Patient-specific registration of 3D CT angiography (CTA) with X-ray fluoroscopy for image fusion during transcatheter aortic valve implantation (TAVI) increases performance of the procedure
- 237 Downloads
The aim of this study was to adapt patient-specifically a co-registration procedure for image fusion (IF) of a pre-interventional CT dataset with real-time X-ray (XR) fluoroscopy during transfemoral transcatheter aortic valve implantation (TAVI), enabling improved performance of the procedure.
The ability to use 3D models of the respective anatomies to complement the anatomic information obtained by XR fluoroscopy and provide a greater degree of real-time anatomical guidance holds great potential for complex cardiac interventions, especially for TAVI procedures with cerebral protection.
Initial registration of two datasets was performed during the femoral puncture and sheath introduction using routinely acquired arteriographies. On-time refinement of the co-registration was then performed during the on-going procedure avoiding additional angiograms for the co-registration. Performance of the method was evaluated quantitatively in terms of procedural characteristics and clinical events.
Significant reduction of the radiation dose [51 (42–55) vs. 64 (49–81) Gy cm2, p = 0.032] and contrast agent (CA) volume [80 (50–95) vs. 100 (80–110) ml, p = 0.010] was achieved with the optimized approach as compared to the control group without IF, with simultaneous decrease of procedural [48 (41–58) vs. 61 (53–67) min, p = 0.002] and fluoroscopy times [14.8 (12.7–18.5) vs. 17.8 (14.3–19.4), p = 0.108].
In this proof-of-concept study we have demonstrated a novel co-registration approach for IF during TAVI not requiring any additional CA or XR scan. We have evaluated its potential benefit with the strong focus on guiding the femoral puncture, placement of the double-filter cerebral embolic protection device, and deployment of the valve prosthesis. We achieved improved performance and safety of the procedure with the introduced approach.
KeywordsImage-based intervention guidance Image fusion Novel co-registration approach CT angiography Double-filter cerebral protection system TAVI
The authors would like to thank Dr. Horst Brunner (Dept. Radiology, Ulm University Medical Center) for ongoing support in CT data acquisition and protocol optimization.
Compliance with ethical standards
Conflict of interest
On behalf of all authors, the corresponding author states that there are no relationships that could be construed as a conflict of interest.
All procedures performed in study involving human participants were approved by the local institution’s ethics committee.
- 2.Schwein A, Chinnadurai P, Shah DJ, Lumsden AB, Bechara CF, Bismuth J (2017) Feasibility of three-dimensional magnetic resonance angiography-fluoroscopy image fusion technique in guiding complex endovascular aortic procedures in patients with renal insufficiency. J Vasc Surg 65(5):1440–1452CrossRefPubMedGoogle Scholar
- 3.Ierardi AM, Duka E, Radaelli A, Rivolta N, Piffaretti G, Carrafiello G (2015) Fusion of CT angiography or MR angiography with unenhanced CBCT and fluoroscopy guidance in endovascular treatments of aorto-iliac steno-occlusion: technical note on a preliminary experience. Cardiovasc Intervent Radiol 39(1):111–116CrossRefPubMedGoogle Scholar
- 16.Thirumala PD, Nguyen FD, Mehta A, Schindler J, Mulukutla S, Jeevanantham V et al (2017) Perioperative stroke, in-hospital mortality, and postoperative morbidity following transcatheter aortic valve implantation: a nationwide study. J Clin Neurol 13(4):351–358CrossRefPubMedPubMedCentralGoogle Scholar
- 19.Bernhardt P, Rodewald C, Seeger J, Gonska B, Buckert D, Radermacher M et al (2016) Non-contrast-enhanced magnetic resonance angiography is equal to contrast-enhanced multislice computed tomography for correct aortic sizing before transcatheter aortic valve implantation. Clin Res Cardiol 105(3):273–278CrossRefPubMedGoogle Scholar
- 21.Karambatsakidou A, Omar A, Chehrazi B, Rück A, Scherp Nilsson J, Fransson A (2016) SKIN dose, effective dose and related risk in transcatheter aortic valve implantation (TAVI) procedures: is the cancer risk acceptable for younger patients? Radiat Prot Dosimetry 169(1–4):225–231CrossRefPubMedGoogle Scholar
- 22.Möllmann H, Bestehorn K, Bestehorn M, Papoutsis K, Fleck E, Ertl G et al (2016) In-hospital outcome of transcatheter vs. surgical aortic valve replacement in patients with aortic valve stenosis: complete dataset of patients treated in 2013 in Germany. Clin Res Cardiol 105(6):553–559CrossRefPubMedGoogle Scholar
- 24.Kim W-K, Meyer A, Möllmann H, Rolf A, Möllmann S, Blumenstein J et al (2016) Cyclic changes in area- and perimeter-derived effective dimensions of the aortic annulus measured with multislice computed tomography and comparison with metric intraoperative sizing. Clin Res Cardiol 105(7):622–629CrossRefPubMedGoogle Scholar
- 28.Wöhrle J, Gonska B, Rodewald C, Seeger J, Scharnbeck D, Rottbauer W (2016) Transfemoral aortic valve implantation with the new Edwards Sapien 3 valve for treatment of severe aortic stenosis—impact of valve size in a single center experience. PLOS ONE 11(3):e0151247CrossRefPubMedPubMedCentralGoogle Scholar
- 30.Kappetein AP, Head SJ, Généreux P, Piazza N, van Mieghem NM, Blackstone EH et al (2012) Updated standardized endpoint definitions for transcatheter aortic valve implantation: the valve academic research consortium-2 consensus document (VARC-2). Eur J Cardiothorac Surg 42(5):S45-60CrossRefPubMedGoogle Scholar
- 41.Thourani VH, Forcillo J, Beohar N, Doshi D, Parvataneni R, Ayele GM et al (2016) Impact of preoperative chronic kidney disease in 2,531 high-risk and inoperable patients undergoing transcatheter aortic valve replacement in the PARTNER trial. Ann Thorac Surg 102(4):1172–1180CrossRefPubMedGoogle Scholar