S. Douglas , Linda D. GillamLinda D. Gillam , Richard P. LewisRichard P. Lewis , Alan S. PearlmanAlan S. Pearlman , John T. PhilbrickJohn T. Philbrick , Pravin M. ShahPravin M. Shah and Roberta G. WilliamsRoberta G. Williams James L. RitchieJames L. Ritchie , Melvin D. CheitlinMelvin D. Cheitlin , Kim A. EagleKim A. Eagle , Timothy J. GardnerTimothy J. Gardner , Arthur GarsonJrArthur GarsonJr , Raymond J. GibbonsRaymond J. Gibbons , Richard P. LewisRichard P. Lewis , Robert A. O'RourkeRobert A. O'Rourke and Thomas J. RyanThomas J. Ryan and Committee Membersand Task Force Members Originally published18 Mar 1997https://doi.org/10.1161/01.CIR.95.6.1686Circulation. 1997;95:1686–1744ContentsPreambleI. Introduction, General Considerations, and ScopeII. Murmurs and Valvular Heart DiseaseMurmursNative Valvular StenosisNative Valvular RegurgitationRepeated Studies in Valvular Heart DiseaseMitral Valve ProlapseInfective Endocarditis: Native ValvesProsthetic ValvesProsthetic Valve Dysfunction and EndocarditisIII. Chest PainIV. Ischemic Heart DiseaseAcute Ischemic SyndromesChronic Ischemic Heart DiseaseV. Cardiomyopathy and Assessment of Left Ventricular Function: Echocardiographic ParametersAssessment of Ejection FractionEdema and DyspneaRegional Left Ventricular FunctionVentricular DysfunctionDilated CardiomyopathyHypertrophic CardiomyopathyRestrictive CardiomyopathyHeart Failure With Normal Systolic FunctionEvaluation of the Right VentricleVI. Pericardial DiseasePericardial EffusionCardiac TamponadeIncreased Pericardial ThicknessPericardial Tumors and CystsConstrictive PericarditisCongenital Absence of the Pericardium and Pericardial Disease After Open-Heart SurgeryVII. Cardiac Masses and TumorsVIII. Diseases of the Great VesselsAortic DissectionAortic AneurysmAortic Rupture and Thoracic Aortic Degenerative DiseaseThe Great VeinsIX. Pulmonary DiseasePulmonary ThromboembolismX. Systemic HypertensionXI. Neurological Disease and Other Cardioembolic DiseaseXII. Arrhythmias and PalpitationCardioversion of Patients With Atrial FibrillationSyncopeScreeningXIII. Echocardiography in the Critically IllEchocardiography in the Trauma PatientXIV. Two-Dimensional Doppler Echocardiography in the Adult Patient With Congenital Heart DiseaseXV. Echocardiography in the Pediatric PatientResource Utilization and AgeCongenital Cardiovascular Disease in the NeonateCardiopulmonary DiseaseArrhythmiasMyocardial Disease in the NeonateCongenital Cardiovascular Disease in the Infant, Child, and AdolescentArrhythmias/Conduction DisturbancesAcquired Cardiovascular DiseasePulmonary Diseases in Pediatric Acquired Cardiovascular DiseaseThrombus/TumorTransesophageal EchocardiographyFetal EchocardiographyReferencesPreambleIt is clearly important that the medical profession plays a significant role in critically evaluation of the use of diagnostic procedures and therapies in the management or prevention of disease. Rigorous and expert analysis of the available data documenting relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and impact the overall cost of care favorably by focusing resources on the most effective strategies.The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly engaged in the production of such guidelines in the area of cardiovascular disease since 1980. This effort is directed by the ACC/AHA Task Force on Practice Guidelines. Its charge is to develop and revise practice guidelines for important cardiovascular diseases and procedures. Experts in the subject under consideration are selected from both organizations to examine subject-specific data and write guidelines. The process includes additional representatives from other medical practitioner and specialty groups as appropriate. Writing groups are specifically charged to perform a formal literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of particular tests or therapies are considered as well as frequency of follow-up and cost-effectiveness.These practice guidelines are intended to assist physicians in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the physician and patient in light of all of the circumstances presented by that patient.The Committee on Clinical Application of Echocardiography was chaired by Melvin D. Cheitlin, MD, FACC, and included the following members: Joseph S. Alpert, MD, FACC, William F. Armstrong, MD, FACC, Gerard P. Aurigemma, MD, FACC, George A. Beller, MD, FACC, Fredrick Z. Bierman, MD, FACC, Thomas W. Davidson, MD, FAAFP, Jack L. Davis, MD, FACC, Pamela S. Douglas, MD, FACC, Linda D. Gillam, MD, FACC, Richard P. Lewis, MD, FACC, Alan S. Pearlman, MD, FACC, John T. Philbrick, MD, FACP, Pravin M. Shah, MD, FACC, and Roberta G. Williams, MD, FACC.The committee is composed of both university-affiliated and practicing physicians and those with specific echocardiographic expertise and senior clinicians who use the technique. Two general physicians (one general internal medicine and one family practitioner) also served on the committee.The document was reviewed by three outside reviewers nominated by the ACC and three outside reviewers nominated by the AHA as well as other individuals from the American Society of Echocardiography, Society of Pediatric Echocardiography, American College of Physicians, and American Academy of Family Physicians.The executive summary and recommendations are published in the March 15, 1997, issue of Journal of the American College of Cardiology. The full text is published in