Three dimensional evaluation of the aortic annulus using multislice computer tomography: are manufacturer’s guidelines for sizing for percutaneous aortic valve replacement helpful? Eur Heart J

Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands.
European Heart Journal (Impact Factor: 15.2). 12/2009; 31(7):849-56. DOI: 10.1093/eurheartj/ehp534
Source: PubMed

ABSTRACT To evaluate the effects of applying current sizing guidelines to different multislice computer tomography (MSCT) aortic annulus measurements on Corevalve (CRS) size selection.
Multislice computer tomography annulus diameters [minimum: D(min); maximum: D(max); mean: D(mean) = (D(min) + D(max))/2; mean from circumference: D(circ); mean from surface area: D(CSA)] were measured in 75 patients referred for percutaneous valve replacement. Fifty patients subsequently received a CRS (26 mm: n = 22; 29 mm: n = 28). D(min) and D(max) differed substantially [mean difference (95% CI) = 6.5 mm (5.7-7.2), P < 0.001]. If D(min) were used for sizing 26% of 75 patients would be ineligible (annulus too small in 23%, too large in 3%), 48% would receive a 26 mm and 12% a 29 mm CRS. If D(max) were used, 39% would be ineligible (all annuli too large), 4% would receive a 26 mm, and 52% a 29 mm CRS. Using D(mean), D(circ), or D(CSA) most patients would receive a 29 mm CRS and 11, 16, and 9% would be ineligible. In 50 patients who received a CRS operator choice corresponded best with sizing based on D(CSA) and D(mean) (76%, 74%), but undersizing occurred in 20 and 22% of which half were ineligible (annulus too large).
Eligibility varied substantially depending on the sizing criterion. In clinical practice both under- and oversizing were common. Industry guidelines should recognize the oval shape of the aortic annulus.

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    • "techniques correlating best to 'real' intraoperative aortic annulus sizing [6] [8]. One key step of aortic annulus measurement in MSCT is detecting the annular plane, which is defined as the most caudal attachment of the three native aortic cusps (so-called nadirs) [8] [9]. At conventional MSCT workstations, detecting this plane requires manual detection and segmentation of the aortic root together with manual adjustment in all three planes to localize the annular plane. "
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    ABSTRACT: Precise measurements of aortic annulus dimensions are crucial for prosthesis size selection in patients undergoing transcatheter aortic valve implantation (TAVI). The so-called effective diameter (derived from area) measured in multislice computed tomography (MSCT) images has evolved to be the most precise measurement tool. Usually, the operator must manually adjust the aortic annular plane. Syngo Aortic ValveGuide (Siemens Healthcare) is a new software tool that allows for automatic aortic root reconstruction and annular plane detection. The aim of this study was to compare the effective diameter measured in automatically detected and manually adjusted annular plane. Seventy-three raw image datasets of preoperative TAVI MSCT scans were analysed using our institutional gold standard (3Mensio Valves™) with manual annular plane adjustment and using Aortic ValveGuide with automatic annular plane detection. The aortic annular circumference was manually marked for both software tools, and the effective diameter was calculated using the formula: effective diameter = 2 × √(circumferential area/π). Automatic annulus plane detection using Syngo Aortic ValveGuide worked well in all MSCT scans. Minor manual adjustment of the detected plane was necessary in only 3 patients. The mean effective aortic annulus diameter was 23.1 ± 2.4 mm for 3Mensio and 23.3 ± 2.4 mm for Syngo Aortic ValveGuide. Bland-Altman analysis of both imaging software tools showed good agreement (mean difference of 0.16 mm and limits of agreement of -0.48 to 0.80 mm). Effective aortic annulus diameter measured with Syngo Aortic ValveGuide, as a new imaging software that allows for automatic aortic annular plane detection, shows good agreement to gold standard measurements. Automatic annulus plane detection might reduce the effort for MSCT analysis and may lead to more reproducible aortic annulus measurements. Aortic ValveGuide is part of the DynaCT and in future aortic annulus dimension measurements may be feasible during intraoperatively acquired DynaCT.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 01/2014; 46(2). DOI:10.1093/ejcts/ezt600 · 3.30 Impact Factor
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    • "According to MSCT data, the aortic valve annulus is noncircular in the vast majority of patients [25]. The mean difference between the maximum and minimum diameter of the aortic annulus is 6.5 mm (95% confidence interval, 5.7—7.2) [26]. This fact explains the potential shortcomings of relying on two-dimensional measurements of the aortic annulus for transcatheter aortic valve sizing (Fig. 4). "
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    ABSTRACT: Patient selection plays a crucial role in the success of transcatheter aortic valve implantation (TAVI). It requires meticulous attention to the smallest of details and needs to be performed in a systematic manner for every patient. In essence, the patient must be assessed from access to implantation site. Becoming over "complacent" and "routine" may lead to failure and impact patient safety. TAVI is indicated for high or prohibitive surgical risk patients with severe aortic stenosis. Some patients, however, are too high risk even for TAVI. In addition to patient risk evaluation, anatomical selection criteria need to be considered. Multimodality imaging, using a combination of angiography, echocardiography and multislice computed tomography, is necessary to determine the anatomical suitability for the procedure.
    Archives of cardiovascular diseases 03/2012; 105(3):165-73. DOI:10.1016/j.acvd.2012.02.007 · 1.84 Impact Factor
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    • "The luminal diameters of the aortic valve (AV) annulus, sinuses of Valsalva, and the sinotubular junction (STJ) were measured in both systole and diastole by a single observer (LMH). In this study, the image reconstruction protocol suggested by Schultz et al. [15] was used. Axial cuts through the aortic root were obtained by aligning the three perpendicular imaging planes (one axial and two longitudinal, respectively, oblique sagittal and oblique coronal; Fig. 1). "
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    ABSTRACT: Cardiac pulsatility and aortic compliance may result in aortic area and diameter changes throughout the cardiac cycle in the entire aorta. Until this moment these dynamic changes could never be established in the aortic root (aortic annulus, sinuses of Valsalva and sinotubular junction). The aim of this study was to visualize and characterize the changes in aortic root dimensions during systole and diastole with ECG-gated multidetector row computed tomography (MDCT). MDCT scans of subjects without aortic root disease were analyzed. Retrospectively, ECG-gated reconstructions at each 10% of the cardiac cycle were made and analyzed during systole (30-40%) and diastole (70-75%). Axial planes were reconstructed at three different levels of the aortic root. At each level the maximal and its perpendicular luminal dimension were measured. The mean dimensions of the total study group (n = 108, mean age 56 ± 13 years) do not show any significant difference between systole and diastole. The individual dimensions vary up to 5 mm. However, the differences range between minus 5 mm (diastolic dimension is greater than systolic dimensions) and 5 mm (vice versa). This variability is independent of gender, age, height and weight. This study demonstrated a significant individual dynamic change in the dimensions of the aortic root. These results are highly unpredictable. Most of the healthy subjects have larger systolic dimensions, however, some do have larger diastolic dimensions.
    The international journal of cardiovascular imaging 02/2011; 27(8):1195-204. DOI:10.1007/s10554-011-9838-x · 1.81 Impact Factor
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