Improving the accuracy of effective orifice area assessment after transcatheter aortic valve replacement: validation of left ventricular outflow tract diameter and pulsed-wave Doppler location and impact of three-dimensional measurements.
BACKGROUND
Echocardiographic calculation of effective orifice area (EOA) after transcatheter aortic valve replacement is integral to the assessment of transcatheter heart valve (THV) function. The aim of this study was to determine the most accurate method for calculating the EOA of the Edwards SAPIEN and SAPIEN XT THVs.


METHODS
One hundred intraprocedural transesophageal echocardiograms were analyzed. To calculate the post-transcatheter aortic valve replacement left ventricular outflow tract (LVOT) stroke volume (SV), four diameters were measured using two-dimensional echocardiography: (1) baseline LVOT diameter (LVOTd_PRE), (2) postimplantation LVOT diameter, (3) native aortic annular diameter, and (4) THV in-stent diameter. Four corresponding areas were planimetered by three-dimensional echocardiography. Two LVOT velocity-time integrals (VTI) were measured with the pulsed-wave Doppler sample volume at (1) the proximal (apical) edge of the valve stent or (2) within the valve stent at the level of the THV cusps. LVOT velocity-time integral with the sample volume at the proximal edge of the valve stent was used with the LVOT and aortic annular measurements above, whereas in-stent VTI was paired with the in-stent THV diameter to yield eight different SVs. Right ventricular outflow tract (RVOT) SV was calculated using RVOT diameter and RVOT VTI and was used as the primary comparator. Transaortic VTI was obtained by continuous-wave Doppler, and EOA calculations using each SV measurement were compared with (1) EOA calculated using RVOTSV and (2) planimetered aortic valve area using three-dimensional echocardiography (AVAplanimetry3D).


RESULTS
Post-transcatheter aortic valve replacement EOA calculated using LVOTd_PRE was not significantly different from EOA calculated using RVOTSV (1.88 ± 0.33 vs 1.86 ± 0.39 cm(2), P = .36) or from AVAplanimetry3D (1.85 ± 0.28, P = .38, n = 34). All other two-dimensional EOA calculations were statistically larger than EOA calculated using RVOTSV. All three-dimensional echocardiography-based EOA calculations were statistically different from AVAplanimetry3D.


CONCLUSIONS
The most accurate EOA after implantation of a balloon-expandable THV is calculated using preimplantation LVOT diameter and VTI.
Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York.
Omar K
OK
Khalique
Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York.
Nadira B
NB
Hamid
Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York.
Susheel K
SK
Kodali
Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York.
Tamim M
TM
Nazif
Morristown Medical Center, Morristown, New Jersey.
Leo
L
Marcoff
Universite Laval, Quebec, Quebec, Canada.
Jean-Michel
JM
Paradis
New York University Medical Center, New York, New York.
Mathew R
MR
Williams
Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York.
Torsten P
TP
Vahl
Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York.
Isaac
I
George
Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York.
Martin B
MB
Leon
Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York. Electronic address: rth2@cumc.columbia.edu.
Rebecca T
RT
Hahn
D000368:Aged; D001024:Aortic Valve Stenosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery*; D018619:Echocardiography, Doppler, Pulsed / Q000379:methods*; D019560:Echocardiography, Three-Dimensional / Q000379:methods*; D005260:Female; D006352:Heart Ventricles / Q000000981:diagnostic imaging*; D006801:Humans; D007089:Image Enhancement / Q000379:methods*; D007090:Image Interpretation, Computer-Assisted / Q000379:methods; D008297:Male; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods; D016896:Treatment Outcome
Aortic stenosis; Echocardiography; TAVR