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Thorax cardio pre procedure ct s cheung
1.
MDCT’s
role
in
pre-‐cardiovascular
procedure
planning
Stephen
CW
Cheung
Radiology,
Queen
Mary
Hospital,
Hong
Kong
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. Other
procedures
• Re-‐do
cardiac
surgery
• Closure
of
para-‐prostheLc
heart
valve
leakage
• Mitral
valve
indirect
annuloplasty.
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. Risk
of
redo
MVR
• Mortality
quoted:
6-‐18%
• Injury
to
cardiac
structure:
5-‐10%
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.
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. 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. 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. USG
to
measure
CFA/CFV
• Ensure
the
vessels
are
of
adequate
size
for
cannulaLon
in
peripheral
cardiopulmonary
bypass
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. 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.
20. 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
31. 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
32. • Greater
CVS
– CS
and
non-‐CS
tributaries
– Drain
LV,
part
of
RV
33. 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
37. 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
39. 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
47. 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
48. 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
