Predicting paravalvular regurgitation following transcatheter valve replacement: utility of a novel method for three-dimensional echocardiographic measurements of the aortic annulus

Background: Studies evaluating three-dimensional echocardiographic (3DE) annular sizing for balloon-expandable transcatheter aortic valve replacement (TAVR) are limited. In this study, a retrospective analysis of transesophageal echocardiographic images was performed to assess the feasibility of multiplanar measurements of annular dimensions by the novel off-label use of commercially available 3DE software and correlate annular sizing with severity of paravalvular regurgitation (PVR).

Methods: Intraprocedural transesophageal echocardiography was performed in 58 patients undergoing TAVR for severe, symptomatic aortic stenosis. Off-label use of commercially available software was used to measure transesophageal 3DE volumes. Pre-TAVR annular linear dimensions included two-dimensional echocardiographic sagittal diameter and 3DE measurements of minimal diameter, maximal diameter (MaxDiam), and the average or mean diameter. Three-dimensional echocardiographic average annular diameter derived from annular perimeter (AveAnnDiamP) and average annular diameter derived from annular area (AveAnnDiamA) were calculated. A cover index was calculated using each measurement. Short-axis PVR color jet areas were summed after deployment and at the end of study.

Results: Two-dimensional echocardiographic sagittal diameter was significantly smaller than 3DE MaxDiam (P < .0001) and AveAnnDiamP (P = .017), significantly larger than 3DE minimal diameter (P < .0001), and not significantly different from 3DE mean diameter (P = .36) and AveAnnDiamA (P = .38). There was a linear relationship between all 3DE annular measurements and immediate post-TAVR PVR area (P ≤ .0001), with the largest R(2) value (0.48) for 3DE MaxDiam, 3DE AveAnnDiamP, and 3DE AveAnnDiamA. The largest areas under the curve to detect greater than mild PVR were for 3DE AveAnnDiamP cover index (0.772) and 3DE AveAnnDiamA cover index (0.769). Intraclass correlation coefficients for interobserver and intraobserver variability were high for 3DE AveAnnDiamP and 3DE AveAnnDiamA and lower for 3DE MaxDiam.

Conclusions: Using a novel approach to 3DE annular measurements, 3DE AveAnnDiamP and 3DE AveAnnDiamA can be reliably measured and correlate best with post-TAVR PVR area. New sizing algorithms with 3DE measurements should be developed.