Patient selection for transcatheter aortic valve replacement: A combined clinical and multimodality imaging approach

Table 1 Contraindications for transcatheter aortic valve implantation

Absolute contraindications

Absence of heart team or surgery on the site

Estimated life expectancy < 1 yr

Improvement of quality of life by TAVI unlikely because of comorbidities

Severe primary associated disease of other valves with major contribution to the patient’s symptoms, that can be treated only by surgery

Inadequate annulus size (< 18 mm, > 29 mm)

Thrombus in the left ventricle

Active endocarditis

Elevated risk of coronary ostium obstruction (asymmetric valve calcification, short distance between annulus and coronary ostium, small aortic sinuses)

Plaques with mobile thrombi in the ascending aorta, or arch

For transfemoral/subclavian approach: inadequate vascular access (vessel size, calcification, tortuosity)

Relative contraindications

Bicuspid or non-calcified valves

Untreated coronary artery disease requiring revascularization

Haemodynamic instability

LVEF < 20%

For transapical approach: severe pulmonary disease, LV apex not accessible

TAVI: Transcatheter aortic valve implantation; LVEF: Left ventricular EF.

Table 2 Magnetic resonance sequences used for pre transcatheter aortic valve implantation evaluation[96]

Three-plane localizer	To localize aortic valve plane
Axial SSFP non ECG gated without contrast	To identify potential ascending aorta and subclavian access sites
	To determinae size, calcification, and presence of aneurysmal dilatation of aorta
Breath held free breathing 2D ECG gated SSFP	To evaluate aortic annulus,aortic valve structure, and sinus higher
Coronal aorta, LVOT and aortic root	Planimetry valve orifice area
SSFP ECG gated images:short axis stak	To calculate ejection fraction, ventricular volumes and mass
Breath held free breathing phase contrast at aortic orifice	Calculate blood flow velocity, pressure gradient, and flow volume across the aortic valve
	Calculate Aortic regurgitant volume
3D Navigator assisted SSFP	Coronary ostia height
	Aortic diameter
T2 black blood	Useful in presence of susceptibility artifacts from sternal wires of prosthetic valves

LVOT: Left ventricular outflow tract; SSFP: Steady state free procession; ECG: Electrocardiogram.

Table 3 Multimodality imaging in pre transcatheter aortic valve replacement evaluation

Technique	Principal advantages	Disadvantages
Transthoracic echocardiography	Widespread availability First line diagnostic tool	Poor acoustic window Frequent discrepancy between different parameters
Transesophageal echocardiography	Good spatial resolution	Suboptimal for distal ascending aorta and arch
3 D reconstruction	Semi-invasive exam	Anatomic definition and annulus measurement
Multislice computed tomography	Multiplanar reconstruction Quantification of calcium score Evaluation of aorto-femoral tract	Potential nephrotoxicity of contrast medium Radiations exposition Controlled heart rate
Magnetic resonance imaging	Tissue characterization Multiplanar reconstruction Evaluation of aorto-femoral tract Controlled heart rate	Reduced availability Poor evaluation of calcifications Contraindicated in metallic devices wearers
Positron emission tomography	Evaluation of calcification and inflammation	Poor spatial resolution