The dynamic assessment of right-ventricular function and its relation to exercise capacity in heart failure.

AIMS: To evaluate right-ventricular (RV) function during stress echocardiography (SE) and to assess its relationship with exercise capacity in heart failure (HF) patients. METHODS AND RESULTS: We included 88 patients aged 60.9 +/- 11.2 years with a mean LVEF of 27.2 +/- 9.5%. The following RV parameters were measured at baseline and peak exercise during semi-supine SE: velocity (IVV) and acceleration during isovolumic contraction (IVA), S', E', A', and ratio of early diastolic tricuspid velocity to E' (E/E') and longitudinal strain and strain rate. Patients were stratified into two groups according to their VO(2peak) values: group 1 (n = 35) with VO(2peak) <14 mL/kg/min and group 2 (n = 53) with VO(2peak) >or=14 mL/kg/min. At rest, all analysed variables were similar in the two groups, but during stress IVV, S', and E' were significantly higher and the E/E' ratio significantly lower in group 2. In broad terms, parameters measured at stress correlated much better with VO(2peak) than parameters assessed at baseline. However, results of multivariable analysis determined that the independent predictors of VO(2peak) were solely the left-ventricular (LV) parameters: E/E' and S'. CONCLUSIONS: Right-ventricular function (whether at rest or during stress tests) was not significantly associated with exercise capacity in our patients with HF. In contrast, systolic and, to a greater extent, diastolic LV parameters during the stress tests emerged as the most important indicators linked to exercise capacity in HF.

The role of carotid intima-media thickness assessment in cardiovascular risk evaluation in patients with polyvascular atherosclerosis.

UNLABELLED: In populational studies, carotid intima-media thickness (CIMT) is a valuable tool in the evaluation of cardiovascular (CV) risk. However, there is not much evidence on the relation between CIMT, and CV events in patients who have already undergone revascularization procedures. AIM: To evaluate the relationship between CIMT, atherosclerosis extent and CV event rates in patients with established atherosclerosis. METHODS AND RESULTS: Baseline mean-CIMT was assessed in 652 patients, including 195; 191; 112; 29 with angiographic arterial stenosis >or=50% in 1; 2; 3 or 4 territories (coronary, supraaortic, renal and/or lower limb arteries), who underwent revascularization procedure in >or=1 arterial territory, and in 125 control subjects without significant lesions. For CIMT >or=1.25mm (>or=3rd quartile), the sensitivity and specificity of >or=2-territory involvement were 81.6% and 81.9%. CV events occurred in 91(14%) subjects. The Kaplan-Meier 2-year CV event-free survival was 95.6%; 93.1%; 83.8%; 77% in patients with mean-CIMT values in the 1st; 2nd; 3rd and 4th quartile. The independent CV adverse event predictors identified in the multivariate Cox proportional hazard model were: mean-CIMT >or=1.25mm (RR=2.52; CI=1.5-4.24; p=0.001); hs-CRP (RR=1.02; CI=1.0-1.03; p=0.011), claudication (RR=1.58; CI=0.98-2.57; p=0.062), accumulation of >or=4 traditional risk factors (RR=2.02; CI=1.31-3.12; p=0.002), 2-3-vessel coronary artery disease (RR=1.95; CI=1.21-3.14; p=0.006). Inclusion of CIMT into the stratification model significantly improved the prediction of CV event risk (DeltaChi(2)=13.27, p=0.0003). CONCLUSIONS: In patients undergoing revascularization procedure(s), CIMT has an important and independent contribution to further CV risk stratification. The mean-CIMT value >or=1.25mm is associated with 2.5-fold increased risk of adverse CV events.

Assessment of resting perfusion defect in patients with acute myocardial infarction: comparison of myocardial contrast echocardiography with contrast-enhanced magnetic resonance imaging.

