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

TAVI Team workTAVI Team workTAVI Team workTAVI Team work

Steps in patients Steps in patients p pp pselection selection

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

TTE measurements of aortic annulus

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

Improvement in MR Improvement in MR ppseverityseverity

Improvement in Improvement in ppFunctional MR severityFunctional MR severity

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

Aortic AtheromaAortic Atheroma

Possible bicuspid Aortic Possible bicuspid Aortic ppValveValve

Bicuspid AV byBicuspid AV by 33 D echoD echoBicuspid AV by Bicuspid AV by 33--D echoD echo

LM occlusion due to AV LM occlusion due to AV leaflets post AV Balloon leaflets post AV Balloon

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 Assessment of the Aortic annulus

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.

Aortic valve annulus measurements

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

LM Height from the AVLM Height from the AVLM Height from the AVLM Height from the AV

Post transPost trans--femoral TAVI femoral TAVI LM occlusion LM occlusion

Bulky AV calcificationBulky AV calcificationBulky AV calcification Bulky AV calcification

LM occlusion with bulky LM occlusion with bulky yyAV calcificationAV calcification

Bicuspid AVBicuspid AVBicuspid AV Bicuspid AV

Bulky AV calcificationBulky AV calcificationBulky AV calcificationBulky AV calcification

Heavy aortic valve, and Heavy aortic valve, and y ,y ,aortic root calcificationaortic root calcification

ParaPara valvularvalvular leakleakParaPara--valvularvalvular leakleak

ParaPara valvularvalvular LeakLeakParaPara--valvularvalvular LeakLeak

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

Aortic CalcificationAortic CalcificationAortic Calcification Aortic Calcification

CT Angio- Aortic gCalcification

Tortuous AortaTortuous Aorta

CT Angio A t fAssessment of the aorta,&

i h lperipheral vessels

Peripheral vessels Peripheral vessels ppmeasurementsmeasurements

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.

Angio measurements of giliofemoral vessels

Cardiac MRICardiac MRI

Aortic annulus Aortic anatomy Aortic anatomy Ilio-femoral vessels size

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

SummarySummarySummarySummary

SummarySummarySummarySummary

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%

MortalityMortalityMortalityMortality

CoreTFTAOne YearWithin 30 Days

0 %16%%1815 %10 %

MorbidityMorbidityMorbidityMorbidity

R i tARFBl diV lPPMCVA RespiratoryARFBleedingVascularcomplications

PPMCVA

6 %4 %10 %7 %7 %Edw: 0%

7 %Edw: 0%Core: 30 %

Post TAVI Gradient Post TAVI Gradient ReductionReduction

Aortic Root Aortic Root MeasurementsMeasurements

CT angio Porcelain aortaCT angio - Porcelain aorta

Clinical DataClinical DataClinical DataClinical Data

Cr > 150CVAPVDNYHAEuroscore

AgeM/F

15 %20 %30%2-320.5±8.379.5±9.224/20/