Journal of Cardiovascular Computed Tomography
GuidelinesSCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR)
Section snippets
Aortic valve stenosis
Aortic valve stenosis is a common disease and frequently affects patients of older age. When symptoms are present, and in selected situations even for asymptomatic persons, aortic valve replacement is indicated.1, 2, 3 Although surgery for aortic valve replacement can usually be performed at relatively low risk, some conditions substantially increase the risk of conventional surgery. The conditions include, among others, frailty, prior radiation therapy that caused significant damage to the
Data acquisition protocols
CT imaging in the evaluation for TAVI/TAVR should include imaging of the aortic root, aorta, and iliac, as well as common femoral arteries. Hence, a large volume must be covered. To achieve the desired accuracy, imaging of the aortic root must be synchronized to the electrocardiogram (ECG) either by retrospective ECG gating or through the use of prospective ECG triggering. Spatial resolution must be high to provide adequate imaging, especially of the aortic root and of the iliofemoral arteries,
Assessment of the access route
The iliofemoral axis remains the most common route of access for TAVI/TAVR. Ongoing refinements have resulted in progressive reduction of the profile of the delivery systems for transfemoral TAVI/TAVR, and the required sheath sizes can be expected to decrease further in the future. Current delivery profiles, as well as the corresponding vendor recommendations for minimal vessel diameters, are listed in Table 3. Single-plane angiography, which is typically performed at the time of coronary
Assessment of the aorta
In addition to the iliac and femoral arteries, the entire aorta should be evaluated by CT angiography before a TAVI/TAVR procedure if a transfemoral approach is considered. Transverse axial images and multiplanar reconstructions are commonly used. Contraindications to a femoral access include massive elongation with kinking of the aorta, dissection, or large thrombi protruding into the lumen or other obstacles that may prevent advancing the valve through the aortic lumen. If a transaortic
Aortic annulus
Choosing the appropriate prosthesis size requires accurate measurement of the dimensions of the aortic annulus. If the prosthesis size is too small, embolization may occur, and paravalvular regurgitation is more frequent, with negative clinical outcome.24, 25, 26 If the prosthesis is too large relative to the aortic annulus, rupture may occur which is often fatal.
The aortic annulus is not a separate anatomic structure. Much rather, it is formed by the 3 lowest points of the aortic valve cusps
Other aortic root dimensions
Besides aortic annulus size, other anatomic measures of the aortic root have relevance for TAVI/TAVR planning. They include distance of the coronary ostia to the aortic valve plane, aortic cusp length, width of the aortic sinus, width of the sinotubular junction, and width of the ascending aorta. These measurements are important to avoid potentially catastrophic complications such as coronary occlusion and root injury.39 CT is well suited to provide these measures because of its multiplanar
Aortic annulus plane for fluoroscopy
During catheter-based implantation especially of the balloon-expandable prosthesis, it is important to use a fluoroscopic projection that provides an exact orthogonal view onto the aortic annular plane. Theoretically, an unlimited number of projections exist which will provide such a view, but most operators prefer a projection whereby the right coronary cusp is central and closest to the image intensifier, whereas the left and noncoronary cusps are positioned symmetrically to either side of
Aortic valve calcification
Calcific aortic valve stenosis is pathologically characterized by thickening of the aortic valve cusps with large calcific nodules that protrude on the aortic surface of the cusps. Unlike surgical aortic valve replacement, the diseased aortic cusps are not removed in TAVI/TAVR. The presence of valvular calcifications may be of importance to ensure prosthesis anchorage and avoid dislodgement.46 By contrast, excessive calcification may hamper the apposition of the prosthesis to the irregular
Data elements to be included in the report
The data elements included in the report are shown in Table 12.
Summary
CT imaging plays an important role in procedural planning for TAVI/TAVR and should be a fully integrated component of any TAVI/TAVR program. The use of CT in TAVI/TAVR is multifaceted and should include the assessment of vascular access of the aortic valve, annulus, and root and of the orientation of the annulus plane. Importantly, the person responsible for the interpretation of the CT examination should be integrated in the TAVI/TAVR team to ensure appropriate incorporation into the patient
References (53)
- et al.
2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement
J Am Coll Cardiol
(2012) - et al.
Current status of transcatheter aortic valve replacement
J Am Coll Cardiol
(2012) - et al.
Comparison of dual-source computed tomography for the quantification of the aortic valve area in patients with aortic stenosis versus transthoracic echocardiography and invasive hemodynamic assessment
Am J Cardiol
(2009) - et al.
Aortic valve stenosis: CT contributions to diagnosis and therapy
J Cardiovasc Comput Tomogr
(2010) - et al.
3-dimensional aortic annular assessment by multidetector computed tomography predicts moderate or severe paravalvular regurgitation after transcatheter aortic valve replacement: implications for sizing of transcatheter heart valves
J Am Coll Cardiol
(2012) - et al.
