Interobserver Variation in Echocardiographic Measurements and Grading of Tricuspid Regurgitation Based on a Novel Web-Based Assessment Environment

Objectives: The primary aim of this study was to assess interobserver variability in grading tricuspid regurgitation (TR) severity. The authors’ secondary goals were to delineate which transesophageal echocardiographic (TEE) parameters best correlate with severity and how consistent the participants were at grading severity. Design: This was a prospective cohort study of how clinicians evaluated previously acquired TEE images and videos. Setting: The 19 TEE studies of patients with TR were recorded by 4 senior echocardiographers across 4 US academic institutions. The participants evaluated these cases on a novel, web-based, assessment environment designed specifically for this study. Participants: Twenty-nine fellowship-trained and board-certified cardiologists and cardiothoracic anesthesiologists volunteered to participate in the study as observers from 19 different institutions. Interventions: No interventions were performed on the participants. Measurements and Main Results: For each case, participants measured the vena contracta (VC), proximal isovelocity surface area (PISA), and jet area before giving a final classification on the severity of TR. Variation was highest for effective regurgitant orifice area and lowest for VC and PISA. The coefficient of variation, defined as the standard deviation from the mean divided by the mean, for all cases of trace, mild, moderate and severe TR were as follows: Jet Area—111%, 46%, 48%, 76%; VC—67%, 44%, 43%, 36%; PISA—52%, 48%, 31%, 35%; and effective regurgitant orifice area—127%, 95%, 66%, 58%. Conclusions: The interobserver variation in quantifying TEE parameters for TR is high, suggesting these may be difficult to measure reliably in a busy perioperative setting. Of the parameters assessed, VC and PISA radius had the highest interobserver agreement and the highest correlation with severity.