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Four-Dimensional Computed Tomography-Guided Valve Sizing for Transcatheter Pulmonary Valve Replacement
Published on: January 20, 2022
Relationship of Annular Sizing Using Multidetector Computed Tomographic Imaging and Clinical Outcomes After
Jeffrey J Popma1, Thomas G Gleason2, Steven J Yakubov2
1From the Departments of Internal Medicine (Cardiovascular Division) and Surgery (Cardiovascular Surgery) of the Beth Israel Deaconess Medical Center, Boston, MA (J.J.P., D.S.P.); Division of Cardiac Surgery, University of Pittsburgh Medical Center, PA (T.G.G.); Riverside Medical Center, Columbus, OH (S.J.Y.); Duke University Medical Center, Durham, NC (J.K.H.); Yale University Medical Center, New Haven, CT (J.K.F.); Pinnacle Health Care, Harrisburg, PA (B.M.); Lenox Hill Medical Center, New York, NY (C.E.R.); Department of Medicine-Cardiovascular Medicine, Case Western Reserve, Cleveland, OH (M.C.); Departments of Medicine (J.R.) and Surgery (J. Conte), Johns Hopkins Medical Center, Baltimore, MD; Division of Cardiac Surgery, Ohio State University, Columbus (J. Crestanello); Statistical Services, Medtronic, Inc, Minneapolis, MN (Y.C.); Department of Cardiovascular Diseases, Mayo Clinic Medical Center, Rochester, MN (J.K.O.); Houston Methodist DeBakey Heart & Vascular Center, TX (M.J.R.); and Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York (D.H.A.). jpopma@bidmc.harvard.edu.
Insights
Adhering to computed tomography sizing algorithms for transcatheter heart valve (THV) replacement in severe aortic stenosis reduces paravalvular aortic regurgitation. This approach ensures optimal valve sizing without increasing complications in high-risk patients.
Area of Science:
- Cardiology
- Radiology
- Medical Imaging
Background:
- Severe aortic stenosis poses significant risks for surgical candidates.
- Multidetector computed tomography (MDCT) is crucial for selecting appropriate transcatheter heart valve (THV) sizes.
- The clinical impact of adhering to MDCT-based sizing algorithms for THV replacement remains unclear.
Purpose of the Study:
- To investigate the relationship between adherence to the CoreValve sizing algorithm and clinical outcomes.
- To evaluate the effectiveness of MDCT in guiding THV sizing for severe aortic stenosis patients.
- To assess the incidence of paravalvular aortic regurgitation (PAR) based on THV sizing compliance.
Main Methods:
- A cohort of 1023 patients with severe aortic stenosis received CoreValve THV implantation.
- Preprocedural MDCT scans were analyzed using standardized software to assess compliance with a recommended sizing algorithm.
- Patients were categorized into below-range, in-range, and above-range THV sizing groups. Device annular sizing ratio (DAR) was calculated.
- Paravalvular aortic regurgitation was evaluated by an independent echocardiographic laboratory.
Main Results:
- Adherence to the sizing algorithm varied by THV size, highest for 31-mm (92.6%) and lowest for 23-mm (38.5%).
- Below-range THV sizing was linked to significantly higher rates of moderate/severe paravalvular aortic regurgitation (15.3%) compared to in-range (6.5%) and above-range (10.0%) sizing.
- Increasing Device Annular Sizing Ratios (DAR) correlated with decreased rates of moderate/severe paravalvular aortic regurgitation (P<0.001).
Conclusions:
- Adherence to MDCT-based sizing algorithms for transcatheter heart valve replacement is associated with reduced paravalvular aortic regurgitation.
- Optimal THV sizing using MDCT can be achieved without an increase in clinical complications.
- The findings support the use of MDCT-guided sizing algorithms for improved outcomes in transcatheter aortic stenosis treatment.
Background:
Multidetector computed tomography is useful for determining the appropriate transcatheter heart valve (THV) size in patients with severe aortic stenosis who are suboptimal surgical candidates. The relationship between adherence to the recommended CoreValve sizing algorithm and clinical outcomes is not known.
Methods And Results:
We evaluated 1023 patients with severe aortic stenosis deemed high or extreme risk for surgery treated with the CoreValve THV. All patients underwent preprocedural multidetector computed tomography, and the scans were reviewed at a central analysis center using standardized software. Compliance to a recommended sizing algorithm was used to identify patients with below-range, in-range, and above-range THV sizing. A device annular sizing ratio (DAR) was also calculated based on the native annulus perimeter and perimeter of the selected THV. Clinical end points included the presence of paravalvular aortic regurgitation evaluated by an independent echocardiographic laboratory. Adherence to the sizing algorithm was highest with a 31-mm THV (92.6%) and lowest with the 23-mm THV (38.5%). Below-range sizing was associated with a higher rate of moderate or severe paravalvular aortic regurgitation (15.3%) than in-range (6.5%) or above-range (10.0%; P<0.001) sizing. Higher DARs were associated with lower rates of moderate or severe paravalvular aortic regurgitation: DAR ≤10%, 17.6%; DAR 10% to 15%, 9.9%; DAR 15% to 20%, 6.3%; and DAR >20%, 4.9%; P<0.001. There was no increase in clinical events associated with higher DARs.
Conclusions:
Adherence to a sizing algorithm guided by multidetector computed tomography resulted in lower rates of paravalvular aortic regurgitation after self-expanding transcatheter valve replacement without an increase in complications.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01240902.
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