SlideShare une entreprise Scribd logo
1  sur  44
Télécharger pour lire hors ligne
PProximalroximal
IIsovelocitysovelocity
SSurfaceurface
AArearea
Dr. Sehran BhattiDr. Sehran Bhatti
 Regurgitant volumes can be estimated by 2Regurgitant volumes can be estimated by 2
methodsmethods
 Volumetric methodVolumetric method
 PISA methodPISA method
 As we knowAs we know
 Flow rate = CSA x VelocityFlow rate = CSA x Velocity
 Volume = CSA x TVIVolume = CSA x TVI
 If regurgitant orifice area is known thenIf regurgitant orifice area is known then
reguritant volume can be estimated as thereguritant volume can be estimated as the
product of effective regurgitant orifice areaproduct of effective regurgitant orifice area
(ERO) and regurgitant TVI(ERO) and regurgitant TVI
 To estimate ERO, Proximal isovelocity surfaceTo estimate ERO, Proximal isovelocity surface
area is usedarea is used
RV = ERO x Regurgitant TVIRV = ERO x Regurgitant TVI
 As blood flow converges towards the regurgitantAs blood flow converges towards the regurgitant
orifice, blood flow velocity increases withorifice, blood flow velocity increases with
formation of multiple shells of isovelocity offormation of multiple shells of isovelocity of
hemispheric shapehemispheric shape
 Remember that velocity of the shell closest toRemember that velocity of the shell closest to
the regurgitant orifice is highest and vice versathe regurgitant orifice is highest and vice versa
 The flow rate at the surface of a hemisphericThe flow rate at the surface of a hemispheric
shell with the same flow velocity is consideredshell with the same flow velocity is considered
equal to the flow rate across the regurgitantequal to the flow rate across the regurgitant
orifice according to the law of conservation oforifice according to the law of conservation of
flow which states thatflow which states that
““What comes in must go out”What comes in must go out”
 By adjusting the Nyquist limit of the color flow map, theBy adjusting the Nyquist limit of the color flow map, the
flow velocity of a hemispheric surface proximal to theflow velocity of a hemispheric surface proximal to the
regurgitant orifice can be determinedregurgitant orifice can be determined
 For e.g. in MR the regurgitant flow travels away from theFor e.g. in MR the regurgitant flow travels away from the
position of the apical transducer ans so the bloodposition of the apical transducer ans so the blood
converging towards the mitral regurgitant orifice in theconverging towards the mitral regurgitant orifice in the
LV is color coded blue until the velocity reaches theLV is color coded blue until the velocity reaches the
negative aliasing velocity of the selected color flow map,negative aliasing velocity of the selected color flow map,
at which time the flow will change color to light orange-at which time the flow will change color to light orange-
redred
 If the negative aliasing velocity of the color map isIf the negative aliasing velocity of the color map is
reduced further, the trasition from blue to orange-red willreduced further, the trasition from blue to orange-red will
occur farther from the regurgitant orifice providing aoccur farther from the regurgitant orifice providing a
larger hemispheric shell radiuslarger hemispheric shell radius
 After a hemisphere with blood flow of isovelocityAfter a hemisphere with blood flow of isovelocity
is identified the flow rate through thisis identified the flow rate through this
hemispheric shell is determined byhemispheric shell is determined by
Flow rate = CSA x VelocityFlow rate = CSA x Velocity
Area of hemispheric shell = 2Area of hemispheric shell = 2ππr², where pie=3.14r², where pie=3.14
Flow rate = 6.28 x r² x Aliasing velocity (from color map)Flow rate = 6.28 x r² x Aliasing velocity (from color map)
 As we have already discussed the flow rate atAs we have already discussed the flow rate at
the surface of a hemispheric shell with the samethe surface of a hemispheric shell with the same
flow velocity is considered equal to the flow rateflow velocity is considered equal to the flow rate
across the regurgitant orifice according to theacross the regurgitant orifice according to the
law of conservation of flowlaw of conservation of flow
 Therefore, this flow across PISA is equal to flowTherefore, this flow across PISA is equal to flow
rate across EROrate across ERO
Flow rate = ERO x regurgitant velocityFlow rate = ERO x regurgitant velocity
ERO = flow rate / peak MR velocityERO = flow rate / peak MR velocity
ERO = 6.28 x r² x Aliasing velocity / MR velocityERO = 6.28 x r² x Aliasing velocity / MR velocity
 Regurgitant Volume = ERO x MR TVIRegurgitant Volume = ERO x MR TVI
Substituting value of ERO we getSubstituting value of ERO we get
Regurg Vol = 6.28 x r² xRegurg Vol = 6.28 x r² x Aliasing velocityAliasing velocity x MRTVIx MRTVI
MR velocityMR velocity
 The concept of PISA can also be applied toThe concept of PISA can also be applied to
calculate the area of stenotic surfaces and hascalculate the area of stenotic surfaces and has
been validated for MV area in patients with mitralbeen validated for MV area in patients with mitral
stenosisstenosis
CaveatsCaveats
 Proximal to a stenotic mitral orifice, PISA mayProximal to a stenotic mitral orifice, PISA may
not be a complete hemisphere but a portion ofnot be a complete hemisphere but a portion of
hemisphere because of mitral leaflets geometryhemisphere because of mitral leaflets geometry
on the atrial sideon the atrial side
 In such cases an angle correction factor isIn such cases an angle correction factor is
appliedapplied
MVA = 6.28 x r² xMVA = 6.28 x r² x Aliasing velocityAliasing velocity xx alphaalpha°°
Peak MS velocity 180Peak MS velocity 180°°
Where alpha is the angle between two mitral leaflets on the atrial sideWhere alpha is the angle between two mitral leaflets on the atrial side
 Sometimes it is difficult to know in which direction theSometimes it is difficult to know in which direction the
baseline should be shifted for optimal PISAbaseline should be shifted for optimal PISA
 For this rule of the thumb is to shift the baseline inFor this rule of the thumb is to shift the baseline in
the direction of the flow jet of interestthe direction of the flow jet of interest
 PISA radius needs to be measured at the same time asPISA radius needs to be measured at the same time as