Circulation. Reprints of both the full text and the executive summary and recommendations are available from both organizations. The document will be reviewed 2 years after publication and yearly thereafter and considered current unless the task force revises or withdraws it from distribution. The document was endorsed by the American Society of Echocardiography.James L. Ritchie, MD, FACC Chair, ACC/AHA Task Force on Practice Guidelines I. Introduction, General Considerations, and ScopeThe previous guidelines for the use of echocardiography were published in December 1990. Since that time there have been significant advances in the technology of Doppler echocardiography and growth in its clinical use and in the scientific evidence leading to recommendations for its proper use.The recommendations are based on a Medline search of the English literature from 1990 to May 1995. Echocardiography was cross-referenced with the following terms: antineoplastic agents, aortic or dissecting aneurysm, arrhythmias, athletes, atrial fibrillation, cardioversion, Marfan syndrome, bacterial endocarditis, myocardial infarction, myocardial ischemia, coronary disease, chest pain, cardiomyopathies, cerebrovascular disorders or cerebral ischemia, embolism, heart neoplasms, heart valve disease, heart murmurs, hypertension, mitral valve prolapse, pericarditis, pericardial effusion, cardiac tamponade, pericardium, pulmonary embolism or pulmonary heart disease or cor pulmonale, screening, shock or aortic rupture or heart rupture, syncope, transplantation, unstable angina, congenital heart disease in the adult, specific congenital lesions, arrhythmias in children, pediatric echocardiography, and fetal echocardiography.The search yielded over 3000 references, which the committee reviewed. This document includes recommendations for the use of Doppler echocardiography in both adult and pediatric patients. The pediatric guidelines also include recommendations for fetal Doppler echocardiography, an increasingly important field. The guidelines include recommendations for the use of Doppler echocardiography in both specific cardiovascular disorders and in the evaluation of patients with frequently observed cardiovascular symptoms and signs, common presenting complaints, or findings of dyspnea, chest discomfort, and cardiac murmur. In this way the guidelines will provide assistance to physicians regarding the use of Doppler echocardiographic techniques in the evaluation of such common clinical problems.The recommendations concerning the use of Doppler echocardiography follow the indication classification system (eg, Class I, II, and III) used in other ACC/AHA guidelines:Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. IIb: Usefulness/efficacy is less well established by evidence/opinion.Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.Evaluation of the clinical utility of a diagnostic test such as echocardiography is far more difficult than assessment of the efficacy of a therapeutic intervention, because the diagnostic test can never have the same direct impact on patient survival or recovery. Nevertheless, a series of hierarchical criteria are generally accepted as a scale by which to judge worth.123Hierarchical Levels of Echocardiography AssessmentTechnical capacityDiagnostic performanceImpact on diagnostic and prognostic thinkingTherapeutic impactHealth-related outcomesThe most fundamental criterion is technical capacity, including adequacy of equipment and study performance. The next is diagnostic performance, which encompasses much of traditional diagnostic test assessment, including delineation of the range of clinical circumstances in which a test is applicable, as well as test sensitivity, specificity, and accuracy for individual applications. The third criterion is the capability of a test to alter diagnostic and prognostic thinking, ie, to offer added value. This level depends on the context in which the test is performed and is therefore affected by such factors as what is already known, the judged value of confirmatory data, and the importance of reassurance in a particular clinical situation. Impact on diagnostic and prognostic thinking is an important link between test results and patient treatment. Subsequent criteria include therapeutic impact and health-related outcomes. Because there are essentially no randomized trials assessing health outcomes for diagnostic tests, the committee has not ranked the available scientific evidence in an A, B, C fashion (as in other ACC/AHA documents) but rather has compiled the evidence in tables. All recommendations are thus based on either this evidence from observational studies or on the expert consensus of the committee.Two-dimensional echocardiography can provide excellent images of the heart, paracardiac structures, and the great vessels. Because it depends on satisfactory examining windows from the body surface to the cardiovascular structures, there may be limitations on its use for adult patients. For patients with chronic obstructive pulmonary disease, the interposition of air-filled lung between the body surface and the heart severely limits access, and complete examination may not be possible. Other circumstances limit the use of transthoracic echocardiography (TTE), especially for patients in the intensive care unit. For example, patients on ventilators, those who cannot be rotated into a lateral position, and those with incisions may not