0:04

Now one of the things that I always encourage you

0:06

to do right off the bat when you're looking at a TAVR case

0:10

is to kind of look at your anatomy of your, of your valve,

0:14

look at your anatomy of the heart structure

0:16

and function to kind of get you an understanding of what,

0:18

what you're going to be doing.

0:20

So what I usually do is I kind of orient my planes

0:24

into the three chamber, four chamber views,

0:26

and I look at the systolic function, wall thickness

0:30

of the heart and the ability for us to kind

0:33

of really assess the anatomy of the heart.

0:34

And here you can see that the ventricle obviously has

0:36

increased wall thickness, normal systolic function.

0:39

You can see that there are really no regional wall motion

0:42

abnormalities with other, you know,

0:45

no significant high risk findings.

0:47

A lot of coronary artery disease, obviously

0:49

as expected given the age of a patient.

0:51

But overall, you know nothing that is too out

0:55

of the ordinary, a dilated right atrium.

0:57

And you can really get an anatomy of the mitral valve.

0:59

You can get an anatomy of the cuspid valve, so,

1:02

and the pulmonic valve as well as the aorta.

1:05

Once I've looked at and assessed that information,

1:07

usually I fill that as part of my report.

1:09

And if you wanted to get an eject fraction assessment,

1:13

you just click this and the workflow recon will walk you

1:16

to the workflow and automatically trace an in dia

1:19

and sly to give you those volumetric assessments if you need

1:22

to for the sake of time.

1:24

And more importantly, not causing a lot of issues

1:26

with the workflow itself

1:27

because this is not something necessarily that you need

1:30

to do for a TAVR case.

1:31

We'll leave that off for now, but if you want me to go over

1:33

and I'm happy to show you how to do that.

1:36

The next thing that I tend to do is, uh, I tend

1:40

to reset my, my NPR.

1:42

And what I'm going to do is I'm gonna look at the anatomy

1:45

of the aortic valve and what I'm interested in seeing.

1:49

It's kind of twofold. I'm interested in seeing

1:52

how the valve itself opens it's anatomy.

1:54

You can see that it's a tri leaflet aortic valve.

1:58

I'm going to also look at the annulus.

2:00

And this is this anatomic area

2:04

that we've made for imaging purposes,

2:06

but it's not really defined by anatomy.

2:09

And I look at it to ensure that there's no evidence

2:11

of calcification.

2:13

Once I've looked at it, I tend to pause

2:15

and I think one of the phase, starting from 25

2:20

all the way through 40.

2:21

And what I'm going to do are a couple of things.

2:23

One, I'm gonna get an assessment of its dimension,

2:26

meaning I wanna see when the valve is definitely

2:29

most open and or mid.

2:33

And more importantly, I wanna see it when the annulus has

2:36

the sharpest and largest dimensions.

2:38

25, 30, 35.

2:42

You see how the annulus here is notably larger.

2:45

You can see that the valve is starting to get closer

2:47

to the end by 40%, the valve is closed.

2:50

And 45, you've definitely completed six delete.

2:54

So you go through these phases

2:55

and you notice that between 25

2:58

and 35 is better, is the largest dimensions.

3:02

Obviously 25 is a little bit too early in systole,

3:05

so we usually tend to go towards like midsole. And

3:09

You know that 35%. So

3:11

Once I have my 35% Anatomy, this is where I now

3:15

Turn my workflow to the TAVR workflow.

3:19

Now there are a couple of things that you can do

3:22

for this overview, and if you click on this, uh,

3:25

terra recon will kind of get you through

3:27

and move on to kind of assess where the aortic

3:29

Valve, I'll show

3:31

You how to do this, but it's not something that

3:33

I am a big fan of letting terra recon do when it comes

3:37

to the extracting of the aorta.

3:38

But it's something that I wanted to show you how it can do.

3:41

It gets rid of a lot of your volumetric assessment.

3:44

Obviously, you're just looking at the heart

3:46

And it can be time consuming just to create a route

3:49

That this stuff really isn't necessary for, for

3:52

You to be able to get the measurements you do.

3:55

But I wanted, I wanted to go through it.

3:57

Now you notice I'm seeing extracting the order

4:00

and you're thinking you must be doing something significant.

4:02

It's really just creating this volumetric assessment,

4:05

Uh, Volumetric rendering on that intense seeds.

4:09

The plugin failed in one of the more phase,

4:11

but again, we just needed to work on this particular phase

4:14

'cause that, that that's, that's the cardiac phase

4:16

That, that we're doing it in, right?

4:19

So if it mutually gives you a plugin failure

4:21

or anything, you know, it, it's wanting you

4:24

to validate all these me center lines, great.

