BJR © 2019 The Authors.

Published by the British Institute of Radiology

https://doi.org/10.1259/bjr.20180707
Received: Revised: Accepted:
09 August 2018 07 January 2019 27 February 2019

Cite this article as:

Hell MM, Achenbach S. CT support of cardiac structural interventions. Br J Radiol 2019; 92: 20180707.

REVIEW ARTICLE

CT support of cardiac structural interventions

MICHAELA M HELL, MD and STEPHAN ACHENBACH, MD
Department of Cardiology, Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany

Address correspondence to: Dr Michaela M Hell

E-mail: michaela.hell@uk-erlangen.de

Abstract: to identify fluoroscopic projection angulations to opti-

Due to its high temporal and isotropic spatial resolu- mally visualize the target structure and place devices.
tion, CT has become firmly established for pre-proce- This review provides an overview of current methods
dural imaging in the context of structural heart disease and applications of pre-interventional CT to support
interventions. CT allows to very exactly measure adult cardiac interventions including transcatheter
dimensions of the target structure, CT can provide aortic valve implantation, percutaneous mitral valve
information regarding the access route and, as a very intervention, left atrial appendage occlusion and para-
valuable addition, volumetric CT data sets can be used valvular leak closure.

INTRODUCTION fluoroscopic projections to provide orthogonal visualiza-

The most frequent indication of cardiac CT imaging is to tion of the target structure without foreshortening, and
detect and rule out coronary artery stenosis.1–3 Intrave- assessment of the vascular access route. For user conve-
nous contrast is injected for the purpose of coronary lumen nience, several software solutions are offered for pre-proce-
visualization and the procedure is referred to as “coronary dural CT data analysis in structural cardiac interventions.
CT angiography” (CTA). In a broader sense, “cardiac CTA” They have been reviewed in recent publications and are not
refers to contrast-enhanced visualization of the morphology part of the current review.5
and structure of the entire heart and adjacent great vessels.
In fact, due to its high spatial resolution which is well below Although cardiac CT is a robust modality that can provide
1 mm in all orientations, contrast-enhanced cardiac CT a large amount of information for pre-procedural planning,
imaging has emerged as a valuable tool for morpholog- a potential drawback is the need for intravenous contrast
ical cardiac imaging in the past years.4 With their close to enhancement. Patients may occasionally have contraindica-
isotropic spatial resolution, modern CT scanners allow the tions for iodinated contrast. Radiation exposure is a further
reconstruction of data sets in any desired plane without potential concern and efforts must be undertaken to keep
losing the ability to visualize small structures and perform radiation dose within reasonable limits. However, many
exact measurements. patients under consideration for structural heart interven-
tions – particularly, TAVI - are of relatively high age and
radiation exposure will be of limited relevance.
In this context, pre-procedural CT imaging for transcath-
eter aortic valve implantation (TAVI) is the most frequent
General aspects of CT image acquisition for
indication, but there are numerous other interventions
which potentially benefit from cardiac CTA and are structural heart disease
discussed in the current review: these include percutaneous Specific acquisition parameters depend on the CT system
interventions of the mitral, tricuspid and pulmonary valves, that is used, but some general principles should be taken
left atrial appendage occlusion, the interventional closure into consideration:
of paravalvular leaks related to prosthetic valve replace- t
To achieve high spatial resolution, multi slice scanner
ment as well as percutaneous revascularization of coronary systems should be used that provide a reconstructed slice
chronic total occlusions. For an interventional cardiolo- width of 0.6 to 0.75 mm.
gist, there are three major aspects for which CT imaging t
Minimization of cardiac motion artefacts is achieved by
can provide valuable information when planning structural ECG-synchronized imaging, either through retrospective
cardiac interventions: precise information regarding the gating or prospective triggering. Diastolic imaging
dimensions of the target structure, information on optimal is commonly applied, timed at approximately 70%
 BJR Hell and Achenbach

