PISA Method Research Articles

Prognostic role of echocardiographic variables in patients with moderate to severe organic mitral regurgitation, normal cardiopulmonary functional capacity and low NT-proBNP level

Background: Mitral regurgitation (MR) is one of the most common valvular heart disease with high morbidity and mortality. Recent studies in patients with organic MR emphasized the role of cardiopulmonary exercise test (CPET) and NT-proBNP in predicting need of surgery or hospitalization for atrial fibrillation (AF) and heart failure (HF). Since most part of patients with moderate to severe organic MR have normal cardiopulmonary functional capacity and low NT-proBNP level we sought to evaluate the prognostic role of echocardiographic variables in this setting. Methods: Between September 2006 and December 2012 patients with moderate to severe organic MR (regurgitant volume (RV) > 40 ml) were evaluated. All patients underwent complete echocardiographic evaluation with 3 methods of MR quantification (PISA, doppler and volumetric methods), cardiopulmonary exercise test and NT-proBNP measurement. Only patients with normal CPET (peak VO2 > 85% of predicted) and low NT-proBNP level (<150 pg/ml) were included in the study. First event rates were estimated with the Kaplan-Meier method, Cox proportional hazards modeling for long-term first events predictors Results: Among 78 patients with moderate to severe organic MR evaluated, 31 had normal CPET (peak VO2>85% of predicted) and low NT-pro BNP level (<150 pg/ml) and were included in the study. NT-proBNP was 69±29 pg/ml (median 74 pg/ml, 25%-75% 55-95), peak VO2 was 27±5 ml/kg/min, RV (Regurgitant Volume) mean (average of 3 quantification methods) 55±15 ml/beat, ERO (Effective Regurgitant Orifice) mean 0,30±0,08 cm2, end diastolic left ventricular (EDLV) volume 165±31 ml, EDLV volume/BSA (Body Surface Area) 89±15 ml/m2, end systolic left ventricular (ESLV) volume 43±18 ml, ESLV volume/BSA 23±9 ml/m2; LA volume 77±26 ml, LA volume/BSA 41±11 ml/m2, LV mass 198±34 g, LV mass/BSA 106±14 g/m2.19 patients (41%) underwent surgery correction of MR and 4 patients (10%) developed new AF. At univariate analysis predictors of need of surgery and/or AF were LV mass (p=0,01), E velocity (p=0,001), EDLV volume (p<0,001), ESLV volume (p=0,001), ERO mean (0<0,001), RV mean (p<0,001). Independent predictors of need of surgery/AF were E velocity (p<0,001), ESLV volume (p=0,02), ERO mean (p=0,006), RV mean (p=0,002) Conclusions: In patients with moderate to severe organic mitral regurgitation, normal cardiopulmonary functional capacity and low NT-proBNP level, E velocity, ESLV volume, ERO, RV, RV/LA volume ratio and PVF reversal are strictly related to need of surgery and/or new AF during follow-up and should be carefully assessed and evaluated.

149 ATRIAL FUNCTION AS A GUIDE TO INTERVENTION IN MITRAL VALVE PROLAPSE

<h3>Introduction</h3> Timing of surgery for patients with mitral valve prolapse and severe mitral regurgitation (MR) remains problematic. In the absence of symptoms, current guidelines emphasise the importance of left ventricular (LV) size and function, pulmonary artery pressures and the development of AF in helping to determine the need for intervention in these individuals. Little is known regarding the impact of chronic mitral regurgitation on atrial physiology, nor has the association between atrial function and the timing of mitral valve surgery been investigated. <h3>Methods</h3> We included consecutive patients reviewed in our specialist valve service. All underwent clinical and echocardiographic assessment. We divided patients according to the severity of MR and whether they had accepted indications for surgery. Echo data recorded included: LV dimensions, LV function, pulmonary artery pressure, and MR severity using the PISA method. Additionally, we measured maximal and minimal left atrial volume (LAV) using the Simpsons biplane method, from which we derived the atrial volume change (AVC), defined as: Finally, using 2D speckle imaging from the apical 2- and 4-chamber views, we recorded the three components of atrial strain: peak negative (contractile), peak positive (conduit), and total (reservoir). <h3>Results</h3> We included 160 patients, divided into 4 groups: severe MR with an indication for surgery (surgical; n=77); severe MR with no surgical indication (non-surgical; n=26); patients with moderate or less MR (moderate; n=32) and 25 controls. AVC correlated strongly to total atrial strain (r=0.86; p&lt;0.0001). AVC was similar in the control, moderate and non-surgical groups, but was significantly lower in the surgical cohort (see Graph 1: AVC surgical 34±10%; non-surgical 55±9%; moderate 57±11%; controls 62±6%; p&lt;0.001 surgical vs other groups), with a similar pattern seen for total atrial strain. The contractile component of atrial function was highest in controls, was reduced similarly in moderate and non-surgical patients, and was reduced further in the surgical group (Graph 2: negative strain surgical −4.5±5.2; non-surgical −14.8±8.0; moderate −14.6±9.3; controls −20.8±5.6). Receiver-operator curve analysis demonstrated that an AVC of &lt;50% is 97% sensitive and 87% specific for severe MR requiring surgical intervention. <h3>Conclusions</h3> The atrium adapts to chronic mitral regurgitation by increasing conduit function at the expense of the contractile component of atrial strain. With ongoing MR the atrium loses overall reservoir capacity and develops a reduced AVC. Loss of normal atrial volume change accurately predicts the need for surgical intervention in these patients and may be useful in guiding surgery in asymptomatic individuals.

