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{| class="wikitable"
{| class="wikitable"
! colspan="3" |TAVR Imaging Checklist
! colspan="4" |TAVR CT Measurement Summary
|-
! colspan="4" |Valve Size and Type
|-
|-
!Region of Interest
!Region of Interest
!Recommended Approach and Key
!Specific
Measures
Measurements
!Additional Comments
!Measurement Technique
|-
!Additional
! colspan="3" |Preprocedure
Comments
|-
|-
|Aortic valve morphology
|Aortic valve morphology
|'''[[TTE]]''':
and function
* Trileaflet, bicuspid or unicuspid
|Aortic valve
 
* Valve [[calcification]]
 
* Leaflet motion
 
* Annular size and shape
|
|
* [[TEE]] if can be safely performed, particularly
* If cine images obtained, qualitative evaluation of valve opening
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
* Planimetry of aortic valve area in rare cases


* Stroke volume index
* 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
* Presence and severity of AR
unclear. May be helpful in defining number of valve cusps.
|Additional parameters
* Dimensionless index
 
* AVA by planimetry (echo, CT, MRI)
 
* Dobutamine stress echocardiography
for LFLG AS-Reduced EF
* Aortic valve calcium score if LFLG AS
diagnosis in question
|-
|-
|LV Geometry and other
|LV geometry and other
cardiac findings
cardiac findings
|'''[[TTE|TTE:]]'''
|LV outflow tract
* LVEF, regional wall motion
|
* Measured with a double oblique plane at narrowest portion of the LV outflow tract


* Hypertrophy, diastolic dysfunction
* Perimeter


* Pulmonary pressure estimate
*  Area


* Mitral valve (MR, MS, MAC)
* Qualitative assessment of calcification
|Quantification of calcification not standardized.
Large eccentric calcium may predispose for paravalvular


* Aortic sinus anatomy and size
regurgitation and annular rupture during valve deployment.
|
*  Myocardial ischemia and scar: CMR, PET,
DSE, thallium
*  CMR imaging for myocardial fibrosis and
scar, identification of cardiomyopathies
|-
|-
|Annular sizing
|Annular sizing
|Aortic annulus
|
|
* TAVR CTA- gated contrast enhanced CT
* Defined as double oblique plane at insertion point of all 3 coronary cusps
thorax with multiphasic acquisition
* Typically reconstructed in systole 30-40%
of the R-R window
|
* Major/minor annulus dimension


* Major/minor average
*  Major/minor diameter


* Annular area
*  Perimeter


* Circumference/perimeter
*  Area
|Periprocedural TEE and/or balloon sizing can confirm
dimensions during case.
|-
|-
|Aortic root measurements
|Aortic root measurements
|Sinus of  Valsalva
|
|
* Gated contrast-enhanced CT thorax with
* Height from annulus to superior aspect of each coronary cusp
multiphasic acquisition.
* Typically reconstructed in diastole 60%–80%.
|
* Coronary ostia heights


* Midsinus of Valsalva (sinus to commissure,
*  Diameter of each coronary cusp to the opposite commissure
sinus to sinus)
* Sinotubular junction


* Ascending aorta (40 cm above valve plane,
*  Circumference around largest dimension
widest dimension, at level of PA)
*  Area of the largest dimension
* Aortic root and ascending aorta calcification
|-
|Coronary disease and
thoracic anatomy
|
* Coronary angiography
 
* 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
history
|}
{| class="wikitable"
! colspan="3" |Vascular Access
|-
!Kidney Function Status
!Recommended Approach
!Key Parameters
|-
|-
|Normal renal function (GFR >60) or
| rowspan="2" |Coronary and thoracic
ESRD not expected to recover
anatomy
|Coronary arteries
|
|
* TAVR CTA
* Height from annulus to inferior margin of left main coronary artery and the inferior margin of the right coronary artery
|Aorta, great vessel, and abdominal aorta
|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.
Dissection; atheroma; stenosis; calcification
 
Iliac/subclavian/femoral luminal dimensions, calcification, and tortuosity
|-
|-
|Borderline renal
|Aortic root
function
angulation
|
|
* Contrast MRA
* Angle of root to left ventricle


* Direct femoral angiography (low contrast)
*  Three-cusp angulation to predict best fluoroscopy angle
|Institutional dependent protocols
|Reduce procedure time and contrast load by reducing number of periprocedural root
Luminal dimensions and tortuosity of peripheral vasculature
injections
|-
|Acute kidney injury or
ESRD with expected
 
recovery
|
* Noncontrast CT of chest, abdomen, and pelvis
 
* Noncontrast MRA
 
* Can consider TEE if balancing risk/benefits
|Degree of calcification and tortuosity of peripheral vasculature
|}
 
 
 
{| class="wikitable"
! colspan="3" |TAVR Imaging Checklist
|-
!Imaging goals
!Recommended Approach
!Additional Details
|-
! colspan="3" |Periprocedure
|-
|Interventional planning
|TAVR [[CT angiography|CTA]]
|Predict optimal fluoroscopy angles for valve
deployment
|-
|Confirmation of annular
sizing
|Preprocedure [[Multidetector computed tomography|MDCT]]
|Consider contrast aortic root injection if
needed
 
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
|
* [[TTE]]
 
* [[Transesophageal echocardiography (TEE)|TEE]] (if using general anesthesia)
Intracardiac echocardiography (alternative)
|
|-
| colspan="3" align="center" style="background:#DCDCDC;"| '''Long-term Postprocedure'''
|-
|Evaluate valve function
|TTE
|Key elements of echocardiography:
* Maximum aortic velocity
 
* Mean aortic valve gradient
 
* [[Aortic valve area]]
 
* Paravalvular and valvular [[Aortic regurgitation|AR]]
|-
|LV geometry and other
cardiac findings
|TTE:
* [[LVEF]], regional wall motion
 
* [[Hypertrophy]], diastolic fucntion
 
* Pulmonary pressure estimate
 
* Mitral valve ([[Mitral regurgitation|MR]], [[MS]], MAC)
|
|}
|}

Revision as of 15:42, 13 January 2017

 
 
 
 
 
 
 
 
 
 
 
TAVR Imaging Evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TAVR CT
 
 
 
 
 
 
 
 
 
 
 
 
 
ECHO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-gated Angigram 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
 
 
Area
 
 
Aortic Sinus to Commissure dimension
 
 
Bypass Grafts
 
 
Estimated Pulmonary pressure
 
 
 
Low gradient AS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other Approaches
 
 
Circumferences
 
 
Sinotubular Junction
 
 
RV to Chest wall position
 
 
Other valvular abnormalities
 
 
 
 
Reduced EF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Carotid
 
 
 
 
 
Ascending Aorta dimension
 
 
 
 
 
 
 
 
 
 
 
 
Preserved EF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Direct Aortic
 
 
 
 
 
Aortic Calcification
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Transvenous
 
 
TAVR CT Measurement Summary
Valve Size and Type
Region of Interest Specific

Measurements

Measurement Technique Additional

Comments

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

anatomy

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

angulation

  • 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

injections

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