have satisfactory precordial or apical windows. TEE may avoid most of these limitations because there is no interposed lung tissue between the transducer and the heart.The definition of echocardiography used in this document incorporates Doppler analysis, M-mode echocardiography, two-dimensional TTE, and, when indicated, TEE. Intravascular ultrasound is not considered here but will be reviewed in the revised guidelines for coronary angiography (in preparation). Echocardiography for evaluating the patient with cardiovascular disease for noncardiac surgery is considered in the ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery.4 The techniques of three-dimensional echocardiography are in the developmental stages and also are not considered here. Intraoperative TEE is not considered in this document because it is the subject of practice guidelines for perioperative TEE.5New techniques that are still rapidly evolving are also not addressed in this document. Echocardiography-contrast substances that can pass through the pulmonary circulation and opacify the left heart are in development. Echocardiography-contrast injections into the coronary artery to quantitate myocardium at risk and perfusion territories and the second harmonic echocardiogram to enhance echocardiographic contrast also are not addressed.With the development of Doppler echocardiography and proof that the modified Bernoulli equation permitted the conversion of instantaneous velocities of blood flow into instantaneous pressure gradients across obstructions, it became possible to precisely localize and quantitate obstruction in the cardiovascular system. This information, when considered with flow volume information provided by Doppler flow velocity integrals, allows a plethora of physiological and functional information to be obtained noninvasively. The differing capabilities of the several types of available Doppler echocardiographic techniques are outlined in Table 1. Recognizing the strengths of each technique will enable the physician to order the appropriate study. Generally a complete transthoracic echocardiogram and Doppler study is called for unless otherwise specified.When faced with a patient needing cardiovascular evaluation and testing, the clinician must choose among available tests. Echocardiography, nuclear testing, magnetic resonance imaging (MRI), and positron emission tomography can yield overlapping if not identical information, often with similar or comparable accuracy. Decisions concerning which technique to use must then be based on such factors as local expertise in performance and interpretation, test availability, cost, and patient preference. Therefore, it is impossible in this document to judge competing tests or recommend the use of one over another.TTE is associated with little if any patient discomfort, and no risks with this procedure have been identified. Moreover, the use of TTE with exercise or vasoactive drugs such as dipyridamole or dobutamine involves the minimal risks of arrhythmia, ischemia, and hypotension seen with exercise and the aforementioned drugs. In TEE, the echocardiographic transducer is mounted on a flexible endoscope and passed into the esophagus and stomach. This involves some discomfort and minimal but definite risk of pharyngeal and esophageal trauma and even rarely esophageal perforation. Rare instances of infective endocarditis have been associated with the use of TEE. An occasional patient has a reaction to either the sedative or the local anesthesia used.The ability of Doppler echocardiography to provide unique noninvasive information with minimal discomfort or risk without using contrast material or ionizing radiation, coupled with its portability, immediate availability, and repeatability, accounts for its use in virtually all categories of cardiovascular disease. However, two-dimensional Doppler echocardiography is best used after a careful history, physical examination, appropriate electrocardiogram (ECG), and chest radiograph have been obtained so that the appropriate questions can be asked. Indiscriminate use of echocardiography or its use for "screening" is not indicated for two principal reasons. First, the cost of echocardiography is not trivial. Second, the current Doppler echocardiographic techniques reveal details of structure and function such as filamentous strands on valves, valvular prolapse, and jet velocities representing minimal and at times transient valvular insufficiency that could generate unnecessary further testing or inappropriate and potentially detrimental therapy.These guidelines contain recommendations concerning not only indications for the use of these techniques but also specific circumstances when Doppler echocardiography adds little or nothing to the care of the patient and is therefore not indicated. An example is the evaluation of the patient with a clearly innocent murmur in the opinion of a qualified, knowledgeable examining physician. Another example is the use of echocardiography in diagnosing mitral valve prolapse (MVP) in a patient with chest pain or premature ventricular contractions in the absence of clinical findings consistent with MVP. Because there is no evidence that such patients have an increased risk of endocarditis beyond the general population which does not have "echo-only" MVP, echocardiography is generally not indicated in this situation.An echocardiographic study is not indicated when the