title: Cross-sectional computed tomographic assessment improves accuracy of aortic annular sizing for transcatheter aortic valve replacement and reduces the incidence of paravalvular aortic regurgitation.
abstract: OBJECTIVE
  In an effort to define the gold standard for annular sizing for transcatheter aortic valve replacement (TAVR), we sought to critically analyze and compare the predictive value of multiple measures of the aortic annulus for post-TAVR paravalvular (PV) regurgitation and then assess the impact of a novel cross-sectional computed tomographic (CT) approach to annular sizing.
  
  
  BACKGROUND
  Recent studies have shown clear discrepancies between conventional 2-dimensional (2D) echocardiographic and CT measurements. In terms of aortic annular measurement for TAVR, such findings have lacked the outcome analysis required to inform clinical practice.
  
  
  METHODS
  The discriminatory value of multiple CT annular measures for post-TAVR PV aortic regurgitation was compared with 2D echocardiographic measures. TAVR outcomes with device selection according to aortic annular sizing using a traditional 2D transesophageal echocardiography-guided or a novel CT-guided approach were also studied.
  
  
  RESULTS
  In receiver-operating characteristic models, cross-sectional CT parameters had the highest discriminatory value for post-TAVR PV regurgitation: This was with the area under the curve for [maximal cross-sectional diameter minus prosthesis size] of 0.82 (95% confidence interval: 0.69 to 0.94; p < 0.001) and that for [circumference-derived cross-sectional diameter minus prosthesis size] of 0.81 (95% confidence interval: 0.7 to 0.94; p < 0.001). In contrast, traditional echocardiographic measures were nondiscriminatory in relation to post-TAVR PV aortic regurgitation. The prospective application of a CT-guided annular sizing approach resulted in less PV aortic regurgitation of grade worse than mild after TAVR (7.5% vs. 21.9%; p = 0.045).
  
  
  CONCLUSIONS
  Our data lend strong support to 3-dimensional cross-sectional measures, using CT as the new gold standard for aortic annular evaluation for TAVR with the Edwards SAPIEN device.
authors.affiliation: Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA.
authors.forename: Hasan
authors.initials: H
authors.lastname: Jilaihawi
authors.forename: Mohammad
authors.initials: M
authors.lastname: Kashif
authors.forename: Gregory
authors.initials: G
authors.lastname: Fontana
authors.forename: Azusa
authors.initials: A
authors.lastname: Furugen
authors.forename: Takahiro
authors.initials: T
authors.lastname: Shiota
authors.forename: Gerald
authors.initials: G
authors.lastname: Friede
authors.forename: Rakhee
authors.initials: R
authors.lastname: Makhija
authors.forename: Niraj
authors.initials: N
authors.lastname: Doctor
authors.forename: Martin B
authors.initials: MB
authors.lastname: Leon
authors.forename: Raj R
authors.initials: RR
authors.lastname: Makkar
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging* / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000517:prevention & control*; D006328:Cardiac Catheterization / Q000379:methods*; D016009:Chi-Square Distribution; D017548:Echocardiography, Transesophageal / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D011183:Postoperative Complications / Q000517:prevention & control; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000379:methods; D011446:Prospective Studies; D011474:Prosthesis Design; D012372:ROC Curve; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D014057:Tomography, X-Ray Computed / Q000379:methods*; D016896:Treatment Outcome