Skip to main content

Angles between the aortic root and the left ventricle assessed by MDCT are associated with the risk of aortic regurgitation after transcatheter aortic valve replacement



To evaluate the impact of the angles quantified by multidetector computed tomography (MDCT) between the ascending aorta’s long axis and, the left ventricular inflow long axis (LVLA), or the left ventricule outflow tract long axis, and the occurrence of post-transcatheter aortic valve replacement (TAVR) aortic regurgitation (AR).


We prospectively included 136 consecutive patients who underwent a transfemoral TAVR with a preoperative MDCT. The groups were defined according to AR <2 or ≥2 assessed by echocardiography at 1 month.


AR ≥2 identified in 21 patients (15.4%), was associated with increased rates of mortality (p value 0.02) and heart failure (p value 0.001) at 1-year follow-up. The aorta–LVLA angle was significantly higher in patients with AR ≥2 (130.5° ± 8.8° vs. 124.6° ± 9.5°; p = 0.009). On univariate analysis, aorta–LVLA angle was predictive of AR ≥2 [OR 1.07 per degree (1.02–1.13); p = 0.011]. After adjustment on annular calcification extent, the percentage of prosthesis-annular mismatch and the type of prosthesis, the relationship between aorta–LVLA angle and the risk of AR ≥2 remained unchanged.


We showed that increased angulation between the ascending aorta and the LVLA is associated with higher rates of AR post-TAVR independent of other potential correlates.

This is a preview of subscription content, access via your institution.

Fig. 1


  1. 1.

    Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M, Dewey T, Kapadia S, Babaliaros V, Thourani VH, Corso P, Pichard AD, Bavaria JE, Herrmann HC, Akin JJ, Anderson WN, Wang D, Pocock SJ (2011) Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 364:2187–2198

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Adams DH, Popma JJ, Reardon MJ, Yakubov SJ, Coselli JS, Deeb GM, Gleason TG, Buchbinder M, Hermiller J Jr, Kleiman NS, Chetcuti S, Heiser J, Merhi W, Zorn G, Tadros P, Robinson N, Petrossian G, Hughes GC, Harrison JK, Conte J, Maini B, Mumtaz M, Chenoweth S, Oh JK (2014) Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med 370:1790–1798

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, Thourani VH, Tuzcu EM, Miller DC, Herrmann HC, Doshi D, Cohen DJ, Pichard AD, Kapadia S, Dewey T, Babaliaros V, Szeto WY, Williams MR, Kereiakes D, Zajarias A, Greason KL, Whisenant BK, Hodson RW, Moses JW, Trento A, Brown DL, Fearon WF, Pibarot P, Hahn RT, Jaber WA, Anderson WN, Alu MC, Webb JG (2016) Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 374:1609–1620

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Athappan G, Patvardhan E, Tuzcu EM, Svensson LG, Lemos PA, Fraccaro C, Tarantini G, Sinning JM, Nickenig G, Capodanno D, Tamburino C, Latib A, Colombo A, Kapadia SR (2013) Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: meta-analysis and systematic review of literature. J Am Coll Cardiol 61:1585–1595

    Article  PubMed  Google Scholar 

  5. 5.

    Hayashida K, Lefevre T, Chevalier B, Hovasse T, Romano M, Garot P, Bouvier E, Farge A, Donzeau-Gouge P, Cormier B, Morice MC (2012) Impact of post-procedural aortic regurgitation on mortality after transcatheter aortic valve implantation. JACC Cardiovasc Interv 5:1247–1256

    Article  PubMed  Google Scholar 

  6. 6.

    Jilaihawi H, Kashif M, Fontana G, Furugen A, Shiota T, Friede G, Makhija R, Doctor N, Leon MB, Makkar RR (2012) 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 59:1275–1286

    Article  PubMed  Google Scholar 

  7. 7.

    Sherif MA, Abdel-Wahab M, Stocker B, Geist V, Richardt D, Tolg R, Richardt G (2010) Anatomic and procedural predictors of paravalvular aortic regurgitation after implantation of the Medtronic CoreValve bioprosthesis. J Am Coll Cardiol 56:1623–1629

    Article  PubMed  Google Scholar 

  8. 8.

