Sebastian Goreczny

Three-dimensional image fusion guidance of percutaneous pulmonary valve implantation to reduce radiation exposure and contrast dose: A comparison with traditional two-dimensional and three-dimensional rotational angiographic guidance

IntroductionThree-dimensional rotational angiography (3DRA) has been used in the guidance of various transcatheter therapies including percutaneous pulmonary valve implantation (PPVI). The most recently available 3D image fusion software (VesselNavigator, Philips) extends this technology to use pre-registered computed tomography or magnetic resonance imaging datasets, promising reductions in contrast and radiation exposure along with shorter procedural times.MethodsIn this retrospective review, patients were assigned to three groups according to the mode of imaging guidance: two-dimensional angiography (2DA), 3DRA and VesselNavigator (VN) assisted valve implantation. Patient characteristics and catheterisation data were reviewed with axa0focus on contrast and radiation exposure, fluoroscopy, and procedural times.ResultsBetween July 2012 and June 2016, 21 patients underwent PPVI: 8 with 2Dxa0guidance, 6xa0patients with 3DRA and most recently 7xa0patients with VN assistance. Patents in the VN group received significantly less absolute and weight indexed contrast when compared with those with 2DA or 3DRA guided PPVI. Patients in the 2DAxa0group received axa0significantly higher total dose area product radiation dose and air kerma in comparison with patients with 3DRA and VN guided intervention. Application of VN resulted in the shortest fluoroscopy time, although not statistically significant, and axa0significantly shorter study time when compared with 2DA.ConclusionsUtilisation of pre-intervention image manipulation with VesselNavigator for 3Dxa0guidance of PPVI results in axa0reduction in contrast and radiation exposure and study time as compared with traditional 2D guidance, and contrast usage as compared with 3DRA.

Technical and anatomical factors affecting the size of the branch pulmonary arteries following first-stage Norwood palliation for hypoplastic left heart syndrome

OBJECTIVESnBranch pulmonary artery (BPA) size is one of the factors that influence the efficacy of the Fontan circulation. Central pulmonary artery stenosis and small left pulmonary artery (LPA) are well-known problems following Norwood palliation for hypoplastic left heart syndrome (HLHS). We investigated anatomical and technical factors that may stand behind these problems.nnnMETHODSnA total of 47 consecutive patients were included in the study. All had complete magnetic resonance imaging (MRI) study pre-second-stage palliation. Measurements were taken using a first-pass 3D angiography technique after intravenous injection of an extravascular contrast agent. Factors investigated included the following: size and site of the pulmonary artery bifurcation stump in relation to the Damus-Kaye-Stansel (DKS) anastomosis, interaortic distance/ratio (neoaorta to descending aorta distance/antero-posterior dimension of the chest) (IAD/IAR), distance from the under surface of the arch and the size of native aorta and pulmonary artery. IAD/IAR were compared between two different arch reconstruction techniques.nnnRESULTSnStenosis occurred either centrally, at the origin of the BPA, or more distally, in the mid-LPA (posterior to DKS). There was a significant lower incidence of central BPA stenosis when the pulmonary artery stump was placed in the mid-position compared with right/left position (26 vs 67%; P = 0.011). A more bulky pulmonary artery stump was also found in those patients with central BPA stenosis (186 vs 137 mm(2)/m(2); P = 0.047). The mid-LPA consistently showed antero-posterior compression (mean cranio-caudal diameter 3.82 mm vs mean antero-posterior diameter 3.07 mm, P < 0.001). Indexed mid-LPA area was only correlated with IAD/IAR (r = 0.49 and 0.51, P < 0.001). No correlation was shown with the distance to the under surface of the arch (r = 0.14, P = 0.37), again confirming antero-posterior compression of the LPA rather than cranio-caudal. In multivariable analysis, the only predictor of indexed mid-LPA area was the IAR (P < 0.001). There was no significant difference in the IAD or IAR between the two arch reconstruction techniques [mean IAD 15.5 vs 13.5 mm (P = 0.14)]; [mean IAR 0.17 vs 0.19 (P = 0.21)].nnnCONCLUSIONSnOf all studied factors, IAR and the size and position of the pulmonary artery bifurcation plays the main role in LPA growth and central BPA stenosis.

