PISA Method — MR Quantification Worksheet
Proximal Isovelocity Surface Area  |  Bedside protocol, equations, severity, & pitfalls
Principle
Blood converges toward the regurgitant orifice through concentric hemispheric shells of equal velocity. Color Doppler aliasing makes one such shell visible. By conservation of flow, flow at the PISA shell equals flow through the orifice.
2πr² × Valiasing  =  EROA × Vpeak MR
EROA (cm²) = 2π × r² × Va Vpeak MR
RegVol (mL) = EROA × VTIMR jet
rPISA radius at first aliasing shell (cm) VaAliasing velocity (cm/s) — baseline-shifted Vpeak MRPeak MR jet velocity by CW (cm/s) VTIMRVTI of MR jet by CW (cm)
Bedside Protocol
  1. Zoom apical 4-chamber centered on the mitral valve.
  2. Shift color baseline in the direction of the regurgitant jet to lower Va → produces a clean hemisphere on the LV side. Target Va ≈ 30–40 cm/s.
  3. Measure r at mid-systole: orifice (vena contracta neck) to the first blue/red color reversal.
  4. CW Doppler through the MR jet → record Vpeak MR (typ. 4–6 m/s) and trace VTIMR.
  5. Compute EROA, then RegVol = EROA × VTIMR.
Bedside shortcut: When Va = 40 cm/s and Vpeak = 5 m/s → EROA ≈ r² / 2.
e.g., r = 1.0 cm → EROA ≈ 0.5 cm² → severe.
Severity Cutoffs (ASE 2017)
ASE 2017 — Primary (degenerative) MR — full 4-grade system
GradeEROA (cm²)RegVol (mL)RegFraction
I — Mild< 0.20< 30< 30%
II — Moderate0.20–0.2930–4430–39%
III — Mod-Severe0.30–0.3945–5940–49%
IV — Severe≥ 0.40≥ 60≥ 50%
Secondary (functional) MR
GradeEROA (cm²)RegVol (mL)
Non-severe< 0.40< 60
Severe≥ 0.40  (COAPT: ≥ 0.30)≥ 60  (MITRA-FR: ≥ 30)
Why secondary MR thresholds are lower: sick LV makes even smaller orifices prognostically heavy. COAPT used EROA > 0.30 cm²; MITRA-FR used > 0.20 cm². Also: PISA tends to underestimate in secondary MR (elliptical orifice).
Memory Anchors
  • EROA = 2πr²Va ÷ Vpeak — flow in = flow out
  • r is squared — 10% radius error → 20% EROA error
  • r²/2 rule: Va = 40, Vpeak = 500 → EROA ≈ r²/2
  • Functional MR → PISA UNDERestimates (crescent/elliptical orifice violates the hemisphere) — cross-check with 3D VCA
  • Always cross-check with VC, PV flow, RegFraction
Common Pitfalls & Interpretation
PitfallEffect & Fix
Eccentric / wall-hugging jet Hemisphere assumption fails. Use 3D vena contracta area or volumetric methods.
Non-circular orifice (functional MR) Crescent-shaped slit → PISA underestimates EROA. Confirm with 3D VCA / planimetry.
Single-frame (mid-systole) If MR is early/late systolic, instantaneous EROA × VTI overstates volumetric burden.
r squared Small calliper error → large EROA error. Use highest zoom; freeze on clearest hemisphere.
Funnel-shaped orifice Apply angle correction α/180° (more common in TR with leaflet tenting).
Multiple jets PISA assumes one orifice. Either sum jets (rough) or move to 3D / volumetric.
Severe MR with high LAP Low LV–LA gradient → low Vpeak → falsely high EROA. Cross-check carefully.
Wrong baseline shift Va too high → tiny PISA, hard to measure. Va too low → oversized hemisphere, geometry distorts. Stay 30–40 cm/s.