pathology and/or systolic ventricular function have been adequately defined by other techniques, making the echocardiographic study redundant. Furthermore, echocardiography should be performed by laboratories with adequately trained physicians and cardiac sonographers where patient volume recommendations are met as previously described.3These guidelines also address recommendations about the frequency with which a Doppler echocardiographic study is repeated. If the frequency with which studies are repeated could be decreased without adversely affecting the quality of care, the economic savings realized would likely be significant. With a noninvasive diagnostic study and no known complications, the potential for repeating the study unnecessarily exists. It is easier to state when a repeat echocardiogram is not needed then when and how often it should be repeated, since no studies in the literature address this question. An adult patient with hemodynamically insignificant aortic regurgitation almost certainly does not need a repeat echocardiogram unless there is a change in the clinical picture. The asymptomatic patient with hemodynamically severe aortic regurgitation probably needs repeat echocardiography to monitor left ventricular function. How often this should be done depends on the individual patient and must be left to the judgment of the physician until evidence-based data addressing this issue are available.The use of two-dimensional Doppler echocardiography in establishing cardiac diagnoses and making therapeutic decisions is well established. Examples include the demonstration of an acquired ventricular septal defect in a patient with an acute myocardial infarction. In the past this diagnosis required catheterization; now the definitive diagnosis can be made in most cases with Doppler echocardiography. At times the Doppler echocardiogram can enable cardiac surgery to proceed without a comprehensive catheterization. Examples of this are the finding of severe aortic stenosis or mitral or aortic regurgitation in the symptomatic young patient or the finding of a left atrial myxoma.The use of repeated Doppler echocardiographic studies in following patients is illustrated in adult patients with moderate aortic stenosis who have a change in symptoms. Similarly the follow-up evaluation of ventricular function in the patient with chronic aortic or mitral valvular insufficiency lesions can help determine the timing of valvular surgery.This document assumes that Doppler echocardiographic studies are performed and interpreted in accordance with the statements for clinical competence in echocardiography set forth by the Joint Task Force of the American College of Physicians/American College of Cardiology/American Heart Association. Optimal training for such studies is set forth by the American Society of Echocardiography, the American College of Cardiology, and the Society of Pediatric Echocardiography.II. Murmurs and Valvular Heart DiseaseEchocardiography is extremely useful in the assessment of cardiac murmurs, stenosis and regurgitation of all four cardiac valves, prosthetic valve function, and patients with infective endocarditis. Echocardiography provides valuable information regarding diagnosis, valvular morphology, etiology of valve disease, identification and quantification of lesions, detection and evaluation of associated abnormalities, delineation of cardiac size and function, and assessment of the adequacy of ventricular compensation. Echocardiography readily detects structural abnormalities such as fibrosis, calcification, thrombus, or vegetation, and abnormalities of valvular motion such as immobility, flail or prolapsing leaflets, or prosthetic valve dehiscence. A full echocardiographic evaluation should provide prognostic as well as diagnostic information, allow for risk stratification, establish baseline data for subsequent examinations, and help guide and evaluate the therapeutic approach.Echocardiography often provides a definitive diagnosis and may obviate the need for catheterization in selected patients. Patients' acceptance of this noninvasive technique for initial and reevaluation observation is high.678 MRI has the capability to detect the presence of stenotic and regurgitant lesions910 and has several advantages. However, MRI instrumentation is substantially more expensive and not as widely available.MurmursCardiac auscultation remains the most widely used method of screening for heart disease. Heart murmurs are produced by turbulent blood flow and are often signs of stenotic or regurgitant valve disease or acquired or congenital cardiovascular defects. In valvular and congenital forms of heart disease, a murmur is usually the major evidence of the abnormality, although some hemodynamically significant regurgitant lesions may be silent.1112 However, many murmurs in asymptomatic people are innocent and of no functional significance. Such murmurs are defined as having the following characteristics: a systolic murmur of short duration, grade 1 or 2 intensity at the left sternal border, a systolic ejection pattern, a normal S2, no other abnormal sounds or murmurs, no evidence of ventricular hypertrophy or dilation, no thrills, and the absence of an increase in intensity with the Valsalva maneuver. Such murmurs are especially common in high-output states such as pregnancy.1314 When the characteristic findings of an individual murmur are considered together