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      Evidence-based recommendations for PISA measurements in mitral regurgitation: systematic review, clinical and in-vitro study ☆☆

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          Guidelines for quantifying mitral regurgitation (MR) using “proximal isovelocity surface area” (PISA) instruct operators to measure the PISA radius from valve orifice to Doppler flow convergence “hemisphere”. Using clinical data and a physically-constructed MR model we (A) analyse the actually-observed colour Doppler PISA shape and (B) test whether instructions to measure a “hemisphere” are helpful.

          Methods and results

          In part A, the true shape of PISA shells was investigated using three separate approaches. First, a systematic review of published examples consistently showed non-hemispherical, “urchinoid” shapes. Second, our clinical data confirmed that the Doppler-visualized surface is non-hemispherical. Third, in-vitro experiments showed that round orifices never produce a colour Doppler hemisphere.

          In part B, six observers were instructed to measure hemisphere radius r h and (on a second viewing) urchinoid distance ( d u ) in 11 clinical PISA datasets; 6 established experts also measured PISA distance as the gold standard. r h measurements, generated using the hemisphere instruction significantly underestimated expert values (− 28%, p < 0.0005), meaning r h 2 was underestimated by approximately 2-fold. d u measurements, generated using the non-hemisphere instruction were less biased (+ 7%, p = 0.03).

          Finally, frame-to-frame variability in PISA distance was found to have a coefficient of variation (CV) of 25% in patients and 9% in in-vitro data. Beat-to-beat variability had a CV of 15% in patients.


          Doppler-visualized PISA shells are not hemispherical: we should avoid advising observers to measure a hemispherical radius because it encourages underestimation of orifice area by approximately two-fold. If precision is needed (e.g. to detect changes reliably) multi-frame averaging is essential.

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          Most cited references 22

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          The emerging role of exercise testing and stress echocardiography in valvular heart disease.

          Exercise testing has an established role in the evaluation of patients with valvular heart disease and can aid clinical decision making. Because symptoms may develop slowly and indolently in chronic valve diseases and are often not recognized by patients and their physicians, the symptomatic, blood pressure, and electrocardiographic responses to exercise can help identify patients who would benefit from early valve repair or replacement. In addition, stress echocardiography has emerged as an important component of stress testing in patients with valvular heart disease, with relevant established and potential applications. Stress echocardiography has the advantages of its wide availability, low cost, and versatility for the assessment of disease severity. The versatile applications of stress echocardiography can be tailored to the individual patient with aortic or mitral valve disease, both before and after valve replacement or repair. Hence, exercise-induced changes in valve hemodynamics, ventricular function, and pulmonary artery pressure, together with exercise capacity and symptomatic responses to exercise, provide the clinician with diagnostic and prognostic information that can contribute to subsequent clinical decisions. Nevertheless, there is a lack of convincing evidence that the results of stress echocardiography lead to clinical decisions that result in better outcomes, and therefore large-scale prospective randomized studies focusing on patient outcomes are needed in the future.
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            Exercise-induced changes in degenerative mitral regurgitation.

            We sought to quantify exercise-induced changes in patients with degenerative mitral regurgitation (MR), to examine the relationship between exercise-induced changes in MR and in systolic pulmonary artery pressure (PAP), and to identify their potential impact on symptom-free survival. MR severity can change during exercise in patients with functional MR. Quantified changes in MR severity during exercise remain undetermined in patients with degenerative MR. Resting and bicycle exercise Doppler-echocardiography were performed in 61 asymptomatic patients (age 62+/-14 years) with moderate to severe degenerative MR (i.e., mitral valve prolapse or flail). Mitral regurgitation was quantified at rest and exercise with effective regurgitant orifice (ERO) area and regurgitant volume calculated with the proximal isovelocity surface area (EROP) and the quantitative Doppler (EROD) methods. At rest, EROP and EROD were well-correlated (r=0.87, p or=10 mm2 and >or=15 ml, respectively. There was good correlation between exercise EROP and EROD (r=0.84, p<0.0001). Changes in systolic PAP were correlated with changes in ERO and regurgitant volume (r=0.59, p=0.02 and r=0.60, p=0.02). Patients with a marked increase in regurgitant volume during exercise had lower symptom-free survival than those in whom MR decreased or remained unchanged (p=0.0015). Degenerative MR might be dynamic and increases during exercise in one-third of patients. Marked changes in MR severity are associated with exercise-induced changes in systolic PAP and reduced symptom-free survival. Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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              Effective mitral regurgitant orifice area: clinical use and pitfalls of the proximal isovelocity surface area method.

              We attempted to determine the accuracy and pitfalls of calculating the mitral regurgitant orifice area with the proximal isovelocity surface area method in a clinical series that included patients with valvular prolapse and eccentric jets. The effective regurgitant orifice area, a measure of lesion severity of mitral regurgitation, can be calculated by the proximal isovelocity surface area method, the accuracy and pitfalls of which have not been established. In 119 consecutive patients with isolated mitral regurgitation, effective regurgitant orifice area was measured by the proximal isovelocity surface area method and compared with measurements simultaneously obtained by quantitative Doppler and quantitative two-dimensional echocardiography. The effective mitral regurgitant orifice area measured by the proximal isovelocity surface area method tended to be overestimated compared with that measured by quantitative Doppler and quantitative two-dimensional echocardiography (38 +/- 39 vs. 36 +/- 33 mm2 [p = 0.09] and 34 +/- 32 mm2 [p = 0.02], respectively). Overestimation was limited to patients with prolapse (61 +/- 43 vs. 56 +/- 35 mm2 [p = 0.05] and 54 +/- 34 mm2 [p = 0.014]) and was restricted to patients with nonoptimal flow convergence (n = 7; 137 +/- 35 vs. 84 +/- 34 mm2 [p = 0.002] and 79 +/- 33 mm2 [p = 0.002]). In patients with optimal flow convergence (n = 112), excellent correlations with both reference methods were obtained (r = 0.97, SEE 6 mm2 and r = 0.97, SEE 7 mm2, p < 0.0001). In calculating the mitral effective regurgitant orifice area with the proximal isovelocity surface area method, the observed pitfall (overestimation due to nonoptimal flow convergence) is rare. Otherwise, the method is reliable and can be used clinically in large numbers of patients.

                Author and article information

                Int J Cardiol
                Int. J. Cardiol
                International Journal of Cardiology
                30 September 2013
                30 September 2013
                : 168
                : 2
                : 1220-1228
                [a ]International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, 59-61 North Wharf Road, London W21LA, UK
                [b ]Department of Chemical Engineering, Imperial College London, SW72AZ, UK
                Author notes
                [* ]Corresponding author at: ICCH building, 59-61 North Wharf Road, London W21LA, UK. Tel.: + 39 3486933036; fax: + 44 2075941706. michela.moraldo@ 123456gmail.com
                © 2013 Elsevier Ireland Ltd.

                This document may be redistributed and reused, subject to certain conditions.


                Cardiovascular Medicine

                mitral regurgitation, pisa method, echocardiography


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