From the Guidelines
The diagnosis for a patient with moderate Mitral Regurgitation (MR) by Pisa (Pulsed Doppler echocardiography using the PISA method) should be approached with caution, as the PISA method may underestimate the severity of MR due to the crescentic shape of the proximal convergence, and a comprehensive assessment including other echocardiographic findings and clinical evidence is necessary. When using the PISA method to evaluate MR severity, it is essential to consider the limitations of this technique, including the assumption of a round orifice and the potential for underestimation of EROA in patients with secondary MR 1. The 2014 AHA/ACC guidelines redefine severe secondary MR as EROA ≥0.2 cm2 or RVol ≥30 ml or RF ≥50%, but emphasize the importance of integrating these parameters with other clinical evidence and considering the quality of the data 1. In clinical practice, a comprehensive assessment of MR severity should include multiple parameters, such as EROA, RVol, and RF, as well as other echocardiographic findings, such as left ventricular size and function, and clinical evidence, such as symptoms and exercise tolerance. The use of 3D echocardiography may provide a more accurate assessment of EROA and RVol, but its availability and expertise may be limited in some settings 1. Ultimately, the diagnosis and management of MR should be individualized based on a thorough evaluation of the patient's clinical presentation, echocardiographic findings, and other relevant factors. It is also important to note that the PISA method may not always provide a accurate measurement of MR severity, and other methods such as 3D echocardiography or cardiac magnetic resonance imaging (CMR) may be necessary to confirm the diagnosis and guide management decisions 1. In summary, a comprehensive assessment of MR severity is necessary, taking into account the limitations of the PISA method and incorporating other echocardiographic findings and clinical evidence.