Table 1 Echo protocol

Parasternal long axis views

Step 1 - Parasternal long axis view 2-D: Visualize mitral valve and aortic valve (used for morphological assessment by expert reviewers) and store loop [3 s].

Step 2 - Parasternal long axis view color Doppler mode, mitral valve: Place the color Doppler window over the mitral valve and left atrium – note if there is a regurgitant jet (blue) and store loop.

Step 3 - Parasternal long axis view color Doppler mode, aortic valve: Place the color over the aortic valve – note if there is a regurgitant jet – If the jet takes up more than half the width of the outflow tract, then measure the width and the outflow tract diameter and store loop.

Apical 4 chamber view

Step 4 - Apical 4 chamber view 2D mode: Obtain image of all 4 chambers, visualizing mitral valve well and store loop.

Step 5 - Apical 4 chamber view color Doppler mode, mitral valve: Place the color window over the mitral valve and left atrium – note if there is a regurgitant jet – Store loop. Place cursor in the left ventricle through the center of the mitral valve and obtain continuous wave Doppler – freeze and trace to obtain a mean gradient and store measurement.

Step 6 - Apical 4 chamber view color Doppler mode, tricuspid valve: Place the color window over the tricuspid valve and right atrium – note if there is a regurgitant jet – Store loop. Place the cursor in the right atrium over the tricuspid regurgitation and obtain a CW Doppler attempting to obtain a full envelope of TR. Freeze and measure the maximum velocity/gradient and store measurement

Apical 5 chamber view

Step 7 - Apical 5 chamber view 2D mode: Visualize aortic valve and store loop.

Step 8 - Apical 5 chamber view color Doppler mode, aortic valve: Place the color window over the aortic valve and left ventricle, and note if there is a regurgitant jet – Store loop. Place the cursor across the aortic valve and obtain a CW Doppler to obtain three full envelopes for the systolic flow across the aortic valve. Trace all three envelopes to obtain peak and mean gradient across the aortic valve and store image.