3dra in the interstage: when is it worth it? · 2019. 10. 31. · angiography in the cath lab •...
TRANSCRIPT
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3DRA in the Interstage:
When is it worth it?
Darren P. Berman, MD
Co-Director, Interventional Cardiology
The Heart Center
Nationwide Children’s Hospital
Associate Professor, Pediatrics
The Ohio State University
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None pertinent to this lecture
Disclosures
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Objectives
• Brief history of 3D-RA
• Describe how 3D-RA is done
• When & why consider 3D-RA in SV interstage patients
• Advantages & disadvantages
• Case examples
• 3D-RA utilization during interstage period
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Angiography in the Cath Lab
• Adult cath labs -- Single plane
• Congenital cath labs -- Biplane
•Imaging complex 3-D structures
• 2D biplane imaging
•Quantitative assessment
•Qualitative assessment
•‘Gold Standard’
•Interventions in the cath lab
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Why Do We Need 3DRA Then?
Why not image complex 3-dimensional structures in 3D?
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History of 3DRA
• First described in 2006
• Neurovascular procedures• Adjunct to subtraction angiography
• More sensitive in detecting subtle lesions
• Subsequently, described in the setting of real-time evaluation of• spinal interventions
• abdominal aortic aneurysm repair
• hepatic vascular chemoembolization
• PA/IVS case report
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3DRA in CHDKapins CEB et al. Use of Rotational 3D (3D-RA) in Congenital Heart Disease Patients: Experience with 53
cases. Rev Bras Cardiol Invasiva. 2010;18(2):199-203.
2010 – First series describing its use in CHD• 53 cases – various diagnoses
Results• 23%, 3D-RA revealed anatomic details not shown by 2D angiography
• 49%, 3D-RA findings were used to aid in treatment decisions
• Exposure to radiation was not statistically different from 2D angiography
• No complications related to 3D-RA
Conclusions• 3D-RA can provide additional useful information
• May reduce the number of angiograms needed during a case
• May limit patient exposure to radiation and contrast medium
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3DRA in CHDGlatz AC et al. Use of angiographic CT imaging in the cardiac catheterization laboratory for congenital heart
disease. JACC Cardiovasc Imaging. 2010 Nov;3(11):1149-57.
• Followed soon there after in the US in late 2010
• 41 caths; range of diagnoses
• RVOT/central pulmonary arteries; CPCs; pulm veins; distal PAs
• Results:
• 71%; Diagnostic-quality imaging
• 12 cases (29%), contributed to clinical outcomes
• Radiation dose was comparable to a biplane cineangiogram
• Conclusions:
• In certain cases, 3DRA provides additional anatomic detail
• Future work is needed to continue to define applications of this new
technology
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How It’s Done
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One 3D-RA200 degree rotational angiogram
•Automatically transferred to a dedicated 3D work
station
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One 3D-RA3D reconstruction
•Additional 3-5 minutes of image post-processing
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One 3D-RACross-sectional CT-like tomographic slices
3DRA -- Advantages• Single rotational angiogram 3D recon
• Assess complex 3D structure in 3D
• “Virtual” real time 3D assessment
• Determine best gantry angle for conventional angiography without taking multiple biplane angiograms
• Potential to reduce total # of angiograms
• Potential to reduce total contrast needed
• Single rotational angiogram cross sectional CT-like tomographic images
• Better understand relationship of PA’s to surrounding structures
• Better understand mechanism of stenoses
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Interstage Single Ventricle Patients: Fragile period
• Mortality 2-16%1
• Reintervention rate 18-37%2
• Increase pulmonary blood flow
• Improve systemic perfusion
• Improve venous mixing
• Urgently performed1Feinstein JA1, Benson DW, Dubin AM, et al. Hypoplastic left heart syndrome: current
considerations and expectations. J Am Coll Cardiol. 2012 Jan 3;59.2Galantowicz M, Cheatham JP, Phillips A, et al. Hybrid approach for hypoplastic left heart syndrome:
intermediate results after the learning curve. Ann Thorac Surg. 2008 Jun;85(6):2063-70.
