0:00

Hi everybody, and thank you for joining us

0:03

for our very last office hours for this course,

0:06

um, for week 10.

0:08

Dr. Feni will be reviewing the, uh, five cases for week 10.

0:13

Just a reminder, if you have a question, you can ask Dr.

0:15

Feni directly where you can put your question in the chat

0:19

or use the emoji to raise your hand and we will call on you.

0:23

So, Dr. Fanni, whenever you're ready.

0:27

Okay, so we're gonna do this, uh, case, uh,

0:32

case one for this week.

0:34

This was probably the hardest case for the course

0:38

because of the complexity of the question being asked

0:42

and really what the goal of this is.

0:44

Now, in this particular case, I think, you know,

0:48

the most important thing for us to really focus on,

0:51

and the goal for this is just to kind

0:53

of go over the evaluation of bioprosthetic valve dysfunction

0:56

and how cardiac CT does

0:58

and what we can do for pre-procedural planning.

1:01

So in this case, you know, as this case

1:03

of seven 4-year-old male had a previous aortic valve

1:06

replacement, and we provide you the size of the valve,

1:09

it's a 23 millimeter, uh, carpentry Edwards magnet 3000.

1:14

And, you know, the clinical VEA shows

1:17

that the patient's having symptoms of shortness

1:18

of breath fatigue to kind of, kind

1:20

of put you along into the evaluation of the cardiac function

1:23

and valve prosthetic dysfunction on the echo, suggesting

1:26

that this valve's abnormal.

1:28

So in this particular case, what we wanted

1:30

to focus on is like how do we evaluate this valve

1:33

and how do we look at it?

1:35

So one of the first things that I did is I loaded,

1:38

in this particular case,

1:40

the cardiac phases at 10% intervals.

1:44

You can, I, I don't know if yours has the same issue

1:47

as mine, it shouldn't, but mine would not let me load all,

1:50

you know, 20 phases at 5% intervals,

1:54

but you don't necessarily need it,

1:56

meaning 10% intervals should be sufficient for you to do it.

2:00

If you wanted to do ejection fraction assessment, you know,

2:02

you need end diastole, which is zero,

2:05

and then ansys, which would be 95 rather than 90%.

2:08

So on that particular case,

2:10

you may wanna load just those two phases

2:12

to get those volumes assessed.

2:15

Regardless of that, you know, here in this particular case,

2:19

we're gonna be focusing on step part one of this

2:23

and that is looking at the valve itself,

2:25

which is the main purpose of this.

2:26

This study was not optimized for evaluation

2:29

of the coronary arteries, so it kind

2:31

of freeze you from having

2:32

to look at the coronaries in detail.

2:35

One of the first things you wanna do when you look at this

2:37

case is to look at the valve

2:40

and trying to line up your, your cross hairs

2:44

along the actual valve itself.

2:48

Ideally, when you're looking at this,

2:50

you wanna be in a preferably systolic phase.

2:54

I usually recommend and systole as a good starting point.

2:58

So we're talking like 40%, uh,

3:02

50% type thing.

3:04

And here at 50%, if you look at this screen, you can see

3:07

that the valve is completely closed.

3:09

And what you're gonna want

3:10

to do is you're gonna wanna line up your cross hairs

3:13

to be aligned with the valve plane gonna start being able

3:18

to scroll through the leaflets to assess.

3:21

Now, bioprosthetic valves, uh, native valves,

3:27

all these valves themselves always have

3:29

to be assessed at the tip of the leaflet in order for you

3:33

to kind of assess for mulching and wall thickening.

3:37

Now the expert consensus statement for the valuation

3:39

of this valves encourages you to use your planes

3:42

and to line them up in this section along each valve

3:47

plane to be able to rotate through.

3:50

See how in this swipe we're looking at this leaflet.

3:53

But in this one we're essentially looking at both

3:57

of these leaflets, perpendicularly and diagonally.

4:01

And what we're gonna try to do is I adjust my window levels

4:04

to really kinda allow the valve

4:07

to be visualized in detail

4:09

and kinda assess the degree of thickness.

4:12

A normal bioprosthetic valve,

4:14

a no normal native valve should be

4:16

so thin without significant degeneration

4:18

or thickening that it should be very difficult

4:21

for you to visualize.

4:22

In this particular case,

4:24

not only can you visualize the valve,

4:25

you can actually see it relatively well

4:28

and easy in in in its structure and its function.

4:32

Once I start playing, I usually like to scroll

4:35

through the image to kind of assess

4:37

how the leaflets themselves are moving

4:39

and to assess for restriction.

4:41

I start with movement

4:42

and then I work my way towards towards

4:45

the structure of them.

4:46

Here you can see that there is restricted motion,

4:49

particularly this leaflet correspond

4:51

to the left non coronary to the left coronary cause leaflet,

4:54

as well as a little bit more on the right coronary cause

4:57

leaflet, less so on the one in the non coronary.

5:00

Then as you can continue

5:01

to scroll further down towards the base of the ring,

5:04

you can actually start assessing a lot of this

5:07

calcification at the, at the base of the leaflets.

5:10

And you can see here the degree of calcification,

5:13

calcification in bowel prosthetic valves is almost always an

5:17

end product of chronic thrombosis.

5:21

Not necessarily like chronic clot,

5:22

but this hyper continuation leaflet thickening in the

5:25

fibrosis that comes as a result of it.

