The International Journal of Cardiovascular Imaging

, Volume 35, Issue 11, pp 2029–2036 | Cite as

Aortic roots assessment by an automated three-dimensional transesophageal echocardiography: an intra-individual comparison

  • Minghui Zhang
  • Linyuan Wan
  • Kun Liu
  • Weichun Wu
  • Hui Li
  • Yuan Wang
  • Bin Lu
  • Hao WangEmail author
Original Paper


To evaluate the accuracy, reproducibility, and transcatheter heart valve (THV) sizing efficiency of an automated 3-dimensional transesophageal echocardiographic (3D-TEE) post-processing software in the assessments of aortic roots, intra-individually compared with multidetector computed tomography (MDCT). We prospectively studied 67 patients with normal aortic roots. We measured diameters of aortic annulus (AA), sinus of Valsalva (SOV), and sino-tubular junction (STJ) by full-automated and semi-automated methods using 3D-TEE datasets, then compared them to corresponding transthoracic echocardiography and MDCT values. THV sizes were chosen based on echocardiography and MDCT measurements according to recommended criterion. Taking MDCT planimetered diameters as reference, the full-automated (r: 0.4745–0.8792) and semi-automated (r: 0.6647–0.8805) 3D-TEE measurements were linearly correlated (p < 0.0001). The average differences between semi-automated or full-automated measurements and reference were 0.3 mm or 1.3 mm for AA, − 1.9 mm or − 0.5 mm for SOV, and − 0.1 mm or 1.9 mm for STJ, respectively. The intra-class correlation coefficients of semi-automated method were 0.79–0.96 (intra-observer) and 0.75–0.92 (inter-observer). THV sizing by semi-automated measurements using echocardiographic criteria was larger than that by MDCT measurements using MDCT criteria (p < 0.0001) but equivalent (p > 0.05) if both using MDCT standards. The new automated 3D-TEE software allows modeling and quantifying aortic roots with high reproducibility. Measurements by the semi-automated method closely approximate and well correlate with the corresponding MDCT, thus THV sizing by this modeled 3D-TEE measurements should adopt recommended MDCT criteria but not echocardiographic criteria. The full-automated 3D-TEE segmentations are yet immature. (Semi-automated assessMent of Aortic Roots by Three-dimensional transEsophageal echocaRdiography [SMARTER], NCT02724709)


Three-dimensional transesophageal echocardiography Multidetector computed tomography Transcatheter aortic valve replacement Automated measurement 



The authors thank Dr. Chuangshi Wang (Medical Research and Biometrics Center, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases; 15 Fengcunxili, Beijing 102308, China) and Dr. Zhilan Zheng (Division of Ultrasound Application, Siemens Healthineers China; 7 Wangjing Zhonghuan South Road, Beijing 100102, China) for their helps.


This work was supported by the Peking Union Medical College Youth Fund from the Fundamental Research Funds for the Central Universities (No. 3332015013, to MZ) and partly by the National Natural Science Foundation of China (No. 81470080, to WH).

Compliance with ethical standards

Conflict of interests

The authors have no conflicts to declare.

Supplementary material

Supplementary file1 (AVI 14875 kb) Dynamic videos of 3D-TEE recording (example)

Supplementary file2 (AVI 11145 kb) Dynamic videos of 3D-TEE recording (example)

10554_2019_1664_MOESM3_ESM.avi (7.3 mb)
Supplementary file3 (AVI 7486 kb) Dynamic videos of automated 3D-TEE modeling (example)
10554_2019_1664_MOESM4_ESM.avi (2.9 mb)
Supplementary file4 (AVI 2969 kb) Dynamic videos of automated 3D-TEE modeling (example)
10554_2019_1664_MOESM5_ESM.avi (6.9 mb)
Supplementary file5 (AVI 7038 kb) Dynamic videos of automated 3D-TEE modeling (example)
10554_2019_1664_MOESM6_ESM.avi (6.1 mb)
Supplementary file6 (AVI 6284 kb) Dynamic videos of automated 3D-TEE modeling (example)
10554_2019_1664_MOESM7_ESM.tif (1.4 mb)
Supplementary file7 (TIFF 1424 kb)
10554_2019_1664_MOESM8_ESM.docx (190 kb)
Supplementary file8 (DOCX 189 kb) Supplementary Figure 2: Bland-Altman analysis of AA, SOV, and STJ diameters, regarding MDCT-Area as reference standard
10554_2019_1664_MOESM9_ESM.docx (195 kb)
Supplementary file9 (DOCX 195 kb) Supplementary Figure 3: Correlation among various measurements of AA diameters
10554_2019_1664_MOESM10_ESM.docx (184 kb)
Supplementary file10 (DOCX 183 kb) Supplementary Figure 4: Correlation among various measurements of SOV diameters
10554_2019_1664_MOESM11_ESM.docx (192 kb)
Supplementary file11 (DOCX 192 kb) Supplementary Figure 5: Correlation among various measurements of STJ diameters
10554_2019_1664_MOESM12_ESM.docx (141 kb)
Supplementary file12 (DOCX 141 kb) Supplementary Figure 6: Variability of the semi-automated and full-automated modeling measurements
10554_2019_1664_MOESM13_ESM.tif (1.6 mb)
Supplementary file13 (TIFF 1642 kb)
10554_2019_1664_MOESM14_ESM.docx (18 kb)
Supplementary file14 (DOCX 18 kb) Supplementary Table 1: Manufacturer recommended sizing criterion (SAPIEN 3 & CoreValve)
10554_2019_1664_MOESM15_ESM.docx (23 kb)
Supplementary file15 (DOCX 22 kb) Supplementary Table 2: MDCT characteristics of the study population
10554_2019_1664_MOESM16_ESM.docx (46 kb)
Supplementary file16 (DOCX 45 kb) Supplementary Table 3: AA, SOV and STJ diameters measured by various methods
10554_2019_1664_MOESM17_ESM.docx (82 kb)
Supplementary file17 (DOCX 81 kb) Supplementary Table 4: The average differences among various measurements of AA, SOV, and STJ diameters