    Leipsic J, Gurvitch R, Labounty TM, Min JK, Wood D, Johnson M, Ajlan AM, Wijesinghe N, Webb JG (2011) Multidetector computed tomography in transcatheter aortic valve implantation. JACC Cardiovasc Imaging 4:416–429

    Article  PubMed  Google Scholar 

  9. 9.

    Abramowitz Y, Maeno Y, Chakravarty T, Kazuno Y, Takahashi N, Kawamori H, Mangat G, Cheng W, Jilaihawi H, Makkar RR (2016) Aortic angulation attenuates procedural success following self-expandable but not balloon-expandable TAVR. JACC Cardiovasc Imaging 9:964–972

    Article  PubMed  Google Scholar 

  10. 10.

    Popma JJ, Reardon MJ, Yakubov SJ, Hermiller JB Jr, Harrison JK, Gleason TG, Conte JV, Deeb GM, Chetcuti S, Oh JK, Boulware MJ, Huang J, Adams DH (2016) Safety and efficacy of self-expanding TAVR in patients with aortoventricular angulation. JACC Cardiovasc Imaging 9:973–981

    Article  PubMed  Google Scholar 

  11. 11.

    Vahanian A, Alfieri O, Al-Attar N, Antunes M, Bax J, Cormier B, Cribier A, De Jaegere P, Fournial G, Kappetein AP, Kovac J, Ludgate S, Maisano F, Moat N, Mohr F, Nataf P, Pierard L, Pomar JL, Schofer J, Tornos P, Tuzcu M, van Hout B, Von Segesser LK, Walther T (2008) Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 29:1463–1470

    Article  PubMed  Google Scholar 

  12. 12.

    Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Pierard L, Price S, Schafers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M (2012) Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 33:2451–2496

    Article  PubMed  Google Scholar 

  13. 13.

    Detaint D, Lepage L, Himbert D, Brochet E, Messika-Zeitoun D, Iung B, Vahanian A (2009) Determinants of significant paravalvular regurgitation after transcatheter aortic valve: implantation impact of device and annulus discongruence. JACC Cardiovasc Interv 2:821–827

    Article  PubMed  Google Scholar 

  14. 14.

    Marwan M, Achenbach S, Ensminger SM, Pflederer T, Ropers D, Ludwig J, Weyand M, Daniel WG, Arnold M (2013) CT predictors of post-procedural aortic regurgitation in patients referred for transcatheter aortic valve implantation: an analysis of 105 patients. Int J Cardiovasc Imaging 29:1191–1198

    Article  PubMed  Google Scholar 

  15. 15.

    del Valle-Fernandez R, Jelnin V, Panagopoulos G, Dudiy Y, Schneider L, de Jaegere PT, Schultz C, Serruys PW, Grube E, Ruiz CE (2010) A method for standardized computed tomography angiography-based measurement of aortic valvar structures. Eur Heart J 31:2170–2178

    Article  PubMed  Google Scholar 

  16. 16.

    Leon MB, Piazza N, Nikolsky E, Blackstone EH, Cutlip DE, Kappetein AP, Krucoff MW, Mack M, Mehran R, Miller C, Morel MA, Petersen J, Popma JJ, Takkenberg JJ, Vahanian A, van Es GA, Vranckx P, Webb JG, Windecker S, Serruys PW (2011) Standardized endpoint definitions for transcatheter aortic valve implantation clinical trials: a consensus report from the Valve Academic Research Consortium. Eur Heart J 32:205–217

    Article  PubMed  Google Scholar 

  17. 17.

    Patsalis PC, Konorza TF, Al-Rashid F, Plicht B, Riebisch M, Wendt D, Thielmann M, Jakob H, Eggebrecht H, Heusch G, Erbel R, Kahlert P (2013) Incidence, outcome and correlates of residual paravalvular aortic regurgitation after transcatheter aortic valve implantation and importance of haemodynamic assessment. EuroIntervention 8:1398–1406

    Article  PubMed  Google Scholar 

  18. 18.

    Takagi K, Latib A, Al-Lamee R, Mussardo M, Montorfano M, Maisano F, Godino C, Chieffo A, Alfieri O, Colombo A (2011) Predictors of moderate-to-severe paravalvular aortic regurgitation immediately after CoreValve implantation and the impact of postdilatation. Catheter Cardiovasc Interv 78:432–443

    PubMed  Google Scholar 

  19. 19.