the peak velocity of the jetthe peak velocity of the jet
 Color M-mode can help in measuring the radiusColor M-mode can help in measuring the radius
reliably at the correct timereliably at the correct time
Measuring PISAMeasuring PISA
 PISA is Proximal Isovelocity Surface AreaPISA is Proximal Isovelocity Surface Area
 It is larger in large volume jets and smaller inIt is larger in large volume jets and smaller in
small volume jetssmall volume jets
 It also will change its size depending on theIt also will change its size depending on the
color Doppler scale factorcolor Doppler scale factor
 PISA is just one of many ways to calculatePISA is just one of many ways to calculate
severity of MRseverity of MR
 There are four hallmarks of flow in mitralfour hallmarks of flow in mitral
regurgitation:regurgitation:
 Flow convergenceFlow convergence that then narrows into anthat then narrows into an
area ofarea of accelarated flowaccelarated flow (narrowest area of(narrowest area of
flow) and then expands into the area offlow) and then expands into the area of
turbulence (what we currently call theturbulence (what we currently call the size ofsize of
the jetthe jet))
 We also can see the downstream effects likeWe also can see the downstream effects like
pulmonary vein flow reversalpulmonary vein flow reversal in systolein systole
Pisa ppt
 So the hallmark flow areas on a diagram ofSo the hallmark flow areas on a diagram of
mitral regurgitationmitral regurgitation
 The PISA can be seen on this TEE MR jetThe PISA can be seen on this TEE MR jet
 And the vena contracta can be seen on thisAnd the vena contracta can be seen on this
same jetsame jet
 The area of flow convergence is where we lookThe area of flow convergence is where we look
for PISAfor PISA
 There are many concentric flow velocity shellsThere are many concentric flow velocity shells
as flow accelerates into the vena contractaas flow accelerates into the vena contracta
 Calculation of PISA requires us to find one ofCalculation of PISA requires us to find one of
these shells and then calculate its surface areathese shells and then calculate its surface area
 This takes a lot of faith and skillThis takes a lot of faith and skill
 It is almost always done from an apical viewIt is almost always done from an apical view
 One thing to remember is that PISA (as well asOne thing to remember is that PISA (as well as
the other hallmark areas) will be larger in largethe other hallmark areas) will be larger in large
degrees of mitral regurgitationdegrees of mitral regurgitation
Pisa ppt
 Every MR jet has a flow convergence area and,Every MR jet has a flow convergence area and,
therefore, a PISA of the jettherefore, a PISA of the jet
 PISA looks at the flow convergencePISA looks at the flow convergence
 Keep in mind, flow is always the area x theKeep in mind, flow is always the area x the
velocityvelocity
 We already know this from the continuityWe already know this from the continuity
equation and in Doppler calculations of cardiacequation and in Doppler calculations of cardiac
outputoutput
 But we can’t clearly see the orifice, so for PISABut we can’t clearly see the orifice, so for PISA
we will look prior to the orificewe will look prior to the orifice
 We will look at one of the isovelocity shellsWe will look at one of the isovelocity shells
 Here area of the shell x velocity of the shellHere area of the shell x velocity of the shell
equals flowequals flow
 By the continuity equation, this flow should beBy the continuity equation, this flow should be
exactly that of the flow at the regurgitant orificeexactly that of the flow at the regurgitant orifice
 So find a velocity shell and move the scale factorSo find a velocity shell and move the scale factor
to help you identify itto help you identify it
Meaning of scale factorMeaning of scale factor
 The use of the scale factor just helps us identifyThe use of the scale factor just helps us identify
a suitable isovelocity shell for measurementa suitable isovelocity shell for measurement
 Then we can use it to calculate flowThen we can use it to calculate flow
 Note the PISA get larger in this MR jet. The jet atNote the PISA get larger in this MR jet. The jet at
the right is the same as on the left, the only thingthe right is the same as on the left, the only thing
changed is the scale factorchanged is the scale factor
 Here is a larger depiction of the previous jetsHere is a larger depiction of the previous jets
 Moving the scale factor down will make the shellMoving the scale factor down will make the shell
bigger and easier to identify.bigger and easier to identify.
 So, now we have the shell and can read theSo, now we have the shell and can read the
velocityvelocity
 Since we have the shell, measuring the radiusSince we have the shell, measuring the radius
will allow you to calculate the area of the shell orwill allow you to calculate the area of the shell or
PISAPISA
 If we multiply the area x velocity we will get theIf we multiply the area x velocity we will get the
flowflow
 So rememberSo remember
LimitationsLimitations
 The biggest limitation of PISA is the incorrectThe biggest limitation of PISA is the incorrect
identification of the proximal flow convergenceidentification of the proximal flow convergence
areaarea
 Here is an example of an area where the flowHere is an example of an area where the flow
convergence is not symmetricconvergence is not symmetric
 This is an example of a perforated mitral leafletThis is an example of a perforated mitral leaflet
from the TEE approach (left)from the TEE approach (left)
 Note the asymmetric flow convergence areaNote the asymmetric flow convergence area
 This is a limitation of PISAThis is a limitation of PISA
 So we worry about non-optimal flowSo we worry about non-optimal flow
convergence and changes in the PISA over timeconvergence and changes in the PISA over time
(the cardiac cycle)(the cardiac cycle)
 Note the changes in size over the cardiac cycleNote the changes in size over the cardiac cycle
 So PISA has limitationsSo PISA has limitations
 Different textbooks have given the ranges ofDifferent textbooks have given the ranges of
values but keep in mind, big is big and small isvalues but keep in mind, big is big and small is
smallsmall
Pisa ppt
Pisa ppt
Thank YouThank You

