MRI evaluation prior to Transcatheter Aortic Valve Implantation (TAVI): When to acquire and how to interpret

Non-contrast MRI is a noninvasive and radiation free diagnostic test that can provide critical pre-TAVI planning information and, thus, replace the use of pre-procedure invasive angiography or CTA. Advantages of MR include the ability to provide both anatomic (annular diameters, perimeter, area) measurements and quantify aortic valve stenosis (flow volumes, peak velocities) with high accuracy [10]. Recent studies have demonstrated that the information gained from both MRI and ECG-gated CTA in the pre-operative assessment of patients undergoing TAVI is reproducible [3, 7, 11‐13]. MRI provides numerically similar measurements in terms of annulus size, left ventricular outflow tract (LVOT), and aortic valve area when compared to TTE [11]. MRI can also provide anatomic assessment of the aortic valve for identifying congenital valvular abnormalities, visualization of cardiac structure & function, and identification of atherosclerotic plaque, aneurysm, or dissection in the ascending aorta.

As the number of TAVI procedures increases, there will also be an increase in the number of patients who cannot be optimally evaluated with CTA, echocardiography, or stress echocardiography. Thus, non-contrast MR may have an important role in preoperative evaluation in the following groups of patients:

Post-gadolinium delayed enhanced imaging has been used to assess the severity of coronary artery disease in patients undergoing TAVI, and it has been demonstrated that there is decreased LVEF recovery after TAVI in the presence of significant delayed enhancement prior to TAVI [15]. Use of Gadolinium however is contraindicated in patients with poor renal function. Gadolinium enhanced MRI is not necessary for the preoperative measurements for TAVI.

Advantages of MRI as compared to CT or catheter angiography include: noninvasive and radiation-free imaging modality, anatomic assessment of the aortic valve for identifying congenital valvular abnormalities, performing planimetry to calculate aortic valve area, visualization of cardiac structures, characterization of the ventricular mass and function, identifying atherosclerotic plaque, aneurysm, or dissection in the ascending aorta. The type and number of available transcatheter aortic valve have evolved and increased over time. Identifying the optimal device and appropriate approach to implant depends on a number of critical measurements.

Although there are publications reviewing the usefulness of MRI, both before and after implantation, for the evaluation of TAVI, these have mostly focused on only a few aspects of the increasingly complex and comprehensive assessment needed for complete assessment prior to TAVI. This article is based on our experience of patients who underwent both contrast enhanced ECG-gated CTA and non-contrast MRI for preoperative assessment for TAVI. It provides a comprehensive review of the key measurements for the pre TAVI assessment as reported on CTA (Tables 1 and 2), most useful acquisition sequences on a 1.5 T MR scanner (Table 3), and the imaging parameters (Table 4) used for these sequences at our institution.

The aortic annulus is a virtual ring formed by connecting the basal hinge points of the aortic valve leaflets. The annulus is not a distinct histological entity or anatomical boundary, but represents the smallest diameter in the blood path between the left ventricle and aorta and represents the position for the implanted prosthetic valve [16] (Fig. 1). Bright blood (SSFP = steady state free precession) aortic root cine stack of 8–10 slices from diastole to systole is acquired parallel to the valve plane (Movie 1). This plane can be prescribed by planning the acquisition perpendicular to the direction of flow in aortic sinus on these two planes: coronal aorta and left ventricle outflow tract (Fig. 2a, b, respectively). This plane is similar to the suggested plane for performing planimetric assessment of the aortic orifice [11, 13, 17] as well as for performing 2-D phase contrast MRI measurements of aortic flow. Obtaining such a plane ensures that annular area and diameter measurements are obtained perpendicular to the axis of blood flow in LVOT and aorta as has been described for aortic measurements. As there is systolic descent of the annular plane, this acquisition should always begin in the left ventricle outflow tract. The annular plane is identified by the end systolic image below the insertion of leaflets by scrolling through this cine stack (Fig. 2c). This slice is used for assessing the minor & major diameters, area, and perimeter of the annulus. Annular diameters can also be obtained from a navigator-assisted free breathing diastolic phase 3-D SSFP sequence [3]. Non-contrast 3-D-FLASH MRA has been proposed to obtain diastolic annular dimensions, and using a correction factor based on systolic measurements from CTA in the same patients, a systolic corrected annular dimension can be obtained [18]. Measurement of the annulus is important for correct selection of prosthesis size, type, and to avoid damage of the annulus if the valve is oversized and avoid paravalvular regurgitation if the valve is undersized. Measurements including and excluding calcification are provided. Accurate measurement of heavily calcified annulus remains challenging, and the best method to measure such an annulus has not been determined. In our practice, on both CTA and MRI, heavily calcified annulus area and diameters are measured by including and excluding the calcification. In one study, using an in vivo model of calcium containing rings, MRI measurements have been demonstrated to be the most accurate for assessing the actual dimensions compared to CT or 3-D echocardiography [19]. When there is still uncertainty, measurements obtained by CTA/MRI are compared to annular sizing by calibrated balloon aortic valvuloplasty [20, 21]. The degree of annular calcification can also be assessed with MRI; however, how well this assessment is compared to CT is not known. In our experience, a change in signal intensity of the aortic wall should be sought as the presence of calcification leads to a darker interface on SSFP sequences (Fig. 3).

