Heterogeneity in the Structure of the Left Ventricular Outflow Tract: A 3-Dimensional Transesophageal...

The left ventricular outflow tract (LVOT) is a composite of adjoining structures; therefore, a circular or elliptical shape at one point may not represent its entire structure. The purpose of this study was to evaluate the presence of heterogeneity in the LVOT.

Patients with normal valvular and ventricular function undergoing elective coronary revascularization surgery were included in the study. Intraoperative R-wave gated 3-dimensional (3D) transesophageal echocardiographic imaging of the LVOT was performed at end-systole, with the midesophageal long axis as the reference view. Acquired data were analyzed with the Philips Q-Lab software with multiplanar reformatting in the sagittal (minor axis), transverse (major axis), and coronal (cross-sectional area by planimetry) views of the LVOT. These measurements were made on the left ventricular side or proximal LVOT, aortic side, or distal LVOT and mid-LVOT.

Fifty patients were included in the study. The LVOT minor (sagittal) axis dimension did not differ across the mid-LVOT, proximal LVOT, and distal LVOT (P = .11). The major axis diameter of LVOT differed among the 3 regions of the LVOT (P < .001). A difference in major axis diameter was observed between the proximal and the distal LVOT (median difference of 0.39 cm; Bonferroni-adjusted 95% confidence interval [CI] of the difference = 0.31-0.48 cm; Bonferroni-adjusted P < .001). Planimetry of the LVOT area differed significantly (P < .001) between the regions analyzed, and we found a difference between the distal and the proximal LVOT (median difference = 0.65 cm, Bonferroni-adjusted 95% CI of the difference = 0.44-0.88 cm, Bonferroni-adjusted P < .001). The LVOT area calculated from minor axis diameter differed significantly from the area obtained by planimetry (P < .001).

There was heterogeneity in the major axis diameter and cross-sectional area for the different regions of the LVOT. The distal LVOT (aortic side) was more circular, whereas the proximal LVOT (left ventricular side) was more elliptical in shape. This change in shape from circular to elliptical was accounted for by a difference in the major axis diameter from proximal to distal LVOT and a relatively similar minor axis diameter. Although the clinical significance of this finding is unknown, the assumption of a uniform structure of LVOT is incorrect. Three-dimensional imaging may be useful for assessing the LVOT shape and size at a specific region of interest.