Simplifying proximal isovelocity surface area as an assessment method of mitral valve area in patients with rheumatic mitral stenosis by fixing aliasing velocity and mitral valve angle

We aimed to test the ability of a simple equation using proximal isovelocity surface area method (PISA), created by fixing the angle to 100° and the aliasing velocity to 33cm/s, to calculate mitral valve area (MVA) and assess severity in patients with rheumatic mitral stenosis (MS). Methods and resultsIn a series of 51 consecutive patients with rheumatic MS, MVA was assessed by four methods, conventional PISA equation (PISAconventional), simple PISA equation (PISAsimple), pressure half time (PHT), and planimetry (PLN) which was taken as the reference method. All methods correlated significantly with PLN with the highest correlation found in case of PISAconventional and PISAsimple (r=0.97, 0.96, p<0.001), while the correlation in case PHT was relatively weaker (r=0.69, p<0.001). Bland–Altman analysis revealed that the level of agreement with PLN was better in case of both PISA methods than PHT and, moreover, were close to each other. The number of cases that showed agreement of severity grade with planinetry was better in case of PISAconventional (42 cases) and PISAsimple (44 cases) than that in case of PHT (34 cases, p=0.037). Finally, the measure of agreement with Cohen’s Kappa test was better in case of PISAconventional and PISAsimple than that in case of PHT. ConclusionProvided that aliasing velocity is fixed at 33cm/s, PISA can effectively predict mitral valve area and severity of MS by a simple equation, with the advantage of easy and accurate calculation over other methods.

Quantitation of Mitral Regurgitation

Mitral regurgitation (MR) is the most frequent valve disease. Nevertheless, evaluation of MR severity is difficult because standard color flow imaging is plagued by considerable pitfalls. Modern surgical indications in asymptomatic patients require precise assessment of MR severity. MR severity assessment is always comprehensive, utilizing all views and methods. Determining trivial/mild MR is usually easy, based on small jet and flow convergence. Specific signs of severe MR (pulmonary venous flow systolic reversal or severe mitral lesion) are useful but insensitive. Quantitative methods, quantitative Doppler (measuring stroke volumes) and flow convergence (aka PISA method), measure the lesion severity as effective regurgitant orifice (ERO) and volume overload as regurgitant volume (RVol). Interpretation of these numbers should be performed in context of specific MR type. In organic MR (intrinsic valve lesions) ERO ≥ 0.40 cm(2) and RVol ≥ 60 mL are associated with poor outcome, while in functional MR ERO ≥ 0.20 cm(2) and RVol ≥ 30 mL mark reduced survival. While MR assessment should always be comprehensive, quantitative assessment of MR provides measures that are strongly predictive of outcome and should be the preferred approach. The ERO and RVol measured by these methods require interpretation in causal context to best predict outcome and determine MR management.