SCCT guidelines on radiation dose and dose-optimization strategies in cardiovascular CT
J Cardiovasc Comput Tomogr
(2011) - et al.
SCCT guidelines for performance of coronary computed tomographic angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee
J Cardiovasc Comput Tomogr
(2009) - et al.
Ultra-low-dose intra-arterial contrast injection for iliofemoral computed tomographic angiography
JACC Cardiovasc Imaging
(2009) - et al.
Clinical outcomes after transcatheter aortic valve replacement using valve academic research consortium definitions: a weighted meta-analysis of 3,519 patients from 16 studies
J Am Coll Cardiol
(2012) - et al.
Standardized endpoint definitions for Transcatheter Aortic Valve Implantation clinical trials: a consensus report from the Valve Academic Research Consortium
J Am Coll Cardiol
(2011)
Transfemoral aortic valve implantation new criteria to predict vascular complications
JACC Cardiovasc Interv
Percutaneous aortic valve replacement: vascular outcomes with a fully percutaneous procedure
J Am Coll Cardiol
Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience
J Am Coll Cardiol
Aortic regurgitation index defines severity of peri-prosthetic regurgitation and predicts outcome in patients after transcatheter aortic valve implantation
J Am Coll Cardiol
Aortic annulus diameter determination by multidetector computed tomography: reproducibility, applicability, and implications for transcatheter aortic valve implantation
JACC Cardiovasc Interv
Structural integrity of balloon-expandable stents after transcatheter aortic valve replacement: assessment by multidetector computed tomography
JACC Cardiovasc Interv
Multimodality imaging in transcatheter aortic valve implantation and post-procedural aortic regurgitation: comparison among cardiovascular magnetic resonance, cardiac computed tomography, and echocardiography
J Am Coll Cardiol
Cross-sectional computed tomographic assessment improves accuracy of aortic annular sizing for transcatheter aortic valve replacement and reduces the incidence of paravalvular aortic regurgitation
J Am Coll Cardiol
Multidetector computed tomography in transcatheter aortic valve implantation
JACC Cardiovasc Imaging
Deformation dynamics and mechanical properties of the aortic annulus by 4-dimensional computed tomography: insights into the functional anatomy of the aortic valve complex and implications for transcatheter aortic valve therapy
J Am Coll Cardiol
Noninvasive evaluation of the aortic root with multislice computed tomography. Implications for transcatheter aortic valve replacement
JACC Cardiovasc Imaging
Multislice computed tomography for prediction of optimal angiographic deployment projections during transcatheter aortic valve implantation
JACC Cardiovasc Interv
Pre-procedural imaging of aortic root orientation and dimensions: comparison between X-ray angiographic planar imaging and 3-dimensional multidetector row computed tomography
JACC Cardiovasc Interv
Correlation of device landing zone calcification and acute procedural success in patients undergoing transcatheter aortic valve implantations with the self-expanding CoreValve prosthesis
JACC Cardiovasc Interv
Six-month results of a repositionable and retrievable pericardial valve for transcatheter aortic valve replacement: the Direct Flow Medical aortic valve
J Thorac Cardiovasc Surg
Acute catastrophic complications of balloon aortic valvuloplasty. The Mansfield Scientific Aortic Valvuloplasty Registry Investigators
J Am Coll Cardiol
Cited by (515)
Cardiac Computed Tomography Protocols in Structural Heart Disease: A State-of-the-Art Review
2024, Seminars in RoentgenologyTechnical recommendations for computed tomography guidance of intervention in the right ventricular outflow tract: Native RVOT, conduits and bioprosthetic valves:: A white paper of the Society of Cardiovascular Computed Tomography (SCCT), Congenital Heart Surgeons’ Society (CHSS), and Society for Cardiovascular Angiography & Interventions (SCAI)
2024, Journal of Cardiovascular Computed TomographyACR Appropriateness Criteria® Preprocedural Planning for Transcatheter Aortic Valve Replacement: 2023 Update
2023, Journal of the American College of RadiologyIntracardiac shunt assessment using CT coronary angiography
2023, Journal of Cardiovascular Computed Tomography
Conflict of interest: S. Achenbach has received speaker honoraria from Siemens and Edwards Lifesciences, research grants from Siemens and Bayer Schering Pharma, and serves as a consultant to Servier and Guerbet. V. Delgado has received consulting fees from Medtronic and St. Jude Medical. J. Hausleiter has received speaker honoraria from Abbott Vascular and Siemens Medical Solutions. P. Schoenhagen has no conflict of interest. J.K. Min has received research support from and served on the medical advisory board of GE Healthcare. J.A. Leipsic has received speaker honoraria from Edwards Lifesciences.