MDCT’s	
  role	
  in	
  pre-­‐cardiovascular	
  
procedure	
  planning	
  

Stephen	
  CW	
  Cheung	
  

Radiology,	
  ...
Use	
  of	
  MDCT	
  before	
  procedures
•  MDCT	
  has	
  expanding	
  and	
  increasing	
  
important	
  role	
  in	
  ...
Other	
  procedures
•  Re-­‐do	
  cardiac	
  surgery	
  
•  Closure	
  of	
  para-­‐prostheLc	
  heart	
  valve	
  leakage...
Re-­‐do	
  procedures
Re-­‐do	
  cardiovascular	
  procedures:	
  
CABG-­‐Valve
•  ReoperaLon	
  for	
  cardiac	
  condiLons	
  are	
  geQng	
  ...
Risk	
  of	
  redo	
  MVR
•  Mortality	
  quoted:	
  6-­‐18%	
  
•  Injury	
  to	
  cardiac	
  structure:	
  5-­‐10%
High	
  risk	
  findings	
  on	
  MDCT	
  include:
•  Bypass	
  grac	
  crossing	
  the	
  midline	
  <1cm	
  from	
  
post...
RV	
  dilataLon,	
  VSD,RCA	
  close	
  to	
  sternum
LIMA	
  relaLon	
  to	
  sternum/chest	
  wall
AddiLonal	
  factors	
  to	
  consider:
•  1. 	
  SVG	
  disease	
  where	
  manipulaLon	
  can	
  cause	
  
distal	
  emb...
ImplicaLon	
  on	
  operaLon
•  A	
  retrospecLve	
  study	
  conducted	
  by	
  Kamdar	
  et	
  al	
  in	
  2008	
  
show...
ImplicaLon	
  on	
  operaLon
•  Another	
  study	
  looking	
  for	
  similar	
  CT	
  features	
  
find	
  that	
  MDCT	
 ...
USG	
  to	
  measure	
  CFA/CFV
•  Ensure	
  the	
  vessels	
  are	
  of	
  adequate	
  size	
  for	
  
cannulaLon	
  in	
...
Ann	
  Thorac	
  Surg	
  2013;96:1358-­‐66
Re-­‐do	
  MVR	
  has	
  low	
  mortality,	
  morbidity	
  and	
  intraopera7ve	
  injury	
  with	
  careful	
  planning

...
Para-­‐prostheLc	
  Heart	
  Valve	
  Leak
Assessment	
  of	
  para-­‐prostheLc	
  valvular	
  
leak	
  

•  Paravalvular	
  leak	
  is	
  esLmated	
  to	
  occur	
 ...
CT	
  of	
  para-­‐prostheLc	
  valvular	
  leak	
  
•  In	
  a	
  small	
  study	
  consisted	
  of	
  20	
  paLents,	
  ...
CT	
  of	
  para-­‐prostheLc	
  
valvular	
  leak	
  
•  MDCT	
  detecLon	
  of	
  
paravalvular	
  leak	
  	
  
–  Clock-...
Paravalvular	
  leak

MV

AV
Recent	
  Case
Paravalvular	
  Leak
Paravalvular	
  leak	
  locaLon
Paravalvular	
  Leak	
  locaLon
Carlos	
  Ruiz,	
  JACC	
  2011	
  (21)
Para-­‐valvular	
  pseudoaneurysm	
  
Just	
  caudal	
  to	
  AV	
  annulus
Percutaneous	
  MV	
  Repair
Development	
  of	
  veins
Greater	
  and	
  Lesser	
  cardiac	
  venous	
  systems
•  Lesser	
  CVS	
  

–  Thebesian	
  veins,	
  common	
  at	
  v...
•  Greater	
  CVS	
  	
  
–  CS	
  and	
  non-­‐CS	
  tributaries	
  
–  Drain	
  LV,	
  part	
  of	
  RV	
  
Veins	
  of	
  LA	
  Wall
•  Septal	
  veins	
  of	
  LA	
  drain	
  into	
  
RA	
  through	
  the	
  septum	
  
•  Most	
...
Veins	
  of	
  LA	
  Wall	
  

Interatrial	
  muscle	
  connecLon
CS	
  System

AIV=	
  anterior	
  interventricular	
  vein	
  
MCV=IIV	
  (inferior	
  interventricular	
  vein)	
  
