Author + information
- Published online March 4, 2019.
- Abdellaziz Dahou, MD, PhD,
- Geraldine Ong, MD,
- Nadira Hamid, MD,
- Eleonora Avenatti, MD,
- Jing Yao, MD, PhD and
- Rebecca T. Hahn, MD∗ ()
- ↵∗Center for Interventional Vascular Therapy, Columbia University Medical Center, HIP6-623, 161 Fort Washington Avenue, New York, New York 10032
Current guidelines recommend quantifying tricuspid regurgitation (TR) using the proximal isovelocity surface area (PISA) method to calculate effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) (1). TR is severe if PISA-EROA is ≥0.40 cm2 and/or RegVol is ≥45 ml. However, the anatomic orifice in functional TR is usually noncircular (along the line of coaptation with the septal leaflet) with leaflet tethering. The objective of this study was to compare quantitative PISA with quantitative Doppler methods for assessing functional TR severity.
Patients who underwent echocardiographic evaluation of TR severity in the context of the transcatheter treatment of TR were prospectively included. Patients were excluded if they had primary TR, ≥ moderate mitral or aortic regurgitation, stenosis, or systolic pulmonary arterial pressure >60 mm Hg. All echocardiograms were analyzed at an independent core laboratory that followed American Society of Echocardiography guidelines (1). Vena contracta (VC) diameters were measured in 2 orthogonal planes (simultaneous multiplane image) or from the 4-chamber and the inflow views, and then averaged (VCavg). The ellipticity of the VC was calculated as the ratio of maximum and minimum VC diameters (VCmax/VCmin). Quantitation of EROA and RegVol was performed by PISA (PISA-EROA), Doppler volumetric method (Doppler-EROA), and 3-dimensional planimetry of the VC area (3D-VCA) method as previously described (2).
Among the 160 cases analyzed, VCavg was available in 127 patients, PISA in 115 patients, quantitative Doppler in 49 patients, and 3D-VCA in 34 patients. Beside individual parameters, TR severity was determined by comprehensive assessment (multiparametric approach). Mean age was 76 ± 6 years, 75% were women, and 74% of patients were in atrial fibrillation. Mean PISA-EROA was 0.55 ± 0.40 cm2, PISA-RegVol was 42 ± 23 ml, VCavg was 1.1 ± 0.4 cm, and 3D-VCA was 1.2 ± 0.74 cm2. Median value of the VC ellipticity index was 1.6 (interquartile range: 1.4 to 2.1).
There was a strong correlation between Doppler-EROA and 3D-VCA (r = 0.92; p < 0.0001) and between VCavg and 3D-VCA (r = 0.83; p < 0.0001). However, there was a modest correlation between PISA-EROA and PISA-RegVol and 3D-VCA (r = 0.65; p = 0.0001 and r = 0.60; p = 0.01, respectively) (Figure 1). The PISA method showed better correlation with the 3D-VCA method in less elliptical regurgitant orifices (VCmax/VCmin <1.6) (r = 0.87; p = 0.001 and r = 0.75; p = 0.01 for PISA-EROA and PISA-RegVol, respectively) compared with more elliptical regurgitant orifices (r = 0.57; p = 0.03 and r = 0.50; p = 0.02, respectively).
PISA-EROA and PISA-RegVol were significantly lower than quantitative Doppler and 3D methods (all p < 0.05). Based on multiparametric assessment, TR was severe in 66% of cases; 32% had a PISA-EROA <0.40 cm2, and 48% had a PISA-RegVol <45 ml. Using Youden’s index, the best cutoff value for severe TR by PISA-EROA was ≥0.34 cm2 (sensitivity: 89%; specificity: 90%); by 3D-VCA, this cutoff was ≥0.60 cm2 (sensitivity: 92%; specificity: 75%), the Doppler-EROA cutoff was ≥0.65 cm2 (sensitivity: 82%; specificity 94%), and the VCavg cutoff was ≥9 mm (sensitivity: 85%; specificity: 97%).
Our study adds to the literature on TR grading by showing: 1) Doppler-EROA and VCavg had high correlation with 3D-VCA; 2) PISA-EROA correlated with 3D-VCA and Doppler-EROA but significantly underestimated the severity of TR in nearly one-third of patients; and 3) different cutoffs might be appropriate to determine severe TR when using PISA-EROA compared with 3D-VCA or Doppler-EROA, particularly with noncircular orifices.
The underestimation of TR severity by PISA-EROA was reported by previous studies. Chen et al. (3) showed that PISA-EROA underestimated 3D-VCA, with worse correlation in the setting of a more elliptical orifice. Song et al. (4) similarly showed the PISA method underestimated 3D-VCA by nearly 2-fold. In concordance with the present study, Chen et al. (3) and Song et al. (4) suggested the 3D-VCA cutoff for severe TR should be 0.57 to 0.60 cm2.
This is the first study to report the high correlation of Doppler-EROA, 3D-VCA, and VCavg. Importantly, using different cutoffs for each method may be the key to more accurate grading of TR severity. Adding these new measurements to the multiparametric assessment of functional TR may prevent the underestimation of TR severity and allow patients to be treated earlier. Further study of these quantitative methods is warranted.
Please note: Dr. Hahn is a speaker for Boston Scientific and Bayliss; is a speaker and consultant for Abbott Vascular, Edwards Lifesciences, Philips Healthcare, and Siemens Healthineers; is a consultant for 3Mensio, Medtronic, and Navigate; and is the Chief Scientific Officer for the Echocardiography Core Laboratory at the Cardiovascular Research Foundation for multiple industry-sponsored trials, for which she receives no direct industry compensation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2019 American College of Cardiology Foundation
- Zoghbi W.A.,
- Adams D.,
- Bonow R.O.,
- et al.
- Hahn R.T.,
- Meduri C.U.,
- Davidson C.J.,
- et al.