0:00

So we'll start with this one.

0:02

The first case is, it's kind of consistent with the,

0:06

with the plan of, of evaluating abnormal,

0:11

uh, echocardiographic findings for evidence

0:14

of congenital disease.

0:16

And one of the advantages that cardiac CT really does have

0:19

is, uh, the ability to assess

0:22

that anatomy in a three-dimensional space, really

0:25

with no limitations.

0:27

You have high definition, uh, thin slices, up

0:30

to half a millimeter in, in thickness,

0:33

and you have the ability to really manipulate the volume in,

0:36

in different ways.

0:38

This particular case, it's important

0:40

that when you protocol your echos

0:43

or your cts, you wanna make sure that you want,

0:45

then you have a biphasic injection, meaning, as you can see,

0:50

we give about 70 to 85 milliliters of contrast

0:55

at a rate of five to six milliliters per second

0:58

with a saline chaser.

1:00

This allows us to kind of use that as a screen to assess

1:04

for any evidence of anomalous, uh, findings

1:07

or any other congenital disease, particularly left

1:10

to right shunting, as the timing of the contrast should be

1:14

gated in a way that it optimizes left-sided structures

1:18

in such a way that if there is a significant left

1:21

to right shunt, you should be able to, to see how the,

1:25

the brightness is nearly equal.

1:26

The attenuation is nearly equal in both the left

1:29

and the right side of the part.

1:30

This particular case, we use the axial image to kind of see

1:33

where theano, the anatomy could be fine

1:36

or abnormal anatomy could find.

1:38

Here you see a persistent left-sided SPI vena cava

1:41

that is coming right into the coronary sinus

1:43

and it's dilated.

1:45

And in the axial images, which is

1:46

what I strongly recommend you do, I always try to make sure,

1:49

um, intentional about looking this at the SPI vena cava.

1:53

The SPI vena cava should be coming on this corner,

1:56

and I always look to see if there's any evidence

1:58

of connections in this particular case.

2:01

You can see how this pulmonary vein connects into that,

2:05

uh, vena cava.

2:07

And here another one connects,

2:08

and eventually you have this large connection

2:11

between the left atrium and itally.

2:14

What is the right atrium?

2:15

And that's by definition the, the sinus benno.

2:19

So what I do, once I identify that anatomy, I try

2:23

to get my images in a way that I can assess the sve cava

2:27

and the in the venosus defect.

2:31

So one of these things to do is simply just put your cross

2:33

hairs where the artifact is

2:35

or where the orifice is just like I did,

2:38

and then look at it in this, uh, coronal orientation

2:41

and here this coronal orientation, you can clearly see one

2:45

and two anomalous pulmonary venous returns coming

2:47

into the intra.

2:49

That severe ven fairly easy to assess

2:51

and more importantly, becomes very easy to assess

2:54

how the connection of the left atrium leads

2:57

into the right atrium.

2:58

You can see that entire connection.

3:00

Once you see that, then the challenge becomes, okay,

3:03

how do we line things up to be able to measure and,

3:06

and identify the defect?

3:08

And right there, there's your or a SD

3:12

and how essentially is contributing to

3:15

that significant shunted remodeling?

3:17

And you can clearly see it here.

3:19

Another option that you can do

3:22

if you wanna stay more consistent in a,

3:24

in an anatomical approach, again,

3:26

you can make your short axis or chamber view orientation

3:31

and kind of scroll through the atrial septum,

3:34

and you'll be able to see how

3:36

this connection becomes that connection.

3:39

Okay? So you can see how from here,

3:43

you go right into the right atrium,

3:45

and that's what makes this very difficult

3:47

to see on echocardiography.

3:49

Very difficult to see in transesophageal echocardiography

3:52

given your intention, but you can tell

3:54

how the ventricular dilatation on this right side is

3:57

leading, it's from that congenital defect.

4:00

Okay? Outside of that,

4:02

you can measure the right ventricular chamber dimensions,

4:04

and you can see how dilated that, uh,

4:07

the ventricle really is on the right

4:10

side compared to the left side.

4:12

And the significant findings with this, you obviously need

4:15

to get further evaluation for this,

4:17

but when you see this, you can essentially report

4:19

that there is not only the presence of, uh, sinus,

4:22

but no citracal defect

4:24

with an anomalous pulmonary venous return,

4:26

but you also have right-sided chamber enlargement in a

4:29

dilated pulmonary artery that tells you you have quite a bit

4:33

of, of, of pulmonary hypertension.

4:36

Okay? So that's that first case follow along

4:40

with the same kinda pattern.

4:43

In this particular case, we have a little bit more complex

4:45

of an anatomy, and this is an example of, uh, of a symitar

4:49

uh, syndrome patient, which, you know,

4:52

this is the constellation of unique findings that,

4:55

that make the symitar.