Comparison of mitral valve area by pressure half-time and proximal isovelocity surface area method in patients with mitral stenosis: effect of net atrioventricular compliance

The aim of this study was to test the hypothesis that, unlike calculation of the mitral valve area (MVA) with the pressure half-time method (PHT), the proximal isovelocity surface area method (PISA) is not affected by changes in net atrioventricular compliance (C(n)). We studied 51 patients with mitral stenosis (MS) from two centres. MVA was assessed with the PISA (MVA(PISA)), PHT (MVA(PHT)), and planimetry (MVA(PLN), serving as the gold standard) method. C(n) was calculated with a previously validated equation using 2D echocardiography. MVA(PISA) closely correlated with MVA(PLN) (r = 0.96, P < 0.0001), while MVA(PHT) and MVA(PLN) showed a weaker but still good correlation (r = 0.69, P < 0.0001). The correlation between MVA(PHT) and MVA(PLN) for patients with C(n) between 4 and 6 mL/mmHg (considered to be normal) was excellent (r = 0.93, P < 0.0001), but that for patients with C(n) of less than 4 or more than 6 mL/mmHg was not as good (r = 0.64, P < 0.0001). Importantly, a significant inverse correlation was detected between the percentage difference among MVA(PHT), MVA(PLN), and C(n) (r = -0.77, P < 0.0001), but the line of fit was nearly flat for the percentage difference among MVA(PISA), MVA(PLN), and C(n) (r = 0.1, P = 0.388). MVA calculated with both the PISA and PHT methods correlated well with MVA calculated with the planimetry method. However, the PISA rather than PHT is recommended for patients with MS and extreme C(n) values because PISA, unlike PHT, is not affected by changes in C(n).

152 Comparison of semi-quantitative and quantitative assessment of AR severity. Clinical implications

Recent studies have emphasized the importance of quantitative assessment of valvular regurgitation. However, in clinical practice mainly semi-quantitative methods remain used despite an unclear diagnostic value. We aimed to define the sensitivity and specificity of semi-quantitative methods compared to the PISA for the diagnostic of severe aortic regurgitation (AR). Degree of AR was prospectively evaluated using the PISA method and 4 semi-quantitative measurements (cardiac output (CO), pressure half time (PHT), vena contracta (VC) and diastolic flow reversal (DFR)) in 224 patients with a wide range of AR severity. Criteria for severe AR were an ERO 30 mm 2 , a CO 10 l/min, a PHT < 200 ms, a VC 6 mm or a DFR 18 cm/ s. Using the PISA method 76 patients (34%) had severe AR. Sensitivity, specificity, VPP, VPN of the recommended thresholds of the 4 semi-quantitative methods for severe AR based on ERO are presented in the Table. Overall, semi-quantitative methods had a good specificity but a poor sensitivity except the VC which presented both a good sensitivity and specificity. For assessment of AR severity, current thresholds are specific but poorly sensitive except the VC which provides a correct discriminative value. Thus, semi-quantitative methods should be integrated in the comprehensive evaluation of AR severity but severe AR should not be excluded only based on semi-quantitative criteria. Our results emphasize the need for quantitative assessment of AR severity in clinical practice and may explain the better prognostic value of quantitative methods than traditional variables. Threshold Sensitivity, % Specificity, % PPV,% NPV,% AUC CO10l/m 38 95 81 73 0.70 VC6 mm 91 77 65 95 0.90 DFR18cm/s 51 86 71 71 0.77 PHT200 ms 12 100 100 60 0.81

OP-102 ASSESSMENT OF ATRIAL CONDUCTION IN PATIENTS WITH ANKYLOSING SPONDYLITIS VIA P WAVE DISPERSION AND ATRIAL ELECTROMECHANICAL DELAY

Methods: We evaluated eighty-nine NIDCMP patients who had left ventricular ejection fraction (EF) below 45% with angiographically normal coronary arteries. Patients with organic mitral regurgitation were excluded. All patients underwent detailed echocardiographic study including mitral valve deformation indices (tenting area-TA, tenting distance-TD), global left ventricular remodelling parameters (ejection fraction-EF, sphericity index-SI, left ventricular end systolic and end diastolic volumesLVESV and LVEDV) as well as local remodelling parameters (interpapillary muscle distance-IPMD, coaptation to septal distance-CSD, mitral annular areaMAA). Severity of mitral regurgitation was quantified by PISA method and patients were divided into two groups according to their effective regurgitant orrifice areas (EROA) as; group A (severe FMR, EROA >0.2 cm2, n=41) and group B (non-severe FMR, EROA <0.2 cm2, n=48). Results: Group A patients with severe FMR had statistically lower levels of EF and higher values of sphericity, MAA, CSD, IPMD, LVESV, LVEDV, TD and TA (all p values were below 0.05) than group B. Multivariate logistic regression analysis with backward conditional method (entry criteria was accepted 0.10, removed criteria was accepted 0.20) was used to define the echocardiographic predictors of severe FMR which revealed that MAA (p=0.065, OR: 1.313), TA (p=0.02, OR: 1.997) and IPMD (p=0.045, OR: 3.802) had statistical significance. Because it had the highest correlation, TA was used in ROC analysis that established a cut-off value of 3.4 cm2 with the highest sensitivity and specificity for severe FMR (sensitivity 85% specificity 74%, AUC:0.843, p<0.001). Conclusions: Our study revealed that, local remodelling and geometrical deformation in mitral valve contribute to the development of FMR instead of global remodelling parameters in patients with NIDCMP. Among all of the echocardiographic parameters related to FMR, tenting area was found to have the highest contribution to FMR severity. Unlike the complex, time-consuming and volume dependent methods for assessing mitral regurgitation, tenting area is a simple, easy and accurate echocardiographic measure for estimating FMR severity with a low intra and interobserver variability.

