Role of Preprocedural Computed Tomography in Transcatheter Aortic Valve Implantation

Abstract

Transcatheter aortic valve implantation (TAVI) is currently considered an acceptable alternative for the treatment of patients with severe aortic stenosis and a high perioperative risk or a contraindication for open surgery. The benefit of TAVI significantly outweighs the risk of the procedure in patients requiring treatment that are not suitable for open surgery, and leads to a lower mortality in the one-year follow-up. The absence of a direct view of the aortic root and valve remains a challenge for the transcatheter approach. While direct inspection of the aortic valve during open surgery allows an adequate prosthesis choice, it is crucial for TAVI to know the individual anatomical details prior to the procedure in order to assure adequate planning of the procedure and proper prosthesis choice and patient selection. Among the imaging modalities available for the evaluation of patients prior to TAVI, computed tomography (CT) plays a central role in patient selection. CT reliably visualizes the dimensions of the aortic root and allows a proper choice of the prosthesis size. The morphology of the access path and relevant comorbidities can be assessed. The present review summarizes the current state of knowledge regarding the value of CT in the evaluation of patients prior to TAVI.

Key Points:

• CT plays a central role in patient selection and planning prior to TAVI.

• CT reliably detects the dimensions of the aortic root including the size of the aortic annulus, the degree of valve calcification and the morphology of the access routes.

• CT provides a more accurate measurement of the aortic annulus than 2D TEE and CT is the only imaging modality that allows a risk assessment for paravalvular leakages based on the calcification of the aortic valve.

Citation Format:

• Lehmkuhl L, Foldyna B, Haensig M et al. Role of Preprocedural Computed Tomography in Transcatheter Aortic Valve Implantation. Fortschr Röntgenstr 2013; 185: 941-949

Zusammenfassung

Katheterbasierte Aortenklappenimplantationen (TAVI) gelten mittlerweile als akzeptierte Alternative zur Behandlung von Patienten mit hochgradiger Aortenklappenstenose und hohem perioperativem Risiko oder einer Kontraindikation für einen offen-chirurgischen Aortenklappenersatz (AKE). Der Nutzen der TAVI überwiegt das Risiko des Eingriffs deutlich bei behandlungsbedürftigen Patienten, die nicht für einen offen-chirurgischen AKE geeignet sind, und führt zu einem Absinken der Mortalität im 1-Jahres-Follow-up. Eine Herausforderung bei der kathetergestützten Vorgehensweise stellt das Fehlen einer direkten Sicht auf die Aortenwurzel und -klappe während der Implantation dar. Während beim offen-chirurgischen AKE die Aortenklappe direkt inspiziert und eine Prothesenwahl getroffen werden kann, ist es bei der TAVI erforderlich, die individuellen anatomischen Details vor der Prozedur zu kennen, um eine adäquate Planung der Prozedur, eine geeignete Prothesenwahl und Patientenselektion zu ermöglichen. Unter den für eine Evaluation von Patienten vor TAVI verfügbaren bildgebenden Modalitäten nimmt die Computertomografie (CT) mittlerweile eine zentrale Rolle bei der Patientenselektion ein, da mit ihr zuverlässig die Dimensionen der Aortenwurzel einschließlich der Wahl der Prothesengröße, die Morphologie des Zugangswegs und relevante Komorbiditäten erfasst werden können. Die vorliegende Übersichtsarbeit fasst den aktuellen Stand des Wissens zum Stellenwert der CT bei der Evaluation von Patienten vor TAVI zusammen.

Key words

aorta - aortic valve - heart - CT - percutaneous

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