5:26

So it's a marker of that.

5:29

Once I've identified that, I usually like to scroll

5:32

through the leaflets themselves,

5:33

like I said in this same orientation

5:36

and kind of sets the degree

5:37

of leaflet thickening based on the extent of calcification.

5:41

You can see that there's calcium extending just from the

5:44

base, almost a little bit more than 50%

5:46

of the leaflet length as well as thickening

5:49

or extending all the way to the leaflet hip.

5:52

And that is how we assess the degree of hypo attenuation,

5:56

leaflet, thickening in the range of mild, minimal, mild,

6:00

moderate, and of course severe.

6:02

So you can assess that here.

6:03

You can see this on the same leaflet,

6:05

you can see less calcification here, more of

6:08

that low attenuation, leaflet, thickening,

6:10

and then some of the calcification near the tips.

6:13

You do the same thing for this other two leaflets.

6:15

And again, you look at the degree of calcification

6:18

and the degree of restricted leaflet mobility.

6:21

So that's where you can assess that there.

6:23

The valve itself,

6:24

and as you read in the description right there is uh,

6:29

abnormal leaflet thick in calcification on two

6:31

of the leaflets, the right coronary cusp, the left

6:35

and the non coronary cuff leaflets.

6:37

And then there is restricted motion, like what we said,

6:41

like hyper attenuation affecting mobility.

6:44

Now, once we have this,

6:46

then we're gonna get back into the approach that we did

6:48

with the TAVRs where we're gonna say, okay, we need

6:51

to replace this valve.

6:53

What I need to see when the valve is most open here,

6:56

you can see that at 30% the leaflets are opening at

6:59

their widest dimension.

7:01

And then more importantly, where can I embed

7:04

or what that valve is going

7:05

to look like when I embed, uh, a valve.

7:08

So what we're going to do is we're gonna change our workload

7:13

to the TAVR workflow.

7:15

Now what's different in this particular approach is yes,

7:17

you can click on the root and the overview.

7:19

I'd like you to just, once you've oriented

7:24

start moving your planes to get

7:26

to the ring at the base of it.

7:28

See we're gonna scroll down

7:30

and come right here at the true base and line things up.

7:34

The surgeon or whoever implanted this did a relatively good

7:37

job kinda in insert putting these leaflets in an orientation

7:41

that'll make it easier for you to, to line up in that plane.

7:45

So instead of going through the oblique measurements,

7:48

which you could say you click oblique

7:50

and then you end up all disoriented here

7:53

'cause the machine really wants to help you.

7:55

It's an option you can do and not against it,

7:57

but it's something, it's a step that I don't want you

8:00

to necessarily feel that you have to absolutely follow

8:04

for you to, to do this case.

8:06

So you come back up here, you kind of see your ring

8:09

and you're gonna go to the oblique measurements.

8:11

Now remember the landmarks remain the same.

8:14

We're gonna start with using the triangle and go to and,

8:18

and with the left.

8:20

And again, you are not gonna be as focused here

8:23

as you are on on the, on the leaflet themselves.

8:27

You're just gonna wanna come to the bottom

8:29

of like the actual ring,

8:31

like really the lower most port of the ring.

8:33

They're gonna come back up here.

8:35

And then on the right you're gonna do kind of the same thing

8:38

and you're using this to kind of orient you.

8:40

So you can see how this, uh,

8:43

right cusp leaflets right here in the right.

8:46

And then you're gonna come here towards the left

8:48

and again, kind of follow it to where you are

8:52

most oriented at the bottom.

8:54

And you see how here we're kind of

8:57

oriented in this direction.

8:59

Once you've had this direction, right, you're going to then

9:04

double click on this landmarks.

9:06

I would change this from from full to a half.

9:10

So you can start seeing the anatomy

9:12

and I would start adjusting my my window level.

9:16

So you can start seeing the transparency to,

9:18

to see the alignment of your, of your valve.

9:22

Now if you feel that your landmarks are off

9:27

or they're not right where they need to be,

9:29

you can't always come back and and erase them.

9:32

You have two ways you delete all

9:34

and this will allow you to move it

9:36

and kind of correct for this, uh, movement here, right?

9:40

So we're gonna hit, uh, left,

9:45

right, and not right.

9:47

So now we're in plain, I'm more comfortable

9:49

with disorientation.

9:51

What you'll do, you'll also again, mark

9:53

where your esophagus is.

9:54

Again, it's not something that you will not do without you,

9:58

you got your cuss views, you got the c-arm orientation.

10:01

Remember you acquire each one of those,

10:04

you put the c-arm orientation and you'll label it for you.

10:07

And then you, you'll come here

10:08

and you'll give you the orientation for that.

10:11

It's in this annulus geometry where this is going to be

10:15

probably the most challenging component.

10:17

So in order to prepare for that, I usually like to zoom in

10:22

and we're gonna let, uh, terra recon kind of work its way

10:26

around identifying where, where this is now you're gonna see

10:31

that the machine is going, the AI is going

10:33

to have a little bit of a challenge orienting,

10:36

especially when you're using the, the, the metal

10:40

as your, as your border.

10:42

Usually what I do is once I have it lined up, I tend to kind

10:46

mostly connect the dots

10:47

and try to stay in the middle of the rim, kind

10:50

of guide the orientation to ensure that I am as consistent

10:54

as I can be and

10:57

and maintain that annulus uh, dimension, right?