Contenu connexe

Tendances

Asd echo assessment
Asd echo assessmentAsd echo assessment
Asd echo assessmentMashiul Alam
 
Right heart catheters
Right heart cathetersRight heart catheters
Right heart cathetersRohitWalse2
 
Percutaneous Pulmonary Valve Interventions
Percutaneous Pulmonary Valve InterventionsPercutaneous Pulmonary Valve Interventions
Percutaneous Pulmonary Valve InterventionsPraveen Nagula
 
Contrast Echocardiography
Contrast EchocardiographyContrast Echocardiography
Contrast EchocardiographyAdhi Arya
 
Echo assessment of cardiomyopathy pdf
Echo assessment of cardiomyopathy pdfEcho assessment of cardiomyopathy pdf
Echo assessment of cardiomyopathy pdfNizam Uddin
 
Quantification of mitral regurgitation by PISA
Quantification of mitral regurgitation by PISA Quantification of mitral regurgitation by PISA
Quantification of mitral regurgitation by PISA Ramachandra Barik
 
Assessment of shunt by cardiac catheterization
Assessment of shunt by cardiac catheterizationAssessment of shunt by cardiac catheterization
Assessment of shunt by cardiac catheterizationRamachandra Barik
 
Coronary anatomy and angiographic views
Coronary anatomy and angiographic viewsCoronary anatomy and angiographic views
Coronary anatomy and angiographic viewsthanigai arasu
 
Echo in restrictive cardiomyopathy
Echo in restrictive cardiomyopathyEcho in restrictive cardiomyopathy
Echo in restrictive cardiomyopathysruthiMeenaxshiSR
 
Intravascular Ultrasound (IVUS)
Intravascular Ultrasound (IVUS)Intravascular Ultrasound (IVUS)
Intravascular Ultrasound (IVUS)Dr.Sayeedur Rumi
 
Echo assessment of aortic stenosis
Echo assessment of aortic stenosisEcho assessment of aortic stenosis
Echo assessment of aortic stenosisNizam Uddin
 
MVP Mitral Valve Prolapse - Echocardiographic Evaluation
 MVP Mitral Valve  Prolapse - Echocardiographic Evaluation MVP Mitral Valve  Prolapse - Echocardiographic Evaluation
MVP Mitral Valve Prolapse - Echocardiographic EvaluationPraveen Nagula
 
M mode echocardiography
M mode echocardiographyM mode echocardiography
M mode echocardiographyFuad Farooq
 
PRESSURE MEASUREMENT by Cardiac catheterisation_Dr Amol Patil.pptx
PRESSURE MEASUREMENT by Cardiac catheterisation_Dr Amol Patil.pptxPRESSURE MEASUREMENT by Cardiac catheterisation_Dr Amol Patil.pptx
PRESSURE MEASUREMENT by Cardiac catheterisation_Dr Amol Patil.pptxAshishSharma907946
 
Echo Mitral Stenosis
Echo Mitral StenosisEcho Mitral Stenosis
Echo Mitral StenosisMashiul Alam
 

Tendances (20)

Asd echo assessment
Asd echo assessmentAsd echo assessment
Asd echo assessment
 
Right heart catheters
Right heart cathetersRight heart catheters
Right heart catheters
 
Percutaneous Pulmonary Valve Interventions
Percutaneous Pulmonary Valve InterventionsPercutaneous Pulmonary Valve Interventions
Percutaneous Pulmonary Valve Interventions
 
Contrast Echocardiography
Contrast EchocardiographyContrast Echocardiography
Contrast Echocardiography
 
Echo assessment of cardiomyopathy pdf
Echo assessment of cardiomyopathy pdfEcho assessment of cardiomyopathy pdf
Echo assessment of cardiomyopathy pdf
 
Echo in pericardial diseases
Echo in pericardial diseasesEcho in pericardial diseases
Echo in pericardial diseases
 
cath Lab Hemoduhynamic
cath Lab Hemoduhynamiccath Lab Hemoduhynamic
cath Lab Hemoduhynamic
 
Quantification of mitral regurgitation by PISA
Quantification of mitral regurgitation by PISA Quantification of mitral regurgitation by PISA
Quantification of mitral regurgitation by PISA
 
VSD devices
VSD devicesVSD devices
VSD devices
 
Echo assessment of RV function
Echo assessment of RV functionEcho assessment of RV function
Echo assessment of RV function
 
Assessment of shunt by cardiac catheterization
Assessment of shunt by cardiac catheterizationAssessment of shunt by cardiac catheterization
Assessment of shunt by cardiac catheterization
 
Coronary anatomy and angiographic views
Coronary anatomy and angiographic viewsCoronary anatomy and angiographic views
Coronary anatomy and angiographic views
 
Echo in restrictive cardiomyopathy
Echo in restrictive cardiomyopathyEcho in restrictive cardiomyopathy
Echo in restrictive cardiomyopathy
 
Asd device closure
Asd device closureAsd device closure
Asd device closure
 
Intravascular Ultrasound (IVUS)
Intravascular Ultrasound (IVUS)Intravascular Ultrasound (IVUS)
Intravascular Ultrasound (IVUS)
 
