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With approval and rapid expansion of transcatheter aortic valve replacement (TAVR) in the United States, the use of this procedure continues to increase.
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Multimodality imaging is essential to the proper diagnosis, preprocedural planning, and intraprocedural assessment for TAVR.
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Intraprocedurally, 3-dimensional transesophageal echocardiography and fluoroscopy are the mainstays of imaging to guide valve position and deployment.
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Newer imaging modalities such as intracardiac echocardiography and
The Role of Preoperative and Intraoperative Imaging in Guiding Transcatheter Aortic Valve Replacement
Section snippets
Key points
Transthoracic Echocardiography
The mainstay of diagnosis of aortic stenosis is transthoracic echocardiography (TTE). With the use of echocardiography and Doppler measurements, aortic valve gradients can be obtained and aortic valve area (AVA) can be calculated, or directly measured by planimetry in a parasternal short axis view (Fig. 1). This is particularly helpful in making a diagnosis of aortic stenosis. TTE also provides useful information regarding ventricular function. An understanding of the limitations of
Intraprocedural imaging
For the TAVR procedural itself, preprocedural imaging should prepare members of the implanting team for potential challenges or difficulties to anticipate during the procedure. Borderline vascular access may require more time or additional equipment to facilitate sheath delivery or may necessitate use of alternative access. Annular sizing should guide valve size, and anatomic issues related to the aortic root complex should be discussed before valve delivery and deployment. Furthermore,
Newer imaging modalities
The future of real time multimodality imaging in TAVR is constantly evolving. Since the initial PARTNER Trial experience, there has been a constant evolution in imaging modalities for annular sizing and real-time imaging from TTE and 2-dimensional TEE imaging to CT angiography and 3D TEE. This will continue to evolve over time. As the trend toward performing the procedure without general anesthesia increases, there will be a need for alternative adjunct imaging modalities. We discuss these
Summary
Optimal intraprocedural imaging is central to the TAVR procedure. Familiarity with the more commonly used modalities is necessary to perform the procedure. However, with our improved understanding of TAVR, the imaging tools that have been employed continue to evolve. CT has an important role in the preprocedural planning of the TAVR procedure. Real-time, intraprocedural imaging is provided by fluoroscopy and echocardiography. The importance of these modalities in ensuring proper valve position,
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Cited by (4)
Fusion imaging in interventional cardiology
2020, Revista Portuguesa de CardiologiaCitation Excerpt :However, with the development of fusion imaging, RA-3D or TEE have come to be used alongside fluoroscopy in real time to aid valve implantation.29 TEE is also key to the post valve implantation stage, as it can immediately indicate if the intervention has been a success, and can assess postoperative complications, such as valve regurgitation, dissection and/or rupture of the aorta, pericardial effusion, ventricular perforation and hemorrhages, among others.4,25–27 Fusion imaging using the EchoNavigator® system has been shown to be quite viable in clinical practice, as it enables good anatomical analysis in real time, taking into account aortic valve movements4,13 and allowing the relationships between the catheters, guidewires, the prosthesis itself and the anatomical structures to be observed.2,27
Computed Tomography Assessment for Transcatheter Aortic Valve Replacement
2018, Interventional Cardiology ClinicsCitation Excerpt :The introduction with TAVR has led to a surge of clinical investigations in the field of multimodality imaging due to the challenges with the design and delivery of transcatheter heart valves (THVs). In the early experience with TAVR, echocardiography was the primary imaging modality used to assess suitability for transcatheter valve intervention, to provide annular sizing and to monitor periprocedural complications, whereas the role of computed tomography (CT) was limited to access site evaluation.2 Multidetector CT quickly gained acceptance, however, as the method of choice for pre-TAVR annular measurement due to its superior sizing accuracy and the wealth of additional pertinent information it provides.3,4
Impact of fused computed tomography and fluoroscopy in the catheterization laboratory
2018, Archives of Cardiovascular DiseasesCitation Excerpt :The overlay of the CT and fluoroscopic images reveals real-time anatomical features that would not be available with fluoroscopy alone [24], including the position of the annulus and the position of the coronary artery ostia in relation to the annulus. Real-time assessment of these anatomical structures supports effective valve positioning and deployment, while minimizing the use of contrast agent (Fig. 3) [25,26]. The main limitation of CT imaging is the non-dynamic and remote acquisition mode, whereas the visualization of valvular calcifications in fluoroscopy enables the interventional cardiologist to be constantly aware of the position of the aortic annulus in “real time”.
The Pressure Is On: Implications of Blood Pressure After Aortic Valve Replacement
2019, Journal of the American Heart Association
Disclosures: Speaking/consulting honorarium for Edwards Scientific, Investigator PARTNER II trial, Investigator for SURTAVI trial, Investigator for REPRISE III trial.