BACKGROUND: Contrast-enhanced magnetic resonance imaging (CE-MRI) can identify myocardial scarring following acute myocardial infarction (AMI). AIM: To compare myocardial contrast echocardiography (MCE) and CE-MRI in detection of resting perfusion defect in patients with acute myocardial infarction. METHODS: Twenty four patients (21 men, 3 women, mean age 58.7 +/- 11.4 years) underwent primary percutaneous coronary angioplasty (PCI) for anterior AMI. All patients underwent MCE: segmental perfusion was estimated in real time before and immediately after PCI and on third day after PCI, using low mechanical index (0.3) after 0.3-0.5 ml bolus injections of intravenous OptisonTM. The MCE was scored semiquantitatively as: 1--homogenous contrast enhancement, 2--patchy contrast enhancement, 3--no contrast (non-viable myocardium). All patients underwent CE-MRI on a 1.5 T scanner (SONATA, Siemens) on the third day after PCI. Acquisition of short axis slices was performed before and 20 min after injection of Gd-DPTA (0.15 mmol/kg) with an inversion recovery TurboFLASH sequence (TE 1.1 ms, TR 700 ms, flip angle 300) in multiple breath-holds. The pattern of hyperenhancement representing MI (which intensity was more than 150% intensity of myocardium) was quantified by planimetry. The CE-MRI was scored according to the severity of myocardial scar as: 1--without scar, 2-- <50% of myocardial thickness, 3 - > 50% of myocardial thickness. RESULTS: Myocardial perfusion was analysed using MCE and contrast-enhanced MRI in 362 segments. Agreement between MCE and CE-MRI for identification of viable versus necrotic myocardium on third day after PCI was 86% (kappa = 0.73). Thirteen (54%) patients showed transmural necrosis at CE-MRI while 11 (46%) showed non-transmural necrosis. Patients from the transmural necrosis group showed a higher creatine kinase peak (p = 0.0001), higher CK-MB (p = 0.00002) and higher troponine level (p = 0.008), and more impaired baseline regional contractile function (p = 0.045). All angiographic parameters were less favourable in this group before as well as after PCI than in patients with non-transmural necrosis. CONCLUSIONS: Myocardial contrast echocardiography correlates very well with CE-MRI in the assessment of myocardial perfusion after PCI in AMI. Contrast-enhanced MRI is accurate technique for assessing the infarct zone. Identification by CE-MRI of transmural necrosis was associated with more impaired left ventricular function, non-reperfused MI, and presence of Q waves in ECG.

Use of coronary calcium score in the assessment of atherosclerotic lesions in coronary arteries.

INTRODUCTION: Increased cardiovascular morbidity leads to search for new, non-invasive diagnostic methods for early detection of atherosclerosis. Among others computed tomography has become a matter of interest. The usefulness of quantitative analysis of calcification using multislice spiral computed tomography (MSCT) in cardiology has been studied recently. AIM: To evaluate the usefulness of calcium score (CS), estimated with MSCT, in identifying the risk of coronary artery stenosis. METHODS: The analysis involved 340 consecutive patients, 222 men and 118 women, mean age 59.7+/-9.38 years. All patients were admitted to hospital with symptoms of coronary artery disease for coronary angiography. In all subjects risk factor assessment and CS estimation using MSCT were performed. RESULTS: Mean CS was 271.1+/-605.9 and it increased with the progression of coronary artery disease. The differences between mean CS values in patients without coronary stenosis and patients with 1-, 2- or 3-vessel disease varied significantly (p <0.001). The cut-off point for total CS for the presence of coronary artery stenosis in the study group was set at > or =56 (sensitivity 85.7% and specificity 85.3%). The likelihood of the absence of significant stenosis (negative predictive value) in the whole study group was 93.5% and in women reached 100%. CONCLUSIONS: Coronary calcium score is a valuable parameter in assessing the likelihood of presence of coronary stenosis. The absence of calcifications in coronary arteries (CS=0) excludes significant coronary stenosis with a high probability.

[Comparison of myocardial contrast echocardiography and 99mTc MIBI single photon emission computed tomography in the assessment of myocardial perfusion in patients with acute myocardial infarction]. / Porównawcza analiza przydatnosci echokardiografii kontrastowej i badania scyntygraficznego w ocenie perfuzji miesnia sercowego u chorych ze swiezym zawalem serca.