Echo assessment of aortic stenosis
Echo assessment of aortic stenosisEcho assessment of aortic stenosis
Echo assessment of aortic stenosis
 
MVP Mitral Valve Prolapse - Echocardiographic Evaluation
 MVP Mitral Valve  Prolapse - Echocardiographic Evaluation MVP Mitral Valve  Prolapse - Echocardiographic Evaluation
MVP Mitral Valve Prolapse - Echocardiographic Evaluation
 
M mode echocardiography
M mode echocardiographyM mode echocardiography
M mode echocardiography
 
PRESSURE MEASUREMENT by Cardiac catheterisation_Dr Amol Patil.pptx
PRESSURE MEASUREMENT by Cardiac catheterisation_Dr Amol Patil.pptxPRESSURE MEASUREMENT by Cardiac catheterisation_Dr Amol Patil.pptx
PRESSURE MEASUREMENT by Cardiac catheterisation_Dr Amol Patil.pptx
 
Echo Mitral Stenosis
Echo Mitral StenosisEcho Mitral Stenosis
Echo Mitral Stenosis
 

En vedette

mitral regurgitation american guidlines 2014
mitral regurgitation american guidlines 2014mitral regurgitation american guidlines 2014
mitral regurgitation american guidlines 2014Basem Enany
 
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATIONECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATIONPraveen Nagula
 
Venezia - Italia
Venezia - ItaliaVenezia - Italia
Venezia - ItaliaJohn *
 
Химия в жизни человека
Химия в жизни человекаХимия в жизни человека
Химия в жизни человекаElen Shkadron
 
Physics 4 21
Physics 4 21Physics 4 21
Physics 4 21tungalag
 
Hémodynamique doppler
Hémodynamique dopplerHémodynamique doppler
Hémodynamique doppleroussama El-h
 
Where did Equity Improve
Where did Equity ImproveWhere did Equity Improve
Where did Equity ImproveEduSkills OECD
 
Mitral regurgitation
Mitral regurgitationMitral regurgitation
Mitral regurgitationPratap Tiwari
 
Anatomy of mitral valve echo evaluation
Anatomy of mitral valve echo evaluationAnatomy of mitral valve echo evaluation
Anatomy of mitral valve echo evaluationmadhusiva03
 
Education in China - a Snapshot
Education in China - a SnapshotEducation in China - a Snapshot
Education in China - a SnapshotEduSkills OECD
 
Status pencapaian malaysia dalam timss dan pisa
Status pencapaian malaysia dalam timss dan pisaStatus pencapaian malaysia dalam timss dan pisa
Status pencapaian malaysia dalam timss dan pisamazizzharfan
 
Mitral valve regurgitation
Mitral valve regurgitationMitral valve regurgitation
Mitral valve regurgitationMohammad Aladam
 

En vedette (19)

Echo Mitral Regurg
Echo Mitral RegurgEcho Mitral Regurg
Echo Mitral Regurg
 
mitral regurgitation american guidlines 2014
mitral regurgitation american guidlines 2014mitral regurgitation american guidlines 2014
mitral regurgitation american guidlines 2014
 
Mitral regurgitation
Mitral regurgitationMitral regurgitation
Mitral regurgitation
 
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATIONECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
 
Venezia - Italia
Venezia - ItaliaVenezia - Italia
Venezia - Italia
 
@Venezia v noci he
@Venezia v noci he@Venezia v noci he
@Venezia v noci he
 
Present
PresentPresent
Present
 
Химия в жизни человека
Химия в жизни человекаХимия в жизни человека
Химия в жизни человека
 
Physics 4 21
Physics 4 21Physics 4 21
Physics 4 21
 
Hémodynamique doppler
Hémodynamique dopplerHémodynamique doppler
Hémodynamique doppler
 
Where did Equity Improve
Where did Equity ImproveWhere did Equity Improve
Where did Equity Improve
 
Mitral regurgitation
Mitral regurgitationMitral regurgitation
Mitral regurgitation
 
Apa itu PISA
Apa itu PISAApa itu PISA
Apa itu PISA
 
Anatomy of mitral valve echo evaluation
Anatomy of mitral valve echo evaluationAnatomy of mitral valve echo evaluation
Anatomy of mitral valve echo evaluation
 
Education in China - a Snapshot
Education in China - a SnapshotEducation in China - a Snapshot
Education in China - a Snapshot
 
Status pencapaian malaysia dalam timss dan pisa
Status pencapaian malaysia dalam timss dan pisaStatus pencapaian malaysia dalam timss dan pisa
Status pencapaian malaysia dalam timss dan pisa
 
Alcohol
AlcoholAlcohol
Alcohol
 
TIMMS DAN PISA
TIMMS DAN PISATIMMS DAN PISA
TIMMS DAN PISA
 
Mitral valve regurgitation
Mitral valve regurgitationMitral valve regurgitation
Mitral valve regurgitation
 

Similaire à Pisa ppt

Basic concepts of valvular regurgitation-Echocardiography
Basic concepts of valvular regurgitation-EchocardiographyBasic concepts of valvular regurgitation-Echocardiography
Basic concepts of valvular regurgitation-EchocardiographyVinayak Vadgaonkar
 
Hemodynamic assessment in cardiology
Hemodynamic assessment in cardiologyHemodynamic assessment in cardiology
Hemodynamic assessment in cardiologySujit Sahu
 
Flowvolumefinalversion
FlowvolumefinalversionFlowvolumefinalversion
FlowvolumefinalversionDuoc Vang
 
