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TAVRTEEPre-procedure / Sizing
TAVR — Annulus Sizing (ME LAX)
The midesophageal long axis (ME LAX / 120–135°) is the primary TEE view for aortic annulus sizing. The annulus diameter, perimeter, and area are measured at end-systole for TAVR prosthesis selection.
Reference image — TAVR — Annulus Sizing (ME LAX)
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Structures / Anatomy
- Aortic annulus (virtual basal ring)
- LVOT
- Aortic root (sinus of Valsalva, STJ)
- Aortic cusps (RCC, LCC, NCC)
- Proximal ascending aorta
Acquisition Steps
- 1Advance probe to mid-esophagus (30–35 cm)
- 2Rotate multiplane angle to 120–135°
- 3Optimize to show LVOT, aortic valve, and aortic root in the same plane
- 4Freeze at end-systole (just before valve closure)
- 5Measure annulus diameter at the hinge points of the aortic cusps
Doppler Assessment
AV CW (ME LAX)Peak and mean gradient — baseline AS severity
LVOT PWBaseline LVOT VTI for cardiac output
AR ColorBaseline AR — note origin and severity before valve deployment
Tips
- Annulus is measured at end-systole — largest dimension
- 3D TEE provides more accurate annulus area and perimeter than 2D diameter
- Bicuspid AV requires special sizing — note raphe and asymmetric anatomy
- LVOT calcification can complicate annulus measurement — note extent
Pitfalls
- Measuring at wrong phase (diastole) underestimates annulus size
- Off-axis ME LAX overestimates or underestimates annulus diameter
- Heavy calcification can shadow the annulus — use 3D for accuracy
Key Measurements
- Annulus diameter (2D, end-systole)
- Sinus of Valsalva diameter
- STJ diameter
- Ascending aorta diameter
- LVOT diameter
- Coronary ostia height (RCA and LCA)
Critical Findings
- Severe LVOT calcification (risk of annulus rupture)
- Low coronary ostia height <10 mm (coronary occlusion risk)
- Bicuspid AV (higher paravalvular leak risk)