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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 Thorax cardio pre procedure ct s cheung Presentation Transcript

    •   MDCT’s  role  in  pre-­‐cardiovascular   procedure  planning   Stephen  CW  Cheung   Radiology,  Queen  Mary  Hospital,   Hong  Kong  
    • 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  
    • Other  procedures •  Re-­‐do  cardiac  surgery   •  Closure  of  para-­‐prostheLc  heart  valve  leakage   •  Mitral  valve  indirect  annuloplasty.    
    • Re-­‐do  procedures
    • 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.
    • 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   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.  
    • 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  embolisaLon.   •  2.  Incidental  lung  or  mediasLnal  mass,   incidence  ~10%  in  this  paLent  group.   •  3.      Evidence  of  previous  mediasLniLs  or   dense  adhesions.  
    • 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).    
    • 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)
    • USG  to  measure  CFA/CFV •  Ensure  the  vessels  are  of  adequate  size  for   cannulaLon  in  peripheral  cardiopulmonary   bypass  
    • Ann  Thorac  Surg  2013;96:1358-­‐66
    • Re-­‐do  MVR  has  low  mortality,  morbidity  and  intraopera7ve  injury  with  careful  planning Ann  Thorac  Surg  2013;96:1358-­‐66  
    • Para-­‐prostheLc  Heart  Valve  Leak
    • 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
    • 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    ×
    • 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
    • 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  ventricular  apex  and  base  of   papillary  muscles   –  Drain  most  of  RV,  LA,  RA   –  Can  be  dilated  acer  MI   –  Not  septal  defects
    • •  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  common  is  antero-­‐ superior  septum   •  They  are  not  septal  defects   or  fistulas Posteroinferior  veins Anterosuperior  veins PFO
    • Veins  of  LA  Wall   Interatrial  muscle  connecLon
    • CS  System AIV=  anterior  interventricular  vein   MCV=IIV  (inferior  interventricular  vein)   Between  AIV  and  IIV:  several  lateral  and  posterior  branches
    • GCV Usually  pass  over  the  LAD  and    LCX  but  can  be  under
    • 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  
    • Monarc   system Viacor CARILLON • Coronary  artery  compression   • 30%   • MI
    • 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  
    • Heart  2011:97
    • Assessment  for  percutaneous  mitral  valve  repair Annulus  calcificaLon   Annulus  size   CondiLons  of  the  leaflets
    • Cardiac  ResynchronizaLon  Therapy
    • Semitransparent  volume   Include  bony  landmarks   Angle  similar  to  that  used  in   fluoroscopy RAO  view AP  view PACE  2009;32:323-­‐329 LAO  view
    • Detailed  mapping  with  CT
    • Avoid  placement  in  infarct  zone Absence  of  a  vein  can  be  due  to  infarct  in  the  same  region
    • Measurements   Angle  of  entrance  to  CS  and  size  of  osLum
    • 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
    • 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
    • Thank  you