TAVR imaging

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Aortic Stenosis Microchapters


Patient Information


Historical Perspective




Differentiating Aortic Stenosis from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis


History and Symptoms

Physical Examination

Cardiac Stress Test


Chest X Ray




Cardiac Catheterization

Aortic Valve Area

Aortic Valve Area Calculation


General Approach

Medical Therapy


Percutaneous Aortic Balloon Valvotomy (PABV) or Aortic Valvuloplasty

Transcatheter Aortic Valve Replacement (TAVR)

Critical Pathway
Patient Selection
Valve Types
TAVR Procedure
Post TAVR management
AHA/ACC Guideline Recommendations

Follow Up


Precautions and Prophylaxis

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

TAVR imaging On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides


American Roentgen Ray Society Images of TAVR imaging

All Images
Echo & Ultrasound
CT Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on TAVR imaging

CDC on TAVR imaging

TAVR imaging in the news

Blogs on TAVR imaging

Directions to Hospitals Treating TAVR imaging

Risk calculators and risk factors for TAVR imaging

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]


Transthoracic Echocardiography (TTE) is the best initial imaging modality for evaluating AS severity.[1] Although, multimodality imaging is needed for preprocedural planning and intraoperative decision making given the complex 3D anatomy of the aortic valve, sinuses, and annulus.[2] Multi-Detector CT (MDCT) is a core element of the standard imaging pathway for the preprocedural planning of TAVR.[3] In patients being evaluated for TAVR, MDCT systems with at least 64 detectors and a spatial resolution of 0.5 to 0.6 mm are recommended. Evaluation of kidney function to avoid contrast induced nephropathy must be taken in to consideration.


AS severity is defined based on imaging findings. Severe symptomatic (Stage D) AS is considered as TAVR candidate.

Abbreviations: ΔP: mean gradient, Vmax: maximum aortic velocity, AVA: aortic valve area. AS: aortic stenosis, AR: aortic regurgitation.

Severe symptomatic AS (stage D)
D1 Symptomatic severe high-gradient AS
  • Exertional dyspnea or decreased exercise tolerance
  • Exertional angina
  • Exertional syncope or presyncope
Severe calcification or congenital stenosis with severely reduced opening
  • Vmax ≥ 4 m/s or mean ΔP ≥ 40 mmHg
  • AVA ≤ 1.0 cm² but may be larger with mixed AS and AR
D2 Symptomatic severe low-flow/low gradient AS with reduced LVEF Severe calcification or congenital stenosis with severely reduced leaflet motion
  • AVA ≤ 1.0 cm² with resting aortic Vmax < 4 m/s or mean ΔP ≥ 40 mmHg
  • LV diastolic dysfunction
D3 Symptomatic severe low gradient with normal LVEF Severe calcification with severely reduced leaflet motion
  • AVA ≤ 1.0 cm² with Vmax < 4 m/s or mean ΔP ≤ 40 mmHg
  • AVA ≤ 0.6 cm²
  • Increased LV relative wall thickness
  • Small LV chamber with low stroke volume
  • Restrictive diastolic filling

TAVR imaging checklist

Abbreviations: CV: Cardiovascular, AVR: Aortic valve replacement, AS: Aortic Stenosis, MR: Mitral Regurgitation, AR: Aortic Regurgitation, PAP: Pulmonary Artery Pressure, RV: Right Ventricle, CTA: CT angiography, PA: Pulmonary Artery, TEE: Trans Esophageal Echocardiography, TTE: Trans Thoracic Echocardiography AVA: Aortic Valve Area; CMR: Cardiovascular Magnetic Resonance Imaging; CT: Computed Tomography; ECG: Electrocardiogram; EF: Ejection Fraction; DSE: Dobutamine Stress Echocardiography; ESRD: End-Stage Renal Disease; GFR: Glomerular Filtration Rate; LFLG: Low-Flow Low-Gradient; LV: Left Ventricular; LVEF: Left Ventricular Ejection Fraction; MAC: Mitral Annular Calcification; MDCT: Multi Detector Computed Tomography; MRA: Magnetic Resonance Angiogram; MRI: Magnetic Resonance Imaging; MS: Mitral Stenosis; PET: Positron Emission Tomography; TAVR: Trans-catheter Aortic Valve Replacement

