CT Essentials for Optimizing Sizing and TAVR Planning Gaby Weissman MD FACC Medstar Heart & Vascular Institute Georgetown University Gaby.Weissman@georgetown.edu

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Slice thickness <1.0mm The Basics The Basics ECG Gating Slice thickness <1.0mm Multiphase imaging is generally not mandatory May be preferable The scanner Contrast dose Radiation dose Image length Aorta Subclavian arteries Iliac and femoral arteries Does not need to be ECG gated

The Report Aortic Annulus Aortic valve Left ventricle Aortic root Short vs long diameter Area Circumference Calcification/ LVOT calcification Aortic valve Cuspidity (tri vs bi) Calcification Left ventricle Masses/ thrombi Aortic root Sinus width Sinus Height Coronary heights Thoracic aorta Tortuosity Intraluminal obstruction/ thrombi Access vessels Luminal diameter Calcification

I. The Annulus

Aortic Annular Anatomy Piazza N. Circ Cardiovasc Intervent. 2008 74-81

Techniques Manual Facilitated Semi automated

The Annulus

The Annulus

The Annulus

The Annulus

Cardiac Phase Blanke P. Radiology 2013.

Aortic Annular Calcifications Barbanti M, Leipsic J. Circulation. 2013 244-253.

Artifact - Motion

Artifact - Contrast Opacification

The Decision on the Valve and size are multifactorial Annular Calcifications The Decision on the Valve and size are multifactorial All data available should be considered Take into account Image quality Factors beyond the annular measures

The Decision on the Valve and size are multifactorial Coronary Height The Decision on the Valve and size are multifactorial All data available should be considered Take into account Coronary height Leaflets/ prosthetic valve leaflets

The Decision on the Valve and size are multifactorial Sinotubular junction The Decision on the Valve and size are multifactorial All data available should be considered Take into account Size of the sinuses of Valsalva Height, size and calcifications of the sinotubular junction

II. Fluoroscopic Orientation

Annular Angulation

III. The Coronaries

Coronary Heights

Coronary Obstruction Ribeiro H JACC: Cardiovasc Intervent. 2013 452-61.

Coronary Obstruction Ribeiro H JACC: Cardiovasc Intervent. 2013 452-61.

IV. The Valve

The valve Bicuspid Tricuspid

Bicuspid Valves

PVAR in TAVR in Bicuspid AS

Outcomes in TAVR in Bicuspid AS

Vi. Bioprosthetic Valves

Bioprosthetic Valve

V. The Aorta

The Aorta

VI. Access

Access

VII. Contrast

Contrast Dose Kawaja MZ. Eurointervention 2012.

Dose Saving Techniques 50/50 contrast mixtures Low kVp scans Intra arterial contrast injections Dual source scanners eGFR based contrast medium dosing