UNLABELLED: The myocardial perfusion assessment in myocardial infarction is crucial to proper therapeutical decisions and patient's prognosis. The aim of the study to assess the efficacy of intravenous contrast echocardiography (MCE) in detecting myocardial perfusion defects in patients with acute myocardial infarction compared with 99mTc MIBI SPECT study. MATERIAL AND METHODS: 86 patients (mean age 58.4 +/- 11.2) underwent primary percutaneous coronary (PCI) for acute anterior myocardial infarction. TIMI grade flow, myocardial blush grade (TMPG), corrected TIMI frame count (cTFC) and segmental contractility and segmental perfusion were estimated in real time before and immediately after PCI, using injections of intravenous Optison. MCE performed before PCI described the risk area as the sum of segments with the lack of perfusion. A MCE perfusion defect size after PCI < 25% of the MCE perfusion defect size before PCI was used to define myocardial reperfusion. MCE was repeated on the third day after PCI. All patients underwent a rest 99mTc MIBI SPECT study (SPECT) on the third day after PCI. RESULTS: Based on MCE, 54 patients had reperfusion ("reflow" group) and 32 had non-reperfusion ("no-reflow" group). Patients from the non-reperfusion group showed a higher creatine kinase peak (p = 0.0034), higher kinase-MB (p = 0.0033) and higher troponine level (p = 0.0629), longer time span between the onset of pain and reperfusion (p = 0.003), and worse baseline regional contractile function (p = 0.0022). All angiographic parameters were worse in this group before as well as after PCI: more often TIMI 0 or 1, TMPG 0 or 1 in patients from "no-reflow" group was observed. These patients had higher cTFC than ones from "reflow" group. The agreement between MCE and SPECT for detecting perfusion abnormality was 87%. CONCLUSIONS: MCE facilitated identification of myocardial perfusion abnormalities in patients with acute myocardial infarction, whereas serial MCE facilitated identification of patients with early and late improvement of myocardial perfusion. MCE correlated very well with SPECT images in assessing perfusion defect.

Assessment of flow changes in the circle of Willis after stenting for severe internal carotid artery stenosis.

PURPOSE: To assess flow velocities in the cerebral arteries after carotid artery stenting (CAS) in patients with unilateral versus bilateral lesions and analyze velocities in patients with neurological complications after CAS. METHODS: Ninety-two patients (68 men; mean age 63.2 +/- 8.4 years, range 44-82) with internal carotid artery (ICA) stenoses were divided according to unilateral (group I, n = 72) or bilateral (group II, n = 20) disease. Fifty age- and gender-matched patients without lesions in the extra- or intracranial arteries served as a control group. Transcranial color-coded Doppler ultrasound was performed prior to and within 24 hours after CAS in the test groups; systolic velocities were assessed ipsilateral (i) and contralateral (c) to the CAS site in the middle cerebral artery (MCA) and anterior cerebral artery (ACA). RESULTS: Collateral flow via the anterior communicating artery (ACoA) was found in all group-II patients and 90% of group-I patients. After CAS, collateral flow through the ACoA ceased, and the velocity increased by 26% in the iMCA in group I compared to controls (p < 0.001). In group II, iMCA flow increased by 30% (p < 0.001) and flow via the ACoA (p < 0.001) increased, resulting in normalization of cMCA velocities (p = 0.928). In 89 (96.7%) subjects, CAS was uncomplicated. Hyperperfusion syndrome occurred in 2 (2.2%) patients, both with bilateral ICA stenoses; 1 (1.1%) transient ischemic attack was seen in a patient with unilateral disease. In the patients with hyperperfusion syndrome, the MCA velocities were 2.7- and 7.4-fold higher, respectively, versus before CAS and 2-fold higher than in controls. CONCLUSION: Uncomplicated CAS results in an iMCA velocity increase >25% compared to controls. MCA velocities in hyperperfusion syndrome were greatly increased versus before CAS and in controls.

[Systolic and diastolic left ventricle function assessment by tissue Doppler echocardiography in patients with perfusion defects in SPECT study]. / Ocena funkcji skurczowej i rozkurczowej lewej komory serca metoda tkankowej echokardiografii Dopplerowskiej u chorych z zaburzeniami perfuzji w badaniu SPECT.