Worked Example
Given: r = 0.9 cm  |  Va = 40 cm/s  |  Vpeak MR = 500 cm/s (5 m/s)  |  VTIMR = 150 cm
Step 1 — PISA flow: 2π(0.9)² × 40 = 6.28 × 0.81 × 40 = 203 mL/s
Step 2 — EROA: 203 ÷ 500 = 0.41 cm² → Severe
Step 3 — RegVol: 0.41 × 150 = 61 mL → Severe
Quick check (r²/2): 0.81 ÷ 2 = 0.40 cm² ✓
When to Trust PISA — and When Not
Trust PISA when…Be skeptical when…
Central, single jet — primary MR (e.g., flail, prolapse) Eccentric / Coandă jet hugging atrial wall
Clean hemispheric shell at Va 30–40 cm/s Crescent orifice (functional MR with tethering)
Holosystolic flow envelope on CW Late-systolic MR (MVP) — PISA overstates RegVol
Findings concordant with VC width & PV flow EROA & RegVol disagree, or discordant with VC / RegFraction
Cross-Checks Before Calling Severity
  • Vena contracta width ≥ 0.7 cm (biplane) supports severe
  • 3D vena contracta area ≥ 0.4 cm² supports severe (best for functional MR)
  • Pulmonary vein flow — systolic blunting/reversal supports severe
  • LA size / LV volumes — chronic severe MR enlarges both
  • Quantitative volumetrics: SVMV inflow − SVLVOT = RegVol
  • RegFraction = RegVol ÷ total LV SV (≥ 50% = severe)
  • CW jet density & contour — dense, triangular, early-peaking favors severe
Report Documentation Language
  • "PISA radius measured at mid-systole with Va = ___ cm/s; EROA = ___ cm², RegVol = ___ mL"
  • "Findings concordant with vena contracta width and pulmonary vein flow pattern"
  • "PISA limited by [eccentric jet / non-circular orifice / late-systolic profile]; severity integrated from multiple parameters"
PISA Method — MR Quantification Reference
PISA — Reading the Echo Data
Where each number lives on the screen  |  The same trace gives you Vpeak AND VTI — they are NOT the same thing
Anatomy of the CW Doppler Envelope
0 -1.5 -3 -5 m/s baseline (0) V_peak deepest point VTI (area under curve) duration of MR
Same trace, two measurements: V_peak (a point) and VTI (an area)
V_peakDeepest point of the paraboladenominator (EROA) VTIArea enclosed by the tracemultiplier (RegVol)
Why VTI has units of cm (not cm/s): velocity (cm/s) × time (s) = distance (cm). VTI is the distance a column of regurgitant blood travels per beat — "stroke distance" of the leak. Multiply by area (EROA) and you get volume per beat.
Never forget
  • V_peak = a single y-coordinate (the tip)
  • VTI = the whole shaded blob (the area)
  • For severe MR: V_peak typ. 4–6 m/s, VTI typ. 100–180 cm
Anatomy of the Color PISA Image
LV LA MV leaflets r aliasing line = V_a (set by baseline shift, ~40 cm/s) flow direction (regurgitant)
Hemispheric color shells converging on the regurgitant orifice
rOrifice to first aliasing line (cm)numerator (squared!) V_aAliasing velocity at that shell (cm/s)numerator
Setting Va: shift the color baseline in the direction of the regurgitant jet. The number on the color scale at the new baseline IS your Va. Target 30–40 cm/s — gives a clean, measurable hemisphere.
