Proximal Isovelocity Surface Area Should Be Routinely

Measured in Evaluating Mitral Regurgitation: A Core Review

A. Stephane Lambert, MD, The proximal isovelocity surface area (PISA) measurement, also known as the
FRCPC “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.
(Anesth Analg 2007;105:940 –3)

P roximal isovelocity surface area (PISA) measure-

ment, also known as the “flow convergence” method,
the velocity of the liquid: Flow rate ⫽ area ⫻
velocity. Liquids, by definition, are essentially
can be used in echocardiography to estimate the area incompressible. Therefore, the continuity prin-
of an orifice through which blood flows. Since its ciple dictates that in the absence of a leak in the
development in the early 1990s, the PISA method has conduit or additional input, the flow rate is
been applied clinically to the evaluation of mitral constant along the length of the conduit (11). If
regurgitation (MR) (1–3), mitral stenosis (4,5), tricus- the cross-sectional area decreases, the velocity
pid regurgitation (6), aortic insufficiency (7), and must increase to compensate and vice versa. The
intracardiac shunts (8 –10) with variable degrees of same holds true for the heart and, assuming
success. The basic principles of PISA discussed below there is no shunt, the flow rate throughout the
hold true for all these applications but, for the pur- heart is constant. What changes is the area and
poses of this discussion, we will focus on MR only. velocity of the column of blood as it flows
through the various parts of the heart. As the
The PISA method is based on 1) the properties of
area changes, the velocity of the blood must
flow dynamics and 2) the continuity principle.
change also, according to the following equation:
1. When a liquid (in this case blood) is forced from
a large chamber into an orifice at a constant flow, A1 ⫻ V 1 ⫽ A 2 ⫻ V 2
its particles accelerate towards the orifice until
the velocity is greatest at the narrowest point of It is important to realize that the continuity principle
the orifice. This acceleration occurs along a series applies equally to blood flowing forward through the
of concentric “hemispheres” or “hemishells” heart (for example in the assessment of valve area in
whose center is at the orifice itself. Those hemi- aortic stenosis), or backward (as in the case of MR).
spheres are contained in an area referred to as
the flow convergence area. EFFECTIVE REGURGITANT ORIFICE AREA
2. The volume of a liquid going through a con- MR is usually caused by a coaptation defect in the
duit per unit time, called the flow rate, equals mitral valve and the severity of MR depends, in large
the cross-sectional area of that conduit times part, on the size of that defect. The goal of the PISA
method is to calculate the area of the defect, also known
From the Division of Cardiac Anesthesiology, University of
Ottawa Heart Institute, Ottawa, Ontario, Canada. as the effective regurgitant orifice area (EROA).
Accepted for publication May 24, 2007. The continuity principle, as explained above, dic-
Address correspondence to A. Stephane Lambert, MD, FRCPC, tates that flow be constant throughout the heart. It also
H2410, 40 Ruskin St., Ottawa, Ontario, K1Y 4W7, Canada. Address dictates that flow be constant along the MR jet. If one
e-mail to slambert@ottawaheart.ca. can calculate the flow at one point within the flow
Reprints will not be available from the author. convergence area, then one knows the flow at any
Copyright © 2007 International Anesthesia Research Society another point along the MR jet, including at the
DOI: 10.1213/01.ane.0000278084.35122.4e
regurgitant orifice itself. Then, once the peak velocity

940 Vol. 105, No. 4, October 2007

 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.
Finally, one calculates the EROA using the initial
formula:

A1 ⫻ V 1 ⫽ A 2 ⫻ V 2

EROA ⫻ V max (CW) ⫽ 2␲ r 2 ⫻ Nyquist Limit

2␲ r 2 ⫻ Nyquist Limit
Figure 1. Still image of flow convergence area. As they are EROA ⫽
V max (CW)
forced from the left ventricle into the mitral regurgitant
orifice, the red blood cells accelerate along a series of
concentric hemispheres until they reach their maximum REGURGITANT VOLUME (RV) AND
velocity at the orifice itself. REGURGITANT FRACTION
These are useful quantitative measurements of MR,
and they can be calculated from the regurgitant orifice
at the regurgitant orifice is known, one can calculate area.
the area of that orifice. Knowing that Volume ⫽ area ⫻ VTI, one can trace
The first step in the PISA method is to demonstrate the velocity-time integral (VTI) of the MR jet on the
the MR jet by color flow Doppler and to calculate the CW signal, and one can calculate the mitral RV
flow of blood within the flow convergence area. This is (RVMR), using the following equation:
most commonly done in the midesophageal views of
the mitral valve. The flow convergence area is the RVMR ⫽ EROA ⫻ VTIMR
colored area on the ventricular side of the mitral valve
in systole (please see video 1 available at www. Once the RV is known, one can calculate the ratio of
anesthesia-analgesia.org). This area contains an infi- RV over total stroke volume, a value known as mitral
nite number of concentric hemispheres along which regurgitant fraction. All these calculations can be done
the blood accelerates towards the regurgitant orifice, manually and they can be time-consuming. Fortu-
as described above (Fig. 1). nately, if one traces the VTI of the MR jet on CW, many
By Doppler convention, the MR jet is displayed in modern echocardiography machines will automati-
shades of red, because the blood flow is directed cally calculate and display the EROA and the RV
towards the transducer in midesophageal views. As when measuring the radius of the PISA hemisphere.
blood cells accelerate, the color goes from dark red to
bright red, to orange, to yellow (along the white arrow LIMITATIONS OF THE PISA METHOD
on Fig. 2a). When the cells reach the aliasing velocity
First, the proximal flow convergence technique is a
(also known as the Nyquist limit), the color suddenly
Doppler technique and it is limited by all the usual
changes to blue (x mark on Fig. 2a). This is the point of
considerations of Doppler echocardiography, espe-
interest, at which the velocity is known with certainty.
cially alignment. Like any other application of Dopp-
(The Nyquist limit is defined as the velocity at which
ler, if the MR jet is eccentric and not aligned with the
the color flow switches from red to blue or blue to
Doppler beam, the usefulness of this technique can be
red.) This number is displayed beside the color
significantly compromised.
scheme on the video screen and one must select the
Also, the PISA method is based on a number of
number in the direction of blood flow.
assumptions, some of which may or may not be true in
If one measures the distance from this point to the
individual cases.
center of the mitral regurgitant orifice (⫽ the radius of
the hemisphere, Fig. 2b), one can then calculate the 1. It assumes that the mitral regurgitant orifice is
surface area of this hemisphere (i.e., the PISA) using circular. 2␲r2 describes the surface area of a
the equation: hemisphere. If the orifice is oval shaped or
irregular, which unfortunately is often the case
Ahemisphere ⫽ 2␲ r 2 in clinical practice, then the flow convergence
area does not consist of hemispheres, and the
(Note that it is important to measure this radius equation does not apply.
between the edge of the blue hemisphere and the 2. As color Doppler parameters are adjusted, the
center of the regurgitant orifice itself. Freezing the hemispheres may become more flattened or

Vol. 105, No. 4, October 2007 © 2007 International Anesthesia Research Society 941
 Figure 2. (a) As the blood cells accelerate
along the white arrow, the color flow
Doppler signal changes from dark red, to
bright red, to orange, to yellow and even-
tually to blue as it reaches the aliasing
velocity (in this case 74 cm/s). This is the
point of interest marked by an “x.” (b) The
radius of the hemisphere r is measured
from the edge of the blue color to the
regurgitant orifice. It helps to toggle the
color on and off to see the precise location
of the regurgitant orifice.