4:57

This is a very rare variant

4:59

of an anomalous pulmonary venous return.

5:02

This always occurs on the right side

5:04

and is characterized by the anomalous drainage of part

5:07

of the entire right lung into the inferior vena cava.

5:11

This also leads into the hypoplasia of the right lung

5:14

and the right pulmonary artery.

5:16

And then you can also get sometimes

5:17

or pulmonary collateral vessels, hypoplasia

5:21

of the left heart, a diaphragmatic hernia,

5:23

and oftentimes pulmonary sequestration, right?

5:27

The, the adult variant of it is really not something seen

5:31

with pulmonary hypertension is very rare.

5:34

So the fact that, you know, we were able

5:36

to identify this in a,

5:37

in a military service member made it kind

5:39

of unique in this presentation.

5:41

So again, keeping in touch with our consistent approach,

5:45

we look at the vena cava, we see

5:47

how there's near equal attenuation of both chambers.

5:51

You get into the inferior cava, which is very much dilated,

5:54

and you can clearly see

5:55

how this anom bone nerve vein connects into that vessel.

6:00

Yes, okay.

6:04

I'll wait for you to finish your question,

6:07

but I add this is, this is a big return once you have this,

6:11

and again, you can simply keep the sagittal view into place,

6:15

and in this TAL orientation, you can really see how the,

6:20

the pulmonary vein clearly returns right into this,

6:24

into this inferior ven cva.

6:26

So once you do that, you have that.

6:29

Uh, and in this case, you know, we never use see this,

6:32

this requires usually surgical intervention.

6:35

Uh, they repair for this,

6:37

they create like essentially a baffle,

6:39

or sometimes they even take, are able

6:40

to take this pulmonary vein

6:42

and directly connect it into the left atrium to avoid that.

6:46

Uh, usually a ventricular aneurysm or dilatation.

6:50

With this, it can happen, it, it hits a,

6:52

it's a volume dependent, um, lesion.

6:58

So it can occur particularly in the absence of, of like,

7:03

uh, uh, atrial septal defect, und septal defect.

7:07

But that's what makes this unique.

7:09

A lot of the time the anatomy gets a little bit distorted

7:12

because you have the hypoplasia of the, the right lung,

7:16

so it kind of affects this.

7:17

But when you put this in a true, uh,

7:20

four chamber short axis orientation, if you were

7:23

to look at the true right ventricle, a lot

7:25

of the quote unquote enlargement that we would expect,

7:28

is it really much enlargement?

7:30

A lot of it ends up being the asymmetry of

7:33

how it sits in the anatomy.

7:34

And this could give you a false reading

7:36

for a dilated, right ventral.

7:39

This is where MRI comes in and becomes more helpful

7:42

because it can help you determine the right ventricular

7:46

volume and index for, for that,

7:49

and then help you determine if you have a dilatation or not.

7:53

Okay. Very good. Any questions?

7:58

Other questions about this particular case?

8:03

No. Okay. Wonderful, wonderful.

8:06

All right, so now case three.

8:08

I thought case three is one of those trickier cases

8:12

that we had in the whole course.

8:15

Given the, the kind of quality of the exam, we,

8:18

we debated many times whether

8:20

or not to include this case, no.

8:24

So general ventricular volume is not necessary on ct.

8:27

I usually report volumes of the left and right ventricle.

8:32

If you have 20 phases of the cardiac cycle,

8:37

meaning you wanna have the entire cardiac cycle to be able

8:40

to measure true diastole and true systole.

8:44

So if you have either a retrospective skin, if you have a,

8:47

you know, routine 64 up to like 132,

8:52

uh, detector row scanner,

8:54

or if you have like a volumetric scanner, you know,

8:57

those 320 large, uh, you know,

9:01

mo large detector row scanners that can do the entire c axis

9:05

of 16 centimeters in a single ganter rotation,

9:08

then if you do that prospectively at zero to 10 per zero

9:11

to 95%, then you're able to get the entire cardiac cycle.

9:16

If you have the right contrast attenuation on the right

9:19

ventricle and the left ventricle,

9:20

you really have all the information you need

9:23

to report ventricular volumes.

9:25

But in the absence of having all the cardiac phases

9:28

and the entire, uh, cardiac cycle,

9:32

I usually don't provide volume measurements

9:35

or ejection fractions.

9:37

I just use linear dimensions by

9:39

wherever it mid diastole if it, if it's provided.

9:42

Does that make sense? But you can do the same measurements

9:47

as you can on MRI.

9:48

With this, theon has a very easy, uh, left ventricle,

9:52

right ventricular ejection fraction button that we're gonna,

9:55

I'm gonna show you how to use that on,

9:57

on the, on the next case.

