Transcatheter Aortic Valve Implantation: The Evolving Role of the Radiologist in 2021

Abstract

Background Transcatheter aortic valve implantation (TAVI) has gained worldwide acceptance and implementation as an alternative therapeutic option in patients with severe aortic valve stenosis unable to safely undergo surgical aortic valve replacement. This transformative technique places the radiologist in a key position in the pre-procedural assessment of potential candidates for this technique, delivering key anatomical information necessary for patient eligibility and procedural safety. Recent trials also provide encouraging results to potentially extend the indication to patients with safer risk profiles.

Method The review is based on a PubMed literature search using the search terms “transcatheter heart valve”, “TAVI”, “TAVR”, “CT”, “imaging”, “MR” over a period from 2010–2020, combined with personal comments based on the author’s experience.

Results and Conclusion CT plays a prominent role in the pre-procedural workup, delivering as a true 3D imaging modality optimal visualization of the complex anatomy of the aortic root with simultaneous evaluation of the patency of the different access routes. As such, the contribution of CT is key for the determination of patient eligibility and procedural safety. This input is supplementary to the contributions of other imaging modalities and forms an important element in the discussions of the Heart Valve Team. Knowledge of the procedure and its characteristics is necessary in order to provide a comprehensive and complete report. While the role of CT in the pre-procedural evaluation is well established, the contribution of CT and MR and the clinical significance of their findings in the routine follow-up after the intervention are less clear and currently the subject of intense investigation. Important issues remain, including the occurrence and significance of subclinical leaflet thrombosis, prosthetic heart valve endocarditis, and long-term structural valve degeneration.

Key Points: 

• CT plays a crucial role in evaluating transcatheter heart valve candidates

• Evaluation must include the dimensions of the aortic root and access paths

• The exact post-procedural role of CT and MRI has not yet been determined.

Citation Format

• Salgado R, El Addouli H, Budde RP. Transcatheter Aortic Valve Implantation: The Evolving Role of the Radiologist in 2021. Fortschr Röntgenstr 2021; 193: 1411 – 1425

Zusammenfassung

Hintergrund Die Transkatheter-Aortenklappenimplantation (TAVI) hat sich weltweit als alternative therapeutische Option bei Patienten mit schwerer Aortenklappenstenose durchgesetzt, bei denen ein Aortenklappenersatz durch offene chirurgische Operation zu risikobehaftet wäre. Bei dieser transformativen Technik nimmt der Radiologe eine Schlüsselposition ein, indem er präprozedural potenzielle Kandidaten beurteilt und wichtige anatomische Informationen liefert, die für die Eignung des Patienten und die Sicherheit des Eingriffs notwendig sind. Neuere Studien zeigen auch ermutigende Ergebnisse hinsichtlich einer Ausweitung der Indikation auf Patienten mit sichereren Risikoprofilen.

Methode Die Übersichtsarbeit basiert auf einer PubMed-Literaturrecherche von 2010–2020 mit den Suchbegriffen „transcatheter heart valve“, „TAVI“, „TAVR“, „CT“, „imaging“, „MR“ verbunden mit persönlichen Kommentaren basierend auf der Erfahrung des Verfassers.

Ergebnisse und Schlussfolgerung Die CT spielt eine herausragende Rolle in der präprozeduralen Aufarbeitung und liefert als echte 3D-Bildgebungsmodalität eine optimale Visualisierung der komplexen Anatomie der Aortenwurzel bei gleichzeitiger Beurteilung der Durchgängigkeit der verschiedenen Zugänge. Somit ist der Beitrag der CT entscheidend für die Feststellung der Eignung des Patienten und für die Sicherheit des Eingriffs. Diese Informationen ergänzen die Beiträge der anderen bildgebenden Verfahren und sind ein wichtiges Element der Diskussionen des Herzklappen-Teams. Die Kenntnis des Eingriffs und seiner Charakteristika ist notwendig, um einen umfassenden und vollständigen Bericht zu erstellen. Während die Rolle der CT in der präprozeduralen Evaluation gut etabliert ist, sind der Beitrag von CT und MR und die klinische Bedeutung ihrer Befunde in der routinemäßigen Nachuntersuchung nach dem Eingriff weniger eindeutig und werden derzeit intensiv untersucht. Es bleiben wichtige Fragen offen, einschließlich des Auftretens und der Bedeutung von subklinischen Klappenthrombosen, Endokarditis der Herzklappenprothese und langfristiger struktureller Klappendegeneration.

Kernaussagen: 

• Die CT spielt eine entscheidende Rolle bei der Beurteilung von Kandidaten für Transkatheter-Herzklappen.

• Die Bewertung muss die Dimensionen der Aortenwurzel und der Zugänge umfassen.

• Die genaue Rolle von CT und MR nach dem Eingriff ist noch ungeklärt.

Key words

TAVI - aortic valve - aortic valve stenosis - TAVR - CT angiography

Publication History

Received: 29 November 2020

Accepted: 08 April 2021

Article published online:
23 November 2021

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