Recommended Initial Imaging for Chronic Rheumatic Heart Disease Valvular Defects
Two-dimensional transthoracic echocardiography (2D TTE) is the recommended initial imaging modality for diagnosing valvular defects in chronic rheumatic heart disease. 1, 2
Primary Imaging Recommendation
TTE is rated "Appropriate" by the American College of Cardiology, American Heart Association, and American Society of Echocardiography for both asymptomatic and symptomatic patients with suspected or known chronic RHD. 2
TTE serves as the first-line imaging modality because it provides comprehensive assessment of valve anatomy, leaflet motion, severity of stenosis or regurgitation, left ventricular size and function, and hemodynamic consequences. 1
The European Association of Cardiovascular Imaging confirms that 2D TTE is often sufficient for diagnosis and should be the starting point for all patients with valvular regurgitation. 1
What TTE Evaluates in RHD
Valve morphology assessment includes identification of leaflet thickening, calcification, restricted motion, commissural fusion, and subvalvular apparatus involvement—all characteristic features of rheumatic valve disease. 3, 4
Severity quantification uses multiple parameters including valve area measurement by planimetry (reference method for mitral stenosis), vena contracta width, proximal isovelocity surface area (PISA), and Doppler-derived pressure gradients. 1, 3
Mechanism classification follows Carpentier's system (Type I: normal motion, Type II: excessive motion, Type III: restrictive motion) to understand the dysfunction pattern. 1, 5
Cardiac chamber assessment documents left ventricular size, systolic function, left atrial enlargement, and pulmonary pressures to gauge hemodynamic impact and chronicity. 1, 5
When to Escalate to Advanced Imaging
Transesophageal Echocardiography (TEE)
TEE is rated "Appropriate" when TTE images are inadequate or when more detailed anatomic information is needed for surgical planning or intervention. 1, 2
TEE provides superior visualization of valve morphology, commissural anatomy, and subvalvular structures—critical for assessing feasibility of percutaneous balloon mitral valvuloplasty in rheumatic mitral stenosis. 6, 3
3D TEE offers more accurate valve area measurement compared to 2D methods and better delineates commissural fusion patterns. 3
Three-Dimensional Echocardiography
3D echocardiography (either transthoracic or transesophageal) provides additional information in patients with complex valve lesions and allows more accurate quantitation of valve area and regurgitant volumes. 1, 3
3D planimetry is more accurate than 2D for mitral valve area measurement in rheumatic mitral stenosis. 3
Other Modalities Are Not First-Line
CT and MRI are rated "Rarely Appropriate" for initial evaluation of suspected RHD by the American College of Cardiology. 2
Cardiac MRI may have adjunctive roles in specific scenarios (assessing myocardial involvement, quantifying regurgitation when echo is inconclusive), but it is not the primary diagnostic tool for RHD valvular assessment. 2, 6, 7
Cardiac CT and MRI can assess pericardial involvement if present, but this does not change the primary recommendation for valve assessment. 6
Clinical Algorithm
Start with 2D TTE in all patients with suspected chronic RHD using multiple standardized views (parasternal long-axis, parasternal short-axis, apical four-chamber, apical two-chamber). 1, 2, 5
If TTE images are adequate, proceed with comprehensive assessment including valve morphology, severity quantification using multiple parameters, and evaluation of cardiac chamber consequences. 1
If TTE images are inadequate or non-diagnostic, proceed to TEE for better visualization. 1, 2
If planning percutaneous intervention (such as balloon mitral valvuloplasty), obtain TEE—preferably 3D—to assess commissural anatomy, subvalvular apparatus, and precise valve area measurement. 3
Reserve advanced imaging (cardiac MRI, CT) for specific scenarios where echocardiography cannot answer the clinical question, such as assessing myocardial involvement or when there is discordance between clinical presentation and echocardiographic findings. 2, 6, 7
Common Pitfalls to Avoid
Do not skip TTE and proceed directly to advanced imaging—this violates appropriate use criteria and wastes resources, as TTE provides the necessary diagnostic information in the vast majority of cases. 2
Do not rely solely on color Doppler jet area to quantify regurgitation severity, as this is not recommended and can be misleading; use quantitative methods (vena contracta, PISA, regurgitant volume). 1
Do not order TEE routinely when TTE provides good quality images and adequate diagnostic information—TEE is reserved for inadequate TTE or when additional anatomic detail is required for intervention planning. 1, 2
Ensure blood pressure is optimized before measuring stenosis severity, as hypertension can affect transvalvular gradients and lead to underestimation of severity. 1