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 interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit Claret Medical Inc. Medtronic, Bard Medtronic, SJM, Edwards Lifesciences, Symetis, Boston Scientific, Bard Claret Medical Inc. None

Multimodal Imaging 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 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 CONTRA no contrast medium needed non-invasive no radiation 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 CONTRA 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) 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?

Tsuneyoshi H, J. Cardiac Surgery 2016, 31, 18-22 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! Axel.Linke@medizin.uni-leipzig.de