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Quantification of mitral regurgitation by PISA
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Quantification of mitral regurgitation by PISA


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Quantification of mitral regurgitation by PISA

Quantification of mitral regurgitation by PISA

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  • 1. Quantification of Mitral Regurgitation PISA :Proximal Isovelocity Surface Area
  • 2. Carpentier’ classification of MR 1. Type I Mitral leaflet motion is normal MR results from annular dilation 2. Type II Excessive leaflet motion Prolapse or flail leaflet 3. Type III is from restricted leaflet motion Type IIIa:Leaflets have restricted motion in both systole and diastole - Rheumatic MR Type IIIb: Restricted motion during systole -Ischemic MR/ functional MR
  • 3. Normal  LV minor axis: ≤2.8 cm/m2  LV end-diastolic volume: ≤82 mL/m2 Maximal LA anteroposterior diameter : ≤2 cm/m2 Maximal LA volume: ≤36 mL/m2
  • 4. Eye balling parameters Parameters Mild MR Moderate MR Severe MR LA size Normal Normal or dilated dilated LV size Normal Normal or dilated dilated Mitral leaflets Normal or abnormal Normal or abnormal Abnormal/flail leaflet/ruptured papillary muscle
  • 5. Supportive parameters ( Doppler ) Parameter Mild MR Mod MR Severe MR Colour flow jet area Small central jet (usually <4 cm2 or <20% of LA area) Variable Large central jet (usually >10 cm2 or >40% of LA area) or variable size wall-impinging jet swirling in LA Mitral inflow, pulsed wave A wave dominant| Variable E wave dominant (E usually 1.2 m/s) Jet density, CW Incomplete or faint Dense Dense Jet contour, CW Parabolic Usually parabolic Early peaking, triangular Pulmonary vein flow Systolic dominance Systolic blunting Systolic flow reversal
  • 6. Definitive(Hard) Parameters Quantitative Parameters Mild MR Mod MR Severe MR Vena contracta width (cm) <0.3 0.3-0.69 ≥0.7 Regurgitant volume (mL/beat) <30 30-44 To 45-59 ≥60 Regurgitant fraction (%) <30 30-39 to 40-49 ≥50 EROA (cm2) <0.20 0.20-0.29 to 0.30- 0.39 ≥0.40
  • 7. What does these measurement mean ?
  • 8. PISA is in LV and ERO is in LA
  • 9. Proximal isovelocity surface area=PISA • Fluid dynamic theory predicts that as flow approaches a circular finite orifice, it forms a series of concentric hemispheric shells with gradually decreasing area and increasing velocity. Arrows refer to direction of flow as it approaches the proximal isovelocity surface area region. R is the radius of a hemispherical shell.With principle of conservation of mass, flow through the regurgitant orifice = flow through the isovelocity surface = 2πr2 × aliasing velocity
  • 10. conservation of mass • Flow through the regurgitant orifice = flow through the isovelocity surface = 2πr2 × aliasing velocity=Regurgitant orifice X MR jet velocity • Regurgitant orifice =2πr2 × aliasing velocity/MR jet velocity • Regurgitant volume=Regurgitant orifice X MR jet VTI • Regurgitant fraction=Regurgitant volume/TSV • TSV=Regurgitant volume+LVOT VTI X LVOT area=Stroke volume can be calculated as: (end-diastolic volume—end-systolic volume)/end- diastolic volume .
  • 11. • Effective orifice area=Vena contracta area
  • 12. Still need clues ! • Flow A=MR regurgitation volume +B flow(LVOT flow)
  • 13. Adjusting Nyquist limit to perfect PISA • Baseline shifting of the Nyquist limit toward the direction of the regurgitant flow results in a larger proximal isovelocity surface area zone for optimal measurement of the proximal isovelocity surface area region radius (right panel).
  • 14. Angle correction(α) • It is required in eccentric MR like flail anterior or posterior leaflet • Angle correction is performed by multiplying the surface area calculation by α/180, where α is the angle between the mitral leaflet and the end of the PISA region confined by the LA wall • This correction does introduce new error • Angle correction is for bench discussion but not used clinically
  • 15. • Radius (r) of PISA • Convergence angle(α) • Proximal convergence field for central (left) and eccentric (right) convergence • The convergence angle is obtained by projecting the most distal point of the isovelocity contour onto the constraining wall.
  • 16. Aliasing velocity Nyquist limit =19cm/sec
  • 17. Effect of PISA radius on PISA shape and flow calculation • Isovelocity hemispheres proximal to a mitral regurgitant orifice (left) at three different distances from the orifice and corresponding plots of calculated flow rates (Qc) as a function of distance from the orifice. The dashed line represents the actual regurgitant flow rate
  • 18. Validity
  • 19. Yes and No Disadvantage • If the valve orifice is not flat or circular, the flow convergence zone will not be hemispheric, thus PISA radius cannot be used for the calculation of the regurgitant flow. • Systolic changes of regurgitant flow are not taken into account. • In assessment of regurgitant flow/volume, errors in calculation of PISA radius are squared. Advantage • Independent of hemodynamic factors, aetiology of the disease and presence of multiple valve alterations. • It can be used in central as well as in eccentric jets (although less accurate) • It is a quantitative estimation of lesion severity and volume overload with an acceptable reproducibility
  • 20. Calculation
  • 21. One page
  • 22. Bench to Bedside • Severe primary MR, class I indications for surgical intervention • Symptomatic • LV decompensation • LV ejection fraction of 0.6 or less • LV end-systolic diameter of 40 mm or more
  • 23. You can make it more beautiful