Shunt quantification
Shunt quantificationShunt quantification
Shunt quantificationAnkur Gupta
 
Echocardiography assessment of Aortic Regurgitation severity
Echocardiography assessment of Aortic Regurgitation severityEchocardiography assessment of Aortic Regurgitation severity
Echocardiography assessment of Aortic Regurgitation severityPRAVEEN GUPTA
 
Hemodynamics in echo lab by Dr. Ranjeet S.Palkar
Hemodynamics  in echo lab by Dr. Ranjeet S.PalkarHemodynamics  in echo lab by Dr. Ranjeet S.Palkar
Hemodynamics in echo lab by Dr. Ranjeet S.PalkarRanjeet Palkar
 
Basics Of CXR interpretation www.radiologydefinition.com
Basics Of CXR interpretation   www.radiologydefinition.comBasics Of CXR interpretation   www.radiologydefinition.com
Basics Of CXR interpretation www.radiologydefinition.comRadiology Definition
 
Tissue doppler imaging
Tissue doppler imagingTissue doppler imaging
Tissue doppler imagingFuad Farooq
 
Basics in echocardiography - an initiative in evaluation of valvular heart di...
Basics in echocardiography - an initiative in evaluation of valvular heart di...Basics in echocardiography - an initiative in evaluation of valvular heart di...
Basics in echocardiography - an initiative in evaluation of valvular heart di...Praveen Nagula
 
Two dimensional echocardiography
Two dimensional echocardiographyTwo dimensional echocardiography
Two dimensional echocardiographyDung le Huu
 
Doppler Hemodynamics with hepatic doppler
Doppler Hemodynamics with hepatic dopplerDoppler Hemodynamics with hepatic doppler
Doppler Hemodynamics with hepatic dopplerDr Varun Bansal
 
Echo assessment of aortic valve disease
Echo assessment of aortic valve diseaseEcho assessment of aortic valve disease
Echo assessment of aortic valve diseaseNizam Uddin
 
How to echo series....Aortic stenosis 2017 guidelines
How to echo series....Aortic stenosis 2017 guidelinesHow to echo series....Aortic stenosis 2017 guidelines
How to echo series....Aortic stenosis 2017 guidelinesVinayak Vadgaonkar
 
Echo assessment of Aortic Stenosis
Echo assessment of Aortic StenosisEcho assessment of Aortic Stenosis
Echo assessment of Aortic Stenosisdrranjithmp
 

Similaire à Pisa ppt (20)

MR Tawfeeq.pptx
MR Tawfeeq.pptxMR Tawfeeq.pptx
MR Tawfeeq.pptx
 
Basic concepts of valvular regurgitation-Echocardiography
Basic concepts of valvular regurgitation-EchocardiographyBasic concepts of valvular regurgitation-Echocardiography
Basic concepts of valvular regurgitation-Echocardiography
 
Hemodynamic assessment in cardiology
Hemodynamic assessment in cardiologyHemodynamic assessment in cardiology
Hemodynamic assessment in cardiology
 
Flowvolumefinalversion
FlowvolumefinalversionFlowvolumefinalversion
Flowvolumefinalversion
 
Shunt quantification
Shunt quantificationShunt quantification
Shunt quantification
 
Echocardiography assessment of Aortic Regurgitation severity
Echocardiography assessment of Aortic Regurgitation severityEchocardiography assessment of Aortic Regurgitation severity
Echocardiography assessment of Aortic Regurgitation severity
 
Hemodynamics in echo lab by Dr. Ranjeet S.Palkar
Hemodynamics  in echo lab by Dr. Ranjeet S.PalkarHemodynamics  in echo lab by Dr. Ranjeet S.Palkar
Hemodynamics in echo lab by Dr. Ranjeet S.Palkar
 
Basics Of CXR interpretation www.radiologydefinition.com
Basics Of CXR interpretation   www.radiologydefinition.comBasics Of CXR interpretation   www.radiologydefinition.com
Basics Of CXR interpretation www.radiologydefinition.com
 
Tissue doppler imaging
Tissue doppler imagingTissue doppler imaging
Tissue doppler imaging
 
Basics in echocardiography - an initiative in evaluation of valvular heart di...
Basics in echocardiography - an initiative in evaluation of valvular heart di...Basics in echocardiography - an initiative in evaluation of valvular heart di...
Basics in echocardiography - an initiative in evaluation of valvular heart di...
 
Lesson 15 pappus theorem
Lesson 15 pappus theoremLesson 15 pappus theorem
Lesson 15 pappus theorem
 
Two dimensional echocardiography
Two dimensional echocardiographyTwo dimensional echocardiography
Two dimensional echocardiography
 
Cut Flow.Doc
Cut Flow.DocCut Flow.Doc
Cut Flow.Doc
 
Doppler Hemodynamics with hepatic doppler
Doppler Hemodynamics with hepatic dopplerDoppler Hemodynamics with hepatic doppler
Doppler Hemodynamics with hepatic doppler
 
Echo assessment of aortic valve disease
Echo assessment of aortic valve diseaseEcho assessment of aortic valve disease
Echo assessment of aortic valve disease
 
Haemodynamic monitoring
Haemodynamic monitoringHaemodynamic monitoring
Haemodynamic monitoring
 
How to echo series....Aortic stenosis 2017 guidelines
How to echo series....Aortic stenosis 2017 guidelinesHow to echo series....Aortic stenosis 2017 guidelines
How to echo series....Aortic stenosis 2017 guidelines
 
Aortic_Stenosis
Aortic_Stenosis Aortic_Stenosis
Aortic_Stenosis
 
Cardiac Anatomy_20120916_南區
Cardiac Anatomy_20120916_南區Cardiac Anatomy_20120916_南區
Cardiac Anatomy_20120916_南區
 