of the cardiac cycle. However, in patients with high heart the diameter of the aortic annulus and not the aortic root diam-
rates and irregular rhythms, systolic imaging may be the eter that dictates the size of the prosthesis, irrespectively of the
preferred option (e.g. 250–350 ms after the R-wave peak). If inserted prosthesis type.13 Incorrect sizing of the aortic valve
necessary, the entire cardiac cycle can be covered to provide prosthesis can lead to severe complications. Prosthesis under-
both systolic and diastolic image data, albeit at the expense sizing (<10% greater than the CT-measured aortic annulus)
of increased radiation exposure. The possibility to pre-treat carries an increased risk of poor hemodynamics, paravalvular
patients with beta-blockers for rate control depends on the leak or prosthesis embolization.14,15 Oversizing, on the other
patient´s underlying cardiac disease and clinical condition. hand, can lead to incomplete expansion of the prosthesis (leading
While usually considered mandatory for coronary imaging, to both valvular and paravalvular regurgitation) or, more likely,
heart rate control does not carry the same relevance when CT to annulus rupture.16 In order to accurately assess aortic annulus
is performed in the context of structural heart interventions size, a stepwise approach is typically applied. First, double-
since image quality does not have to be as high as for coronary oblique multiplanar reconstructions are created in a plane that
artery visualization. is exactly aligned with the aortic annulus (Figure  1A,B,C).17
t
Respiration must be suspended during acquisition to avoid Once the aortic annulus plane has been obtained, three different
severe motion artefacts. Patients must therefore be thoroughly methods for determining the aortic annulus diameter have been
instructed regarding breathhold commands prior to imaging. proposed (Figure 1D,E,F): (1) calculation of the mean diameter
t
The volume of iodinated contrast should be minimized, from the long and short diameters of the oval aortic annulus, (2)
common doses are 50–100 ml. Typically, a peripheral venous planimetry of the aortic annulus area and (3) measurement of
contrast injection rate of at least 4 ml s−1 should be applied the circumference of the aortic annulus. In the latter two cases,
to achieve adequate intravascular contrast (consider 3 ml the mean diameter is calculated under the assumption that after
s−1 in patients with renal insufficiency). For pre-procedural implantation of a prosthesis, the annulus will assume full circu-
TAVI imaging, protocols with substantially lower amounts of larity while maintaining the identical area and circumference.
contrast agent have been published.6,7 Especially for area measurements, this assumption is mathemat-
ically incorrect, but not to an extent that this would influence
Transcatheter aortic valve implantation clinical practice. Interobserver comparisons have demonstrated
a moderate to excellent agreement for manual assessment of
Transcatheter aortic valve implantation has emerged as treat-
the aortic annulus size.18,19 The use of automated algorithms
ment of choice for symptomatic severe aortic stenosis in patients
with a high operative risk.8 As opposed to open heart surgery, is feasible in daily routine with accurate and reproducible
direct visualization of the target area is not available during the results.20–25 Infrequently, patients may have annulus sizes for
TAVI procedure, making pre-procedural imaging crucial for the which no suitable prostheses are currently available (e.g. diam-
success of the intervention. CT is the preferred imaging method eters less than 18 mm or greater than 31 mm).
in this context.9 CT imaging should include evaluation of aortic
root and aortic annulus dimensions, assessment of aortic valve The extent of calcification of the aortic annulus and commis-
structure and calcifications, determination of fluoroscopic sures as well as of the left ventricular outflow tract (LVOT) has
viewing angles exactly orthogonal to the aortic annulus as well as been associated with the risk of post-procedural paravalvular
analysis of the vascular access route. Measurement of the aortic aortic regurgitation which, in turn, has been shown to signifi-
valve anatomical orifice area is feasible by CT. However, echocar- cantly increase mortality in the short and long-term course.26,27
diography remains the preferred image modality to establish the Marwan et al reported a significantly higher rate of post-proce-
severity of aortic valve stenosis. dural paravalvular regurgitation in patients with annular calcifi-
cation when using a balloon-expandable prosthesis.28 Reduced
While imaging of the heart and aortic root requires ECG-syn- aortic annular flexibility, prosthesis undersizing and a shallow
chronized imaging, the aorta and ilio-femoral arteries can be position of the prosthesis frame in the LVOT have also been
imaged in a non-gated mode. Frequently, two separate data sets identified as factors increasing the rate of post-procedural para-
are acquired: A gated data set of the heart and a non-gated, much valvular regurgitation.29,30
more rapid acquisition to cover the vascular access route. Split-
ting acquisition into two different data sets can reduce radiation Coronary ostial occlusion is a severe complication after TAVI.
exposure and contrast volume (due to faster volume coverage of It has an incidence of less than 1% but is frequently fatal.31 A
the non-gated scan). When sizing the aortic annulus, dynamic short distance between the aortic annulus and the coronary ostia
changes during the cardiac cycle have to be taken into account. and a shallow sinus of Valsalva have been shown to be associated
The short-axis diameter, area, and perimeter have been shown with coronary obstruction (Figure 2).32 Risk is further increased
to exhibit a small, but significant increase in size during systole by the presence of bulky calcifications on the aortic cusps.33
compared with diastole.10,11 Therefore, diastolic compared with Using appropriately oriented multiplanar reconstructions, the
systolic measurements can result in undersizing TAVI prostheses distance from the aortic annular plane to the left and the right
in patients with large conformational changes. coronary ostium and the lengths of the native leaflets can easily
be measured.34 There is no minimum distance from the annular
The aortic annulus is a virtual, ovally shaped structure formed plane to the coronary ostia which could be considered “safe”.
by connecting the three most caudal insertion points of the Much rather, the presence of large calcifications on the aortic
aortic valve cusps (so-called “hinge points”).12 Importantly, it is valve cusps, the depth of the sinus of Valsalva, the cusp length