Protruding annular calcifications > 4 mm and adherent calcification >6 mm (particularly left-sided) or calcifications with an Agatston score of > 3000 [22] are important predictors of paravalvular leaks after TAVI [23]. Comparative CT and MRI studies of heavily calcified annulus and aortic plaques have not been done. In our experience, on MRI, measurement should be obtained from the outer edge to the outer edge. In case of suspected porcelain aorta, a non-contrast CT should be obtained to better characterize the degree and extent of calcification. Evaluation of this aortic root cine stack also helps identify nodular thickening in the valve leaflets, annulus, LVOT, and for the presence of aortomitral continuity calcification/thickening (Fig. 2).

The distance from the annulus to the coronary ostia is of importance to prevent occlusion of the coronary arteries by the displacement of the native aortic valve leaflets by the prosthesis. Risk of coronary ostia occlusion is less with the CoreValve prosthesis than with the Edwards Sapien prosthesis. For the latter, minimum distance values of 10–14 mm between the coronary ostia and leaflet insertion are usually suggested. A 3-D SSFP free breathing stack obtained in late diastole with a respiratory navigator can be used to assess the height of coronary ostia from the annular plane (Fig. 3a-b, c-d: comparative images from CTA in same patient).

Detailed anatomic assessment of the aortic valve can distinguish tricuspid vs. bicuspid, or the quadricuspid valve. TAVI has been successfully performed in selected high-risk patients with severe bicuspid aortic valve stenosis [24]. The severity of aortic stenosis is mostly quantified by transthoracic or transesophageal echocardiogram. In patients with low flow and low gradient but clinically suspected severe stenosis, dobutamine stress TTE is used to augment flow and unmask severe stenosis. Stress TTE may be contraindicated in some patients (Appendix A). Aortic stenosis can be quantified on MRI by different methods. Planimetry of maximal visible valve opening in systole on MRI (Fig. 4) correlate well with planimetry measurements obtained on CT [7, 11, 17]. Severe aortic stenosis is suggested when the aortic valve area is <1 cm². The valve leaflets can be evaluated on the 2-D ECG-gated SSFP images (Fig. 5). Stenosis calculation based on the Hakki formula (aortic valve area = cardiac flow/√maximum gradient) correlate well with measurements obtained from echocardiography [25]. In addition, the velocity ratio based on peak velocity in the LVOT and aortic sinuses can also be calculated from two separate 2-D phase contrast MR acquisitions. A velocity ratio of < 0.25 is compatible with severe stenosis.

Measurements of the sinus of valsalva diameters and height are critical for proper positioning of the device to ensure that there is no infringement of the coronary ostia (Tables 1 and 2). Sinus diameter and height measurement can be obtained from breath held or free breathing SSFP sequences (Fig. 5 a-c, e-f: comparable measurements in the same patient from CTA). Sinotubular junction height is critical for proper positioning of the device and verifying no infringement on coronary ostia especially for CoreValve. Susceptibility artefacts can limit evaluation of SSFP sequences in patients who have implantable devices or sternal wires from prior thoracic surgery. In these cases, additional non-fat suppressed T2 black blood images (coronal plane prescribed to aorta for left, and sagittal plane for right coronary artery) can be used to identify sinus diameter, height, etc.

