Three‐dimensional transesophageal echocardiography is an attractive alternative to cardiac multi‐detector computed tomography for aortic annular sizing: Systematic review and meta‐analysis

Abstract

Background Cardiac imaging is the cornerstone of the pretranscatheter aortic valve replacement (TAVR) assessment. Multi‐detector computed tomography (MDCT) is considered the conventional imaging modality. However, there is still no definitive gold standard. Targeted cohort of inoperable high‐risk patients with underlying comorbidities, particularly renal impairment, makes apparent the need for MDCT alternative. We aimed to demonstrate the correlation extent between MDCT and three‐dimensional transesophageal echocardiography (3DTEE) aortic annular area measures and to answer the question: Is 3DTEE a good alternative to MDCT? Methods A systematic literature search and meta‐analysis were conducted to evaluate the degree of correlation and agreement between 3DTEE and MDCT aortic annular sizing. A thorough assessment of EMBASE, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed. All studies comparing 3DTEE and MDCT in relation to aortic annular sizing were included. Results Thirteen studies were included (N = 1228 patients). A strong linear correlation was found between 3DTEE and MDCT measurements of aortic annulus area (r = 0.84, P < 0.001), mean perimeter (r = 0. 0.85, P < 0.001), and mean diameter (r = 0.80, P < 0.001). Bland–Altman plots revealed smaller mean 3DTEE values in comparison to MDCT for aortic annular area, the mean difference being −2.22 mm2 with 95% limits of agreement −12.79 to 8.36. Conclusion Aortic annulus measurements obtained by 3DTEE demonstrated a high level of correlation with those evaluated by MDCT. This makes 3DTEE a feasible choice for aortic annulus assessment, with advantage of real time assessment, lack of contrast, and no radiation exposure.

Aortic Annular Sizing Using Novel Software in Three-Dimensional Transesophageal Echocardiography for Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

“…To the best of the authors’ knowledge, the two previous studies have attempted to methodically compare 3D-TEE and MDCT for TAVR sizing in the same patient population [ 60 , 61 ]. Both studies, however, basically used the 3D-TEE manual technique for annular measurements.…”

Clinical and perioperative applications of three-dimensional echocardiography

“…Multiple studies have shown good correlation between 3D annular and perimeter measurements of the aortic annulus compared to CT. In a meta-analysis by Elkaryoni and colleagues including 14 studies and 1,228 patients, there was excellent agreement between 3D TEE annular area and perimeter with CT-derived measurements (r > 0.8) [28] .…”

“…Valve area immediately after repair can also be accurately assessed by 3D planimetry [42] . Multiplanar reformatting (MPR) is used for linear annular measurements of the tricuspid and mitral valves [47,48] and aids in the periprocedural sizing of rings and valves, sizing of ASDs, sizing of LAA for LAA closure devices, and valve sizing for transcatheter valve replacement [28,49,50] . 3D TEE has been shown to have increased accuracy compared to 2D echo which in many cases is relevant for improved clinical outcomes.…”

3D transesophageal echocardiography in TAVR

“…Equivalence with annular measurements obtained by multidetector CT (MDCT) has been demonstrated consistently with a strong linear correlation between the two modalities for annular area (r = .86) 9 and perimeter (r = .85). 10 The proviso being that 3D TEE predictably undersizes with respect to MDCT (mean difference −2.2 mm 2 in the largest meta-analysis). [9][10][11] As measurements are performed on static images, spatial resolution can be prioritized over temporal resolution, being mindful of the necessary trade-off between frame rate and line density.…”

“…10 The proviso being that 3D TEE predictably undersizes with respect to MDCT (mean difference −2.2 mm 2 in the largest meta-analysis). [9][10][11] As measurements are performed on static images, spatial resolution can be prioritized over temporal resolution, being mindful of the necessary trade-off between frame rate and line density. The current consignment of European and American guidelines 12 do not suggest a gold standard for imaging in this area, advising that 3D TEE is appropriate for THV sizing when performed in a center with sufficient experience in the technique.…”