Impact of correcting the 2D PISA method on the quantification of functional tricuspid regurgitation severity

Abstract

Aims In functional tricuspid regurgitation (FTR) patients, tricuspid leaflet tethering and relatively low jet velocity could result in proximal flow geometry distortions that lead to underestimation of TR. Application of correction factors on two-dimensional (2D) proximal isovelocity surface area (PISA) equation may increase its reliability. This study sought to evaluate the impact of the corrected 2D PISA method in quantifying FTR severity. Methods and results In 102 patients with FTR, we compared both conventional and corrected 2D PISA measurements of effective regurgitant orifice area [EROA vs. corrected (EROAc)] and regurgitant volume (RegVol vs. RegVolc) with those obtained by volumetric method (VM) using three-dimensional echocardiography (3DE), as reference. Both EROAc and RegVolc were larger than EROA (0.29 ± 0.26 vs. 0.22 ± 0.21 cm2; P < 0.001) and RegVol (24.5 ± 20 vs. 18.5 ± 14.25 mL; P < 0.001), respectively. Compared with VM, both EROAc and RegVolc resulted more accurate than EROA [bias = −0.04 cm2, limits of agreement (LOA) ± 0.02 cm2 vs. bias = −0.15 cm2, LOA ± 0.31 cm2] and RegVol (bias = −3.29 mL, LOA ± 2.19 mL vs. bias = −10.9 mL, LOA ± 13.5 mL). Using EROAc and RegVolc, 37% of patients were reclassified in higher grades of FTR severity. Corrected 2D PISA method led to a higher concordance of TR severity grade with the VM method (ĸ = 0.84 vs. ĸ = 0.33 for uncorrected PISA, P < 0.001). Conclusion Compared with VM by 3DE, the conventional PISA underestimated FTR severity in about 50% of patients. Correction for TV leaflets tethering angle and lower velocity of FTR jet improved 2D PISA accuracy and reclassified more than one-third of the patients.

The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype

“…RV free-wall longitudinal strain (RVFWLS) and 4-chamber RV strain (RV4CHLS) were obtained from the RV-focused apical view according to the current recommendations ( 26 , 27 ). TR severity was graded as mild, moderate, or severe using the recommended multiparametric approach, which included: the average vena contracta (VC) width (measured in apical RV-focused and parasternal long-axis RV inflow views), the proximal isovelocity surface area (PISA) radius of the regurgitant jet at a Nyquist limit of 29 cm/s, the effective regurgitant orifice area (EROA) ( 23 – 25 , 28 , 29 ). To calculate the EROA and the regurgitant volume we used the PISA formula corrected for the TV leaflet tethering angle and the TR flow velocity ( 29 ).…”

“…TR severity was graded as mild, moderate, or severe using the recommended multiparametric approach, which included: the average vena contracta (VC) width (measured in apical RV-focused and parasternal long-axis RV inflow views), the proximal isovelocity surface area (PISA) radius of the regurgitant jet at a Nyquist limit of 29 cm/s, the effective regurgitant orifice area (EROA) ( 23 – 25 , 28 , 29 ). To calculate the EROA and the regurgitant volume we used the PISA formula corrected for the TV leaflet tethering angle and the TR flow velocity ( 29 ). Full-volume 3DE acquisitions of the RV, TV, and RA were obtained from the RV-focused apical view using electrocardiogram gating over 4 to 6 consecutive cardiac cycles during a single breath-hold.…”

Epidemiology, pathophysiology, diagnosis and management of chronic right‐sided heart failure and tricuspid regurgitation. A clinical consensus statement of the Heart Failure Association (HFA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

“…33 However, due to the large regurgitant orifice, the frequent tethering of the leaflets, and the low atrio-ventricular pressure gradient usually associated with significant secondary TR, the conventional proximal isovelocity surface area Doppler method grossly underestimates the severity of moderate or severe secondary TR in about 30% of patients. 70,71 In this context, three-dimensional parameters may be particularly useful for TR quantification, especially three-dimensional colour Doppler planimetry of the vena contracta area obtained by both TTE or TOE. 69,72,73 The importance of a novel, multimodality approach to TV imaging is increasingly recognized.…”

Three-dimensional echocardiography of the tricuspid valve

“…3D VCA correlates well with effective regurgitant orifice area (EROA), moderately well with VC diameter, and weakly with jet area/right atrial area ratio ( 25 , 44 ). The effective orifice area of the TV is often derived from the 2D evaluation of proximal isovelocity surface area (PISA), but this often requires making an often incorrect assumption of the shape of the flow acceleration, which can often underestimate STR severity ( 45 ). A corrected 2D PISA method, using a correction factor obtained from referencing 3D volumetric assessment, has been proposed and shown a more accurate assessment of STR severity ( 45 ).…”

“…The effective orifice area of the TV is often derived from the 2D evaluation of proximal isovelocity surface area (PISA), but this often requires making an often incorrect assumption of the shape of the flow acceleration, which can often underestimate STR severity ( 45 ). A corrected 2D PISA method, using a correction factor obtained from referencing 3D volumetric assessment, has been proposed and shown a more accurate assessment of STR severity ( 45 ). Recently, there have been suggestions that the TR grading system span beyond that of severe to include “massive” (3D VCA 95–114 mm 2 ) and “torrential” (3D VCA ≥ 115 mm 2 ), citing that many patients have evidence of regurgitant jets that progress multiple grades beyond the current definition of severe, although these numerical cutoffs have not been validated ( 46 , 47 ).…”