Is radiation used during Transcatheter Aortic Valve Replacement (TAVR)?

Radiation Use During TAVR

Yes, radiation is routinely used during Transcatheter Aortic Valve Replacement (TAVR) procedures in the form of fluoroscopy, which is essential for proper valve positioning and deployment. 1

Fluoroscopy's Role in TAVR

Fluoroscopy provides real-time X-ray imaging that is critical throughout the TAVR procedure:

• Pre-implantation: Used to identify optimal fluoroscopic views for device deployment by placing a pigtail catheter in the noncoronary or right coronary cusp to establish a "coplanar" or coaxial view 1
• During positioning: Helps guide precise positioning of the transcatheter valve across the annulus in the predetermined coaxial annular plane 1
• During deployment: Ensures proper valve placement and expansion 1
• Post-deployment: Used to assess valve position and function 1

Radiation Exposure Considerations

The radiation exposure during TAVR has important clinical implications:

• Typical radiation dose: Median radiation dose during TAVR is approximately 1,639 mGy or 188 Gy*cm² 2

• Approach differences: Radiation exposure is significantly lower with transapical (TA) approach compared to transfemoral (TF) approach:

  • TA: 946 mGy vs. TF: 1,932 mGy 2
  • TA: 89 Gycm² vs. TF: 236 Gycm² 2
  • Fluoroscopy time: TA: 10 minutes vs. TF: 30 minutes 2

• Overall radiation exposure: For patients undergoing TAVR, the total effective dose from all related procedures (including pre-procedural imaging) averages 37.3 mSv, with only about 11% coming from the TAVR procedure itself 3

Fusion Imaging Technology

Advanced imaging techniques are being developed to enhance TAVR precision while potentially reducing radiation exposure:

• Fusion imaging: Co-registration of echocardiographic images onto fluoroscopic images is now feasible and may reduce contrast load and fluoroscopy time 1
• 3D angiographic reconstructions: Obtained by rotational C-arm fluoroscopic imaging can enhance precision 1

Facility Requirements for TAVR

To safely perform TAVR with appropriate radiation capabilities, facilities must have:

• Dedicated imaging equipment: Fixed radiographic imaging systems with flat-panel fluoroscopy, capable of cineangiography, digital subtraction angiography, and large-field image storage 1
• Adequate space: Minimum room size of 800 square feet to accommodate all necessary equipment 1
• Radiation safety: All personnel involved must receive radiation safety training 1
• Mobile C-arm inadequacy: Use of a mobile C-arm imaging system in an operating room is not adequate or acceptable for TAVR procedures 1

Patient Risk Factors for Higher Radiation Exposure

Certain factors predict increased radiation exposure during TAVR:

• Higher patient weight
• Cutdown transfemoral access (versus percutaneous)
• Higher pre-procedure creatinine and hemoglobin
• Vascular complications 4

Clinical Implications

• Cancer survivors: Patients with prior chest radiation therapy have higher all-cause mortality (29% vs. 15%) and major adverse cardiac events (57% vs. 27%) after TAVR 5
• Hybrid OR vs. Cath Lab: Procedures performed in hybrid operating rooms are associated with higher operator radiation exposure compared to catheterization labs 6

Radiation is an essential component of TAVR procedures, but continued efforts to minimize exposure through improved techniques and technology are important for both patient and operator safety.