New Cardiovascular Devices and Interventions: Non-Contrast MRI for TAVR Abhishek Chaturvedi Assistant Professor. Cardiothoracic Radiology
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1 New Cardiovascular Devices and Interventions: Non-Contrast MRI for TAVR Abhishek Chaturvedi Assistant Professor Cardiothoracic Radiology
2 Disclosure I have no disclosure pertinent to this presentation.
3 Background Pre-procedure imaging for assessing the anatomy. 1. ECG-gated CTA of the chest. 2. Non-gated CTA of abdomen & pelvis. Leon MB. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med.
4 Indications for MRI 1. Severe allergy to iodinated contrast. 2. Impaired renal function (acute kidney injury or chronic kidney injury with serum creatinine 2mg/dL). 3. Evaluation of severity of AS in patients with poor acoustic window, low cardiac output/low gradient AS (aortic stenosis) with reduced left ventricular ejection fraction (LVEF). 4. Evaluating severity of aortic stenosis in patients with moderate stenosis by TTE but symptomatic and who have contraindications for stress echocardiography.
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6 Advantages of MRI Noninvasive and radiation-free. Detailed anatomic assessment of the aortic valve and performing planimetry. Detailed visualization of cardiac structures and provides superior characterization of the ventricular mass and function. Depicts pathologic conditions of the ascending aorta. MRI provides numerically similar measurements in terms of annulus size, left ventricular outflow tract (LVOT), and AVA when compared to TTE. LGE! Rajani R. The art of assessing aortic stenosis. Heart. La Manna, Cardiovascular magnetic resonance for the assessment of patients undergoing transcatheter aortic valve implantation: a pilot study. J Cardiovasc Magn Reson.
7 Sequence Purpose Three plane localizer Axial SSFP non-gated without contrast Breath held/free breathing 2D ECG-gated SSFP: Coronal Aorta, LVOT and Aortic Root SSFP gated images: short axis stack Breath held/free breathing phase contrast at aortic orifice 3D Navigator assisted SSFP T2 Black Blood Localize aortic valve plane Identify potential ascending aorta and subclavian access sites, determine size, calcification, and presence of aneurysmal dilatation of aorta Evaluate aortic annulus, aortic valve structure, and sinus height Planimetry valve orifice area Calculate ejection fraction, ventricular volumes and mass Calculate blood flow velocity, pressure gradient and flow volume across the aortic valve Calculate aortic regurgitant volume Coronary ostia height Useful in presence of susceptibility artifacts from sternal wires or prosthetic valves
8 Edwards Sapien Valve Native Annular size TEE: Diameter/Area (mm/mm2) Mean Aortic Annulus Diameter (mm) Aortic Annulus Perimeter Aortic Annulus Area (mm2) Area derived Diameter Sapien 23 mm 18-22/ Sapien 26 mm 21-25/ Sapien 29 mm 24-28/ Sapien3: 20 mm Sapien3: 23 mm Sapien3: 26 mm Sapien3: 29 mm
9 Core Valve Valve Aortic Annulus Diameter (mm) Aortic Annulus Area (mm2) Aortic Annulus Perimeter Ascending Aortic Diameter Sinus of valsalva: Height/Width (mm) CoreValve mm 15/ 25 CoreValve mm 15/ 27 CoreValve mm 15/ 29 CoreValve mm 15/ 29
10 Sequence Axial SSFP non-gated without contrast Flip Angle TE/TR Slice Thickness/Gap (mm) /3.4 6/0 Breath held/free breathing 2D ECG-gated SSFP: Coronal Aorta, LVOT and Aortic Root /3.4 5/0 T2 Black Blood 90 41/1791 8/0 Breath held/free breathing phase contrast at aortic orifice / D Navigator assisted SSFP /4 2
11 Evaluation of the aortic annulus and root Measurement of aortic annular minimal and maximal diameter, perimeter, and area Measurement of distance between annular plane and origin of coronary ostia Measurement of the diameter at the aortic-root, sino-tubular junction and proximal aorta Aortic root angle Valvular and ventricular function analysis Planimetry of the AVA Leaflet morphology Assessment of ejection fraction Ventricular volume and mass Evaluation of the Thoracic Aorta Measurement of ascending aorta, aortic arch, and descending aorta Distance between access site and aortic annulus Evaluation of LV Apex Evaluation of scar/ prior infarct, thrombus Location of the LV apex
12 A B
13 Aortic Annulus
14 Coronary Ostia
15 Annular Calcification Feuchtner G, (2013) Prediction of paravalvular regurgitation after transcatheter aortic valve implantation by computed tomography: value of aortic valve and annular calcification.