TAVR Imaging Checklist
Region of Interest Recommended Approach and Key


Additional Comments
Aortic valve morphology TTE:
  • Trileaflet, bicuspid or unicuspid
  • Leaflet motion
  • Annular size and shape
  • TEE if can be safely performed, particularly useful for subaortic membranes
  • Cardiac MRI if echocardiography nondiagnostic
  • ECG-gated thoracic CTA if MRI contraindicated
Aortic valve function TTE:
  • Maximum aortic velocity
  • Mean aortic valve gradient
  • Aortic valve area
  • Stroke volume index
  • Presence and severity of AR
Additional parameters
  • Dimensionless index
  • Aortic valve calcium score if LFLG AS diagnosis in question
LV Geometry and other

cardiac findings

  • LVEF, regional wall motion
  • Hypertrophy, diastolic dysfunction
  • Pulmonary pressure estimate
  • Mitral valve (MR, MS, MAC)
  • Aortic sinus anatomy and size
  • CMR imaging for myocardial fibrosis and scar, identification of cardiomyopathies
Annular sizing
  • TAVR CTA- gated contrast enhanced CT thorax with multiphasic acquisition
  • Typically reconstructed in systole 30-40% of the R-R window
  • Major/minor annulus dimension
  • Major/minor average
  • Annular area
  • Circumference/perimeter
Aortic root measurements
  • Gated contrast-enhanced CT thorax with multiphasic acquisition.
  • Typically reconstructed in diastole 60%–80%.
  • Coronary ostia heights
  • Midsinus of Valsalva (sinus to commissure, sinus to sinus)
  • Sinotubular junction
  • Ascending aorta (40 cm above valve plane, widest dimension, at level of PA)
Coronary disease and

thoracic anatomy

  • Nongated thoracic CTA
  • Coronary artery disease severity
  • Bypass grafts: number/location
  • RV to chest wall distance
  • Aorta to chest wall relationship
Noncardiac imaging
  • Carotid ultrasound
  • Cerebrovascular MRI
May be considered depending on clinical


Vascular Access
Kidney Function Status Recommended Approach Key Parameters
Normal renal function (GFR >60) or

ESRD not expected to recover

Aorta, great vessel, and abdominal aorta

Dissection; atheroma; stenosis; calcification

Iliac/subclavian/femoral luminal dimensions, calcification, and tortuosity

Borderline renal


  • Direct femoral angiography (low contrast)
Institutional dependent protocols

Luminal dimensions and tortuosity of peripheral vasculature

Acute kidney injury or

ESRD with expected


  • Noncontrast CT of chest, abdomen, and pelvis
  • Noncontrast MRA
  • Can consider TEE if balancing risk/benefits
Degree of calcification and tortuosity of peripheral vasculature

TAVR Imaging Checklist
Imaging goals Recommended Approach Additional Details
Interventional planning TAVR CTA Predict optimal fluoroscopy angles for valve


Confirmation of annular


Preprocedure MDCT Consider contrast aortic root injection if


3C TEE to confirm annular size

Valve placement Fluoroscopy under general anesthesia TEE (if using general anesthesia)
Paravalvular leak Direct aortic root angiography TEE (if using general anesthesia)
Procedural complications
  • TEE (if using general anesthesia)

Intracardiac echocardiography (alternative)

Long-term Postprocedure
Evaluate valve function TTE Key elements of echocardiography:
  • Maximum aortic velocity
  • Mean aortic valve gradient
  • Paravalvular and valvular AR
LV geometry and other

cardiac findings

  • LVEF, regional wall motion
  • Pulmonary pressure estimate
  • Mitral valve (MR, MS, MAC)

Specific CT measurements for TAVR

TAVR CT Measurement Summary
Valve Size and Type
Region of Interest Specific


Measurement Technique Additional


Aortic valve morphology

and function

Aortic valve
  • If cine images obtained, qualitative evaluation of valve opening
  • Planimetry of aortic valve area in rare cases
  • Calcium score with Agatston technique or a volumetric technique to quantify calcification of aortic valve
Most useful in cases of LFLG AS where diagnosis is otherwise

unclear. May be helpful in defining number of valve cusps.