INTRODUCTION: Tissue Doppler imaging (TDI) facilitates the quantitative assessment of the regional systolic and diastolic left ventricle function. Heart scintigraphy (SPECT) facilitates the assessment of regional perfusion of the myocardium. The aim of the study was the evaluation of the correlation between the regional myocardial perfusion defects observed in the SPECT study and the regional systolic and diastolic left ventricle function observed in TDI examination in the ischaemic heart disease patients. MATERIAL AND METHODS: In 40 patients (33 men and 7 women) aged 43-74 years (mean age 56 years) diagnosed of ischaemic heart disease on the basis of coronary angiography, rest TDI examination was performed. Maximal systolic and maximal early-diastolic myocardial velocities were assessed in 13 myocardial segments of the left ventricle, supplied by respective coronary arteries (left anterior descending artery--LAD, circumflex artery--Cx, right coronary artery--RCA). During rest and exercise perfusion scintigraphy of the heart (Tc99 MIBI SPECT) myocardial perfusion was evaluated in the segments analysed previously during TDI study. On the basis of the SPECT examination results the patients were divided into three groups: group I) patients with fixed perfusion defects, group II) patients with exercise-induced perfusion defects and normal rest perfusion, group III) patients with normal perfusion during rest and exercise. RESULTS: Systolic and diastolic myocardial velocity in LAD and Cx supplied segments were significantly higher in group II and group III as compared with group I. Systolic and diastolic velocities of myocardium supplied by LAD were significantly lower in group II as compared with group III. In Cx supplied region the diastolic myocardial velocity was significantly lower in group II as compared with group Ill. CONCLUSIONS: In the left ventricle myocardial regions with fixed perfusion defects, statistically significant decrease of systolic and diastolic myocardial velocities was observed. Moreover, the decrease of diastolic myocardial velocity in the rest TDI examination was found in patients with normal rest perfusion and exercise-induced perfusion defects.

Clinical and echocardiographic assessment of pregnant women with valvular heart diseases--maternal and fetal outcome.

UNLABELLED: The study aimed to compare the outcome of pregnancy in women with valvular heart diseases. MATERIAL: Two hundred and fifty-nine pregnant women with cardiac diseases, aged 18-42, were observed. Group I-158 patients with mitral valve disease: 30 patients with mitral stenosis; 44 patients with mitral regurgitation, 33 patients with combined mitral valve disease, 51 patients with mitral valve prolapse; Group II-54 patients with aortic valve disease: 32 patients with aortic stenosis, 22 with aortic regurgitation; Group III-47 patients after valve replacement (36 mechanical; 11 homograft valves). Medical history and physical examination, NYHA class assessment, ECG, and echocardiography were performed during consecutive trimesters of pregnancy and after delivery. RESULTS: Clinical deterioration was observed in 38 patients-in 25 women of Group I, 6 women of Group II, and 7 women of Group III. Newborns outcome : 250 healthy (10 prematures, 12 with intrauterine growth retardation), 6 aborted, 2 stillbirths, 1 neonatal death. Method of delivery : 200 vaginally, 53 cesarean sections. CONCLUSIONS: (1). Pregnants with critical mitral valve stenosis form a high-risk group of life-threatening complications. (2) In women with severe aortic stenosis, pregnancy could lead to sudden clinical status deterioration. (3) Cardiac complications can be expected in patients with left ventricular enlargement and its depressed function. (4) Key factors influencing successful course of pregnancy and labour in patients with prosthetic valves: adequate left ventricular function, properly functioning valves, and effective anticoagulation.

[Left ventricle TEI index--assessment of clinical role in patients with aortic valve stenosis]. / Ocena przydatnosci indeksu TEI u chorych ze zwezeniem zastawki aortalnej.

AIM: The study aimed to assess the clinical efficacy of the TEI index in patients with aortic valve stenosis (AVS). METHODS: The study group comprised 30 consecutive patients (12 F; 18 M; mean age: 60.1 +/- 9.2; range: 48-70 years) with aortic valve stenosis. Their clinical status was evaluated according to the NYHA criteria. A complete 2-dimensional, Doppler and color flow Doppler examination was performed. To assess systolic and diastolic left ventricle function we used ejection fraction--EF (%) and transmitral inflow velocity E/A ratio, respectively. The TEI index was calculated as (a - b)/b, were a is the interval between the cessation and onset of mitral inflow, and b is the ejection time. We also determined: maximal transaortic gradient--Ao max gr (mmHg), aortic valve area--AVA (cm2) and left ventricular mass index--LV mass index (g/m2). Based on clinical symptoms we divided patients into two groups: Group 1 (NYHA I/II) and Group 2 (NYHA III and IV). RESULTS: There were no significant differences in age, Ao max gr, AVA, EF and ejection time (b) between groups. But we found significantly prolonged time interval (a) and consequently significantly higher TEI index (p<0.001) in the group with severe symptoms. LV mass index and E/A ratio were also related to the patient's clinical status (p<0.05) but the TEI index seems to be more sensitive in distinguishing severely limited patients. CONCLUSION: The TEI index revealed to be closely related to symptoms in patients with aortic valve stenosis. The patient's clinical status seems to depend more on the TEI than on the conventional measured parameters like aortic valve area and transaortic gradient.