11:01

So essentially when we're looking at this,

11:03

you're looking at an annulus

11:06

of approximately 22 millimeters.

11:09

We know that from the carpentier magnet valves.

11:12

Again, this is something that you can look up.

11:15

There are applications for this,

11:17

but in all reality is

11:18

what you really need is this average diameter

11:20

that's your annulus diameter average

11:23

and that's gonna be your best determinant of what kind

11:25

of valves you'll need

11:27

for a 22 millimeter diameter derived perimeter from uh,

11:30

derive dia ans diameter of 22 millimeters.

11:33

We are looking at two types of valves.

11:35

If you're gonna do a sapiens valve,

11:36

you're usually looking at a valve of uh,

11:39

a sapiens valve number, uh, 23.

11:42

And if you're looking at a evolut pro valve

11:45

or an evolut effects, you're looking at a size 26

11:48

because if you know about those valves,

11:50

the mar maximum annulus diameter,

11:53

which would be this average diameter,

11:55

and it tends to be anywhere between 22 and 23 millimeters.

11:58

And again, these are things that as you get more experience

12:01

with these valves, you'll you'll learn what these are.

12:05

The next step really is probably the hardest step in this

12:08

procedure and that has to do with the, uh, anatomy.

12:13

So you'll have terra recon give you these options for,

12:16

for different valves.

12:19

So you have the option to kinda modify

12:24

or use or assess.

12:26

My advice to you is to kind either create a valve,

12:30

which I'm gonna show you how to do.

12:33

So the location we're gonna make a, uh,

12:37

a sapiens valve, the height of

12:39

that valve is always 18 millimeters

12:41

for a 23 vessel diameter.

12:43

The diameter being a 23 valve is not really 23,

12:46

but it's an annulus maximum distance of 22 millimeters.

12:50

So we're gonna make this into 22 millimeters in dimension.

12:55

See, just like this, yeah,

13:00

so the part code, which is name it three,

13:02

so you're gonna do 23 millimeter S3.

13:05

So now you're going be able to label it right?

13:09

Once you've made it and adjusted, you can undo this

13:13

and it automatically knows to offset the annulus at 80%,

13:17

meaning 80% of the valve is above the plane,

13:21

20% is right underneath the annulus, which is

13:23

what the manufacturer recommends

13:25

for the entire recon knows that.

13:27

And it's going to give you this option.

13:29

Now, instead of 3D vr, you can do fluoroscope

13:33

and this is the one, uh, image that you have seen on,

13:37

on the, on the case stitching

13:41

file where it allows you to do that.

13:42

Now, I try not to encourage you to move this

13:44

because if you move it, you will offset the annulus,

13:47

but if you do, don't be too concerned, right?

13:50

You're like, oh, I moved this, what do I do?

13:52

Now you can really come in here

13:54

and just set up this offset at 80%

13:56

and it'll allow you to, to maintain consistency in it

14:00

once you've had this valve embedded.

14:03

The next major measurement

14:05

that you're really interested in is going to be this

14:09

distance of this virtual valve to the left main,

14:13

which again, you can see here as you're scrolling

14:16

how the stent of this valve see the top of it

14:21

is going to be at the level

14:23

or right above the left main osteum.

14:26

So if you put a valve in it

14:28

and you open the leaflets, that leaflet essentially is going

14:30

to create a covered stent.

14:32

So if you're gonna have a covered stent, you're going

14:34

to assume that all of this is going to be covered.

14:38

So you want to see if there's space

14:40

between the covered stent and origin of your coronary bowel.

14:44

And this is where we measured from here to the oste

14:49

and get those measurements right.

14:51

In this particular case, the distance from the valve,

14:56

the sapiens valve to the OS

14:58

of the left main ends up being 7.9 millimeters.

15:01

You come up to where you see the os

15:03

of the right coronary artery.

15:05

And again, you need to measure this

15:07

and it ends up being anywhere between like five.

15:11

It's a little bit here, so it's about five millimeters,

15:14

which is what I would tell you.

15:16

I would take a picture of each one of these and go.

15:18

Now if you look here at your model, you'll see

15:23

how this valve is not gonna come anywhere

15:25

to the cubular junction.

15:28

You can also do this by verifying meaning I always like

15:31

to measure at the top of my uh, line

15:36

where is the last place where I see this.

15:38

And this is not in the san tubular junction,

15:40

which is reassuring, meaning you look at all this gap

15:43

around it, there's plenty of space for you to be able

15:46

to allow blood flow

15:47

to occur at any point in the cardiac cycle,

15:50

meaning you're not going to obstruct

15:51

the synott tubular junction.

15:53

Now this is for this valve, I would make the measurements

15:57

and all the other measurements, you know,

15:59

we would coronary high osteo height,

16:02

et cetera at the three views, et cetera.

16:05

Now once you finish that, you captured,

16:09

I would recommend you save the state.

16:10

So save, save scene, I would do, uh, S3 valve

16:17

simulation, right?

16:19

That's how I would do this.

16:22

And then once you've saved that, remove the valve,

16:25

we're going to make an evolut.

16:27

And again, if you've made this, you can modify it.

16:29

So again, the location and height are different.

16:34

All evolut valves have a height, meaning from the bottom

16:37

of the valve to where the top of that skirt,

16:39

where the valve is going to be super annular.