Echokardiografische Pitfalls bei Herzklappenerkrankungen

Cardiac ultrasound and clinical evaluation form the basis of clinical decision making in patients with valvular heart disease. Indication to perform cardiac catheterization and indication fpr surgery largely depend on clinical and echocardiographic findings. Although rapid development of technology contributes significantly to the robustness of ultrasound measurements one has to consider that echocardiography is an observer dependend and thus subjective method. This review focusses on potential pitfalls in image acquisition and interpretation of echocardiographic findings in acquired valvular heart disease. Machine settings have to be tailored to the individual patient very carefully to maximize image quality and color Doppler signals in order to judge chamber and valve geometry and function. A key issue in asymptomatic severe regurgitant lesions is not to miss worsening of left ventricular function. Thus serial evaluation of left ventricular dimensions and ejection fraction help to assess ventricular function. For quantification of LV ejection fraction the modified Simpson’s rule is standard and Teicholz formula is obsolete. Yet, EF is load dependent and newer parameters derived from deformation imaging (strain and strain rate) give a better understanding of ventricular contractility but are currently not part of guidelines. Left heart contrast agents can contribute to better endocardial border delineation in difficult to image patients. Aortic stenosis ist the most common lesion in adults that requires surgical treatment. The most robust parameter to judge severity is valve area based on continuity equation (severe when < 0,75 cm 2 ) or direct planimetry by TEE (severe when < 1,0 cm 2 ). A pitfall is to report valve gradient alone, specifically in impaired LV function where low gradients may be misleading. Dobutamine stress echo may help identify critical low gradient low output aortic stenosis. Even in preserved LV functrion gradients may be low when total arterial compliance is low and there is severe LV hypertrophy in small ventricles. Evaluation of mitral regurgitation should rely on the synopsis of several parameters such as vena contracta and if possible calculation of effective regurgitant orifice area using the PISA method. Jet dimensions largely depend on arterial blood pressure and can be misleading. In asymptomatic patients worsening of LV function, ventricular enlargement and endsystolic LV dimesions ≥ 45 mm should lead to plan surgery. Aortic regurgitation also mandates close monitoring of ventricular dimesions when judged severe by vena contracta in asymptomatic patients (LVEDD ≥ 70 mm, EF < 50 % or LVESD ≥ 50 mm are accepted cut off limits to consider surgery). Doppler parameters such as pressure half time or deceleration rate can be confounded by ventricular pathology influencing filling pressures. Since in severe regurgitant lesions as well as in severe mitral and aortic stenosis the indication for surgery is usually clear in symptomatic patients it is a challenge to assess symptomatic state in patients in routine practice. Especially elderly patients usually adapt to their physical limitation and tend to report to be symptom free when asked by the physician. Such asymptomatic” conditions should be objectified by subjecting the patient to careful exercise. Not to objectify an asymptomatic state may be the greatest pitfall in evaluating patients with valvular heart disease. Future results in ongoing studies may clarify the impact of deformation imaging to detect progressive impairment in ventricular function.

