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From the Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Address correspondence to A. Stephane Lambert, MD, FRCPC, H2410, 40 Ruskin St., Ottawa, Ontario, K1Y 4W7, Canada. Address e-mail to slambert{at}ottawaheart.ca.
Abstract
The proximal isovelocity surface area (PISA) measurement, also known as the "flow convergence" method, can be used in echocardiography to estimate the area of an orifice through which blood flows. It has many applications, but this review focuses only on its use in the intraoperative evaluation of mitral regurgitation. In that setting, PISA provides a quantitative assessment of the severity of mitral regurgitation and it is useful in clinical decision-making in the operating room. In this review, I discuss the physical principles behind the PISA method, along with the various mathematical formulas used to calculate the effective mitral regurgitant orifice area, the regurgitant volume, and the regurgitant fraction. A step-by-step approach is presented and illustrated with graphic and video demonstrations. Finally, I will discuss the various limitations and technical considerations of PISA measurement in the operating room.
Proximal isovelocity surface area (PISA) measurement, also known as the "flow convergence" method, can be used in echocardiography to estimate the area of an orifice through which blood flows. Since its development in the early 1990s, the PISA method has been applied clinically to the evaluation of mitral regurgitation (MR) (1–3), mitral stenosis (4,5), tricuspid regurgitation (6), aortic insufficiency (7), and intracardiac shunts (8–10) with variable degrees of success. The basic principles of PISA discussed below hold true for all these applications but, for the purposes of this discussion, we will focus on MR only.
The PISA method is based on 1) the properties of flow dynamics and 2) the continuity principle.
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It is important to realize that the continuity principle applies equally to blood flowing forward through the heart (for example in the assessment of valve area in aortic stenosis), or backward (as in the case of MR).
EFFECTIVE REGURGITANT ORIFICE AREA
MR is usually caused by a coaptation defect in the mitral valve and the severity of MR depends, in large part, on the size of that defect. The goal of the PISA method is to calculate the area of the defect, also known as the effective regurgitant orifice area (EROA).
The continuity principle, as explained above, dictates that flow be constant throughout the heart. It also dictates that flow be constant along the MR jet. If one can calculate the flow at one point within the flow convergence area, then one knows the flow at any another point along the MR jet, including at the regurgitant orifice itself. Then, once the peak velocity at the regurgitant orifice is known, one can calculate the area of that orifice.
The first step in the PISA method is to demonstrate the MR jet by color flow Doppler and to calculate the flow of blood within the flow convergence area. This is most commonly done in the midesophageal views of the mitral valve. The flow convergence area is the colored area on the ventricular side of the mitral valve in systole (please see video 1 available at www.anesthesia-analgesia.org). This area contains an infinite number of concentric hemispheres along which the blood accelerates towards the regurgitant orifice, as described above (Fig. 1).
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By Doppler convention, the MR jet is displayed in shades of red, because the blood flow is directed towards the transducer in midesophageal views. As blood cells accelerate, the color goes from dark red to bright red, to orange, to yellow (along the white arrow on Fig. 2a). When the cells reach the aliasing velocity (also known as the Nyquist limit), the color suddenly changes to blue (x mark on Fig. 2a). This is the point of interest, at which the velocity is known with certainty. (The Nyquist limit is defined as the velocity at which the color flow switches from red to blue or blue to red.) This number is displayed beside the color scheme on the video screen and one must select the number in the direction of blood flow.
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If one measures the distance from this point to the center of the mitral regurgitant orifice (= the radius of the hemisphere, Fig. 2b), one can then calculate the surface area of this hemisphere (i.e., the PISA) using the equation:
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(Note that it is important to measure this radius between the edge of the blue hemisphere and the center of the regurgitant orifice itself. Freezing the image and toggling the color on/off will help to determine exactly where the center of the orifice is.)
The next step consists of measuring the maximum velocity of blood at the mitral regurgitant orifice using continuous wave (CW) Doppler of the MR jet (Fig. 3). As usual, one must make sure that the Doppler beam is lined-up with the MR jet.