16:43

It's always for all their valves, 26 millimeters in height.

16:47

The valve itself to the top of it, not all

16:50

of it has valve itself tends to be 45 millimeters in length.

16:55

But the actual part that matters for this tends

16:57

to be 26 millimeters in height.

17:00

The inner di the diameter of this valve,

17:02

even though it's a 26 always is 23 millimeters.

17:06

And that's why we've selected this.

17:08

So I wanted to give you this example.

17:11

You can always change the shape to rigid tube, to tube,

17:15

et cetera, and they'll even let you change the color.

17:17

So if you're more like, I like my, uh, my valve

17:22

yellow, so yellow valve

17:26

or purple, whatever color you would like, regardless

17:29

of the choice of valve that you had,

17:31

you cannot get back to the same thing.

17:34

The only thing that's different this time,

17:36

and you'll kind of assess this, is with this new valve,

17:41

there's really not a change in the distance.

17:43

See that? So it shouldn't really cost too much

17:47

of a change where you've had it.

17:48

'cause again, the valve is gonna simulate where it needs

17:50

to be, but what's going to be different is the height.

17:54

See how here in the previous valve we were

17:56

not at the san tubular junction.

17:58

Here you come all the way up

18:00

and you can see that there's definitely contact

18:02

with San tubular junction.

18:03

Now, I would not be too worried about this valve not having

18:08

the ability or causing obstruction of the coronaries

18:11

because think about it this way, well,

18:13

there's no contact here by the angulation of this.

18:17

There's really lots of space in nearly 75% of

18:21

that annulus, meaning blood will be able to get around

18:24

and more importantly, you'll be able

18:26

to get into the coronary sinuses to be able to fill the,

18:30

the valve or the coronaries in, in diastole.

18:34

Another measurement that oftentimes gets asked

18:38

for this valve is you see our plane here,

18:40

you're gonna create a line follows this,

18:45

and then you're going to follow this

18:49

to the angle of the root, right?

18:52

And this will be the angulation that is part

18:57

of the valve and more importantly,

19:00

whether this valve will be flexible enough to be

19:04

implanted into that.

19:05

So into this valve at this location, it's a step that we do

19:09

for the evolut valve that's important for you to know,

19:11

but it falls the direction of where this intersect is

19:15

and then where this intersect is located, right?

19:18

So it's 63 degrees, which again, it's not less than 40%,

19:21

but it's an angle that you need to be aware of

19:23

as we discussed during our our lecture series.

19:27

So again, once you have all this, my advice

19:30

to you is to save.

19:32

So I would save, uh, evolut

19:36

26 simulation

19:41

and then you'll be able to have this for your review

19:44

and assessment for what you need.

19:46

The rest of the, of the procedure, like we've mentioned,

19:49

is measuring the aortic root,

19:50

whether dejection fraction is certain level.

19:53

So most of that, you know,

19:54

we've dis we've discussed in other cases, but

19:57

because of the extent of this case by itself,

20:00

and we have other cases, I don't wanna spend too much time

20:03

looking over at this particular case

20:05

longer than what we need to.

20:06

Do you have any questions about this case

20:08

or any other concerns?

20:11

No. Okay, if there's no questions, then

20:15

what I'll do is I'll move on to, to the next case.

20:19

Okay, so we case two again,

20:23

this one was, um, another one of the cases

20:27

that we wanted to include.

20:28

And this one is a bicuspid valve.

20:31

And I was surprised to see how many folks in the course, uh,

20:36

had a, a more difficult time identifying the

20:39

a morphology of this valve.

20:41

So I kind of wanted to, to go over that particularly

20:44

because I saw a lot of reports with, uh,

20:47

I tricuspid tried leaflet or functional by cuspid.

20:51

So you saw how I lined up to the aortic root, I wanted

20:54

to then get it there and then I would play the image.

20:59

And a lot of it has to do with whether

21:01

or not this Raffi is moving or not.

21:03

But you can see here as you come to the leaflet tips,

21:07

which is where you wanna assess morphology, add the tips,

21:11

you can see that this is indeed fused

21:14

and they have a single Raffi.

21:16

So this is a bicuspid valve by definition.

21:19

And, and, and the Seaver type, which is one Raffi.

21:22

So Seaver type one. Okay?

21:24

So that's one of the, of the findings that I wanted

21:28

to be able to discuss with all of you.

21:31

The other reason why we picked this case is again,

21:34

bicuspid aortic valves tend to be very,

21:37

very difficult to size.

21:38

And you wanna want to look at when this

21:42

valve is going to have the largest dimension

21:46

and win phase in which phase.

21:48

Now remember we say normally 20 to 40%,

21:52

so sometimes 15% will come up and that's reasonable,

21:55

but you wanna see it when it's largest.

21:57

And in this particular case, 20% tended

21:59

to be the the largest area.

22:02

Once you have that, the other issue

22:05

that came up on this particular case is the degree

22:07

of left ventricular outflow tract calcification.

22:10

There's a lot of calcium in this valve,

22:12

but I want you to follow this

22:14

and you can see how there's a very prominent amount

22:16

of calcium single, it's protruding,

22:19

it's got quite the length,

22:20

but it technically meets the criteria

22:22

for severe left ventricular outflow tract calcification.

22:26

And and we discussed that on on the, on the lecture series

22:30

that I first you to review.

