Severity of AS Degree of AV calcification (? Bicuspid AV), annulus size, & aortic root

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1 The role of Cardiac Imaging modalities in evaluation & selection of patients for Trans-catheter Aortic Valve Implantation Dr.Saeed AL Ahmari Consultant Cardiologist Prince Sultan Cardaic Center, Riyadh

2 TAVI Team work

3 Steps in patients selection

4 TTE Assessment Severity of AS Degree of AV calcification (? Bicuspid AV), annulus size, & aortic root measurements LV function, and intracardiac masses Associated valvular l lesions, PAP

5 TTE measurements of aortic annulus

6 Parasternal Long Axis View 5 cm Ascending ao junction sinus Aorta root measurements

7 Echo Parameters AVA PG MG EF PAP Mod- Severe MR 0.5 ± 0.12 cm² 86.7 ± 22.1 mmhg 50.9 ± 13 mmhg 48.6± 12.2 % 48.75±16 mmhg 33 %

8 Improvement in MR severity

9 Improvement in Functional MR severity

10 TEE Assessment Degree of AV calcification Annulus size, and aortic root measurements LM height Intra cardiac masses Other valvular lesions Aorta disease

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13 Aortic Atheroma

14 Possible bicuspid Aortic Valve

15 Bicuspid AV by 3-D Decho

16 LM occlusion due to AV leaflets post AV Balloon

17 CT Angiogram Degree of AV Calcification Aortic annulus measurements Height of coronary ostia Aortic root morphology, and measurements Porcelain aorta Aorta diameter, tortuously, and calcification Ilio-femoral vessels diameter, and calcification

18 CT Assessment of the Aortic annulus

19 CT reconstruction of Aortic root 4.5 cm Ascending AO STJ sinus height ANNULUS CT reconstruction of Aortic Root. Measure the distances as shown in the picture. Please make 2-D reconstructions in two different planes.

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21 Aortic valve annulus measurements

22 Edward Sapien Valve THV SIZING RECOMMENDATIONS 18-21mm Annulus 23mm Valve mm Annulus 26mm Valve Sizing Considerations: 1) )P Patient Size 2) Degree of root and aortic calcification

23 Selection of Prosthesis Size 26 mm inflow 29 i fl device smaller Sinusheight 15mm!!!!! 29 mm inflow device larger 40 mm (Ascending aorta) 27 mm (Sinus of Valsalva) mm (AV annulus) 43 mm 29 mm mm

24 Aortic Root Measurements Aortic annulus Sinus Width Sinus Height STJ width Ascending Aorta Height of the LM Porcelain Aorta 21.9 ± mm mm mm 32-44mm 12.8 ± %

25 LM Height from the AV

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27 Post trans-femoral TAVI LM occlusion

28 Bulky AV calcification

29 LM occlusion with bulky AV calcification

30 Bicuspid AV

31 Bulky AV calcification

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33 Heavy aortic valve, and aortic root calcification

34 Para-valvular leak

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36 Para-valvular Leak

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38 Angio : bifurcation abdominal AO/iliaca Determine if there are any abnormalities that could cause a difficult implantation. Measure the diameter of the arteries en look for calcifications

39 Aortic Calcification

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41 CT Angio- Aortic Calcification

42 Tortuous Aorta

43 CT Angio Assessment of the aorta,& peripheral vessels

44 Peripheral vessels measurements

45 Peripheral Arteries Measurements RCI REI RFA LCI LEI LFA 4-13 mm 6-11 mm 6-10 mm 4-13 mm 7-11mm 6-10mm

46 Angiogram Coronary angiogram ± PCI Aortic root angiogram Ilio-femoral angiogram Ideal aortic root sinus view for valve implantation

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48 Angio of Aortic Root 4.5 cm Ascending AO STJ sinus Sinus height Angio of Aortic Root with use of a graduated pigtail catheter, measure the distances as shown in the picture.

49 Angio measurements of iliofemoral vessels

50 Cardiac MRI Aortic annulus Aortic anatomy Ilio-femoral vessels size

51 Conclusion Team work is mandatory for success of TAVI program Proper selection of patients is essential for TAVI procedure Clinical experience, and eye balling of patients general condition are very important in the selection process

52 Conclusion Integrating all imaging modalities for proper selection, and proper sizing of the valve are the corner stone for the procedure success. Bulky aortic calcification, bicuspid id AV, and short distance ( <8 mm) between the aortic annulus, and LM are prohibitive for TAVI from our experience

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54 Summary

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66 Objectives TAVI is an emerging technique for treating non operable patients with severe aortic stenosis. We report our experience in using different cardiac imaging modalities in evaluation, & selection of patients for TAVI

67 Methods All eligible patients for TAVI therapy underwent detailed transthoracic echocardiography, where peak (PG), mean (MG) gradients, aortic, valve area (AVA), aortic annulus size (AA), ejection fraction (EF), severity of mitral regurgitation (MR) were assessed. Contrast gated cardiac CT scan was performed to measure aortic annuls, height ht of the coronaries from annulus, aortic root size, aortic calcification, peripheral vessel size & calcification. Transesophageal echocardiography (TEE) was done if needed to measure annulus, to assess MR severity, and aortic atheroma

68 Parasternal Long Axis View height LVOT annulus Aortic Root Sinotubular junction Basal attachment of AV leaflets al. Image with courtesy of Nicolo Piazza et Annulus LVOT measurement

69 Coronary Artery disease Normal CA Previous CABG MILD/Mod CAD PCI 27 % 12 % 28 33

70 Procedural Data GA Local A Edwards/ d Core TA23 TA26 TF23 TF26 CORE26 CORE 29 82% 82% 77%/23 % 25% 25% 16% 11.5% 18 % 4.5%

71 Mortality Within 30 Days One Year TA TF Core 10 % 15 % %18 16% 0 %

72 Morbidity CVA PPM Vascular complications Bleeding ARF Respiratory 7% 7 % Edw: 0% Core: 30 % 7 % 10 % 4 % 6 %

73 Post TAVI Gradient Reduction

74 Aortic Root Measurements

75 CT angio - Porcelain aorta

76 Clinical Data M/F Age Euro score NYHA PVD CVA Cr > / ± ± % 20 % 15 %