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Figure 1. Determination of aortic annulus dimensions in CT. (A,B) Creation of a double-oblique plane of the aortic annulus (white
bold line) containing the lowest insertion points of the right, left, and noncoronary aortic valve cusps (C, arrows). Ao, aorta; LV,
left ventricle. Three different approaches to determine aortic annulus size have been suggested: (D) From the long and short
diameters, the mean diameter can be calculated. (E) From the annulus area, the diameter can be deducted under the assumption
that this area changes to a circle when a valve is implanted. (F) From the circumference, the diameter can be derived assuming
that the circumference will stay constant during the implantation and that the annulus will achieve a perfectly circular shape after
prosthesis implantation.

Figure 2. Assessment of native valve leaflet length and coronary ostium height. (A) Routinely, the length of the native valve leaflet
and the height of the left and right coronary ostia are measured to predict possible ostial occlusion during prosthesis implanta-
tion. LM, left main coronary artery; RCA, right coronary artery. (B) Aortic root of a 82-year-old female patient showing a shallow
left sinus of Valsalva, a native left leaflet length of 13 mm and an annulus-ostium distance of 12 mm, portending a moderate risk of
ostial occlusion. (C) Subtotal stenosis of the left main coronary artery ostium after transcatheter implantation of an aortic valve
prosthesis (arrow). (D) Left main coronary artery ostium after implantation of a stent (arrow).

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Figure 3. Determination of a suitable fluoroscopic angulation. (A) Double-oblique plane at the level of the aortic valve commis-
sures. The white line corresponds to the angulation of an image plane that is orthogonal both to the aortic annulus plane and to
the commissural line between the left and noncoronary aortic valve. R, right coronary cusp; N, noncoronary cusp; L, left coronary
cusp. (B) The predicted angulation (LAO 2°/caudal 7°) was used during the TAVI procedure as C-arm angulation for the first aor-
togram. (C) Final angiogram with the implanted TAVI prosthesis.