4:27

I, I would not be too worried about these things,

4:30

but I would encourage you to,

4:31

and again, it's trying to start getting into

4:34

that orientation of your valve, right?

4:36

And, and what, what I mean by that is,

4:38

like we talked in the lecture, you're going

4:41

to get this aortic root oriented toward the center

4:44

and you're gonna wanna have your,

4:46

your valve oriented you in a, in a bubble leak orientation.

4:52

Once you have this valve in a double oblique

4:54

orientation, right?

4:56

You're gonna move through this

4:58

and you're gonna use the right coronary cusp as your,

5:01

as your landmark.

5:03

I'm gonna come right to the bottom of

5:05

that right coronary cusp.

5:06

See right here, see where we are correctly here.

5:09

I'm gonna try to see if I can show my, uh,

5:14

my cross hairs all the way through

5:16

so you can really kinda appreciate without a gap where the,

5:20

where the intersects of this line are.

5:23

Once you have this, you can rotate around

5:26

and you're gonna turn kind

5:27

of like towards eight o'clock position.

5:30

And in this position, you're gonna kind

5:31

of get into the short axis

5:33

and your goal is to move this plane away

5:38

from, from the heart, right?

5:40

You're gonna wanna be right through here, kinda

5:45

roll right through where you're not capturing that.

5:49

See we're right at the bottom of it.

5:50

And there on this end, you see

5:52

how this plane intersects through here.

5:54

You're gonna come just right to the bottom of

5:56

It, it to where you can lose.

5:59

See here on the short axis,

6:01

you can really see the end of it.

6:02

Now the reason why I'm making you do this manually, I find

6:07

that, that you really can limit the, uh, the accuracy

6:11

of your measurements depending on how you approach this.

6:15

Now once you have this, there's a couple of measurements

6:18

that you're going to need to make or, or locations

6:21

and anatomical you need to name.

6:22

This is the first landmark, which is the points in this.

6:26

Now, one of the first things you wanna do is you're gonna

6:28

turn your volume retrospective into this half space.

6:32

I don't know why I did that. So I'm gonna undo that.

6:34

We'll do that after we monitor landmarks in

6:36

case it starts to move off.

6:38

But you're going to begin

6:41

by marking your landmarks using this triangle.

6:44

Now, Terracon likes you to start

6:45

with the left, which is fine.

6:47

So this is the left coronary cusp.

6:49

Then you're going to go to the right coronary cusp,

6:51

which is here, and then you're going

6:53

to the non coronary caster, right?

6:57

And it's going create this line.

6:58

Now, you should be able to turn this into half.

7:02

You should be able to window your way through it, pan out,

7:06

see where these landmarks are, right?

7:08

You're gonna go to your landmarks, click three times

7:12

and you're going to then now use this to kinda

7:15

assess the position of your landmarks on, on these views.

7:18

Use. As you scroll through, you can see how

7:21

this ended up here.

7:22

So you can see

7:24

how the left coronary cusp marking ends up being there.

7:27

If you wanna move it closer. See, I moved it closer.

7:29

That's not quite to where I want it to be.

7:32

So if you are like, no, I I I made a mistake, just undo,

7:37

undo again, sorry, you can undo again.

7:41

But it, it doesn't quite respond like what you need it to.

7:44

You simply just find your, uh, your anatomical location and,

7:49

and bring it from now.

7:51

Okay? Okay. So you wanna move it

7:53

through these planes to kind of assess.

7:55

So again, you look at these check on each plane to ensure

7:59

that the non-ordinary cusp, you see

8:01

how it's right at the root that's in a good position.

8:03

So I'm not going to move it.

8:05

You're gonna come to the right,

8:07

which is in an excellent position here, so I'm not going

8:10

to move it in the left.

8:12

Coronary cusp leaflet marking tends to be right at

8:16

that intersect point where, where you need it to be, right?

8:20

Once you've had those there, Rico's gonna ask you

8:23

to mark where the esophagus is.

8:24

You come to the arrow mark where the esophagus is,

8:28

and then you go to the views.

8:29

These are the cusp views that you'll need.

8:32

So if you click on the C-arm icon,

8:34

it'll give you the three cuss view.

8:36

You can capture this image for your report interior view.

8:40

It gives you the orientation in the CR and the,

8:43

and this view, which are the views that the,

8:46

the interventionists are going to use for this.

8:49

Right? After this, you're gonna come double click on this

8:51

and you're gonna do the annual list measurement.

8:54

And once you click this donut, you have two options.

8:56

You can press shift or you can just kinda hold your left,

9:01

click onto recon

9:04

and just move this around.

