TAVR evaluation
Aortic Stenosis Microchapters |
Diagnosis |
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Percutaneous Aortic Balloon Valvotomy (PABV) or Aortic Valvuloplasty |
Transcatheter Aortic Valve Replacement (TAVR) |
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TAVR evaluation On the Web |
American Roentgen Ray Society Images of TAVR evaluation |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]
Overview
Patient evaluation for TAVR procedure is divided in to 3 steps. Preprocedure, periprocedure and postprocedure evaluation are important steps for successful procedure.
TAVR Evaluation
Preprocedural Evaluation
Aortic Valve Morphology
- Transthoracic Echocardiography (TTE) is performed for initial visualization of aortic valve to identify the number of leaflets; size, location, extent of calcification, leaflet motion, and a preliminary view of annular size and shape.
- If additional imaging is needed, valve anatomy and function can be evaluated by cardiac magnetic resonance imaging (CMR) or ECG-gated MDCT.[1]
Aortic Valve Function
Doppler echocardiography is superior to other imaging modalities to evaluate Aortic valve function. AS severity should be evaluated according to the ESE/ASE Recommendations for Evaluation of Valvular Stenosis and staged according to the AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease.[2][3]
LV Geometry and Other Cardiac Findings
TTE also is recommended for evaluation of LV hypertrophy, chamber size, LV diastolic function, regional wall motion, and ejection fraction as well as newer measures of LV function such as global longitudinal strain. In addition, TTE is useful for assessment of aortic dilation, presence of subvalvular outflow tract obstruction, estimation of pulmonary pressures, and identification of other significant valve abnormalities.
Annular Sizing
The 3D dataset provided by MDCT are more accurate than TTE findings regarding annular size.[4] Measurement of LV outflow tract diameter on TTE has been well validated for calculation of aortic valve area and continues to be the standard for determination of AS severity. CMR can also provide comprehensive assessment of the aortic valve, annulus, and aortic root with good correlation with MDCT.[5] CMR can be a valuable tool in patients who cannot undergo MDCT.
Aortic Root Measurements
MDCT allows for the careful measurement of the size of the sinuses of Valsalva, the coronary ostia distance from the annulus, the size of the aorta at the sinotubular junction and 40mm above the annulus, and the extent and position of aortic calcifications.[6]
Presurgical Planning
MDCT also may be of use in identification of coronary artery and coronary bypass graft location and stenosis, evaluation of the RV to chest wall position, and identification of the aorta and LV apex to chest wall position in direct aortic approaches.
Noncardiac Imaging
Because of high prevalence of dementia and atherosclerosis in this elderly patient population, a preprocedural work-up including carotid ultrasound and cerebrovascular MRI might be considered prior to considering or such patients for TAVR.
Vascular Access
Because of the relatively large diameter of the delivery sheaths, appropriate vascular access imaging is critical for TAVR. It is important to evaluate the entire thoracoabdominal aorta, major thoracic arterial vasculature, carotids, and iliofemoral vasculature. MDCT is able to provide valuable dataset regarding vascular anatomy.
References
- ↑ Makkar RR, Fontana G, Jilaihawi H, Chakravarty T, Kofoed KF, de Backer O, Asch FM, Ruiz CE, Olsen NT, Trento A, Friedman J, Berman D, Cheng W, Kashif M, Jelnin V, Kliger CA, Guo H, Pichard AD, Weissman NJ, Kapadia S, Manasse E, Bhatt DL, Leon MB, Søndergaard L (2015). "Possible Subclinical Leaflet Thrombosis in Bioprosthetic Aortic Valves". N. Engl. J. Med. 373 (21): 2015–24. doi:10.1056/NEJMoa1509233. PMID 26436963.
- ↑ Bertrand PB, Verbrugge FH, Verhaert D, Smeets CJ, Grieten L, Mullens W, Gutermann H, Dion RA, Levine RA, Vandervoort PM (2015). "Mitral valve area during exercise after restrictive mitral valve annuloplasty: importance of diastolic anterior leaflet tethering". J. Am. Coll. Cardiol. 65 (5): 452–61. doi:10.1016/j.jacc.2014.11.037. PMC 4372048. PMID 25660923.
- ↑ 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.
- ↑ Bucher AM, De Cecco CN, Schoepf UJ, Wang R, Meinel FG, Binukrishnan SR, Spearman JV, Vogl TJ, Ruzsics B (2014). "Cardiac CT for myocardial ischaemia detection and characterization--comparative analysis". Br J Radiol. 87 (1043): 20140159. doi:10.1259/bjr.20140159. PMC 4207157. PMID 25135617.
- ↑ Jabbour A, Ismail TF, Moat N, Gulati A, Roussin I, Alpendurada F, Park B, Okoroafor F, Asgar A, Barker S, Davies S, Prasad SK, Rubens M, Mohiaddin RH (2011). "Multimodality imaging in transcatheter aortic valve implantation and post-procedural aortic regurgitation: comparison among cardiovascular magnetic resonance, cardiac computed tomography, and echocardiography". J. Am. Coll. Cardiol. 58 (21): 2165–73. doi:10.1016/j.jacc.2011.09.010. PMID 22078422.
- ↑ Achenbach S, Delgado V, Hausleiter J, Schoenhagen P, Min JK, Leipsic JA (2012). "SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR)". J Cardiovasc Comput Tomogr. 6 (6): 366–80. doi:10.1016/j.jcct.2012.11.002. PMID 23217460.