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Finally, one calculates the EROA using the initial formula:
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REGURGITANT VOLUME (RV) AND REGURGITANT FRACTION
These are useful quantitative measurements of MR, and they can be calculated from the regurgitant orifice area.
Knowing that Volume = area x VTI, one can trace the velocity-time integral (VTI) of the MR jet on the CW signal, and one can calculate the mitral RV (RVMR), using the following equation:
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Once the RV is known, one can calculate the ratio of RV over total stroke volume, a value known as mitral regurgitant fraction. All these calculations can be done manually and they can be time-consuming. Fortunately, if one traces the VTI of the MR jet on CW, many modern echocardiography machines will automatically calculate and display the EROA and the RV when measuring the radius of the PISA hemisphere.
LIMITATIONS OF THE PISA METHOD
First, the proximal flow convergence technique is a Doppler technique and it is limited by all the usual considerations of Doppler echocardiography, especially alignment. Like any other application of Doppler, if the MR jet is eccentric and not aligned with the Doppler beam, the usefulness of this technique can be significantly compromised.
Also, the PISA method is based on a number of assumptions, some of which may or may not be true in individual cases.
r2 describes the surface area of a hemisphere. If the orifice is oval shaped or irregular, which unfortunately is often the case in clinical practice, then the flow convergence area does not consist of hemispheres, and the equation does not apply. r2 may not apply. It has been reported that the PISA hemispheres are closest to being true hemispheres when their radius is between 11 and 15 mm. To achieve that, the baseline and/or Nyquist limit can be adjusted (12). On most echocardiography machines, this is done by turning a knob identified as "pulse repetition frequency" or "color Doppler scale." 
) of the flow convergence hemisphere divided by 180 (Fig. 4). This angle is not automatically measured by the echocardiography machine and must be estimated by the operator. This can be a significant source of error. |
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The technical considerations of PISA measurements become obvious when one remembers the above limitations of the technique. If the Nyquist limit and gain are adjusted to optimize the shape of the hemispheres in the flow convergence area, and if the technique is reserved for reasonably central jets, where the PISA shells are less distorted and where there is minimal need for angle correction, then the diagnostic accuracy of the method is improved.
SIMPLIFIED METHODS
PISA calculations can be time-consuming, and a simplified formula was developed and validated, provided that certain hemodynamic conditions are present. Indeed, if the Nyquist limit is set at 40 cm/s on the machine, and if the MR velocity is 500 cm/s, then the equation simplifies to:
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Hemodynamically, the MR velocity can reasonably be assumed to be about 500 cm/s when the left ventricle to left atrium gradient is about 100 mm Hg; that is, when the difference between the systolic arterial blood pressure and the wedge pressure is about 100 mm Hg. Because the simplified PISA equation introduces additional assumptions and potential sources of errors, it is strongly recommended that it be used only as a quick screening method, and that the detailed method be used whenever clinical decisions depend on the information.
The values of EROA and RVMR and mitral regurgitant fraction for various degrees of MR are listed in Table 1 (14). Table 2 summarizes the steps in the measurement of PISA and Video 2 (please see video 2 available at www.anesthesia-analgesia.org) is a step-by-step demonstration of this technique.
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CONCLUSION
In summary, the flow convergence method is based on principles of flow dynamics and on the continuity equation. It can be used to calculate orifice sizes within the heart, including mitral regurgitant orifice. Its use, however, is restricted by a number of technical limitations, and it may not be applicable to every patient.
Footnotes
Accepted for publication May 24, 2007.
Reprints will not be available from the author.
REFERENCES
This article has been cited by other articles:
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  Y. Kawase, H. Q. Ly, F. Prunier, D. Lebeche, Y. Shi, H. Jin, L. Hadri, R. Yoneyama, K. Hoshino, Y. Takewa, et al. Reversal of cardiac dysfunction after long-term expression of SERCA2a by gene transfer in a pre-clinical model of heart failure. J. Am. Coll. Cardiol., March 18, 2008; 51(11): 1112 - 1119. [Abstract] [Full Text] [PDF]
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