Self-expanding stent implantation in arterial duct during hybrid palliation of hypoplastic left heart syndrome: midterm experience with a specially designed stent.

AIMSnThe lack of a specifically designed stent for the arterial duct has led to the off-label use of stents during hybrid palliation of hypoplastic left heart syndrome (HLHS). We evaluated the implantation and performance of a specially designed self-expanding stent in hybrid palliation of HLHS.nnnMETHODS AND RESULTSnWe implanted 39 sinus-SuperFlex (SSF) stents in 24 patients at a median age of seven days (range 2-27 days) and median weight of 2.85 kg (range 1.3-3.8 kg). A single stent was implanted in nine patients and two overlapping stents in 15 patients. There was one intraoperative death, not related to ductal stenting and one additional in-hospital death. During median follow-up of 137 days (range 38-522 days), nine patients required 11 interstage interventions. Four patients have undergone a biventricular repair, 11 have undergone the next stage of univentricular palliation and seven are awaiting a second-stage palliation.nnnCONCLUSIONSnThe SSF stent provides effective maintenance of ductal patency in patients undergoing hybrid palliation of HLHS and its variants. It conforms to the ductal anatomy but the lack of stents longer than 20 mm has required overlapping stents in longer ducts. This has not been of haemodynamic consequence.

A 10-year single-centre experience in percutaneous interventions for multi-stage treatment of hypoplastic left heart syndrome

OBJECTIVESnThe purpose of this paper is to report our 10 years of experience of interventional treatment of patients with hypoplastic left heart syndrome and to focus on the frequency, type, and results of percutaneous interventions during all the stages of palliation, considering the different techniques, devices, and complications.nnnBACKGROUNDnConstant progress in surgical treatment of congenital heart defects in the last decade has significantly improved the prognosis for children with hypoplastic left heart syndrome. However, morbidity and mortality remain relatively high. Modern interventional procedures complement or occasionally replace surgical treatment.nnnMETHODSnBetween January, 2001 and December, 2010, 161 percutaneous interventions were performed in 88 patients with hypoplastic left heart syndrome. Patients were divided into four groups: (a) before the first surgical treatment including hybrid approach, (b) after first-stage Norwood operation, (c) after second-stage bidirectional Glenn operation, and (d) after third-stage Fontan operation.nnnRESULTSnPercutaneous interventions resulted in statistically significant changes in pulmonary artery pressures, vessel diameters, and O2 saturation. Complications occurred in 4.3% of interventions and were related mainly to stent implantation in stenosed pulmonary arteries.nnnCONCLUSIONSnPercutaneous interventions may result in haemodynamic stability and reduction in the number of operations. They may result in significant changes in pulmonary artery pressures, vessel diameters, O2 saturation, with a low rate of complications, which are mainly related to stent implantation in the pulmonary arteries.

Novel Three-Dimensional Image Fusion Software to Facilitate Guidance of Complex Cardiac Catheterization

We report initial experience with novel three-dimensional (3D) image fusion software for guidance of transcatheter interventions in congenital heart disease. Developments in fusion imaging have facilitated the integration of 3D roadmaps from computed tomography or magnetic resonance imaging datasets. The latest software allows live fusion of two-dimensional (2D) fluoroscopy with pre-registered 3D roadmaps. We reviewed all cardiac catheterizations guided with this software (Philips VesselNavigator). Pre-catheterization imaging and catheterization data were collected focusing on fusion of 3D roadmap, intervention guidance, contrast and radiation exposure. From 09/2015 until 06/2016, VesselNavigator was applied in 34 patients for guidance (nxa0=xa028) or planning (nxa0=xa06) of cardiac catheterization. In all 28 patients successful 2D–3D registration was performed. Bony structures combined with the cardiovascular silhouette were used for fusion in 26 patients (93%), calcifications in 9 (32%), previously implanted devices in 8 (29%) and low-volume contrast injection in 7 patients (25%). Accurate initial 3D roadmap alignment was achieved in 25 patients (89%). Six patients (22%) required realignment during the procedure due to distortion of the anatomy after introduction of stiff equipment. Overall, VesselNavigator was applied successfully in 27 patients (96%) without any complications related to 3D image overlay. VesselNavigator was useful in guidance of nearly all of cardiac catheterizations. The combination of anatomical markers and low-volume contrast injections allowed reliable 2D–3D registration in the vast majority of patients.

