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JACC: CARDIOVASCULAR INTERVENTIONS VOL. 8, NO. 2, 2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 1936-8798/$36.00 PUBLISHED BY ELSEVIER INC. Letter TO THE EDITOR image acquisition was performed during an inspiratory breath hold, while the electrocardiogram was recorded simultaneously to allow retrospective Valve Sizing for Pure Aortic Regurgitation During Transcatheter Aortic Valve Replacement Deformation Dynamic of the Aortic Annulus in Different Valve Pathology May Be Different gating of the data. The 3-dimensional dataset of the contrast-enhanced scan was reconstructed in 10% increments over the cardiac cycle, generating 4-dimensional computed tomography data for assessment of the dynamic motion of the aortic valve annulus. Our results revealed a potentially dramatic change in the geometric morphology of the aortic valve annulus (the basal ring) during the cardiac cycle (Figure 1). In some cases, the aortic valve annulus even became irregularly shaped during the diastolic We read with great interest the report by Seiffert et al. phase (Figure 2). The underlying reasons for this (1) on the initial German experience with transapical unique phenomenon may be the pliability of a non- implantation of a second-generation transcatheter calcified aortic valve, senile fibroelastic degeneration heart valve for the treatment of aortic regurgitation. of the aortic annulus, and the Venturi effect caused With the development of second-generation trans- by regurgitation jet flow. Although these results still catheter aortic value replacement (TAVR) devices, need further validation, caution should be used in TAVR indications have been expended to high-risk annular sizing in patients with pure aortic regurgita- patients with pure aortic regurgitation. We are par- tion undergoing TAVR. Deformation dynamics of the ticularly interested in the measurement of the aortic aortic valve annulus in different valve pathologies annular size in patients with pure aortic regurgita- may be very different. tion. However, the measurement method was not detailed in this paper. It is well known that accurate assessment of the aortic annulus anatomy including its size and shape is of paramount importance in TAVR to avoid complications such as device dislodgment, paravalvular leakage, and annular rupture. In addition, with regard to this unique beating heart procedure, assessing the dynamic aspects of aortic annular functional anatomy, such as potential timedependent changes throughout the cardiac cycle, may be particularly important (2). Recent evidence confirmed a dynamic motion of the aortic annulus Da Zhu, MD Wei Chen, MD Liqing Peng, MD *Yingqiang Guo, MD *Department of Cardiovascular Surgery West China Hospital Chengdu Sichuan Peoples Republic of China 610041 E-mail: [email protected] http://dx.doi.org/10.1016/j.jcin.2014.11.011 during the cardiac cycle in both normal and stenotic aortic valves (2,3). With regard to patients with REFERENCES calcified aortic stenosis undergoing TAVR, these 1. Seiffert M, Bader R, Kappert U, et al. Initial German experience with changes are almost negligible because tissue properties allow very little expansion (2). However, the deformation dynamics of the aortic annulus may be dramatically different in patients with noncalcified aortic regurgitation. At our institution, 6 high-risk patients with severe pure aortic regurgitation underwent TAVR using transapical implantation of a second-generation transcatheter heart valve for the treatment of aortic regurgitation. J Am Coll Cardiol Intv 2014;7: 1168–74. 2. Hamdan A, Guetta V, Konen E, et al. Deformation dynamics and mechanical properties of the aortic annulus by 4-dimensional computed tomography: insights into the functional anatomy of the aortic valve complex and implications for transcatheter aortic valve therapy. J Am Coll Cardiol 2012;59: 119–27. another type of second-generation TAVR device. Dur- 3. Peng LQ, Yang ZG, Shao H, et al. Dynamic assessment of normal aortic valve throughout the cardiac cycle with dual-source computed tomography. ing preoperative computed tomography angiography, Int J Cardiol 2011;151:358–60. JACC: CARDIOVASCULAR INTERVENTIONS VOL. 8, NO. 2, 2015 Letter to the Editor FEBRUARY 2015:372–3 F I G U R E 1 Variation in Aortic Annulus Dimensions (Basal Ring) Between Mid-Diastolic and Mid-Systolic Phase The data are from 6 high-risk patients with severe aortic regurgitation (mean age, 74 years of age). Marked differences were noted between 2 phases for long-diameter, short-diameter, cross-sectional area as well as the perimeter, indicating a potentially dramatic change in aortic valve annulus geometry during the cardiac cycle. Min (D) ¼ minimal value, mid-diastolic phase; Max (S) ¼ maximum value, mid-systolic phase. F I G U R E 2 Computed Tomography Angiogram Image of Aortic Valve Annulus in Mid-Diastolic and Mid-Systolic Phases Computed tomography angiogram of the aortic valve annulus (dotted lines indicates basal ring) in the mid-diastolic and mid-systolic phases of 2 patients with severe regurgitation. The dramatic change in aortic valve annulus geometric morphology could be clearly identified. The shape of the aortic valve annulus even becomes irregular during the diastolic phase. 373