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

2. Axel Linke, MD
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Company
Grant/Research Support
Consulting Fees/Honoraria
Major Stock Shareholder/Equity
Royalty Income
Ownership/Founder
Intellectual Property Rights
Other Financial Benefit
Claret Medical Inc. Medtronic, Bard
Medtronic, SJM, Edwards Lifesciences, Symetis, Boston Scientific, Bard
Claret Medical Inc.
None

3. Multimodal Imaging Echocardiography Right/left heart catheter
Angiography
MS-CT
Dyna-CT
Cardio-MRT

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

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. 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)

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. Systolic vs. Diastolic Assessment
Systole
Diastole

16. 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

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

18. 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

19. Anatomical Preconditions – Assessment by TOE

20. 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

21. 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

22. 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?

23. Tsuneyoshi H, J. Cardiac Surgery 2016, 31, 18-22
2D-TTE vs. 3D-TEE vs. 4DCT
Tsuneyoshi H, J. Cardiac Surgery 2016, 31, 18-22

24. 2D-TTE vs. 3D-TEE vs. 4DCT

25. 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. (Low contrast 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 balloon-expandable valves in bicuspid aortic stenosis.

26. Thank you!