22:32

The good news is a lot of

22:33

that left ventricular outflow tract calcification,

22:35

you get a better appreciation for the extent you're like in

22:38

that short axis view.

22:39

Doesn't look to be that significant,

22:40

but when you look at it on this view, you're like, yeah,

22:42

that, that's a lot of calcification in the left

22:45

ventricular outflow tract.

22:46

It's the location and the risk of annular rupture.

22:49

So that's why it's important to ensure that we categorize

22:51

that correctly now in this valves.

22:54

And again, I want to kind of go over to

22:57

how do we align our planes to where they need to be?

23:00

And this is a really, really

23:02

challenging step in bicuspid valves.

23:05

And it's one of the things that tends

23:06

to be the most difficult things to be able

23:09

to do when doing advertising.

23:12

You want to be able to line up in this direction

23:16

and in this direction

23:17

and you see how we keep missing this particular valve here,

23:22

see how we bring one in this direction?

23:25

And you're, you're kind of almost playing whack-a-mole with,

23:28

with this rotation and that that's kind of expected

23:31

because of the nature of it.

23:33

And that's why in bicuspid valves there's always this

23:37

additional step to kind of center your planes

23:40

and then once it's center to adjust it.

23:43

Because without that additional step, without

23:46

that adjustment, you are going to have issues with,

23:50

with getting the proper annual.

23:52

So see right here, almost there, right there.

23:58

And then in this particular valve,

24:00

you are gonna wanna center it, you're gonna want to rotate

24:04

to where this is, right?

24:06

And you see here how this is coming just smooch

24:11

right here and a little bit this way

24:16

and that's it, right, right in here.

24:21

There we go. Okay, this is our annulus

24:25

and we can see it large, we can see it sharp.

24:28

And then we go to our tavr, uh, workflow.

24:32

Again, I would not click the oblique, I would go straight

24:34

to the measurements, right?

24:37

I would go to my landmarks, I would say left,

24:40

I would say right?

24:42

And I would say non coronary cusp.

24:45

From here I go

24:46

to my three cost view, okay?

24:50

And again, you can change this from full

24:54

to half, okay?

24:56

Don't panic, just click the landmarks, it will show you that

25:00

and you'll clean up the model.

25:03

Okay? And then your three views,

25:08

check, check, and check.

25:13

Okay, last

25:14

but not least, ends up

25:15

with your annulus diameters and measurements.

25:18

So again, you get into this

25:20

and you can start to appreciate the centricity

25:23

of this annulus.

25:24

Now the calcification is gonna make it quite challenging

25:27

for us to do that.

25:29

'cause obviously you can see

25:31

how the machine is having a little bit of a struggle

25:33

with it, but it is, it is an option.

25:36

One of the things that you can also do if you don't want to

25:40

have too much of this,

25:41

and again, this is more of a, a preference of mine,

25:47

is once you find your valve plane,

25:50

you can actually come in here

25:51

and use the, uh, polygon feature

25:54

and you can draw dots around it to be more in control

26:00

and, and have your measurements and the right, see,

26:11

see, it'll give you the average diameter,

26:13

it'll give you largest, smallest.

26:16

And and you'll have this information readily available.

26:20

You can always also measure it manually.

26:24

So one, you can also measure this the other way.

26:29

Two, okay?

26:31

So that way you have your measurements right from here,

26:36

you actually don't have to worry too much about the,

26:39

the height of this being inaccurate

26:41

because as long as your valve plane is set, which it is,

26:45

it's locked, you don't really have

26:47

to worry too much about like

26:49

where the annulus geometry is made

26:52

'cause your, your height's already locked.

26:55

So you can see this height is locked

26:57

and then you can go to the right

26:59

and then again get the, get the height

27:03

properly locked into place for measurement.

27:06

Okay? So we've done enough TAVRs for this,

27:09

but the most important measurements is ensuring

27:11

that your annulus dimensions and diameters match.

27:14

Here. We got third 2.4 24.5 with a mean diameter,

27:18

which again, it's your average dam or 28.5.

27:21

The area is rather large, 637 millimeters squared.

27:25

It's a, it's a pretty big annulus.

27:27

So the valve is going to be different.

27:29

The derived perimeter of 92 again gives you,

27:32

you're gonna be looking at the largest size valves

27:34

for this type of anatomy.

27:37

So we have that, we have all those things, whether you need

27:40

to embed a geometry or not,

27:42

it's not something that I would recommend.

27:43

We've gone over the TAVR workflow, so for the sake of time,

27:46

I'm just going to skip that component

27:49

and move on to the next part, which is, you know,

27:52

the evaluation of another,

27:55

uh, by test bed.

27:58

Yeah. So again,

28:03

we're gonna load this

28:10

and we wanna get into the habit

28:11

of like loading all these phases,

28:15

looking at the valves themselves

28:17

and then trying to determine what,

28:20

what the issue ends up being here, right?

28:27

So again, we're gonna line up things in

28:30

this particular case.

28:32

Uh, I want you to kind of see the anatomy.

28:35

This particular case is also important

28:37

because you can see that there's a cardiac device

28:39

that's going to create some beam hardening artifact could

28:42

affect your ability to assess the ejection fraction

28:45

and function as it does with MRI,

28:48

but you really can see how this really doesn't affect our

28:50

ability to assess the right ventricular wall motion,

28:54

ejection fraction regional wall motion abnormality.