Figure 4. The proximal isovelocity surface area technique

assumes that the hemispheres are complete hemispheres, in
other words it assumes that ␣ ⫽ 180° (dotted line). If it is not,
because it is restricted by a leaflet or a ventricular wall, the
angle-width of the proximal isovelocity surface area hemi-
sphere must be measured and included in the “angle correc-
tion factor.”

by the operator. This can be a significant source of

error.

Figure 3. The peak velocity (Vmax) of the mitral regurgitant 2␲ r 2 ⫻ Nyquist Limit ␣
jet is measured by continuous wave Doppler. Care must be EROA ⫽ ⫻
taken to align the Doppler signal with the mitral regurgitant V max (CW) 180
jet and to use the same units as the Nyquist limit. One can
also trace the velocity-time integral of the regurgitant jet to 4. Finally, if there are multiple regurgitant orifices,
calculate the regurgitant volume. the flow convergence method may be completely
inaccurate in estimating the EROA. In theory,
one could measure each smaller orifice indepen-
more cone-shaped, even if the regurgitant orifice dently, but it would be too cumbersome to be
is circular. Again the equation 2␲r2 may not practical. Besides, the various flow convergence
apply. It has been reported that the PISA hemi- areas might overlap and mask each other, ren-
spheres are closest to being true hemispheres dering the technique inaccurate.
when their radius is between 11 and 15 mm. To The technical considerations of PISA measurements
achieve that, the baseline and/or Nyquist limit become obvious when one remembers the above limi-
can be adjusted (12). On most echocardiography tations of the technique. If the Nyquist limit and gain
machines, this is done by turning a knob identi- are adjusted to optimize the shape of the hemispheres
fied as “pulse repetition frequency” or “color in the flow convergence area, and if the technique is
Doppler scale.” reserved for reasonably central jets, where the PISA
3. The PISA method assumes that the hemisphere is a shells are less distorted and where there is minimal
complete hemisphere. If the flow is restricted lat- need for angle correction, then the diagnostic accuracy
erally by one of the mitral leaflets, or by a ventric- of the method is improved.
ular wall, then the PISA calculation must be mul-
tiplied by an “angle correction factor” (13). That SIMPLIFIED METHODS
correction factor is the actual angle-width (␣) of the PISA calculations can be time-consuming, and a
flow convergence hemisphere divided by 180 (Fig. simplified formula was developed and validated, pro-
4). This angle is not automatically measured by the vided that certain hemodynamic conditions are present.
echocardiography machine and must be estimated Indeed, if the Nyquist limit is set at 40 cm/s on the
942 Proximal Isovelocity Surface Area in Mitral Regurgitation ANESTHESIA & ANALGESIA
Table 1. Values for Effective Regurgitant Orifice Area (EROA), Table 1 (14). Table 2 summarizes the steps in the
Regurgitant Volume (RVMR), and Mitral Regurgitant Fraction measurement of PISA and Video 2 (please see video 2
(RFMR) by the Proximal Isovelocity Surface Area (PISA) Method available at www.anesthesia-analgesia.org) is a step-
Doppler Mild Moderate Severe by-step demonstration of this technique.
parameters MR MR MR
EROA (cm2) ⬍0.20 0.20–0.40 ⱖ0.40
RVMR (mL) ⬍30 30–60 ⱖ60 CONCLUSION
RFMR (%) ⬍30 30–50 ⬎50 In summary, the flow convergence method is based
MR ⫽ mitral regurgitation. on principles of flow dynamics and on the continuity
equation. It can be used to calculate orifice sizes within
Table 2. Summary of the Steps in Measuring the Effective the heart, including mitral regurgitant orifice. Its use,
Regurgitant Orifice Area (EROA) by the Proximal Isovelocity however, is restricted by a number of technical limi-
Surface Area (PISA) Method tations, and it may not be applicable to every patient.
1 Center the mitral valve in the sector screen and
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Vol. 105, No. 4, October 2007 © 2007 International Anesthesia Research Society 943