Three-Dimensional Morphology of the Left Ventricular Outflow Tract: Impact on Grading Aortic Stenosis Severity.

[en] BACKGROUND: Left ventricular outflow tract (LVOT) measurement is a critical step in the quantification of aortic valve area. The assumption of a circular morphology of the LVOT may induce some errors. The aim of this study was to assess the three-dimensional (3D) morphology of the LVOT and its impact on grading aortic stenosis severity. METHODS: Fifty-eight patients with aortic stenosis were studied retrospectively. LVOT dimensions were measured using 3D transesophageal echocardiography at three levels: at the hinge points (HP) of the aortic valve and at 4 and 8 mm proximal to the annular plane. Results were compared with standard two-dimensional echocardiographic measurements. RESULTS: Three-dimensional transesophageal echocardiography showed a funnel shape that was more circular at the HP and more elliptical at 4 and 8 mm proximal to the annular plane (circularity index = 0.92 vs 0.83 vs 0.76, P < .001). Cross-sectional area was smaller at the HP and larger at 4 and 8 mm from the annular plane (3.6 vs 3.9 vs 4.1 cm2, P = .001). The best correlation between two-dimensional and 3D transesophageal echocardiographic dimensions was at the HP (intraclass correlation coefficient = 0.75; 95% CI, 0.59-0.86). When the HP approach was selected, there was a reduction in the percentage of patients with low flow (from 41% to 29%). CONCLUSIONS: A large portion of patients with aortic stenosis have funnel-shaped and elliptical LVOTs, a morphology that is more pronounced in the region farther from the annular plane. Two-dimensional LVOT measurement closer to the annular plane has the best correlation with 3D measurements. Measurement of the LVOT closer to the annular plane should be encouraged to reduce measurement errors.

Disciplines :

Cardiovascular & respiratory systems

Author, co-author :

Caballero, Luis

Saura, Daniel

Oliva-Sandoval, Maria Jose

Gonzalez-Carrillo, Josefa

Espinosa, Maria Dolores

Garcia-Navarro, Miguel

Valdes, Mariano

Lancellotti, Patrizio ; Université de Liège > Département des sciences cliniques > Imagerie cardiaque fonctionnelle par échographie

de la Morena, Gonzalo

Language :

English

Title :

Three-Dimensional Morphology of the Left Ventricular Outflow Tract: Impact on Grading Aortic Stenosis Severity.

Publication date :

2017

Journal title :

Journal of the American Society of Echocardiography

ISSN :

0894-7317

eISSN :

1097-6795

Publisher :

C.V. Mosby Company, United States - Missouri

Volume :

Issue :

Pages :

28-35

Peer reviewed :

Peer Reviewed verified by ORBi

Commentary :

Available on ORBi :

