Post on 10-Feb-2019
The role of Cardiac Imaging The role of Cardiac Imaging modalities in evaluation &modalities in evaluation &
selection of patients for selection of patients for TransTrans--catheter Aortic Valvecatheter Aortic ValveTransTrans catheter Aortic Valve catheter Aortic Valve
ImplantationImplantation
Dr.SaeedDr.Saeed AL AL AhmariAhmariConsultant CardiologistConsultant CardiologistPrince Sultan Prince Sultan CardaicCardaic Center, RiyadhCenter, Riyadh, y, y
TTE AssessmentTTE Assessment
Severity of AS Degree of AV calcification (? Bicuspid Degree of AV calcification (? Bicuspid
AV), annulus size, & aortic root measurementsmeasurements
LV function, and intracardiac massesA i t d l l l i PAP Associated valvular lesions, PAP
Parasternal Long Axis ViewParasternal Long Axis View
5 cm
Ascending ao
sinus
junction
g
Aorta root Aorta root measurementsmeasurements
Echo ParametersEcho ParametersEcho ParametersEcho Parameters
Mod-SevereMR
PAPEFMGPGAVA
33 %48.75±16mmHg
48.6±12.2 %
50.9 ± 13 mmHg
86.7 ±22.1mmHg
0.5 ±0.12 cm²
TEE AssessmentTEE Assessment
Degree of AV calcification Annulus size and aortic root Annulus size, and aortic root
measurements LM height LM height Intra cardiac masses Other valvular lesions Aorta disease
CT AngiogramCT Angiogram
D f AV C l ifi ti Degree of AV Calcification Aortic annulus measurements Height of coronary ostia Aortic root morphology, and p gy
measurements Porcelain aorta Aorta diameter, tortuously, and
calcification Ilio-femoral vessels diameter, and
calcification
CT reconstruction of Aortic CT reconstruction of Aortic rootrootrootroot
STJ
4.5 cm
Ascending AO
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.
EdwardEdward SapienSapien ValveValveEdward Edward SapienSapien ValveValve
THV SIZING RECOMMENDATIONSTHV SIZING RECOMMENDATIONS THV SIZING RECOMMENDATIONSTHV SIZING RECOMMENDATIONS–– 1818--2121mm Annulus mm Annulus 2323mm Valvemm Valve
2222 2525mm Annulusmm Annulus 2626mm Valvemm Valve–– 2222--2525mm Annulus mm Annulus 2626mm Valvemm Valve Sizing Considerations: Sizing Considerations:
11) P i Si) P i Si–– 11) Patient Size) Patient Size–– 22) Degree of root and aortic calcification) Degree of root and aortic calcification
Selection of Prosthesis Selection of Prosthesis SizeSizeSizeSize
26 mm inflow 29 i fl26 mm inflow device
“smaller”
29 mm inflow device
“larger”
Sinusheight 15mm !!!!!
40 mm 43 mm
smaller “larger”
27 mm 29 mm
40 mm 43 mm(Ascending aorta)
20-23 mm 23-27 mm
27 mm 29 mm
(AV l )
(Sinus of Valsalva)
(AV annulus)
Aortic Root Aortic Root MeasurementsMeasurements
Porcelain Aorta
Height of the LM
Ascending Aorta
STJ width
Sinus Height
Sinus Width
Aorticannulus Aortathe LMAorta widthHeightWidthannulus
5 %12.8 ± 2.432-44mm18-22 mm
15-18 mm
26-30mm
21.9 ±1.5
Heavy aortic valve, and Heavy aortic valve, and y ,y ,aortic root calcificationaortic root calcification
Angio : bifurcation Angio : bifurcation abdominal AO/iliacaabdominal AO/iliacaabdominal AO/iliacaabdominal AO/iliaca
Determine if there are any abnormalities that could cause a difficult implantation. Measure the diameter of the arteries en look for calcifications
Peripheral Arteries Peripheral Arteries ppMeasurementsMeasurements
LFALEILCIRFAREIRCI CC
6-10mm7-11mm4-13 mm6-10 mm6-11 mm4-13 mm
AngiogramAngiogram
Coronary angiogram ± PCI Aortic root angiogram Aortic root angiogram Ilio-femoral angiogram
Id l ti t i i f l Ideal aortic root sinus view for valve implantation
Angio of Aortic RootAngio of Aortic RootAngio of Aortic RootAngio of Aortic Root4.5 cm
Ascending AO
sinus
STJ
Sinus height
Angio of Aortic Root with use of a graduated pigtail catheter, h di h i h imeasure the distances as shown in the picture.
