Rapid Fire Session

Session: Rapid Fire Session 1: Vascular, Coronary, and Cardiomyopathy (Monitor 9)

Overcorrection of Aortic Diameters by BSA and Height Indexing in Turner Syndrome: A Comparison with Z-scores

Thursday, February 5, 2026

10:43 AM - 10:50 AM

Location: Galapagos / Aruba / Ilhabela (2nd Lower Level)

Presenting Author(s)

gilles soulat, MD, PhD

professor of Radiology
Université Paris Cité, INSERM, PARCC, APHP, Hôpital Européen Georges Pompidou
PARIS, Ile-de-France, France

Primary Author(s)

gilles soulat, MD, PhD

professor of Radiology
Université Paris Cité, INSERM, PARCC, APHP, Hôpital Européen Georges Pompidou
PARIS, Ile-de-France, France

Co-Author(s)

aM

adele Magalhaes, MD

Cardiologist
European Hospital Georges Pompidou APHP
PARIS 15, Ile-de-France, France
BD

Bruno Donadille, MD

Endocrinologist
Assistance Publique – Hôpitaux de Paris Hôpital Saint Antoine, Ile-de-France, France
SC

Sophie CHRISTIN-MAITRE, MD, PhD

Professor
Assistance Publique – Hôpitaux de Paris Hôpital Saint Antoine
Paris, France
LI

Laurence Iserin, MD

Assistance Publique Hôpitaux de Paris.Centre, Hôpital Européen Georges Pompidou, F-75015 Paris, France
Paris, Ile-de-France, France
EM

Elie Mousseaux, MD, PhD

Professor
Université Paris Cité, INSERM, PARCC, APHP, Hôpital Européen Georges Pompidou, France

Background: Turner syndrome (TS) is a genetic disorder in females associated with an increased risk of aortic dilatation and dissection[1]. The smaller body size of these individuals complicates the assessment of aortic dimensions, leading guidelines to recommend indexing to body surface area (BSA) height, or using Z-scores[2]. However, the validity of these methods is debated, as indexing may overcorrect for body size and misrepresent risk. This study aimed to evaluate the utility of BSA- and height-indexed aortic dimensions compared to Z-scores in TS patients and age- and size-matched controls.

Methods: This retrospective study included 95 adult women with TS who were matched 1:1 for age and height with 95 female controls. Aortic diameters were measured at ten levels on 1.5-T cardiac MRI scans. Measurements were analyzed as absolute values, indexed to BSA and height, and converted to Z-scores using published methods[3–5]. To assess the effect of body size indexing, a separate analysis was performed on a control cohort (n=134) stratified by height (figure 1).

Results: Patients with TS had significantly larger non-indexed aortic diameters than controls at the sinuses of Valsalva (median 29.7 mm vs. 27.3 mm, p< 0.001) and mid-ascending aorta (27.0 mm vs. 25.7 mm, p=0.008). After indexing, these differences remained significant (table 1). However, in the control-only cohort, BSA-indexing resulted in paradoxically larger indexed aortas in shorter women compared to taller women (17.1 mm/m² vs. 16.3 mm/m², p=0.014. In contrast, Z-scores were similar between shorter and taller controls, showing effective normalization. Consequently, 13.7% of controls met the threshold for aortic dilatation using BSA-indexing, versus only 6.3% using the Quezada Z-score( figure 2 ).

Conclusion: Indexing aortic diameters to BSA or height leads to a significant overcorrection for body size. This overcorrection may lead to an overestimation of risk and a high proportion of healthy individuals, particularly those of smaller stature, meeting thresholds for intervention. Z-scores provide a more robust and effective method for normalizing aortic dimensions. These findings suggest that current thresholds should be interpreted with caution, and Z-scores may be a more reliable tool for risk stratification in this population.