[Use of cardiovascular magnetic resonance (CMR) in preoperative assessment of aortic stenosis--case report]. / Zastosowanie kardiologicznego rezonansu magnetycznego (CMR) w przedoperacyjnej ocenie stenozy aortalnej--opis przypadku.

PURPOSE: CMR is a helpful additional diagnostic method in cardiac imaging. Thanks to high spatial and temporal resolution and high quality of obtained images this method is used in patients with poor echocardiographic acoustic window. We present a case of a patient, in whom CMR was conclusive as a non-invasive method of aortic valve stenosis assessment before qualification to cardiosurgery. METHODS: CMR was performed in a 70-year-old female A. C. who was under cardiological control due to symptomatic aortic stenosis. Because of difficulties in echocardiographic examinations (TTE) the aortic valve area was impossible to evaluate and aortic gradient value was difficult to assess and it differed in consecutive TTE performed over a short period (maximal gradient: 66-91 mmHg; mean gradient: 37-50 mmHg). The patient underwent CMR (Magnetom Vision Plus 1.5 T, Siemens) with the use of cine gradient echo sequences which made possible morphological and functional assessment of the valve and left ventricle. LV mass indices, IVS thickness, EF, aortic valve area, maximal aortic valve gradient were measured. RESULTS: CMR revealed: left ventricle muscle hypertrophy (IVS--1.8 cm; LV mass index--210 g/m2), EF--70%, no regional contractility disturbances and aortic valve area less than 1 cm2. In aortic valve and anulus extensive calcifications were visualised as low intensity signal area. Turbulent flow through aortic valve was found, maximal gradient about 64 mmHg. On the basis of all clinical symptoms and measurements based on imaging methods, the patient was qualified for cardiosurgery which was held in the Department of Cardiovascular Surgery and Transplantology. Coronary angiography revealed no significant stenosis. The operation was performed in extracorporeal circulation, general hypothermia and cardioplegia. Calcified aortic valve leaflets were excised and replaced by artificial valve (St. Jude Medical 21A Masters). The patient is in good health and was discharged. CONCLUSIONS: CMR is a valuable non invasive imaging method complementary to TTE in morphological and functional assessment of aortic valve and left ventricle, especially in patients with poor acoustic window in TTE.

[Assessment of ejection fraction by cardiovascular magnetic resonance in comparison with 99mTc gated SPECT]. / Ocena frakcji wyrzutowej lewej komory serca metoda rezonansu magnetycznego w porównaniu z bramkowana scyntygrafia z zastosowaniem 99mTc.

BACKGROUND: Impaired left ventricular (LV) function with decreased ejection fraction (EF) is a frequent finding in patients with ischaemic heart disease. As a non-invasive method, cardiovascular magnetic resonance (CMR) has become an important diagnostic method in cardiology within the past decade, especially for assessing myocardial function. AIM: The purpose of this study is to compare EF estimated with 99mTc gated SPECT (GSPECT) and with CMR. METHODS: The study was performed in a group of 35 patients (11 F, 24 M; mean age 57 SD 10) after myocardial infarction. EF in CMR procedure was calculated using cine gradient echo sequences. GSPECT measured EF was estimated by Tc 99. RESULTS: The mean value of EF measured with scintigraphy was 50.5 +/- 17%, and measured with CMR 48.3 +/- 15%. The difference in mean values of EF was not statistically significant. CONCLUSIONS: 1. EF in CMR was highly concordant with GSPECT. 2. The mean value of EF measured with CMR in 75% of study patients was smaller than in the scintigraphy group, but the difference was not statistically significant. 3. CMR is a simple, precise and reproducible diagnostic method for monitoring left ventricle systolic function, and which is an additional non-invasive imaging technique in cardiac diagnosis.

Assessment of myocardial perfusion in patients with coronary artery disease. Comparison of myocardial contrast echocardiography and 99mTc MIBI single photon emission computed tomography.

