Zusammenfassung
Durch das Fehlen der direkten intraoperativen Sicht auf die Aortenklappe ist die „Transkatheter-Aortenklappenimplantation“ (TAVI) maßgeblich von der standardisierten und präzisen Bildgebung abhängig. Die Echokardiographie dient der eigentlichen Diagnosestellung der Aortenklappenstenose. Zur präoperativen Planung ist die Computertomographie (CT) des Herzens und der gesamten Aorta das standardmäßige Verfahren, mit dem sich alle TAVI-relevanten Informationen gewinnen lassen. Das CT ermöglicht die Bestimmungen des Anulusdurchmessers sowie der Abstände der Koronarostien zum Anulus und gibt Aufschluss über Verkalkungen der Aortenwurzel, einschließlich der Aortenklappe. Für die Planung des Zugangsweges werden im CT Femoral- und Iliakalgefäße beurteilt. Stenosen, Durchmesser und Kinking müssen berücksichtigt werden, um eine transfemorale TAVI zu planen. Die TAVI-Bildgebung hat sich in den letzten Jahren stark weiterentwickelt, v. a. in Bezug auf Software, die eine teilautomatisierte TAVI-spezifische Analyse von CT-Daten ermöglicht. Am weitesten verbreitet ist die Software 3mensio™ Structural Heart. Ebenfalls im klinischen Einsatz befinden sich HeartNavigator™ und syngo Aortic Valve Guidance™. 3mensio ist unabhängig vom Angiographiesystem und bietet Analysen von Aortenwurzel und Aorta bis in die Femoralarterien. Die beiden anderen Systeme sind mit der Angiographieanlage desselben Herstellers gekoppelt und erlauben die direkte Interaktion (z. B. Overlay). Für die Mitralklappe werden die ersten kathetergestützten Prothesen in Zulassungsstudien untersucht; auch hier ist die Bildgebung von enormer Bedeutung, v. a., da die Anatomie der Mitralklappe deutlich komplexer ist als die der Aortenklappe.
Abstract
Transcatheter aortic valve implantation (TAVI) is a closed chest procedure without a direct intraoperative view of the aortic valve. Therefore, standardized and precise imaging is mandatory. Echocardiography is used for the actual diagnosis of the aortic valve stenosis. The standard imaging technique for TAVI planning is computed tomography (CT) of the heart and the complete aorta down to the femoral arteries. This provides all relevant anatomical information for TAVI procedures. The CT enables determination of the diameter of the annulus, the distance between the coronary ostia and the annulus and gives information about the aortic root and annular calcification. The diameter of the femoral and iliac arteries, stenosis and kinking are assessed in CT and are relevant parameters for planning of the transfemoral access. Imaging in TAVI has progressed rapidly in recent years, especially in terms of semi-automatic TAVI-specific software tools for CT scan analysis. The most commonly used tool is 3mensio™ Structural Heart. Furthermore, HeartNavigator™ and syngo Aortic Valve Guidance™ are also commercially available. The 3mensio is independent of the angiography system used and enables analysis of the aortic root and aorta as far as the femoral arteries. The other software tools are linked to the corresponding angiography systems of the same manufacturer and provide direct interaction (e. g. overlay). First clinical approval trials for transcatheter mitral valve implantation are ongoing and imaging for these procedures is even more important due to the complex anatomy of the mitral valve.
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A. Van Linden ist als Berater für Siemens Healthineers tätig. T. Walther gibt an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.
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Van Linden, A., Walther, T. Bildgebung bei Transkatheter-Aortenklappenimplantation. Z Herz- Thorax- Gefäßchir 33, 231–238 (2019). https://doi.org/10.1007/s00398-018-0293-z
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DOI: https://doi.org/10.1007/s00398-018-0293-z
Schlüsselwörter
- Aortenklappenstenose
- Kalzifikation der Aortenklappe
- Dreidimensionale Bildgebung
- Computertomographie
- Mitralklappe