9:07

There are different ways to kinda or orient this.

9:11

Once you've clicked this, you can click shift if you need

9:14

to make some adjustments, okay? It'll ask

9:17

If this Is something that you wanna do or not,

9:19

or if you wanna change the changes and,

9:21

and kind of ensure that the borders end up being where,

9:25

where you need 'em to, right?

9:28

I'm not a big fan of having to do that myself.

9:31

That's just, you know, my personal opinion.

9:34

'cause I don't wanna like, I don't like using too much

9:36

error, but I'm just demonstrating here

9:38

how you can measure these things.

9:40

Once you have this and you've got your measurements,

9:43

it's going to give you all of these things.

9:45

It's give you the major axis, minor axis.

9:48

I usually like to look to ensure that it is giving it

9:51

to me at the widest possible measurement, right?

9:55

And then obviously it's positioned properly.

9:57

You wanna be here to this end, this end to that end

10:00

to ensure that you get your measurements.

10:02

So in this case we got 24.6 or,

10:05

and by 19.9, which again,

10:08

those are the measurements that I would provide.

10:11

A 35% face, you have a mean diameter

10:14

or average diameter of like 20, 22 0.4.

10:19

And then you have a perimeter of 71.5 millimeters

10:23

with an area of 393

10:24

Centimeters squared. So once

10:25

you have this, you have then the next

10:28

Challenge And part of your report is

10:30

to look at the coronary heights.

10:33

Now usually you're gonna start with the left coronary height

10:36

and the left coronary height is going

10:37

to be right on this view.

10:39

Remember based on our lecture, you're gonna make

10:43

that measurement from the,

10:46

Uh, bottom Of the, or the root of

10:49

or the lower border of the coronary main To the plane.

10:54

See this to this plane? There you go.

10:56

And if you need to adjust it, you just simply adjust it.

10:58

So yes, 14.6 millimeters on,

11:02

on this coronary osteo height.

11:05

And, and then you have where, where that is.

11:08

So let me continue

11:10

and give you the rest of the measurements.

11:12

So now we're going to look at the, um,

11:16

at the left coronary cusp.

11:18

Um, so let me get this next one

11:22

and we're gonna go to the right.

11:24

And again, you go from here to right about here.

11:28

See 11.5 millimeters, 14.6 millimeters. Okay?

11:33

So now that we have those

11:36

and we have the coronary heights, the next step is

11:39

to measure the sinuses.

11:41

So I like to look at the sinuses starting with the left.

11:43

So I measure from the top of the sin tubular junction

11:47

to the the annular plane.

11:50

And then you're gonna do the same thing for the right,

11:53

You're going to come to the right

11:55

and you're gonna measure from the top of the sinus

11:58

all the way down here, right?

12:00

So now you have those. Next you're gonna measure your

12:04

sinus mean diameter.

12:06

And again, this is one where you

12:09

know you can move your plane to the sinuses, right?

12:15

And inter recon will allow you to do this.

12:18

I usually like to measure from, you know,

12:21

commissure to sinus.

12:22

That's what the SECT guidelines recommend.

12:25

So I usually include another measurement.

12:28

Last but not least, uh, one last measurement here. See?

12:33

So then you have those three measurements, sinus,

12:35

the commissure to sinus, the commissure, right?

12:38

And then you move up to your synott tubular junction.

12:41

So you come right all the way to the sano tubular junction

12:46

here, right?

12:47

So then your position, and again, you make a measurement

12:52

from this end to this end.

12:55

And last but not least, yeah.

12:57

And you're going to make a measurement from this

13:00

end to include that.

13:01

'cause the calcium is diseased.

13:02

So you include in your measurement, right?

13:05

Last but not least, you then proceed

13:07

to your ascending aorta.

13:08

And this is one where, whether you wanna do it on this phase

13:12

or if you wanna do it on another phase,

13:14

really there is no no preference.

13:17

I usually like to include the ascending aorta measurement in

13:20

my systolic phase

13:21

because this is when we're gonna be deploying the valve.

13:24

This is the phase where it's likely going

13:26

to have the most, uh, significance.

13:28

So they'll ask you if you want

13:30

to unlock your valve plane to do this.

13:32

And the answer is yes, obviously you're gonna want

13:34

to be at the widest dementia for this, for this, right?

13:39

So then you continue to your aorta

13:42

and you're gonna continue to your aorta o on this end.

13:45

See right along here.

13:47

So now that you've got your aortic measurements

13:50

and you've gotten those things, you're gonna wanna get

13:52

to the abdominal aorta and the rest of your angiogram.

