Multimodal Assessment of the Aortic Annulus Diameter Implications for Transcatheter Aortic Valve Implantation

INSERM, U698, University Paris 7, Paris, France.
Journal of the American College of Cardiology (Impact Factor: 16.5). 01/2010; 55(3):186-94. DOI: 10.1016/j.jacc.2009.06.063
Source: PubMed


We sought to compare 3 methods of measurements of the aortic annulus, transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and multislice computed tomography (MSCT), and to evaluate their potential clinical impact on transcatheter aortic valve implantation (TAVI) strategy.
Exact measurement of the aortic annulus is critical for a patient's selection and successful implantation.
Annulus diameter was measured using TTE, TEE, and MSCT in 45 consecutive patients with severe aortic stenosis referred for TAVI. The TAVI strategy (decision to implant and choice of the prosthesis' size) was based on manufacturer's recommendations (Edwards-Sapien prosthesis, Edwards Lifesciences, Inc., Irvine, California).
Correlations between methods were good but the difference between MSCT and TTE (1.22 +/- 1.3 mm) or TEE (1.52 +/- 1.1 mm) was larger than the difference between TTE and TEE (0.6 +/- 0.8 mm; p = 0.03 and p < 0.0001, respectively). Regarding TAVI strategy, agreement between TTE and TEE overall was good (kappa = 0.68), but TAVI strategy would have been different in 8 patients (17%). Agreement between MSCT and TTE or TEE was only modest (kappa = 0.28 and 0.27), and a decision based on MSCT measurements would have modified the TAVI strategy in a large number of patients (40% to 42%). Implantation, performed in 34 patients (76%) based on TEE measurements, was successful in all but 1 patient with grade 3/4 regurgitation.
In patients referred for TAVI, measurements of the aortic annulus using TTE, TEE, and MSCT were close but not identical, and the method used has important potential clinical implications on TAVI strategy. In the absence of a gold standard, a strategy based on TEE measurements provided good clinical results.

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Available from: Fabien Hyafil, Dec 15, 2014
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    • "Annulus measurements with 3-dimensional multislice computed tomography offers the possibility of measuring the value that is closest to reality. Similar to 3-dimensional echo, measurements made with multislice computed tomography have been shown to change the TAVI strategy by 40% [30]. However, lack of specialized radiologists in this field is the biggest handicap and it forces us as cardiologists to consult three-dimensional TEE measurements more often. "
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    ABSTRACT: Transcatheter aortic valve implantation is a promising alternative to high risk surgical aortic valve replacement. The procedure is mainly indicated in patients with severe symptomatic aortic stenosis who cannot undergo surgery or who are at very high surgical risk.
    Full-text · Article · Jun 2014 · Postepy w Kardiologii Interwencyjnej / Advances in Interventional Cardiology
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    • "However, the values of the aortic annulus diameter vary significantly in different CT and TEE assessments and this matter can be associated with valve dislocation. Indeed, it has been well recognized that TTE routinely underestimates the true annulus diameter compared to TEE or CT [7]. In this case we experienced a rare but possible complication of TAVI, although the recommended procedural managements were applied. "
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    ABSTRACT: Transcatheter aortic valve implantation has been increasingly used in symptomatic patients with severe aortic stenosis who are inoperable or at high risk. However it remains associated with the potential for serious complications. We report a case in which an Edwards Sapien (Edwards, Irvine, CA, USA) valve prosthesis dislocated to the left ventricular outflow tract with hemodynamic collapse 6. h following implantation.<. Learning objective: Transcatheter aortic valve implantation (TAVI) is an alternative method to surgical aortic valve replacement in patients with severe aortic stenosis and high surgical risk. Despite continuous improvements in operators' expertise and device technology, it remains associated with the potential for serious complications such as valve dislocation. Dislocation after TAVI is a life-threatening complication that requires immediate diagnosis and treatment.>.
    Preview · Article · Apr 2014 · Journal of Cardiology Cases
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    • "The numbers behind the letters indicate the amount of ovality, 1 being round, 2 slightly oval and 3 showing a strong ovality. The ovals defining the aortic annulus were constructed following the requirement that the orifice area remain equal, as literature describes this as the gold standard for valve sizing (Kempfert et al., 2012; Messika-Zeitoun et al., 2010). The lengths of the axes of the ellipsis were varied as follows: The parameter k was introduced as the relation of the long axis (a) to the short axis (b) as k¼ a/b. "
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    ABSTRACT: Background Although CT-studies as well as intraoperative analyses have described broad anatomic variations of the aortic annulus, which is predominantly found non-circular, commercially available transcatheter aortic heart valve prostheses are circular. In this study, we hypothesize that the in vitro hydrodynamic function of a self-expanding transcatheter heart valve (Medtronic CoreValve®) assessed in an oval compartment representing the aortic annulus will differ from the conventionally used circular compartment. Methods Medtronic CoreValve® prostheses were tested in specifically designed and fabricated silicone compartments with three degrees of defined ovalities. The measurements were performed in a left heart simulator at three different flow rates. In this setting, regurgitation flow, effective orifice area, and systolic pressure gradient across the valve were determined. In addition, high speed video recordings were taken to investigate leaflet kinematics. Results The pressure difference across the prosthesis increased with rising ovality. The effective orifice areas were only slightly impacted. The analyses of the regurgitation showed minor changes and partially lower regurgitation when switching from round to slightly oval settings, followed by strong increases for further ovalization. The high speed videos show minor central leakage and impaired leaflet apposition for strong ovalities, but no leaflet/stentframe contact in any setting. Conclusion This study quantifies the influence of oval expansion of transcatheter heart valve prostheses on their hydrodynamic performance. While slight ovalities were well tolerated by a self-expanding prosthesis, more significant ovality led to worsening of prosthesis function and regurgitation.
    Full-text · Article · Mar 2014 · Journal of Biomechanics
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