Imaging in TAVI. Jeroen J Bax Dept of Cardiology Leiden Univ Medical Center The Netherlands Davos, feb 2013
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1 Imaging in TAVI Jeroen J Bax Dept of Cardiology Leiden Univ Medical Center The Netherlands Davos, feb 2013 Research grants: Medtronic, Biotronik, Boston Scientific, St Jude, BMS imaging, GE Healthcare, Edwards Lifescience
2 Case example: 87 year-old male Ischemic cardiomyopathy (LVEF 30%). CABG. Diabetes, hypercholesterolemia, hypertension Peripheral vascular disease COPD, GFR 48 ml/min Severe aortic stenosis Dyspnoea NYHA III/IV, angina CCS 3. LogEUROSCORE 22%
3
4 1. Confirmation of aortic stenosis severity 2. Procedural feasibility: Aortic valve and aortic root anatomy and dimensions Peripheral artery anatomy 3. Exclusion of contraindications 4. Procedural approach selection Transfemoral Transapical
5 Confirmation of aortic stenosis severity Jet velocity >4.0 m/s Mean gradient >40-50 mmhg AVA <1.0 cm 2 AVA indexed <0.6 cm 2 /m 2 Baumgartner et al. European Journal of Echocardiography (2009) 10, 1 25
6 Feasibility: Aortic valve anatomy Tricuspid Bicuspid
7 Feasibility: Aortic valve anatomy
8 Feasibility: Aortic valve anatomy
9 Feasibility: Aortic valve calcifications Quantification of calcium score
10 Feasibility: Aortic valve calcifications Schultz et al. J Am Coll Cardiol 2009 Delgado et al. Eur Heart J 2010 John et al. J Am Coll Cardiol Intervent 2010
11 Feasibility: Aortic valve annular size TTE TEE
12 Feasibility: Aortic valve annular size 3-D imaging Ng et al. Circ Cardiovasc Imaging 2010 Tops et al. J Am Coll Cardiol Imaging 2008 Messika-Zeitoun et al. J Am Coll Cardiol 2010
13 Anatomical requirements THV Edwards SAPIEN XT Medtronic CoreValve 23-mm mm 26-mm mm 26-mm mm 29-mm mm 29-mm mm
14 Feasibility: Aortic root dimensions 1.- Annulus >28 mm? 2.- Sinus of Valsalva 27 mm 3.- Sino-tubular junction 43 mm 4.- Ascending aorta <45 mm Vahanian et al. Eur Heart J 2008
15 Feasibility: Coronary ostia LM RCA RCA Distance relative to the annular plane mm LM LV Tops et al. J Am Coll Cardiol Imaging 2008
16 Feasibility: Peripheral arteries and aorta Joshi et al. J Am Coll Cardiol Intervent. 2009
17 Anatomical requirements THV Edwards SAPIEN XT Medtronic CoreValve 23-mm 18F 26-mm 19F >7 mm >8 mm 26-mm - 18F 29-mm 18F 6 mm
18 Feasibility: Left ventricular geometry
19 Exclusion of contraindications 1. Significant coronary artery stenosis 2. LV thrombus
20 Procedural planning: check list Severe aortic stenosis Tricuspid anatomy and calcifications Aortic root dimensions Coronary ostia height Aortic valve annular dimensions Selection of prosthesis size Medtronic CoreValve Edwards SAPIEN XT 26-mm mm 23-mm mm 29-mm mm 26-mm mm
21 Procedural planning: check list Procedural approach Peripheral vascular access Medtronic CoreValve Edwards SAPIEN XT 26-mm 29-mm 6mm 23-mm 26-mm >7mm >8mm Yes Favourable? No Favourable? Yes No Transfemoral Trans-subclavian Transfemoral Transapical
22 Case 1 85 year-old man CV risk factors: Hypertension, hypercholesterolemia Comorbidities: COPD, prior myocardial infarction LogEuroscore: 23.4% Severe AS: Max/Mean gradient 96 / 50 mmhg, AVA 0.8 cm 2 Symptoms: Dyspnea NYHA III-IV
23 Confirmation of aortic stenosis severity
24 MSCT: Morphology of the aortic valve Tricuspid/Bicuspid Calcifications Annulus sizing Distance from the coronary ostia to the Coronal view annulus plane NCC RCC LCC Sagittal view LCA RCA
25 MSCT: Semiautomatic approach 1. Centerline across the aortic valve and aorta Annulus sizing Distance from the coronary ostia to the annular plane
26 Centerline Annular plane The annular plane displays a cross sectional view along the centerline.
27 MIP view of the aortic valve to assess calcifications Vessel reconstructions along the centerline to assess aortic root diameters and distance between the coronary ostia and the annular plane Left coronary ostium Right coronary ostium
28 MSCT: 2. Evaluation of peripheral arteries (transfemoral approach) Calcifications and tortuosity
29 The centerline is placed automatically across the peripheral arteries. The coronal, sagittal and axial views of the peripheral arteries permit the alignment of the centerline along the entire vessel.
30 The software displays the vessel view of the arteries. The internal diameter of the artery is measured and compared to the size of the delivery system. A dimension smaller than the delivery system is coded in red surface. The tortuosity is color-coded in yellow shades. The brighter yellow, the more tortuous.
31 MSCT: 3. Transapical approach: Evaluation of the LV apex LV sigmoid septum
32 Patients with pronounced sigmoid septum may be more amenable for transapical approach since the positioning of the prosthesis (Edwards-Sapien) may be more stable.
33 Transapical approach
34 Valve function after TAVI?
35 AR after TAVI?
36 TEE during TAVI Balloon inflation
37 TEE during TAVI Guiding of catheter position
38 AR - mechanism? Valvular or paravalvular?
39 Mechanism: valvular (catheter in-situ)
40 Paravalvular AR post-tavi Severe aortic valve calcifications
41 Mechanism? 1. V: Too small prosthesis undersizing 2. V: After ballooning damage to leaflet 3. V: Malfunction of leaflet ( frozen leaflet ) 4. PV: Valve / annular calcifications
42 Quantification paravalvular AR <10% circumferential extent >20% circumferential extent
43
44 Case 2 87 year-old woman CV risk factors: Hypertension, diabetes Comorbidities: Prior myocardial infarction (PCI), cerebral stroke LogEuroscore: 24.5% Severe AS: Max/Mean gradient 100 / 61 mmhg, AVA 0.9 cm 2 LVEF 55% Symptoms: Dyspnea NYHA III-IV
45
46 MSCT: Morphology of the aortic valve Tricuspid/Bicuspid Calcifications Annulus sizing Distance from the coronary ostia to the annulus plane Coronal view
47
48 Left coronary ostium Right coronary ostium
49 MSCT: Transfemoral approach
50 Angiography: Transfemoral approach
51
52
53
54 MSCT: 1-month follow-up Evaluation of prosthesis deployment and position
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