  1. 1.
    Giannini F, Baldetti L, Gallone G et al (2018) Transcatheter valve replacement in Asia Pacific: current practice and perspectives. J Am Coll Cardiol 72:3189–3199CrossRefGoogle Scholar
  2. 2.
    Khalique OK, Hamid NB, White JM et al (2017) Impact of methodologic differences in three-dimensional echocardiographic measurements of the aortic annulus compared with computed tomographic angiography before transcatheter aortic valve replacement. J Am Soc Echocardiogr 30:414–421CrossRefGoogle Scholar
  3. 3.
    Leipsic JA, Blanke P, Hanley M et al (2017) ACR appropriateness criteria((R)) imaging for transcatheter aortic valve replacement. J Am Coll Radiol 14:S449–S455CrossRefGoogle Scholar
  4. 4.
    Soon J, Pibarot P, Blanke P et al (2017) Multimodality imaging for planning and follow-up of transcatheter aortic valve replacement. Can J Cardiol 33:1110–1123CrossRefGoogle Scholar
  5. 5.
    Bons LR, Duijnhouwer AL, Boccalini S et al (2019) Intermodality variation of aortic dimensions: how, where and when to measure the ascending aorta. Int J Cardiol 276:230–235CrossRefGoogle Scholar
  6. 6.
    Dulgheru R, Pibarot P, Sengupta PP et al (2016) Multimodality imaging strategies for the assessment of aortic stenosis: Viewpoint of the Heart Valve Clinic International Database (HAVEC) group. Circ Cardiovasc Imaging 9:e4352CrossRefGoogle Scholar
  7. 7.
    Blanke P, Weir-McCall JR, Achenbach S et al (2019) Computed tomography imaging in the context of transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR): an expert consensus document of the Society of Cardiovascular Computed Tomography. JACC Cardiovasc Imaging 12:1–24CrossRefGoogle Scholar
  8. 8.
    Pibarot P, Magne J, Leipsic J et al (2019) Imaging for predicting and assessing prosthesis-patient mismatch after aortic valve replacement. JACC Cardiovasc Imaging 12:149–162CrossRefGoogle Scholar
  9. 9.
    Kato N, Shibayama K, Noguchi M et al (2018) Superiority of novel automated assessment of aortic annulus by intraoperative three-dimensional transesophageal echocardiography in patients with severe aortic stenosis: comparison with conventional cross-sectional assessment. J Cardiol 72:321–327CrossRefGoogle Scholar
  10. 10.
    Lang RM, Badano LP, Tsang W et al (2012) EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr 25:3–46CrossRefGoogle Scholar
  11. 11.
    Garcia-Martin A, Lazaro-Rivera C, Fernandez-Golfin C et al (2016) Accuracy and reproducibility of novel echocardiographic three-dimensional automated software for the assessment of the aortic root in candidates for thanscatheter aortic valve replacement. Eur Heart J Cardiovasc Imaging 17:772–778CrossRefGoogle Scholar
  12. 12.
    Yang L, Xu L, Schoepf UJ et al (2015) Prospectively ECG-triggered sequential dual-source coronary CT angiography in patients with atrial fibrillation: influence of heart rate on image quality and evaluation of diagnostic accuracy. PLoS ONE 10:e134194Google Scholar
  13. 13.
    Wang Y, Wang M, Song G et al (2019) Optimal pre-TAVR annulus sizing in patients with bicuspid aortic valve: area-derived perimeter by CT is the best-correlated measure with intraoperative sizing. Eur Radiol 29:259–269CrossRefGoogle Scholar
  14. 14.
    Ren X, Zhang M, Liu K et al (2016) The significance of aortic valve calcification in patients with bicuspid aortic valve disease. Int J Cardiovasc Imaging 32:471–478CrossRefGoogle Scholar
  15. 15.
    Mayr A, Klug G, Reinstadler SJ et al (2018) Is MRI equivalent to CT in the guidance of TAVR? A pilot study. Eur Radiol 28:4625–4634CrossRefGoogle Scholar
  16. 16.
    Mahmood F, Shernan SK (2016) Perioperative transoesophageal echocardiography: current status and future directions. Heart 102:1159–1167CrossRefGoogle Scholar
  17. 17.
