Valve Regurgitation

How pediatric echo grades MR, AR, TR and PR, with the adult ASE criteria for reference

Valve

Mitral regurgitation


In Children
Child	Grade by the color jet(s), LA and LV dilation by z-score, and pulmonary-vein systolic reversal. 3D quantification is not validated.	ASE 2024 pediatric

Why; AVSD repair data

Multiple jets, inconsistent definitions and poor reproducibility limit the adult methods in children.
After AV septal defect repair (149 children, median age 1 year), vena contracta measures had the best observer agreement but were only slightly better than the qualitative grade; regurgitant volume by stroke-volume difference came out negative in 75% (Prakash 2012). No pediatric indexed thresholds exist.

Chronic MR, Adult Grading · ASE 2017, Table 8. Bold = specific for that grade.
Parameter	Mild	Moderate	Severe
Valve	None or mild abnormality	Moderate abnormality or tenting	Severe lesion
Color jetNyquist 50–70 cm/s	Small, central, narrow, often brief	Variable	Large central (>50% of LA) or eccentric wall-hugging
Flow convergence	None, transient or small	Intermediate	Large throughout systole
CW jet	Faint, partial, parabolic	Dense, partial or parabolic	Holosystolic, dense, triangular
Vena contracta (cm)	<0.3	Intermediate	≥0.7 (>0.8 biplane)
Pulmonary-vein flow	Systolic dominance	Normal or blunted	Minimal systolic flow, or systolic reversal
Mitral inflowValid mainly in adults >50 y; healthy children are E-dominant	A-wave dominant	Variable	E-wave dominant (>1.2 m/s)
EROA (cm²)	<0.20	0.20–0.29 / 0.30–0.39	≥0.40
Regurgitant volume (mL)	<30	30–44 / 45–59	≥60
Regurgitant fraction (%)	<30	30–39 / 40–49	≥50

Aortic regurgitation


In Children
Child	Pressure half-time and slope are not validated; grade by the jet, aortic diastolic reversal and LV dilation.	ASE 2024 pediatric
Child	Abdominal holodiastolic reversal separated 1–2+ from 3–4+ AR (sensitivity 100%); brief early reversal is normal. Not AR-specific: exclude PDA and collaterals first.	Tani 1997 abstract
Child	Descending-aorta reverse/forward VTI >0.38 predicted CMR regurgitant fraction >33% (specificity 100%, sensitivity 71%; 27 patients 6–18 y).	Ibrahim 2019 abstract

Chronic AR, Adult Grading · ASE 2017, Table 11. Bold = specific.
Parameter	Mild	Moderate	Severe
Leaflets	Normal or abnormal	Normal or abnormal	Flail or wide coaptation defect
Jet width in LVOT (central)	Small	Intermediate	Large
Jet width / LVOT width (%)	<25	25–45 / 46–64	≥65
Jet area / LVOT area (%)	<5	5–20 / 21–59	≥60
Vena contracta (cm)	<0.3	0.3–0.6	>0.6
Pressure half-time (ms)Not validated in children	>500	500–200	<200
Descending aorta, diastolic reversal	Brief, early	Intermediate	Prominent holodiastolic
Regurgitant volume (mL)	<30	30–44 / 45–59	≥60
Regurgitant fraction (%)	<30	30–39 / 40–49	≥50
EROA (cm²)	<0.10	0.10–0.19 / 0.20–0.29	≥0.30

ASE 2017: holodiastolic reversal in the descending aorta means at least moderate AR; in the abdominal aorta it is consistent with severe AR.

Tricuspid regurgitation


In Children and Neonates
Pediatric	As for MR, with RA/RV size and hepatic-vein systolic reversal (unreliable with arrhythmia or pacing).
Pediatric	Severe TR can look benign: low velocity (about 2 m/s), dense early-peaking or sine-wave CW; wide-open TR may show no color jet.

Neonates; repaired tetralogy

In neonates TR is mainly a tool to estimate RV pressure. Transitional TR is common: 83% of healthy term and preterm newborns had a recordable TR jet in one study (Schmitz 1997).
Repaired tetralogy (ASE 2014): vena contracta is called the most reliable TR measure; the adult >0.7 cm severe threshold is used without pediatric validation.

