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Updated: Apr 27, 2026
Evaluation of Left Ventricular Structure and Function using 3D Echocardiography
Published on: October 28, 2020
Erroneous measurement of the aortic annular diameter using 2-dimensional echocardiography resulting in inappropriate
Darren Mylotte1, Magdalena Dorfmeister2, Yacine Elhmidi2
1Department of Interventional Cardiology, McGill University Health Centre, Montreal, Quebec, Canada; Department of Cardiology, University Hospital Galway, Galway, Ireland.
Insights
Transesophageal echocardiography (TEE) overestimated transcatheter heart valve (THV) oversizing, leading to undersized valves in 50% of patients. Computed tomography (CT) sizing improved adherence and reduced paravalvular leak (PVL).
Area of Science:
- Cardiology
- Medical Imaging
- Interventional Cardiology
Background:
- Computed tomography (CT) is increasingly used for transcatheter heart valve (THV) sizing, offering an alternative to transesophageal echocardiography (TEE).
- Accurate THV sizing is critical for optimal outcomes and minimizing complications like paravalvular leak (PVL).
Purpose of the Study:
- To compare the adherence to THV oversizing principles between TEE and CT.
- To evaluate the impact of TEE- versus CT-based sizing on the incidence of PVL.
Main Methods:
- Retrospective analysis of CT datasets to determine aortic annular diameters.
- Comparison of TEE-derived and CT-derived annular dimensions and calculated THV oversizing.
- Correlation of PVL incidence with TEE- and CT-based oversizing calculations.
Main Results:
- CT analysis revealed larger annular diameters than TEE, resulting in significantly less oversizing (10.4% vs. 20.1%).
- CT analysis indicated that up to 50% of patients received an inappropriately sized THV based on TEE measurements.
- Adherence to CT-based oversizing criteria was associated with a 21% lower incidence of PVL (14% vs. 35%) and independently reduced PVL risk.
Conclusions:
- TEE-based sizing for CoreValve implantation led to incorrect valve selection in 50% of patients, with actual oversizing being half of that calculated.
- CT-based annular sizing demonstrated better adherence to oversizing principles and was independently associated with a reduced incidence of PVL, suggesting its superiority for THV sizing.
Objectives:
This study sought to assess the differential adherence to transcatheter heart valve (THV)-oversizing principles between transesophageal echocardiography (TEE) and multislice computed tomography (CT) and its impact on the incidence of paravalvular leak (PVL).
Background:
CT has emerged as an alternative to 2-dimensional TEE for THV sizing.
Methods:
In our early experience, TEE-derived aortic annular diameters determined THV size selection. CT datasets originally obtained for vascular screening were retrospectively interrogated to determine CT-derived annular diameters. Annular dimensions and expected THV oversizing were compared between TEE and CT. The incidence of PVL was correlated to TEE- and CT-based oversizing calculations.
Results:
Using TEE-derived annulus measurements, 157 patients underwent CoreValve implantation (23 mm: n = 66; 29 mm: n = 91). The estimated THV oversizing on the basis of TEE was 20.1 ± 8.2%. Retrospective CT analysis yielded larger annular diameters than TEE (p < 0.0001). When these CT diameters were used to recalculate the percentage of oversizing achieved with the TEE-selected CoreValve, the actual THV oversizing was only 10.4 ± 7.8%. Consequently, CT analysis suggested that up to 50% of patients received an inappropriate CoreValve size. When CT-based sizing criteria were satisfied, the incidence of PVL was 21% lower than that with echocardiography (14% vs. 35%; p = 0.003). Adherence to CT-based oversizing was independently associated with a reduced incidence of PVL (odds ratio 0.36; 95% confidence interval: 0.14 to 0.90; p = 0.029); adherence to TEE-based sizing was not.
Conclusions:
Retrospective CT-based annular analysis revealed that CoreValve size selection by TEE was incorrect in 50% of patients. The percentage of oversizing with CT was one-half of that calculated with TEE resulting in the majority of patients receiving a THV that was too small.
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