Optimal Imaging Technique Prior to TAVI -Echocardiography-
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1 2014 KSC meeting Optimal Imaging Technique Prior to TAVI -Echocardiography- Geu-Ru Hong, M.D. Ph D Associate Professor of Medicine Division of Cardiology, Severance Cardiovascular Hospital Yonsei University College of Medicine, Seoul, Korea
2 Worldwide Cardiology Market Trends New market segments may exceed PCI market size by 2020 Emergence of future segments relies on technology and clinical data OUS markets will lead and exceed the size of US markets
3 Current Generation of Devices Edward Life sciences Balloon expandable Medtronic CoreValve Self expandable
4 Current State of TAVI
5 Current State of TAVI
6 Current State of TAVI
7 Current State of TAVI
8 Possible Complication Stroke Vascular events Bleeding Paravalvular regulgitation Need for new Pacemaker
9 Indication for TAVI Multidisciplinary Team (Heart team) - 2 surgeons, 2 interventional cardiologists, 1 cardiac anesthetist and cardiac imaging specialist should agree Joint Consensus Statement and Guideline on Trans-catheter Aortic Valve Implantation (TAVI) 23 August 2011 Vahanian A, Eur Heart J. 2012;33:
10 Imaging is a fundamental component for performing TAVI procedure
11 Specific Roles of Cardiac Imaging in TAVI Pre-TAVI - Assessment of valvular & LV function (Echo) - Iiofemoral evaluation (CT) - Aortic size (CT/Echo) - Annular sizing (CT/Echo) - AV morphological assessment (CT/Echo) - Annular/LVOT calcium (CT) During TAVI - Angle of intra-procedural fluoroscopic projection (CT) - Monitoring of complications (Echo) - Assessment of valvular function-pv leak (Echo) Post TAVI - Follow-up of valvular function (Echo) - Long term evaluation: migration/stent fracture (CT)
12 Specific Roles of Cardiac Imaging in TAVI Pre-TAVI - Assessment of valvular & LV function (Echo) - Iiofemoral evaluation (CT) - Aortic size (CT/Echo) - Annular sizing (CT/Echo) - AV morphological assessment (CT/Echo) - Annular/LVOT calcium (CT) During TAVI - Angle of intra-procedural fluoroscopic projection (CT) - Monitoring of complications (Echo) - Assessment of valvular function-pv leak (Echo) Post TAVI - Follow-up of valvular function (Echo) - Long term evaluation: migration/stent fracture (CT)
13 Role of Pre-TAVI Imaging Patient selection Evaluation of severity and morphology of aortic stenosis - Aortic root geometry - Subaortic geometry Iliofemoral assessment Evaluation of aorta Other valve disease Other cardiac/cardiovascular disease
14
15 Four steps Patient selection - Confirmation the severity of AS - Evaluation of symptoms - Analysis of the risk of surgery and evaluation of life expectancy and quality of life - Assessment of the feasibility and exclusion of contraindications for TAVI European Heart Journal (2008) 29,
16 Confirmation of severe AS Echocardiography Valve area Flow-dependent indices (Peak / mean pressure gradient) pseudo severe AS Low-dose dobutamine echocardiography is useful to differentiate European Heart Journal (2008) 29,
17 Risks of surgery Life expectancy and Quality of life Risk of surgery The EuroScore (or logistic EuroScore) The STS Predicted Risk of Mortality score the Ambler score Not yet specifically established Life expectancy <1 year; contraindication
18 Determining severity Assessing etiology Excluding other cause of LV outflow tract obstruction Device selection - Annular sizing Echo in TAVI - Aortic root and STJ sizing - Position of the coronary arteries
19 Structural Heart
20 Aortic Atheroma - TEE
21 Echo in TAVI Determining severity Assessing etiology Excluding other cause of LV outflow tract obstruction Device selection - Annular sizing - Aortic root and STJ sizing - Position of the coronary arteries
22 Normal Anatomy of Aortic Valve
23 Annulus Sizing is Crucial
24 Annulus Sizing is Crucial Undersizing - Paravalvular regurgitation - Valve embolization Oversizing - Reduce valve durability - Conduction disturbance - Annular rupture
25 TAVI-Annulus measurement TEE TTE 3D TEE CT Angio
26 Annulus Measurement by Echo
27 2D TTE / TEE
28 Annulus Easy to underestimate the annulus diameter
29 Aortic Annular View with TEE