Aortic root orientation is critical for precise positioning of the device, in particular for the CoreValve. Inappropriate alignment is associated with post-procedural complications such as device malposition or distal embolization. Root angulation can be measured on coronal non-gated SSFP MRI in relation to body axis For example, if the root angle > 30°, a subclavian arterial approach cannot be used for CoreValve implantation [26].

Assessment of the thoracic aorta for plaque burden is important. MRI is not optimal for assessment of aortic calcifications [9]. On MRI, calcifications would lead to signal voids and, hence, appear dark. Silveresa et al., studied carotid and femoral artery plaques using MRI and FDG-PETCT and demonstrated complementary values of these modalities. In this study, lipid-rich plaques were more inflamed than either calcified or collagen-rich plaques. For MRI, they measured the plaque using T2 weighted sequence [27]. Noncalcified atherosclerotic plaque burden of the thoracic aorta may increase the risk for acute renal injury post valve implantation. Aortic wall thickness that exceeded ≥ 2 mm is defined as a diseased segment [28]. Assessment of plaque thickness between echocardiography and CTA is good [29]. Noninvasive MRI also compares well with TEE for the assessment of atherosclerotic plaque thickness, extent, and composition [30]. Although there are no comparative studies evaluating CT and MRI for thickness of the aortic plaque, plaque thickness should be noted and measured using suggested comparative studies, i.e., distance between the aortic border and the point of greatest luminal protrusion [30].

In addition, evaluating the tubular ascending aorta for any aneurysm or ectasia is important for implanting a CoreValve. Heights of the Edwards Sapien prostheses are between 15–19 mm, and they do not extend beyond the aortic sinus; however, the height of the CoreValve is between 52–55 mm, and these valves extend into the tubular ascending aorta. Therefore, aortic diameter is measured for these at a distance of 40 mm from the valve plane. Significant aneurysmal dilatation is considered a contraindication for TAVI using this device [21]. All measurements of aortic diameter should be obtained perpendicular to the axis of blood flow [31].

The direct transaortic approach is considered as an alternative endovascular access site in patients with unsuitable iliofemoral anatomy. Measurement of the distance from the ascending aorta access site to the skin and valve plane can be performed using axial non-gated SSFP MRI. A favourable puncture site is at the greater curve, typically the right lateral side of aorta with the following criteria: absence of calcification, atheroma, thrombi, and dissection flap or previous surgery [32]. The minimal distance from the aortic annulus to this access site needs to be at least 5 cm. This access site needs to be at least 1 cm distal to coronary venous grafts or foreign bodies (Fig. 6). The relation of the ascending aorta to the sternum helps in identifying the surgical approach. A mini J sternotomy is preferred if the ascending aorta is in midline or toward the left and >6 cm deep to the sternum. A mini right thoracotomy is preferred if the ascending aorta is right sided (>50 % of the aorta is present on the right of the sternal boarder) at the level of the second intercostal space and is <6 cm deep to the sternum [32]. How well are the calcified plaques or porcelain aorta assessed with MRI compared to CT is not known. Presence of calcification may cause loss of signal in the aortic wall (Fig. 3). When porcelain aorta is suspected, a non-contrast CT may be obtained for better evaluation.

The transapical approach is considered as an alternative access site option for balloon expandable transcatheter valves in patients with unsuitable iliofemoral, subclavian, or aortic anatomy. The left ventricle (LV) apex is evaluated for scar/prior infarct and thrombus. Measurements of the LV apex from the sternum and skin surface can be performed using axial non-gated SSFP MRI similar to CTA (Fig. 7). Advantages of the transapical approach compared to a transfemoral approach include more reliable coaxial alignment of the transcatheter valve with the aortic annulus and greater ability to control delivery of the valve [33].

Aortic regurgitation (AR) is the most frequent post-procedural complication after TAVI and is linked to adverse outcomes and mortality. MRI is another quantitative imaging modality that can be used to assess aortic regurgitation after valve implantation. Transthoracic echocardiography displays higher variability and significantly underestimates AV annulus size and underestimates AR when compared to MRI [34, 35]. Compared to echocardiography, quantitative measurement of AR by MRI demonstrates better correlation with quantitative assessment by angiography [36]. MRI may be the modality of choice when there is discordance in grading AR by echocardiography [37].