SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement.

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Presentation transcript:

SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR) Stephan Achenbach, MD, FSCCT, Victoria Delgado, MD, Jörg Hausleiter, MD, Paul Schoenhagen, MD, James K. Min, FSCCT, Jonathon A. Leipsic, MD, FSCCT Journal of Cardiovascular Computed Tomography Volume 6, Issue 6, Pages 366-380 (November 2012) DOI: 10.1016/j.jcct.2012.11.002 Copyright © 2012 Society of Cardiovascular Computed Tomography Terms and Conditions

Figure 1 Implanted CoreValve (A) and Edwards Sapien valve (B) in contrast-enhanced, multiplanar reformatted CT. Journal of Cardiovascular Computed Tomography 2012 6, 366-380DOI: (10.1016/j.jcct.2012.11.002) Copyright © 2012 Society of Cardiovascular Computed Tomography Terms and Conditions

Figure 2 The aortic annulus has an oval shape in most patients. On the basis of their viewing angle, both transthoracic echocardiography (TTE; parasternal long-axis view) and transesophageal echocardiography (TEE; 120-degree left ventricular outflow tract view) usually show the smaller diameter of the left ventricular outflow tract and aortic annulus (see arrows). Journal of Cardiovascular Computed Tomography 2012 6, 366-380DOI: (10.1016/j.jcct.2012.11.002) Copyright © 2012 Society of Cardiovascular Computed Tomography Terms and Conditions

Figure 3 The oval shape of the aortic annulus will typically change to a more circular geometry after a catheter-based valve is implanted. Shown here are CT cross-sections in identical position and orientation in a patient before and after catheter-based implantation of a balloon-expandable valve. Journal of Cardiovascular Computed Tomography 2012 6, 366-380DOI: (10.1016/j.jcct.2012.11.002) Copyright © 2012 Society of Cardiovascular Computed Tomography Terms and Conditions

Figure 4 This sequence describes a method of creating a plane that precisely corresponds to the aortic annulus/basal ring. A multiplanar reconstruction will be rendered which includes all 3 lowest insertion points of the aortic valve cusps (hinge points). This approach can be followed with any image processing software that allows free multiplanar reconstruction and in which the reference lines can be “locked” in orthogonal position. In this way, it is possible to ensure that all planes will remain orthogonal to each other during manipulation of other imaging planes. The principle of this approach is to create a double-oblique plane (the formerly axial plane) which contains all 3 cusp insertion points. (A) Step 1, start out with multiplanar images in axial, sagittal, and coronal orientation. (B) Step 2, use the reference line in the coronal image to rotate the former axial plane in a way so that it crudely approximates the plane of the aortic valve. (C) Step 3: in the coronal image, move the reference line that controls the former axial plane up and down to identify the lowest insertion point of the right coronary cusp which is usually located at about the 1 o’clock position. Position the formerly axial plane exactly at the level of that cusp insertion point. Then, move the crosshair in the formerly axial plane exactly onto the right coronary cusp insertion point. (D) Step 4, rotate (without moving up and down or left and right) the reference lines in the formerly axial plane in a way so that the line that controls the former sagittal plane crosses the lowest insertion point of the noncoronary cusp, which is located at approximately the 8 o’clock position (note: it is not shown here that this may require to interactively change the level of the formerly axial plane by moving it up and down with the use of the reference line in the formerly coronal image, without rotating it so that the orientation remains unchanged). (E) Step 5, the formerly sagittal plane will now show the lowest insertion point both of the right coronary cusp and the noncoronary cusp. In this window, move and rotate the reference line of the former axial plane so that it very exactly crosses both of these insertion points. Once this is achieved, the formerly axial plane will contain 2 of the 3 lowest cusp insertion points. (F) Step 6, in the former coronal plane, rotate (without moving it) the reference line of the former axial plane until the lowest insertion point of the left coronary cusp just barely appears in the formerly axial window (arrow). Now, the former axial plane is exactly aligned with the lowest cusp insertion points of all 3 aortic cusps and represents both the orientation as well as the level of the “aortic annulus” (image on left). Measurements of aortic annulus dimensions should be performed in this plane. Journal of Cardiovascular Computed Tomography 2012 6, 366-380DOI: (10.1016/j.jcct.2012.11.002) Copyright © 2012 Society of Cardiovascular Computed Tomography Terms and Conditions

Figure 5 Determination of aortic annulus dimensions in CT. After an appropriate plane that exactly contains the 3 lowest insertion points of the coronary cusps has been created, 3 different methods of determining aortic annulus size have been proposed. The long and short diameter can be measured to calculate the mean diameter. The area can be measured and the diameter can be deducted under the assumption that this area changes to a circle when a valve is implanted. Finally, it can be assumed that the circumference will stay constant during the implantation, and the diameter can be derived from the circumference, again assuming that the annulus will achieve a perfectly circular shape. The more eccentric the aortic annulus, the more these 3 measurements will differ from one another, with the circumference-based method yielding the largest results. Journal of Cardiovascular Computed Tomography 2012 6, 366-380DOI: (10.1016/j.jcct.2012.11.002) Copyright © 2012 Society of Cardiovascular Computed Tomography Terms and Conditions

Figure 6 Measurement of the distance of the coronary ostia from the aortic annulus plane. Journal of Cardiovascular Computed Tomography 2012 6, 366-380DOI: (10.1016/j.jcct.2012.11.002) Copyright © 2012 Society of Cardiovascular Computed Tomography Terms and Conditions

Figure 7 Ideal projection for implantation of a catheter-based aortic valve in fluoroscopy. All tree coronary cusps are in the same plane, with the right coronary cusp in the middle and the left and noncoronary cusp symmetrically to the left and right. Journal of Cardiovascular Computed Tomography 2012 6, 366-380DOI: (10.1016/j.jcct.2012.11.002) Copyright © 2012 Society of Cardiovascular Computed Tomography Terms and Conditions

Figure 8 Determination of an appropriate projection on the basis of the CT dataset. First, the exact plane of the aortic annulus needs to be identified as explained in Fig. 4. Then the plane is moved to a more cranial position (without changing its orientation) to show the commissures of the aortic valve. Multiplanar reconstructions are rendered orthogonal to the aortic annulus plane and, in the reference image, orthogonal to the commissure between the left coronary cusp and noncoronary cusp (thicker white reference line than in the left image). The obtained image (right, corresponds to the thicker white reference line) is exactly in the desired plane. Most software programs will display the angulation of that image (arrows). The displayed values can be used to angulate the C-arm. Journal of Cardiovascular Computed Tomography 2012 6, 366-380DOI: (10.1016/j.jcct.2012.11.002) Copyright © 2012 Society of Cardiovascular Computed Tomography Terms and Conditions