Never forget
  • r is YOU measuring (with callipers, mid-systole)
  • Va is YOU choosing (the baseline shift)
  • V_peak & VTI are the JET telling you (CW)
THE FOUR NUMBERS YOU NEED — AND WHERE TO GET THEM
rColor zoom view, baseline-shifted, mid-systolecallipers on screenEROA numerator VaRead off color bar at new baselineset to 30–40 cm/sEROA numerator Vpeak MRCW Doppler: deepest point of envelopeauto-traced or peakEROA denominator VTIMRCW Doppler: traced area under envelopemanual traceRegVol multiplier
PISA Method — Reading Echo Data
PISA — Worked Examples
Four cases, broken down step-by-step  |  Each one teaches a different lesson
CASE 1 67M with new murmur — TEE shows P2 flail (degenerative MR)
Echo data:
r = 1.0 cm Va = 40 cm/s Vpeak = 5 m/s (500) VTI = 160 cm
1PISA flow rate at the shell = 2πr² × Va
= 2 × 3.14 × (1.0)² × 40 = 6.28 × 1.0 × 40 = 251 mL/s
2EROA = PISA flow ÷ Vpeak = 251 ÷ 500 = 0.50 cm²
3RegVol = EROA × VTI = 0.50 × 160 = 80 mL
4Sanity check (r²/2 trick): 1.0² ÷ 2 = 0.50 cm² ✓
Answer: EROA 0.50 cm² + RegVol 80 mL → SEVERE primary MR (both criteria met). Surgical referral.
Lesson #1 — The "5-and-40" trick: Whenever Va = 40 cm/s and Vpeak = 500 cm/s, the equation collapses to EROA ≈ r² / 2. Memorize this once and you'll never need a calculator at the bedside for textbook MR.
Math: 2π × 40 / 500 = 251/500 = 0.502 ≈ 0.5
CASE 2 54F asymptomatic, screening echo — mild rheumatic MR
Echo data:
r = 0.4 cm Va = 40 cm/s Vpeak = 5 m/s (500) VTI = 110 cm
1PISA flow rate = 2π × (0.4)² × 40 = 6.28 × 0.16 × 40 = 40.2 mL/s
2EROA = 40.2 ÷ 500 = 0.08 cm²
3RegVol = 0.08 × 110 = 8.8 mL
4Sanity check (r²/2): 0.16 ÷ 2 = 0.08 cm² ✓
Answer: EROA 0.08 cm² + RegVol 9 mL → MILD MR. Monitor.
Lesson #2 — r is SQUARED, not linear: Compare to Case 1 — r dropped from 1.0 to 0.4 (a 2.5× change). EROA dropped from 0.50 to 0.08 — a 6.25× change. Why? Because 2.5² = 6.25. A 1 mm error in your calliper placement can move a patient between severity grades. Zoom hard, freeze on the clearest hemisphere, measure twice.
CASE 3 72F with AFib, RVR at 130 bpm — secondary MR
Echo data:
r = 0.7 cm Va = 40 cm/s Vpeak = 5 m/s (500) VTI = 90 cm (short systole)
1PISA flow rate = 2π × (0.7)² × 40 = 6.28 × 0.49 × 40 = 123 mL/s
2EROA = 123 ÷ 500 = 0.25 cm² → moderate by primary cutoffs, but borderline-severe by functional cutoffs
3RegVol = 0.25 × 90 = 22 mL → mild by volume!
4Sanity check: 0.49 ÷ 2 = 0.245 ✓
Answer: EROA says moderate (borderline-severe by the lower functional-MR thresholds). RegVol says mild. Discordance — report both, integrate clinically. In AFib RVR, average 5–10 cycles and re-image after rate control before committing to severity.
Lesson #3 — EROA and RegVol can DISAGREE: They tell you different things.
• EROA = how big is the hole (instantaneous orifice area)
• RegVol = how much actually leaks per beat (orifice × stroke distance)
A big hole open for a short time leaks less total volume than a smaller hole open longer. Tachycardia, late-systolic MR, or short ejection → low VTI → RegVol underestimates relative to EROA. Always report both numbers.
CASE 4 58M, day 5 post-MI, acute pulmonary edema — suspected papillary muscle rupture
Echo data:
r = 0.7 cm Va = 40 cm/s Vpeak = 3.8 m/s (380) low! VTI = 80 cm
1PISA flow rate = 2π × (0.7)² × 40 = 123 mL/s (same as Case 3 — same r)
2EROA = 123 ÷ 380 = 0.32 cm² → calculation says approaching severe
3RegVol = 0.32 × 80 = 26 mL
4Sanity check fails! r²/2 = 0.245 — but EROA came out 0.32. Why? Vpeak ≠ 500.