Quantification of mitral-valve regurgitation in a paediatric population by real-time three-dimensional echocardiography

Evaluation of mitral-regurgitation (MR) severity in infants is challenging. Real-time three-dimensional echocardiography (RT3DE) allows accurate left-ventricular volumetric measurements in adults. To validate RT3DE by measuring stroke volume in a normal paediatric population, then to use this new method to calculate regurgitant volume in paediatric patients with MR. Fifty-four patients, aged one week to 19 years, (29 without and 25 with MR) had two-dimensional echocardiography coupled with RT3DE left-ventricular volumetric acquisition. Stroke volume was calculated by the Doppler method at the aortic annulus (SV(D)). End-systolic and end-diastolic left-ventricular volumes were measured using the QLab semi-automated method; three-dimensional stroke volume (SV(3D)) was calculated as their difference. In the MR group, regurgitant volume was calculated by the PISA method (RV(PISA)) and as the difference between SV(3D) and SV(D) (RV(3D)). Regurgitant fraction was also evaluated by these methods (RF(PISA) and RF(3D)). Measurement feasibility was 88%. In the normal group, SV(3D) (27.9+/-18.1 ml) was highly correlated with SV(D) (30.7+/-19.6 ml; r=0.98; p<0.000). In the MR group, RV(PISA) (15.7+/-14.4 ml) and RV(3D) (11.0+/-10.2 ml) were well correlated (r=0.83; p<0.001). Regurgitant fractions were also well correlated (RF(PISA)=30.4+/-17.0%; RF(3D)=24.3+/-15.9%; r=0.79, p=0.006). RT3DE is a simple, rapid and reliable method for evaluating stroke volume in children and may, therefore, be useful for evaluating regurgitant volume and fraction in paediatric patients with MR.

Abstract 1603: Factors and Mechanisms Associated with Improved Cardiopulmonary Performance after Cardiac Resynchronization Therapy. An Exercise Echocardiography Study.

Background: Cardiac resynchronization therapy (CRT) leads to better cardiopulmonary performance in congestive heart failure (CHF) patients (pts). Mechanisms underlying the benefits are not fully elucidated. Aim: To investigate factors and mechanisms associated with improved cardiopulmonary performance after CRT. Methods: Twenty-three pts (EF 26±7%, QRS complex 170±26 msec) were studied by simultaneous quantitative semi-supine exercise echocardiography and cardiopulmonary exercise testing before and 3 months after CRT. Pts with an increase (Δ) in peak VO 2 ≥1.1 ml/kg/min were considered clinical responderes. Effective regurgitant orifice (ERO) of the mitral regurgitation (MR) was assessed using the PISA method. Results: In the entire population, CRT was associated with a decrease in LV dyssynchrony from 53±2 to 23±9 msec (p&lt;0.001), increase LV ejection fraction (EF) from 26±7 to 36±9% (p&lt;0.001) and ERO reduction from 0.24±0.11 to 0.13±0.06 cm 2 (p&lt;0.001) In addition, peak VO 2 increased from 11.6±2.3 to 12.9±3.6 ml/kg/min (p&lt;0.01) and Nt-pro BNP decreased from 2795±1644 to 2021±1353 pg/ml (p&lt;0.05). At follow-up (Table ), ERO at rest was similar but exercise-induced ERO and Nt-pro BNP were significantly lower in responders vs nonresponders. Change in peak VO 2 correlated inversely with the extent of exercise-induced MR at follow-up (r=−0.47, p&lt;0.05), with baseline Nt-pro BNP levels (r=−0.53, p&lt;0.05) and change in LVESV (r=−0.49, p&lt;0.05). Conclusions. Improved cardiopulmonary performance after CRT is related to changes in exercise-induced MR rather than resting MR. Thus, effects on the exercise-induced MR in parallel to reverse LV remodelling appear to contribute to improved cardiopulmonary performance and clinical benefits of the CRT.

Abstract 2066: Does Mitral Regurgitation Regress After Aortic Valve Replacement For Aortic Stenosis ? A Prospective Multicenter Study

