Accuracy and usefulness of aortic annular measurement using real-time three-dimensional transesophageal echocardiography: Comparison with direct surgical sizing

•We measured the aortic annulus by 3D and 2D transesophageal echocardiography (TEE) and transthoracic echocardiography.•We compared those measurements with direct measurement.•3D TEE measurement agreed better with the direct measurement than 2D.•3D TEE measurement could predict aortic valve replacement with aortic annular enlargement more accurately than 2D. There is a paucity of data that demonstrates a clinical impact of anatomical measurements of the aortic annulus by three-dimensional (3D) transesophageal echocardiography (TEE) on surgical aortic valve replacement (AVR). The aim of this study is to validate the accuracy of 3D TEE measurements compared with the direct intraoperative annular diameter and to investigate an impact of 3D TEE on a prediction of AVR with aortic annular enlargement (AAE). We retrospectively enrolled 61 patients who underwent both two-dimension (2D) and 3D TEE and transthoracic echocardiography (TTE) before AVR. The annular diameters were measured noninvasively with 2D TEE (D2D) and TTE (DTTE) in a classical manner and the area- and perimeter-derived annular diameters (Darea, Dperim) were measured from using 3D TEE analysis. Intraoperative annular diameter was measured with the manufacture's sizer (Dintraope). Darea showed the best agreement with Dintraope in the Bland–Altman analysis. Darea, Dperim, D2D, and DTTE correlated well with Dintraope (r=0.821, 0.820, 0.532, and 0.610, respectively; all p