Imaging Guidance in Transcatheter Aortic Valve Implantation (Preprocedural and Intraprocedural Imaging)

The development of transcatheter aortic valve implantation (TAVI) has revolutionized the landscape of interventional cardiology over the past 20 years. Although the TAVI procedure has evolved dramatically with the introduction of multimodality imaging planning, the redesign of novel devices, and a shift toward a minimalist approach, fluoroscopic angiography remained the bedrock of all TAVI procedures (1). Angiography is the most familiar image modality to interventionists that is readily available and simple to perform with an acceptable resolution, most notably, angiography is limited by its two-dimensional nature, with inherent shortcomings such as parallax and foreshortening, on top of radiation and contrast exposure. Thus, the history of angiography is marked by a series of refinements. However, with the introduction of multi-slice computed tomography (MSCT), modern fluoroscopic angiography has gone through a paradigm shift. On the other hand, the development of videodensitometric aortic regurgitation (AR) assessment marked another key improvement in fluoroscopic technologies. Modern fluoroscopic angiography aims to reduce procedure time and increase procedure success while minimizing complications such as acute kidney injury, paravalvular regurgitation, conduction disturbance, or valve embolization. In this chapter, we will explore angiography guidance for TAVI based on the previously described fluoroscopic anatomy with a special focus on videodensitometric AR assessment.