Computed tomography angiography/magnetic resonance imaging-based preprocedural planning and guidance in the interventional treatment of structural heart disease

FIGURE 1. Proposed and conventional approach to include planning details during interventional procedures. Conventionally, a preprocedural 3D image is prepared for image fusion using an image fusion-focused proprietary software system (PSS), i.e., segmented and planning details added with integrated modules. Due to proprietary and vendor-specific implementation, data generated by independent sources, such as open-source software (OSS) or planning-focused PSS, can usually not be considered for intraprocedural guidance; however, providing more powerful planning support than fusion-focused PSS. To avoid the resulting restrictions, planning details exported from the planning tools as surface meshes, centerline coordinates, or annotated 3D DICOM image volumes were converted to generate an interface to the image fusion software. Thus, enabling the use of vendor-agnostic planning data during image fusion and procedural guidance.

FIGURE 2. Transcatheter tricuspid annuloplasty. (A) CTA-derived optimal first anchor position. (B) Patient-specific anchoring is shown in angiographical simulation with marked anatomical landmarks including the right coronary artery (RCA, green), aortic root (AO, yellow), and tricuspid valve annulus (TV, red). (C,D) Manual registration based on angiographies of the RCA. (E) Image fusion of anatomical landmarks (red), trajectory (orange), and anchors (blue cylinders) during implantation of the first anchor (white arrow). The catheter is aligned with the vena cava inferior. (F) Image fusion of the lastly implanted anchor. Anchor heads are aligned with the planned trajectory. The commissures (blue spheres) indicated a potentially higher risk of the catheter slipping off the annulus.

FIGURE 3. Transcatheter aortic valve replacement. (A) CTA-based determination of the transfemoral puncture site. (B) Volume rendering shows the route for implantation of the cerebral protection device. (C) Overlay of the femoral centerline on fluoroscopy. Image fusion of the patient-specific vascular centerline (orange line) during (D) and after (E) implantation of the cerebral protection system. (F) Depiction of aortic cusp hinge points (yellow circles), coronary ostia (red and blue circle, arrows), and aortic centerline (orange line) during valve implantation.

FIGURE 4. Transcatheter mitral valve replacement. (A) CTA-based identification of relevant anatomical landmarks, including pronounced trabecularization of subannular left ventricular walls (arrow) bearing the potential for entanglement during subannular looping. Determination of optimal C-arm angulation with panel (B) showing the simulated short-axis view including determined mitral (red) and aortic valve annuli (yellow). (C) Manual registration based on aorta (AO) and right atrium (RA). (D) Image fusion in the short axis view shows the loop placement catheter (white arrows) aligned to the mitral valve annulus. Image fusion in a 4-chamber view indicates the target area and correct positioning of the ring to which the prosthesis is attached (E) and a good correlation between successfully implanted HighLife™ valve after valve implantation (F).

FIGURE 5. Transseptal puncture. (A) MRI-based identification of the interatrial septum. (B) Simulation of posterior–anterior projection including MRI-based identification of left atrial appendage (LAA), septum, transseptal puncture (TSP), and vena cava (VC). (C,D) Manual registration is based on the aortic arch (AO) and right atrium (RA). Image fusion during TSP (E) and after successful access to the target structure (F).

FIGURE 6. Left atrial appendage occlusion. (A) MRI-based assessment of left atrial appendage (LAA) shape and diameters. (B) Angiographical simulation including defined ostium (orange) and landing zone (green). (C,D) Manual registration based on right atrium and aortic arch. Image fusion includes planning details during the approach to the LAA (E) and after occlusion (F).