3d and 4d imaging of the aortic root - · pdf file3d and 4d imaging of the aortic root 3d and...

3D and 4D Imaging of the Aortic Root

3D and 4D Imaging of the Aortic Root

Dominik FleischmannDepartment of Radiology

Stanford University

Dominik FleischmannDominik FleischmannDepartment of RadiologyDepartment of Radiology

Stanford UniversityStanford University

20th Annual Summer Practicum, Masters in Body ImagingJackson Lake Lodge, Moran, Wyoming

August 8-11, 2010

Research support: Research support: General ElectricGeneral ElectricSpeaker's board: Speaker's board: BraccoBracco

SiemensSiemens

Conflicts of Interest DisclosureConflicts of Interest Disclosure

Dominik FleischmannDepartment of Radiology

Stanford University

Dominik FleischmannDominik FleischmannDepartment of RadiologyDepartment of Radiology

Stanford UniversityStanford University


August 8-11, 2010

Progressive root enlargement (Marfan's)Progressive root enlargement (Marfan's)

Jan '04

24 mm

45 mm

30 mm

Nov '04

28 mm

47 mm

32 mm

Sep '05

29 mm

49 mm

33 mm

with ECG gating

3D and 4D Imaging of the Aortic Root3D and 4D Imaging of the Aortic Root

Learning Objectives / OutlineLearning Objectives / Outline

••Technique: Technique: 'gated chest' CT'gated chest' CT

••Surgical anatomy of thoracic aortaSurgical anatomy of thoracic aorta

••Clinical Clinical prepre-- and postop. imaging and postop. imaging inin

-- Marfan's diseaseMarfan's disease

-- Bicuspid aortic valve disease / aneurysmBicuspid aortic valve disease / aneurysm

Aortic Root Aneurysms Aortic Root Aneurysms

Etiology and associated conditionsEtiology and associated conditions

••genetic genetic (congenital wall defect)(congenital wall defect)

Marfan's Marfan's Bicuspid aortic valveBicuspid aortic valve

••atherosclerotic atherosclerotic

••chronic dissection chronic dissection

••infectious infectious ('mycotic', syphilis)('mycotic', syphilis)

••vasculitisvasculitis••postpost--traumatictraumatic rarerare

veryverycommoncommon

Aortic Root Aneurysms (TAA)Aortic Root Aneurysms (TAA)

Etiology and associated conditionsEtiology and associated conditions

congenital (intrinsic, defect of aortic wall):congenital (intrinsic, defect of aortic wall):

Marfan'sMarfan's FBNFBN--11 gene gene fibrillin= extracell.matrix fiber fibrillin= extracell.matrix fiber regulates TGFregulates TGF--ββ

Bicuspid AVBicuspid AV fibrillin, fibrillin, MMP 2MMP 2

EEhlershlers--DanlosDanlos--IVIV COL 3A1COL 3A1 gene (procollagen gene (procollagen IIIIII))

LoeysLoeys--DietzDietz TGFBR1TGFBR1 or or TGFBR2TGFBR2 genegene

TGF: transforming growth factor, MMP: matrix metalloproteinase; TGF: transforming growth factor, MMP: matrix metalloproteinase;

(0.01(0.01--0.02 %)0.02 %)

(1(1--2 % prevalence)2 % prevalence)

BAV diseaseBAV disease(bicuspid aortic valve disease)(bicuspid aortic valve disease)

Prevalence Prevalence 11--2%2%

Complications (>33%)Complications (>33%)

•• valve degeneration valve degeneration and stenosisand stenosis

•• endocarditisendocarditis

•• aortic root dilatation aortic root dilatation (50% of young pts.) (50% of young pts.)

ao. root aneurysmao. root aneurysm

Sievers et al.; J Thorac Cardiovasc Surg 2007;133:1226Sievers et al.; J Thorac Cardiovasc Surg 2007;133:1226--3333

Bicuspid aortic valve (BAV)Bicuspid aortic valve (BAV)

Classification (Sievers)Classification (Sievers)

BAV diseaseBAV disease(bicuspid aortic valve disease)(bicuspid aortic valve disease)





••Clinical focusClinical focus

pre and postoperative imaging pre and postoperative imaging



EKG gated CTA of the ThoraxEKG gated CTA of the Thorax(16(16-- channel MDCT)channel MDCT)

'Gated Chest''Gated Chest'

••entire thoracic aorta entire thoracic aorta

••not thinnest not thinnest collimation (1.25mm)collimation (1.25mm)