The trick only works at Vpeak = 5 m/s. Here, lower Vpeak → smaller denominator → LARGER EROA for the same r.
Clinical reality: Patient has acute severe MR (LV is hyperdynamic, LA is small & non-compliant, LAP is sky-high). The low Vpeak is itself a sign of severity — LA pressure has risen so much that the LV-LA gradient is narrow. Don't be reassured by a "modest" RegVol — this is a surgical emergency.
Lesson #4 — Low Vpeak changes the math AND the interpretation:
The math: EROA = (2πr²Va) ÷ Vpeak. If Vpeak drops 25% (500 → 380), EROA inflates ~33%. The r²/2 shortcut breaks.
The clinical read: low Vpeak in acute MR doesn't mean the leak is mild — it means the LV-LA gradient is collapsing because LA pressure is enormous. Cross-check with VC width, dense triangular early-peaking CW envelope, S-wave reversal in pulm veins, small hyperdynamic LV, and the clinical picture (flash pulmonary edema).
Bottom line: trust the math but interpret with the patient.
CASE 5 48F with MVP and late-systolic murmur — PISA looks "severe" but isn't
The instantaneous-vs-time-averaged orifice problem. PISA measures EROA at one moment (peak convergence). The equation then assumes that orifice is open and leaking for all of systole. That works for holosystolic MR. It overestimates for late-systolic MR (classic MVP) because the orifice is only open during the last fraction of systole.
True RegVol = ∫ EROA(t) · V(t) dt  —  PISA assumes EROA is constant across systole
Echo data (same patient as Case 1, but MVP instead of flail):
r = 1.0 cm Va = 40 cm/s Vpeak = 5 m/s (500) VTI = 70 cm (short, late)
1PISA flow rate = 2π × (1.0)² × 40 = 251 mL/s (same as Case 1)
2EROA = 251 ÷ 500 = 0.50 cm² → "looks severe" by PISA EROA alone
3RegVol = 0.50 × 70 = 35 mL → only moderate by volume
4Why the disconnect? CW envelope is dagger-shaped & late-peaking. Orifice is only open for ~40% of systole. The shorter VTI partially self-corrects RegVol — but PISA EROA still overstates the leak's true burden.
Answer: EROA 0.50 cm² + RegVol 35 mL → moderate MR (not severe). Don't trust PISA EROA alone in MVP. Cross-check with VC, 3D VC area, pulm vein flow, RegFraction.
Same EROA, different cardiac-cycle phase — very different leaks
Holosystolic MR (e.g., flail / functional) Late-systolic MR (classic MVP)
Orifice timing Open entire systole (~0.30 s) Open only last ~40% (~0.12 s)
CW envelope Full parabolic, dense, holosystolic Dagger-shaped, late-peaking, truncated
PISA EROA 0.50 cm² 0.50 cm² (same!)
VTI of MR jet ~150 cm ~70 cm
RegVol 75 mL → severe 35 mL → moderate
True severity Severe PISA EROA overstates
Mental model — "hose diameter vs how long the water flows"
ConceptTranslation
EROADiameter of the hose — how big is the leak orifice right now?
VTIHow far a column of leaking blood travels per beat — captures both velocity AND duration
RegVol = EROA × VTIVolume per beat — partially self-corrects for short orifice opening because VTI shrinks
Why it still overestimates in MVPPISA reads peak EROA at one instant. Real EROA(t) is zero for half of systole → integral of flow is smaller than peak-EROA × VTI suggests
ASE 2017 guidance for late-systolic / biphasic MR
  • Do NOT grade severity on PISA EROA alone
  • Always compute RegVol = EROA × VTI (never EROA × estimated systolic time)
  • Integrate with: VC width, 3D VC area, PV flow pattern, LA/LV size, RegFraction
  • Consider 3D volumetric quantification — gold standard in MVP because it integrates flow over the actual leaking window
Lesson #5 — PISA assumes a constant orifice; MVP violates that:
The PISA equation snapshots EROA at one instant and treats the leak as if it were holosystolic. In MVP, the leak is late-systolic only — same instantaneous EROA, but the orifice is only open for ~40% of systole. Result: PISA overstates severity.
