CT

wor

kup

of T

rans

cath

eter

Aor

tic

Valv

e R

epla

cem

ent (

TAV

R)

Jeffr

ey H

. Mak

i, M

D, P

hD, F

SCB

TMR

Dire

ctor

of B

ody

MR

I, Pr

ofes

sor o

f Rad

iolo

gyU

nive

rsity

of W

ashi

ngto

n, S

eattl

e, W

A

Dis

clos

ures

–Je

ffre

y H

. Mak

i

•N

o re

leva

nt d

iscl

osur

es

Goa

ls o

f Pre

sent

atio

n•

Rev

iew

the

proc

ess o

f Tra

nsca

thet

erA

ortic

Val

ve R

epla

cem

ent (

TAV

R)

•U

nder

stan

d w

hat p

re-p

roce

dura

l in

form

atio

n C

TA c

an p

rovi

de•

Bec

ome

fam

iliar

with

the

CT

prot

ocol

s an

d po

st-p

roce

ssin

g pe

rfor

med

for

TAV

R•

Be

awar

e of

the

cx th

at c

an b

e re

duce

d w

ith p

re-p

roce

dura

l im

agin

g

Que

stio

n #1

1.D

o th

is a

ll th

e tim

e …

lots

of e

xper

ienc

e2.

Seei

ng m

ore

case

s, so

mew

hat c

omfo

rtabl

e w

ith th

e pr

oces

s3.

See

som

e ca

ses,

feel

som

ewha

t lac

king

in

unde

rsta

ndin

g m

y ro

le a

s a ra

diol

ogis

t4.

Not

som

ethi

ng h

appe

ning

yet

at m

y in

stitu

tion

By

Han

ds:

Your

leve

l of e

xper

ienc

e/kn

owle

dge

rega

rdgi

ngTA

VR

?

Tran

scat

hete

rAor

tic V

alve

R

epla

cem

ent (

TAV

R)

•In

dica

tions

(US)

-C

ritic

al a

ortic

sten

osis

-V

alve

are

a <

0.8

cm2

(crit

eria

for t

rials

)-

On

labe

l USA

�in

oper

ativ

e or

hig

h su

rgic

al ri

sk

patie

nts(

redu

ced

rate

of d

eath

at 1

yea

r –Pa

rtner

*)•

Con

train

dica

tions

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vere

aor

tic/m

itral

regu

rgita

tion

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icus

pid

aorti

c va

lve

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yper

troph

y pr

oxim

al L

V se

ptum

-LV

EF <

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-A

nato

mic

con

side

ratio

ns•

Ileof

emor

alve

ssel

s•

Ca++

aorta

/arc

h/va

lve

•A

ssym

etric

AO

VPr

imar

y R

ole

of C

TA*L

eon,

M. B

., Sm

ith, C

. R.,

Mac

k, M

., M

iller

, D. C

., M

oses

, J. W

., Sv

enss

on, L

. G.,

Tuzc

u, E

. M.,

et a

l. (2

010)

.NEJ

M, 3

63(1

7), 1

597–

1607

Tra

nsca

thet

erA

ortic

V

alve

Rep

lace

men

t•

Larg

est e

xper

ienc

e in

Eur

ope

(200

7 ap

prov

al)

•Tr

ansf

emor

alvs

. Tra

nsap

ical

•Tw

o m

anuf

actu

rers

-Ed

war

ds S

API

EN (a

ppro

ved

USA

and

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ope)

*-

Med

troni

c C

oreV

alve

(app

rove

d Eu

rope

onl

y)

•M

ultim

odal

ity w

orku

p es

sent

ial

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TA (p

re p

roce

dure

) [C

MR

(pre

pro

cedu

re)]

-Tr

anse

soph

agea

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o (p

re a

nd in

tra-p

roce

dure

) -

Flou

ro(in

tra-p

roce

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)

•In

crea

sing

vol

ume

CT

in w

orku

p-

UW

~30

0 C

TA/y

ear �

50+

TAV

R/y

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Edw

ards

SA

PIEN

Bal

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exp

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veB

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on e

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tinol

TAV

R -

Dev

ices

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iver

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stem

25-

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r

ab

c

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troni

c C

oreV

alve

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loon

exp

anda

ble

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iver

y sy

stem

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r(s

mal

ler c

omin

g)

TAV

R -

Dev

ices

Edw

ards

SA

PIEN

Bal

loon

exp

anda

ble

SS

Tra

nsfe

mor

al A

ppro

ach

Proc

edur

e

1.Fe

mor

al a

cces

s is

obta

ined

.2.

