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Optimizing Valve Sizing: Role of CT vs. Echo Axel Linke 1University of Leipzig, Heart Center, Leipzig, Germany, Axel Linke, MD Affiliation/Financial Relationship Company • • Grant/Research Support Consulting Fees/Honoraria • • • • • • • Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit • • • • • Medtronic Inc., Claret Medical Inc. Medtronic Inc., S. Jude Medical Inc., Claret Medical Inc., Boston Scientific, Edwards Lifesciences none none none none none Multimodal Imaging • • • • • • Echocardiography Right/left heart catheter Angiography MS-CT Dyna-CT Cardio-MRT *Messe SR et al, Circulation 2014;129:2253-2261 Anatomical Preconditions (Annulus/Aorta) Surgical Anatomy of the Heart, 3rd Edition, Benson R. Wilcox, UNC Hospitals, Andrew C. Cook, Robert H. Anderson, Copyright © 2004 Cambridge University Press (figures 3.41, p. 69 and 4.101, p. 182) . Reprinted with the permission of Cambridge University Press. Important TAVI Measurements Size of aortic valve annulus Size and height of Sinus valsalvae Diameter at sinutubuläre junction Diameter of ascending aorta Distance coronary ostia to valve Diameter of the LVOT *Messe SR et al, Circulation 2014;129:2253-2261 The Annulus Virtual plain through the deepest points of the three cusps Important parameter to determine transcatheter valve size Aorta LV Aortic Annulus MSCT - The Reference Method for Annulus Sizing CT as the Reference – The Literature Considerations Methods of Measurement CT PRO - 3-dimensional picture - good assessment of the ascending aorta - distance to the coronary ostia available - assessment of calcification (calcium score) - additional information about co-morbidities CONTRA - high amount of contrast medium - impaired imaging in case of severe calcification - additional time need - cooperation of the patient MSCT: Multiplanar Reconstruction MSCT: Verify Aortic Annular Plane MSCT: Reconstruct the Annulus (Circumference) *Messe SR et al, Circulation 2014;129:2253-2261 Annular Parameters Diameter (minor, major, mean) Area Perimeter Annulus often elliptical or irregular Which one are we going to use for determination of valve size? Precision of annular assessment by Echo and MSCT Transthoracic Echocardiography Assessment of • • • • • • Valve morphology Jet velocity Orifice area Level of AR Aortic root Ascending aorta • • • • • • LV function LV hypertrophy LVOT obstruction Diastolic function Mitral valve PA-Pressure Anatomical Preconditions (Annulus/Aorta) Methods of Measurement - TTE - Annulus: 20 mm - ascend. aorta: 32 mm - native valve moderately calcified Anatomical Preconditions (Annulus/Aorta) Methods of Measurement TTE PRO - no contrast medium needed - non-invasive - no radiation CONTRA - impaired imaging quality in many elderly patients: assessment not reliable - no information about the distance between the ostia of the coronaries and the native valve - limited information about the ascending aorta Anatomical Preconditions – Assessment by TOE Anatomical Preconditions (Annulus/Aorta) Methods of Measurement TEE PRO - no contrast medium needed - non-invasive - no radiation - reliable assessment of the annulus and ascending aorta - good information about the shape of the annulus (round vs. oval) CONTRA - cooperation of the patient - impaired imaging quality in patients with severe calcification - identification of the coronary ostia requires some experience Annulus Size • • • • • exact longitudinal axis of the ascending aorta required sinus and STJ have to be visable measurement at the insertion of the NCC and RCC consider calcium protruding into the LVOT average 3 assessments Decision on valve size Anatomy of the Aortic Root • Size of Sinus valsalvae • Sinus height, STJ size • Size of the ascending aorta Room to accomodate the calcified leaflets ? Fixation of the valve possible? Summary - The CT appears to be the ideal way to assess the annulus and the vasculature. - However, the method of assessment should take comorbidities into account. (No CT in severe RF!) - In case of any uncertainty: use a second method! - In bicuspid valves, CT is essential to determine the annulus size. Be careful with ballon-expandable valves in bicuspid aortic stenosis. Thank you! [email protected]