••no betano beta--blockers, blockers, no subling. nitrono subling. nitro

••recon. 10 phases recon. 10 phases (0(0––90% of RR interval)90% of RR interval)

••no ECGno ECG--pulsing pulsing (constant mA)(constant mA)

Coronary CTACoronary CTA

••heartheart

•• thinnest collimation thinnest collimation (0.625mm) (0.625mm)

••betabeta--blockers, and blockers, and subling. nitrosubling. nitro

••recon. 1 diastolic recon. 1 diastolic phase (65% of RR) phase (65% of RR)

••ECG pulsing on ECG pulsing on (dose reduction)(dose reduction)

'Gated Chest''Gated Chest'

••entire thoracic aorta entire thoracic aorta

••not thinnest not thinnest collimation (1.25mm)collimation (1.25mm)

••no betano beta--blockers, blockers, no subling. nitrono subling. nitro

••recon. 10 phases recon. 10 phases (0(0––90% of RR interval)90% of RR interval)

••no ECGno ECG--pulsing pulsing (constant mA)(constant mA)

Coronary CTACoronary CTA

••heartheart

•• thinnest collimation thinnest collimation (0.75 mm) (0.75 mm)

••betabeta--blockers, and blockers, and subling. nitrosubling. nitro

••recon. 1 diastolic recon. 1 diastolic phase (65% of RR) phase (65% of RR)

••ECG pulsing on ECG pulsing on (dose reduction)(dose reduction)

EKG gated CTA of the ThoraxEKG gated CTA of the Thorax(16(16-- channel MDCT)channel MDCT)

s/ps/p Ross procedure (pulmonaryRoss procedure (pulmonary-- to aorta autograft)to aorta autograft)susp. leak/pseudoaneurysmsusp. leak/pseudoaneurysm

diastolediastole systolesystole

Advantages:Advantages:

••motionmotion--'free' (3D)'free' (3D) and and dynamic (4D)dynamic (4D)visualization of thor. aorta + aortic rootvisualization of thor. aorta + aortic root

••high 3D spatial resolution (0.5mmhigh 3D spatial resolution (0.5mm33))

"Gated Chest""Gated Chest"(16(16--slice CT, 64slice CT, 64--slice CT)slice CT)

Limitations:Limitations:

••temporal resolution (~165ms)temporal resolution (~165ms)

••lack of flow informationlack of flow information

••radiation dose (25radiation dose (25--50mSv*) 50mSv*)

*(~3*(~3--6 times of std.chest CT)6 times of std.chest CT)

DualDual--Source CTSource CT

(~85ms)(~85ms)

(8(8--15mSv)15mSv)allows ECGallows ECG--dose modulationdose modulation

58 yo woman58 yo woman

••abnormal valve (BAV?),abnormal valve (BAV?),••aneurysmal aortic rootaneurysmal aortic root••LV dilatation, lowLV dilatation, low--normal EFnormal EF

••53kg (117 lbs)53kg (117 lbs)••65 bpm heart rate65 bpm heart rate

24.7

cm

24.7

cm

Gated Chest, DualGated Chest, Dual--Source CTSource CT27.01 mGy, (667mGy*cm), [~11mSv]27.01 mGy, (667mGy*cm), [~11mSv]

100 kVp100 kVpECG pulsing ECG pulsing (30(30--70% of RR Interval)70% of RR Interval)

Gated Chest, DualGated Chest, Dual--Source CTSource CT27.01 mGy, (667mGy*cm), [~11mSv]27.01 mGy, (667mGy*cm), [~11mSv]

58 yo woman58 yo woman

100 kVp100 kVpECG pulsing ECG pulsing (30(30--70% of RR Interval)70% of RR Interval)

Asce

ndin

g Ao

. Descending Ao.

Transverse Arch

Aortic Anulus

STJ*

* Sino-tubular Junction# Sinuses of Valsalva

Ao.

Roo

t

SOV#

Descending Aorta Descending Aorta

Transverse AortaTransverse Aorta

Ascending Aorta Ascending Aorta

Aortic RootAortic Root

••Sinotubular junctionSinotubular junction

••Sinuses of ValsalvaSinuses of Valsalvaaortic valveaortic valvecoronary ostiacoronary ostia

••Aortic anulusAortic anulus

Thoracic AortaThoracic Aorta

Surgical AnatomySurgical Anatomy

Normal diameter of thoracic aorta Normal diameter of thoracic aorta

AnulusAnulusnormal normal 2323--27mm27mm>27mm>27mm anuloaortic ectasiaanuloaortic ectasia

Thoracic aorta (incl. sinuses and STJ)Thoracic aorta (incl. sinuses and STJ)normal normal ageage--, sex, sex--, body size dependent, body size dependent'ectatic''ectatic' appears enlarged, but appears enlarged, but ≤≤4cm4cm>4.0 cm >4.0 cm aneurysm (root, asc., tra., desc.)aneurysm (root, asc., tra., desc.)

