pre-tavi planning ct. ?how we do it ? 2

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Sep 18, 2016 - Gandolfo, Francesco Saia, Corrado Tamburino, George. Mak, Christopher Thompson, David Wood, Jonathon. Leipsic and John G. Webb.

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama Niki (1), Patris Vasileios (2), Fagkrezos, Dimitrios (1), Gourtsoyianni Sofia (1), Tsapaki Virginia (3), Triantopoulou Charikleia (1), Maniatis Petros (1), Argyriou Mihalis (2) 1. Konstantopouleio General Athens Hospital (CT department) 2. Evaggelismos General Athens Hospital (Cardiac Surgery department) 3. Konstantopouleio General Athens Hospital (Medical Physics department)

LAMA NIKI MD, EDIR, EBCR CARDIOVASCULAR RADIOLOGIST

HEART TEAM

Journal of Cardiovascular Computed Tomography (2012) 6, 366–380 Guidelines

SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR) Stephan Achenbach, MD, FSCCTa,*, Victoria Delgado, MDb, Jo€rg Hausleiter, MDc, Paul Schoenhagen, MDd, James K. Min, FSCCTe, Jonathon A. Leipsic, MD, FSCCTf

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY a 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER VOL. 69, NO. 10, 2017 ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2016.12.006

ACC CLINICAL DOCUMENT

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

Normal renal function (GFR □ TAVR CTA >60) or ESRD not expected to recover Borderline renal □Contrast MRA

function

□Direct femoral angiography (low contrast)

Acute kidney injury or ESRD with □Noncontrast CT of chest, expected recovery abdomen, and pelvis □Noncontrast MRA □Can consider TEE if balancing risk/benefits 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

In patients being evaluated for TAVR

MDCT systems with at least 64 detectors and a spatial resolution of 0.5 mm to 0.6 mm are recommended.

Processing should be performed on a dedicated workstation with the ability to manipulate double oblique orthogonal planes of a 3D dataset. 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

Although scanning protocols vary by vendor, typical protocols involve 2 main components, of contrast-enhanced CT scan.. Ø The first is an electrocardiogram (ECG)-gated acquisition of the aortic annulus and aortic root. Ø The second step is a full chest, abdomen, and pelvic acquisition of the arterial vasculature, which does not typically require ECG gating.

ECG-synchronized imaging reduces motion artifact and allows reconstruction at any acquired phase of the cardiac cycle. Typically reconstructed in systole 30%–40% of the R-R window. 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

Philips IntelliSpace Portal Clinical application CT TAVI planning

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

TAVR CT Measurement Summary Valve Size and Type Region of Interest Aortic valve morphology and function

Specific Measurements Aortic valve

LV geometry and other cardiac findings

LV outflow tract

Annular sizing

Aortic annulus

Aortic root measurements

Sinus of Valsalva

Coronary and thoracic anatomy

Coronary arteries

Aortic root angulation

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

Measurement Technique Additional Comments □If cine images obtained, qualitative □Most useful in cases of LFLG AS where evaluation of valve opening diagnosis is otherwise unclear. May be helpful □Planimetry of aortic valve area in rare cases in defining number of valve cusps. □Calcium score with Agatston technique or a volumetric technique to quantify calcification of aortic valve □Measured with a double oblique plane at □Quantification of calcification not narrowest portion of the LV outflow tract standardized. Large eccentric calcium may □Perimeter predispose for paravalvular regurgitation and □Area annular rupture during valve deployment. □Qualitative assessment of calcification □Defined as double oblique plane at insertion □Periprocedural TEE and/or balloon sizing point of all 3 coronary cusps can confirm dimensions during case. □Major/minor diameter □Perimeter □Area □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 □Height from annulus to inferior margin of left □Short coronary artery height increases risk of main coronary artery and the inferior margin of procedure. the right coronary artery □Evaluation of coronary artery and bypass graft stenosis on select studies. Estimate risk of coronary occlusion during valve deployment. □Angle of root to left ventricle □Reduce procedure time and contrast load by □Three-cusp angulation to predict best reducing number of periprocedural root fluoroscopy angle injections.

TAVR CT Measurement Summary Valve Size and Type Region of Interest Specific Measurements Aortic valve Aortic valve morphology and function

Measurement Technique 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

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

Mass score Agatston score

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

TAVR CT Measurement Summary LV geometry and LV outflow tract □Measured with a double other cardiac oblique plane at findings narrowest portion of the LV outflow tract □Perimeter □Area □Qualitative assessment of calcification

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

□Quantification of calcification not standardized. Large eccentric calcium may predispose for paravalvular regurgitation and annular rupture during valve deployment.

LVOT

LVOT calcifications PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

Valve calcifications

TAVR CT Measurement Summary Valve Size and Type Annular sizing

Aortic annulus Defined as double oblique □Periprocedural TEE plane at Insertion point of and/or balloon sizing all 3 coronary cusps can confirm dimensions during □Major/minor diameter case. □Perimeter □Area

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

Annulus Defined as double oblique plane at insertion point of all 3 coronary cusps Major/minor diameter Perimeter Area

TAVR CT Measurement Summary Valve Size and Type Aortic root Sinus of Valsalva measurements

□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

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

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 PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

TAVR CT Measurement Summary Valve Size and Type Coronary and thoracic Coronary arteries anatomy

Height from annulus to inferior Short coronary artery margin of left main coronary height increases risk of artery and the inferior margin of procedure. the right coronary artery 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 Reduce procedure time and contrast load by Three-cusp angulation to reducing number of predict best fluoroscopy angle periprocedural root injections.

