Utility of conventional aortic root shot angiography for SAPIEN 3 prosthesis sizing in TAVI – feasibility and inter-reader variability

Objectives We aimed to investigate whether conventional aortic root angiography (CA) alone can reliably facilitate valve selection, and to describe its inter-reader variability. Background The gold standard approach to prosthesis sizing before transcatheter aortic valve implantation (TAVI) is multi-slice computed tomography (MSCT). Methods Five TAVI specialists (three interventional cardiologists and two cardiac surgeons) independently reviewed pre-procedural CAs for 50 patients implanted with the Edwards SAPIEN 3 valve. Results The prosthesis size selected based on visual CA appraisal matched that based on MSCT in 60% of cases (range: 50–68%), with undersizing in 11% (4–33%) and oversizing in 29% (10–46%; p=0.187 for equality of proportions test). Agreement between CA-based and MSCT-based valve selection was moderate (K=0.41; Kw=0.61). Reassessment of choice following awareness of the annulus long-axis diameter did not significantly improve this agreement (0.40 and 0.63, respectively), though more undersizing (14%) and less oversizing (25%) occurred. Correct valve selection was more common in interventional cardiologists than cardiac surgeons (66% vs. 53%; p=0.0391), who made more oversizing errors. Conclusions There is modest agreement between CA-based and MSCT-based SAPIEN 3 selection. While the former should not be performed routinely, it may be informative in settings where MSCT and transesophageal echocardiography are unavailable.