The Role of Imaging in Transcatheter Aortic Valve Implantation
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1 The Role of Imaging in Transcatheter Aortic Valve Implantation Helmut Baumgartner Westfälische Wilhelms-Universität Münster Division of Adult Congenital and Valvular Heart Disease Department of Cardiovascular Medicine University Hospital Muenster Germany
2 Declaration of Interests Speaker fees, advisory boards, education grants Edwards Life Sciences Actelion AGA (St. Jude Medical)
3 The Role of Imaging in Transcatheter Aortic Valve Implantation Pre-procedural evaluation Guiding and monitoring of the procedure Post-procedural evaluation and follow-up
4 The Role of Imaging in Transcatheter Aortic Valve Implantation Pre-procedural evaluation Guiding and monitoring of the procedure Post-procedural evaluation and follow-up Choice of imaging technique Echo (TTE/TEE), CT, CMR, conventional angiography
5 The Role of Imaging in TAVI: PRE-PROCEDURAL EVALUATION Assessment of aortic stenosis gradients/valve area -> severity valve morphology LV size and function, LVH MR (other additional valve lesions) PAP Echocardiography
6 The Role of Imaging in TAVI: PRE-PROCEDURAL EVALUATION Assessment of aortic stenosis gradients/valve area -> severity valve morphology LV size and function, LVH MR (other additional valve lesions) PAP Technical suitability
7 The Role of Imaging in TAVI: PRE-PROCEDURAL EVALUATION Assessment of aortic stenosis gradients/valve area -> severity valve morphology LV size and function, LVH MR (other additional valve lesions) PAP Technical suitability Choice of valve size
8 The Role of Imaging in TAVI: PRE-PROCEDURAL EVALUATION Technical Suitability Vascular access: femoral/iliac arteries Aorta (course, aneurysm, plaques, thrombi) Aortic root size and shape Coronary artery distance Valve morphology (calcification) Left ventricle (length, thrombus) Chest deformation, apex location (apical approach)
9
10 Transcatheter Aortic Valve Implantation Vascular Access: Vessel tortuiosity
11 Transcatheter Aortic Valve Implantation Vascular Access: Calcification
12 Transcatheter Aortic Valve Implantation Vascular Access: Vessel diameter
13 Vessel Size Requirements Minimal vessel diameters (esheath 16/18/20F) 23mm Sapien XT: 6.0mm 26mm Sapien XT: 6.5mm 29mm Sapien XT: 7.0 mm Siemens Syngo via 3Mensio Valves
14 Transcatheter Aortic Valve Implantation Aortic Root / Coronary artery distance
15 Distance From Coronary Ostia to the Aortic Valve Annulus Expected distances and valve hights: LCA: 14.4±2.9 mm (range of 7.1 to 22.7 mm) RCA: 17.2±3.3 mm (range of 9.2 to 26.3 mm) 14.3mm 17.2mm 19.1mm Tops et al JACC CV Imaging 2008
16 Transcatheter Aortic Valve Implantation Aortic Root Morphology
17 Transcatheter Aortic Valve Implantation Aortic Valve Calcification
18 Transcatheter Aortic Valve Implantation Chest anatomy / apex location
19 Transcatheter Aortic Valve Implantation Incidental CT findings
20 The Role of Imaging in TAVI: PRE-PROCEDURAL EVALUATION Technical Suitability Imaging of femoral and iliac arteries diameter tortuosity calcification Ultrasound Invasive angio Imaging of the aorta kinking complex plaques root morphology MR angio CT angio (Imaging of the chest anatomy)
21 The Role of Imaging in TAVI: PRE-PROCEDURAL EVALUATION Assessment of aortic stenosis gradients/valve area -> severity valve morphology LV size and function, LVH MR (other additional valve lesions) PAP Technical suitability Choice of valve size Critical for: embolization annulus perforation residual AR
22 Patients % Paravalvular Aortic Regurgitation Partner A P < P < P < Days 6 Months None Trace Mild Moderate Severe 1 Year
23 PARTNER A Cohort: 2-Year Results Kodali SK et al N Engl J Med 2012; March 26
24 Choice of Valve Size Annulus Sizing Which Motality? TTE / TEE
25 Choice of Valve Size Annulus Sizing Which Motality? TEE / CT
26 Annulus sizing: TTE vs TEE vs CT Diameter difference in 3-chamber-view: TEE vs TTE: 0.6 +/- 0.8 mm CT vs TTE: /- 1.3 mm CT vs TEE: /- 1.1 mm Mean diameter (long/short axis) measured by CT against TTE/TEE: 38% change in valve size (12/10 of 17 larger in CT) Messika-Zeitoun et al JACC 2010
27 Relation of Echo Measurements to the Anatomic Annulus Comparison of annulus size estimated by 2D echo with surgical valve sizer: TTE: 21.5 ± 1.8mm TEE: 22.0 ± 1.6mm Sizer: 23.2 ± 1.9mm Do we systematically underestimate the real annulus by using 2D echo? Babaliaros et al JACC Cardiovascular interventions 2008