Echo assessment of Aortic Stenosis
Echo assessment of Aortic StenosisEcho assessment of Aortic Stenosis
Echo assessment of Aortic Stenosis
 

Plus de Fuad Farooq

Cardiology 2019 trial and meta analysis
Cardiology 2019 trial and meta analysisCardiology 2019 trial and meta analysis
Cardiology 2019 trial and meta analysisFuad Farooq
 
Heart failure / cardiac failure
Heart failure / cardiac failureHeart failure / cardiac failure
Heart failure / cardiac failureFuad Farooq
 
Eisenmenger syndrome
Eisenmenger syndromeEisenmenger syndrome
Eisenmenger syndromeFuad Farooq
 
Mechanism of arrythmias
Mechanism of arrythmiasMechanism of arrythmias
Mechanism of arrythmiasFuad Farooq
 
Electrocardiogaram - ECG EKG
Electrocardiogaram - ECG EKGElectrocardiogaram - ECG EKG
Electrocardiogaram - ECG EKGFuad Farooq
 
Angiographic projections
Angiographic projectionsAngiographic projections
Angiographic projectionsFuad Farooq
 
Intracardiac shunts
Intracardiac shuntsIntracardiac shunts
Intracardiac shuntsFuad Farooq
 
Precath preparation
Precath preparationPrecath preparation
Precath preparationFuad Farooq
 
Lesion complexity
Lesion complexityLesion complexity
Lesion complexityFuad Farooq
 
Coronary artery spasm
Coronary artery spasmCoronary artery spasm
Coronary artery spasmFuad Farooq
 
Coronary artery dissection and perforation
Coronary artery dissection and perforationCoronary artery dissection and perforation
Coronary artery dissection and perforationFuad Farooq
 
Cardiac cath complications
Cardiac cath complicationsCardiac cath complications
Cardiac cath complicationsFuad Farooq
 
Stress echocardiography
Stress echocardiographyStress echocardiography
Stress echocardiographyFuad Farooq
 
Infective endocarditis and heart masses
Infective endocarditis and heart massesInfective endocarditis and heart masses
Infective endocarditis and heart massesFuad Farooq
 
Diseases of the aorta
Diseases of the aortaDiseases of the aorta
Diseases of the aortaFuad Farooq
 
Finaale pulmonary stenosis
Finaale pulmonary stenosisFinaale pulmonary stenosis
Finaale pulmonary stenosisFuad Farooq
 
Echo assessment of lv systolic function and swma
Echo assessment of lv systolic function and swmaEcho assessment of lv systolic function and swma
Echo assessment of lv systolic function and swmaFuad Farooq
 
Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathyHypertrophic cardiomyopathy
Hypertrophic cardiomyopathyFuad Farooq
 

Plus de Fuad Farooq (20)

Cardiology 2019 trial and meta analysis
Cardiology 2019 trial and meta analysisCardiology 2019 trial and meta analysis
Cardiology 2019 trial and meta analysis
 
Heart failure / cardiac failure
Heart failure / cardiac failureHeart failure / cardiac failure
Heart failure / cardiac failure
 
Hypertension
HypertensionHypertension
Hypertension
 
Eisenmenger syndrome
Eisenmenger syndromeEisenmenger syndrome
Eisenmenger syndrome
 
Mechanism of arrythmias
Mechanism of arrythmiasMechanism of arrythmias
Mechanism of arrythmias
 
Electrocardiogaram - ECG EKG
Electrocardiogaram - ECG EKGElectrocardiogaram - ECG EKG
Electrocardiogaram - ECG EKG
 
Angiographic projections
Angiographic projectionsAngiographic projections
Angiographic projections
 
Intracardiac shunts
Intracardiac shuntsIntracardiac shunts
Intracardiac shunts
 
Precath preparation
Precath preparationPrecath preparation
Precath preparation
 
Lesion complexity
Lesion complexityLesion complexity
Lesion complexity
 
Coronary artery spasm
Coronary artery spasmCoronary artery spasm
Coronary artery spasm
 
Coronary artery dissection and perforation
Coronary artery dissection and perforationCoronary artery dissection and perforation
Coronary artery dissection and perforation
 
Cardiac cath complications
Cardiac cath complicationsCardiac cath complications
Cardiac cath complications
 
Stress echocardiography
Stress echocardiographyStress echocardiography
Stress echocardiography
 
Infective endocarditis and heart masses
Infective endocarditis and heart massesInfective endocarditis and heart masses
Infective endocarditis and heart masses
 
Diseases of the aorta
Diseases of the aortaDiseases of the aorta
Diseases of the aorta
 
Aortic stenosis
Aortic stenosisAortic stenosis
Aortic stenosis
 
Finaale pulmonary stenosis
Finaale pulmonary stenosisFinaale pulmonary stenosis
Finaale pulmonary stenosis
 
Echo assessment of lv systolic function and swma
Echo assessment of lv systolic function and swmaEcho assessment of lv systolic function and swma
Echo assessment of lv systolic function and swma
 
Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathyHypertrophic cardiomyopathy
Hypertrophic cardiomyopathy
 