Treatment indication (elective)Treatment indication (elective)

>4.5>4.5--5.0cm5.0cm (syndromic patients) (syndromic patients) >6.0 +cm>6.0 +cm (degenerative)(degenerative)rapid diameter increase (rapid diameter increase (>5mm/year>5mm/year))Ao. rootAo. root valve insufficiencyvalve insufficiency

••73 y/o retired RN73 y/o retired RNascending aortic aneurysmascending aortic aneurysm

MIP (thinMIP (thin--slab) centered at valveslab) centered at valve

anulu

s

anulu

s

sinus.of Vals.

sinus.of Vals.

sin.tub.

sin.tub.--junct.

junct.

asc.ao.asc.ao.

••3D thoracic Aorta3D thoracic Aorta•• VR (candyVR (candy--cane view)cane view)

••Measurements Measurements •• MIP (5mm) ~ aMIP (5mm) ~ a--pp•• MIP (5mm) ~ lat.MIP (5mm) ~ lat.•• (MPR othogonal)(MPR othogonal)

••Coronary AnatomyCoronary Anatomy•• VR VR

••Sinuses + valveSinuses + valve•• VR 'transparent' VR 'transparent' •• MinIP (inverted)MinIP (inverted)•• 3 Chamber view3 Chamber view

Interactive Visualization Interactive Visualization –– InterpretationInterpretation

Asce

ndin

g Ao

. Descending Ao.

Transverse Arch

Aortic Annulus

STJ*

* Sino-tubular Junction# Sinuses of Valsalva

Ao.

Roo

t

SOV#

Aortic RootAortic Root

••AnuloplastyAnuloplasty

••Composite graftComposite graftnn Contains valveContains valvenn Coronary Coronary

reimplantationreimplantation

••Valve Sparing SurgeryValve Sparing Surgerynn Resect sinuses down Resect sinuses down

to valve insertionsto valve insertionsnn Preserve native valvesPreserve native valvesnn Coronary reimpl.Coronary reimpl.

Thoracic AortaThoracic Aorta

Surgical OptionsSurgical Options

41 yo man41 yo manMarfan'sMarfan's

anulusanulus

sinus.of Vals.

sinus.of Vals.sin.tub.sin.tub.--junct.

junct.

Valve Sparing Aortic Root ProceduresValve Sparing Aortic Root ProceduresTirone DavidTirone David-- I I ““ReimplantationReimplantation”” TechniqueTechnique

PREPRE--OPOP

VR (slab)VR (slab) VR VR (transparent blood)(transparent blood)

27 y/o man, Marfan's27 y/o man, Marfan's

Surgical Surgical procedureprocedurecoronary coronary

ostiumostium

valvevalveleafletsleaflets

coronary reiplantedcoronary coronary reiplantedreiplanted

POSTPOST--OPOP

27 year old man27 year old man

bicuspid aortic valve root bicuspid aortic valve root aneurysmaneurysm

valve prolaps with severe valve prolaps with severe aortic regurgitation and left aortic regurgitation and left ventricular dilatationventricular dilatation

Bicuspid Aortic ValveBicuspid Aortic Valve

Severe prolaps of R+L Severe prolaps of R+L -- leafletleaflet

Raphe 'L+R' leafletRaphe 'L+R' leaflet

Bicuspid Aortic ValveBicuspid Aortic Valve

Severe prolaps of R/LSevere prolaps of R/L--cuspcuspdue to rupture of commissural suspensory 'chord'due to rupture of commissural suspensory 'chord'

'L+R' sinus'L+R' sinusraphe/chordraphe/chord


SUMMARYSUMMARY






-- Bicuspid aortic valve Bicuspid aortic valve

Thank you..Thank you..

DC Miller DC Miller RS MitchellRS MitchellM FischbeinM Fischbein


August 8-11, 2010

3d and 4d imaging of the aortic root - · pdf file3d and 4d imaging of the aortic root 3d and...

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