What to do: use RegVol (not EROA alone), cross-check with multiple parameters, and lean on 3D for definitive grading. If the CW envelope is dagger-shaped instead of holosystolic, downgrade your trust in PISA EROA before you commit to severity.
CASE 6 73F with class 3 dyspnea, ischemic CMP, secondary MR — PISA UNDERESTIMATES
The elliptical-orifice problem — mirror image of Case 5. Functional/secondary MR creates a slit-shaped or crescentic orifice (commissure-to-commissure leaflet tethering), not a circle. PISA's hemispheric assumption breaks: a flat 2D measurement of a non-circular orifice underestimates EROA. Direct from Mayo lecture (slide 73).
Echo data (real case):
r = 0.95 cm Va = 31 cm/s Vpeak = 4.8 m/s (480) VTI = 145 cm
1PISA flow rate = 2π × (0.95)² × 31 = 6.28 × 0.9025 × 31 = 176 mL/s
2EROA = 176 ÷ 480 = 0.37 cm² → "moderate-severe" by PISA alone
3RegVol = 0.37 × 145 = 53 mL → moderate-severe
43D vena contracta cross-check = 0.72 cm² → clearly SEVERE. True RegVol ≈ 0.72 × 145 = 104 mL.
Answer: PISA EROA 0.37 / RV 53 mL UNDERESTIMATED the true severity by ~50%. 3D VCA = 0.72 cm² confirms severe secondary MR. Refer for intervention (TEER vs surgery).
Lesson #6 — The two-sided PISA failure: it OVERestimates in MVP and UNDERestimates in functional MR:
• MVP (Case 5): instantaneous orifice, brief opening → PISA OVERstates
• Functional MR (Case 6): elliptical/crescent orifice → PISA UNDERstates
What to do: in any secondary MR (ischemic or non-ischemic CMP, AFib-related atrial MR), always cross-check PISA with 3D VCA. If 3D VCA is > 2D PISA EROA, trust 3D. The discrepancy is biggest with central, biphasic jets and tethered leaflets.
PISA's sweet spot: central, holosystolic, circular orifice in primary MR (Cases 1–3). Outside that, integrate.
MULTIPLE JETS — SUMMING PISA
Two regurgitant jets with PISA radii r₁ and r₂ → combined R = √(r₁² + r₂²)
Example: r₁ = 0.6 cm, r₂ = 0.4 cm → combined R = √(0.36 + 0.16) = √0.52 = 0.72 cm
THE THREE-STEP NEVER-FORGET RECIPE
  1. Color zoom + baseline shift → measure r, read Va off the scale
  2. CW through the jet → note Vpeak (deepest point), trace VTI (area under)
  3. Calculate: EROA = (2πr²Va) ÷ Vpeak  →  RegVol = EROA × VTI
Bedside shortcut: when Va = 40, Vpeak = 500 → EROA ≈ r² / 2.    Severe = EROA ≥ 0.40 cm².
