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