since 22 January 2017

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Bibliography

1 Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC)European Association for Cardio-Thoracic Surgery (EACTS), Vahanian, A., Alfieri, O., Andreotti, F., Antunes, M.J., et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 33 (2012), 2451–2496.
2 American College of Cardiology/American Heart Association Task Force on Practice Guidelines Society of Cardiovascular Anesthesiologists Society for Cardiovascular Angiography and Interventions Society of Thoracic Surgeons, Bonow, R.O., Carabello, B.A., et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 114 (2006), e84–e231.
3 Nishimura, R.A., Otto, C.M., Bonow, R.O., Carabello, B.A., Erwin, J.P., Guyton, R.A., et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 63 (2014), 2438–2488.
4 Baumgartner, H., Hung, J., Bermejo, J., Chambers, J.B., Evangelista, A., Griffin, B.P., et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 22 (2009), 1–23.
5 Saitoh, T., Shiota, M., Izumo, M., Gurudevan, S.V., Tolstrup, K., Siegel, R.J., et al. Comparison of left ventricular outflow geometry and aortic valve area in patients with aortic stenosis by 2-dimensional versus 3-dimensional echocardiography. Am J Cardiol 109 (2012), 1626–1631.
6 Saitoh, T., Tanaka, J., Furugen, A., Harada, K., Izumo, M., Fukuoka, Y., et al. Impact of energy loss index and valvuloarterial impedance in patients with aortic stenosis using three-dimensional echocardiography. Echocardiography 32 (2015), 654–659.
7 Ng, A.C., Delgado, V., van der Kley, F., Shanks, M., van de Veire, N.R., Bertini, M., et al. Comparison of aortic root dimensions and geometries before and after transcatheter aortic valve implantation by 2- and 3-dimensional transesophageal echocardiography and multislice computed tomography. Circ Cardiovasc Imaging 3 (2010), 94–102.
8 Watanabe, Y., Morice, M.C., Bouvier, E., Leong, T., Hayashida, K., Lefèvre, T., et al. Automated 3-dimensional aortic annular assessment by multidetector computed tomography in transcatheter aortic valve implantation. JACC Cardiovasc Interv 6 (2013), 955–964.
9 Gaspar, T., Adawi, S., Sachner, R., Asmer, I., Ganaeem, M., Rubinshtein, R., et al. Three-dimensional imaging of the left ventricular outflow tract: impact on aortic valve area estimation by the continuity equation. J Am Soc Echocardiogr 25 (2012), 749–757.
10 Mor-Avi, V., Sugeng, L., Lang, R.M., Real-time 3-dimensional echocardiography: an integral component of the routine echocardiographic examination in adult patients?. Circulation 119 (2009), 314–329.
11 Poh, K.K., Levine, R.A., Solis, J., Shen, L., Flaherty, M., Kang, Y.J., et al. Assessing aortic valve area in aortic stenosis by continuity equation: a novel approach using real-time three-dimensional echocardiography. Eur Heart J 29 (2008), 2526–2535.
12 Lang, R.M., Badano, L.P., Mor-Avi, V., Afilalo, J., Armstrong, A., Ernande, L., et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the american society of echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28 (2015), 1–39.
13 Skjaerpe, T., Hegrenaes, L., Hatle, L., Noninvasive estimation of valve area in patients with aortic stenosis by Doppler ultrasound and two-dimensional echocardiography. Circulation 72 (1985), 810–818.
14 De la Morena, G., Saura, D., Oliva, M.J., Soria, F., González, J., García, M., et al. Real-time three-dimensional transoesophageal echocardiography in the assessment of aortic valve stenosis. Eur J Echocardiogr 11 (2010), 9–13.
15 Douglas, P.S., Waugh, R.A., Bloomfield, G., Dunn, G., Davis, L., Hahn, R.T., et al. Implementation of echocardiography core laboratory best practices: a case study of the PARTNER I trial. J Am Soc Echocardiogr 26 (2013), 348–358.e3.
16 LaBounty, T.M., Miyasaka, R., Chetcuti, S., Grossman, P.M., Deeb, G.M., Patel, H.J., et al. Annulus instead of LVOT diameter improves agreement between echocardiography effective orifice area and invasive aortic valve area. JACC Cardiovasc Imaging 7 (2014), 1065–1066.
17 Pibarot, P., Dumesnil, J.G., Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction. J Am Coll Cardiol 60 (2012), 1845–1853.
18 Pibarot, P., Dumesnil, J.G., Paradoxical low-flow, low-gradient aortic stenosis: new evidence, more questions. Circulation 128 (2013), 1729–1732.
