The added value of 3D to quantify the severity of functional mitral regurgitation

by Sorina Mihaila1,2, MD, PhD; Patrizia Aruta1, MD; Denisa Muraru1, MD, PhD
1Department of cardiac, thoracic and vascular sciences, University of Padua, School of Medicine, Padua, Italy
2University of Medicine and Pharmacy “Carol Davila” Bucharest, Romania

Clinical Case

  • Male, 70 yrs old
  • Dilated cardiomyopathy with moderate impairment of the LV systolic function
  • Symptoms of heart failure on admission
  • Referred to the echo laboratory for the quantitation of the severity of functional mitral regurgitation

2D color Doppler echocardiography from 4-chamber view showed functional mitral regurgitation jet.

2D color echocardiography from 2-chamber view, showed a wider origin of the central mitral regurgitation jet

Spectral CW Doppler tracing of mitral regurgitation flow. The VTI was used for the calculation of mitral regurgitation orifice area by PISA method

Conventional 2D PISA analysis showing a flat PISA shell. Effective regurgitant orifice area (EROA) and regurgitant volume calculations corresponded to a MODERATE functional mitral regurgitation

Color M-Mode tracing showed a holosystolic mitral regurgitation, suggesting severe functional mitral regurgitation

Real-time 3D full-volume, color Doppler acquisition of the regurgitant jet (Acuson SC2000, Siemens, CA ) recorded with baseline shift set at 37 cm/sec. 3D PISA analysis (eSie PISA, Siemens, CA) allowed the measurement of the actual volume of the PISA shell, independent on assumptions about its shape, which was then used for the calculation of EROA and regurgitant volume.

The 3D volume of the PISA shell can be both visualized and measured in all systolic frames.

The 3D PISA shell seems round from above

Longitudinal view of the 3D PISA shell showed its flat morphology which provided a small PISA radius

Quantitative analysis of mitral regurgitation using 3D PISA resulted in an EROA greater than 0.20 cm2 in all the 5 frames of the regurgitant period (0.40, 0.38, 0.34, 0.33, and 0.36 cm2), corresponding to a severe functional mitral regurgitation which was more correspondent to the overall impression obtained from multiparametric echo/Doppler assessment

Key Messages

2D/Doppler echocardiography:

  • The formula for the EROA calculation assumes that PISA shell is always hemi-spheric and the regurgitant orifice is rounded
  • In functional mitral regurgitation the PISA shell is often flat, with a small radius (mainly due to the elevated left ventricular filling pressures), and the regurgitant orifice is frequently slit-like or crescentic. Both characteristics result in a significant underestimation of the actual regurgitant orifice area

3D echocardiography:

  • Allowed real-time measurement of the actual volume of the PISA shell withoou assumptions about its shape, in each frame of the regurgitant jet
  • The regurgitant orifice area calculated by this method allowed to overcome the limitations of conventional 2D/Doppler echocardiography and to re-classify the severity of the functional mitral regurgitation in our patient with better agreement betweeen quantitative and semiquantitative/qualitative parameters


  • Lancellotti P, Moura L, Pierard LA, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology. 2010;11(4):307-32.
  • Thavendiranathan P, Liu S, Datta S, et al. Quantification of chronic functional mitral regurgitation by automated 3-dimensional peak and integrated proximal isovelocity surface area and stroke volume techniques using real-time 3-dimensional volume color Doppler echocardiography: in vitro and clinical validation. Circulation Cardiovascular imaging. 2013;6(1):125-33.

Dr Sorina Mihaila, MD, PhD, Assistant Professor


Dr. Sorina Mihaila is a young cardiologist working in the Emergency and University Hospital of Bucharest, Romania, at present member of the EACVI Club 35 Committee.

Winner of an EACVI Research Grant on 2012 and an ESC Training Grant in 2014, she was trained in the field of three-dimensional echocardiography in Padova, Italy.
Areas of interest: mitral annulus dynamics and function, mitral valve disease, tricuspid regurgitation.