#echofirst needs common sense DX of MR: If PISA says severe MR (EROA/RVol), don't stop at the number. Ask 2 questions: 1️⃣ Did I measure it correctly? PISA has pitfalls: geometry, eccentric/multiple jets, non-holosystolic MR, aliasing and measurement errors. 2️⃣ Does the physiology agree? Does: Total LV SV − LVOT forward SV ≈ PISA Reg. Vol? And is the regurgitant fraction ≥50%? Then look for supporting consequences: large LA/LV, dominant E >1.2 m/s, dense holosystolic CW signal, pulmonary-vein abnormalities. 👉So never stop at PISA, VC or 3D VCA go and validate your claim 🚨Never report a large MR regurgitant volume by PISA if the LV volumes you used to calculate EF are smaller.