The role and indications for imaging in patients with cardiovascular disease is dependent on the clinical characteristics, presentation, and overall patient conditions. Professional societies have developed numerous guidelines,1
appropriateness use criteria, decision pathways for management,6
and other standards documents that help the clinician approach patients according to their existing or suspected pathology and decide when—and which—imaging modality may be warranted.
The overall goals and roles of cardiac imaging in the patient with structural heart disease are listed in Table 39.1
. A roadmap to the imaging needs and goals for the currently approved transcatheter procedures can be found in Table 39.2
(transcatheter aortic valve replacement [TAVR
]), Table 39.3
, (mitral valve repair with MitraClip©) and Table 39.4
(implantation of left atrial appendage occluder devices). Examples of images obtained during preprocedural planning and intraprocedural imaging are displayed in Figures 39.1, 39.2, 39.3 and 39.4
Transthoracic echocardiogram (TTE
) is usually the initial imaging modality to evaluate patients with valvular disease or other suspected structural heart diseases, because it is widely available, noninvasive, and has almost no contraindications. A complete TTE
allows for a comprehensive evaluation of cardiac chamber size and function, including visualization of valves and identification of most cardiac pathologies. The use of Doppler imaging (color and spectral) in addition to two- and three-dimensional (2D and 3D) TTE
is critical to evaluate hemodynamic abnormalities such as intracardiac shunts, valvular stenosis, and valvular regurgitation. On certain occasions, TTE
can be improved by using related techniques such as agitated saline injection (for detection of right-to-left shunts), ultrasound enhancing agents (for better delineation of the endocardium, intracardiac thrombus or masses, and myocardial perfusion imaging for alcohol septal ablation), or myocardial strain imaging (for left ventricular [LV] function).
Once a pathology is identified, a thorough evaluation must include quantifying severity, size, morphology, and mechanisms underlying the pathology, as well as the
consequences of the pathology to other structures within the heart (ie, ventricular or atrial remodeling, pulmonary hypertension, etc).
TABLE 39.1 Role and Goals of Cardiac Imaging in Structural Heart Disease
Diagnose the pathology
Determine its severity and need for intervention
Evaluate indications and contraindications for intervention
Determine the most appropriate procedure
Monitor the patient post intervention, including complications
Long-term follow-up to evaluate device function and cardiac response
frequently provides most of the information needed, the cardiac imager must understand the limitations of this modality and utilize alternative imaging modalities (ie, transesophageal echo [TEE
], cardiac computed tomography [CT], cardiac magnetic resonance imaging [CMR
]) when some of the needed information cannot be addressed with confidence by TTE
. Although the severity of valvular disease or shunts is best assessed with TTE
, detailed anatomy and morphology is best evaluated with TEE
or CT. Furthermore, 3D imaging provides anatomic information that cannot be obtained from 2D imaging and allows for more accurate measurements of structures in all their dimensions, including perimeter, volume, area, and circumference, which is critical for the selection of the appropriate-sized devices. For the most part, 3D imaging for structural procedures can be obtained through TEE
, multislice cardiac CT, or CMR
TEE offers better spatial resolution than TTE
(structures are better seen except those in the apex of the LV) with a similarly high temporal resolution; however, it is more invasive and requires moderate sedation. TEE
‘s main contraindication is known or suspected obstructive disease of the upper gastrointestinal tract (ie, oropharyngeal, esophageal, or gastric).
TABLE 39.2 Role, Goals, and Types of Cardiac Imaging in Patients Undergoing TAVR
Assess aortic valve anatomy (TTE, TEE, or CTA)
Perform aortic annulus sizing (CTA or 3D TTE)
Determine coronary artery height and aortic root dimensions (CTA or 3D TTE)
Guide vascular access (femoral, subclavian, etc) (CTA)
Immediate post implant, including complications (TTE, TEE)
Long-term follow-up to evaluate device function and cardiac response (predischarge, 30 days, and yearly by TTE)
Paravalvular leak (TTE)
Valve hemodynamics: deterioration, stenosis (CTA, TEE if high gradients)
LV remodeling, pulmonary hypertension (TTE)
CTA, computed tomography angiography; LV, left ventricle; MR, mitral regurgitation; TAVR, transcatheter aortic valve replacement; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.
Data from Otto CM, Kumbhani DJ, Alexander KP, et al. 2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2017;69(10):1313-1346.
TABLE 39.3 Role and Goals of Cardiac Imaging in Patients Undergoing Mitral Valve Repair With Edge-To-Edge Leaflet Approximation
MR severity, need for intervention (TTE)
Determine etiology (functional, degenerative, mixed; Carpentier classification) (TTE, TEE)
Evaluate indications and contraindications for intervention (TTE)
Determine most appropriate procedure (TEE)
Mitral gradients and area, MR severity
Interatrial septal puncture and catheter guidance
Guide clip position and number to be deployed
Monitor the patient post intervention, including complications
Leaflet adverse events (single leaflet device attachment, laceration, etc)
Mitral gradients (stenosis)
Long-term follow-up to evaluate device function and cardiac response (predischarge, 30 days, every 6-12 months)
Valve hemodynamics (stenosis) and regurgitation (TTE)
Cardiac remodeling (left ventricle, atrium, pulmonary hypertension) (TTE)
MR, mitral regurgitation; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography (MitraClip©).
Data from Bonow RO, O’Gara PT, Adams DH, et al. 2020 Focused Update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2020;75(17):2236-2270.
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