Measurement of the aortic annulus size by real-time three-dimensional transesophageal echocardiography

Department of Cardiology, West-German Heart Center Essen, University of Duisburg-Essen, Germany.
Minimally invasive therapy & allied technologies: MITAT: official journal of the Society for Minimally Invasive Therapy (Impact Factor: 1.27). 04/2011; 20(2):85-94. DOI: 10.3109/13645706.2011.557385
Source: PubMed


We sought to determine the level of agreement and the reproducibility of two-dimensional (2D) transthoracic (2D-TTE), 2D transesophageal (2D-TEE) and real-time three-dimensional (3D) transesophageal echocardiography (RT3D-TEE) for measurement of aortic annulus size in patients referred for transcatheter aortic valve implantation (TAVI). Accurate preoperative assessment of the dimensions of the aortic annulus is critical for patient selection and successful implantation in those undergoing TAVI for severe aortic stenosis (AS). Annulus size was measured using 2D-TTE, 2D-TEE and RT3D-TEE in 105 patients with severe AS referred for TAVI. Agreement between echocardiographic methods and interobserver variability was assessed using the Bland-Altman method and regression analysis, respectively. The mean aortic annuli were 21,7 ± 3 mm measured with 2D-TTE, 22,6 ± 2,8 mm with 2D-TEE and 22,3 ± 2,9 mm with RT3D-TEE. The results showed a small but significant mean difference and a strong correlation between the three measurement techniques (2D-TTE vs. 2D-TEE mean difference 0,84 ± 1,85 mm, r = 0,8, p < 0,0001; 2D-TEE vs. 3D-TEE 0,27 ± 1,14 mm, r = 0,91, p < 0,02; 2D-TTE vs. 3D-TEE 0,58 ± 2,21 mm, r = 0,72, p = 0,02); however, differences between measurements amounted up to 6,1 mm. Interobserver variability for 2D-TTE and 2D-TEE was substantially higher compared with RT3D-TEE. We found significant differences in the dimensions of the aortic annulus measured by 2D-TTE, 2D-TEE and RT3D-TEE. Thus, in patients referred for TAVI, the echocardiographic method used may have an impact on TAVI strategy.

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Available from: Rolf Alexander Jánosi, Feb 21, 2015
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    • "A second lesson learned while gaining more TAVI experience is that 2D TEE does not respect the 3D oval shape of the aortic annulus and might lead to imprecise aortic annulus diameter measurements [6] [16] [17]. Three-dimensional TEE becomes more and more available and seems to better reflect the annular anatomy than 2D TEE [18] [19] [20] [21], and is a useful tool for aortic annulus diameter measurement. In addition, MSCT has been established as a technique for precise measurement of the complex 3D geometry of the aortic annulus including its calcification [6–10, 22]. "
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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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    • "We found good reproducibility in determination of AoA size with all echocardiographic modalities, the highest being with 3DTEE which has also been shown in other studies [12,31,32]. On the contrary, AoA measurements performed by CT has been demonstrated to have poor inter-observer variability [26]. "
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    ABSTRACT: Background: Aortic stenosis (AS) is a relevant common valve disorder. Severe AS and symptoms and/or left ventricular dysfunction (EF <50%) have the indication for aortic valve replacement (AVR). Majority of the patients with AS are elderly often with co-morbidities and generally have high preoperative risk. Transcatheter aortic valve implantation (TAVI) is offered in this group. Four different sizes of Corevalve prosthesis are available. Correct measurement of aortic size prior to TAVI is of great important to choose the right prosthesis size to avoid among others paravalvular leak or prosthesis patient mismatch.Aim of the study is to assess the aortic annulus diameter in patients undergoing TAVI by biplane (BP) mode using transesophageal echocardiography (TEE) and compare it to two-dimensional (2D) transthoracic echocardiography (TTE) and 2DTEE using three-dimensional (3D) TEE as reference method. Methods: The study population consisted of 50 patients retrospectively (24 men and 26 women, mean age 85±8 years of age) who all had undergone echocardiography examination prior to TAVI. Results: The mean aortic annulus diameter was 20.4±2.2 mm with TTE, 22.3±2.5 mm with 2DTEE, 22.9±1.9 mm with BP-mode and 23.1±1.9 mm with 3DTEE. TTE underestimated the mean aortic annulus diameter in comparison to transesophageal imaging modalities (p<0.001). Using 3DTEE, 2% of patients were unsuitable for TAVI due to a too-small AoA (n=1). This figure was similar with BP (4%, n=2; p=1.00) but considerably larger with 2DTTE (36%, n=18; p < 0.001) and 2DTEE (12%, n=6; p=0.06). There was a strong correlation between BP-mode and 3DTEE for assessment of aortic annulus diameter (r-value 0.88) with small mean difference (-0.2±0.9 mm) whereas the other modalities showed larger 95% confidence interval and modest correlation (2DTTE vs. 3DTEE, -6.3 to 0.9 mm, r=0.64 and 2DTEE vs. 3DTEE, -4.8 to 3.2 mm, r=0.61). Conclusion: A multi-dimensional method is preferred to assess aortic annulus diameter in TAVI patients since there is risk of underestimation using single plane. Biplane mode is the method of choice in view of speedy post-processing with no need for expensive dedicated software. Lastly, single plane methods lead to misclassification of patients as unsuitable for TAVI. This may be of major clinical importance.
    Cardiovascular Ultrasound 01/2013; 11(1):5. DOI:10.1186/1476-7120-11-5 · 1.34 Impact Factor
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    ABSTRACT: Neue Kathetertechniken zur Behandlung von strukturellen Herzerkrankungen haben dazu geführt, dass immer mehr Patienten, die für einen operativen Eingriff nicht geeignet sind, interventionell behandelt werden können. Die Echokardiographie spielt dabei nicht nur für die präprozedurale Auswahl dieser Patienten, sondern insbesondere auch für das intraprozedurale Monitoring eine essenzielle Rolle, um eine sichere Durchführung der Interventionen zu gewährleisten. Echokardiographische 2-D- und 3-D-Techniken sind daher neben der konventionellen Röntgendurchleuchtung fester Bestandteil der Bildgebung im Herzkatheterlabor geworden. Diese Übersichtsarbeit soll neue Entwicklungen beim Einsatz der Echokardiographie während Katheterinterventionen im Kontext der aktuellen Literatur und neuer Empfehlungen darstellen.
    Herz 02/2013; 38(1). DOI:10.1007/s00059-012-3750-6 · 0.69 Impact Factor
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