image assistance in tavi why ct › pdf › pdf › 2495_won-jangkim.pdfimage assistance in tavi why...
TRANSCRIPT
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Image Assistance in TAVIWhy CT ?
Won-Jang Kim, MD, PhDClinical Assistant Professor of Medicine, Heart Institute,
A M di l C t S l KAsan Medical Center, Seoul, Korea
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Major Uses of CT in TAVIMajor Uses of CT in TAVI
• Ileofemoral Arterial Sytem :Patient Selection & PlanningIleofemoral Arterial Sytem : Size, Calcification, Tortuosity, Plaques
• 3D annular & root morphology & dimensions
Patient Selection & Planning
• 3D annular & root morphology & dimensions• Amounts of calcium in valve
D i I l t ti• Optimal angle (TF) or puncture site (TA)• Relationship of annulus to both coronary ostia
During ImplantationRelationship of annulus to both coronary ostia
• Merging Image during Implantation
• Post TAVI assessmentFollow-up
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Evaluation of Access RoutesRoutes
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Ileofemoral Artery Evaluation Ileofemoral Artery Evaluation
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Ileofemoral Artery Evaluation Ileofemoral Artery Evaluation
Size Measure, Calcium distribution, Tortuosity,,,
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Vascular ComplicationsVascular ComplicationsVascular ComplicationsVascular Complicationsascu a Co p cat o sascu a Co p cat o sPotential risk factorsPotential risk factors
ascu a Co p cat o sascu a Co p cat o sPotential risk factorsPotential risk factors
•• Patient relatedPatient related •• Device relatedDevice relatedPatient relatedPatient related-- Vessel SizeVessel Size-- CalcificationCalcification
Device relatedDevice related-- TAVI systemTAVI system-- SheathSheath
-- TortuosityTortuosity-- Vessel stenosisVessel stenosis
SheathSheath-- Guide wiresGuide wires-- BalloonBalloon
-- PlaquePlaque
•• Technique/operator relatedTechnique/operator related
-- Closure device Closure device CT Can Predict•• Technique/operator relatedTechnique/operator related
-- Aggressive manipulationAggressive manipulation-- Inaccurate calibration andInaccurate calibration and-- Inaccurate calibration and Inaccurate calibration and
measurementsmeasurements-- Poor controlPoor control-- Prolonged procedural timeProlonged procedural time
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Femoral Artery Puncture under Femoral Artery Puncture under yFluoroscopic Guidance
yFluoroscopic Guidance
Anteriorsuperior
iliac spine Inguinaliliac spineInguinal
skin crease
gligament
Femoral
Commonfemoral
thead artery
SuperficialProfundaPuncture site, CFASuperficial
femoralartery
femoralartery
Initial Ileofemoral AortographyMade by Adw 4.5, GE healthcare system
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Baseline Angiography & CT Baseline Angiography & CT
Made by Adw 4.5, GE healthcare system
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Difficulty in Advancement S l ifi ll lDifficulty in Advancement
S l ifi ll lSevere calcific small vesselSevere calcific small vessel
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Various Access Sites
TranssubclavianTransaortal
Transapical
T f lTransfemoral
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Annulus sizingAnnulus sizing
Cannot be emphasized enough…
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Clinician Publications: ImagingClinician Publications: Imaging
1. Sizing is an important part of pre-case planning for TAVI
2. Most current literature suggests a multi-modality approach and many prefer 3D method (MSCT)
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Paravalvular Leak
Sizing and calcification are being investigated as major determinants of g jTAVI outcomes, for both Medtronic CoreValve® & Edwards Sapien®
Device size selection cannot be emphasized enough
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Anatomy of Aortic Valvar Anatomy of Aortic Valvar ComplexComplex
Anatomy of Aortic Valvar Anatomy of Aortic Valvar ComplexComplexComplexComplexComplexComplex
Stability of valve Stability of valve probably probably
d t i d b thd t i d b th
Aortic Root thus composed of 3 rings andAortic Root thus composed of 3 rings and
determined by the determined by the “virtual ring”“virtual ring”
Aortic Root thus composed of 3 rings and Aortic Root thus composed of 3 rings and one crownone crown--like ringlike ring
Piazza, N. et al. Circ Cardiovasc Intervent 2008;1:74Piazza, N. et al. Circ Cardiovasc Intervent 2008;1:74--8181
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Device Sizing Can Impact Procedural Device Sizing Can Impact Procedural g pOutcomes
g pOutcomes
• Significant variation exists in TAVI device• Significant variation exists in TAVI device selection
• Imaging modality differencesImaging modality differences• Definition of aortic annulus• Industry differencesIndustry differences• Physician preference and experience
• The aortic annulus is a non-circular structureThe aortic annulus is a non circular structure and proper imaging is important
• Several publications have demonstrated a pcorrelation between sizing and clinical outcomes
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Aortic Annulus on CT
Mean = 1.29 ± 0.11
Circular Annulus is Very Small ProportionDistribution of Dmax/Dmin from 164 TAVI patients
Courtesy of Dr. Piazza and Prof. Lange, German Heart Center, Munich Germany
Circular Annulus is Very Small Proportion
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A Limitation of Echoc
??
