title: Impact of Methodologic Differences in Three-Dimensional Echocardiographic Measurements of the Aortic Annulus Compared with Computed Tomographic Angiography Before Transcatheter Aortic Valve Replacement.
abstract: BACKGROUND
  Three-dimensional (3D) echocardiographic (3DE) imaging is an alternative to multi-detector row computed tomography (MDCT) for aortic annular measurement before transcatheter aortic valve replacement (TAVR). A commonly used direct planimetry from a reconstructed short-axis view has not been compared with semiautomated 3DE methods. Typically accepted optimal cutoffs for percent prosthesis-area oversizing of the balloon-expandable SAPIEN or SAPIEN XT valve to native annular size are approximately 5% to 15%. The aim of this study was to compare semiautomated and direct planimetric 3DE methods for aortic annular sizing with a gold standard of MDCT to determine predictive value for paravalvular regurgitation (PVR) and balloon postdilatation.
  
  
  METHODS
  In this retrospective analysis, aortic annular cross-sectional area was measured from pre-TAVR imaging using (1) MDCT (CT_Area), (2) a 3D transesophageal echocardiographic (TEE) semiautomated method (3DE_Area_SA), and (3) a 3D TEE direct planimetric method (3DE_Area_Direct). Annular area percent oversizing was calculated. PVR after TAVR was assessed from intraoperative TEE imaging. Need for balloon postdilatation was recorded.
  
  
  RESULTS
  One hundred patients who underwent TAVR with either the SAPIEN or SAPIEN XT balloon-expandable prosthesis were analyzed. Twenty-three patients had mild or greater PVR after TAVR. CT_Area was 442 ± 79 mm2, 3DE_Area_SA was 435 ± 81 mm2, and 3DE_Area_Direct was 429 ± 82 mm2. Both 3DE_Area_SA and 3DE_Area_Direct underestimated MDCT (P < .05). All methods were highly correlative (R = 0.88-0.93, P < .0001). Percent oversizing obtained by the three methods significantly predicted mild or greater PVR and need for balloon postdilatation by receiver operating characteristic analysis, with optimal cutoffs for CT_Area (9%-10%) and 3DE_Area_SA (14%) within the recommended ranges for the studied transcatheter valves and for 3DE_Area_Direct higher than the recommended range (18%-19%). Inter- and intraobserver reproducibility were lowest for 3DE_Area_Direct.
  
  
  CONCLUSIONS
  Caution must be used when using 3D TEE direct planimetry of the aortic annulus, as optimal percent oversizing ranges approach the level associated with root injury, and measurements are less reproducible. Therefore, semiautomated 3DE planimetry is preferred to 3DE direct planimetry for aortic annulus sizing.
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York. Electronic address: ok2203@cumc.columbia.edu.
authors.forename: Omar K
authors.initials: OK
authors.lastname: Khalique
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York.
authors.forename: Nadira B
authors.initials: NB
authors.lastname: Hamid
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York.
authors.forename: Jonathon M
authors.initials: JM
authors.lastname: White
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York.
authors.forename: David J
authors.initials: DJ
authors.lastname: Bae
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York.
authors.forename: Susheel K
authors.initials: SK
authors.lastname: Kodali
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York.
authors.forename: Tamim M
authors.initials: TM
authors.lastname: Nazif
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York.
authors.forename: Torsten P
authors.initials: TP
authors.lastname: Vahl
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York.
authors.forename: Jean-Michel
authors.initials: JM
authors.lastname: Paradis
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York.
authors.forename: Isaac
authors.initials: I
authors.lastname: George
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York.
authors.forename: Martin B
authors.initials: MB
authors.lastname: Leon
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York.
authors.forename: Rebecca T
authors.initials: RT
authors.lastname: Hahn
mesh_terms: D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery*; D000072226:Computed Tomography Angiography / Q000379:methods*; D019560:Echocardiography, Three-Dimensional / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D061330:Multidetector Computed Tomography / Q000379:methods*; D011300:Preoperative Care / Q000379:methods; D017755:Prosthesis Fitting / Q000379:methods*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods*; D016896:Treatment Outcome
keywords: Aortic annulus; TAVR; Three-dimensional echocardiography