Cross-Sectional Computed Tomographic Assessment Improves Accuracy of Aortic Annular Sizing for Transcatheter Aortic Valve Replacement and Reduces the Incidence of Paravalvular Aortic Regurgitation

Study Questions:

Using the outcome measure of post-procedure paraprosthetic aortic regurgitation, what is the optimal method for aortic annulus sizing for transcatheter aortic valve implantation (TAVI)?

Methods:

The discriminatory value of multiple computed tomography (CT) annular measures for post-TAVI paraprosthetic aortic regurgitation was compared with two-dimensional echocardiographic measures. TAVI outcomes with device selection according to aortic annular sizing using a traditional two-dimensional transesophageal echocardiography–guided or a novel CT-guided approach also were studied.

Results:

In receiver-operating characteristic models, cross-sectional CT parameters had the highest discriminatory value for post-TAVI paraprosthetic regurgitation. Receiver operating curves yielded best results using maximal cross-sectional diameter minus prosthesis size (area under the curve, 0.82; 95% confidence interval, 0.69-0.94; p < 0.001) and circumference-derived cross-sectional diameter minus prosthesis size (area under the curve, 81; 95% confidence interval, 0.70-0.94; p < 0.001). In contrast, traditional echocardiographic measures were nondiscriminatory in relation to post-TAVI paraprosthetic aortic regurgitation. The prospective application of CT-guided annular sizing resulted in a lower incidence of > mild paraprosthetic aortic regurgitation following TAVI (7.5% vs. 21.9%, p = 0.045).

Conclusions:

The authors concluded that three-dimensional cross-sectional measures using CT are the new gold standard for aortic annular evaluation for TAVI with the Edwards SAPIEN device.

Perspective:

Introspective imagers understand the limitations as well as the strengths of their imaging technique. Two-dimensional echocardiography, whether transthoracic or transesophageal, cannot reliably image the three-dimensional and often asymmetric shape of the diseased aortic valve annulus; and three-dimensional echocardiography lacks adequate spatial resolution. With data suggesting that significant aortic regurgitation represents a risk after TAVI, this study supports the three-dimensional assessment of aortic annular size using CT.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound

Keywords: Outcome Assessment (Health Care), Heart Valve Prosthesis, Heart Valve Prosthesis Implantation, Angioplasty, Heart Diseases, Prostheses and Implants, Incidence, Tomography, Heart Valve Diseases, Confidence Intervals, ROC Curve, Esophagus, Echocardiography


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