title: Reproducibility of proximal isovelocity surface area, vena contracta, and regurgitant jet area for assessment of mitral regurgitation severity.
abstract: OBJECTIVE
  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 > or =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.
authors.affiliation: Division of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
authors.forename: Simon
authors.initials: S
authors.lastname: Biner
authors.forename: Asim
authors.initials: A
authors.lastname: Rafique
authors.forename: Farhad
authors.initials: F
authors.lastname: Rafii
authors.forename: Kirsten
authors.initials: K
authors.lastname: Tolstrup
authors.forename: Omid
authors.initials: O
authors.lastname: Noorani
authors.forename: Takahiro
authors.initials: T
authors.lastname: Shiota
authors.forename: Swaminatha
authors.initials: S
authors.lastname: Gurudevan
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Siegel
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D018618:Echocardiography, Doppler, Color; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007557:Israel; D007564:Japan; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging* / Q000503:physiopathology; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D009200:Myocardial Contraction; D015588:Observer Variation; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D014481:United States