Betwe...
GCV

Usually	
  pass	
  over	
  the	
  LAD	
  and	
  	
  LCX	
  but	
  can	
  be	
  under
Assessment	
  for	
  percutaneous	
  mitral	
  valve	
  repair	
  
Indirect	
  Annuloplasty
•  Percutaneous	
  repair	
  o...
Monarc	
  
system
Viacor

CARILLON

• Coronary	
  artery	
  compression	
  
• 30%	
  
• MI
Assessment	
  for	
  percutaneous	
  mitral	
  valve	
  repair
•  The	
  course	
  of	
  the	
  lec	
  circumflex	
  artery...
Heart	
  2011:97
Assessment	
  for	
  percutaneous	
  mitral	
  valve	
  repair

Annulus	
  calcificaLon	
  
Annulus	
  size	
  
CondiLons	
...
Cardiac	
  ResynchronizaLon	
  Therapy
Semitransparent	
  volume	
  
Include	
  bony	
  landmarks	
  
Angle	
  similar	
  to	
  that	
  used	
  in	
  
fluoroscopy...
Detailed	
  mapping	
  with	
  CT
Avoid	
  placement	
  in	
  infarct	
  zone

Absence	
  of	
  a	
  vein	
  can	
  be	
  due	
  to	
  infarct	
  in	
  the	...
Measurements	
  

Angle	
  of	
  entrance	
  to	
  CS	
  and	
  size	
  of	
  osLum
Vein	
  of	
  Marshall	
  
(Oblique	
  vein	
  of	
  LA)

• 
• 
• 
• 

Persistent	
  LSVC	
  
Define	
  the	
  boundary	
  ...
Venous	
  valves
•  Can	
  hinder	
  advancement	
  of	
  guidewires/leads	
  
•  May	
  not	
  be	
  well	
  seen	
  on	
...
Thank	
  you
Thorax cardio pre procedure ct s cheung
Thorax cardio pre procedure ct s cheung
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Thorax cardio pre procedure ct s cheung

