Maximum Aortic Valve Opening Phase for Annulus Sizing in Pre-TAVR CTA

      Rationale and Objectives

      The optimal phase for the measurement of the aortic annular area for transcatheter aortic valve replacement (TAVR) is not standardized, although most agree that systolic measurements are preferred, when the annulus is larger. We hypothesized that the maximum annular area occurs at the cardiac phase of the maximum aortic valve opening (MAVO) and that this phase can be accurately and reproducibly assessed by visual inspection only.

      Materials and Methods

      The aortic valve opening area was inspected visually by two readers to determine the MAVO phase. The annular area was measured at the MAVO phase and the typical systolic phase (35% of the R-R interval). Differences in the annular area that would change valve sizing for prostheses were noted.


      Fifty patients (mean age 81) were studied. Ninety percent had the MAVO at the 15%–25% R-R interval. There was high interobserver correlation (0.89) for determining the MAVO phase by visual inspection. For 49 out of 50 patients, the annular area was maximal at the MAVO phase. The mean difference in the annular area between the MAVO phase and 35% was 22.3 (±4.57) mm2. In 12% of the patients, the difference in the annular area changed the recommended size of a self-expanding prosthesis and would have altered the procedure in 32% for balloon-expandable prostheses.


      Visually assessed MAVO occurs in early systole for most patients and is almost always the cardiac phase of the maximal aortic annular area. This method allows rapid and reproducible determination of the appropriate phase for TAVR planning measurements. Consideration should be given to optimizing pre-TAVR computed tomography acquisitions for early systolic reconstruction and visual determination of the MAVO.