Chronic TR, Adult Grading · ASE 2017, Table 14. Bold = specific.
Parameter	Mild	Moderate	Severe
Valve	Normal or mildly abnormal	Moderately abnormal	Severe lesion
Color jet	Small, narrow, central	Moderate central	Large central or eccentric wall-hugging; area >10 cm²
CW jet	Faint, partial, parabolic	Dense, parabolic or triangular	Dense, often triangular
Vena contracta (cm)	<0.3	0.3–0.69	≥0.7
PISA radius (cm)Baseline shift to 28 cm/s	≤0.5	0.6–0.9	>0.9
Hepatic-vein flow	Systolic dominance	Systolic blunting	Systolic reversal
Tricuspid inflow	A-wave dominant	Variable	E wave >1.0 m/s
EROA (cm²)	<0.20	0.20–0.39	≥0.40
Regurgitant volume (mL)	<30	30–44	≥45

PISA discrepancy; massive/torrential

The ASE 2017 algorithm (Figure 31) uses a PISA radius <0.4 cm at a Nyquist of 30–40 cm/s for mild, which differs from the table. The 2025 ASE adult reporting guideline allows "massive" and "torrential" as subgroups of severe TR without defining them. Our note: the numbers proposed for those grades come from adult work and have no pediatric role.

Pulmonary regurgitation


Repaired Tetralogy and Other Congenital PR
Repaired TOF or PS	Branch PA diastolic reversal: best single sign of severe PR (sensitivity, specificity 87% vs CMR; main PA alone, specificity 39%).	Renella 2010, as quoted by ASE 2017 secondary
Child	Main PA diastolic/systolic VTI: about 0.49 matched CMR fraction 20%, 0.72 matched 40%; every ratio >1 had >40% (8–18 y).	Mercer-Rosa 2012
Adolescent, adult	Suspected more than moderate PR in an adolescent or adult with CHD: CMR is indicated.	ASE 2017

Jet width, spectral pattern

Jet width ≥50% of the annulus with branch reversal predicts severe PR (ASE 2014). In young patients, jet/annulus ≥0.5 predicted CMR regurgitant fraction ≥20%, and ≥0.7 with branch reversal predicted ≥40% (Puchalski 2008).
Spectral pattern: mild, a persistent gradient at end-diastole; moderate, PA–RV equalisation only at end-diastole; severe, early diastolic equalisation (ASE 2014 Figure 1). Free PR is easy to miss on color because the flow is low-velocity and laminar.
Mercer-Rosa 2012 cohort aged 8–18 y; color assessment over-called mild PR in 36%.

PR Grading, Adult and Congenital · ASE 2017, Table 16
Parameter	Mild	Moderate	Severe
Color jet	Thin, usually <10 mm long, narrow origin	Intermediate	Broad origin, variable depth
Jet width / annulus	—	—	>0.7 (CMR fraction ≥40%)The 2017 text cites >0.5; ASE 2014 uses ≥50% with branch reversal
CW density and contour	Soft	Dense	Dense, early termination of diastolic flow
Pressure half-time (ms)	—	—	<100Unreliable with high RV end-diastolic pressure
Deceleration time (ms)	—	—	<260
PR indexPR duration / diastole	—	<0.77 identifies CMR fraction >25% (printed in both columns)
Branch or main PA diastolic reversal	—	—	Prominent
Regurgitant fraction (CMR) (%)	<20	20–40	>40

Insignificant PR

A jet shorter than 10 mm is considered insignificant PR. Trace to mild PR is present in about 75% of people.

Physiologic versus pathologic regurgitation


Physiologic (Trivial) Regurgitation: Our Summary
Pediatric	Normal valve and chamber sizes; no venous or aortic reversal.
Pediatric	Thin, short jets (MR, AR usually under 1 cm; TR, PR up to about 1–2 cm), often brief or only at valve closure; faint, incomplete CW; one view.

Prevalence

In structurally normal children: PR and TR common (in some series most children); MR occasional; AR rare (0–2%). Among 25,590 newborns, AR was seen in 1.3%, mostly trivial (vena contracta <1 mm); vena contracta ≥1 mm was associated with more bicuspid valves (13% vs 1.1%) and larger aortic dimensions (Copenhagen Baby Heart Study, 2026).

Pathologic MR and AR · all four criteria must be met (World Heart Federation 2012; 2023 update not reviewed)
Criterion	Pathologic MR	Pathologic AR
Views	Seen in two views	Seen in two views
Jet length	≥2 cm in at least one view	≥1 cm in at least one view
Peak velocity	≥3 m/s for one complete envelope	≥3 m/s in early diastole
Timing	Pansystolic in at least one envelope	Pandiastolic in at least one envelope

Key points

No pediatric-validated numeric grading. The adult quantitative indices are limited or not validated in children (ASE 2010, 2024).
Grade (ASE 2024) by color jet, chamber dilation by z-score and downstream reversal: pulmonary veins (MR), hepatic veins (TR), aorta (AR), branch PAs (PR).
Adult absolute values are size-bound (60 mL or 0.7 cm differ in an infant); ratios carry over better. Our reading, not a guideline.
Abdominal aortic holodiastolic reversal is not AR-specific in children: PDA, collaterals, AVM, shock and sedation cause it too.
Trace TR and PR are common and normal; AR is not (ASE 2017). Our note: AR after the newborn period: look for bicuspid valve, VSD with cusp prolapse, aortic dilation.

