0:00

Next we're gonna talk about annular calcifications.

0:03

So why are annular calcifications important? Well,

0:05

it turns out that calcifications in what's considered the landing zone,

0:09

and this includes valve cusps, the annulus,

0:13

and then the area below the annulus known as the left ventricular outflow tract.

0:17

These calcifications increased risk for three things, annular rupture,

0:22

paravalvular regurgitation, and conduction block after implantation.

0:26

And these are all things obviously we really wanna avoid, uh,

0:28

as much as possible. Um,

0:31

this image on the right just shows an image of an a patient with a large, uh,

0:34

landing zone calcification. Uh, actually in this case it's, uh,

0:38

at the level of the annulus. And you can see it's this protruding, um,

0:42

calcium sitting, uh, in this sort of posterior aspect of the annulus here.

0:46

And you can imagine if you try to put a TAVR device in here,

0:49

you're gonna have a really tough time getting a nice, uh,

0:52

equal seal all the way around because the device is not gonna be able to deform,

0:56

uh, perfectly around this protruding, um, piece of calcium. So certainly,

1:00

um, just by looking at this image,

1:02

you can understand why paravalvular regurgitation for sure, uh,

1:06

would be higher risk.

1:09

So how do we evaluate and report annular calcifications? Well,

1:13

right now, um, there is no accepted, um,

1:17

quantitative way to do annular calcification, uh, evaluation.

1:21

And so we do rely on a qualitative assessment. Um, and this is, um,

1:26

an image that's taken from this reference down here in the bottom right hand

1:30

corner. This is actually a guideline statement from the, uh,

1:33

journal of Cardiovascular CT about performing, um, TAVR CT scans.

1:38

Um, and they, um, provide these images, uh, basically showing you mild,

1:42

moderate, or severe cases of annular calcification. In particular,

1:45

you can notice the severe, just like the one we saw in the previous slide,

1:49

this protruding nodule that sits in the annulus and obviously can

1:54

make a big impact on the ability of the stent to really fit in nicely,

1:59

uh, to the annulus. So you definitely wanna mention any protruding nodules,

2:03

like, like, um, you see here in the bottom, uh, right hand image. Um,

2:08

and also the location of those nodules should be mentioned because some

2:11

locations in particular below the non coronary cusp are higher risk.

2:16

Um, and then specifically if you see calcification of the valvular fibrosis,

2:21

also known as the aorta mitral continuity,

2:23

or also known as the aorta mitral curtain, if you see calcification of that,

2:28

those patients have even further increased risk.

2:31

And we'll see that in the next slide. So this is what aorta mitral continuity,

2:36

um, or curtain calcification looks like.

2:39

You have this calcification that basically comes from below the aortic valve and

2:42

the L V O T all the way into the region of the mitral valve, um,

2:47

here and here. So this really extensive calcification, again,

2:50

puts patients at higher risk, um,

2:52

for all those things that we talked about at the beginning. So if you see this,

2:56

you certainly wanna report it.