3D advanced imaging overlay with rapid registration in CHD to reduce radiation and assist cardiac catheterisation interventions

Novel commercially available software has enabled registration of both CT and MRI images to rapidly fuse with X-ray fluoroscopic imaging. We describe our initial experience performing cardiac catheterisations with the guidance of 3D imaging overlay using the VesselNavigator system (Philips Healthcare, Best, NL). A total of 33 patients with CHD were included in our study. Demographic, advanced imaging, and catheterisation data were collected between 1 December, 2016 and 31 January, 2019. We report successful use of this technology in both diagnostic and interventional cases such as placing stents and percutaneous valves, performing angioplasties, occlusion of collaterals, and guidance for lymphatic interventions. In addition, radiation exposure was markedly decreased when comparing our 10-15-year-old coarctation of the aorta stent angioplasty cohort to cases without the use of overlay technology and the most recently published national radiation dose benchmarks. No complications were encountered due to the application of overlay technology. 3D CT or MRI overlay for CHD intervention with rapid registration is feasible and aids decisions regarding access and planned angiographic angles. Operators found intraprocedural overlay fusion registration using placed vessel guidewires to be more accurate than attempts using bony structures.

Multimodality imaging for no contrast trans-catheter closure of an arteriovenous fistula

A 6-year-old patient was diagnosed with an arteriovenous fistula in the neck region. Non-invasive three-dimensional imaging, including computed tomography and ultrasonography, was used for guidance of percutaneous closure of the fistula and evaluation of the final outcome.

Magnetic resonance and computed tomography imaging fusion for live guidance of percutaneous pulmonary valve implantation

Introduction

Until recently, two-dimensional (2D) angiography was the mainstay of guidance for percutaneous pulmonary valve implantation (PPVI). Recent advances in fusion software have enabled direct fusion of pre-intervention imaging, magnetic resonance imaging (MRI) or computed tomography (CT) scans, to create a reliable three-dimensional (3D) roadmap for procedural guidance.

Aim

To report initial two-center experience with direct 2D–3D image fusion for live guidance of PPVI with MRI- and CT-derived 3D roadmaps.

Material and methods

We performed a prospective study on PPVIs guided with the new fusion imaging platform introduced in the last quarter of 2015.

Results

3D guidance with an MRI- (n = 14) or CT- (n = 8) derived roadmap was utilized during 22 catheterizations for right ventricular outflow tract balloon sizing (n = 7) or PPVI (n = 15). Successful 2D–3D registration was performed in all but 1 patient. Six (27%) patients required intra-procedural readjustment of the 3D roadmap due to distortion of the anatomy after introduction of a stiff wire. Twenty-one (95%) interventions were successful in the application of 3D imaging. Patients in the CT group received less contrast volume and had a shorter procedural time, though the differences were not statistically significant. Those in the MRI group had significantly lower weight adjusted radiation exposure.

Conclusions

With intuitive segmentation and direct 2D–3D fusion of MRI or CT datasets, VesselNavigator facilitates PPVI. Our initial data show that utilization of CT-derived roadmaps may lead to less contrast exposure and shorter procedural time, whereas application of MRI datasets may lead to lower radiation exposure.

Stent implantation to ductus arteriosus in a patient with interrupted aortic arch guided by CT image overlay

A 15-day-old premature patient with ventricular septal defect and interrupted aortic arch type B underwent "hybrid" initial treatment consisting of bilateral pulmonary artery banding followed by stenting of the ductus arteriosus. A pre-registered CT scan was re-purposed with a new three-dimensional image fusion software (VesselNavigator) to create a roadmap for stent delivery.

Novel Three-Dimensional Image Fusion Software to Facilitate Guidance of Complex Cardiac Catheterization : 3D image fusion for interventions in CHD

We report initial experience with novel three-dimensional (3D) image fusion software for guidance of transcatheter interventions in congenital heart disease. Developments in fusion imaging have facilitated the integration of 3D roadmaps from computed tomography or magnetic resonance imaging datasets. The latest software allows live fusion of two-dimensional (2D) fluoroscopy with pre-registered 3D roadmaps. We reviewed all cardiac catheterizations guided with this software (Philips VesselNavigator). Pre-catheterization imaging and catheterization data were collected focusing on fusion of 3D roadmap, intervention guidance, contrast and radiation exposure. From 09/2015 until 06/2016, VesselNavigator was applied in 34 patients for guidance (n = 28) or planning (n = 6) of cardiac catheterization. In all 28 patients successful 2D-3D registration was performed. Bony structures combined with the cardiovascular silhouette were used for fusion in 26 patients (93%), calcifications in 9 (32%), previously implanted devices in 8 (29%) and low-volume contrast injection in 7 patients (25%). Accurate initial 3D roadmap alignment was achieved in 25 patients (89%). Six patients (22%) required realignment during the procedure due to distortion of the anatomy after introduction of stiff equipment. Overall, VesselNavigator was applied successfully in 27 patients (96%) without any complications related to 3D image overlay. VesselNavigator was useful in guidance of nearly all of cardiac catheterizations. The combination of anatomical markers and low-volume contrast injections allowed reliable 2D-3D registration in the vast majority of patients.

Three-dimensional image fusion guidance of percutaneous pulmonary valve implantation to reduce radiation exposure and contrast dose: A comparison with traditional two-dimensional and three-dimensional rotational angiographic guidance

INTRODUCTION

Three-dimensional rotational angiography (3DRA) has been used in the guidance of various transcatheter therapies including percutaneous pulmonary valve implantation (PPVI). The most recently available 3D image fusion software (VesselNavigator, Philips) extends this technology to use pre-registered computed tomography or magnetic resonance imaging datasets, promising reductions in contrast and radiation exposure along with shorter procedural times.

METHODS

In this retrospective review, patients were assigned to three groups according to the mode of imaging guidance: two-dimensional angiography (2DA), 3DRA and VesselNavigator (VN) assisted valve implantation. Patient characteristics and catheterisation data were reviewed with a focus on contrast and radiation exposure, fluoroscopy, and procedural times.

RESULTS

Between July 2012 and June 2016, 21 patients underwent PPVI: 8 with 2D guidance, 6 patients with 3DRA and most recently 7 patients with VN assistance. Patents in the VN group received significantly less absolute and weight indexed contrast when compared with those with 2DA or 3DRA guided PPVI. Patients in the 2DA group received a significantly higher total dose area product radiation dose and air kerma in comparison with patients with 3DRA and VN guided intervention. Application of VN resulted in the shortest fluoroscopy time, although not statistically significant, and a significantly shorter study time when compared with 2DA.

CONCLUSIONS

Utilisation of pre-intervention image manipulation with VesselNavigator for 3D guidance of PPVI results in a reduction in contrast and radiation exposure and study time as compared with traditional 2D guidance, and contrast usage as compared with 3DRA.

Use of pre-intervention imaging with a novel image fusion software for guidance of cardiac catheterisation in a patient with pulmonary atresia and major aortopulmonary collaterals

We present a 3.5-year-old patient with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals, after repeat implantation of a central shunt, in whom we successfully re-purposed previous imaging scans with a novel image fusion software to guide diagnostic heart catheterisation. The pre-registered CT scan was segmented before the procedure and subsequently manually fused with two-dimensional fluoroscopy images. The overlaid roadmap enhanced selective cannulation of all major vessels originating from the aorta, making aortography unnecessary.