  1. 1.   MDCT’s  role  in  pre-­‐cardiovascular   procedure  planning   Stephen  CW  Cheung   Radiology,  Queen  Mary  Hospital,   Hong  Kong  
  2. 2. Use  of  MDCT  before  procedures •  MDCT  has  expanding  and  increasing   important  role  in  the  planning  of  various   endovascular  procedures.       –  PCI,  especially  complicated  lesions  and  CTO   –  TAVI   –  LAA  closure   –  Cardiac  re-­‐synchronisaLon  
  3. 3. Other  procedures •  Re-­‐do  cardiac  surgery   •  Closure  of  para-­‐prostheLc  heart  valve  leakage   •  Mitral  valve  indirect  annuloplasty.    
  4. 4. Re-­‐do  procedures
  5. 5. Re-­‐do  cardiovascular  procedures:   CABG-­‐Valve •  ReoperaLon  for  cardiac  condiLons  are  geQng   more  prevalent     –  >10%  of  all  MVR  in  US   –  CABG  seems  to  be  declining  (6%  in  2000,  3.4%  in   2009)   –  associated  with  increased  morbidity  and   mortality.       •  progression  of  disease  condiLons   •  advanced  paLent  age   •  risks  introduced  by  previous  surgery  which  can   potenLally  be  well  evaluated  by  preoperaLve  imaging   using  MDCT.
  6. 6. Risk  of  redo  MVR •  Mortality  quoted:  6-­‐18%   •  Injury  to  cardiac  structure:  5-­‐10%
  7. 7. High  risk  findings  on  MDCT  include: •  Bypass  grac  crossing  the  midline  <1cm  from   posterior  surface  of  sternum  or  fixed  to   sternum   •  Close  proximity  of  the  RV  or  adjacent   pericardium  to  the  chest  wall,  <1cm.   •  Ascending  aorta  <1cm  to  the  inner  edge  of   chest  wall  or  sternum.   •  Excessive  length  of  the  LIMA  grac  or  one  not   adequately  mobilised.  
  8. 8. RV  dilataLon,  VSD,RCA  close  to  sternum
  9. 9. LIMA  relaLon  to  sternum/chest  wall
  10. 10. AddiLonal  factors  to  consider: •  1.  SVG  disease  where  manipulaLon  can  cause   distal  embolisaLon.   •  2.  Incidental  lung  or  mediasLnal  mass,   incidence  ~10%  in  this  paLent  group.   •  3.      Evidence  of  previous  mediasLniLs  or   dense  adhesions.  
  11. 11. ImplicaLon  on  operaLon •  A  retrospecLve  study  conducted  by  Kamdar  et  al  in  2008   shows  one  or  more  of  these  features  are  observed  in  49%   of  paLents,  cohort  size=  167.    The  most  common  finding  is   finding  1,  noted  in  38%  of  paLents.       •  These  CT  findings  have  impact  on  surgical  approach,  with  7   paLents  had  the  surgery  cancelled.       •  In  88  paLents  (55%  of  the  remaining  160  paLents)  the   surgeons  adopted  some  form  of  prevenLve  measures     –  –  –  –  non-­‐midline  incision  eg.  R  thoracotomy  (n=14)     deep  hypothermic  circulatory  arrest  (n=7)     peripheral  cardiopulmonary  bypass  before  incision  (n=18)     peripheral  arterial  and  venous  dissecLon  before  incision  (n=  83).    
  12. 12. ImplicaLon  on  operaLon •  Another  study  looking  for  similar  CT  features   find  that  MDCT  before  the  operaLon  is   associated  with     –  shorter  perfusion  and  cross  clamp  Lme     –  shorter  ICU  stay       –  less  frequent  perioperaLve  MI       •  (Maluenda  et  al  2010)
  13. 13. USG  to  measure  CFA/CFV •  Ensure  the  vessels  are  of  adequate  size  for   cannulaLon  in  peripheral  cardiopulmonary   bypass  
  14. 14. Ann  Thorac  Surg  2013;96:1358-­‐66
  15. 15. Re-­‐do  MVR  has  low  mortality,  morbidity  and  intraopera7ve  injury  with  careful  planning Ann  Thorac  Surg  2013;96:1358-­‐66  
  16. 16. Para-­‐prostheLc  Heart  Valve  Leak
  17. 17. Assessment  of  para-­‐prostheLc  valvular   leak   •  Paravalvular  leak  is  esLmated  to  occur   in  3-­‐12.5%  of  prosthesis  within  a  few   years  of  operaLon.       •  With  the  large  number  of  procedures   done  every  year,  the  number  of  leaks   requiring  treatment  is  increasing.       •  With  the  advent  of  percutaneous   closure  instead  of  re-­‐operaLon,  high   quality  imaging  is  needed.       •  2D/3D  TEE  is  usually  the  main  state  of   imaging  while  CT  is  also  gaining  greater   importance-­‐  crescent  shaped