Background: Mitral regurgitation (MR) is common in patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS). Whether its severity may decrease after AVR remains controversial. Previous studies were mainly retrospective and the degree of MR was assessed at best semi-quantitatively. This study sought to prospectively and quantitatively assess how AVR may affect MR severity. Methods: Patients with AS scheduled for isolated AVR and presenting holosystolic MR which was not considered for replacement or repair were included. Previous mitral valve surgery; severe aortic regurgitation and poor acoustic windows were excluded. Thirty-five patients (mean age 77±7 years) were studied before (median 1, range 1– 41 days) and after AVR (median 7, range 4 –19 days). All patients underwent a comprehensive echocardiographic examination; MR was assessed by Doppler echocardiography using color flow mapping of the regurgitant jet and the PISA method. No patient had prolapsed or flail mitral leaflet as mechanism of MR. Results: Preoperative maximal and mean transaortic pressure gradients and aortic valve area were 74±26 mmHg, 44±16 mmHg, and 0.57±0.18 cm 2 , respectively. Left ventricular (LV) ejection fraction increased from 49±16 % to 55±15 % after AVR (p&lt;0.001). LV end-diastolic volume decreased from 91±32 ml to 77±30 ml (p&lt;0.001).The ratio of MR jet to left atrial area decreased from 30±16% to 20±14% (p&lt;0.001). MR effective regurgitant orifice (ERO) and regurgitant volume decreased from 10±5 mm 2 to 8±6 mm 2 (p=0.015) and from 19±10 ml to 11±9 ml (p&lt;0.0001). The decrease in ERO and in regurgitant volume was similar in patients with preserved or depressed LV ejection fraction (≤45 %) (2±3 vs 3±6 mm 2 and 7±9 vs 8±7 ml; p=NS, respectively). Conclusions: AVR is associated with an early postoperative reduction of the quantified degree of MR. This mainly results from a decrease in regurgitant volume and only modestly from a reduction in ERO, emphasizing the contributing role of the decrease in driving pressure accross the mitral regurgitant orifice.

1057 Changes in deformation in asymptomatic patients with isolated severe mitral regurgitation detected by strain rate imaging

s S179 Eur J Echocardiography Abstracts Supplement, December 2006 ejection fraction (EF), sphericity index (SI), the wall motion score index (WMSI).The quantitative assessment of MR was performed using echocardiography by PISA method (regurgitant volume-RV and effective regurgitant orifice areaERO were calculated) and CMR by using velocity encoded imaging by subtracting left ventricle stroke volume and aortic flow. Results: No correlations between the mitral deformation indices, nor the global left ventricle remodeling and severity of MR expressed as ERO and RV were established in the analysis of any parameters obtained in TTE. Upon using CMR a good correlation was observed between RV and end-diastolic mitral annular area (p<0.01; r=0.73), mitral annulus diameter anterior mitral leaflet lenght ratio (p<0.01; r=0.72), coaptation height (p<0.01; r=0.69), respectively, and a weaker correlation between RV and end-systolic mitral annular area (p<0.1; r=0.49). Upon analysing left ventricle geometry parameters the strongest correlation was observed between RV and EDV/BSA (p<0.1; r=0.54). Conclusions: 1. In mild and moderate MR neither mitral deformation indices, nor global left ventricle remodeling, as assessed by echocardiographic method, correlated with quantitative parameters of MR. 2. CMRI appears to be a more accurate and sensitive method in assessing left ventricle remodeling and deformation of mitral valve than echocardiography.

Which method should be the reference method to evaluate the severity of rheumatic mitral stenosis? Gorlin's method versus 3D-echo

Several studies have shown a wide variability among different methods to determine the valve area in patients with rheumatic mitral stenosis. Our aim was to evaluate if 3D-echo planimetry is more accurate than the Gorlin method to measure the valve area. Twenty-six patients with mitral stenosis underwent 2D and 3D-echo echocardiographic examinations and catheterization. Valve area was estimated by different methods. A median value of the mitral valve area, obtained from the measurements of three classical non-invasive methods (2D planimetry, pressure half-time and PISA method), was used as the reference method and it was compared with 3D-echo planimetry and Gorlin's method. Our results showed that the accuracy of 3D-echo planimetry is superior to the accuracy of the Gorlin method for the assessment of mitral valve area. We should keep in mind the fact that 3D-echo planimetry may be a better reference method than the Gorlin method to assess the severity of rheumatic mitral stenosis.

Evaluation of mitral valve area by the proximal isovelocity surface area method in mitral stenosis: Could it be simplified?