Fluo

rosc

opy

and

echo

card

iogr

aphy

use

d to

pl

ace

guid

ewire

acro

ss th

e st

enot

icao

rtic

valv

e.3.

Rap

id v

entri

cula

r pac

ing

to fi

x ao

rtic

valv

e in

the

open

pos

ition

.4.

Bal

loon

ang

iopl

asty

of t

he d

isea

sed

aorti

c va

lve

5.Sh

eath

pla

ced

in lo

wer

abd

omin

al a

orta

6.B

allo

on c

athe

ter c

arry

ing

the

pros

thet

ic v

alve

po

sitio

ned

at th

e ao

rtic

annu

lus.

7.B

allo

on e

xpan

ded

to se

cure

pro

sthe

tic v

alve

*Figures�and

�movie��cou

rtesy�of�Edw

ards�life�sc

iences.���Ada

pted

�from

�Lam

DL,

Mits

umor

iLM

, Don

CW

, Rab

kin

D, K

im M

, Mok

adam

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, War

ren

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man

W

P. P

ercu

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Aorti

c Va

lve

Rep

lace

men

t: Pr

epro

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T Sc

anni

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D Im

age

Post

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Biop

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�ao

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ulus

3. P

rost

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then

depl

oyed

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a gu

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ire

2. A

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the

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Tran

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edur

e

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6t

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s

*Cou

rtesy�of�Dr.�Lee�Mitsum

ori,�UnivWA.��

TAV

R -

Size

s

Prop

er si

zing

impo

rtant

to a

void

per

i-val

ve le

aks

App

rova

l exp

ecte

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, Sha

h D

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ahm

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. Mul

timod

ality

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sive

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ing

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cath

eter

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alve

Impl

anta

tion:

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rimer

. M

etho

dist

Deb

akey

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diov

asc

J. 20

12 A

pr;8

(2):2

9-37

.

29 m

m

Rol

e of

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A -

TA

VR

1.Ev

alua

te P

elvi

c A

cces

s Arte

ries

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ppro

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depe

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ize/

tortu

osity

/ath

eros

cler

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di

seas

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ac a

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SAPI

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5-28

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8-9

mm

) [sm

alle

r com

ing]

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ort

min

dz

segm

ents

can

be

1-2

mm

smal

ler s

heat

h–

7 m

m v

esse

l min

imum

•H

igh

inci

denc

e va

scul

ar in

jury

(~15

%)

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arte

ries t

oo d

isea

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trans

apic

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proa

ch (4

0% U

SA)

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aque

/Ca++

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cent

ric u

sual

ly o

k•

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plex

pla

que

or c

ircum

fere

ntia

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inal

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mor

epr

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mat

ic-

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ulat

ion

•>9

0oge

nera

lly p

robl

emat

ic

MIP

-C

alci

ficat

ion

•V

isua

l vie

w o

f deg

ree

of

vasc

ular

cal

cific

atio

n•

Circ

umfe

rent

ial o

r lu

min

al c

alci

ficat

ion

mor

e pr

oble

mat

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MIP

–C

urve

d Pl

anar

•U

se to

sele

ct lo

catio

ns w

ith

the

smal

lest

lum

en c

alib

er

(inne

r –to

–in

ner

endo

lum

inal

mar

gins

)•

Mea

sure

from

orth

ogon

al

proj

ectio

ns•

Ann

otat

e on

cur

ved

plan

ar

refo

rmat

s•

Scre

en sa

ve a

ll

Vol

ume

Ren

dere

d w

/Bon

y La

ndm

arks

-M

easu

rem

ents

•Sm

alle

st lu

men

cal

iber

in

the

right

and

left

iliac

ar

terie

s ind

icat

ed o

n a

volu

me

rend

ered

(VR

)

•Pr

ovid

es lo

catio

n re

fere

nce

to b

ony

land

mar

ks

•Ev

alua

te to

rtuos

ity

•Sc

reen

save

Rig

ht V

ascu

latu

re A

men

able

to T

AV

R

Acc

ess?