9:59

Okay, very good. Yeah.

10:03

Now for this case, you know, again, kind of keeping up

10:06

with the cha with the case, you can see

10:08

that there's definitely a very dilated pulmonary artery,

10:12

and the question is to kind of look at the pulmonary veins

10:15

to see where they are in location.

10:17

But the tips and tricks

10:18

that I would recommend you always do when assessing

10:20

pulmonary veins is to put your cross hairs here

10:23

where the green plane intersects the left

10:25

and right pulmonary veins.

10:26

And this should be able to give you a quick scroll

10:30

through to assess the anatomy.

10:31

You can see that there are one two

10:32

pulmonary veins on this side.

10:34

You can see that there are also one

10:36

and two pulmonary veins on this side,

10:38

but then you can clearly see here

10:40

that there's this other pulmonary vein that makes its way

10:43

through and, and connects into the VNA cava.

10:48

So when you do that, it makes it relatively easier to, uh,

10:52

to evaluate and assess.

10:53

So let me show you, uh, reset orientation.

10:57

You can see right up here, right where we suspect

11:01

right in here, it's where you see that vein come in

11:06

and connect right into the sphere of vena cava.

11:09

And the reason why we kinda picked this case is subtle.

11:12

Uh, the contrast timing was a little bit off,

11:15

but it becomes one of those things that is difficult

11:18

to, to miss.

11:19

The nice thing about this case is also there's not an

11:22

associated sinus osis defect.

11:25

So the degree of pulmonary hypertension, the patient's age

11:29

also contribute to that.

11:30

Whether or not this is is a significant shunt

11:33

or not in this particular case, you know,

11:37

because the patient 65 years of age

11:40

and without the sinus venos, a SD is less likely

11:44

that the anomalous pulmonary renal return is contributing

11:48

to the dilatation of the right ventricle

11:50

and pulmonary hypertension, particularly given the history

11:53

of risk factors that she has.

11:55

So, and this is important just to kind

11:57

of remember those things in place

12:00

and, you know, just noted, uh, you know, whether

12:04

or not that needs further evaluation.

12:06

Okay, now we're gonna move on

12:10

to the next case, which is case four.

12:13

And this will be a, a, a TAVR case.

12:15

And I wanna split this into two components.

12:18

We're gonna evaluate the, the heart in,

12:22

in a two-pronged approach.

12:24

We're going to first thing look at the heart and,

12:29

and measure the, the systolic function

12:34

and chamber dimensions.

12:35

And the reason why I usually start my TAVR cases in this

12:39

approach is kind of get an overall bird's eye view of

12:42

what I'm going to be needing.

12:44

I like to align my cross hairs in a four chamber

12:47

orientation just like this.

12:51

And then once I'm in this position,

12:53

I usually like to place play.

12:55

And now you have all the information you need

12:58

for assessment of wall motion.

12:59

You can see the wall motions on the in interior

13:03

and inferior walls.

13:04

You can see the interior septum, the inferior lateral walls.

13:07

You can scroll through here

13:09

and you can see the anterior inferior anterior septum,

13:13

inferior lateral, inferior septum, inferior lateral,

13:16

anterior lateral, inferior lateral walls.

13:18

And you can assess for wall motion abnormalities,

13:21

wall thickness, and obviously volumes.

13:24

Terra recon does have this option on this where if you click

13:28

LVEF, oh, apparently I don't have the license on it, uh,

13:32

but technically all you do is click on this

13:35

and then it will essentially trace the ventricular volumes

13:39

just like on MRI

13:41

and be able to kind of give you an injection fraction value

13:44

as well as volumes that if you provide the patient's height

13:49

and weight, we'll actually index it

13:51

and you'll have that information.

13:53

In this case, you can see

13:54

that the ejection fraction is relatively normal.

13:56

You don't see any significant wall motion abnormalities

14:00

or areas of hypokinesis kinesis or,

14:04

or other functions.

14:05

I strongly recommend that when you do have this,

14:08

that when you report your reports

14:11

that you provide the specific information

14:13

for not just the chamber size, obviously you do have that,

14:16

but the wall function,

14:18

the regional wall motion abnormalities,

14:21

how the myocardium thick, you can see that this,

14:23

my current is definitely thick.

14:25

And then the pattern in which is thick

14:27

and it's in a concentric pattern, as well as

14:30

to note any other findings involving the myocardi,

14:33

which can include, you know, mitral annular calcification

14:36

that you can kind of see here in ob mitral annulus, as well

14:39

as other important findings.

14:41

Once I get all of that information evaluated, I like to kind

14:46

of get back into the anatomy of the valve

14:49

that I'm going to be doing.

