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Valvular heart disease
How to assess aortic annular size before transcatheter aortic valve implantation (TAVI): the role of echocardiography compared with other imaging modalities
  1. Cliona Kenny,
  2. Mark Monaghan
  1. Department of Cardiology, King's College Hospital, London, UK
  1. Correspondence to Professor Mark Monaghan, King's College Hospital, Denmark Hill, London SE5 9RS, UK; mark.monaghan{at}

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Learning objectives

  • After reading this article, the reader should be able to:

  • Recognise the complex 3 dimensional anatomy of the aortic annulus.

  • Select appropriate cardiac imaging modalities for measurement of aortic annulus size and distinguish the different measurements which may be made.

  • Describe the advantages & limitations of different imaging modalities with reference to clinical outcomes and complications.

Curriculum topic: Valvular heart diseases

Severe aortic stenosis (AS) is associated with debilitating symptoms and reduced survival if left untreated. According to European Society of Cardiology (ESC) guidelines, valve replacement is indicated for all patients with symptoms and severe AS, or severe AS with left ventricular (LV) systolic dysfunction.1 In patients with severe AS, aortic valve replacement (AVR) is associated with improved survival, regression of LV hypertrophy, and recovery of LV systolic function. Traditionally, surgical aortic valve replacement has been carried out with cardiopulmonary bypass, using either a mechanical or biological valve prosthesis. Valve sizing is performed intraoperatively using manufacturer specific sizing devices after excision of the native valve.

In patients who are at high or prohibitive risk for surgical replacement of the valve, transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment. Clinical trials have shown TAVI to have outcomes similar to surgical AVR up to 2 years after the procedure.2–4 The procedure is performed off cardiopulmonary bypass via a percutaneous transarterial (usually transfemoral) approach or via a transapical approach by limited left thoracotomy. During the procedure a stent-mounted pericardial prosthesis is implanted within the native valve, displacing the native valve leaflets into the sinuses of Valsalva. Currently, both self-expanding and balloon expandable valve prostheses are commercially available.5 ,6 Excellent outcomes have been confirmed by registry data, with overall survival of 76% at 1 year (rising to 81% in the lower risk transfemoral population).7

Clinical outcomes following TAVI are directly related to appropriate …

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  • Contributors The work was drafted and images selected by CK and revised and approved by MM.

  • Competing interests In compliance with EBAC/EACCME guidelines, all authors participating in Education in Heart have disclosed potential conflicts of interest that might cause a bias in the article. The authors have no competing interests.

  • Provenance and peer review Commissioned; externally peer reviewed.

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