LV geometry and other

cardiac findings

LV outflow tract
  • Measured with a double oblique plane at narrowest portion of the LV outflow tract
  • Perimeter
  • Area
  • Qualitative assessment of calcification
Quantification of calcification not standardized.

Large eccentric calcium may predispose for paravalvular

regurgitation and annular rupture during valve deployment.

Annular sizing Aortic annulus
  • Defined as double oblique plane at insertion point of all 3 coronary cusps
  • Major/minor diameter
  • Perimeter
  • Area
Periprocedural TEE and/or balloon sizing can confirm

dimensions during case.

Aortic root measurements Sinus of Valsalva
  • Height from annulus to superior aspect of each coronary cusp
  • Diameter of each coronary cusp to the opposite commissure
  • Circumference around largest dimension
  • Area of the largest dimension
Coronary and thoracic


Coronary arteries
  • Height from annulus to inferior margin of left main coronary artery and the inferior margin of the right coronary artery
Short coronary artery height increases risk of procedure. Evaluation of coronary artery and bypass graft stenosis on select studies. Estimate risk of coronary occlusion during valve deployment.
Aortic root


  • Angle of root to left ventricle
  • Three-cusp angulation to predict best fluoroscopy angle
Reduce procedure time and contrast load by reducing number of periprocedural root


Vascular Access Planning
Vascular access Aorta Major/minor diameters of the following:
  • Aorta at sinotubular junction
  • Ascending aorta in widest dimension
  • Midaortic arch
  • Descending aorta at level of pulmonary artery
  • Abdominal aorta at the iliac bifurcation
  • Measurements must be perpendicular to aorta in 2 orthogonal planes.
  • Identify aortopathies.
  • Evaluate burden of atherosclerosis.
  • Identify dissection or aneurysms.
Primary peripheral vasculature Major/minor dimensions, tortuosity, calcification of the following:
  • No well-defined cutoff or definition of tortuosity or calcification has been established.


Stenosis of the following:
Relationship of

femoral bifurcation

and femoral head

Distance from inferior margin of femoral

head to femoral biforcation

TAVR Imaging Evaluation
Non-gated Angiogram of Chest, Abdomen and Pelvic arteries for vascular access selection
ECG gated CT of annulus and Aortic root for valve sizing selection
Left ventricles and other findings
Confirm severe Aortic Stenosis
Transfemoral Approach
Annular sizing
Aortic Root sizing
Additional Procedural Planning
Subclavian Approach
Major/Minor Dimension
Coronary Ostia height
Fluoroscopy Angulation
LVEF and LV dimension
High gradient AS
Apical Approach
Aortic Sinus to Commissure dimension
Bypass Grafts
Estimated Pulmonary pressure
Low gradient AS
Other Approaches
Sinotubular Junction
RV to Chest wall position
Other valvular abnormalities
Reduced EF
Ascending Aorta dimension
Preserved EF
Direct Aortic
Aortic Calcification


  1. Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, Iung B, Otto CM, Pellikka PA, Quiñones M (2009). "Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice". J Am Soc Echocardiogr. 22 (1): 1–23, quiz 101–2. doi:10.1016/j.echo.2008.11.029. PMID 19130998.
  2. Hahn RT (2016). "Transcathether Valve Replacement and Valve Repair: Review of Procedures and Intraprocedural Echocardiographic Imaging". Circ. Res. 119 (2): 341–56. doi:10.1161/CIRCRESAHA.116.307972. PMID 27390336.
  3. Binder RK, Webb JG, Willson AB, Urena M, Hansson NC, Norgaard BL, Pibarot P, Barbanti M, Larose E, Freeman M, Dumont E, Thompson C, Wheeler M, Moss RR, Yang TH, Pasian S, Hague CJ, Nguyen G, Raju R, Toggweiler S, Min JK, Wood DA, Rodés-Cabau J, Leipsic J (2013). "The impact of integration of a multidetector computed tomography annulus area sizing algorithm on outcomes of transcatheter aortic valve replacement: a prospective, multicenter, controlled trial". J. Am. Coll. Cardiol. 62 (5): 431–8. doi:10.1016/j.jacc.2013.04.036. PMID 23684679.