The present case report illustrates the clinical applicability of the proximal isovelocity surface area (PISA) method in identifying, locating and assessing paravalvular prosthetic mitral regurgitation by transthoracic echocardiography

A Vitarelli

Caroline Leonnet

D Khanna

Emmanuel Roux

GI Cohen

GS Bargiggia

Jean-François Avierinos

JS Gottdiener

S Arques

SH Little

Stephane Arques

V Fernandes

WA Zoghbi

English

PubMed

Springer - Publisher Connector

Identification and quantification of prosthetic mitral regurgitation by flow convergence method using transthoracic approach

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BioMed CentralCardiovascular Ultrasound
ssOpen AcceCase report
Identification and quantification of prosthetic mitral regurgitation 
by flow convergence method using transthoracic approach
Stephane Arques*1, Caroline Leonnet1, Emmanuel Roux1 and Jean-
François Avierinos2
Address: 1Department of Cardiology, Aubagne Hospital, Aubagne, France and 2Department of Cardiology, La Timone University of Medicine, 
Marseille, France
Email: Stephane Arques* - pyarques@gmail.com; Caroline Leonnet - cleonnet@ch-aubagne.fr; Emmanuel Roux - eroux@ch-aubagne.fr; Jean-
François Avierinos - jfavierinos@ap-hm.fr
* Corresponding author    
Abstract
The present case report illustrates the clinical applicability of the proximal isovelocity surface area
(PISA) method in identifying, locating and assessing paravalvular prosthetic mitral regurgitation by
transthoracic echocardiography.
Background
There is now large evidence that the proximal isovelocity
surface area (PISA) is a simple, reliable method for the
noninvasive assessment of native mitral regurgitation by
Doppler echocardiography. Despite some limitations [1],
the PISA method is widely used in daily practice as well as
in clinical trials for diagnostic, therapeutic and prognostic
purposes [2,3]. However, its applicability is underecog-
nized in the setting of paravalvular prosthetic mitral regur-
gitation [2,3]. The present case report illustrates the
clinical usefulness of the PISA method in identifying and
evaluating paravalvular prosthetic mitral regurgitation by
transthoracic Doppler echocardiography.
Case presentation
Mr B., 61 year old, has been admitted at our institution for
severe anemia. His medical history included mitral valve
replacement (bileaflet mechanical valve) in 1993, diabe-
tes mellitus, systemic arterial hypertension and vascular
dementia. The patient was free of symptoms and signs of
heart failure. Apical holosystolic murmur 2/6 was found
at physical examination. The chest radiography did not
show any abnormality. Sinus rhythm and left ventricular
hypertrophy were present on the electrocardiogram.
Blood sample analysis revealed severe anemia (5.5 g/dl).
Transthoracic Doppler echocardiography was performed
by an experienced cardiologist after informed consent was
obtained. Left ventricular ejection fraction was 71%, left
ventricular mass 115 g/m2, and there was no structural
abnormality of the native aortic valve. Indexed left atrial
volume was 29 ml/m2 and the mean gradient accross the
prosthetic mitral valve was 3.5 mm Hg. Peak early diasto-
lic velocity of mitral filling was 158 cm/s and PHT 88 ms
(Figure 1). A postero-lateral paravalvular prosthetic mitral
regurgitation was identified by careful analysis of the
prosthetic mitral valve both in parasternal and apical
views (Figure 2). The peak instantaneous regurgitant flow
rate (Qmax, ml/s), calculated as follows: Qmax = 2 × π ×
r2 x Va where r was the radius of the flow convergence
hemisphere at mid-systole (in cm) and Va the aliasing
velocity (in cm/s), was 92 ml/s (Figure 3). The regurgitant
volume (RV, ml), calculated as follows: RV1 = Qmax × t
where t (in secondes) was the regurgitation time meas-
ured by color M-mode, was 24 ml (Figure 3). The regur-
Published: 12 February 2009
Cardiovascular Ultrasound 2009, 7:7 doi:10.1186/1476-7120-7-7
Received: 29 September 2008
Accepted: 12 February 2009
