CT workup of Transcatheter Aortic Valve Replacement (TAVR) Jeffrey H. Maki, MD, PhD, FSCBTMR Director of Body MRI, Professor of Radiology University of Washington, Seattle, WA
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
-Se
vere
aor
tic/m
itral
regu
rgita
tion
-B
icus
pid
aorti
c va
lve
-H
yper
troph
y pr
oxim
al L
V se
ptum
-LV
EF <
20%
-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
Eur
ope)
*-
Med
troni
c C
oreV
alve
(app
rove
d Eu
rope
onl
y)
•M
ultim
odal
ity w
orku
p es
sent
ial
-C
TA (p
re p
roce
dure
) [C
MR
(pre
pro
cedu
re)]
-Tr
anse
soph
agea
lEch
o (p
re a
nd in
tra-p
roce
dure
) -
Flou
ro(in
tra-p
roce
dure
)
•In
crea
sing
vol
ume
CT
in w
orku
p-
UW
~30
0 C
TA/y
ear �
50+
TAV
R/y
ear
Edw
ards
SA
PIEN
Bal
loon
exp
anda
ble
SSM
edtro
nic
Cor
eVal
veB
allo
on e
xpan
dabl
e ni
tinol
TAV
R -
Dev
ices
Del
iver
y sy
stem
25-
28 F
r
ab
c
Med
troni
c C
oreV
alve
Bal
loon
exp
anda
ble
nitin
ol
Del
iver
y sy
stem
25-
28 F
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
NA
, War
ren
BH
, Shu
man
W
P. P
ercu
tane
ous
Aorti
c Va
lve
Rep
lace
men
t: Pr
epro
cedu
ralC
T Sc
anni
ng, 3
D Im
age
Post
proc
essi
ngan
d R
epor
ting.
RSN
A, C
hica
go, I
L, U
SA
Native�sten
oticvalve
Biop
rosthe
ticvalve�in�place�at�the
�ao
rtic�ann
ulus
3. P
rost
hetic
valv
eis
then
depl
oyed
over
a gu
idew
ire
2. A
n in
trodu
cers
heat
hpl
aced
thro
ugh
the
apex
ofhe
arta
ndba
lloon
valv
ulop
last
yis
perf
orm
ed
Tran
sapi
calA
ppro
ach
Proc
edur
e
1. In
cisi
onbe
twee
nth
ele
ft5t
h &
6t
h rib
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
d so
on
Littl
e SH
, Sha
h D
J, M
ahm
aria
nJJ
. Mul
timod
ality
Non
inva
sive
Imag
ing
for T
rans
cath
eter
Aor
tic V
alve
Impl
anta
tion:
A p
rimer
. M
etho
dist
Deb
akey
Car
diov
asc
J. 20
12 A
pr;8
(2):2
9-37
.
29 m
m
Rol
e of
CT
A -
TA
VR
1.Ev
alua
te P
elvi
c A
cces
s Arte
ries
•A
ppro
ach
depe
nds s
ize/
tortu
osity
/ath
eros
cler
otic
di
seas
e ili
ac a
rterie
s-
SAPI
EN 2
5-28
Fr(
8-9
mm
) [sm
alle
r com
ing]
•Sh
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
%)
•If
arte
ries t
oo d
isea
sed �
trans
apic
alap
proa
ch (4
0% U
SA)
-Pl
aque
/Ca++
•Ec
cent
ric u
sual
ly o
k•
Com
plex
pla
que
or c
ircum
fere
ntia
l/lum
inal
Ca++
mor
epr
oble
mat
ic-
Ang
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
ic
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
-Ex
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)
•Sy
stol
e be
st –
but r
equi
res
retro
spec
tive
CTA
= h
ighe
r dos
e+
•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
•Fa
lse
aneu
rysm
•A
V fi
stul
a•
Iliac
/fem
oral
arte
ry
perf
orat
ion
•D
isse
ctio
n-
Ret
rope
riton
eal B
leed
ing
-Pe
riphe
ral i
sche
mia
•N
erve
inju
ry-
Unp
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
arre
gurg
itatio
n•
MV
dys
func
tion
•H
eart
bloc
k•
Mis
-siz
ed V
alve
-Pa
rava
lvul
arre
gurg
itatio
n•
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
the
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.
•#1
= 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
c/s +
30
cc sa
line
flush
•#2
= Pr
ospe
ctiv
e tri
gger
ed C
TA c
hest
Abo
ve a
rch
to d
iaph
ragm
Smar
t-pre
p as
cend
ing
thor
acic
aor
ta70
cc
cont
rast
@ 5
cc/
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•
Mea
sure
and
dep
ict l
ocat
ions
of d
isea
se a
nd lu
men
ca
liber
of t
he a
cces
s ves
sels
•M
PRs a
ortic
root
•M
easu
re ro
ot a
nd si
notu
bula
rjun
ctio
n si
zes
•D
ista
nce
from
ann
ulus
to c
oron
ary
ostia
and
sino
tubu
lar
junc
tion
•A
sses
s the
deg
ree
of v
alvu
larc
alci
ficat
ion
Than
k Yo
u