Characteristics of Turner Syndrome Patients and Controls Patients

	Turner (n = 95)	controls (n = 95)	p value
Age at MRI (years)	37.1 [31.3 – 42.7]	38.9 [31.8 – 44.9]	0.230
Height (cm)	157 [153 – 162]	160 [155 – 163]	0.101
Weight (kg)	58.0 [51.0 – 67.0]	62.0 [53.0 – 72.0]	0.101
BMI(kg/m²)	23.5 [21.4 – 26.8]	24.3 [20.7 – 29.4]	0.456
BSA (m²)
Boyd	1.61 [1.50 – 1.75]	1.69 [1.55 – 1.83]	0.062
Haycock	1.59 [1.49 – 1.73]	1.67 [1.81 – 1.53]	0.058
Dubois	1.58 [1.47 – 1.69]	1.65 [1.53 – 1.75]	0.034
Bicuspid Aortic Valve	21 [22]	0 [0]	< 0.001
Repaired Aortic coarctation	5.0 [5.3]	0 [0]	0.023
Karyotype (n = 85)
Monosomy 45.X	21 [25]	–
Mosaicism	52 [61]	–
Other	12 [14]	–
Active Smoking	10 [10.5]	–
Dyslipidemia	6 [6.3]	–
Diabetes	5 [5.2]	–
Hypertension	8 [8.4]	–
Growth Hormone (GH) Treatment	60 [63]	–
Hormone Replacement Therapy (HRT)	76 [80]	–
Thyroid Hormone Supplementation	37 [39]	–
Clinical indication for MRI
Dilated cardiomyopathy	–	15 [15.7]
Hypertophic Cardiomyopathy	–	11 [11.6]
Chest pain	–	12 [12.6]
Ischemic Heart disease	–	8 [8.4]
Myocarditis	–	8 [8.4]
arrhythmias	–	14 [14.7]
other	–	27 [28.4]
Measurments Non indexed
Left ventricular outflow tract (LVOT) (mm)	21.0 [19.6 – 22.4]	19.5 [18.0 – 20.7]	< 0.001
Aortic annulus (mm)	21.8 [20.0 – 23.0]	19.2 [18.0 – 21.2]	< 0.001
Average diameter of the sinuses of Valsalva (mm)	29.7 [27.8 – 32.2]	27.3 [25.3 – 29.2]	< 0.001
Maximum diameter of the sinuses of Valsalva (mm)	31.0 [28.6 – 33.0]	28.0 [26.7 – 30.3]	< 0.001
Sino-tubular junction (STJ) (mm)	24.5 [22.2 – 27.3]	22.7 [21 – 24.5]	< 0.001
Mid ascending aorta (mm)	27.0 [25.0 – 31.0]	25.7 [23.0 – 28.7]	0.008
Anterior aortic arch (mm)	22.0 [20.0 – 24.0]	22.0 [20.0 – 24.3]	0.297
Mid aortic arch (mm)	19.0 [17.6 – 20.0]	21.0 [19.0 – 23.0]	< 0.001
isthmus	19.0 [17.0 – 21.0]	18.6 [17.0 – 21.0]	0.667
Descending aorta (mm)	19.1 [17.8 – 21.0]	19.3 [17.5 – 21.0]	0.823
Diaphragmatic aorta (mm)	18.0 [16.0 – 19.0]	17 [15.0 – 19.0]	0.080
Measurements Indexed to BSA*
Maximum diameter of the sinuses of Valsalva (mm/m²)	18.8 [16.9 – 21.2]	16.9 [15.7 – 19.0]	< 0.001
Mid ascending aorta (mm/m²)	16.5 [14.7 – 18.2]	15.3 [13.7 – 17.3]	< 0.001
Measurements Indexed to height
Maximum diameter of the sinuses of Valsalva (mm/m)	19.5 [17.8 – 21.2]	17.6 [16.6 – 19.4]	< 0.001
Mid ascending aorta (mm/m)	17.3 [15.5 – 19.3]	16.5 [14.6 – 17.9]	0.004
Z scores
Quezada sinuses	1.06 [0.39 – 1.85]	0.26 [-0.260 – 1.02]	< 0.001
Quezada Mid Ascending	0.49 [-0.02 – 1.56]	0.098 [-0.573 – 0.86]	0.002
Roman sinuses	0.56 [-0.24 – 1.72]	-0.29 [-1.060 – 0.54]	< 0.001
Devereux sinus according to BSA	0.29 [-0.48 – 1.31]	-0.54 [-1.255 – 0.09]	< 0.001
Devereux sinus according to height	0.36 [-0.66 – 1.70]	-0.71 [-1.47 – 0.08]	< 0.001
n [%] or median [Q1 – Q3]. * bsa based an Haycock formula

Figure 1: Study Flow chart.
Figure 2: Proportion of turner and controls reaching dilatation and interventions thresholds