13:55

This is the part where things get a little bit complicated,

13:57

but you come to your series management

14:00

and you're gonna go load series, okay?

14:03

There are recon, load the series

14:06

and then you'll switch to it.

14:08

See that? So this is how terra recon is going to allow you

14:12

to switch between one part

14:13

of the TAVR protocol and the other.

14:16

If you don't do that, oftentimes you may get an error

14:19

that you know, you're trying to do too many things at once

14:22

and then, you know, you get confused.

14:23

I get confused and everybody gets confused.

14:26

Now, when you are in this, you go to workflow, right?

14:29

And you go where it says curve multiplayer reconstruction,

14:32

you're gonna go to auto, okay?

14:35

And then you're simply going to pick,

14:37

you can pick on the 3D, which vessel you want to assess.

14:41

So I usually look at the s

14:43

and you should crack it all the way down.

14:47

Okay? And then you come back

14:50

to it, show you this.

14:54

So you're going here and again, you come back

14:56

to your 3D and there you go.

14:57

Now, once you've had this iliacs here, left

15:00

or right, the nice thing,

15:02

and you know this is a nice feature of to recon,

15:04

is you got this measurements.

15:06

Now this measurements, uh, may not necessarily be the,

15:11

the measurements you're interested in seeing or,

15:13

or you may have an issue with the accuracy like, oh look,

15:16

that may be off, or it's not, it's not correcting it to

15:20

where I need it, et cetera.

15:22

I wouldn't be too worried about those things in the sense

15:25

that I'm gonna show you how to adjust these.

15:28

You can adjust this with the threshold

15:32

and just kinda press shift and hold.

15:35

Uh, and by holding this, it'll, it'll allow you

15:39

to measure your border to to where you need it to, right?

15:42

So that's a nice feature.

15:44

See how this is all disrupted come to threshold

15:48

and oh, just my click left, click holding it will correct a,

15:53

a measurement to, to

15:54

where the threshold needs to be where it is.

15:56

So that's just one example of

15:58

how you can make those measurements automated.

16:01

Now, you don't have to measure every segment of it,

16:03

but if you notice that, uh, it's not doing

16:07

what you're supposed to, then let me see.

16:11

There you go. Okay, threshold here, get rid

16:14

of the inner lumen and then you can correct for it

16:18

accordingly, right?

16:19

And it'll give you those measurements.

16:20

So once you have those areas of interest,

16:24

like the ascending aorta we've measured already,

16:26

you need a descending aorta at the arch in

16:29

between those three vessels.

16:30

And again, you just, uh, press shift,

16:34

hold the threshold button

16:36

and it should let you, you should be able to, um,

16:42

to do this without too much of an issue.

16:46

So if it still gives you grief

16:47

or you have too many problems,

16:48

you simply come, yeah, that's what it wants.

16:50

I got rid of the lesion. Yeah. So yeah, that's what it is.

16:56

So we go from here

16:57

and again, you can see how the measurement should go,

17:02

it should go on.

17:05

There you go. There it is. And it's just a bug in this.

17:10

So I was holding it too long. Too many clicks.

17:13

So you go through it

17:14

and you'll be able to kind of give you

17:16

what the thresholds number are for each segment

17:18

of, of the aorta.

17:20

Okay? Now last

17:22

but not least, um, if you need to make the measurement

17:25

or you feel you don't wanna trust the machine,

17:27

or it's giving you too many issues,

17:29

you wouldn't worry too much.

17:30

You come back to your measurements, uh,

17:33

you do the tavr, okay?

17:36

And we'll walk you through like each one of the centers.

17:39

So like the diameter of abdominal aorta, you just scroll

17:43

through this phase, right?

17:45

Scroll right through, tell you where, oh,

17:50

it'll tell you where you are in the aorta, right?

17:53

You can follow deletion area

17:55

and you can just make your measurements yourself for

17:59

smallest, largest diameter and, and continue your needle.

18:03

Keep track of each one of those if you come

18:05

to the right common iliac.

18:06

So again, you just move your,

18:08

or in this case, the left column iliac,

18:10

come right here and see it already.

18:12

Make the measurements. So just a matter of continuation

18:16

to ensure that the measurements

18:17

that you get are where they need to be.

18:19

And ensuring that you document the smallest diameter when

18:22

you do get to the femoral head

18:24

here might be a little bit different.

18:25

'cause obviously this patient has, uh, hip surgery,

18:28

but you wanna make sure you get those diameters documented

18:31

and put in your report as, as we've

18:33

provided, if you need to switch vessels,

18:35

you can simply do the same thing

18:37

and continue to, to, uh,

18:39

to make those measurements individually.