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With this next video we're gonna discuss how to approach measuring the sinus of

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Al Salva widths and heights.

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I'm gonna be showing you a manual approach using just a standard double bleak M

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P R approach that I'm using on my packs. Certainly I think,

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uh, many of you will be using, uh,

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three D software that can help assist you get the annular planning and make

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these TAVR measurements a lot easier.

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But conceptually the same measurements will be made whether you're using a

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manual approach or a software assisted approach.

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So I'm gonna show you the manual approach next.

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So I've got a standard double oblique N P R.

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We've got the axial coronal and sagittal planes. This, uh,

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upper left hand image you can ignore for now that's just defined by this red

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plane here, which is freely, uh, movable independent of the others.

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So let's start with, um, defining our annular plane,

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which is the beginning point for all of our measurements.

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And what I'd like to do is start with the coronal image here,

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just as I've shown in previous videos,

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start with the coronal image and then drop the um,

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cross hairs right at the point where the cusps for the aortic valve

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leaflet come together. And then once I do that,

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I wanna rotate my axial plane so that it's parallel to the aortic valve.

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I'm gonna do that and then I'm also gonna do the same thing on the sagittal

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view. Again, I'm gonna look for where these leaflets come together.

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Then I'm gonna place my cross hairs in the middle.

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And finally I'm gonna rotate my axial plane counterclockwise

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so that I'm more or less parallel to the aortic valve plane.

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Once I've done that, I should have a really nice look at the aortic valve,

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which I see here. This is a tricuspid valve.

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I see some relatively mild to moderate calcifications and you can see that the

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opening of the valve leaflets is restricted in this patient as these images were

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obtained in in sly. So I'm gonna try to find the ideal, uh, annular plane.

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As I've uh, shown on previous videos,

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it looks to me like there's quite a bit of asymmetry between the leaflets as I

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scroll down towards the annular.

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So I know I'm not quite right in terms of my plane location.

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What I'm gonna do is I'm gonna rotate this plane here so that I'm

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bisecting the non coronary cusp and that allows me to get a

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nice plane for adjusting the sizes of the asymmetry

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of the valve cusps. So now that I've done that,

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I'm going to just adjust a little bit this plane in the bottom right and I see

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that that actually changes the symmetry of the right and the left cusps.

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Here in this upper right hand image, as I move clockwise and counterclockwise,

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they become more and less symmetric and I'm shooting for that perfect symmetry

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between the right and left cusps. So something like that.

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And then for this other plane in the bottom left hand corner,

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I'm grabbing this coronal oblique plane here and I'm gonna rotate it clockwise

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and counterclockwise. And that's gonna adjust the symmetry

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Between the more anterior right and left cusps and the more posterior

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non coronary cusp.

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So you see how as I adjust that the symmetry becomes more and less

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symmetric, right? Just ignore that red line that's jumping around there.

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So I'm gonna stop where I find the nice and symmetric and then I'm gonna

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continue to scroll down towards the annulus one more time here.

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I'm a little bit asymmetric where my non coronary cusp is a little bit bigger

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than the others.

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So I made a tiny adjustment and then maybe here my right is a little bit bigger

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than my left, so I'm gonna make a tiny uh, adjustment again.

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And then finally when you're kind of happy,

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you get down to the bottom and you see all those coronary cusps disappear at

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exactly the same time as you click down those slices.

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And now I'm at the annular plane. Now here,

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don't move the location of your plane.

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You wanna make sure you capture that plane because that's where you're gonna

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make your measurements from.

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And so how do you go about measuring the sinus of El Salva heights from here?

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Well, basically what I tend to do, let me scroll up one more time,

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is I actually go from the clock face. So, um,

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if I'm calling this kind of a clock with 12 o'clock at the top and six o'clock

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at the bottom,

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that's the middle of the right coronary cusp and the commissure between the left

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and the non.

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So the middle of my cusp is at around 12 o'clock around the sort of four o'clock

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position and then around roughly the eight o'clock position. So as I head down,

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I'm going to rotate so that my plane is at around the 12 o'clock position.

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Um, I can scroll up just to be sure.

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And there I am at 12 o'clock and I'll go down to Thelist right there.

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And now I know that here I need to measure this leaflet and I'm looking for the

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right coronary cusp.

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That's the one that's going to be right up against the right ventricular outflow

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tract here. So I gotta figure out where that is

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from these planes. I should also,

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sometimes if you wanna find some other landmarks,

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you can look for the right coronary artery by scrolling through that.

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So I know that my right coronary artery actually is down here.

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So I'm going to be able to use this cusp. This is my right coronary cusp.

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I move my annular plane down first. So I'm gonna make my measurement right here.

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And again, you're gonna do a straight measurement from uh,

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the perpendicular of the annular plane all the way up to the top of the synott

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tubular junction. So that's the right coronary cusp and it's 26 millimeters.

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Now I want to go and look for the left coronary cusp.

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What I like to do just to not get lost,

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is I actually like to take the same plane.

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So I know this line right here is going through the right coronary cusp and I'm

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gonna rotate that line through to the left

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and I'm gonna keep going until I hit the middle of the left.

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And now I know that that same image that I use to measure

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the right I can use to measure the right.

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So I'm gonna still be measuring on the right hand side of this image here and

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that's gonna be my left coronary sinus.

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And so I just need to scroll back down to the level of the basal plane.

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And then again, please ignore the red line, which is a little bit confusing.

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I go down from the synott tubular junction,

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a straight drop to the level of the a**l plane,

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and that's my height for the left coronary cusp. That's 20 millimeters.

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If you're ever concerned that you might have it wrong,

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you can always do some adjustments to again see the left coronary origin.

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That's my left coronary origin.

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So I know based on this image that I'm really close to the left coronary origin

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and sure enough, that's right where I'm there so I'm in the right spot.

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And then again, just for simplicity,

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what I like to do is continue to rotate this same plane here

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all the way through the non coronary cusp right there.

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I know then that the same side of the same image that I've been measuring,

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I can use again for my non coronary cusp,

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but all I need to do is go down to the basal plane here or the annular plane

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and then make my measurement from synott tubular junction to the annular plane

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just like so. And that's 23. So we report all three measurements,

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then take the average and uh, that'll give you the mean uh,

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sinus of el Salva heights. Now what about the widths? These are actually much,

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much more simple to measure the widths.

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You go to what looks like the middle of the sinuses of al

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Salva and you drag your plane up to the widest part and then

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you make your measurements there. I kind of eyeball it a little bit too,

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just to make sure. I think I'm at the widest part.

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Looks like that's about the widest.

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And then you do cusp to commissure measurements. So that's from the commissure,

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which is where the two leaflets come together.

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This is the commissure for instance,

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for the way this is the commissure between the right and the left leaflets right

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here, commissure between the left and the non leaflets is right here,

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commissure between the right and the non right here. So I'm gonna get again,

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to the widest part of my sinuses.

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I'm gonna measure cusp to commissure three times

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and I get three different measurements. 31, 32, 33.

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You take the average of 32 as the average sinus of salvo diameter.

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And uh, that's a manual approach. Doing these measurements,

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you can see that they're a little tricky using the uh,

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manual N p R mode. So certainly if you have available to you three D software,

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um, with a sort of a TAVR module to make this a little bit easier,

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that can help quite a bit. So yeah,

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this is just a summary of the approach to doing manual measurements of the, uh,

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science of Salvo heights and widths.