with other patient information and clinical data from the physical examination, the correct diagnosis can usually be established.15 In patients with ambiguous clinical findings, the echocardiogram may be the preferred test because it can provide a definitive diagnosis, rendering a chest radiograph and/or ECG unnecessary. In some patients the Doppler echocardiogram is the only noninvasive method capable of identifying the cause of a heart murmur.1216In the evaluation of heart murmurs, the purposes of performing a Doppler echocardiogram are to Define the primary lesion and its etiology and judge its severity.Define hemodynamics.Detect coexisting abnormalities.Detect lesions secondary to the primary lesion.Evaluate cardiac size and function.Establish a reference point for future observations.Reevaluate the patient after an intervention.As valuable as echocardiography may be, the basic cardiovascular evaluation is still the most appropriate method to screen for cardiac disease and will establish many clinical diagnoses.17 Echocardiography should not be used to replace the cardiovascular examination but can be helpful in determining the etiology and judging the severity of lesions, particularly in pediatric and elderly patients.15171819Native Valvular StenosisTwo-dimensional and Doppler echocardiography reliably identify and quantitate the severity of stenotic lesions of both native and prosthetic valves. Mitral stenosis is accurately quantified by planimetry of transthoracic or transesophageal two-dimensional images, Doppler measurement of transvalvular gradients, and estimation of valve area by the pressure half-time or continuity methods.20212223 Prognostic information is obtained from assessment of the hemodynamic response to exercise24 and/or delineation of morphological characteristics,25 which in turn help guide the selection of therapeutic interventions.26TEE has also been useful in guiding balloon valvuloplasty procedures.27Although tricuspid stenosis is readily detected and assessed hemodynamically, the accuracy of Doppler echocardiographic determinations is less well validated but still preferred over other methods.28Aortic stenosis is accurately quantified by Doppler measurements of instantaneous and mean transvalvular gradients, estimation of valve area by the continuity method, or determination of aortic valve resistance.293031 In patients with reduced LV function, gradient measurements may appear falsely low, while valve area and resistance measurements will more reliably predict the severity of stenosis. Dobutamine perturbation with Doppler assessment of gradients may also be of use.32 Pulmonic valve gradients are similarly quantified. While still experimental, contrast injection may allow more accurate recording of stenotic jet velocities and therefore transvalvular gradients.33Native Valvular RegurgitationDoppler echocardiography is the most sensitive technique available for detection of native valve regurgitation; care must be taken to distinguish physiological phenomena from pathological lesions. Mild retrograde flow disturbances are frequently detected in normal subjects3435 and if trivial should be identified as being within the expected normal range and not suggestive of the presence of valvular heart disease. On the other hand, significant regurgitation may be silent on auscultation, most often, but not always, in unstable symptomatic patients.36 Because the finding of clinically silent valvular regurgitation in an asymptomatic patient carries an unknown significance, performance of Doppler echocardiography to exclude valvular heart disease in an asymptomatic patient with a normal physical examination is not indicated.Precise assessment of the severity of regurgitant valvular lesions is difficult using any invasive or noninvasive technique, and no gold standard is available to judge relative accuracy.7 Doppler methods for detection of regurgitation are similar for all four native valves and prosthetic valves. Methods include assessment of regurgitant jet characteristics (length, height, area, and width at the vena contracta), effective regurgitant orifice area, and measurement of regurgitant flow volume using the proximal isovelocity surface area.7373839404142434445 The severity of semilunar valve regurgitation is also assessed by the rate of decline in regurgitant gradient as measured by the slope of diastolic flow velocity envelope.4647 The severity of atrioventricular regurgitation is also reflected by reduction or reversal of the systolic components of venous inflow.48 Finally, in isolated valve disease, regurgitant fraction may be assessed by comparison of stroke volumes at the regurgitant valve and an uninvolved valve.Doppler echocardiography is also the test of choice in the reevaluation of regurgitant lesions and in determination of the timing of operative intervention.495051 Echocardiographically obtainable information about the severity of regurgitation and associated structural and functional changes are all important to this therapeutic decision. The choice between mitral valve repair and replacement is greatly aided by TTE and TEE; intraoperative assessment of valve repair is essential to optimal surgical practice, while intraoperative determination of prosthetic valve seating and function is also useful.52Repeated Studies in Valvular Heart DiseaseA routine follow-up echocardiographic examination is not indicated after an initial finding of mini