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Catheterization RISk score for Pediatrics (CRISP)
Predicted incidence of SAE for
inter-stage single ventricle
patient:
Nykanen DG, Forbes TJ, Du W, et al. CRISP: Catheterization RISk score for
Pediatrics: A Report from the Congenital Cardiac Interventional Study
Consortium (CCISC). Catheter Cardiovasc Interv. 2016 Feb 1;87(2):302-9. doi:
10.1002/ccd.26300. Epub 2015 Nov 3.
6.2% - 36.8%
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Is 3DRA worth it? =
Is 3DRA worth the risk?
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Benefit of 3DRA
Improves
understanding of
anatomy
Guides intervention
Defines optimal
gantry angles for
2D imaging
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Barriers/Risks to 3DRA in Urgent
Interstage Catheterizations
• Increased radiation dose ?
• Increased contrast dose ?
• Increased procedural time ?
• Modify (decrease) stroke volume with RRVP
•Additional vascular access
•Possible clinical decline with pacing
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3DRA vs 2D Digital Angiography:Radiation Dose
Haddad L, Waller BR, Johnson J, et al.
Radiation Protocol for Three-Dimensional Rotational
Angiography to Limit
Procedural Radiation Exposure in the Pediatric
Cardiac Catheterization Lab. Congenit Heart Dis.
2016 Apr 14. doi: 10.1111/chd.12356.
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Uitlity of 3D-RA in SV patients
Additional value of three-dimensional rotational angiography
in the diagnostic evaluation and percutaneous treatment
of children with univentricular heartsFemke van der Stelt, MD; Gregor J. Krings, MD, PhD; Mirella C. Molenschot,
MD; Johannes M. Breur*, MD, PhD
Published 24 August 2018
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Methods and results:
Between January 2003 and March 2017, 140 patients
underwent 183 CAs and 107 3DRAs. 3DRA image
quality was superior to CA with fewer diagnostic
angiographies performed (p<0.001). Intervention rate
(p<0.001) and interventional success (p=0.03) were
higher with 3DRA, while complication rates were similar.
Mean radiation was lower in the 3DRA group, reaching
significance pre-PCPC. 3DRA was considered of
additional value in imaging of cardiovascular anatomy,
collaterals, stenoses, and vessel-vessel and vessel-
bronchi interactions.
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Barriers/Risks to 3DRA in Urgent
Interstage Catheterizations
• Increased radiation dose
• Increased contrast dose
• Increased procedural time
• Modify (decrease) stroke volume with RRVP
•Additional vascular access
•Possible clinical decline with pacing
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Transesophageal Pacing
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Case 1: Retrograde Aortic Arch Obstruction
• 3 month-old female
• HLHS (MA/AA)
• S/P Hybrid stage I
palliation
• Decreased RUE pulse
• TTE w/increasing gradient
across the retrograde
aortic arch
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3D Reconstruction
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Implantation of 4mm x12 mm Integrity
Coronary Stent
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Case #2: Sano Shunt
• 1 month-old male
• HLHS (AS/MS) s/p
Norwood operation with a
4 mm Gore-Tex Sano
shunt
• Progressive cyanosis
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3D Reconstruction
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Sano Shunt Angiogram
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Balloon Angioplasty with 3.5 mm x 15 mm
Quantum Maverick Balloon
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Post Procedural Angiogram
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Case #3: mBTTS
• 3 month-old male
• Complex SV s/p Norwood
operation with a 3.5 mm R
mBTT shunt
• Progressive cyanosis
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Case #4 – 6 day old F;
PA/VSD with single source PBF via PDA
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Case #5: Insufficient PBF
• 4 mo old male
• DORV, remote VSD,
pulmonary atresia
• s/p 3.5mm central
shunt
• Increasing hypoxia
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Case #6: PA/IVS, hypoplastic RV, RVDCC
• 1 week-old male
• S/P 3.5 mm Gore-Tex
modified BTT shunt
• Severe post-operative
cyanosis
• Severe cyanosis + inotropes
•Operator choice
•no 3DRA
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Selective Angiogram
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Implantation of a 3.5 mm x 18 mm
Integrity Stent
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Final Angiogram
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Summary
• Interstage SV patients are at high risk for morbidity and SAE
during cardiac catheterization
• There are perceived barriers and risks of 3D-RA
•Are just that – perceived 3D-RA is safe
• Wealth of information provided by a single 3D-RA
• More informed better decisions with how best to manage the
residual lesions we find
• Use of 3D-RA in this setting should be determined on an
individual basis