European Radiology

, Volume 29, Issue 1, pp 259–269 | Cite as

Optimal pre-TAVR annulus sizing in patients with bicuspid aortic valve: area-derived perimeter by CT is the best-correlated measure with intraoperative sizing

  • Yuan Wang
  • Moyang Wang
  • Guanyuan Song
  • Wei Wang
  • Bin Lv
  • Hao Wang
  • Yongjian WuEmail author



To clarify the optimal measurements for patients with bicuspid aortic valve (BAV) preferred for transcatheter aortic valve replacement (TAVR), our study compared intraoperative sizing with five different approaches by transthoracic echocardiography (TTE), three-dimensional transesophageal echocardiography (3DTEE) and computed tomography (CT).


We enrolled 104 BAV patients prescreened for TAVR but who underwent surgery with direct intraoperative annulus sizing. All five approaches [2DTTE, 3DTEE, area-derived perimeter (CTarea), perimeter-derived diameter (CTperi) and mean diameter (CTmean)] were compared with intraoperative sizing, respectively. Agreements on theoretical valve selections by five methods with those by intraoperative sizing were analyzed.


CTarea showed the highest correlation (r = 0.932) and the best agreement with intraoperative sizing. Agreement for theoretical surgical and TAVR prosthesis selection was found in 84.6% and 74.0% BAVs by CTarea (κ = 0.791, κ = 0.585). CTperi-based prosthesis selection led to overestimation of 26.9% for surgical valves (κ = 0.589) and 36.5% for TAVR valves (κ = 0.425). Good correlations were observed between CT measurements and intraoperative sizing regardless of the predominant site of aortic valve calcification (r = 0.860-0.953).


The CTarea, which demonstrated the optimal approach to annulus sizing and prosthesis choice of BAVs with high eccentricity, should be included into the BAV-specific annulus sizing recommendation. The insufficiency of CTperi lay in overestimation of surgical or TAVR valve selections. Good agreement of 3DTEE sizing proved its superiority in annulus sizing for BAVs unsuitable for CT, but it should be used with caution for patients with a calcified annulus, where partial acoustic shadowing could lead to image inaccuracy.

Key Points

The area-derived perimeter by CT is the optimal approach to annulus sizing of BAVs.

The perimeter-derived approach is prone to overestimation of BAVs.

3DTEE showed its superiority in annulus sizing for BAVs unsuitable for CT, but it should be used with caution in patients with a calcified annulus.


Aortic valve Transcatheter aortic valve replacement Echocardiography Multidetector computed tomography Aortic valve stenosis 



Bicuspid aortic valve


Body surface area


Tricuspid aortic valve


Transcatheter aortic valve replacement



The authors thank the staff members of the imaging department for their invaluable contribution.


This study was supported by grants from the Pecking Union Medical College Student Innovation Fund (project no. 2016-1002-01-05, Beijing, China) to YW.

Compliance with ethical standards


The scientific guarantor of this publication is Dr. Yongjian Wu.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• randomized controlled trial

• performed at one institution

Supplementary material

330_2018_5592_MOESM1_ESM.docx (20 kb)
ESM 1 (DOCX 20 kb)