30 Errors Annulus Sizing
31 The Annulus: Facts Systolic > diastolic Eccentric shape Calcification: important for leak
32 Annulus CT Mostly oval shape Shortest at AP diameter 2D measurement is hard to assess true annulus size
33 CT: Axial cuts at multiple levels
34 CT sizes annulus larger than TEE 50 patients after TAVI Different THV size would be selected in 44-40% of cases, when a strategy of valve-sizing is undertaken using CT CT > TEE: 1.5mm Gurvitch et al. JACC Intv 2011
35 Correlation Between TTE, TEE, MDCT Messika-Zeitoun et al, JACC 2010
36 4D Change in Annulus Dimensions over Cardiac Cycle Hamdan et al. JACC 2012
37 109 pts imaged pre-tavr (CT) Moderate or severe regurgitation (12.7%) was associated with device undersizing (p<0.01) Difference on CT between valve and annulus size was predictive of regurgitation 3D aortic annular measurement are predictive of moderate or severe regurgitation post TAVR Wilson AB, J Am Coll Cardiol, 2012 Apr 3;59(14):
38 Annulus size measurement Measurement of annulus is very critical for successful TAVI 3D Data set provides the most useful information because the annulus is not circular Decision making is evolving with increasing experience and availability of different sizes
39 CoreValve Sizing
40 Edward Sapien Sizing
41 Annulus size by 2D TEE Mean annulus diameter Mean sinus of Valasalva diameter N= mm 31.4 mm Actual valve size (mm) TEE derived size determination (mm) total total
42 Breathing Artifacts
43 Cardiac Motion
44 PVC
45 Motion artifact on aorta
46 New Imagings for TAVI Improving TAVI outcomes Reducing the risk of complications Pursuit of Perfection 3D Quantatative Automated Real-time
47 Why 3D? 1982 Tron 2010 Avatar 2013 Ironman3
48 3D measurement
49 Alignment of Aortic Root with 3D-TEE
50 3D TEE vs. CT Perimeter: 78 (24.8π) mm Area: 440 mm 2 (23.7 mm) Perimeter: 77.6 (24.7π) mm Area: 443 mm 2 (23.8 mm) Annulus 21 mm
51 Aortic Annulus Automated Quantitative Modeling - Echo
52 Aortic Annulus 2-D versus Automated 3-D TEE
53 Automated 3-D TEE of Aortic Root Annulus to Ostia Distances Left 8.0 mm Right 12.3 mm
54 Circ Cardiovasc Imaging 2013;6: Automated 3D modeling TEE compared with 2D TEE and 3D CT ie33 system (Philips) X72t-TEE probe
55 Circ Cardiovasc Imaging 2013;6:
56 Heart 2011;97: consecutive patients with severe AS undergoing TAVI < Methods> 2D TTE 2D TEE 3D TEE Dual-source CT Angiography < Parameters> Aortic annulus diameters - coronal - sagital Distance between aortic annulus & LM os.
57 Angiography 2D echo 3D TEE DSCT 3D imaging techniques should be used to evaluate aortic annu lus diameters 3D TEE provides measurements of aortic annulus diameters similar to those obtained by DSCT. Heart 2011;97:
58 3D Echocardiography (Philips) 3D TEE CT Perimeter 72.1 mm Diameter 24.3 x x 20.4 Area 4.06 cm cm 2
59 3D Echocardiography (GE)
60 3D TEE vs. CT Perimeter: 78 (24.8π) mm Area: 440 mm 2 (23.7 mm) Perimeter: 77.6 (24.7π) mm Area: 443 mm 2 (23.8 mm) Annulus 21 mm
61 87 year old Female with Dyspnea C.C Dyspnea for 10 days Chest discomfort for 6 months History Hypertension on medication Chronic renal failure
62 EKG
63 CXR
64 Lab CBC (WBC-Hb-Plt) 5470 (54.6%) k BUN/Creatinie 35.2/1.92 Glucose 111 Electrolyte (Na/K/Cl/tCO 2 ) OT/PT/T.bil CK/CK-MB NT-proBNP CRP 3.0
65
66
67 CAG
68 Cardiac CT for pre-procedure (TAVI) screening
69 After CT scan After 1 day After 2 day After 3 day
70 Advantage of Echo Inexpensive Safe Portable Repeat Hemodynamic information - Do not require offline analysis
71 Pitfalls of Echocardiography Image quality - Good vs poor Subjective Machine factor Operator dependent - Expert vs beginner
72
73 Conclusion Cardiac imaging has an essential role in the planning and provision of TAVI Echocardiography allows appropriate case selection, correct choice of prosthetic size and type, guides successful implantation, and facilitates the treatment of complications The imaging specialist must possess procedural knowledge, and precision in quantification, and communication in order to be part of a team that delivers good outcomes
74 Thank you for your attention
75 Aortic Annular Measurement
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