Does the aortic annulus undergo conformational change throughout the cardiac cycle? A systematic review

Accurate annular sizing in transcatheter aortic valve implantation (TAVI) planning is essential. It is now widely recognized that the annulus is an oval structure in most patients, but it remains unclear if the annulus undergoes change in size and shape during the cardiac cycle that may impact prosthesis size selection. Our aim was to assess whether the aortic annulus undergoes dynamic conformational change during the cardiac cycle and to evaluate possible implications for prosthesis size selection. We performed a systematic search in PubMed and Embase databases and reviewed all available literature on aortic annulus measurements in at least two cardiac phases. Twenty-nine articles published from 2001 to 2014 were included. In total, 2021 subjects with and without aortic stenosis were evaluated with a mean age ranging from 11 ± 3.6 to 84.9 ± 7.2 years. Two- and three-dimensional echocardiography was performed in six studies each, magnetic resonance imaging was used in one and computed tomography in 17 studies. In general, the aortic annulus was more circular in systole and predominantly oval in diastole. Whereas the annular long-axis diameter showed insignificant change throughout the cycle, the short-axis diameter, area, and perimeter were significantly larger in systole compared with diastole. Hence, the aortic annulus does undergo dynamic changes during the cardiac cycle. In patients with large conformational changes, diastolic compared with systolic measurements can result in undersizing TAVI prostheses. Due to the complex annular anatomy and dynamic change, three-dimensional assessment in multiple phases has utmost importance in TAVI planning to improve prosthesis sizing.