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2D Features of MR
LA & LV enlargement
Thickened leaflets
Domed/stenotic leaflets (decreased movement or flailing)

Regurgitant Jet Area (RJA) of MR
Best measured in apical view
Mild MR RJA
< 20% of LA area

Severe MR RJA
> 50% of LA area

Vena Contracta
Narrowest cross-sectional area of regurgitant jet in color Doppler
Located just after then regurgitant orifice (ERO)
Measuring Vena Contracta Width (VCW)
Zoomed in PLAX (or apical 4 chamber if needed) - NEVER use apical 2 chamber
Should see convergence, neck, and MR jet in image
Measure the width of the neck/narrowest diameter of the jet

Mild MR VCW
< 0.3 cm
Severe MR VCW
≥ 0.7 cm
Mild MR Doppler Features
Faint, soft, or incomplete jet
Peaks at mid-cycle

Moderate MR Doppler Features
Somewhat bright signal with dense areas
Parabolic-shaped

Severe MR Doppler Features
Bright, dense signal
Triangular-shaped

Normal Pulmonary Vein Doppler Flow

Pulmonary Vein Features of Mild MR
Dominant A-wave inflow pattern
Pulmonary Vein Features of Severe MR
Flow reversal in systole
> 1 pulmonary vein contains flow reversal (look at all 4)

Proximal Isovelocity Surface Area (PISA)
Measures effective regurgitant orifice area (EROA) and calculates the volume of blood being regurgitated
Uses the area of color flow convergence
How to Measure PISA for MR
Zoomed apical 4 chamber view
Lower Nyquist limit (30-40 cm/s)
Measure convergence radius - must be hemisphere/circular
Measure MR VTI & peak velocity

PISA Radius of Severe MR
> 1 cm
Limitations of PISA
Multiple jets - can't use if more than 1 jet
Poor sphere convergence
Eccentric jet
Measuring radius at the same point in cardiac cycle as peak MR velocity
MR must be holosystolic
Accompanying AI can cause measurement problems
Unit conversions (should be automatic on machine)
Regurgitant Fraction
Only use if PISA can't differentiate severity
Compares stroke volume of MV annulus to LVOT flow
Regurgitant Fraction for Mild MR
< 30%
Regurgitant Fraction for Severe MR
≥ 50%
Advantages of Regurgitant Fraction
Can assess multiple & eccentric jets
Pressure Changes with MR
Increased LA pressure
Decreased LV pressure