  18. 18. CT  of  para-­‐prostheLc  valvular  leak   •  In  a  small  study  consisted  of  20  paLents,  MDCT   has  been  used  to  evaluate  para-­‐prostheLc  aorLc   valve  leak  and  regurgitaLon.    Excellent   correlaLon  was  found  between  MDCT   determined  regurgitaLon  orifice  area  and   echocardiogram/surgical  findings.   •  However  beam  hardening  artefacts  are   significant  and  depend  on  type  of  prosthesis,   rendering  12  of  these  subjects  non-­‐evaluable.   –  SJM  standard    √   –  SJM  HP,  SJM  Regent    ×
  19. 19. CT  of  para-­‐prostheLc   valvular  leak   •  MDCT  detecLon  of   paravalvular  leak     –  Clock-­‐face  view   –  Surgical   •  used  as  a  guidance   during  fluoroscopy  for   passing  guidewire  and   deployment  of  vascular   plugs
  20. 20. Paravalvular  leak MV AV
  21. 21. Recent  Case
  22. 22. Paravalvular  Leak
  23. 23. Paravalvular  leak  locaLon
  24. 24. Paravalvular  Leak  locaLon
  25. 25. Carlos  Ruiz,  JACC  2011  (21)
  26. 26. Para-­‐valvular  pseudoaneurysm   Just  caudal  to  AV  annulus
  27. 27. Percutaneous  MV  Repair
  28. 28. Development  of  veins
  29. 29. Greater  and  Lesser  cardiac  venous  systems •  Lesser  CVS   –  Thebesian  veins,  common  at  ventricular  apex  and  base  of   papillary  muscles   –  Drain  most  of  RV,  LA,  RA   –  Can  be  dilated  acer  MI   –  Not  septal  defects
  30. 30. •  Greater  CVS     –  CS  and  non-­‐CS  tributaries   –  Drain  LV,  part  of  RV  
  31. 31. Veins  of  LA  Wall •  Septal  veins  of  LA  drain  into   RA  through  the  septum   •  Most  common  is  antero-­‐ superior  septum   •  They  are  not  septal  defects   or  fistulas Posteroinferior  veins Anterosuperior  veins PFO
  32. 32. Veins  of  LA  Wall   Interatrial  muscle  connecLon
  33. 33. CS  System AIV=  anterior  interventricular  vein   MCV=IIV  (inferior  interventricular  vein)   Between  AIV  and  IIV:  several  lateral  and  posterior  branches
  34. 34. GCV Usually  pass  over  the  LAD  and    LCX  but  can  be  under
  35. 35. Assessment  for  percutaneous  mitral  valve  repair   Indirect  Annuloplasty •  Percutaneous  repair  of  MV  can  be  performed   by  placing  device  inside  the  great  cardiac  vein   and  coronary  sinus  aiming  at  providing  inward   pressure  on  the  mitral  annulus  to  achieve   beser  leaflet  apposiLon.   –  Reduce  septal  lateral  dimension  
  36. 36. Monarc   system Viacor CARILLON • Coronary  artery  compression   • 30%   • MI
  37. 37. Assessment  for  percutaneous  mitral  valve  repair •  The  course  of  the  lec  circumflex  artery  and   OM  branches  are  of  potenLal  importance   since  excessive  pressure  on  these  arteries  can   result  in  ischemia.       –  GCV  and  OM   •  There  is  significant  anatomical  variaLon  in  the   cardiac  venous  anatomy  and  relaLon  of  the   coronary  sinus  to  the  mitral  annulus.   –  PTOLEMY  Trial:  9/29  subjects  excluded  
  38. 38. Heart  2011:97
  39. 39. Assessment  for  percutaneous  mitral  valve  repair Annulus  calcificaLon   Annulus  size   CondiLons  of  the  leaflets
  40. 40. Cardiac  ResynchronizaLon  Therapy
  41. 41. Semitransparent  volume   Include  bony  landmarks   Angle  similar  to  that  used  in   fluoroscopy RAO  view AP  view PACE  2009;32:323-­‐329 LAO  view
  42. 42. Detailed  mapping  with  CT
  43. 43. Avoid  placement  in  infarct  zone Absence  of  a  vein  can  be  due  to  infarct  in  the  same  region
  44. 44. Measurements   Angle  of  entrance  to  CS  and  size  of  osLum
  45. 45. Vein  of  Marshall   (Oblique  vein  of  LA) •  •  •  •  Persistent  LSVC   Define  the  boundary  of  GCV  and  CS   Seen  in  35-­‐40%  of  CT   Increased  risk  of  perforaLon  if   entered  during  CRT
  46. 46. Venous  valves •  Can  hinder  advancement  of  guidewires/leads   •  May  not  be  well  seen  on  CTA   •  Seen  as  a  depression  on  the  outer  surface   –  Thebesian  valve  at  CS  origin   –  Valve  of  Vieussens  at  CS/GCV  juncLon
  47. 47. Thank  you
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