28:56

So that's one of the advantages of cardiac CT when it comes

29:00

to these particular assessments of questions

29:02

of the right ventricular size, function,

29:05

and dimensions in patients with established

29:07

and known intracardiac device.

29:10

You can also see the benefits

29:12

of having a dual source scanner

29:13

and the temporal resolution

29:15

as you see very minimal motion in the opening

29:17

and closure of the mitral valve as well as the myocardium

29:20

during systole and dle.

29:22

So this temporal resolution is pretty difficult to to,

29:27

to challenge in this particular case.

29:30

Uh, what we're going to do is we're also going

29:33

to now align ourselves to the, uh, to the vow.

29:37

Now what I wanna emphasize here is how we're going to look,

29:41

look at this valve and its morphology, right?

29:44

You wanna assess it, you wanna see it,

29:46

but you're also interested in

29:48

how the valve itself is moving.

29:50

So while this person has bicuspid aortic valve

29:54

and is being evaluated for aortic valve stenosis, I want you

29:57

to see this and you can see why it's so important.

30:01

I don't think this was mentioned at all in any of the cases.

30:04

And that's in the reports.

30:06

And this is one of the things that I wanted

30:07

to ensure we reviewed together

30:09

because you can see the leaflet in here,

30:13

the valve itself does not look that restricted.

30:15

In fact, it seems to open quite well.

30:18

So for a valve that's quote unquote stenotic,

30:20

that's a pretty good motion of the valve quite opening.

30:24

But you see that there's definitely poor

30:26

co-optation of the valve.

30:28

And you can see there's a notable gap as a result of this

30:32

that's likely contributing to a significant degree

30:34

of aortic valve regurgitation.

30:38

When you get into this plane

30:41

and you're trying to orient in this direction to kind

30:45

of see the size of the gap, right?

30:47

You, you, you're seeing this here

30:49

and this is where you're going to be able

30:51

to really assess the degree of regurgitation in here.

30:55

And you can see how that poor coaptation

30:57

and that prolapsing of the valve leaflet

31:00

into the left ventricular outflow tract is what's likely

31:03

contributing to this patient's symptoms.

31:04

So in this case where there was concern about like they have

31:08

severe aortic valve stenosis

31:10

and evaluation, you see that there is actually not

31:14

so much severe stenosis,

31:16

but more so, uh, a valve leaflet that has some regurgitation

31:22

that is contributing to a lot of these, uh, findings.

31:26

So that's an important thing to remember

31:30

and important thing to kind of not forget to assess

31:32

and mention on, on your case report.

31:35

Okay? So as far as the annulus dimension,

31:39

we've gone extensively through how to do that in tavr.

31:42

I'm happy to do that if you want to,

31:44

but I was going to move on to the next cases for,

31:48

for the pulmonary vein assessment and,

31:51

and the atrial fibrillation cases 'cause that was missed.

31:53

So are we, are you okay if I move on to the next case

31:57

or if you have any questions about the

32:00

uh, about the valve?

32:08

No. Okay, we can move. Okay, perfect.

32:11

All right, now case four,

32:16

and in case five, these are really important cases

32:20

and why I want you to kind of see them both in terra recon.

32:25

While you can open the post-processing feature,

32:28

it's always important for you to, um,

32:31

see if you can load two series together.

32:35

Now, when you look two series together, it's going

32:38

to give you this option of having them link together.

32:42

And I think this is a, a neat picture of terra recon,

32:45

especially if the, uh, the valve, the, the anatomy matches.

32:51

So I wanted to show you how the workflow here allows us

32:54

to really synchronize both volumes

32:59

to kinda allow you to expedite your workflow

33:01

to answer the question before.

33:04

And in this particular case, we're doing cardiac CT

33:07

for the evaluation of the pulmonary anatomy

33:10

for a pre-procedural evaluation.

33:12

Usually it's either for a pulmonary vein isolation.

33:17

Nowadays in the American guidelines

33:19

for atrial fibrillation assessment, we can use cardiac CT

33:23

to the, and rule out a left atrial appendage prior

33:25

to a cardioversion, as well as pre-procedural planning

33:28

for left atrial appendage occlusion.

33:30

In this particular case, this workflow allows us to kind

33:34

of assess the anatomy of the heart in a way

33:37

that we can assess the question.

33:40

So when, when I look at these structures, I usually like

33:45

to count the, the number of, of leaflet

33:49

of pulmonary veins in that.

33:51

So what I usually start to do is, you know,

33:54

using this feature of like switching between one

33:57

or two volumes loaded, I like to count my pulmonary veins

34:01

by putting my planes at the pulmonary va, uh,

34:04

vein origins in near the atrium on a sagittal view,

34:07

putting my green plane through it,

34:10

and then allowing me to simply scroll

34:13

through the left atrium in a coronal

34:16

orientation to count them.

34:18

So you can see there's one, maybe a third one here, two

34:22

as well as three and four.

34:25

And you can see that this a very clear separate osteum.

34:29

This one has its own osteum, this saws osti.

34:32

Well this one tends to have a little bit more of a huge type

34:36

of oste, meaning if you scroll on this direction

34:39

towards the pulmonary veins here, you can see

34:43

how they share this osteum rather than you'll see them

34:47

separate but very far into the left atrium.

34:52

So why is this relevant?