Sources and how this page was checked

Guidelines (full text read)

Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the ASE developed in collaboration with the SCMR. J Am Soc Echocardiogr 2017;30:303-371. doi:10.1016/j.echo.2017.01.007. Adult document; Tables 8, 11, 14, 16 and Figures 18, 25, 31, 35.
Lopez L, Saurers DL, Barker PCA, et al. Guidelines for performing a comprehensive pediatric transthoracic echocardiogram: recommendations from the ASE. J Am Soc Echocardiogr 2024;37:119-170. doi:10.1016/j.echo.2023.11.015.
Lopez L, Colan SD, Frommelt PC, et al. Recommendations for quantification methods during the performance of a pediatric echocardiogram. J Am Soc Echocardiogr 2010;23:465-495. doi:10.1016/j.echo.2010.03.019.
Valente AM, Cook S, Festa P, et al. Multimodality imaging guidelines for patients with repaired tetralogy of Fallot: a report from the ASE. J Am Soc Echocardiogr 2014;27:111-141. doi:10.1016/j.echo.2013.11.009.
Taub CC, Stainback RF, et al. Guidelines for the standardization of adult echocardiography reporting: recommendations from the ASE. J Am Soc Echocardiogr 2025;38:735-774. doi:10.1016/j.echo.2025.06.001 (TR terminology only).

Studies

Mercer-Rosa L, Yang W, Kutty S, et al. Quantifying pulmonary regurgitation and right ventricular function in surgically repaired tetralogy of Fallot. Circ Cardiovasc Imaging 2012;5:637-643. doi:10.1161/CIRCIMAGING.112.972588 (full text).
Prakash A, Lacro RV, Sleeper LA, et al. Challenges in echocardiographic assessment of mitral regurgitation in children after repair of atrioventricular septal defect. Pediatr Cardiol 2012;33:205-214. doi:10.1007/s00246-011-0107-5 (full text).
Renella P, Aboulhosn J, Lohan DG, et al. Two-dimensional and Doppler echocardiography reliably predict severe pulmonary regurgitation as quantified by cardiac magnetic resonance. J Am Soc Echocardiogr 2010;23:880-886. doi:10.1016/j.echo.2010.05.019 (abstract; sensitivity and specificity as quoted by ASE 2017).
Puchalski MD, Askovich B, Sower CT, et al. Pulmonary regurgitation: determining severity by echocardiography and magnetic resonance imaging. Congenit Heart Dis 2008;3:168-175. doi:10.1111/j.1747-0803.2008.00184.x (abstract).
Tani LY, Minich LL, Day RW, et al. Doppler evaluation of aortic regurgitation in children. Am J Cardiol 1997;80:927-931. doi:10.1016/S0002-9149(97)00547-X (abstract).
Ibrahim A, Borrelli N, Krupickova S, et al. Pure aortic regurgitation in pediatric patients. Am J Cardiol 2019;124:1731-1735. doi:10.1016/j.amjcard.2019.08.042 (abstract).
Schmitz AJ, et al. Angiology 1997;48:725-734. doi:10.1177/000331979704800809 (abstract; neonatal TR).
Farooqui AF, et al. Prevalence of congenital aortic valve regurgitation in a newborn cohort. Pediatr Cardiol 2026. doi:10.1007/s00246-025-04149-0 (abstract).
Physiologic regurgitation in children: Brand A, et al. Am Heart J 1992 (doi:10.1016/0002-8703(92)90763-L); Thomson JD, et al. Heart 2000 (doi:10.1136/heart.83.2.185); Lee ST, Lin MH. J Formos Med Assoc 2010 (doi:10.1016/S0929-6646(10)60021-6); Webb RH, et al. J Am Soc Echocardiogr 2015 (doi:10.1016/j.echo.2015.03.012). Abstracts.
World Heart Federation 2012 criteria as reproduced in Marangou J, et al. Glob Heart 2024;19:44. doi:10.5334/gh.1327 (full text; secondary source).

How it was checked

The ASE documents were read in full (October 2026) and the grading tables copied from them; wording is condensed. Studies marked abstract were checked against the authors' abstracts only.
Inconsistencies inside ASE 2017, shown as printed: PR jet width/annulus is >0.5 in the text, >0.7 in Table 16 and ≥70% in Figure 35; the PR index <0.77 sits in both the moderate and severe columns; the TR PISA radius for mild is ≤0.5 cm in Table 14 but <0.4 cm in Figure 31.
No pediatric-validated, body-size-indexed thresholds for vena contracta, EROA or regurgitant volume were found.