16 Aortic Stenosis
17 Aortic Diameter A B C D Noncalcified atherosclerotic plaque burden of the thoracic aorta may increase the risk for ARF Aortic wall thickness that exceeded 2 mm is defined as a diseased segment van Rosendael PJ, (2015) Atherosclerosis burden of the aortic valve and aorta and risk of acute kidney injury after transcatheter aortic valve implantation. J Cardiovasc Comput Tomogr.
18 Sinus of Valsalva Height
19 Valve Leaflets
20 Aortic Root Angle Aortic root orientation is critical for precise positioning of the device. Inappropriate alignment is associated with post-procedural complications such as stent embolization. If root angle > 30, subclavian approach cannot be used. *Tuzcu, EM, et al. Cardiovasc Interv. 2008;72:S79-80.
21 Trans Aortic Access Right lateral side of aorta No calcification/ thrombi No dissection or prior surgery 1 cm from graft Minimal distance from the aortic annulus 5 cm Bapat V, (2012) Transaortic Transcatheter Aortic Valve Implantation: Step-by-Step Guide. Semin Thorac Cardiovasc Surg.
22 Transapical Access LV Apex: Scar/prior infarct and thrombus Localize
23 Late Gadolium Enhancement None Transmural Low LV EF Subendocardial Mid Wall: syncopal, low RV EF RV insertion points Major Adverse cardiac event: mid wall Role of myocardial scar on 30day outcome after TAVI. Britta Butzbach. J Cardiovasc Magn Reson. 2015
24 Post Implantation PVL TTE: Higher variability Significantly underestimates AV annulus size Underestimates AR
25 Limitations Calcifications Severe Dyspnea
26 Conclusion Non-contrast MRI may play a pivotal role in assessment of aortic valve in patients who cannot undergo a CTA or stress Echo. It provides hemodynamic information with high accuracy. MRI can accurately provide the critical measurements needed for identifying the most appropriate prosthesis.
27 References: 1. Bennett CJ. CT and MR imaging of the aortic valve: radiologic-pathologic correlation. Radiographics. 2. Leon MB, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med Quail MA. Use of cardiovascular magnetic resonance imaging for TAVR assessment in patients with bioprosthetic aortic valves: Comparison with computed tomography. Eur J Radiol. 4. ACR Manual on contrast media In: ACR, Rajani R, Hancock J, Chambers JB. The art of assessing aortic stenosis. Heart La Manna A, et al. Cardiovascular magnetic resonance for the assessment of patients undergoing transcatheter aortic valve implantation: a pilot study. Journal of cardiovascular magnetic resonance Jabbour A, et al. Multimodality imaging in transcatheter aortic valve implantation and post-procedural aortic regurgitation: comparison among cardiovascular magnetic resonance, cardiac computed tomography, and echocardiography. Journal of the American College of Cardiology Koos R, et al. Evaluation of aortic root for definition of prosthesis size by magnetic resonance imaging and cardiac computed tomography: implications for transcatheter aortic valve implantation. Int J Cardiol Paelinck BP, et al. Comparison of magnetic resonance imaging of aortic valve stenosis and aortic root to multimodality imaging for selection of transcatheter aortic valve implantation candidates. Am J Cardiol Koos R, et al. Association of aortic valve calcification severity with the degree of aortic regurgitation after transcatheter aortic valve implantation. International journal of cardiology Puymirat E, et al. Hakki's formula for measurement of aortic valve area by magnetic resonance imaging. The American journal of cardiology Litmanovich DE. Imaging in Transcatheter Aortic Valve Replacement (TAVR): role of the radiologist. Insights into imaging Bapat V, Attia R. Transaortic Transcatheter Aortic Valve Implantation: Step-by-Step Guide. Seminars in thoracic and cardiovascular surgery Orwat S, et al. Aortic regurgitation severity after transcatheter aortic valve implantation is underestimated by echocardiography compared with MRI. Heart
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