34:53

If you do a pulmonary vein abl isolation procedure,

34:57

you're gonna want to create an ablation line right here

34:59

because this ablation line will allow you

35:02

to essentially isolate both the pulmonary veins on this

35:04

side, on the right side without having

35:06

to individually having to come in here and,

35:10

and draw isolation lines here.

35:13

And here is the reason why we tend

35:16

to not worry too much about the diameter

35:20

and osteo of the pulmonary veins

35:22

because if we can isolate them externally, then we

35:25

minimize the risk of having to do coronary vein stenosis as

35:29

as we used to do before.

35:31

Now in this particular case,

35:33

as we looked at the appendage anatomy,

35:36

and this is one of the things that often gets, uh, missed

35:40

or becomes difficult is so what is the best way

35:44

to assess a pulmonary, uh, left a uh, left atrial appendage?

35:47

And I would tell you always on your axillary orientation

35:51

the direction of where the appendage is.

35:53

And you can see here there's a filling defect right here.

35:56

There's definitely contrast not going in the, into the apex

36:00

of the vent of the left atrial antigen in patients

36:03

who have a history of atrial fibrillation is extremely

36:05

important to find out if this is indeed due to a thrombus

36:09

or, or cardiac or slow cardiac ending velocities.

36:13

Now, cardiac ct, when you look at the data behind cardiac CT

36:17

and you look at how sensitive

36:19

and how specific is for if this is a finding,

36:23

how sure are we that this is not a thrombus, right?

36:28

When you look at the vessel, uh, by itself and, and then

36:32

and the at the appendage by itself

36:34

with just a contrast image,

36:36

there's been many different methods looking at the ville

36:38

units here, comparing it to the aorta and the deriving

36:42

or ratio that did not have a very good result,

36:44

very poor specificity.

36:46

The specificity of cardiac CT increases to that of,

36:50

you know, any transits of a geo echocardiography to almost

36:54

a hundred percent

36:56

whenever you start adding what's called delayed imaging.

36:59

So what I'm going to do is I'm going to move on

37:03

to multi-data, and this is what we mean by delayed imaging.

37:08

When you look at this filling defect

37:11

on your CT

37:13

and l let me move this down so you can kind of see

37:16

what I'm referring to here.

37:19

You look at this defect on your appendage, right?

37:23

We have this filling defect at the end

37:26

and you're going to try

37:27

to determine if this an a plot or not.

37:31

You can also remove this on your cross

37:33

hair, cross hair style.

37:34

You can see small, right?

37:36

And this will allow you to really get out of the way.

37:39

And you'll see that on this light images

37:42

where you had a filling defect,

37:43

there's really nothing in there that would be indicative of,

37:48

of a filling defect consistent with a thrombus.

37:51

This approach, with

37:52

that delay image obtained at about 45 seconds, up

37:56

to 120 milliseconds from the end of your contrast injection,

38:01

is not to the end of the image acquisition.

38:02

It's to the actual end, end of the contrast injection

38:06

That increases that specificity to where it is, where

38:10

you really can go through with a high degree of certainty.

38:13

Then the presence

38:15

or absence of a left atrial appendage thrombus in a left

38:18

atrium appendage is

38:21

accurate at ruling out that thrombo.

38:23

So this is why when you have patients

38:25

with a left atrial appendage procedure

38:28

or atrial fibrillation, you almost always,

38:32

or a history of atrial fibrillation, if that's

38:35

provided to you on ct, you almost always want

38:37

to look at the left atrial appendage, um,

38:41

with delayed imaging

38:42

because this filling defect tends to be quite,

38:46

quite common and frequent.

38:48

Okay? Now we've looked at this

38:51

and in this particular case, as you imagine,

38:54

we have evidence of a left atrial, um,

38:59

filling defect secondary to slow

39:02

e empty cardiac velocities.

39:05

Now you see how I manipulated this to ensure

39:07

that both my planes are aligned with the apex of the,

39:10

of the appendage.

39:11

We can change my cross hairstyle to small.

39:14

And you really have the ability

39:15

to look at all the different lobules and ations

39:20

and trabeculations of this appendage with a high degree

39:23

of certainty and more importantly,

39:25

a high spatial resolution.

39:27

We're talking like six millimeters lines thickness, uh,

39:32

half a half a millimeter, slight thickness for a lot

39:34

of these findings, which no other imaging

39:36

modality can give you.

39:38

Or more importantly, the complexity of the anatomy

39:41

of this structure is no longer an issue for us in CT

39:44

because we have a 360 degree full volumetric assessment

39:48

to be able to, to look at this and,

39:51

and define every part of the anatomy that we need to.

39:54

So essentially when you do these cases,

39:57

and you know, you saw this in the reports,

39:58

you wanna provide a, an assessment of where is the anatomy

40:02

of the pulmonary veins in the number two left, two, right?

40:05

Again, separate osteo do they have a shared osteo?

40:09

The other thing that often electrophysiologists need to know

40:12

and want to know and should always be included in your

40:15

report, is the relationship of the esophagus

40:18

to the pulmonary veins.

40:20

Now, I know that seems a little bit redundant,

40:22

but they wanna see where that esophagus comes closest

40:26

to the osteum of a pulmonary vein

40:28

because they often like to

40:31

avoid significant doing significant

40:33

or frequent radio frequency lines here

40:36

because you can see the tissue line separating the esophagus

40:39

from the left atrium.