  1. 1.
    Mack MJ, Leon MB, Smith CR et al (2015) 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 385:2477–2484CrossRefGoogle Scholar
  2. 2.
    Perlman GY, Blanke P, Dvir D et al (2016) Bicuspid aortic valve stenosis: favorable early outcomes with a next-generation transcatheter heart valve in a multicenter study. JACC Cardiovasc Interv 9:817–824CrossRefGoogle Scholar
  3. 3.
    Pontone G, Andreini D, Bartorelli AL et al (2012) Aortic annulus area assessment by multidetector computed tomography for predicting paravalvular regurgitation in patients undergoing balloon-expandable transcatheter aortic valve implantation: a comparison with transthoracic and transesophageal echocardiography. Am Heart J 164:576–584CrossRefGoogle Scholar
  4. 4.
    Nishimura RA, Otto CM, Bonow RO et al (2014) 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 148:e1–e132CrossRefGoogle Scholar
  5. 5.
    Otto CM, Kumbhani DJ, Alexander KP et al (2017) 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults with Aortic Stenosis: A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 69:1313–1346CrossRefGoogle Scholar
  6. 6.
    Wijesinghe N, Ye J, Rodés-Cabau J et al (2010) Transcatheter aortic valve implantation in patients with bicuspid aortic valve stenosis. JACC Cardiovasc Interv 3:1122–1125CrossRefGoogle Scholar
  7. 7.
    Hayashida K, Bouvier E, Lefèvre T et al (2013) Transcatheter aortic valve implantation for patients with severe bicuspid aortic valve stenosis. Circ Cardiovasc Interv 6:284–291CrossRefGoogle Scholar
  8. 8.
    Stolzmann P, Leschka S, Scheffel H et al (2008) Dual-source CT in step-and-shoot mode: noninvasive coronary angiography with low radiation dose. Radiology 249:71–80CrossRefGoogle Scholar
  9. 9.
    Jilaihawi H, Chen M, Webb J et al (2016) A bicuspid aortic valve imaging classification for the TAVR Era. JACC Cardiovasc Imaging 9:1145–1158CrossRefGoogle Scholar
  10. 10.
    Kerl JM, Ravenel JG, Nguyen SA et al (2008) Right heart: split-bolus injection of diluted contrast medium for visualization at coronary CT angiography. Radiology 247:356–364CrossRefGoogle Scholar
  11. 11.
    Shin HJ, Shin JK, Chee HK et al (2015) Characteristics of aortic valve dysfunction and ascending aorta dimensions according to bicuspid aortic valve morphology. Eur Radiol 25:2103–2114CrossRefGoogle Scholar
  12. 12.
    Vaquerizo B, Spaziano M, Alali J et al (2016) Three-dimensional echocardiography vs. computed tomography for transcatheter aortic valve replacement sizing. Eur Heart J Cardiovasc Imaging 17:15–23PubMedGoogle Scholar
  13. 13.
    Schnell S, Smith DA, Barker AJ et al (2016) Altered aortic shape in bicuspid aortic valve relatives influences blood flow patterns. Eur Heart J Cardiovasc Imaging 17:1239–1247CrossRefGoogle Scholar
  14. 14.
    Pham T, Martin C, Elefteriades J et al (2013) Biomechanical characterization of ascending aortic aneurysm with concomitant bicuspid aortic valve and bovine aortic arch. Acta Biomater 9:7927–7936CrossRefGoogle Scholar
  15. 15.
    Zhao ZG, Jilaihawi H, Feng Y et al (2015) Transcatheter aortic valve implantation in bicuspid anatomy. Nat Rev Cardiol 12:123–128CrossRefGoogle Scholar
  16. 16.
    Yano M, Nakamura K, Nagahama H et al (2012) Aortic annulus diameter measurement: what is the best modality? Ann Thorac Cardiovasc Surg 18:115–120CrossRefGoogle Scholar
  17. 17.
    Tamborini G, Fusini L, Muratori M et al (2014) Feasibility and accuracy of three-dimensional transthoracic echocardiography vs. multidetector computed tomography in the evaluation of aortic valve annulus in patient candidates to transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 15:1316–1323CrossRefGoogle Scholar
  18. 18.
    Jurencak T, Turek J, Kietselaer BL et al (2015) MDCT evaluation of aortic root and aortic valve prior to TAVI. What is the optimal imaging time point in the cardiac cycle? Eur Radiol 25:1975–1983CrossRefGoogle Scholar
  19. 19.
    Murphy DT, Blanke P, Alaamri S et al (2016) Dynamism of the aortic annulus: Effect of diastolic versus systolic CT annular measurements on device selection in transcatheter aortic valve replacement (TAVR). J Cardiovasc Comput Tomogr 10:37–43CrossRefGoogle Scholar
  20. 20.
    Kempfert J, Van Linden A, Lehmkuhl L et al (2012) Aortic annulus sizing: echocardiographic versus computed tomography derived measurements in comparison with direct surgical sizing. Eur J Cardiothorac Surg 42:627–633CrossRefGoogle Scholar
  21. 21.
    Wang H, Hanna JM, Ganapathi A et al (2015) Comparison of aortic annulus size by transesophageal echocardiography and computed tomography angiography with direct surgical measurement. Am J Cardiol 115:1568–1573CrossRefGoogle Scholar
  22. 22.
    Salaun E, Zenses AS, Evin M et al (2016) Effect of oversizing and elliptical shape of aortic annulus on transcatheter valve hemodynamics: an in vitro study. Int J Cardiol 208:28–35CrossRefGoogle Scholar
  23. 23.
    Kim WK, Meyer A, Mollmann H et al (2016) Cyclic changes in area- and perimeter-derived effective dimensions of the aortic annulus measured with multislice computed tomography and comparison with metric intraoperative sizing. Clin Res Cardiol 105:622–629CrossRefGoogle Scholar
  24. 24.
    Rixe J, Schuhbaeck A, Liebetrau C et al (2012) Multi-detector computed tomography is equivalent to trans-oesophageal echocardiography for the assessment of the aortic annulus before transcatheter aortic valve implantation. Eur Radiol 22:2662–2669CrossRefGoogle Scholar
  25. 25.
    Podlesnikar T, Prihadi EA, van Rosendael PJ et al (2018) Influence of the quantity of aortic valve calcium on the agreement between automated 3-dimensional transesophageal echocardiography and multidetector row computed tomography for aortic annulus sizing. Am J Cardiol 121:86-93Google Scholar
  26. 26.
    George I, Guglielmetti LC, Bettinger N et al (2017) Aortic valve annular sizing: intraoperative assessment versus preoperative multidetector computed tomography. Circ Cardiovasc Imaging 10(5).
  27. 27.
    Ruile P, Blanke P, Krauss T et al (2016) Pre-procedural assessment of aortic annulus dimensions for transcatheter aortic valve replacement: comparison of a non-contrast 3D MRA protocol with contrast-enhanced cardiac dual-source CT angiography. Eur Heart J Cardiovasc Imaging 17:458–466CrossRefGoogle Scholar
  28. 28.
    Schmauss D, Schmitz C, Bigdeli AK et al (2012) Three-dimensional printing of models for preoperative planning and simulation of transcatheter valve replacement. Ann Thorac Surg 93:31–33CrossRefGoogle Scholar
  29. 29.
    Patsalis PC, Al-Rashid F, Neumann T et al (2013) Preparatory balloon aortic valvuloplasty during transcatheter aortic valve implantation for improved valve sizing. JACC Cardiovasc Interv 6:965–971CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Yuan Wang
    • 1
  • Moyang Wang
    • 1
  • Guanyuan Song
    • 1
  • Wei Wang
    • 2
  • Bin Lv
    • 3
  • Hao Wang
    • 4
  • Yongjian Wu
    • 1
    Email author
  1. 1.Department of Cardiology, Ward 52, Fuwai Hospital, National Center for Cardiovascular DiseaseChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
  2. 2.Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular DiseaseBeijingChina
  3. 3.Department of Radiology, Fuwai Hospital, National Center for Cardiovascular DiseaseBeijingChina
  4. 4.Department of Ultrasound, Fuwai Hospital, National Center for Cardiovascular DiseaseBeijingChina

Personalised recommendations