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Purpose: Previous multi-detector computed tomography (MDCT) studies have raised controversy regarding aortic root remodeling in tricuspid aortic stenosis (AS). We hypothesized that aortic root remodeling is different between tricuspid AS and bicuspid AS that could be assessed by real-time 3D transesophageal echocardiography (3DTEE). The aims of this study were: (1) to validate the accuracy of 3DTEE measurements of aortic root against MDCT as a reference, and (2) to determine aortic root geometry between tricuspid and bicuspid AS patients.Methods: Protocol 1: 3DTEE and contrast-enhanced MDCT were performed in 40 patients. Multiplanar reconstruction was used to measure aortic annulus area, sinus of Valsalva area, STJ area, distance from aortic annulus to STJ, and aortic root volume from the annulus to STJ. Protocol 2: The same 3DTEE measurements were performed in patients with tricuspid AS (n=51, 76±7 years, 25 men), bicuspid AS patients (n=8, 67±10 years, 7 men) and control patients (n=43, 69±13 years, 21 men).Results: Protocol 1: Excellent correlations of aortic root geometry indices were noted between the 2 modalities (r=0.86 to 0.96). Protocol 2: All patients could be assessed aortic root geometry using 3DTEE. Data were indexed to body surface area. Although annulus area was not different compared to control patients, patients with tricuspid AS showed negative transverse remodeling on sinus of Valsalva and STJ and negative longitudinal remodeling. In contrast, patients with bicuspid AS showed positive transverse remodeling but no longitudinal remodeling (table).Conclusions: 3DTEE successfully delineated different aortic root geometry between tricuspid and bicuspid AS. These data provide useful information for making new transcatheter aortic valve implantation device.