Pisa ppt

  • 2.  Regurgitant volumes can be estimated by 2Regurgitant volumes can be estimated by 2 methodsmethods  Volumetric methodVolumetric method  PISA methodPISA method  As we knowAs we know  Flow rate = CSA x VelocityFlow rate = CSA x Velocity  Volume = CSA x TVIVolume = CSA x TVI
  • 3.  If regurgitant orifice area is known thenIf regurgitant orifice area is known then reguritant volume can be estimated as thereguritant volume can be estimated as the product of effective regurgitant orifice areaproduct of effective regurgitant orifice area (ERO) and regurgitant TVI(ERO) and regurgitant TVI  To estimate ERO, Proximal isovelocity surfaceTo estimate ERO, Proximal isovelocity surface area is usedarea is used RV = ERO x Regurgitant TVIRV = ERO x Regurgitant TVI
  • 4.  As blood flow converges towards the regurgitantAs blood flow converges towards the regurgitant orifice, blood flow velocity increases withorifice, blood flow velocity increases with formation of multiple shells of isovelocity offormation of multiple shells of isovelocity of hemispheric shapehemispheric shape  Remember that velocity of the shell closest toRemember that velocity of the shell closest to the regurgitant orifice is highest and vice versathe regurgitant orifice is highest and vice versa  The flow rate at the surface of a hemisphericThe flow rate at the surface of a hemispheric shell with the same flow velocity is consideredshell with the same flow velocity is considered equal to the flow rate across the regurgitantequal to the flow rate across the regurgitant orifice according to the law of conservation oforifice according to the law of conservation of flow which states thatflow which states that ““What comes in must go out”What comes in must go out”
  • 5.  By adjusting the Nyquist limit of the color flow map, theBy adjusting the Nyquist limit of the color flow map, the flow velocity of a hemispheric surface proximal to theflow velocity of a hemispheric surface proximal to the regurgitant orifice can be determinedregurgitant orifice can be determined  For e.g. in MR the regurgitant flow travels away from theFor e.g. in MR the regurgitant flow travels away from the position of the apical transducer ans so the bloodposition of the apical transducer ans so the blood converging towards the mitral regurgitant orifice in theconverging towards the mitral regurgitant orifice in the LV is color coded blue until the velocity reaches theLV is color coded blue until the velocity reaches the negative aliasing velocity of the selected color flow map,negative aliasing velocity of the selected color flow map, at which time the flow will change color to light orange-at which time the flow will change color to light orange- redred  If the negative aliasing velocity of the color map isIf the negative aliasing velocity of the color map is reduced further, the trasition from blue to orange-red willreduced further, the trasition from blue to orange-red will occur farther from the regurgitant orifice providing aoccur farther from the regurgitant orifice providing a larger hemispheric shell radiuslarger hemispheric shell radius
  • 6.  After a hemisphere with blood flow of isovelocityAfter a hemisphere with blood flow of isovelocity is identified the flow rate through thisis identified the flow rate through this hemispheric shell is determined byhemispheric shell is determined by Flow rate = CSA x VelocityFlow rate = CSA x Velocity Area of hemispheric shell = 2Area of hemispheric shell = 2ππr², where pie=3.14r², where pie=3.14 Flow rate = 6.28 x r² x Aliasing velocity (from color map)Flow rate = 6.28 x r² x Aliasing velocity (from color map)
  • 7.  As we have already discussed the flow rate atAs we have already discussed the flow rate at the surface of a hemispheric shell with the samethe surface of a hemispheric shell with the same flow velocity is considered equal to the flow rateflow velocity is considered equal to the flow rate across the regurgitant orifice according to theacross the regurgitant orifice according to the law of conservation of flowlaw of conservation of flow  Therefore, this flow across PISA is equal to flowTherefore, this flow across PISA is equal to flow rate across EROrate across ERO Flow rate = ERO x regurgitant velocityFlow rate = ERO x regurgitant velocity ERO = flow rate / peak MR velocityERO = flow rate / peak MR velocity ERO = 6.28 x r² x Aliasing velocity / MR velocityERO = 6.28 x r² x Aliasing velocity / MR velocity
  • 8.  Regurgitant Volume = ERO x MR TVIRegurgitant Volume = ERO x MR TVI Substituting value of ERO we getSubstituting value of ERO we get Regurg Vol = 6.28 x r² xRegurg Vol = 6.28 x r² x Aliasing velocityAliasing velocity x MRTVIx MRTVI MR velocityMR velocity
  • 9.  The concept of PISA can also be applied toThe concept of PISA can also be applied to calculate the area of stenotic surfaces and hascalculate the area of stenotic surfaces and has been validated for MV area in patients with mitralbeen validated for MV area in patients with mitral stenosisstenosis
  • 10. CaveatsCaveats  Proximal to a stenotic mitral orifice, PISA mayProximal to a stenotic mitral orifice, PISA may not be a complete hemisphere but a portion ofnot be a complete hemisphere but a portion of hemisphere because of mitral leaflets geometryhemisphere because of mitral leaflets geometry on the atrial sideon the atrial side  In such cases an angle correction factor isIn such cases an angle correction factor is appliedapplied MVA = 6.28 x r² xMVA = 6.28 x r² x Aliasing velocityAliasing velocity xx alphaalpha°° Peak MS velocity 180Peak MS velocity 180°° Where alpha is the angle between two mitral leaflets on the atrial sideWhere alpha is the angle between two mitral leaflets on the atrial side
  • 11.  Sometimes it is difficult to know in which direction theSometimes it is difficult to know in which direction the baseline should be shifted for optimal PISAbaseline should be shifted for optimal PISA  For this rule of the thumb is to shift the baseline inFor this rule of the thumb is to shift the baseline in the direction of the flow jet of interestthe direction of the flow jet of interest  PISA radius needs to be measured at the same time asPISA radius needs to be measured at the same time as the peak velocity of the jetthe peak velocity of the jet  Color M-mode can help in measuring the radiusColor M-mode can help in measuring the radius reliably at the correct timereliably at the correct time
