Sizing the Aortic Valve

Roman M. Sniecinski, MD, FASE

Associate Professor of Anesthesiology
Division of Cardiothoracic Anesthesia
Application of Echo
Emory University School of Medicine

Upon completion of this session, the participant should be able to:

Describe the various imaging modalities used to size an AV for intervention
State the information important to gain from each imaging modality for AV sizing
Compare TEE to other imaging modalities for AV sizing

Anatomy of the Aortic Root

The aortic root begins at the ventriculo-arterial junction, incorporates three bulges and
their respective valvar leaflets (the sinuses of Valsalva), and ends at a slightly thickened
ridge in the aortic wall where the ascending aorta begins (the sinotubular junction).
Histologically, the walls of the aortic root are
composed of fibrous tissue, but there is an
increase in the elastic fiber content as the
upper portion blends into the elastic tissue and
smooth muscle in the aortic wall media.(1)
Interspersed between the bulging of the
sinuses are fibrous triangles and small
crescents of ventricular muscle. It is this
heterogeneity of tissue that makes the aortic
root a complex transition zone from the
TheAorticRoot.Adaptedfrom(2).
muscular left ventricle to the elastic proximal
STJ=sinotubularjunction.
aorta. The hinge lines of the aortic valve
leaflets extend from the STJ to a point below the anatomical ventriculo-arterial junction,
at the so-called virtual basal ring. This is the point commonly measured via
echocardiography as the annulus, although the existence of such a structure is a point
of debate between surgeons and anatomists.(2)

Measurements with TEE

Echocardiographic measurements of the

aortic root are made in the ME AV LAX view.
Four measurements are of particular interest in
the setting of AV surgery: the annulus (i.e.
hinge points of the aortic valve leaflets), the
diameter at the sinuses of Valsalva (typically
the maximal root diameter), the sinotubular
junction (STJ), and the proximal ascending
aorta (usually measured within 2cm of the
STJ). In general, the measurements are made at end
diastole using the inner edge to inner edge
technique, as this best correlates with other
modalities such as MRI or CT.(3) It should be
noted, however, that most normative data for
echocardiography has been established using the
leading edge to leading edge technique. Unlike
measurement of the left ventricular outflow tract,
there is not a significant difference in these 4
parameters between systole and diastole.

Imaging Modalities for AV Sizing

The advent of transcatheter aortic valve implantation

Methods of Sizing AV Prosthesis
(TAVI) has increased interest in sizing of the aortic
Echocardiography
Computed Tomography
annulus and other components of the aortic root.(4)
Magnetic Resonance Like standard open aortic valve replacement, pre-
Balloon Sizing procedural
imaging can
help determine the appropriate sized prosthesis. From (5)
This is probably more important in TAVI since
the interventionalist cannot directly inspect the
implantation site. Additionally, it must be
ensured that the prosthesis does not obstruct the
coronary ostia. There are multiple methods for
determining the correct prosthetic valve size,
each with particular advantages and
disadvantages.(5) Typically, a combination of
modalities is used to assess the following:
Aortic annulus size
Leaflet length and calcification
Location of the coronary ostia
Identification of other interfering factors

Whatever modality is used, it should be

recognized that the aortic annulus is not actually
circular. This means that there is an inherent
inaccuracy in any 2D measurement. This is one of
the reasons that TEE tends to underestimate the
cylindrical sizers used during surgery.(6)
Multiplanar modalities may therefore be preferred.
The bi-plane function on 3D TEE probes is
particularly helpful in this respect since it allows
simultaneous viewing of both sagittal (i.e. long axis 3D TEE demonstrating elliptical shape
- where the annular measurement is typically taken) of AV annulus. From (5)
and transverse (i.e. short axis) planes. This ensures the sagittal plane is bisecting the
largest dimension of the aortic annulus and not obtaining an oblique view that would
underestimate the annulus diameter.

Ideally, the ME long axis view centered on the LVOT, AV, and ascending aorta (the
so-called 3-chamber view) during mid-
systole should be used for 2D measurements
of the AV annulus.(7) While the right
coronary cusp hinge point is usually well
visualized, the upper hinge point is more
difficult to see.

ME 3C view with proper alignment

In general, transthoracic and TEE 2D 4 points mark the aortic root. It is often difficult
measurements correlate well, with the to visualize the proximal superior point.
TEE annular diameter about 1mm larger.
Compared to multi-slice CT, the TEE measurement is about 1 1.5mm smaller.(8)

Key Points

The aortic annulus is not perfectly circular, leading to

inaccuracies in 2-dimensional measurements
Although multi-slice CT is commonly used pre-op for
TAVI, TEE remains the standard for sizing in the OR
When using TEE, be sure to avoid oblique measurements
While the RCC hinge point is easily visualized, the
LCC/NCC point is not
Measurement by CT will be 1 1.5mm larger than 2D TEE
 References

1. Ho SY. Structure and anatomy of the aortic root. European journal of

echocardiography : the journal of the Working Group on Echocardiography of the
European Society of Cardiology 2009;10:i3-10.

2. Anderson RH. The surgical anatomy of the aortic root. MMCTS 2006.

3. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA,
Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT,
Sutton MS, Stewart WJ. Recommendations for chamber quantification: a report
from the American Society of Echocardiography's Guidelines and Standards
Committee and the Chamber Quantification Writing Group, developed in
conjunction with the European Association of Echocardiography, a branch of the
European Society of Cardiology. Journal of the American Society of
Echocardiography : official publication of the American Society of
Echocardiography 2005;18:1440-63.

4. Tuzcu EM, Kapadia SR, Schoenhagen P. Multimodality quantitative imaging of

aortic root for transcatheter aortic valve implantation: more complex than it
appears. Journal of the American College of Cardiology 2010;55:195-7.

5. Bloomfield GS, Gillam LD, Hahn RT, Kapadia S, Leipsic J, Lerakis S, Tuzcu M,
Douglas PS. A practical guide to multimodality imaging of transcatheter aortic
valve replacement. JACC Cardiovascular imaging 2012;5:441-55.

6. Babaliaros VC, Liff D, Chen EP, Rogers JH, Brown RA, Thourani VH, Guyton
RA, Lerakis S, Stillman AE, Raggi P, Cheesborough JE, Veledar E, Green JT,
Block PC. Can balloon aortic valvuloplasty help determine appropriate
transcatheter aortic valve size? JACC Cardiovascular interventions 2008;1:580-6.

7. Zamorano JL, Badano LP, Bruce C, Chan KL, Goncalves A, Hahn RT, Keane
MG, La Canna G, Monaghan MJ, Nihoyannopoulos P, Silvestry FE,
Vanoverschelde JL, Gillam LD. EAE/ASE recommendations for the use of
echocardiography in new transcatheter interventions for valvular heart disease.
Journal of the American Society of Echocardiography : official publication of the
American Society of Echocardiography 2011;24:937-65.

8. Messika-Zeitoun D, Serfaty JM, Brochet E, Ducrocq G, Lepage L, Detaint D,

Hyafil F, Himbert D, Pasi N, Laissy JP, Iung B, Vahanian A. Multimodal
assessment of the aortic annulus diameter: implications for transcatheter aortic
valve implantation. Journal of the American College of Cardiology 2010;55:186-
94.