40:41

It is, uh, not thick, it is relatively thin,

40:45

and you can imagine the complexity of having, uh,

40:48

an atrial esophageal fistula

40:50

and what the mortality of that is and, and,

40:52

and the catastrophic consequence of that.

40:54

So it's something that they're always interested in knowing.

40:57

And then the feeling defect,

40:58

if you do see one, what is it from?

41:01

How can you do about it

41:02

and what, what can we do to resolve it?

41:04

So that's that case questions about the particular case

41:08

or should we be able to move on to the next?

41:13

Nope, no questions. Okay, we'll move on to the next,

41:17

last case for the course is case five.

41:21

And again, it's one of those things where you have separate

41:26

sequences that you're gonna want to load together, okay?

41:33

Now in this particular case, you're gonna have both

41:38

this condition as well as, uh,

41:41

I don't know why it didn't do that.

41:43

It should have loaded it, it might be because it's delayed.

41:47

It's, they're not aligned correctly.

41:49

So if that happens, you can always click on the, on the,

41:54

on the of the image and look at it here.

41:57

Now in this particular case, you have a patient

41:59

who has a history of like clearly mitral valve repair,

42:03

prior atrial fibrillation ablation.

42:05

'cause you can see the calcium in the left atrium.

42:07

That's what that's from. And you are concerned about the

42:11

presence of a left atrial appendage thrombus.

42:13

But you can look at the delayed at the contrast

42:17

images as you should.

42:19

Really looking at the delayed images,

42:20

particularly at the scanner, if you have the luxury

42:23

of being at the scanner is so important

42:26

because in here you can see

42:27

that there's a persistent filling defect at the left atrial

42:30

appendage, and that is consistent with a thrombus.

42:34

We know that it's a thrombus based on the persistence of it,

42:37

especially in the timing of that.

42:39

And like I mentioned, the data behind that.

42:41

In this particular case, you can see this patient,

42:44

it definitely has a thrombus in here

42:46

and it's quite a bit of an extensive thrombus.

42:48

It's not a small thrombus.

42:50

Now if you compare this thrombus in size to

42:54

what you were seeing on the contrast image, you can see

42:57

how this can be quite deceiving.

42:59

You can think like, oh my goodness, all

43:01

of this ends up being thrombus.

43:02

But when you compare it to what's actually at the apex in

43:05

size is not as extensive, which tells you that the component

43:09

of slow carding

43:10

or stasis of the left atrium contributes a lot to this

43:16

specificity of whether it's a thrombus and the extent of it.

43:18

But in this case, you can clearly tell that,

43:21

that it's a thrombus, that it's related to that.

43:24

And again, you can appreciate the left

43:26

atrial ablation lines.

43:28

You can appreciate the history of prior mitral valve repair,

43:31

the thickening of the mitral valve leaflet,

43:33

and more importantly, the degree of left atrial enlargement.

43:36

Now, when patients have this large dilated atrium,

43:39

they have bio prosthetic valves,

43:40

so they have rheumatic disease or abnormalities for it.

43:43

It's really, really important to be able to assess whether

43:46

or not this thrombus ends up involving the left atrial free

43:49

wall or not,

43:50

because that's an important marker of what we're going

43:54

to do in regards to anticoagulation

43:56

and more importantly, the extent of the condition.

43:58

So you can see this is, uh,

44:00

this is a very large left atrial appendage with a lot of,

44:04

uh, thrombus in, in it and, and what it can do.

44:09

So you can see here, you can see here

44:12

and more importantly what what it does.

44:14

Okay. Questions about this case.

44:17

This surprisingly was one of the most missed, um,

44:23

feedback on, on the, on this case report.

44:26

So we wanted to make sure we went over that

44:29

and, and, and cleared out.

44:30

Any questions? Any questions, any other concerns? No.

44:36

Okay, wonderful.

44:38

So last but not least,

44:40

we always have additional cases for you.

44:42

And this is one where we had an additional case

44:44

that we wanted you to do if you're interested in kinda

44:47

assessing and,

44:49

and kind of having an additional trial for it.

44:53

And this one illustrates what a left atrial appendage

44:56

occlusion looks like.

44:58

More importantly, what a watch a watchman flex device looks

45:01

like and what are the findings that you would expect

45:03

to see when you have a successful, uh, close

45:07

of, of the device.

45:08

So I encourage you to kind

45:09

of review it if you're interested.

45:11

If not, it's no problem.

45:12

But that's kind of what we have for this case

45:15

and the last set of cases for discourse.

45:18

Any questions? Any other concerns?

45:23

No.

45:25

No, I don't see anything coming through the chat

45:27

except if thank Wonderful.

45:30

Yeah. All righty.

45:31

Well, those are the hardest cases we had for the court

45:34

and that's why we leave them to the end.

45:36

So if you think of anything

45:37

or there's any other concerns, please let me know so

45:40

that we can, um, discuss it and proceed from there. Okay?

45:44

Yes. Thank you Dr. Fontes.

45:46

And just a reminder, this recording is being, this

45:51

session is being recorded

45:52

and will be made available within 10 days.

45:54

It'll be emailed to you or posted and posted in the course.

45:57

So thank you again, Dr.

45:59

Fni and everyone that joined us, and have a good evening

46:03

Too. Take care.

46:04