Three-Year-Old Child With Middle Aortic Syndrome Treated by Endovascular Stent Implantation

Middle aortic syndrome (MAS) is an extremely rare anomaly and represents both a diagnostic and therapeutic challenge, particularly in young children. A case of a 3.5xa0year-old child with MAS and arterial hypertension is reported, where owing to the patient’s young age and the length of the hypoplastic aortic segment, surgical correction with end-to-end anastomosis was not feasible. Instead of palliative bypass grafting between the thoracic and abdominal aorta, successful percutaneous balloon angioplasty and stenting of the lesion was performed with the assistance of three-dimensional rotational angiography.

Interventional treatment of critical coarctation of the aorta in an extremely low birth weight preterm neonate.

The authors describe successful balloon angioplasty of aortic coarctation in a preterm neonate weighing 670 grams. The intervention was performed in an open incubator to ensure stable temperature comfort and to minimise the risk of hypothermia during the procedure of obtaining surgical vessel access, performing balloon angioplasty, and closure of the wound.

Early experience with the Occlutech PLD occluder for mitral paravalvar leak closure through a hybrid transapical approach.

AIMSnWe sought to evaluate the feasibility and efficacy of hybrid transapical closure of paravalvar mitral leaks using a new Occlutech PLD occluder in patients with heart failure and/or haemolytic anaemia.nnnMETHODS AND RESULTSnRetrospective analysis of clinical and procedural data was undertaken for patients who had attempted closure of paravalvar mitral leaks via a hybrid transapical approach with the Occlutech PLD occluder. Eight patients (four males, median age 69 years) underwent closure of 10 mitral paravalvar leaks using eight Occlutech PLD occluders and two AMPLATZER Vascular Plugs (AVP II). Successful deployment, with significant reduction of the paravalvar leak was achieved in seven patients with short procedure (median 131 min) and fluoroscopy times (median 22 min). One patient had mechanical interference with prosthetic valve function, requiring surgery. Another patient with a high EuroSCORE (48.8%) died of multi-organ failure two days after the procedure. Clinical improvement in either heart failure or haemolysis was seen in all discharged patients.nnnCONCLUSIONSnIn our series of patients with challenging anatomy, the Occlutech PLD occluders performed well when implanted via a hybrid transapical approach. Further work is needed to assess this methodology fully for a wider population and to assess other deployment approaches for this promising new occluder.

Novel 3-Dimensional Image Fusion Software for Live Guidance of Percutaneous Pulmonary Valve Implantation

A 7-year-old patient (28 kg) born with aortic stenosis, having undergone the Ross procedure and a repeat surgical intervention including patch plasty of the stenosed conduit and mechanical valve implantation in the mitral position, presented with recurrence of right ventricular outflow tract conduit narrowing.nnTransthoracic echocardiography showed obstruction of the conduit (Vmax=4 m/s) with moderate pulmonary regurgitation. Cardiac computed tomography confirmed stenosis of the graft with a minimum diameter of 12×18 mm, unobstructed pulmonary arteries, and coronary arteries sufficiently separated from the graft.nnThe computed tomography scan was uploaded to the dedicated workstation for processing with the novel VesselNavigator (Philips Healthcare) 3-dimensional (3D) image fusion software. The automatically created 3D reconstruction was manually modified with a single-click segmentation tool (Figure [A]) to …

Use of pre-intervention imaging with a novel image fusion software for guidance of cardiac catheterisation in a patient with pulmonary atresia and major aortopulmonary collaterals.

We present a 3.5-year-old patient with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals, after repeat implantation of a central shunt, in whom we successfully re-purposed previous imaging scans with a novel image fusion software to guide diagnostic heart catheterisation. The pre-registered CT scan was segmented before the procedure and subsequently manually fused with two-dimensional fluoroscopy images. The overlaid roadmap enhanced selective cannulation of all major vessels originating from the aorta, making aortography unnecessary.