It is possible a true diameter is not measured due to the imaging plane acquired
Piazza N, et al. Circ Cardiovasc Intervent. 2008;1:74.
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Low Correlation Between Echo & CT
MEAN DIAMETER
162 patients Low correlation between echo diameter and all CT derived measurements (major, minor, & mean diameters, perimeter, and area)
Courtesy of Dr. Piazza and Prof. Lange, German Heart Center, Munich Germany
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CT is Highly Reproducible Compared to EchoEcho
Echo MSCT
Tzikas A, et al. Catheter Cardiovasc Intervent. 2011;77:868.
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Aortic Annulus on MSCTAortic Annulus on MSCTCoronal measurements do not equal those from theCoronal measurements do not equal those from the
annular plane
MPRMPR
Coronal Image Oblique Coronal Image
Aortic Annulus
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Aortic Annulus on MSCTAortic Annulus on MSCTSagittal measurements do not equal those from theSagittal measurements do not equal those from the
annular plane
MPRMPR
Sagittal Image Oblique Sagittal Image
Aortic Annulus
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The Aortic Annulus on MSCT
Aortic RVOTAortic Annulus
RVOT
RALAA
Descending A t
LA
Aorta
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New CT Parameters
Area-derived virtual Diameter√(4*Area/π)
Minimum DiameterArea
√(4 Area/π)
Elli ti it R tiEllipticity RatioMaximum Diameter/Minimum Diameter
Maximum Diameter
PerimeterDiameter
Perimeter-derived virtual DiameterPerimeter/π
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CT Measurements of Aortic Annulus
Perimeter: linear distance of tracing around gthe aortic annulus
Area area contained ithin tracing aro ndArea: area contained within tracing around the aortic annulus
Major & Orthogonal Minor Diameters: linear distances through the center of the gaortic annulusMean Diameter: Calculated mean of major and minor diametersand minor diameters
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TEE 3-Chamber Coronal Basal Mean Area-derived Rule of sineTEE vs CT (N=30) AMC data
TEE 3 Chamber Coronal
20.4±1.6 20.3±2.1 22.5±1.9 22.6±2.0 22.6±2.0 24.5±2.7
3-Chamber Coronal Basal Mean Area-derived Rule of sineInter-Reader Reliability by ICC (N=30)• CT measurements for annulus are usually larger than
echocardiography0.51 (.40-0.62) 0.75 (0.63-0.80) 0.80 (0.70-0.85) 0.81 (0.71-0.89) 0.81 (0.72-0.88)
Perimeter0 86 (0 9 0 92)
echocardiography
0.86 (0.79-0.92)
Intra-Reader Reliability by ICC (N=30)• Most reproducible CT measurements are perimeter3-Chamber Coronal Basal Mean Area-derived Rule of sine
1 0.72(0.47-0.88) 0.89(0.76-0.94) 0.94(0.84-0.96) 0.95(0.88-0.98) 0.94(0.85-0.97)
Intra Reader Reliability by ICC (N 30)• Most reproducible CT measurements are perimeter, area-derived, basal mean, and rule of sine method
2 0.51(.40-0.62) 0.93(0.84-0.97) 0.95(0.88-0.97) 0.96(0.89-0.99) 0.93(0.83-0.96)
Perimeter
0 97(0 93 0 98)
IIC, Intraclass correlation coefficient
0.97(0.93-0.98)0.95 (0.86-0.98)
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Anatomic Implications for TAVI I iImaging
• The aortic annulus is clearly a complex structure and requires imaging that can take q g ginto account its elliptical and irregular shape
• Single diameter sizing methods can provide misleading results
• 3D imaging can provide a more accurate representation of the aortic annulusrepresentation of the aortic annulus
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What to do with CT annular t tl ?measurements currently?
• Multidisciplinary approach - team members from the interventional and surgical teams reviewing g gaortic annuli with the CT and echo teams
• Root geometry and annular configuration by CT affords the implanting physician greateraffords the implanting physician greater understanding of the patient’s anatomy and allows for a more individualized TAVI approachfor a more individualized TAVI approach
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What are the current recommendations?
What are the current recommendations?recommendations?recommendations?