*Images�Cou

rtesy�of�Dr.�Lee�Mitsum

ori,�UnivWA.��

Too

smal

l(n

eed

7mm

)

Rol

e of

CT

A T

AV

R

2.Th

orac

ic A

orta

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tens

ive

Ca++

or “

porc

elai

n” a

orta

con

train

dica

tion

-A

sses

s pre

senc

e an

eury

sm/d

isse

ctio

n

Aor

tic R

oot -

MIP

•Ev

alua

te d

egre

e of

Ca++

inao

rta

•Ex

clud

e co

exis

tant

dise

ase

–an

eury

sm/d

isse

ctio

n

•Sc

reen

save

Rol

e of

CT

A T

AV

R

3.A

ortic

Val

ve/R

oot

-D

egre

e of

Ca++

-A

nato

mic

eva

luat

ion

valv

e, a

nnul

us, r

elat

ions

hip

to

coro

nary

arte

ries

Aor

tic V

alve

Cal

cific

atio

ns

Severe�calcification�may�increase�th

e�likelihoo

d�of�paravalvular�leak�du

e�to�less�optim

al�

deploymen

t�of�a

ortic�valve�prosthe

sis.

Aortic�valve�calcification�can�be

�assessed�an

d�grad

ed�as�follows:

Tops�L.F.,�et�al.,�Non

invasiv

e�evalua

tion�of�th

e�ao

rtic�root�with

�multislicecompu

ted�tomog

raph

y:�im

plica

tions�fo

r�transcatheter

aortic�valve�

replacem

ent.�JACC

�CardiovascIm

aging�20

08;�3

:25–

32.

Grad

e�1:�

No�calcificatio

n

Grad

e�2:�

Mildly�calcifie

d(small�isolated�spots)

Grad

e�3:�

Mod

erately�calcified

�(m

ultip

le�larger�sp

ots)

Grad

e�4:�

Heavily�calcifie

d(exten

sive�calcificatio

ns)

Need�im

ages C

omm

ent o

n C

a++, s

tack

of M

PR’s

Aortic�Ann

ulus

Sino

tubu

larjun

ction

Root�Ana

tomy*

Root�Ana

tomy*

Root�at�w

idest�p

oint

Imag

ing

Aor

tic R

oot

*Figure�Co

urtesy�of�D

r.�Lee�Mitsum

ori,�UnivWA.��

Aortic�Ann

ulus

Sino

tubu

larjun

ction

Root�Ana

tomy*

Root�Ana

tomy*

Root�at�w

idest�p

oint

Imag

ing

Aor

tic R

oot

*Figure�Co

urtesy�of�D

r.�Lee�Mitsum

ori,�UnivWA.��

•“E

n fa

ce”

view

val

ve

•M

easu

re si

nus-

com

mis

sure

(x3)

•C

omm

ent C

a++an

d nu

mbe

r of

sinu

ses p

rese

nt

Aortic�Ann

ulus

Sino

tubu

larjun

ction

Root�Ana

tomy*

Root�Ana

tomy*

Root�at�w

idest�p

oint

Imag

ing

Aor

tic R

oot

*Figure�Co

urtesy�of�D

r.�Lee�Mitsum

ori,�UnivWA.�

+ Bloom

field,�G

.�S.,�Gillam,�L.�D

.,�Ha

hn,�R

.�T.,�Ka

padia,�S.,�Leipsic

,�J.,�Lerakis,�S.,�Tu

zcu,�M

.,�et�al.�(201

2).�A

�Practical�Guide

�to�M

ultim

odality

�Imaging�of�

Tran

scathe

terA

ortic�Valve�Rep

lacemen

t.�JCMG,�5(4),�44

1–45

5.�doi:10.10

16/j.jcmg.20

11.12.01

3��•

Ann

ulus

ova

l –m

ajor

/min

or a

xes

•A

ccur

ate

sizi

ng e

xtre

mel

y im

porta

nt –

dete

rmin

es si

ze

pros

thes

is(T

EE a

lso)

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stol

e be

st –

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equi

res

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spec

tive

CTA

= h

ighe

r dos

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•Si

ze T

TE ~

1mm

< T

EE ~

1-1.