This article is available from: http://www.cardiovascularultrasound.com/content/7/1/7
© 2009 Arques et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Cardiovascular Ultrasound 2009, 7:7 http://www.cardiovascularultrasound.com/content/7/1/7gitant flow was recorded by continuous wave Doppler and
the velocity time integral (VTI, cm) and the peak regur-
gitant flow (Vmax, m/s) were measured (Figure 3). The
effective regurgitant orifice area (EROA, mm2) calculated
as follows: EROA1 = (RV1 × 100)/VTI, was 15 mm2 (Fig-
ure 3). The EROA calculated as follows: EROA2 = Qmax/
Vmax, was 18 mm2 (Figure 3). The RV, calculated as fol-
lows: RV2 = (Qmax × VTI)/(Vmax × 100), was 27 ml (Fig-
ure 3). All these parameters derived from PISA method
were consistent with a mild to moderate prosthetic mitral
regurgitation. The patient refused to give informed con-
sent for transesophageal echocardiography. The diagnosis
at discharge was hemolytic anemia related to mild parav-
Recording of the transprothetic mitral inflow by continuous wave Doppler in a 4-chamber apical viewFigu e 1
Recording of the transprothetic mitral inflow by con-
tinuous wave Doppler in a 4-chamber apical view. The 
peak early diastolic velocity was 158 cm/s, the mean gradient 
3.5 mmHg and PHT 88 ms.
Visualization of the paravalvular prosthetic mitral regurgita-tion (arrow) in parastern  long axis view (upper part) and 4-chambe  apical view (lower p t)F gure 2
Visualization of the paravalvular prosthetic mitral 
regurgitation (arrow) in parasternal long axis view 
(upper part) and 4-chamber apical view (lower part). 
AO: aorta; LA: left atrium; LV: left ventricle; RV: right ventri-
cle.
Upper part: measurement of the radius (r = 0.7 cm) of the flow convergence zone (FCZ, arrow) at mid-systole in a 4-chamber apical view, with an aliasing veloc ty of 30 cm/sFigure 3
Upper part: measurement of the radius (r = 0.7 cm) 
of the flow convergence zone (FCZ, arrow) at mid-
systole in a 4-chamber apical view, with an aliasing 
velocity of 30 cm/s. LA: left atrium; LV: left ventricle. Mid-
dle part: measurement of the regurgitation time (t, in sec-
ondes) by color M-mode at the level of flow convergence 
hemisphere; t = 0.261 secondes. Lower part: measurement 
of the velocity time integral (VTI, cm) and the peak regur-
gitant flow (Vmax, m/s) by continuous wave Doppler. VTI = 
155 cm and Vmax = 5.2 m/sPage 2 of 4
(page number not for citation purposes)
Cardiovascular Ultrasound 2009, 7:7 http://www.cardiovascularultrasound.com/content/7/1/7alvular leak according to all the data collected during hos-
pitalization.
Discussion
The severity of paravalvular prosthetic mitral regurgitation
is commonly assessed with simple Doppler indexes that
indirectly reflect volume overload [4]. Bargiggia et al have
first reported the usefulness of PISA method in identifying
and locating prosthetic mitral regurgitation by transtho-
racic echocardiography [5]. The visualization of the flow
convergence zone by thransthoracic echocardiography
has been proposed by Cohen et al as a marker of signifi-
cant prosthetic mitral regurgitation, however such a qual-
itative assessment suffers from lack of specificity [6]. With
the steady improvement of the quality of Doppler
echocardiographs, the PISA method presently offers the
ability to provide useful information not only on identifi-
cation and location but also on quantitative assessment of
paravalvular prosthetic mitral regurgitation by transtho-
racic approach [7]. To our knowledge, only one clinical
study has addressed the applicability of PISA method by
transthoracic Doppler echocardiography in the setting of
paravalvular prosthetic mitral regurgitation, which
included 30 consecutive patients with mitral prosthesis
(21 with mechanical valve and 9 with bioprosthesis).
Four, 13 and 13 patients had mild, moderate and severe
paravalvular prosthetic mitral regurgitation, respectively.
Assuming the radius r and Qmax constant over the sys-
tole, RV was measured as follows: RV = (Qmax × t) × α/
180, where α/180 was the angular correction applied in