PISA Method — Worked Examples
Beyond PISA — Cross-Checks & Integrative Assessment
Other semiquant signs  |  Continuity equation  |  3D VCA  |  ASE 2017 integrative algorithm
Semiquantitative Signs of Severe MR
ParameterSevere MRSpecificity / note
Vena contracta width≥ 7 mm (biplane average)Specific for severe; intermediate 3–6.9 mm
3D vena contracta area≥ 0.40 cm²Best for elliptical/eccentric orifice; gold std for functional MR
Pulm vein systolic flowReversal (S-wave below baseline)Highly specific for severe; blunting alone is non-specific
Mitral inflow E-wave> 1.2 m/s + high E/ASevere MR or restrictive filling
Mitral inflow (mild MR)A-dominant patternSpecific for mild MR (low E)
LA sizeEnlarged (chronic)Acute severe may have normal LA
LV sizeEnlarged (chronic primary)Normal LV = specific for non-severe MR
CW Doppler Profile — Mild vs Severe
FeatureMild MR envelopeSevere MR envelope
DensityFaint, incompleteDense, full envelope
ShapeSymmetric, parabolicAsymmetric, dagger-shaped
PeakMid-systolicEarly-peaking (severe), then sharp decline
DurationHolosystolic but faintHolosystolic + dense
If non-holosystolicMid-late = MVP  |  Early systolic only = secondary MR  |  Both suggest LESS severe than the EROA implies
"Cut-off sign": in acute severe MR, sharp early-systolic deceleration of the CW envelope reflects rapid LA pressure equalization — the V-wave of the LA pressure trace pushed up against the LV pressure curve. Strongly suggests severe + acute.
Variability & Why Quantitation Matters
Thaden et al. Circ CV Imaging 2017: External echos read as ≤ moderate were re-read internally as > moderate in 60% of cases. With diagnostic quantitation, discordance dropped from 31% to 15%. Quantitative parameters are the difference-maker between operators — not visual gestalt.
Continuity Equation Method (Quantitative Doppler)
Independent of PISA. Compares total mitral inflow stroke volume to LVOT (forward) stroke volume. The difference is the regurgitant volume.
RegVol = SVMV inflow − SVLVOT
SV = π (D/2)² × VTI   (annular cross-section × flow VTI)
DLVOTLVOT diameter, PSLAX, mid-systole (cm) VTILVOTPW Doppler at LVOT, A5C view (cm) DMVMitral annulus diameter, A4C, early diastole (cm) VTIMVPW Doppler at MV annulus, A4C (cm)
Then derive EROA
EROA = RegVol ÷ VTIMR jet
Worked example (from lecture): SVMV 218 mL − SVLVOT 71 mL = RegVol 147 mL. With MR VTI 216 cm → EROA = 0.68 cm².
Pitfalls of continuity equation
  • > mild AR — LVOT SV is contaminated by regurgitant flow; use RVOT instead
  • Calcified annuli — D² error magnifies (D is squared, like PISA radius)
  • Trace MODAL velocity for mitral annular VTI (brightest line, not peak edge)
  • Learning curve — reproducibility lower than PISA
3D Vena Contracta Area
Directly measures the regurgitant orifice in cross-section using 3D color Doppler MPR. No hemispheric assumption — ideal for non-circular orifices.
  • VCA ≥ 0.40 cm² = severe
  • Best for: functional/secondary MR, eccentric jets, biphasic jets
  • In primary MR: 3D VCA and 2D PISA EROA agree (mean diff 0.04 cm²)
  • In secondary MR: 3D VCA exceeds 2D PISA EROA by ~0.12 cm² on average (Zeng et al. Circ CV Imaging 2011)
Integrative Approach (ASE 2017)
BucketComponents
2D FindingsFlail leaflet, LV enlargement, LA enlargement, mechanism
Semiquant DopplerVC width, PV flow, mitral inflow, CW Doppler profile
Quant DopplerEROA + RegVol + RegFraction (PISA, continuity, or 3D)
Algorithm: Does MR meet specific criteria for mild OR severe? → Yes, label it. → If intermediate (or borderline), perform quantitation always. → If discordant or poor quality, label indeterminate and consider TEE/CMR.