BACKGROUND: Myocardial perfusion (MP) can be assessed in real time when using a low mechanical index (MI) and harmonic imaging following an intravenous injection of contrast agent. The aim of the study was to determine the feasibility and accuracy of the real-time imaging of contrast echocardiography (MCE) for detecting myocardial perfusion defects at rest and during dobutamine stress echocardiography (DE) compared with 99m Tc MIBI SPECT. The study group consisted of 44 patients (24 men, 20 women, mean age 58.9+/-7.8) with suspected coronary artery disease (CAD). All patients underwent DE. Wall motion (WM) and segmental perfusion were estimated in real time before and at peak stress using a low MI (0.4) after 0.3 ml bolus injections of intravenous Optison. All patients underwent a rest and exercise 99mTc MIBI SPECT study (SPECT). A 16-segment model of the left ventricle was used for the analysis of MP, WM and SPECT by a blinded reviewer. All patients underwent coronary angiography. Significant coronary artery disease was defined as >60% luminal diameter stenosis. RESULTS: All patients had significant CAD. Twenty-nine patients had single-vessel and 15 patients had double-vessel disease. For all patients, agreement between MCE and SPECT was 89%, between MCE and WM -86%, and between SPECT and WM -82%. The agreement between MCE and SPECT for LAD, RCA and Cx territories was 81, 91 and 73%, respectively. The sensitivity of MCE and SPECT for detecting perfusion defects due to significant CAD (confirmed angiographically) was 97% and 93%, respectively, and the specificity was 93 and 84%, respectively. CONCLUSION: MCE in real-time imaging with Optison has significant potential for the identification of MP abnormalities. MCE correlates very well with SPECT images.

[Contrast echocardiography in the assessment of left ventricular function and myocardial perfusion]. / Rola echokardiografii kontrastowej w ocenie funkcji i ukrwienia miesnia lewej komory.

Myocardial contrast echocardiography is a non-invasive method used to detect coronary artery disease. It was first described in 1968. New contrast agents which can go through the pulmonary vessels were discovered in the last years. Contrast echocardiography is useful in improving the endocardial border delineation and left ventricular cavity visualisation especially in patients with suboptimal acoustic windows. As the contrast passes further into the coronary artery normal myocardium perfusion is enhanced while ischaemic areas lack enhancement. Analysis of perfusion allows indirect identification of narrowed coronary arteries. Left ventricular function and its myocardium perfusion are made with contrast echocardiography at rest and during pharmacological stress tests. These examinations allow for detection patient with coronary artery disease as well as estimating efficacy of revascularisation procedures.

[Assessment of myocardial perfusion using myocardial contrast echocardiography--case report]. / Analiza perfuzji miesnia sercowego przy uzyciu echokardiografii kontrastowej--opis przypadku.

A 58-year-old woman with symptoms of angina underwent coronary angioplasty, which showed critical narrowing of the right coronary artery (80%) and borderline narrowing of the left anterior descending coronary artery (50%). We decided to analyse myocardial perfusion in this patient to estimate the degree of atherosclerosis in the target arteries. She underwent myocardial contrast echocardiography at rest and during dobutamine stress. The examination showed a transient perfusion defect in the right coronary bed and in the left anterior descending coronary. A similar perfusion defect was revealed in scintigraphy. We carried out a successful two vessel percutaneous coronary revascularisation.

[Comparison of quantitative echocardiographic methods with angiography for assessment of mitral regulation]. / Ilosciowa ocena niedomykalnosci mitralnej--porównanie metody echokardiograficznej i angiograficznej.

UNLABELLED: The aim of this study was to compare echocardiographic assessment of the severity of mitral regurgitation (MR) with angiographic grading. MATERIAL: 51 patients (patients) with MR (43 men and 8 women), aged from 38 to 75 (mean 56 +/- 9 years), were used in the study. The etiology of MR was: Coronary artery disease (28 pts), infective endocarditis (3 patients), rheumatic disease (5 patients), dilated cardiomyopathy (7 patients), mitral valve prolapse (8 patients). EXCLUSION CRITERIA: Aortic stenosis and/or aortic insufficiency, mitral stenosis, mechanical prostheses and atrial fibrillation. METHODS: The mitral regurgitant volume (RV) and effective regurgitant orifice (ERO) were estimated by the proximal convergence method (PISA), regurgitant fraction (RF) and vena contracta width (VCW) by color Doppler quantitative method and compared to the cine ventriculographic grades. The angio-graphic severity of MR was classified as 1 to 4 grades according to the Sellers criteria. RESULTS: There was a good correlation between the angiographic grading and ERO (r = 0.855, p < 0.001), RV (r = 0.868, p < 0.001), RF (r = 0.923, p < 0.001) and VCW (r = 0.846, p < 0.001). CONCLUSIONS: 1. PISA method is clinically useful in routine evaluation of the severity of MR. 2. VCW provides a simple method for the identification of patients with severe MR. 3. These methods offer an alternative approach in quantifying MR noninvasively.