and the ostium-annulus distance on the one hand, versus the imaging guidance, the technique of transcatheter mitral valve
operative risk on the other hand have to be considered for the implantation (TMVI) has been further developed.46–50 Given
final decision to undergo TAVI in the individual patient. the complex problems of mitral valve interventions listed above,
pre-procedural CT imaging for TMVI must address anatom-
Of critical importance for the catheter-based implantation of ical assessment and measurement of the mitral valvular and
bioprosthetic aortic valves is the identification of a fluoroscopic sub valvular apparatus, assessment of annular calcification,
projection that provides an exactly orthogonal visualization of prediction of LVOT obstruction, investigation of mitral regur-
the aortic valve plane. Suitable views can be determined intra gitation aetiology and prediction of an orthogonal fluoroscopic
procedurally by repeated angiograms but this may be time-con- angulation.
suming and requires repeated contrast injections.35 CT data
sets can be used to identify suitable projections that provide Assessment of the mitral valvular and sub valvular apparatus
an orthogonal view on the aortic valve plane with a significant using 2D imaging has been shown to over simplify the complex
reduction in contrast agent volume required during the TAVI 3D geometry. Hence, 3D segmentation of the mitral annulus
procedure compared to a conventional approach (Figure 3).36–39 should be favored.42 Measurement of leaflet lengths and angula-
The slightly different position of the patient between CT acquisi- tions using thin-section multiplanar reconstruction images has
tion and the TAVI procedure causes no noticeable problem. been demonstrated to provide good correlation with 3D transe-
sophageal echocardiography.51 To best account for the needs of
Percutaneous mitral valve interventions TMVI, a D-shaped model of the mitral annulus involving trun-
Mitral regurgitation is the second most common valvular cation of the saddle-shaped mitral annular contour at a virtual
disease in adult patients.8 Approximately 20% of patients with interconnecting line between both fibrous trigones (the trigone-
heart failure and 12% of patients with previous myocardial to-trigone distance) has been introduced.52 From this model, the
infarction suffer from at least moderate mitral regurgitation.40,41 annular area and perimeter can readily be derived.
While the aortic valve anatomy is well suited for the percuta-
neous implantation of tubular prostheses, the mitral valve has A relevant procedural complication of transcatheter-based
a complex saddle-shaped structure with a non-planar annulus, implantation of a prosthetic valve in mitral position is the
an anterior and posterior peak, a complex subvalvular apparatus obstruction of the LVOT due to the elongation of the outflow
and highly variable anatomy.42 The mitral valve further lacks a tract by the implanted device, previously described as
circular, fibrous annular structure to support a prosthesis and is “neo-LVOT”.53 Patient-specific, CT-based virtual, stereolitho-
in close proximity to the LVOT. Simply transferring the TAVI graphic device simulation as well as 3D-printing approaches
implantation technique for treating mitral regurgitation is not have been suggested to allow pre-procedural identification of
an option, so that several percutaneous repair devices have patients which are at an increased anatomical risk for a narrow
been developed. The MitraClip® device is the most frequently neo-LVOT.54Identification of mitral valve prolapse has been
used method.43,44 Based on the principle of surgical edge-to- shown to be highly accurate in comparison to traditional echo-
edge mitral valve repair, the MitraClip® device clamps and cardiographic imaging.55 Further characteristics of mitral valve
converges the anterior and posterior leaflets thereby reducing prolapse, including myxomatous and degenerative leaflets and
the grade of regurgitation. However, effectiveness is inferior to disjunction between the posterior mitral valve leaflet insertion
surgical mitral valve repair.45 Recently, supported by advanced and the atrioventricular junction, can also be identified.

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Figure 4. Caseous Mitral Annular Calcification. Caseous mitral annular calcification (arrows). (A) Density within the liquefied core
is typically similar to contrast enhanced blood. (B) Hence, an additional non-enhanced acquisition is highly useful to identify this
condition.

