Journal of Echocardiography

, Volume 16, Issue 4, pp 162–172 | Cite as

Geometry of the left ventricular outflow tract assessed by 3D TEE in patients with aortic stenosis: impact of upper septal hypertrophy on measurements of Doppler-derived left ventricular stroke volume

  • Dan Koto
  • Masaki IzumoEmail author
  • Takafumi Machida
  • Kengo Suzuki
  • Kihei Yoneyama
  • Tomomi Suzuki
  • Ryo Kamijima
  • Yasuyuki Kobayashi
  • Tomoo Harada
  • Yoshihiro J. Akashi
Original Investigation



It is unclear how upper septal hypertrophy (USH) affects Doppler-derived left ventricular stroke volume (SV) in patients with AS. The aims of this study were to: (1) validate the accuracy of 3D transesophageal echocardiography (TEE) measurements of the left ventricular outflow tract (LVOT), (2) evaluate the differences in LVOT geometry between AS patients with and without USH, and (3) assess the impact of USH on measurement of SV.


In protocol 1, both 3D TEE and multi-detector computed tomography were performed in 20 patients with AS [aortic valve area (AVA) ≤ 1.5 cm2]. Multiplanar reconstruction was used to measure the LVOT short and long diameters in four parts from the tip of the septum to the annulus. In protocol 2, the same 3D TEE measurements were performed in AS patients (AVA ≤ 1.5 cm2, n = 129) and controls (n = 30). We also performed 2D and 3D transthoracic echocardiography in all patients.


In protocol 1, excellent correlations of LVOT parameters were found between the two modalities. In protocol 2, the USH group had smaller LVOT short and long diameters than the non-USH group. Although no differences in mean pressure gradient, or SV calculated with the 3D method existed between the two groups, the USH group had greater SV calculated with the Doppler method (73 ± 15 vs. 66 ± 15 ml) and aortic valve area (0.89 ± 0.26 vs. 0.73 ± 0.24 cm2) than the non-USH group.


3D TEE can provide a precise assessment of the LVOT in AS. USH affects the LVOT geometry in patients with AS, which might lead to inaccurate assessments of disease severity.


Aortic valve stenosis Echocardiography Three-dimensional echocardiography Transesophageal echocardiography 


Compliance with Ethical Standards

Conflict of interest

Dan Koto, Masaki Izumo, Takafumi Machida, Kihei Yoneyama, Tomomi Suzuki, Ryo Kamijima, Yasuyuki Kobayashi, Tomoo Harada, and Yoshihiro J. Akashi declare that they have no conflicts of interest.

Human rights statements and informed consent

All procedure followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later revisions. The participants were well-informed prior to the test; written informed consent was obtained before enrollment.


