Reproducibility of Proximal Isovelocity Surface Area, Vena Contracta, and Regurgitant Jet Area for Assessment of Mitral Regurgitation Severity
Simon Biner, MD*, ,
Asim Rafique, MD,
Farhad Rafii, MD ,
Kirsten Tolstrup, MD,
Omid Noorani, MS ,
Takahiro Shiota, MD,
Swaminatha Gurudevan, MD,
Robert J. Siegel, MD,*
* Division of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
Division of Cardiology, Cedars-Sinai Medical Center, University of California, Los Angeles, Los Angeles, California
Department of Internal Medicine, Kaiser Permanente, University of California, Los Angeles, Los Angeles, California
Department of Biomathematics, University of California, Los Angeles, Los Angeles, California
* Reprint requests and correspondence: Dr. Robert J. Siegel, 8700 Beverly Boulevard, Room 5623, Los Angeles, California 90048-1804 (Email: siegel{at}cshs.org).
Objectives: The aim of this study was to evaluate the interobserver agreement of proximal isovelocity surface area (PISA) and vena contracta (VC) for differentiating severe from nonsevere mitral regurgitation (MR).
Background: Recommendation for MR evaluation stresses the importance of VC width and effective regurgitant orifice area by PISA measurements. Reliable and accurate assessment of MR is important for clinical decision making regarding corrective surgery. We hypothesize that color Doppler-based quantitative measurements for classifying MR as severe versus nonsevere may be particularly susceptible to interobserver agreement.
Methods: The PISA and VC measurements of 16 patients with MR were interpreted by 18 echocardiologists from 11 academic institutions. In addition, we obtained quantitative assessment of MR based on color flow Doppler jet area.
Results: The overall interobserver agreement for grading MR as severe or nonsevere using qualitative and quantitative parameters was similar and suboptimal: 0.32 (95% confidence interval [CI]: 0.1 to 0.52) for jet area–based MR grade, 0.28 (95% CI: 0.11 to 0.45) for VC measurements, and 0.37 (95% CI: 0.16 to 0.58) for PISA measurements. Significant univariate predictors of substantial interobserver agreement for: 1) jet area–based MR grade was functional etiology (p = 0.039); 2) VC was central MR (p = 0.013) and identifiable effective regurgitant orifice (p = 0.049); and 3) PISA was presence of a central MR jet (p = 0.003), fixed proximal flow convergence (p = 0.025), and functional etiology (p = 0.049). Significant multivariate predictors of raw interobserver agreement  80% included: 1) for VC, identifiable effective regurgitant orifice (p = 0.035); and 2) for PISA, central regurgitant jet (p = 0.02).
Conclusions: The VC and PISA measurements for distinction of severe versus nonsevere MR are only modestly reliable and associated with suboptimal interobserver agreement. The presence of an identifiable effective regurgitant orifice improves reproducibility of VC and a central regurgitant jet predicts substantial agreement among multiple observers of PISA assessment.
Key Words: mitral valve • regurgitation • echocardiography
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Abbreviations and Acronyms
| | CFD = color flow Doppler | | EROA = effective regurgitant orifice area | | MR = mitral regurgitation | | PISA = proximal isovelocity surface area | | VC = vena contracta |
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