Degenerative mitral annular calcification, commonly found in risk. Implantation of transcatheter valves into the caval veins,
the elderly population, is most frequently located at the poste- so-called heterotopic transcatheter valve implantation, requires
rior rim but its extent can vary from mild localized to exuberant the measurement of caval vein diameters at the cavoatrial junc-
circumferential involvement.56 A rare variation of mitral annular tion for device sizing and the assessment of the distance between
calcification is caseous annular calcification, most frequently the inferior cavoatrial junction to the first hepatic vein in order to
found along the posterior rim. Caseous mitral annular calcifi- avoid vein obstruction by the device.59 For transcatheter tricuspid
cation is typically a large-volume, tumor-like lesion which can annuloplasty, evaluation of the course of the right coronary artery
be easily detected by CT (while difficult to judge by echocardi- along the atrioventricular groove and the distance to the tricuspid
ography). Cases of spontaneous regression of the caseous calci- annulus is crucial to avoid impingement during implantation of
fication have been reported.57 The density within caseous mitral the suture pledgets and anchoring systems.62 Preprocedural CT
calcification can be similar to the contrast-enhanced blood imaging for implantation of a spacer device, designed to reduce
pool, so that combined visualization with contrast-enhanced the leaflet coaptation gap caused by tricuspid annular dilatation
and non-contrast images may be required (Figure  4).57,58 The and leaflet tethering, includes the measurement of the tricuspid
identification of caseous annular calcification is of importance valve annulus and right ventricular dimensions, the distance from
as it may interfere with the apposition of self-expandable TMVI the tricuspid annulus plane to the right ventricular septal free wall
systems.42 groove as well as the luminal diameters of the left subclavian and
axillary veins.59 When transcatheter valve implantation into a
Similar to TAVI, pre-procedural CT allows the prediction of surgically placed ring or prosthesis is considered, the valve size
suitable C-arm angulations orthogonal to the mitral annulus for can be selected based on the sewing ring’s nominal size or on the
the TMVI procedure. Due to a relatively vertical orientation of measurements of the reconstructed CT cross-sectional views of
the mitral annulus, very cranio-caudal angulations have been the tricuspid valve prosthesis or ring.59
described to be necessary.56
Whereas transcatheter pulmonary valve replacement has revo-
Transcatheter valve interventions of the right heart lutionized pediatric cardiology by using a catheter-based rather
With the success of transcatheter therapies for aortic and mitral than surgical approach in many congenital heart disease patients,
valve disease, percutaneous treatments have subsequently been it plays only a minor role in adult cardiology. As radiation may
developed for severe tricuspid regurgitation.59 Tricuspid valve be an issue for this predominately young patient cohort, echo-
anatomy and its relationships with surrounding structures, the cardiography and cardiac magnetic resonance tomography are
aetiology and severity of regurgitation, right ventricular anatomy the common imaging modalities used for procedure planning.63
and function are key aspects to assess in patients considered Valve anatomy, right ventricular outflow tract dimensions and
for transcatheter tricuspid valve therapy. CT has been shown to the distance of the coronary arteries from the outflow tract are
accurately assess tricuspid annulus geometry and dimensions.60 important parameters to be assessed preprocedurally.64
For measurements of the right ventricle, an excellent correlation
with cardiac MRI has been demonstrated.61 Depending on the Left atrial appendage occlusion
type of interventional device used, specific anatomical aspects The left atrial appendage (LAA) is the origin of thrombus forma-
have to be assessed preprocedurally to minimize complication tion in about 90% of patients who develop atrial thrombi in the

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context of atrial fibrillation.65 LAA morphology is highly vari- In order to measure LAA dimensions using two-dimensional
able. Four main configurations have been described (”chicken (2D) CT images, oblique views are superior over orthogonal
wing”, “windsock”, “cauliflower”, and “cactus”), with the “chicken views in the horizontal, coronal, and sagittal plane, since they
wing” morphology reported to have the lowest risk for thrombus better account for the typically elliptical shape of the LAA
formation.66 Occlusion of the LAA provides effective stroke orifice.66 While 3-dimensional CT reconstructions may offer a
prevention and is clinically used in patients with a high bleeding more comprehensive visualization of the LAA, superiority in
risk on anticoagulation therapy.65 Several percutaneous LAA sizing over 2D oblique imaging could not be demonstrated.66
closure devices have been developed (with the WATCHMANTM The LAA orifice is defined as the plane connecting the pulmo-
device the only one to have FDA approval).67,68 Correct sizing nary vein ridge superiorly to the inferior junction of the left
of the LAA is crucial for successful and safe device implanta- atrium and the LAA at the level of the circumflex artery.74 An
tion. Serious complications have been reported in 4% of cases important aspect to take into consideration is the fact that the
and include hemodynamically relevant pericardial effusion, “landing zone” of the occlusion device varies between different
severe bleeding, device embolization or stroke.69 Pre-procedural occluder types72,74: The WATCHMANTM device is placed
imaging is commonly limited to transesophageal echocardiog- approximately 10–20 mm distal to the LAA ostium (Figure 6).
raphy but some operators also use CT. CT analysis, in this case, As the sheath-constrained length of the WATCHMANTM device
includes reporting of LAA ostial diameters and LAA depth, is very similar to its unconstrained diameter once deployed,
LAA morphology including the number of lobes, as well as the the length of the appendage along a clear line of sight from the
assessment of the anatomic relation to surrounding structures proposed landing zone should be at least as long as the diam-
(pulmonary veins, mitral annulus, left circumflex artery) for eter of the device selected.72 The AMPLATZER Amulet device,
possible interference with the deployed occluder. LAA dimen- consisting of a self-expanding nitinol mesh forming a lobe and
sions are highly dependent on the patient´s volume status. It is disk, is implanted with the lobe anchoring approximately 10 mm
therefore recommended to hydrate the patient before imaging inside of the LAA orifice.75
(usually 500–1000 ml saline solution) in order to achieve
comparable filling conditions to the implantation procedure Periprocedural guidance by transesopheagal echocardiography
is common. However, one has to be aware that underestimation
(left atrial pressure >12 mmHg).70 As LAA occlusion devices
of the LAA ostium diameter by 2D-transesopheagal echocardi-
are delivered transvenously and through the interatrial septum,
ography compared to CT-based measurements can easily occur
identification of atrial septal aneurysms and of septal lipoma-
if the plane is not exactly aligned with the largest diameter of the
tous hypertrophy is important. The presence of thrombi in the
LAA orifice.76
LAA must be reported.71,72 It should be noted that filling of the
LAA with contrast is often incomplete, potentially mimicking
the presence of a thrombus. A delayed second acquisition 60 sec Paravalvular leak occlusion
after the initial contrast bolus may therefore be useful in order Paravalvular leaks are a common complication of surgical (inci-
to identify thrombi. The method has been reported to have dence of relevant leak: 2–18%) and interventional prosthetic
100% sensitivity and 99% specificity for LAA thrombus detec- valve replacement (11–12%) and are associated with increased
tion (Figure 5).73 mortality.77–81 Aortic paravalvular leaks are most commonly