28 Aortic Annulus: Anatomy vs MS CT Piazza et al. 2008, Circ CV Int.
29 Aortic Annulus: MS CT Mearsurement Activate sagital view, adjust plane to double oblique position until you see all three cusps being symmetrically visible
30 Aortic Annulus: MS CT Mearsurement Scroll down to basal ring until you see hinge point and do the fine tuning with both planes until all hinge points are present & symmetrically visible
31 Aortic Annulus: MS CT Mearsurement Ovale shape of the aortic annulus in appr. 50% Diameter calculation for valve size choice: Area: 3.42 cm 2 Diameter: 2.09 cm Perimeter: 6.5cm Diameter: 2.07cm Shortest DM: 1.83cm Longest DM: 2.26cm Mean DM: 2.0 cm
32 Shape of the Annulus Ovale shape in appr. 50% Stent shapes to circular long-axis diameter (coronal): short-axis diameter (sagital): mean diameter: 27.5±3.1 mm 21.7±2.3 mm 24.6±2.4 mm -> 3-4mm difference to mean diameter Messika-Zeitoun et al JACC 2010
33 CT is Superior to Echo in Preventing Perivalvalvular Regurgitation Jilaihawi et al 2012, JACC Paravalv. AR % 78 % Paravalv. AR 0 45% 24 % CT TEE CT TEE
34 CT is Superior to Echo in Valve Sizing TEE: 23mm CT: 27mm
35 CT is Superior to Echo in Valve Sizing 29mm Sapien XT
36 The Role of Imaging in Transcatheter Aortic Valve Implantation Pre-procedural evaluation Guiding and monitoring of the procedure Post-procedural evaluation and follow-up Choice of imaging technique Echo (TTE/TEE), CT, CMR, conventional angiography
37 The Role of Imaging in TAVI Procedural Guiding / Monitoring TEE Wire interference with mitral apparatus Valve positioning
38 The Role of Imaging in TAVI Procedural Guiding / Monitoring Comlpications: Causes of hypotension Tamponade Severe AR / MR Myocardial dysfunct. Annulus rupture Bleeding TEE
39 The Role of Imaging in TAVI Procedural Guiding / Monitoring (Wire interference with mitral apparatus) Valve positioning TEE Complications: Causes of hypotension Tamponade Severe AR Severe MR Myocardial dysfunction (after pacing) Annulus rupture Bleeding
40 The Role of Imaging in TAVI Procedural Guiding / Monitoring Optimal Imaging Plane / Postioning
41 The Role of Imaging in TAVI Procedural Guiding / Monitoring Optimal Imaging Plane / Postioning
42 The Role of Imaging in TAVI Procedural Guiding / Monitoring Optimal Imaging Plane / Postioning
43 The Role of Imaging in TAVI Procedural Guiding / Monitoring Optimal Imaging Plane / Postioning
44 The Role of Imaging in TAVI Procedural Guiding / Monitoring Optimal Imaging Plane / Postioning
45 The Role of Imaging in TAVI Procedural Guiding / Monitoring Evaluation of the Result
46 The Role of Imaging in TAVI Procedural Guiding / Monitoring Evaluation of the Result
47 The Role of Imaging in TAVI Procedural Guiding / Monitoring Evaluation of the Result
48 The Role of Imaging in Transcatheter Aortic Valve Implantation Pre-procedural evaluation Guiding and monitoring of the procedure Post-procedural evaluation and follow-up Choice of imaging technique Echo (TTE/TEE), CT, CMR, conventional angiography
49 The Role of Imaging in TAVI Procedural Guiding / Monitoring Follow-up Gradients/valve area Regurgitation Valve morphology LV size and function, LVH MR PAP
50 The Role of Imaging in TAVI Procedural Guiding / Monitoring Follow-up 63 consecutive Pts. after TAVI (Sapien XT) Orwat S et al ESC 2012
51 The Role of Imaging in Transcatheter Aortic Valve Implantation Pre-procedural evaluation Guiding and monitoring of the procedure Post-procedural evaluation and follow-up Choice of imaging technique Echo (TTE/TEE), CT, CMR, conventional angiography
52 Thank you for your attention!
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