Calculate EROA and regurgitant volume using the PISA method for valvular regurgitation assessment. Grade mitral, aortic, and tricuspid regurgitation severity.
The Proximal Isovelocity Surface Area (PISA) method is a quantitative echocardiographic technique used to assess the severity of valvular regurgitation. By measuring the flow convergence zone proximal to a regurgitant orifice, clinicians can calculate the Effective Regurgitant Orifice Area (EROA) and regurgitant volume — key parameters for grading regurgitation severity.
The PISA method is based on the principle of conservation of mass: as blood accelerates toward a regurgitant orifice, it forms concentric hemispheric shells of increasing velocity. At the aliasing boundary visible on color Doppler, the velocity equals the Nyquist limit, and the radius of this hemisphere can be measured to calculate instantaneous flow rate.
This calculator applies the standard PISA formula to compute flow rate, EROA, and regurgitant volume for mitral, aortic, and tricuspid valves. Results are graded according to ASE/ACC guidelines for regurgitation severity. While PISA is most validated for mitral regurgitation with a circular orifice, it is widely used across all valves with appropriate clinical judgment.
The PISA method provides a quantitative, reproducible assessment of regurgitation severity that goes beyond subjective color jet area. Accurate grading is critical for surgical decision-making — severe mitral regurgitation may warrant repair or replacement, while mild-to-moderate regurgitation is typically managed conservatively. This calculator streamlines the multi-step PISA computation and applies current guideline criteria.
PISA Flow Rate = 2π × r² × Va (mL/s) EROA = PISA Flow Rate ÷ Peak Regurgitant Velocity (cm²) Regurgitant Volume = EROA × Regurgitant VTI (mL) Where r = PISA radius (cm), Va = aliasing velocity (cm/s)
Result: EROA = 0.41 cm², Regurgitant Volume = 61 mL — Severe mitral regurgitation
With PISA radius 0.9 cm and aliasing velocity 40 cm/s, PISA flow = 2π × 0.81 × 40 = 203.6 mL/s. EROA = 203.6 ÷ 500 = 0.41 cm². Regurgitant volume = 0.41 × 150 = 61 mL. Both EROA ≥ 0.40 and RVol ≥ 60 indicate severe MR.
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PISA stands for Proximal Isovelocity Surface Area. It is a method of quantifying regurgitant flow by measuring the hemispheric convergence zone on color Doppler imaging proximal to a regurgitant orifice.
PISA is well-validated for mitral regurgitation with circular orifices and correlates well with cardiac MRI. Accuracy decreases with eccentric jets, non-circular orifices, or when the convergence zone is not truly hemispheric.
Effective Regurgitant Orifice Area is the cross-sectional area of the regurgitant orifice through which blood flows backward. It is the single best quantitative parameter for grading regurgitation severity.
PISA is recommended as a primary quantitative method for mitral regurgitation. For aortic regurgitation, use pressure half-time and holodiastolic flow reversal. PISA can supplement any valve assessment.
Shift the color Doppler baseline to achieve aliasing at 30–40 cm/s. This creates a well-defined hemispheric convergence zone. Lower velocities produce larger, easier-to-measure hemispheres.
Limitations include: assumption of a hemispheric convergence zone (may be constrained by walls), assumption of a circular orifice (may be crescentic in functional MR), difficulty measuring when the jet is eccentric, and flow entrainment artifacts. Use this as a practical reminder before finalizing the result.