One limitation for a wider use of the proximal isovelocity surface area method (PISA) for the evaluation of the mitral valve area (MVA) in patients with mitral stenosis (MS) is the requirement of an angle correction factor (angle alpha between the mitral leaflets) which cannot be obtained using the machine's built-in software and requires a manual measurement. The aim of the present study was to evaluate if the use of a fixed angle could provide an acceptable MVA estimation. In 48 patients (53 +/- 14 years, 75% female and 32% atrial fibrillation), MVA was prospectively measured by planimetry (MVA(2D)) and PISA (PISA(mes)). The angle alpha was manually measured on paper prints using a protractor. MVA(2D) was 1.38 +/- 0.56 cm(2) [0.5-2.40]. PISA(mes) (alpha = 104 +/- 13 degrees inter-quartiles 90-115) was 1.34 +/- 0.64 cm(2) [0.31-2.95] and did not differ from and correlated well with MVA(2D) (P = 0.25; r = 0.93, P < 0.0001). MVA estimated using the PISA method and a fixed angle value from 90 to 110 (MVA(alpha)(=90) to MVA(alpha)(=110)) progressively increased from 1.20 +/- 0.66 to 1.48 +/- 0.81 cm(2). Only MVA(alpha)(=100) (1.34 +/- 0.74 cm(2)) did not differ from and correlated well with both MVA(2D) and PISA(mes) (both P > 0.35 and r > 0.90, P < 0.0001). The angle formed by the mitral leaflet only slightly changes in between patients and use of a fixed angle value of 100 degrees provides an accurate estimation of the MVA by the PISA method in patients with MS. This simplification would facilitate and extend the use of the PISA as an additional method for the assessment of MS severity in routine practice.

222 Echocardiographic determinants of tricuspid regurgitation in patients with severe pulmonary arterial hypertension

s S21 222 Echocardiographic determinants of tricuspid regurgitation in patients with severe pulmonary arterial hypertension C. Jimenez, I. Gomez, R. Tello, R. Martin, L. Mora, P. Escribano, J. Jimenez, E Lombera. Hospital Doce de Octubre, Cardiology, Madrid, Spain Functional tricuspid regurgitation (TR)is a common finding in patients with severe pulmonary arterial hypertension (PAH). It is not well known which laclors are involved in the developing of such TR. Objective: To analize the anatomic, lunctional and hemodynamic determinants ol tricuspid regurgitation severity in patients with severe PAH Methods: A translhoracic echocardiogram was perlormed in 39 patients with severe PAH (28 women, mean age 44,84-13,5. NYHA lunctional class 1-28%, 11-33% and III 39%). Severity of TR was assessed quantifying the elleclive regurgilanl orifice (ERO) by PISA method. Dilferent measurements involving right venlricular (RV) lunction and geometry (RV myocardial performance index, RV sphericity index, end diastolic RV area), tricuspid valve anatomy (tricuspid valve systolic annulus, valve tenting height), were analized. Hemodynamic assessment was obtained by measuring cardiac output and systolic RV-RA gradient. Correlations between ERO and the different parameters were analized. Results: Correlations are shown in table. Correlations with ERO TV TV RV RV RV Tel RV-RA Cardiac Tenting height systolic annulus diastolic area sphericity index Tel index gradient Output r 0,61 0,53 0,58 0,6 0,25 0,15 0,26 p <0,0001 0,001 <0,001 <0,0001 0,1 0,3 0,1

Chronic ischaemic mitral regurgitation: exercise testing reveals its dynamic componentThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

This editorial refers to ‘Exercise-induced changes in mitral regurgitation in patients with prior myocardial infarction and left ventricular dysfunction: relation to mitral deformation and left ventricular function and shape’† by V. Giga et al ., on page 1860 Ischaemic mitral regurgitation (IMR) is a complication of coronary heart disease, particularly in the setting of a prior myocardial infarction. Its incidence and clinical importance are largely underestimated partly because physical examination is rather insensitive. IMR occurs despite a structurally normal mitral valve as a consequence of a ventricular disease. It results from distortion of left ventricular (LV) geometry tethering the mitral leaflets and from decreased LV force to close them.1 When present, IMR may exhibit a broad range of severity and conveys a dismal prognosis. The increased mortality risk relates not only to the presence, but also more importantly to the quantified degree of IMR. Several methods can be used to determine the severity of IMR. Semi-quantitative approaches, the colour flow mapping of the regurgitant jet, and the vena contracta width seem to be of limited value, whereas both the Doppler and the PISA methods can quantitate IMR accurately. The effective regurgitant orifice (ERO) area of IMR is the most robust measurement. In the setting of ischaemic heart disease, an ERO ≥20 mm2 is considered severe and associated with excess mortality.2 However, the evaluation of IMR only under resting conditions might underestimate the full impact … *Corresponding author. Tel: +32 4 366 71 94; fax: +32 4 366 71 95. E-mail address : plancellotti{at}chu.ulg.ac.be

Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography

Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography

Quantification of mitral regurgitation orifice area by 3-dimensional echocardiography: comparison with effective regurgitant orifice area by PISA method and proximal regurgitant jet diameter

Background: The evaluation of mitral regurgitation (MR) by 3-dimensional (3D) echo has generally been performed by reconstruction of Doppler regurgitant jets but there are little data on measuring anatomic regurgitant orifice area (AROA) directly from 3D mitral valve (MV) reconstructions. Methods and results: Transoesophageal echo (TOE) 3D images were acquired from 38 unselected patients (age 59±11 years, ten in atrial fibrillation) with various degrees of MR. In all patients MV was reconstructed en face from the left atrium (LA) and the left ventricle (LV). AROA was measured by planimetry from 3D pictures and compared to the effective regurgitant orifice area (EROA) by proximal isovelocity surface area and proximal MR jet width from 2D echo. AROA was measured in 95% of patients from LA, 89% from LV and in 84% from both LA and LV. Good correlation was found between EROA and AROA measured from both LA ( r=0.97, P<0.0001) and LV ( r=0.87, P<0.0001). The mean difference between LA-AROA and EROA was −3.01±6.12 mm 2 and −7.18±13.84 mm 2 for LV-AROA ( P<0.01, respectively). An acceptable correlation was found between the proximal MR jet width and AROA from LA ( r=0.71, P<0.0001) and LV perspective ( r=0.68, P<0.0001). AROA≥25 mm 2 differentiated mild MR (graded 1–2) from moderately severe (graded 3–4) with 80–90% accuracy. Conclusions: 3D TOE provides important quantitative information on both the mechanism and the severity of MR in an unselected group of patients. AROA enables quantification of MR with excellent agreement with the accepted clinical method of proximal flow convergence.

Single step generation of protein arrays from DNA by cell-free expression and in situ immobilisation (PISA method).

We describe a format for production of protein arrays termed 'protein in situ array' (PISA). A PISA is rapidly generated in one step directly from PCR-generated DNA fragments by cell-free protein expression and in situ immobilisation at a surface. The template for expression is DNA encoding individual proteins or domains, which is produced by PCR using primers designed from information in DNA databases. Coupled transcription and translation is carried out on a surface to which the tagged protein adheres as soon as it is synthesised. Because proteins generated by cell-free synthesis are usually soluble and functional, this method can overcome problems of insolubility or degradation associated with bacterial expression of recombinant proteins. Moreover, the use of PCR-generated DNA enables rapid production of proteins or domains based on genome information alone and will be particularly useful where cloned material is not available. Here we show that human single-chain antibody fragments (three domain, V(H)/K form) and an enzyme (luciferase) can be functionally arrayed by the PISA method.

Effects of blood viscosity on proximal flow convergence calculations of regurgitant flow rate and jet dimensions as evaluated by color Doppler flow mapping: An in vitro study

There are limited data on the potential influence of blood viscosity on the quantification of valvular regurgitation by color Doppler in the clinical setting. This study was designed to evaluate the effects of blood viscosity on jet dimensions and the proximal flow convergence (proximal isovelocity surface area, PISA) method of estimating valvular insufficiency severity. We used an in vitro flow model filled with human blood at varying hematocrits (15%, 35%, and 55%) and blood viscosity (blood/water viscosity: 2.6, 4.8, 9.1) in which jets were driven through a known orifice (16 mm2) into a 110-mL compliant receiving chamber (compliance: 2.2 mL/mm Hg) by a power injection pump. Blood injections (2 and 4 mL) at flow rates of 4, 6, 8, 10, and 12 mL/s were performed. Proximal flow convergence and spatial distribution of jets were imaged by a 3.5-MHz transducer. Pressure and volume in the flow model were kept constant before each injection. Ultrasound settings were the same for all experiments. Jet area decreased significantly with increasing blood viscosity, but the difference in jet dimensions was much larger for lower than for higher flow rates and for highest blood viscosity. Estimation of flow rate by the PISA method was not significantly influenced by blood viscosity. Blood viscosity has a major influence in jet area, especially for lower flow rates, but did not change significantly the grading of regurgitation by the PISA method. Thus this factor should be considered for determining the method of choice when quantification of valvular regurgitation is performed in patients with anemia or polycythemia. (J Am Soc Echocardiogr 2001;14:569-79.)