Echocardiographic versus angiographic measurement of the aortic valve annulus in children undergoing balloon aortic valvuloplasty: method affects outcomes

Cardiol Young. 2020 Dec;30(12):1923-1929. doi: 10.1017/S1047951120003194. Epub 2020 Oct 14.


Objective: Operators are mindful of the balloon-to-aortic annulus ratio when performing balloon aortic valvuloplasty. The method of measurement of the aortic valve annulus has not been standardised.

Methods and results: Patients who underwent aortic valvuloplasty at two paediatric centres between 2007 and 2014 were included. The valve annulus measured by echocardiography and angiography was used to calculate the balloon-to-aortic annulus ratio and measurements were compared. The primary endpoint was an increase in aortic insufficiency by ≥2 degrees. Ninety-eight patients with a median age at valvuloplasty of 2.1 months (Interquartile range (IQR): 0.2-105.5) were included. The angiographic-based annulus was 8.2 mm (IQR: 6.8-16.0), which was greater than echocardiogram-based annulus of 7.5 mm (IQR: 6.1-14.8) (p < 0.001). This corresponded to a significantly lower angiographic balloon-to-aortic annulus ratio of 0.9 (IQR: 0.9-1.0), compared to an echocardiographic ratio of 1.1 (IQR: 1.0-1.1) (p < 0.001). The degree of discrepancy in measured diameter increased with smaller valve diameters (p = 0.041) and in neonates (p = 0.044). There was significant disagreement between angiographic and echocardiographic balloon-to-aortic annulus ratio measures regarding "High" ratio of >1.2, with angiographic ratio flagging only 2/12 (16.7%) of patients flagged by echocardiographic ratio as "High" (p = 0.012). Patients who had an increase in the degree of aortic insufficiency post valvuloplasty, only 3 (5.5%) had angiographic ratio > 1.1, while 21 (38%) had echocardiographic ratio >1.1 (p < 0.001). Patients with resultant ≥ moderate insufficiency more often had an echocardiographic ratio of >1.1 than angiographic ratio of >1.1 There was no association between increase in balloon-to-aortic annulus ratio and gradient reduction.

Conclusions: Angiographic measurement is associated with a greater measured aortic valve annulus and the development of aortic insufficiency. Operators should use caution when relying solely on angiographic measurement when performing balloon aortic valvuloplasty.

Keywords: Aortic valve disease; CHD; paediatric intervention.

MeSH terms

  • Angiography
  • Aortic Valve / diagnostic imaging
  • Aortic Valve / surgery
  • Aortic Valve Stenosis* / diagnosis
  • Aortic Valve Stenosis* / surgery
  • Balloon Valvuloplasty*
  • Child
  • Echocardiography
  • Humans
  • Infant
  • Infant, Newborn
  • Retrospective Studies
  • Treatment Outcome