Download Anatomical Preconditions (Annulus/Aorta)

Optimizing Valve Sizing: Role of CT vs. Echo
Axel Linke
University of Leipzig, Heart Center, Leipzig, Germany
Leipzig Heart Institute, Leipzig, Germany
Axel Linke, MD
Within the past 12 months, I or my spouse/partner have had a financial
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Affiliation/Financial Relationship
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Consulting Fees/Honoraria
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Royalty Income
Ownership/Founder
Intellectual Property Rights
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Claret Medical Inc. Medtronic, Bard
Medtronic, SJM, Edwards
Lifesciences, Symetis, Boston
Scientific, Bard
Claret Medical Inc.
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Multimodal Imaging
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Echocardiography
Right/left heart catheter
Angiography
MS-CT
Dyna-CT
Cardio-MRT
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
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
CONTRA
- 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
- 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)
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
Systolic vs. Diastolic Assessment
Systole
Diastole
Transthoracic Echocardiography
Assessment of
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Valve morphology
Jet velocity
Orifice area
Level of AR
Aortic root
Ascending aorta
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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
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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?
2D-TTE vs. 3D-TEE vs. 4DCT
Tsuneyoshi H, J. Cardiac Surgery 2016, 31, 18-22
2D-TTE vs. 3D-TEE vs. 4DCT
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. (Low contrast 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 balloon-expandable valves in bicuspid
aortic stenosis.
Thank you!
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