title: Dynamism of the aortic annulus: Effect of diastolic versus systolic CT annular measurements on device selection in transcatheter aortic valve replacement (TAVR).
abstract: BACKGROUND
  Annular dimensions, including cross-sectional area, perimeter and subsequently derived diameters, are subject to dynamic changes throughout the cardiac cycle. There is ongoing controversy as to whether perimeter measurement changes between systole and diastole are too small to impact on valve sizing.
  
  
  OBJECTIVE
  To assess both the variability of aortic annular dimensions throughout the cardiac cycle across a range of sub-annular calcification using computed tomography (CT) and the impact of this variability on device size selection for balloon-expandable valves in a large, all-comer multi-center cohort.
  
  
  METHODS
  ECG-gated CT data of 507 patients (mean 81 ± 7.5 years, 60.1% male) were analyzed in this retrospective, multicenter analysis. Aortic annulus dimensions were assessed on pre-specified systolic and diastolic phases by planimetry, yielding both area and perimeter. Contour smoothing was employed to avoid artificial increase in perimeter values by uneven contours. The extent of subannular calcification was graded semi-quantitatively and assessed in relation to the degree of annular dynamism. Hypothetical device sizing was undertaken to assess the impact of using systolic and diastolic measurements on valve selection.
  
  
  RESULTS
  Mean annular dimensions were larger during systole than diastole (area: 474.4 ± 87.4 mm(2) vs. 438.3 ± 84.3 mm(2) or 8.23%, p < 0.001; perimeter: 78.5 ± 7.2 mm vs. 75.9 ± 7.2 mm or 3.36%, p < 0.001). The magnitude of annular area and perimeter change (systolic minus diastolic measurement) was greater among patients without calcification compared to patients with grade 3 calcification. Using diastolic rather than systolic data for device sizing resulted in a change of the recommended valve size in nearly half of patients for both annular area and perimeter.
  
  
  CONCLUSIONS
  The systematic differences between systolic and diastolic annular measurements for cross-sectional area and perimeter have implications for device sizing with potential for valve under-sizing if diastolic annular dimensions are employed.
authors.affiliation: Department of Radiology, St Paul's Hospital and University of British Columbia, Vancouver, BC, Canada. Electronic address: dmurphy@providencehealth.bc.ca.
authors.forename: Darra T
authors.initials: DT
authors.lastname: Murphy
authors.affiliation: Department of Radiology, St Paul's Hospital and University of British Columbia, Vancouver, BC, Canada. Electronic address: phil.blanke@googlemail.com.
authors.forename: Philipp
authors.initials: P
authors.lastname: Blanke
authors.affiliation: Department of Radiology, St Paul's Hospital and University of British Columbia, Vancouver, BC, Canada. Electronic address: drshalan@gmail.com.
authors.forename: Shalan
authors.initials: S
authors.lastname: Alaamri
authors.affiliation: Department of Radiology, St Paul's Hospital and University of British Columbia, Vancouver, BC, Canada. Electronic address: chris.naoum@gmail.com.
authors.forename: Christopher
authors.initials: C
authors.lastname: Naoum
authors.affiliation: Cardiology Department, Lady Davis Carmel Medical Centre, Haifa, Israel. Electronic address: ronenrub@clalit.org.il.
authors.forename: Ronen
authors.initials: R
authors.lastname: Rubinshtein
authors.affiliation: Division of Cardiovascular Radiology, University Hospital Freiburg, Freiburg, Germany. Electronic address: gregor.pache@universitaets-herzzentrum.de.
authors.forename: Gregor
authors.initials: G
authors.lastname: Pache
authors.affiliation: Department of Radiology, St Paul's Hospital and University of British Columbia, Vancouver, BC, Canada. Electronic address: bpreciou@dal.ca.
authors.forename: Bruce
authors.initials: B
authors.lastname: Precious
authors.affiliation: Department of Radiology, St Paul's Hospital and University of British Columbia, Vancouver, BC, Canada. Electronic address: adam.berger@unsw.edu.au.
authors.forename: Adam
authors.initials: A
authors.lastname: Berger
authors.affiliation: Department of Radiology, St Paul's Hospital and University of British Columbia, Vancouver, BC, Canada. Electronic address: rekharaju@hotmail.com.
authors.forename: Rekha
authors.initials: R
authors.lastname: Raju
authors.affiliation: Department of Cardiology, St Paul's Hospital and University of British Columbia, Vancouver, BC, Canada. Electronic address: danny.dvir@gmail.com.
authors.forename: Danny
authors.initials: D
authors.lastname: Dvir
authors.affiliation: Department of Cardiology, St Paul's Hospital and University of British Columbia, Vancouver, BC, Canada. Electronic address: david.wood@vch.ca.
authors.forename: David A
authors.initials: DA
authors.lastname: Wood
authors.affiliation: Department of Cardiology, St Paul's Hospital and University of British Columbia, Vancouver, BC, Canada. Electronic address: webb@providencehealth.bc.ca.
authors.forename: John
authors.initials: J
authors.lastname: Webb
authors.affiliation: Department of Radiology, St Paul's Hospital and University of British Columbia, Vancouver, BC, Canada. Electronic address: jleipsic@providencehealth.bc.ca.
authors.forename: Jonathon A
authors.initials: JA
authors.lastname: Leipsic
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001011:Aorta / Q000601:surgery*; D001027:Aortography / Q000379:methods*; D003971:Diastole; D005260:Female; D006801:Humans; D038622:Internationality; D008297:Male; D008875:Middle Aged; D009929:Organ Size; D011300:Preoperative Care / Q000379:methods; D017755:Prosthesis Fitting / Q000379:methods*; D011857:Radiographic Image Interpretation, Computer-Assisted / Q000379:methods*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D013599:Systole; D014057:Tomography, X-Ray Computed / Q000379:methods*; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods*
keywords: Aortic annulus; Computed tomography; MDCT; Multidetector CT; TAVI; TAVR; Transcatheter aortic valve implantation; Transcatheter aortic valve replacement