Figure 5. Detection of left atrial appendage thrombus by CT angiography. (A) First pass CT angiogram demonstrating a filling
defect (white arrow) in the left atrial appendage suggestive of a thrombus. (B) Delayed phase CT angiogram acquired 60 sec after
contrast application confirms the presence of a thrombus (white arrow).

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Figure 6. Measurement of left atrial appendage ostium. (A) The plane of the LAA orifice is formed by the pulmonary vein ridge
superiorly to the inferior junction of the left atrium and the LAA at the level of the circumflex artery. In a transaxial plane, the
left circumflex coronary artery is identified (white arrow). Perpendicular to the left circumflex (white line), an oblique section is
created which produces a vertical long-axis view of the heart (B) with the left circumflex coronary artery (white arrow) displayed
in cross-section below the left atrial appendage (LAA) ostium. (C) Depending on the applied device system, the landing zone
of the occluder varies. For a WATCHMANTM occluder, the plane of implantation is identified approximately 10–20 mm (*, here 15
mm) from the ostium (dashed lined) and measured between the left circumflex coronary artery and the edge of the landing zone
(blue line). (D) Short axis of the plane of implantation for measurement of minimum (20 mm) and maximum (25 mm) diameter
predicting a 27 mm WATCHMANTM occluder. (E) Imaging of the implanted 27 mm WATCHMANTM occluder.

located at the noncoronary cusp, while mitral paravalvular leaks An acquisition covering the entire R-R-interval can demonstrate
are typically found in an anterolateral/posteromedial location.82 valve dehiscence with excess valve motion, to allow assessment
The lesser degree of invasiveness and convincing success rates of mechanical valve leaflet motion, and to reduce the risk for
favor a transcatheter approach for closure, with surgical repair inaccurate assessment of a potential paravalvular leak tract.86 For
being reserved for excessively large paravalvular leaks, contra- differentiation between contrast continuity and pledgets placed
indications to transcatheter closure, and unsuccessful proce- during surgery, an additional non-contrast scan should usually
dures.83–85 Echocardiography is used to initially identify the be considered. When assessing the image, adequate windowing
presence and hemodynamic severity of paravalvular leaks but it
is essential, a very soft window has been suggested to minimize
can be difficult to assess the exact location, size and course of
beam hardening in prosthetic valves.89 Based on our experience,
the sometimes serpiginous leaks. CT angiography can provide
we start with the set up window 1500 HU and center 400 HU
detailed information on the exact location and morphological
characteristics of paravalvular leaks including size, course and with subsequent windowing adjustments (Figure  7A). The CT
shape as well as the presence of multiple communications.86 Since orientation for identifying the location of a paravalvular leak is
metal components of the valve prosthesis can cause beam hard- demonstrated in Figure 7B–H. To report the location of the para-
ening artifacts, it is crucial to minimize motion artefacts during valvular leak, it has been recommended to use the simple trian-
acquisition. It is therefore recommended to maximize image gulation method based on anatomic relationships of the atrial
quality by using beta-blockers for heart rate control and to revert septum, LAA, and aortic valve with anatomically correct termi-
to systolic acquisition if heart rates remain >65 beats/min.87,88 nology (anterior vs posterior, superior vs inferior and lateral vs

