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syngo DynaCT Cardiac - Paravalvular Mitral Valve Leakage

Author: Samir Kapadia
Heart and Vascular Institute Cleveland, USA

Patient History

72-year-old, male patient with previously placed bioprosthetic mitral valve.

Diagnosis

Mitral regurgitation (grade 3+) due to periprosthetic leak (Video 1).

Treatment

Closure of the paravalvular leak with an 8 mm VSD closure device under TEE (transesophageal echo) and fluoroscopic guidance. syngo iGuide Toolbox graphics were overlaid as additional guidance.

Comments

The case demonstrated that the overlay of 3D information on the live fluoroscopic images provided additional helpful information.

More detailed information can be found in the following publication:
Krishnaswamy A, Tuzcu EM, Kapadia S., Three-dimensional computed tomography in the cardiac catheterization laboratory, Catheter Cardiovasc Interv. 2010

Detailed workflow description

Pre-procedural cardiac CT data was retrieved from the PACS. (Video 2) The following structures were marked with syngo iGuide Toolbox graphics:

  • Mitral valve plane
  • Positions of the paravalvular leaks (based on the information of the diagnostic TEE Figure 3)
  • Aortic valve plane (Figure 4)
  • Area for transseptal puncture (Figure 5)


The patient was positioned on the table with arms up to match the patient’s position during the pre-procedural cardiac CT. Arms were kept up during the whole procedure. A 5-second syngo DynaCT Cardiac run was performed without contrast (Video 6). During this rotational acquisition a pigtail catheter was positioned in the aortic root to visualize the position of the aorta and the aortic root as landmarks for the syngo InSpace 3D/3D registration. Patient was asked just to hold his breath, i.e., no deep inspiration or expiration in order to be in a similar breathing situation as during the remaining procedure. This helps increasing the overlay accuracy.

3D/3D registration of syngo DynaCT Cardiac image and CT was performed in syngo InSpace with the pigtail catheter and the mitral valve serving as landmarks. (Video 7).

The overlaid 3D markers helped as additional guidance during the procedure for:

  • a) the puncture of the atrial septum
  • b) the progression of a guidewire through a leak (Video 8)
  • c) the adjustment of the closure devices (Video 9)

Video 1
Diagnostic TEE showing the paravalvular leak.

Video 2
Pre-procedural cardiac CT.

Figure 3
syngo DynaCT Cardiac with syngo iGuide Toolbox markers indicating the positions of the paravalvular leaks from TEE.

Figure 4
syngo DynaCT Cardiac with syngo iGuide Toolbox markers indicating the plane of the aortic valve.

Figure 5
syngo DynaCT Cardiac with syngo iGuide Toolbox markers indicating the desired region of the transseptal puncture.

Video 6
5s syngo DynaCT Cardiac acquisition; Protocol: 5sDRc

 

Video 7
3D/3D registration of cardiac CT and syngo DynaCT Cardiac.

Video 8
Live fluoroscopic image with overlaid syngo iGuide Toolbox graphics. Video 8 shows the alignment of a closure device (two radiopaque markers).

Video 9
Live fluoroscopic image with overlaid syngo iGuide Toolbox graphics. Video 9 shows the guidewire through a leak.

Download Case Study

Date: Mar 16, 2011


Angiography - Case Studies

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