  1. 1.
    Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: a population-based study. Lancet. 2006;368:1005–11.CrossRefGoogle Scholar
  2. 2.
    Carabello BA, Paulus WJ. Aortic stenosis. Lancet. 2009;373:956–66.CrossRefGoogle Scholar
  3. 3.
    Carabello BA. Clinical practice. Aortic stenosis. N Engl J Med. 2002;346:677–82.CrossRefGoogle Scholar
  4. 4.
    Saikrishnan N, Kumar G, Sawaya FJ, et al. Accurate assessment of aortic stenosis: a review of diagnostic modalities and hemodynamics. Circulation. 2014;129:244–53.CrossRefGoogle Scholar
  5. 5.
    Delgado V, Ng AC, Schuijf JD, et al. Automated assessment of the aortic root dimensions with multidetector row computed tomography. Ann Thorac Surg. 2011;91:716–23.CrossRefGoogle Scholar
  6. 6.
    Tops LF, Wood DA, Delgado V, et al. Noninvasive evaluation of the aortic root with multislice computed tomography implications for transcatheter aortic valve replacement. J Am Coll Cardiol Img. 2008;1:321–30.CrossRefGoogle Scholar
  7. 7.
    Akhtar M, Tuzcu EM, Kapadia SR, et al. Aortic root morphology in patients undergoing percutaneous aortic valve replacement: evidence of aortic root remodeling. J Thorac Cardiovasc Surg. 2009;137:950–6.CrossRefGoogle Scholar
  8. 8.
    Stolzmann P, Knight J, Desbiolles L, et al. Remodelling of the aortic root in severe tricuspid aortic stenosis: implications for transcatheter aortic valve implantation. Eur Radiol. 2009;19:1316–23.CrossRefGoogle Scholar
  9. 9.
    Otani K, Takeuchi M, Kaku K, et al. Assessment of the aortic root using real-time 3D transesophageal echocardiography. Circ J. 2010;74:2649–57.CrossRefGoogle Scholar
  10. 10.
    Wu VC, Kaku K, Takeuchi M, et al. Aortic root geometry in patients with aortic stenosis assessed by real-time three-dimensional transesophageal echocardiography. J Am Soc Echocardiogr. 2014;27:32–41.CrossRefGoogle Scholar
  11. 11.
    Lang RM, Bierig M, Devereux RB, et al. Chamber Quantification Writing Group; American Society of Echocardiography’s Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18:1440–63.CrossRefGoogle Scholar
  12. 12.
    Pibarot P, Clavel MA. Left ventricular outflow tract geometry and dynamics in aortic stenosis: Implications for the echocardiographic assessment of aortic valve area. J Am Soc Echocardiogr. 2015;28:1267–9.CrossRefGoogle Scholar
  13. 13.
    Goor D, Lillehei W, Edwards JE. The “sigmoid septum” variation in the contour of the left ventricular outlet. AJR Am J Roentgenol. 1969;107:366–76.CrossRefGoogle Scholar
  14. 14.
    Diaz T, Pencina MJ, Benjamin EJ, et al. Prevalence, clinical correlates, and prognosis of discrete upper septal thickening on echocardiography: the Framingham Heart Study. Echocardiography. 2009;26:247–53.CrossRefGoogle Scholar
  15. 15.
    Funabashi N, Umazume T, Takaoka H, et al. Sigmoid shaped interventricular septum exhibit normal myocardial characteristics and has a relationship with aging, ascending aortic sclerosis and its tilt to left ventricle. Int J Cardiol. 2013;168:4484–8.CrossRefGoogle Scholar
  16. 16.
    Jilaihawi H, Kashif M, Fontana 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. 2012;59:1275–86.CrossRefGoogle Scholar
  17. 17.
    Hachicha Z, Dumesnil JG, Bogaty P, et al. Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation. 2007;115:2856–64.CrossRefGoogle Scholar
  18. 18.
    Lancellotti P, Magne J, Donal E, et al. Clinical outcome in asymptomatic severe aortic stenosis: insights from the new proposed aortic stenosis grading classification. J Am Coll Cardiol. 2012;59:235–43.CrossRefGoogle Scholar
  19. 19.
    Ozkan A, Hachamovitch R, Kapadia SR, et al. Impact of aortic valve replacement on outcome of symptomatic patients with severe aortic stenosis with low gradient and preserved left ventricular ejection fraction. Circulation. 2013;128:622–31.CrossRefGoogle Scholar
  20. 20.
    Doddamani S, Grushko MJ, Makaryus AN, et al. Demonstration of left ventricular outflow tract eccentricity by 64-slice multi-detector CT. Int J Cardiovasc Imaging. 2009;25:175–81.CrossRefGoogle Scholar
  21. 21.
    Saitoh T, Shiota M, Izumo M, 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. 2012;109:1626–31.CrossRefGoogle Scholar
  22. 22.
    Garcia J, Kadem L, Larose E, et al. Comparison between cardiovascular magnetic resonance and transthoracic Doppler echocardiography for the estimation of effective orifice area in aortic stenosis. J Cardiovasc Magn Reson. 2011;13:25.CrossRefGoogle Scholar
  23. 23.
    Le Ven F, Freeman M, Webb J, et al. Impact of low flow on the outcome of high-risk patients undergoing transcatheter aortic valve replacement. J Am Coll Cardiol. 2013;62:782–8.CrossRefGoogle Scholar
  24. 24.
    Clavel MA, Berthelot-Richer M, Le Ven F, et al. Impact of classic and paradoxical low flow on survival after aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol. 2015;65:645–53.CrossRefGoogle Scholar
  25. 25.
    Dayan V, Vignolo G, Magne J, et al. Outcome and impact of aortic valve replacement in patients with preserved LVEF and low-gradient aortic stenosis. J Am Coll Cardiol. 2015;66:2594–603.CrossRefGoogle Scholar
  26. 26.
    Poh KK, Levine RA, Solis 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. 2008;29:2526–35.CrossRefGoogle Scholar
  27. 27.
    Mehrotra P, Flynn AW, Jansen K, et al. Differential left ventricular outflow tract remodeling and dynamics in aortic stenosis. J Am Soc Echocardiogr. 2015;28:1259–66.CrossRefGoogle Scholar
  28. 28.
    Sato K, Seo Y, Ishizu T, et al. Reliability of aortic stenosis severity classified by 3-dimensional echocardiography in the prediction of cardiovascular events. Am J Cardiol. 2016;118:410–7.CrossRefGoogle Scholar

Copyright information

© Japanese Society of Echocardiography 2018

Authors and Affiliations

  • Dan Koto
    • 1
  • Masaki Izumo
    • 1
    Email author return OK on get
  • Takafumi Machida
    • 2
  • Kengo Suzuki
    • 1
  • Kihei Yoneyama
    • 1
  • Tomomi Suzuki
    • 1
  • Ryo Kamijima
    • 1
  • Yasuyuki Kobayashi
    • 3
  • Tomoo Harada
    • 1
  • Yoshihiro J. Akashi
    • 1
  1. 1.Division of Cardiology, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
  2. 2.Department of PharmacologySt. Marianna University School of MedicineKawasakiJapan
  3. 3.Department of RadiologySt. Marianna University School of MedicineKawasakiJapan

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