ConclusionConclusion
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
l tiselection process
ConclusionConclusionConclusionConclusion
Integrating all imaging modalities for Integrating all imaging modalities for proper selection, and proper sizing of the valve are the corner stone for thevalve are the corner stone for the procedure success.B lk ti l ifi ti bi id AV dB lk ti l ifi ti bi id AV d Bulky aortic calcification, bicuspid AV, and Bulky aortic calcification, bicuspid AV, and short distance ( <short distance ( <8 8 mm) between the mm) between the
ti l d LM hibiti fti l d LM hibiti faortic annulus, and LM are prohibitive for aortic annulus, and LM are prohibitive for TAVI from our experienceTAVI from our experience
ObjectivesObjectivesObjectivesObjectives
TAVI is an emerging technique for TAVI is an emerging technique for treating non operable patients with treating non operable patients with g p pg p psevere aortic stenosis. severe aortic stenosis.
We report our experience in using We report our experience in using different cardiac imaging modalities indifferent cardiac imaging modalities indifferent cardiac imaging modalities in different cardiac imaging modalities in evaluation, & selection of patients for evaluation, & selection of patients for TAVITAVITAVITAVI
MethodsMethodsMethodsMethods
All eligible patients for TAVI therapy underwent detailedAll eligible patients for TAVI therapy underwent detailedtransthoracic echocardiography, where peak (PG), mean (MG) transthoracic echocardiography, where peak (PG), mean (MG)
gradients, aortic, valve area (AVA), aortic annulus size (AA), ejection gradients, aortic, valve area (AVA), aortic annulus size (AA), ejection fraction (EF), severity of mitral regurgitation (MR) were assessed. fraction (EF), severity of mitral regurgitation (MR) were assessed.
Contrast gated cardiac CT scan was performed to measure aortic Contrast gated cardiac CT scan was performed to measure aortic l h i ht f th i f l ti t i til h i ht f th i f l ti t i tiannuls, height of the coronaries from annulus, aortic root size, aortic annuls, height of the coronaries from annulus, aortic root size, aortic
calcification, peripheral vessel size & calcification . calcification, peripheral vessel size & calcification .
Transesophageal echocardiography (TEE) was done if needed toTransesophageal echocardiography (TEE) was done if needed to Transesophageal echocardiography (TEE) was done if needed to Transesophageal echocardiography (TEE) was done if needed to measure annulus, to assess MR severity, and aortic atheromameasure annulus, to assess MR severity, and aortic atheroma
Parasternal Long Axis ViewParasternal Long Axis View
height
annulusLVOT
A ti R tAortic Root
Basal attachment of AV leaflets
Sinotubular junction
leaflets
I ith t f Ni l Pi t
Annulus Annulus –– LVOT LVOT measurementmeasurement
Image with courtesy of Nicolo Piazza et al.
Coronary Artery diseaseCoronary Artery diseaseCoronary Artery diseaseCoronary Artery disease
PCI MILD/Mod CAD
Previous CABG
Normal CA
332812 %27 %
Procedural DataProcedural DataProcedural DataProcedural Data
CORECORE26TF26TF23TA26TA23Ed d /L lGA CORE29
CORE26TF26TF23TA26TA23Edwards/Core
LocalA
GA
4.5%18 %11.5%16%25%25% %2377%/82%82%
MorbidityMorbidityMorbidityMorbidity
R i tARFBl diV lPPMCVA RespiratoryARFBleedingVascularcomplications
PPMCVA
6 %4 %10 %7 %7 %Edw: 0%
7 %Edw: 0%Core: 30 %