5 m

m <

MD

CT+

Aortic�Ann

ulus

Sino

tubu

larjun

ction

Root�Ana

tomy*

Root�Ana

tomy*

Root�at�w

idest�p

oint

Imag

ing

Aor

tic R

oot

Aortic�Ann

ulus�to

�sin

otub

ular

junctio

n�distan

ce

Aortic�Ann

ulus�to

�corona

ry�artery�

origin�distan

ce

*Figures�Cou

rtesy�of�Dr.�Lee�Mitsum

ori,�UnivWA.��

•Ve

rtica

l dis

tanc

e an

nulu

s to

coro

nary

orig

in a

nd S

TJ•

Crit

ical

to a

void

no

infr

inge

men

t on

cor

onar

y os

tia•

Scre

en sa

ve a

ll

Opt

imal

Imag

e In

tens

ifier

Ang

le

•Se

lect

and

“pa

int”

eac

h si

nus o

f val

salv

aon

“en

fa

ce”

view

root

•Im

age

post

-pro

cess

ing

is

used

to d

epic

t the

an

gula

tion

whe

re th

e th

ree

sinu

ses a

re p

rofil

ed•

Can

aid

pro

per p

lace

men

t

Imag

e In

tens

ifier

Ang

ulat

ions

Pote

ntia

l TA

VR

com

plic

atio

ns•

Proc

edur

al-

Acc

ess (

14.8

%)

•H

emat

oma

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lse

aneu

rysm

•A

V fi

stul

a•

Iliac

/fem

oral

arte

ry

perf

orat

ion

•D

isse

ctio

n-

Ret

rope

riton

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leed

ing

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riphe

ral i

sche

mia

•N

erve

inju

ry-

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lann

ed su

rgic

al re

pair

•Fa

ilure

to c

ross

val

ve

(<1%

)•

Faile

d va

scul

ar a

cces

s

•M

ispl

aced

val

ve-

Too

high

•Pa

rava

lvul

arre

gurg

itatio

n•

Aor

tic in

jury

•A

ortic

em

boliz

atio

n•

Cor

onar

y oc

clus

ion

(~1%

)-

Too

low

•LV

em

boliz

atio

n (~

2%)

•Pa

rava

lvul

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gurg

itatio

n•

MV

dys

func

tion

•H

eart

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k•

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-siz

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alve

-Pa

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Val

ve m

igra

tion

•V

alve

mal

func

tion

•V

alve

thro

mbo

sis

•M

yoca

rdia

l inf

arct

ion

(7%

)•

Perf

orat

ion

+ he

mop

eric

ardi

um•

Stro

ke (1

.5-3

.3%

)Le

fevr

eT.

, et a

l., O

ne y

ear f

ollo

w-u

p of

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mul

ti-ce

ntre

Euro

pean

PAR

TNER

tran

scat

hete

rhea

rt v

alve

stud

y.Eu

rHea

rt J,

2011

. 32(

2): p

. 148

-57.

Kod

aliS

.K.,

et a

l., E

arly

and

Lat

e (O

ne Y

ear)

Out

com

es F

ollo

win

g Tr

ansc

athe

terA

ortic

Val

ve Im

plan

tatio

n in

Pat

ient

s With

Sev

ere

Aort

ic S

teno

sis (

from

th

e U

nite

d St

ates

REV

IVAL

Tri

al).

The

Am

eric

an Jo

urna

l of C

ardi

olog

y, 2

011.

107

(7):

p. 1

058-

1064

.

CT

pro

toco

l TA

VR

-U

WUn

iversity�of�W

ashing

ton�Protocol

•Tw

o se

para

te sc

ans w

ith

two

cont

rast

inje

ctio

ns

* D

ata

trans

ferr

ed to

a3D

Wor

ksta

tion

for p

ost-p

roce

ssin

g.

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= N

on-g

ated

hel

ical

CTA

of t

he

abdo

men

and

pel

vis

Dia

phra

gm to

fem

oral

troc

hant

ers

Smar

t pre

p at

L1

80 c

c co

ntra

st @

5 c

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30

cc sa

line

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= Pr

ospe

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e tri

gger

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TA c

hest

Abo

ve a

rch

to d

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ragm

Smar

t-pre

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aor

ta70

cc

cont

rast

@ 5

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s + 3

0 cc

salin

e flu

sh

Exam

ple

Stur

ctur

edR

epor

t Tem

plat

e

•Ex

ampl

e te

mpl

ate

used

at

our i

nstit

utio

n fo

r rep

orte

d m

easu

red

dim

ensi

ons p

re-

proc

edur

al T

AVR

CT

exam

s•

Labe

l scr

een

save

s

Sum

mar

y of

CTA

Pos

t-Pr

oces

sing

for T

AV

R•

MIP

S of

abd

omin

al a

orta

and

ilia

c ar

terie

s•

Dem

onst

rate

loca

tion/

degr

ee o

f vas

cula

r cal

cific

atio

n

•V

R, C

PR a

nd M

PRs o

f tho

raci

c ao

rta, i

liofe

mor

alar

terie

s•

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sure

and

dep

ict l

ocat

ions

of d

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