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

Height from annulus to inferior margin of left main coronary artery and the inferior margin of the right coronary artery

Aortic root angulation

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

Three-cusp angulation to predict best fluoroscopy angle

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

Planning Vascular access

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

Aorta Major/minor diameters of the following: •Aorta at sinotubular junction •Ascending aorta in widest dimension •Ascending aorta prior to brachiocephalic artery •Midaortic arch •Descending aorta at isthmus •Descending aorta at level of pulmonary artery •Descending aorta at level of diaphragm

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

•Abdominal aorta at level of renal arteries •Abdominal aorta at the iliac bifurcation

left

right

Small luminal diameter, dense and circumferential and/or horseshoe calcifications, severe tortuosity are common in the iliofemoral vasculature in these patients and increase the risk of access site complications and cerebral embolization.

Access points 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis, JACC

Aorta / subclavian / iliac / femoral : major/ minor luminal dimensions (measurements must be perpendicular to aorta in 2 orthogonal planes)

Calcification and tortuosity

Dissection, atheroma, stenosis, aneurysms !!!!! PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

Calcification and tortuosity

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

The extent of atherosclerotic plaque in the ascending aorta and the arch, has been shown to be associated with worse outcomes following cardiac surgery and is also likely associated with increased periprocedural complications following TAVR.

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

Left subclavian artery

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

Multidetector CT angiography of the carotid arteries

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

VALVE - in - VALVE

TAV in SAV: what “heart team” needs to know Conference Paper N. Lama, P. Maniatis, V. P. Patris, D. Fagrezos, P. Moschouris, C. Triantopoulou, M. Argiriou, I. Papailiou; Athens/GR Conference: ECR 2017, At VIENNA, AUSTRIA PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

Radiopaque preventive landmarks' placement during stentless bioprosthesis implantation. Lama N, Patris V, Fagkrezos D, Moschouris P, Giakoumidakis K, Triantopoulou C, Maniatis P, Argiriou M. J Thorac Dis. 2018 Jun;

BICUSPID AORTIC VALVE J Cardiovasc Surg (Torino). 2018 Jun;59(3):381-391 Transcatheter aortic valve replacement in bicuspid aortic valve stenosis: where do we stand? Yoon SH1, Sharma R1, Chakravarty T1, Miyasaka M1, Ochiai T1, Nomura T1, Gellada N1, Nemanpour S1, Nakamura M1, Chen W1, Makkar R2.

Journal of the American College of Cardiology, Volume 70, Issue 13, September 2017 Outcomes of TAVR in Bicuspid Aortic Valve Stenosis Abdul Hakeem and Mehmet Cilingiroglu

European Heart Journal, Volume 38, Issue 16, 21 April 2017, Pages 1177–1181 TAVI in Bicuspid Aortic Valves ‘Made Easy’ Antonio H. Frangieh, MD MPH Albert Markus Kasel, MD EuroIntervention. 2016 Sep 18;12(Y):Y42-5. Transcatheter aortic valve implantation in bicuspid aortic valve stenosis. Perlman GY1, Blanke P, Webb JG. JACC: Cardiovascular Interventions Volume 9, Issue 8, April 2016 Bicuspid Aortic Valve Stenosis Favorable Early Outcomes With a Next-Generation Transcatheter Heart Valve in a Multicenter Study Gidon Y. Perlman, Philipp Blanke, Danny Dvir, Gregor Pache, Thomas Modine, Marco Barbanti, Erik W. Holy, Hendrik Treede, Philipp Ruile, Franz-Josef Neumann, Caterina Gandolfo, Francesco Saia, Corrado Tamburino, George Mak, Christopher Thompson, David Wood, Jonathon Leipsic and John G. Webb PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

Bicuspid aortic stenosis (AS) is not rare in patients treated with transcatheter aortic valve implantation (TAVI). Bicuspid valves have unique anatomy which could affect the results of TAVI; however, multiple recent reports have shown that TAVI is safe and effective in this population. Nevertheless, the growing experience, accumulated knowledge, and advancements of new technology lead to the expand use of TAVR to other pathologies or other populations such as bicuspid AS. With integration of imaging multimodalities (computed tomography and echocardiography), the diagnosis and classification of bicuspid aortic valve has been changing. Due to unfavorable anatomic features of bicuspid AS, the outcomes of TAVR in bicuspid AS was suboptimal, particularly when using the firstgeneration transcatheter valves. However, the newer-generation transcatheter valves significantly improved the outcomes of TAVR in bicuspid AS. Nonetheless, several issues still remain to be resolved. Given longer life expectancy in patients with bicuspid AS undergoing TAVR, durability of transcatheter valves is concerned. In addition, patients with bicuspid aortic valves often have concomitant dilatation of proximal part of ascending aorta (aortopathy), but limited data exist about the clinical prognosis of bicuspid aortic valve with concomitant aortopathy in elderly patients. Considering the expanding indication of TAVR to lower surgical risk and younger population, these issues should be evaluated in future studies.

Functional

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al

THANK YOU

PRE-TAVI PLANNING CT. HOW WE DO IT ? Lama et al