1. Optimizing Valve Sizing: Role of CT vs. Echo
Axel Linke
1University of Leipzig, Heart Center, Leipzig, Germany,

2. Axel Linke, MD Affiliation/Financial Relationship Company
Grant/Research Support
Consulting Fees/Honoraria
Major Stock Shareholder/Equity
Royalty Income
Ownership/Founder
Intellectual Property Rights
Other Financial Benefit
Medtronic Inc., Claret Medical Inc.
Medtronic Inc., S. Jude Medical Inc., Claret Medical Inc., Boston Scientific, Edwards Lifesciences
none

3. Multimodal Imaging Echocardiography Right/left heart catheter
Angiography
MS-CT
Dyna-CT
Cardio-MRT
*Messe SR et al, Circulation 2014;129:

4. Anatomical Preconditions (Annulus/Aorta)
Surgical Anatomy of the Heart, 3rd Edition, Benson R. Wilcox, UNC Hospitals, Andrew C. Cook, Robert H. Anderson,
Copyright © 2004 Cambridge University Press (figures 3.41, p. 69 and 4.101, p. 182) . Reprinted with the permission of Cambridge University Press.

5. Important TAVI Measurements
Size of aortic valve annulus
Size and height of Sinus valsalvae
Diameter at sinutubuläre junction
Diameter of ascending aorta
Distance coronary ostia to valve
Diameter of the LVOT
*Messe SR et al, Circulation 2014;129:

6. The Annulus
Virtual plain through the deepest points of the three cusps
Important parameter to determine transcatheter valve size
Aorta LV
Aortic Annulus

7. MSCT - The Reference Method for Annulus Sizing

8. CT as the Reference – The Literature

9. Methods of Measurement
Considerations
Methods of Measurement CT
PRO
CONTRA
- 3-dimensional picture
good assessment of the
ascending aorta
distance to the coronary ostia available
assessment of calcification (calcium score)
additional information about co-morbidities
high amount of contrast
medium
impaired imaging in case
of severe calcification
additional time need
cooperation of the patient

10. MSCT: Multiplanar Reconstruction

11. MSCT: Verify Aortic Annular Plane

12. MSCT: Reconstruct the Annulus (Circumference)
*Messe SR et al, Circulation 2014;129:

13. Annular Parameters
Diameter
(minor, major, mean)
Area
Perimeter
Annulus often elliptical or irregular
Which one are we going to use for determination of valve size?

14. Precision of annular assessment by Echo and MSCT

15. Transthoracic Echocardiography
Assessment of
Valve morphology
Jet velocity
Orifice area
Level of AR
Aortic root
Ascending aorta
LV function
LV hypertrophy
LVOT obstruction
Diastolic function
Mitral valve
PA-Pressure

16. Anatomical Preconditions (Annulus/Aorta)
Methods of Measurement - TTE
- Annulus: 20 mm
- ascend. aorta: 32 mm
- native valve moderately calcified

17. Anatomical Preconditions (Annulus/Aorta)
Methods of Measurement
TTE
PRO
CONTRA
no contrast medium needed
non-invasive
no radiation
impaired imaging quality in many elderly patients: assessment not reliable
no information about the distance between the ostia of the coronaries and the native valve
limited information about the
ascending aorta

18. Anatomical Preconditions – Assessment by TOE

19. Anatomical Preconditions (Annulus/Aorta)
Methods of Measurement
TEE
PRO
CONTRA
no contrast medium needed
non-invasive
no radiation
reliable assessment of the annulus and ascending aorta
good information about the shape of the annulus
(round vs. oval)
cooperation of the patient
impaired imaging quality
in patients with severe calcification
- identification of the coronary ostia requires some experience

20. Annulus Size exact longitudinal axis of the ascending aorta required
sinus and STJ have to be visable
measurement at the insertion of the NCC and RCC
consider calcium protruding into the LVOT
average 3 assessments
Decision on valve size

21. Anatomy of the Aortic Root
Size of Sinus valsalvae
Sinus height, STJ size
Size of the ascending aorta
Room to accomodate the calcified leaflets ?
Fixation of the valve possible?

22. Summary
- The CT appears to be the ideal way to assess the annulus and the vasculature.
However, the method of assessment should take comorbidities into account. (No CT in severe RF!)
- In case of any uncertainty: use a second method!
In bicuspid valves, CT is essential to determine the annulus
size. Be careful with ballon-expandable valves in bicuspid aortic stenosis.

23. Thank you!