What can you learn from CT procedural planning

What can you learn from CT procedural planning João L. Cavalcante MD, FACC, FASE, FSCCT Director, Structural Cardiovascular Imaging and Core Lab University of Pittsburgh – UPMC joaocavalcantemd@gmail. com/ @Joao. LCavalcante www. cvinnovations. org

Disclosures: - Invest. Initiated Research Grant (Medtronic Inc. ) - Consulting (Circle, Medtronic Inc. , Mitralign) - Research Support (Medtronic Inc. , Mitralign, Tom. Tec Inc. ) www. cvinnovations. org

Imaging Needs for TV interventions Prihadi et al. JACC Cardiovasc Imaging. 2018 May; 11(5): 736 -754.

CTA Procedural Planning • Data Acquisition: Thin slices (< 1 mm) with contrast – Obtain images throughout the cardiac cycle (0 -100% R-R) – Images of the entire chest (same as TAVR, exclude the legs) • Weight- and EF-based contrast injection protocols • Tricuspid annular assessment requires dedicated postprocessing software – Size and geometry – Landing zone – RCA distance to tricuspid annulus • Fluoro angles Naoum C, et al. Circ CV Img 2017; 10: e 005331

RV evaluation by 2 D Echo • No anatomical references to warrant RV image optimization (risk of under/overestimation of RV size, depending on probe position and rotation). Rudski et al. JASE 2010

Best Practices in CTA Scanning for RV/Tricuspid Valve www. cvinnovations. org

Evolution of Cardiac CT Technology Lewis MA et al. Br J Radiol. 2016 Sep; 89(1065): 20160376.

A couple words in Temporal Resolution for CTA • Consider as the shutter speed • At HR ~ 70 bpm, to freeze cardiac motion, the ideal Temporal Resolution ~ 50 -60 msec. • The Temporal Resolution in MDCT is determined by the speed of the gantry rotation Temporal resolution = gantry rotation time / 2 (or /4 if DSCT) • Putting more detectors makes it heavier to rotate the gantry which approaches current engineering limits for gravitational forces. • Solution to improve TR add 2 nd source of X-rays Dual-Source CT (DSCT)

Adequate opacification of the right side requires specific contrast protocols Test Bolus – Allows for Bolus Tracking Scanning @ Asc. Ao Saline/Contrast mixture (allows for better and longer RV opacification, avoids strong contrast arrival through SVC) Hinzpeter R et al. Euro. Intervention 2017; 12(15): e 1828 -36

Reduced image quality due to Afib. Contrast timing is suboptimal (mixing) RV 4 ch View RV 2 ch View

RV 4 ch View Gating ok, but inappropriate IV contrast timing RV SAX View Right Atrium Right Ventricle

RV 2 ch View RV 4 ch View RV 3 ch View

RA, RV Volumes & EF RV SAX View Right Atrium Right Ventricle

Severe TR seen through CTA

CT Anatomical Analysis www. cvinnovations. org

Tricuspid Annulus 4 ch Diameter 2 ch Diameter Area & Major/Minor Diameter

Tethering Area, Height and Anatomical Reg. Orifice Area 4 ch Area and Height 2 ch Area and Height Anatomical ROA

Anatomical ROA – Average Systolic Frames Systolic Frame 10% Systolic Frame 20% Systolic Frame 30% Average Anatomical ROA=0. 629 cm 2

CTA for Fluoroscopy Angle Planning

CTA for Procedural Planning A distance between RCA and TV annulus of ≤ 2 mm is considered less favorable Prihadi et al. JACC Cardiovasc Imaging. 2018 May; 11(5): 736 -754. Hahn et al. JACC Imaging 2018. In production

Conclusions • CTA planning to TV interventions requires specific acquisition protocol and measurements according to the device which will be used. • CTA quantification of RV volumes and RVEF is feasible provided adequate temporal resolution is achieved. • CMR should be integrated in the conventional risk assessment for VHD patients when uncertainty exists (discrepancies in symptoms vs severity). Most of the applications don’t require IV gadolinium. • Further education initiatives and valve trials integrating Cardiac MRI are needed to improve the understanding of valve-related myopathy and its relationship to outcomes individualizing patient selection to transcatheter therapies.