  • 12. Measuring PISAMeasuring PISA  PISA is Proximal Isovelocity Surface AreaPISA is Proximal Isovelocity Surface Area  It is larger in large volume jets and smaller inIt is larger in large volume jets and smaller in small volume jetssmall volume jets  It also will change its size depending on theIt also will change its size depending on the color Doppler scale factorcolor Doppler scale factor
  • 13.  PISA is just one of many ways to calculatePISA is just one of many ways to calculate severity of MRseverity of MR
  • 14.  There are four hallmarks of flow in mitralfour hallmarks of flow in mitral regurgitation:regurgitation:  Flow convergenceFlow convergence that then narrows into anthat then narrows into an area ofarea of accelarated flowaccelarated flow (narrowest area of(narrowest area of flow) and then expands into the area offlow) and then expands into the area of turbulence (what we currently call theturbulence (what we currently call the size ofsize of the jetthe jet))  We also can see the downstream effects likeWe also can see the downstream effects like pulmonary vein flow reversalpulmonary vein flow reversal in systolein systole
  • 16.  So the hallmark flow areas on a diagram ofSo the hallmark flow areas on a diagram of mitral regurgitationmitral regurgitation
  • 17.  The PISA can be seen on this TEE MR jetThe PISA can be seen on this TEE MR jet
  • 18.  And the vena contracta can be seen on thisAnd the vena contracta can be seen on this same jetsame jet
  • 19.  The area of flow convergence is where we lookThe area of flow convergence is where we look for PISAfor PISA  There are many concentric flow velocity shellsThere are many concentric flow velocity shells as flow accelerates into the vena contractaas flow accelerates into the vena contracta
  • 20.  Calculation of PISA requires us to find one ofCalculation of PISA requires us to find one of these shells and then calculate its surface areathese shells and then calculate its surface area  This takes a lot of faith and skillThis takes a lot of faith and skill  It is almost always done from an apical viewIt is almost always done from an apical view
  • 21.  One thing to remember is that PISA (as well asOne thing to remember is that PISA (as well as the other hallmark areas) will be larger in largethe other hallmark areas) will be larger in large degrees of mitral regurgitationdegrees of mitral regurgitation
  • 23.  Every MR jet has a flow convergence area and,Every MR jet has a flow convergence area and, therefore, a PISA of the jettherefore, a PISA of the jet
  • 24.  PISA looks at the flow convergencePISA looks at the flow convergence
  • 25.  Keep in mind, flow is always the area x theKeep in mind, flow is always the area x the velocityvelocity  We already know this from the continuityWe already know this from the continuity equation and in Doppler calculations of cardiacequation and in Doppler calculations of cardiac outputoutput
  • 26.  But we can’t clearly see the orifice, so for PISABut we can’t clearly see the orifice, so for PISA we will look prior to the orificewe will look prior to the orifice  We will look at one of the isovelocity shellsWe will look at one of the isovelocity shells
  • 27.  Here area of the shell x velocity of the shellHere area of the shell x velocity of the shell equals flowequals flow  By the continuity equation, this flow should beBy the continuity equation, this flow should be exactly that of the flow at the regurgitant orificeexactly that of the flow at the regurgitant orifice
  • 28.  So find a velocity shell and move the scale factorSo find a velocity shell and move the scale factor to help you identify itto help you identify it
  • 29. Meaning of scale factorMeaning of scale factor  The use of the scale factor just helps us identifyThe use of the scale factor just helps us identify a suitable isovelocity shell for measurementa suitable isovelocity shell for measurement  Then we can use it to calculate flowThen we can use it to calculate flow
  • 30.  Note the PISA get larger in this MR jet. The jet atNote the PISA get larger in this MR jet. The jet at the right is the same as on the left, the only thingthe right is the same as on the left, the only thing changed is the scale factorchanged is the scale factor
  • 31.  Here is a larger depiction of the previous jetsHere is a larger depiction of the previous jets
  • 32.  Moving the scale factor down will make the shellMoving the scale factor down will make the shell bigger and easier to identify.bigger and easier to identify.  So, now we have the shell and can read theSo, now we have the shell and can read the velocityvelocity
  • 33.  Since we have the shell, measuring the radiusSince we have the shell, measuring the radius will allow you to calculate the area of the shell orwill allow you to calculate the area of the shell or PISAPISA
  • 34.  If we multiply the area x velocity we will get theIf we multiply the area x velocity we will get the flowflow
  • 35.  So rememberSo remember
  • 36. LimitationsLimitations  The biggest limitation of PISA is the incorrectThe biggest limitation of PISA is the incorrect identification of the proximal flow convergenceidentification of the proximal flow convergence areaarea
  • 37.  Here is an example of an area where the flowHere is an example of an area where the flow convergence is not symmetricconvergence is not symmetric
  • 38.  This is an example of a perforated mitral leafletThis is an example of a perforated mitral leaflet from the TEE approach (left)from the TEE approach (left)  Note the asymmetric flow convergence areaNote the asymmetric flow convergence area  This is a limitation of PISAThis is a limitation of PISA
  • 39.  So we worry about non-optimal flowSo we worry about non-optimal flow convergence and changes in the PISA over timeconvergence and changes in the PISA over time (the cardiac cycle)(the cardiac cycle)
  • 40.  Note the changes in size over the cardiac cycleNote the changes in size over the cardiac cycle
  • 41.  So PISA has limitationsSo PISA has limitations  Different textbooks have given the ranges ofDifferent textbooks have given the ranges of values but keep in mind, big is big and small isvalues but keep in mind, big is big and small is smallsmall