Comparison of Two-Dimensional and Three-Dimensional Imaging Techniques for Measurement of Aortic Annulus Diameters Before Transcatheter Aortic Valve Implantation

Study Questions:

What is the comparative efficacy of different 2D and 3D imaging techniques, and the accuracy of 3D transesophageal echocardiography (TEE) for accurate analysis of aortic annulus dimensions?


In 49 consecutive patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) angiography, 2D transthoracic echocardiography (TTE), 2D and 3D TEE, and dual-source computed tomography (DSCT) were performed to determine aortic annulus diameters. TTE and 2D TEE provided only one diameter of the aortic annulus. Angiography, DSCT, and 3D TEE allowed measurement of diameters in sagittal and coronal views. The distance between aortic annulus and left main coronary artery ostium was measured by angiography, DSCT, and 3D TEE.


Sagittal diameters determined by angiography, TTE, 2D TEE, 3D TEE, and DSCT were smaller than coronal diameters determined by angiography, 3D TEE, and DSCT. Coronal and sagittal diameters determined by 3D TEE were in high agreement with corresponding measurements by DSCT (23.60 ± 1.89 vs. 23.46 ± 2.07 mm and 22.19 ± 1.96 vs. 22.27 ± 2.01 mm, respectively; mean ± SD). There was a high correlation between DSCT and 3D TEE for the definition of coronal and sagittal aortic annulus diameters (r = 0.88, SEE = 0.89 mm and r = 0.77, SEE = 1.26 mm, respectively). Correlation of 3D TEE (13.47 ± 1.67 mm) and DSCT (13.64 ± 1.82 mm) in the analysis of the distance between aortic annulus and left main coronary artery ostium was better (r = 0.54, SEE = 1.55 mm) than between angiography (14.85 ± 3.84 mm) and DSCT (r = 0.35, SEE = 1.77 mm).


The authors concluded that 3D imaging techniques should be used to evaluate aortic annulus diameters, as 2D imaging techniques, providing only a sagittal view, underestimate them.


This study confirms previous observations that the aortic annulus has an oval shape and that 2D imaging techniques may result in underestimation of aortic annulus diameters, and 3D imaging techniques should be used to evaluate aortic annulus diameters. Furthermore, 3D TEE provides aortic root dimensions similar to those obtained by DSCT and may be used as a substitute for DSCT for the critical role of prosthesis sizing before TAVI.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Aortic Surgery, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: Heart Valve Prosthesis, Succinimides, Piperazines, Angioplasty, Prostheses and Implants, Tomography, Cardiology, Acoustic Maculae, Coronary Vessels, Adventitia, Echocardiography

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