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Figure 7. (A) Paravalvular leak (arrow) in a patient with a prosthetic aortic valve. Windowing is set to window 1500 HU and center
400 HU to minimize beam hardening effects. (B-H) A 53-year-old male patient with a paravalvular leak 8 months after biopros-
thetic aortic valve replacement. (B,C,D) Pre-procedural CT angiography shows the presence of a paravalvular leak (white arrow)
between the aortic valve prosthesis (Edwards CE Perimount 23 mm) and the noncoronary cusp. (E) CT-derived measurement in a
double oblique plane revealed a 0.48 × 0.73 cm leak. The purple line corresponds to the desired plane in (F) which is orthogonal
to the prosthetic valve plane (RAO 14°/caudal 6°) and was used during the implantation procedure for C-arm angulation (G). (G)
Invasive angiogram of the implanted 7 mm occluder (Ductus arteriosus occluder Hyperion PDA-I 07) (white arrow) in RAO 14° and
caudal 6° angulation. (H) Device enhancement imaging of the implanted occluder (white arrow).

medial).86,90 Furthermore, assessment of the shape and size of failed PCI,98 assigning one point for each parameter and adding
the leak may be helpful for device selection. them per CTO lesion. The likelihood of successful guidewire
crossing within 30 min ranges from 95% for a CT-RECTOR score
of 0 to 22% for a score of 3.
Percutaneous revascularization of coronary chronic
total occlusions Furthermore, the CTO intervention itself may be facilitated
A coronary total occlusion (CTO) is defined as a coronary artery by coronary CTA. Higher CTO intervention success rates in
with complete interruption of the antegrade blood flow exceeding 3 comparison to non-CTA guidance have been reported when CTA
months duration as proven by prior angiography or estimated from datasets were directly imported to the catheterization laboratory
the clinical course.91 Percutaneous revascularization of CTOs is with the possibility of automatic alignment according to the
recommended in patients with angina resistant to medical therapy angulation of the C-arm.99 CT guidance by real-time automated
or with a large area of documented ischaemia in the territory of the co-registration of coronary CTA centreline and calcification onto
occluded vessel.92 However, it is a technically challenging procedure live fluoroscopic images has been shown to be feasible.100
with only moderate success rates which is complicated by the fact
that visualization of the anatomic and morphological features of CONCLUSION
the occluded segment in invasive angiography is incomplete.93 For In summary, CT is an increasingly important imaging tool for the
this reason, coronary CTA can be particulary advantageous adjunct expanding field of structural cardiac disease interventions. Current
to invasive angiography for the visualization of long and tortuous indications for pre-procedural CT imaging in cardiac interven-
CTO lesions, the detection of multiple occlusion sites and ostial tional procedures include transcatheter aortic valve implantation,
occlusions and when the distal CTO segment cannot be visualized percutaneous interventions of the mitral, tricuspid and pulmonary
in invasive angiography.94–97 Scores such as the CT-RECTOR score valves, LAA occlusion, paravalvular leak occlusion as well as percu-
permit prediction of procedural success rates. The CT-RECTOR taneous revascularization of coronary chronic total occlusions. The
score includes 6 CTA-based and clinical parameters: the presence most important information CT can provide concerns the access
of multiple occlusions, a blunt stump, severe calcification, bending route, measurement of dimensions of the target structure and iden-
of the occluded segment, a CTO age ≥12 months, and previously tification of an optimal viewing angulation.

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