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TAVR Imaging Evaluation

TAVR CT

ECHO

Non-gated Angigram of Chest, Abdomen and Pelvic arteries for vascular access selection

ECG gated CT of annulus and Aortic root for valve sizing selection

Left ventricles and other findings

Confirm severe Aortic Stenosis

Transfemoral Approach

Annular sizing

Aortic Root sizing

Additional Procedural Planning

Subclavian Approach

Major/Minor Dimension

Coronary Ostia height

Fluoroscopy Angulation

LVEF and LV dimension

High gradient AS

Apical Approach

Area

Aortic Sinus to Commissure dimension

Bypass Grafts

Estimated Pulmonary pressure

Low gradient AS

Other Approaches

Circumferences

Sinotubular Junction

RV to Chest wall position

Other valvular abnormalities

Reduced EF

Carotid

Ascending Aorta dimension

Preserved EF

Direct Aortic

Aortic Calcification

Transvenous

TAVR CT Measurement Summary
Valve Size and Type
Region of Interest	Specific Measurements	Measurement Technique	Additional Comments
Aortic valve morphology and function	Aortic valve	If cine images obtained, qualitative evaluation of valve opening ?Planimetry of aortic valve area in rare cases ?Calcium score with Agatston technique or a volumetric technique to quantify calcification of aortic valve	Most useful in cases of LFLG AS where diagnosis is otherwise unclear. May be helpful in defining number of valve cusps.
LV geometry and other cardiac findings	LV outflow tract	Measured with a double oblique plane at narrowest portion of the LV outflow tract ?Perimeter ? Area ?Qualitative assessment of calcification	Quantification of calcification not standardized. Large eccentric calcium may predispose for paravalvular regurgitation and annular rupture during valve deployment.
Annular sizing	Aortic annulus	Defined as double oblique plane at insertion point of all 3 coronary cusps ? Major/minor diameter ? Perimeter ? Area	Periprocedural TEE and/or balloon sizing can confirm dimensions during case.
Aortic root measurements	Sinus of Valsalva	Height from annulus to superior aspect of each coronary cusp ? Diameter of each coronary cusp to the opposite commissure ? Circumference around largest dimension ? Area of the largest dimension
Coronary and thoracic anatomy	Coronary arteries	Height from annulus to inferior margin of left main coronary artery and the inferior margin of the right coronary artery	Short coronary artery height increases risk of procedure.? Evaluation of coronary artery and bypass graft stenosis on select studies. Estimate risk of coronary occlusion during valve deployment.
	Aortic root angulation	Angle of root to left ventricle ? Three-cusp angulation to predict best fluoroscopy angle	Reduce procedure time and contrast load by reducing number of periprocedural root injections

TAVR Procedural Complications and Management
Complication	Treatment Options
Valve embolization Aortic Left ventricle	Recapture or deploy in descending aorta if still attached to delivery system (self-expanding) Valve-in-valve Endovascular (snare) SAVR and extraction
Central valvular aortic regurgitation	Usually self-limited, but may require gentle probing of leaflets with a soft wire or catheter Delivery of a second TAVR device
Paravalvular aortic regurgitation	Post-deployment balloon dilation Delivery of a second TAVR device Repositioning of valve if low (recapture, snare) Percutaneous vascular closure devices (e.g., Amplatzer Vascular Plug) SAVR
Shock or hemodynamic collapse	Assess and treat underlying cause if feasible Inotropic support Mechanical circulatory support CPB
Coronary occlusion	PCI (easier if coronaries already wired before valve implantation) CABG
Annular rupture	Reverse anticoagulation Surgical repair Pericardial drainage
Ventricular perforation	Reverse anticoagulation Surgical repair Pericardial drainage
Complete heart block	Transvenous pacing with conversion to PPM if needed
Stroke Ischemic Hemorrhagic	Catheter-based, mechanical embolic retrieval for large ischemic CVA Conservative
Bleeding/hemorrhage	Treat source if feasible Transfusion Reversal of anticoagulation
Access site-related complications	Urgent endovascular or surgical repair