Annulus size by TEE
26mm Valve
23mm Valve
Usually tend to oversize by at least 2mm on echocardiography
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CT Sizing for CoreValveCT Sizing for CoreValve
6.45%91.129mm31mm
Cover IndexPerimeterDiameterValve Size
16 13%81 7263112.90%84.827mm31mm10.30%8828mm31mm
6 90%84 827mm29mm
16.13%81.726mm31mm
13.80%78.525mm29mm10.30%81.726mm29mm6.90%84.827mm29mm
11 50%72 323mm26mm
17.20%75.424mm29mm
19.20%6621mm26mm15.40%69.122mm26mm11.50%72.323mm26mm
23.10%62.820mm26mm
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CT Sizing for Edwards ValveCT Sizing for Edwards Valvegg
Annular Area (mm2) Edwards valve size (mm)Annular Area (mm2) Edwards valve size (mm)
230 - 300 20
310 - 320 20 or 23
330 - 400 23
410 23 or 26
420 510 26420 - 510 26
520 26 or 29
530 - 660 29
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Aortic root dimension and spatial relationship with surrounding relationship with surrounding
structures
LM
RCARCA
From annulus to LMCAFrom annulus to LMCA
LVLV
From annulus to RCA osFrom annulus to RCA os
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Navigator For Transapical ApproachNavigator For Transapical Approach
Direction of Puncture or Wire
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Aortic Valve MorphologyAortic Valve Morphology& Amount of Calcium
Scanty calciumScanty calcium
Heavy eccentric calcium
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Vague Number of Leaflet Vague Number of Leaflet TTE
R/O Bicuspid AV
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It is clearly Tricuspid Valve It is clearly Tricuspid Valve
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Echocardiographic findings Echocardiographic findings It is hard to deterimine how much calcium is in valve
TEE TTE
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Lack of Calcium Lack of Calcium
It is risk factor for migration or annulus rupture
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Heavy Eccentric Calcium Heavy Eccentric Calcium
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Heavy Eccentric Calcium Heavy Eccentric Calcium
Heavy calcium on non-coronary cuspHeavy calcium on non-coronary cusp
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Heavy Eccentric Calcium Heavy Eccentric Calcium
Basal portionBasal portion
Top of valve
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Valve Position & ImplantationValve Position & Implantationpp
LAO 1 CAUD 26 ; 26mm ValveLAO 1 CAUD 26 ; 26mm Valve
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Final Aortogram
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Echocardiographic evaluation
Mild to moderate PVL, No severe AR sign in pressure curve
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Sudden Drop of Vital Sign,Embolized valve to LVOTEmbolized valve to LVOT
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Major OperationMajor Operationj pj p
Removal of embolized Edwards valveRemoval of embolized Edwards valveAV Replacement (Magna 21 mm)Patient was cared in ICU.
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Valve positioningp g
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Line of Perpendicularity- Predicted A l
Line of Perpendicularity- Predicted A lAnglesAngles
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Aortic Valve Plane by CT ScanAortic Valve Plane by CT Scan
RCCRCC
LCC
NCC
LAO CranialRAO Caudal
RCCLCC
NCC
RAO Caudal LAO Cranial
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Merged Imaging Tools Merged Imaging Tools g g gg g g
Courtesy by Philips
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Follow up evaluation
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Examples of ConformabilityCoreValve Cases
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Volume Rendering ImageVolume Rendering Imageg gg g
LM
RCA
Made by Adw 4.5, GE healthcare system
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Spatial relationship with surrounding structuressurrounding structures
Coronal ViewCoronal View
LM
RCA
Made by Adw 4.5, GE healthcare system
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Spatial relationship with surrounding structuressurrounding structures
Sagittal ViewSagittal View
LM
Made by Adw 4.5, GE healthcare system
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Double Oblique ViewDouble Oblique Viewqq
No Valve Migration, Fracture, Circumferentiality
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New Imaging Modalitiesusing the CT image
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DynaCT Image Acquisition with y g qrapid pacing
C t Si S tCourtesy Siemens Systems
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Valve deployment under DynaCTValve deployment under DynaCT
Edwards SAPIEN CoreValve
Courtesy by Alois Nöttling Siemens
Edwards SAPIEN CoreValve
Courtesy by Brockmann German Heart Center Munich
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Conclusion: Why CT?• CT is the only 3D method that:
- Allows for several measurements of the aortic annulus, including perimeter.
- Allows for complete patient assessment, including access routes (femoral subclavianincluding access routes (femoral, subclavian, or direct aortic).
- Allows for calcification assessment.
• MRI is limited by spatial resolution and calcification assessment is limited. Plus it is a more technically challenging technique to get the correct images. Better for hemodynamic evaluation (reconstruction can be challenging), flowg g),
• 3D echo is limited by spatial resolution, calcification, and does not readily allow for the , yassessment of access routes