presence of parietal constraint. It is of clinical importance
to emphasize that this alternative method offers the abil-
ity to overcome the difficulty of adequatly recording the
regurgitant flow by transthoracic continuous wave Dop-
pler in the setting of excentric jets. By this way, the feasi-
bility of RV was high (93%), with an intra- and inter-
observer variability of 6 and 8%, respectively. RV was a
strong predictor of severe prosthetic mitral regurgitation
with an optimal cut-off value of 53 ml (area under the
ROC curve of 0.97 [0.82–0.99], p < 0.0001; sensitivity of
92% and specificity of 93%). The standard cut-off value of
60 ml used for defining severe native mitral regurgitation
was 69% sensitive and 100% specific. Notably, the flow
convergence zone could not be distinguished from the
ejection flow in the left ventricular outflow tract in the 2
patients with moderate paravalvular leak located at the
septal side of mitral prosthesis. The regurgitant flow by
transthoracic continuous wave Doppler, and subse-
quently the EROA, were obtained in 63% of patients.
EROA was a good predictor of severe prosthetic mitral
regurgitation with an optimal cut-off value of 32 mm2
(area under the ROC curve of 0.90 [0.68–0.98], p < 0.001;
sensitivity of 91% and specificity of 75%). The standard
cut-off value of 40 mm2 used for defining severe native
mitral regurgitation was 64% sensitive and 100% specific.
The reliability of the PISA method has been later con-
firmed in this clinical setting by Vitarelli et al using trans-
esophageal echocardiography [8]. 47 patients with
mechanical valve were included, of whom 25 had severe
paravalvular prosthetic mitral regurgitation. Qmax > 200
ml/s and EROA > 45 mm2 were 96% sensitive and 90%
specific for the prediction of severe mitral regurgitation.
Nevertheless, the use of transthoracic echocardiography
offers the ability to overcome the limitations inherent to
other invasive methods for follow-up. Further studies will
address the usefulness of new echocardiographic modali-
ties, such as real-time three-dimensional color Doppler
echocardiography, in this clinical setting [9].
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
SA performed Doppler echocardiography, participated in
the design of the study and wrote the manuscript. CL and
ER were involved in the patient's clinical care. JFA criti-
cally reviewed the manuscript and participated in the
design of the study. All the authors read and approved the
final manuscript.
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Abstract The present case report illustrates the clinical applicability of the proximal isovelocity surface area (PISA) method in identifying, locating and assessing paravalvular prosthetic mitral regurgitation by transthoracic echocardiography.</p

Roux Emmanuel

Leonnet Caroline

Arques Stephane

Avierinos Jean-François

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Cardiovascular Ultrasound

Montemartini C: Color Doppler diagnosis of mechanical prosthetic mitral regurgitation: usefulness of the flow convergence region proximal to the regurgitant orifice.

NJ: American Society of Echocardiography. American Society of Echocardiography recommendations for use of echocardiography in clinical trials.

of Echocardiography. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography.

SG: Transthoracic and transesophageal echocardiographic assessment of mitral regurgitation severity: usefulness of qualitative and semiquantitative techniques. Echocardiography

Stellato S: Assessment of severity of mechanical prosthetic mitral regurgitation by transoesophageal echocardiography. Heart

Zoghbi WA: In vitro validation of real-time three-dimensional color Doppler echocardiography for direct measurement of proximal isovelocity surface area in mitral regurgitation.

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Identification and quantification of prosthetic mitral regurgitation by flow convergence method using transthoracic approach

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