      Key Words

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        • Kodali S.K.
        • Williams M.R.
        • Smith C.R.
        • et al.
        Two-year outcomes after transcatheter or surgical aortic-valve replacement.
        N Engl J Med. 2012; 366: 1686-1695
        • Makkar R.R.
        • Fontana G.P.
        • Jilaihawi H.
        • et al.
        Transcatheter aortic-valve replacement for inoperable severe aortic stenosis.
        N Engl J Med. 2012; 366: 1696-1704
        • Lehmkuhl L.
        • Foldyna B.
        • Von Aspern K.
        • et al.
        Inter-individual variance and cardiac cycle dependency of aortic root dimensions and shape as assessed by ECG-gated multi-slice computed tomography in patients with severe aortic stenosis prior to transcatheter aortic valve implantation: is it crucial for correct sizing?.
        Int J Cardiovasc Imaging. 2013; 29: 693-703
        • de Heer L.M.
        • Budde R.P.
        • Mali W.P.
        • et al.
        Aortic root dimension changes during systole and diastole: evaluation with ECG-gated multidetector row computed tomography.
        Int J Cardiovasc Imaging. 2011; 27: 1195-1204
        • Bertaso A.G.
        • Wong D.T.
        • Liew G.Y.
        • et al.
        Aortic annulus dimension assessment by computed tomography for transcatheter aortic valve implantation: differences between systole and diastole.
        Int J Cardiovasc Imaging. 2012; 28: 2091-2098
        • Leipsic J.
        • Gurvitch R.
        • Labounty T.M.
        • et al.
        Multidetector computed tomography in transcatheter aortic valve implantation.
        JACC Cardiovasc Imaging. 2011; 4: 416-429
        • Holmes Jr, D.R.
        • Mack M.J.
        • Kaul S.
        • et al.
        2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement.
        J Am Coll Cardiol. 2012; 59: 1200-1254
        • Achenbach S.
        • Delgado V.
        • Hausleiter J.
        • et al.
        SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR).
        J Cardiovasc Comput Tomogr. 2012; 6: 366-380
        • Hamdan A.
        • Guetta V.
        • Konen E.
        • et al.
        Deformation dynamics and mechanical properties of the aortic annulus by 4-dimensional computed tomography: insights into the functional anatomy of the aortic valve complex and implications for transcatheter aortic valve therapy.
        J Am Coll Cardiol. 2012; 59: 119-127
        • Lehmkuhl L.
        • Foldyna B.
        • Haensig M.
        • et al.
        Role of preprocedural computed tomography in transcatheter aortic valve implantation.
        Rofo. 2013; 185: 941-949
        • Feuchtner G.M.
        • Dichtl W.
        • Friedrich G.J.
        • et al.
        Multislice computed tomography for detection of patients with aortic valve stenosis and quantification of severity.
        J Am Coll Cardiol. 2006; 47: 1410-1417
        • Kasel A.M.
        • Cassese S.
        • Bleiziffer S.
        • et al.
        Standardized imaging for aortic annular sizing: implications for transcatheter valve selection.
        JACC Cardiovasc Imaging. 2013; 6: 249-262
        • Blanke P.
        • Russe M.
        • Leipsic J.
        • et al.
        Conformational pulsatile changes of the aortic annulus: impact on prosthesis sizing by computed tomography for transcatheter aortic valve replacement.
        JACC Cardiovasc Interv. 2012; 5: 984-994
        • Willson A.B.
        • Webb J.G.
        • Freeman M.
        • et al.
        Computed tomography-based sizing recommendations for transcatheter aortic valve replacement with balloon-expandable valves: comparison with transesophageal echocardiography and rationale for implementation in a prospective trial.
        J Cardiovasc Comput Tomogr. 2012; 6: 406-414
        • Gurvitch R.
        • Webb J.G.
        • Yuan R.
        • et al.
        Aortic annulus diameter determination by multidetector computed tomography: reproducibility, applicability, and implications for transcatheter aortic valve implantation.
        JACC Cardiovasc Interv. 2011; 4: 1235-1245
        • Willson A.B.
        • Webb J.G.
        • Labounty T.M.
        • et al.
        3-Dimensional aortic annular assessment by multidetector computed tomography predicts moderate or severe paravalvular regurgitation after transcatheter aortic valve replacement: a multicenter retrospective analysis.
        J Am Coll Cardiol. 2012; 59: 1287-1294
        • Binder R.K.
        • Webb J.G.
        • Willson A.B.
        • et al.
        The impact of integration of a multidetector computed tomography annulus area sizing algorithm on outcomes of transcatheter aortic valve replacement: a prospective, multicenter, controlled trial.
        J Am Coll Cardiol. 2013; 62: 431-438
        • Vahanian A.
        • Alfieri O.
        • Al-Attar N.
        • et al.
        Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European association of cardio-thoracic surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI).
        EuroIntervention. 2008; 4: 193-199
        • Tops L.F.
        • Wood D.A.
        • Delgado V.
        • et al.
        Noninvasive evaluation of the aortic root with multislice computed tomography implications for transcatheter aortic valve replacement.
        JACC Cardiovasc Imaging. 2008; 1: 321-330
        • Wood D.A.
        • Tops L.F.
        • Mayo J.R.
        • et al.
        Role of multislice computed tomography in transcatheter aortic valve replacement.
        Am J Cardiol. 2009; 103: 1295-1301
        • Detaint D.
        • Lepage L.
        • Himbert D.
        • et al.
        Determinants of significant paravalvular regurgitation after transcatheter aortic valve: implantation impact of device and annulus discongruence.
        JACC Cardiovasc Interv. 2009; 2: 821-827
        • Tay E.L.
        • Gurvitch R.
        • Wijeysinghe N.
        • et al.
        Outcome of patients after transcatheter aortic valve embolization.
        JACC Cardiovasc Interv. 2011; 4: 228-234
        • Blanke P.
        • Reinohl J.
        • Schlensak C.
        • et al.
        Prosthesis oversizing in balloon-expandable transcatheter aortic valve implantation is associated with contained rupture of the aortic root.
        Circ Cardiovasc Interv. 2012; 5: 540-548
        • Pasic M.
        • Buz S.
        • Dreysse S.
        • et al.
        Transapical aortic valve implantation in 194 patients: problems, complications, and solutions.
        Ann Thorac Surg. 2010; 90 (discussion 9–70): 1463-1469
        • Schultz C.J.
        • Moelker A.D.
        • Tzikas A.
        • et al.
        Cardiac CT: necessary for precise sizing for transcatheter aortic implantation.
        EuroIntervention. 2010; 6: G6-G13
        • Doddamani S.
        • Grushko M.J.
        • Makaryus A.N.
        • et al.
        Demonstration of left ventricular outflow tract eccentricity by 64-slice multi-detector CT.
        Int J Cardiovasc Imaging. 2009; 25: 175-181
        • Altiok E.
        • Koos R.
        • Schroder J.
        • et al.
        Comparison of two-dimensional and three-dimensional imaging techniques for measurement of aortic annulus diameters before transcatheter aortic valve implantation.
        Heart. 2011; 97: 1578-1584
        • Dashkevich A.
        • Blanke P.
        • Siepe M.
        • et al.
        Preoperative assessment of aortic annulus dimensions: comparison of noninvasive and intraoperative measurement.
        Ann Thorac Surg. 2011; 91: 709-714
        • Blanke P.
        • Siepe M.
        • Reinohl J.
        • et al.
        Assessment of aortic annulus dimensions for Edwards SAPIEN Transapical Heart Valve implantation by computed tomography: calculating average diameter using a virtual ring method.
        Eur J Cardiothorac Surg. 2010; 38: 750-758
        • Colli A.
        • Nofrerias E.F.
        • Escudero A.
        Aortic root rupture during trans-catheter aortic valve implantation.
        Eur J Cardiothorac Surg. 2011; 39: 788
        • Buzzatti N.
        • Maisano F.
        • Latib A.
        • et al.
        Computed tomography-based evaluation of aortic annulus, prosthesis size and impact on early residual aortic regurgitation after transcatheter aortic valve implantation.
        Eur J Cardiothorac Surg. 2013; 43 (discussion 50–51): 43-50
        • Jurencak T.
        • Turek J.
        • Kietselaer B.L.
        • et al.
        MDCT evaluation of aortic root and aortic valve prior to TAVI. What is the optimal imaging time point in the cardiac cycle?.
        Eur Radiol. 2015; 25: 1975-1983
        • Feuchtner G.M.
        • Muller S.
        • Bonatti J.
        • et al.
        Sixty-four slice CT evaluation of aortic stenosis using planimetry of the aortic valve area.
        AJR Am J Roentgenol. 2007; 189: 197-203