    Auffret V, Lefevre T, Van Belle E, Eltchaninoff H, Iung B, Koning R, Motreff P, Leprince P, Verhoye JP, Manigold T, Souteyrand G, Boulmier D, Joly P, Pinaud F, Himbert D, Collet JP, Rioufol G, Ghostine S, Bar O, Dibie A, Champagnac D, Leroux L, Collet F, Teiger E, Darremont O, Folliguet T, Leclercq F, Lhermusier T, Olhmann P, Huret B, Lorgis L, Drogoul L, Bertrand B, Spaulding C, Quilliet L, Cuisset T, Delomez M, Beygui F, Claudel JP, Hepp A, Jegou A, Gommeaux A, Mirode A, Christiaens L, Christophe C, Cassat C, Metz D, Mangin L, Isaaz K, Jacquemin L, Guyon P, Pouillot C, Makowski S, Bataille V, Rodes-Cabau J, Gilard M, Le Breton H (2017) Temporal trends in transcatheter aortic valve replacement in France: FRANCE 2 to FRANCE TAVI. J Am Coll Cardiol 70:42–55

    Article  PubMed  Google Scholar 

  20. 20.

    Ewe SH, Ng AC, Schuijf JD, van der Kley F, Colli A, Palmen M, de Weger A, Marsan NA, Holman ER, de Roos A, Schalij MJ, Bax JJ, Delgado V (2011) Location and severity of aortic valve calcium and implications for aortic regurgitation after transcatheter aortic valve implantation. Am J Cardiol 108:1470–1477

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Koos R, Mahnken AH, Dohmen G, Brehmer K, Gunther RW, Autschbach R, Marx N, Hoffmann R (2011) Association of aortic valve calcification severity with the degree of aortic regurgitation after transcatheter aortic valve implantation. Int J Cardiol 150:142–145

    Article  PubMed  Google Scholar 

  22. 22.

    Staubach S, Franke J, Gerckens U, Schuler G, Zahn R, Eggebrecht H, Hambrecht R, Sack S, Richardt G, Horack M, Senges J, Steinberg DH, Ledwoch J, Fichtlscherer S, Doss M, Wunderlich N, Sievert H (2013) Impact of aortic valve calcification on the outcome of transcatheter aortic valve implantation: results from the prospective multicenter German TAVI registry. Catheter Cardiovasc Interv 81:348–355

    Article  PubMed  Google Scholar 

  23. 23.

    Katsanos S, Ewe SH, Debonnaire P, van der Kley F, de Weger A, Palmen M, Scholte AJ, Schalij MJ, Bax JJ, Marsan NA, Delgado V (2013) Multidetector row computed tomography parameters associated with paravalvular regurgitation after transcatheter aortic valve implantation. Am J Cardiol 112:1800–1806

    Article  PubMed  Google Scholar 

  24. 24.

    Willson AB, Webb JG, Labounty TM, Achenbach S, Moss R, Wheeler M, Thompson C, Min JK, Gurvitch R, Norgaard BL, Hague CJ, Toggweiler S, Binder R, Freeman M, Poulter R, Poulsen S, Wood DA, Leipsic J (2012) 3-dimensional aortic annular assessment by multidetector computed tomography predicts moderate or severe paravalvular regurgitation after transcatheter aortic valve replacement: a multicenter retrospective analysis. J Am Coll Cardiol 59:1287–1294

    Article  PubMed  Google Scholar 

  25. 25.

    Schultz CJ, Tzikas A, Moelker A, Rossi A, Nuis RJ, Geleijnse MM, van Mieghem N, Krestin GP, de Feyter P, Serruys PW, de Jaegere PP (2011) Correlates on MSCT of paravalvular aortic regurgitation after transcatheter aortic valve implantation using the Medtronic CoreValve prosthesis. Catheter Cardiovasc Interv 78:446–455

    Article  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Vincent Roule.

Ethics declarations

Conflict of interest

This study was performed without specific funding and there is no conflict of interest.

Ethical approval

This study has been approved by the ethics committee and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Roule, V., Placente, A., Sabatier, R. et al. Angles between the aortic root and the left ventricle assessed by MDCT are associated with the risk of aortic regurgitation after transcatheter aortic valve replacement. Heart Vessels 33, 58–65 (2018).

Download citation


  • Aortic regurgitation
  • Aortic valve implantation
  • Computed tomography
  • Angulation
  • Mortality