    Khalique OK, Kodali SK, Paradis JM et al (2014) Aortic annular sizing using a novel 3-dimensional echocardiographic method: use and comparison with cardiac computed tomography. Circ Cardiovasc Imaging 7:155–163CrossRefGoogle Scholar
  18. 18.
    Prihadi EA, van Rosendael PJ, Vollema EM et al (2018) Feasibility, accuracy, and reproducibility of aortic annular and root sizing for transcatheter aortic valve replacement using novel automated three-dimensional echocardiographic software: comparison with multi-detector row computed tomography. J Am Soc Echocardiogr 31:505–514CrossRefGoogle Scholar
  19. 19.
    Achenbach S, Delgado V, Hausleiter J et al (2012) SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR). J Cardiovasc Comput Tomogr 6:366–380CrossRefGoogle Scholar
  20. 20.
    Podlesnikar T, Delgado V (2016) Update: Cardiac Imaging (II). transcatheter aortic valve replacement: advantages and limitations of different cardiac imaging techniques. Rev Esp Cardiol (Engl Ed) 69:310–321CrossRefGoogle Scholar
  21. 21.
    Husser O, Holzamer A, Resch M et al (2013) Prosthesis sizing for transcatheter aortic valve implantation—comparison of three dimensional transesophageal echocardiography with multislice computed tomography. Int J Cardiol 168:3431–3438CrossRefGoogle Scholar
  22. 22.
    Ng AC, Delgado V, van der Kley F et al (2010) 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 3:94–102CrossRefGoogle Scholar
  23. 23.
    Vaquerizo B, Spaziano M, Alali J et al (2016) Three-dimensional echocardiography vs. computed tomography for transcatheter aortic valve replacement sizing. Eur Heart J Cardiovasc Imaging 17:15–23PubMedGoogle Scholar
  24. 24.
    Tamborini G, Fusini L, Muratori M et al (2014) 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 15:1316–1323CrossRefGoogle Scholar
  25. 25.
    Calleja A, Thavendiranathan P, Ionasec RI et al (2013) Automated quantitative 3-dimensional modeling of the aortic valve and root by 3-dimensional transesophageal echocardiography in normals, aortic regurgitation, and aortic stenosis: comparison to computed tomography in normals and clinical implications. Circ Cardiovasc Imaging 6:99–108CrossRefGoogle Scholar
  26. 26.
    Zamorano J, Pardo A (2016) 3D-ECHO for TAVI: two arrows, just in case. Eur Heart J Cardiovasc Imaging 17:9–10CrossRefGoogle Scholar
  27. 27.
    Hahn RT, Little SH, Monaghan MJ et al (2015) Recommendations for comprehensive intraprocedural echocardiographic imaging during TAVR. JACC Cardiovasc Imaging 8:261–287CrossRefGoogle Scholar
  28. 28.
    Liao YB, Zhao ZG, Wei X et al (2017) Transcatheter aortic valve implantation with the self-expandable venus A-Valve and CoreValve devices: preliminary experiences in China. Catheter Cardiovasc Interv 89:528–533CrossRefGoogle Scholar
  29. 29.
    Jurencak T, Turek J, Kietselaer BL et al (2015) MDCT evaluation of aortic root and aortic valve prior to TAVI. What is the optimal imaging time point in the cardiac cycle? Eur Radiol 25:1975–1983CrossRefGoogle Scholar
  30. 30.
    Sengupta PP, Adjeroh DA (2018) Will artificial intelligence replace the human echocardiographer? Circulation 138:1639–1642CrossRefGoogle Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  • Minghui Zhang
    • 1
  • Linyuan Wan
    • 1
  • Kun Liu
    • 2
  • Weichun Wu
    • 1
  • Hui Li
    • 1
  • Yuan Wang
    • 3
  • Bin Lu
    • 2
  • Hao Wang
    • 1
    Email author
  1. 1.Department of Echocardiography, Fuwai HospitalChinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBeijingChina
  2. 2.Department of Radiologic Imaging, Fuwai HospitalChinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBeijingChina
  3. 3.Department of Cardiology, Fuwai HospitalChinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBeijingChina

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