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PISA Underestimates TR Severity In Patients With Functional TR
Abdellaziz Dahou1, Geraldine Ong2, Nadira Hamid2, Eleonora Avenatti2, Jing Yao2, Rebecca T. Hahn1.
1Cardiovascular Research Foundaion; Columbia University, New York, NY, USA, 2Cardiovascular Research Foundaion, New York, NY, USA.

Background: With the emergence of transcatheter solutions for the treatment of severe symptomatic tricuspid regurgitation (TR), accurate quantitation of effective regurgitant orifice area (EROA) and regurgitant volume (Reg Vol) are required. Current guidelines recommend using the proximal isovelocity surface area method (PISA). However, the anatomic orifice in function TR makes the accuracy of this method questionable.
Methods: Patients evaluated for transcatheter treatment of severe symptomatic tricuspid regurgitation were included into the present analysis. Various 2D parameters of TR severity (Quantitative Doppler, PISA, and Vena Contracta) were measured and compared to the 3D planimetered EROA.
Results:
There was a strong correlation between EROA by Quantitative Doppler and 3D-EROA (R=0.92, P<0.0001) and between Vena Contracta (average) and 3D-EROA (p=0.83, p<0.0001). However, there was a modest correlation between EROA by PISA and Reg vol by PISA and 3D-EROA (p=0.60 and 0.48 respectively, p<0.05 for both). 32% of patients having severe TR using a comprehensive assessment (multiparametric approach) had a PISA-EROA < 0.40 cm2. ROC analysis showed that the best cutoff value for EROA by PISA to determine severe TR was close to 0.3 cm2 with a good sensitivity and specificity (0.89 and 0.80 respectively).
Conclusions:
In patients with functional TR, the use of PISA method modestly correlates with 3D- EROA and was found to underestimate the TR severity in about 1/3 of patients, which may lead to suboptimal clinical decision making. The EROA by quantitative Doppler and the Vena Contracta (average) strongly correlate with 3D-EROA and might be preferred to PISA for accurate assessment of TR severity in these patients. When PISA method is used, lower cut-point value (0.30 rather than 0.40 cm2) should be used to define severe TR. Further studies are needed to confirm these results.


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