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In this case,

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we're gonna review a case of hypo attenuating leaflet thrombosis after

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TAVR or halt and just talk about some of the typical imaging findings.

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So I'm gonna start with the axial slices here. And as you scroll first,

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you're gonna see that this patient for sure has a TAVR device, right?

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You can see the struts. And then as you head down inferiorly,

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you can see the leaflets on this TAVR device.

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And you can see this really low attenuation stuffed, which is,

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um, sitting in the expected location of the leaflets.

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So that's your hypo attenuated leaflet thickening. Now on the axial images,

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it's kind of hard to tell exactly how much thickening there is,

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so we're certainly gonna rely on the multiplanar images for better definition

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of what's going on. So as before,

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it's really best to start with these cornal images. And

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what you can do is you can reorient your plane so that you're aligned with

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parallel to the aortic valve.

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This is gonna give you another long axis image here

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and your short axis image here.

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So what you do is you first can assess the extent of

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le thickening with the long axis images. So in this case, you know,

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it's zero to 25, 25 to 50. You know,

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we go by quartiles and in this case I'd say

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it's at least around 75% of this leaflet is occupied by thrombus.

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And so you can go through that leaflet by leaflet.

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In this case we were looking at,

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it looks like this is the right coronary cusp here.

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That's this leaflet posteriorly. That one doesn't look quite as bad.

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Actually, I take that back. There's still a fair bit of, uh, thrombus. So, um,

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similarly, somewhere in that 75% range. There you go.

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And then opposite to that, if you look and cross correlate,

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it looks like we're looking actually at the left coronary cusp here,

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based on the location of this pink line here, which defines this plane.

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So that's about 75% as well. And then if we're looking at the, um,

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additional purple plane, which is the non coronary cusp, uh, you know,

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maybe that's a little more like 50% that you can see. Uh,

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actually I take that back. I think it's probably still about about 75% or so.

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So that's how much of the leaflet's involved by the halts.

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And then the next question is, what about the restriction of motion?

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So right now we're in the diastolic phase,

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so you want to get yourself into the systolic phase.

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So I'm gonna hit the play button and we're gonna just first watch what happens

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and as we're going through the cardiac cycle,

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and you can see you definitely get a lot of artifact as

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the device is moving through the cardiac site hold because of

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Just motion related blur.

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See if we center ourselves on the device, again, centered on it,

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now we can look at all the different planes and try to figure out what's maximal

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point of opening. And, uh, systole, um, in this case,

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you wanna look for the spot where the, uh,

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ventricles really squeezed down tight and the leaflets seem

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to open up to the greatest degree. So we're heading into assistly.

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Um, now right about there

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maximal leaflet opening. It's gonna be right around these phases here.

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So I scroll downwards through, uh, images here in the bottom,

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uh, right hand corner.

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I can just page through the different phases and see where I find

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the maximum degree of opening. So in this case, we're,

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um, you can't see the numbers, but we're about 30% phase.

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And then now we're moving backwards in the cardiac cycle.

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And now we're at around the 25% phase.

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And that's actually around the 20% phase,

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which we know is usually around peak system.

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And I think this is where we see a good degree of leaflet opening.

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And I'll just check, uh, 15 to see if that's any different.

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Looks pretty similar. And same with 10 as well.

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So I think any of those phases really is probably gonna be, um, safe to use.

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We've got a fair bit of motion related artifact on this 10% phase.

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So I'm gonna skip ahead to 20 and then we can measure the

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relative leaflet opening. Um, we'll just do it for one leaflet.

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And the way you do that is you select your distance measurement tool.

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You find where you see the most distortion of the leaflet from the

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thrombus.

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You measure the maximal distance across the valve of that

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level. That's 21. You divide that by two.

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So 10 and a half you do a secondary measurement from the

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tip of that leaflet filled with the thrombus to the wall, you get six.

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And so then our degree of leaflet restriction is going to be

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six over 10 and a half, or you know, six over 10, which is roughly 60%.

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So that would fall into the, the moderate range.

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So that's your roughly your approach to evaluating patients for hypo attenuating

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leaflet that can.