PISA Method — Cross-Checks & Integrative Assessment
PISA — Mechanism, Prognosis, & Surgical Indications
Carpentier classification  |  Repairability  |  Outcomes  |  When to operate
Carpentier Classification of MR Mechanism
TypeLeaflet motionEtiologiesRepairability
Type I Normal Annular dilatation (atrial MR), leaflet perforation (endocarditis) Potentially repairable
Type II Excess (prolapse / flail) Degenerative MVP, chordal rupture, papillary muscle rupture (acute MI) Highly repairable
Type IIIA Restricted in both systole & diastole Rheumatic, mitral annular calcification (MAC), drug-induced (e.g., serotonin) Not repairable → replacement
Type IIIB Restricted in systole only Ischemic CMP (papillary muscle displacement), nonischemic CMP (leaflet tethering) Medical first; repair/replace 2nd line
Special cases:
• SAM-mediated MR: mid-late systolic timing (matches LVOT obstruction), typically posteriorly directed, dynamic (varies with loading conditions)
• Endocarditis: can produce multiple mechanisms simultaneously (perforation + flail + paravalvular)
• Atrial functional MR: Type I (annular dilatation) from chronic AFib + LA enlargement — growing recognition
PISA by MR Mechanism — What to Expect
MechanismPISA tendencyWhy
Primary, holosystolic (flail, perforation)AccurateCircular orifice, constant area, high gradient
MVP (mid-late systolic)OVERestimates EROABrief opening, peak ROA snapshot × full VTI
Functional/secondary (Type IIIB)UNDERestimates EROAElliptical/crescent orifice violates hemisphere
Eccentric / wall-huggingUnreliableCoandă effect, distorted convergence
Acute severe (papillary rupture)EROA inflated by low VpeakHigh LAP narrows LV-LA gradient
Multiple jetsUnderestimates if only one measuredCombined R = √(r₁² + r₂²)
Surgical Indications — Severe Primary MR (ACC/AHA + Mayo)
Class 1 (operate)
  • Symptomatic severe primary MR — any LVEF (Stage D)
  • Asymptomatic with LV systolic dysfunction — LVEF ≤ 60% and/or LVESD ≥ 40 mm (Stage C2). 2020 ACC/AHA makes this a Class 1 recommendation, not IIa.
Class 2a (reasonable in asymptomatic, normal LV function)
  • New-onset atrial fibrillation
  • PASP > 50 mmHg (rest)
  • Likelihood of a durable repair > 95% with expected mortality < 1% at a primary or comprehensive Valve Center
Why these thresholds matter: in primary MR, the LV unloads into the LA. EF < 60% means systolic function is already abnormal (would be lower without the regurgitant pop-off). Wait too long → irreversible LV dysfunction post-op.
Severe secondary MR — very different pathway
  • GDMT first (BB, ACEi/ARNI, MRA, SGLT2)
  • CRT if eligible
  • If still symptomatic: TEER (MitraClip) per COAPT criteria, or surgery in selected
Prognosis by EROA — The Data
Sarano NEJM 2005 / Circulation 2018 — primary MR survival under medical management
EROA10-yr survivalNote
None / no MR~83%Reference
1–19 mm²~70%Mild
20–39 mm²~62%Moderate
≥ 40 mm² (≥ 0.40 cm²)~40%Severe — massive survival deficit, even asymptomatic
Topilsky Circulation 2012 — mid-late vs holosystolic MR
Pattern5-yr CV events
Holosystolic MR40.4 ± 6.2%
Mid-late systolic MR (MVP-pattern)15.9 ± 4.7%
Bottom line: for the SAME EROA, mid-late systolic MR has dramatically better outcomes than holosystolic MR. Confirms that PISA EROA alone in MVP overstates the prognostic burden. Always integrate timing.
The 30-Second Bedside Workflow
  1. Mechanism: Carpentier type? Primary or secondary?
  2. Color Doppler: jet area, eccentricity, flow convergence visible?
  3. Vena contracta: ≥ 7 mm? < 3 mm?
  4. Pulm vein flow: systolic blunting or reversal?
  5. Mitral inflow: E > 1.2 m/s or A-dominant?
  6. CW envelope: dense + dagger-shaped + holosystolic? Or symmetric + faint?
  7. PISA: EROA + RegVol via the recipe
  8. Cross-check: 3D VCA in functional MR; continuity equation if PISA limited
  9. 2D context: LV size, LA size, EF, PASP — do they match the severity grade?
  10. Final call: ASE grade I–IV. Indeterminate → CMR.
PISA Method — Mechanism, Prognosis & Surgical Indications