Transcatheter Aortic Valve Implantation The Role of Cardiac CT Koen Nieman, MD, FESC Erasmus MC, Rotterdam, The Netherlands
Outline • • • • •
Identification of eligible candidates Pre-procedural planning Per-procedural guidance Evaluation of results Prediction of outcome
CT Valve Imaging • High spatial resolution • Multiphase resonstruction • Limitless 3D crosssections • No flow measurements • Limited temp resolution • High radiation exposure
CT Valve Imaging • High spatial resolution • Multiphase resonstruction • Limitless 3D crosssections • No flow measurements • Limited temp resolution • High radiation exposure
Stenosis Severity
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AoVA = 1.0 cm2
Feuchtner et al, JACC 2006
Devices and procedures
Metal balloon expanded Edwards Sapien Valve
Nitinol self-expanding Medtronic CoreValve
Aortic Valve Morphology
LVOT / Aortic Dimensions
24 x 29 mm
Edwards Sapien Valve
LVOT / Aortic Dimensions 24 x 29 mm
Medtronic CoreValve
Valve sizing
Dmax / Dmin = 1.28 (0.13) (Schutz et al, 2009)
No reproducible LVOT sizefrom single cross-section 3D imaging required for perimetric LVOT sizing
TAVI Eligibility – CoreValve
* [annulus too small in 23%],; ** [annulus too large]
Schultz CJ, EHJ, 2010
TAVI Eligibility – Edwards Valve
; ** [annulus too large]
Messika-Zeitoum, JACC, 2009
Sizing and PAR: CoreValve PAR<2 N=42
PARâ&#x2030;Ľ2 N=14 (25%)
21 (2)
23 (3)*
Dmax
26 (3)
28 (2)*
DCSA
23 (2)
25 (3)**
1.27 (0.09) 1.41 (0.20)
1.27 (0.18) 1.28 (0.22)*
Diameters in mm Dmin
Ratio Dmax /Dmin Nominal prosthesis inflow CSA / native LVOT CSA
CJ Schultz et al, CCI, 2011
Vascular Access
Optimal projection: what and how B
A
D
R C
NC
LC
C
Conventional scan protocol • ECG-gated spiral CT scan: heart • Non-gated spiral CT scan: total body
Dose/contrast hygienic protocol • ECG-triggered high-pitch spiral scan: heart / body • 50cc contrast medium for single scan
Post-implant
Achenbach, JCCT 2012