19 Lancellotti, P., Magne, J., Donal, E., Davin, L., O'Connor, K., Rosca, M., et al. Clinical outcome in asymptomatic severe aortic stenosis: insights from the new proposed aortic stenosis grading classification. J Am Coll Cardiol 59 (2012), 235–243.
20 Hachicha, Z., Dumesnil, J.G., Bogaty, P., Pibarot, P., Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation 115 (2007), 2856–2864.
21 Eleid, M.F., Sorajja, P., Michelena, H.I., Malouf, J.F., Scott, C.G., Pellikka, P.A., Flow-gradient patterns in severe aortic stenosis with preserved ejection fraction: clinical characteristics and predictors of survival. Circulation 128 (2013), 1781–1789.
22 Adda, J., Mielot, C., Giorgi, R., Cransac, F., Zirphile, X., Donal, E., et al. Low-flow, low-gradient severe aortic stenosis despite normal ejection fraction is associated with severe left ventricular dysfunction as assessed by speckle-tracking echocardiography: a multicenter study. Circ Cardiovasc Imaging 5 (2012), 27–35.
23 Mehrotra, P., Jansen, K., Flynn, A.W., Tan, T.C., Elmariah, S., Picard, M.H., et al. Differential left ventricular remodelling and longitudinal function distinguishes low flow from normal-flow preserved ejection fraction low-gradient severe aortic stenosis. Eur Heart J 34 (2013), 1906–1914.
24 González-Cánovas, C., Muñoz-Esparza, C., Oliva, M.J., González-Carrillo, J., López-Cuenca, A., Saura, D., et al. Severe aortic valve stenosis with low-gradient and preserved ejection fraction: a misclassification issue?. Rev Esp Cardiol 66 (2013), 255–260.
25 Doddamani, S., Grushko, M.J., Makaryus, A.N., Jain, V.R., Bello, R., Friedman, M.A., et al. Demonstration of left ventricular outflow tract eccentricity by 64-slice multi-detector CT. Int J Cardiovasc Imaging 25 (2009), 175–181.
26 Khaw, A.V., von Bardeleben, R.S., Strasser, C., Mohr-Kahaly, S., Blankenberg, S., Espinola-Klein, C., et al. Direct measurement of left ventricular outflow tract by transthoracic real-time 3D-echocardiography increases accuracy in assessment of aortic valve stenosis. Int J Cardiol 136 (2009), 64–71.
27 Tamborini, G., Fusini, L., Muratori, M., Cefalù, C., Gripari, P., Ali, S.G., et al. Feasibility and accuracy of three-dimensional transthoracic echocardiography vs. multidetector computed tomography in the evaluation of aortic valve annulus in patient candidates to transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 15 (2014), 1316–1323.
28 Tsang, W., Bateman, M.G., Weinert, L., Pellegrini, G., Mor-Avi, V., Sugeng, L., et al. Accuracy of aortic annular measurements obtained from three-dimensional echocardiography, CT and MRI: human in vitro and in vivo studies. Heart 98 (2012), 1146–1152.
29 Jilaihawi, H., Kashif, M., Fontana, G., Furugen, A., Shiota, T., Friede, G., et al. Cross-sectional computed tomographic assessment improves accuracy of aortic annular sizing for transcatheter aortic valve replacement and reduces the incidence of paravalvular aortic regurgitation. J Am Coll Cardiol 59 (2012), 1275–1286.
30 Pibarot, P., Clavel, M.A., Left ventricular outflow tract geometry and dynamics in aortic stenosis: implications for the echocardiographic assessment of aortic valve area. J Am Soc Echocardiogr 28 (2015), 1267–1269.
31 Mehrotra, P., Flynn, A.W., Jansen, K., Tan, T.C., Mak, G., Julien, H.M., et al. Differential left ventricular outflow tract remodeling and dynamics in aortic stenosis. J Am Soc Echocardiogr 28 (2015), 1259–1266.
32 Jilaihawi, H., Doctor, N., Kashif, M., Chakravarty, T., Rafique, A., Makar, M., et al. Aortic annular sizing for transcatheter aortic valve replacement using cross-sectional 3-dimensional transesophageal echocardiography. J Am Coll Cardiol 61 (2013), 908–916.
33 Hahn, R.T., Guidance of transcatheter aortic valve replacement by echocardiography. Curr Cardiol Rep, 16, 2014, 442.
34 Fermanian, J., (Trans.) Measurement of agreement between 2 judges. Qualitative cases Rev Epidemiol Sante Publique 32 (1984), 140–147.
35 Khalique, O.K., Kodali, S.K., Paradis, J.M., Nazif, T.M., Williams, M.R., Einstein, A.J., et al. Aortic annular sizing using a novel 3-dimensional echocardiographic method: use and comparison with cardiac computed tomography. Circ Cardiovasc Imaging 7 (2014), 155–163.
36 Zamorano, J.L., Badano, L.P., Bruce, C., Chan, K.L., Gonçalves, A., Hahn, R.T., et al. EAE/ASE recommendations for the use of echocardiography in new transcatheter interventions for valvular heart disease. Eur J Echocardiogr 12 (2011), 557–584.