Prediction of Optimal Deployment Projection for Transcatheter Aortic Valve Replacement

Abstract

Background-Identifying the optimal fluoroscopic projection of the aortic valve is important for successful transcatheter aortic valve replacement (TAVR). Various imaging modalities, including multidetector computed tomography (MDCT), have been proposed for prediction of the optimal deployment projection. We evaluated a method that provides 3-dimensional angiographic reconstructions (3DA) of the aortic root for prediction of the optimal deployment angle and compared it with MDCT. Methods and Results-Forty patients undergoing transfemoral TAVR at St Paul's Hospital, Vancouver, Canada, were evaluated. All underwent preimplant 3DA and 68% underwent preimplant MDCT. Three-dimensional angiographic reconstructions were generated from images of a C-arm rotational aortic root angiogram during breath-hold, rapid ventricular pacing, and injection of 32 mL contrast medium at 8 mL/s. Two independent operators prospectively predicted perpendicular valve projections. The implant angle was chosen at the discretion of the physician performing TAVR. The angles from 3DA, from MDCT, the implant angle, and the postdeployment perpendicular prosthesis view were compared. The shortest distance from the postdeployment perpendicular prosthesis projection to the regression line of predicted perpendicular projections was calculated. All but 1 patient had adequate image quality for reproducible angle predictions. There was a significant correlation between 3DA and MDCT for prediction of perpendicular valve projections (rϭ0.682, PϽ0.001). Deviation from the regression line of predicted angles to the postdeployment prosthesis view was 5.1Ϯ4.6°for 3DA and 7.9Ϯ4.9°for MDCT (Pϭ0.01). Conclusions-Three-dimensional angiographic reconstructions and MDCT are safe, practical, and accurate imaging modalities for identifying the optimal perpendicular valve deployment projection during TAVR. (Circ Cardiovasc Interv. 2012;5:247-252.)

3D Hybrid Imaging for Structural and Congenital Heart Interventions in the Cath Lab

“…[22][23][24][25] Consequently, a reduction in peri-and post-interventional complications such as device malpositioning, paravalvular leakage, trauma of surrounding structures as well as other organ damage (acute kidney failure) was shown. 22,24 Excellent implant angles determined by Aortic Valve Guide are significantly more likely to be associated with no paravalvular regurgitation compared to satisfactory or poor implant angles (41.3% vs. 21.6%, respectively, p = 0.045) independent of operator experience.…”

Standard imaging techniques in transcatheter aortic valve replacement

“…Annular measurements by cardiac CTA have resulted in lower rates of paravalvular AI, a major determinant of short-and long-term outcomes (13,14,20). Measurements of annular perimeter tend to yield the lower interobserver variability (10) and larger diameters than annular area or the mean of the major and minor diameters (16,21).…”

“…This deployment angle requires multiple "trial-and-error" aortograms with repositioning of the fluoroscopy arm until an adequate 3-cusp view is seen, but can be predicted with cardiac CTA. Cardiac CTA guided determination of the deployment angle may reduce procedure time, contrast volume, and radiation exposure, with improvements in the rate of correct fluoroscopic projections at the time of TAVR and improved outcomes (16,20,26) (Figure 7). A B C D …”

Combined Retrograde/Antegrade Approach to Transcatheter Closure of an Aortic Paravalvular Leak

“…3). 2 From the femoral artery, with use of a 6F multipurpose angiographic catheter (Boston Scientific Corporation; Natick, Mass), we easily passed a straight-tipped, hydrophilic Radifocus ® Glidewire ® Advantage Peripheral Guidewire (Terumo Interventional Systems; Tokyo, Japan) retrograde from the aorta to the LV, through the PVL; however, the catheter would not cross the defect. A 4F Glidecath ® hydrophilic Coated Catheter (Terumo) was able to cross over this wire, and through that catheter we shuttled an Amplatz Super Stiff  Guidewire (Boston Scientific) across the defect into the LV.…”