14:50

So while I can start pulling up information on the aortic

14:53

valve, I usually like to align my planes in an orientation

14:58

that allows me to really see a couple of items.

15:01

One, where's the left ventricular outflow tract?

15:05

Is there any evidence of calcification in it?

15:09

Is there any evidence of other abnormalities?

15:12

And then last but not least, what do the leaflets

15:14

of the bowel look like in this particular case?

15:17

You press play and you can see

15:19

how there are 1, 2, 3 leaflets.

15:23

They all open and close. There's no fusion of the leaflets.

15:27

This is separate, this is separate, these are separate.

15:30

So this is what makes a tricuspid aortic valve

15:33

easy to identify.

15:34

And sly. As you come up into thes tubular junction,

15:37

you can see this indentations for each of the areas

15:40

where the cusp are separate,

15:42

and you'll be able to track all three

15:44

of 'em into the sano tubular junction,

15:45

which is another thing that you can use to kind

15:48

of help guide whether or not you have a tricuspid versus

15:52

bicuspid aortic valve.

15:54

And here you can get a lot

15:55

of information about the aortic valve.

15:57

Where's the leaflet thickening, where is the calcification?

16:01

Is the calcification asymmetric? Is it symmetric?

16:04

Is there outflow track, uh, calcification, if it's, so,

16:08

is there a small amount, large amount?

16:10

Is it flat? Is it protruding? Is there a centric?

16:14

All those informations are part of the TAVR template.

16:17

Now, we gave you a TAVR template that you can use

16:20

to pro start providing the structural cases

16:22

that are consistent with the A-S-C-C-T and a CR

16:27

and all the other interventional cardiology structural

16:30

societies for the proper reporting of TAF R cases.

16:34

Now for the sake of time, I'm going to go ahead

16:38

and just load the previous measurements that I had made

16:41

for this, but you know, essentially you're going

16:44

to bring inter recon all of the systolic faces of the heart

16:49

and kind of line things up for you

16:51

to assess the orientation.

16:53

Now, when it comes to assessing these, it,

16:56

it really varies on the software that you have

16:59

and your, your experience aligning things for where the left

17:04

or when the right uh, leaflets are located,

17:08

and more importantly, how to align the annulus.

17:11

One of the things that I'm going

17:12

to show you once this finishes loading is how to kind

17:15

of get your plane into view so that you can easily tag

17:20

or mark where the right coronary cause leaflets are located,

17:24

where the left coronary cause leaflets are located.

17:27

And so one of the things that you first want

17:29

to do is you always wanna go to the phase in systole

17:33

where your annulus, which is this structure of interest, is

17:38

widest in diameter, has the sharpest or cleanest dimensions,

17:43

and allows you to make the easiest measurements.

17:46

Now if you look at your cross hairs, you can see how

17:49

we align the cross hairs in a way that this plane

17:53

intersects at the bottom of the right coronary cusp leaflet.

17:57

And as you look on this orthogonal orientation,

18:00

this plane literally intersects both on this leaflet,

18:03

which is the left coronary cus

18:05

and then the non coronary cusp leaflet right

18:07

along the same plane.

18:09

Essentially, you want your cross hairs

18:11

to be adjusted in a way that your annulus looks like.

18:15

There are no visualized segments

18:17

of the aortic valve leaflets.

18:20

That's the challenge. Depending on the software

18:22

that you have, for example, uh, Vitria

18:26

or Toshiba Canon software allows you to kind of scroll down

18:30

and then put a marker on it to tag it, uh, single via

18:35

with, uh, Siemens also allows you to do something similar

18:38

where you just scroll down and it's semi-automated there.

18:42

The vessel leaflet allows you to just put a tag.

18:45

Terra recon kind of has a little bit of its limitations

18:48

where it doesn't quite let you do that, so you kind of have

18:51

to line up and tell it where they are

18:53

because if you don't have it at least

18:55

oriented in an oblique orientation, it's not going to do

19:00

1, 2, 3, it wants you to do it on the same plane.

19:03

But again, it's, it's, it's important

19:05

for you to be able to do that.

19:07

Once you do that, then you'll be able to draw the perimeter

19:10

and, you know, on the case discussion, as we've mentioned,

19:13

you want to ensure that when you are drawing this,

19:16

that you try to get the diameter in a way

19:19

where you don't use your pre hand to kind of trace this,

19:22

you want like the spline

19:25

manual play segment points connected by a cubic spline

19:28

with like interpolation, kinda like an elastic ruler

19:31

because that's what's been studied

19:33

to have the highest number of, of, uh, accuracy.

19:38

Once you have your landmarks, you kind of have

19:40

to set up your, your views and,

19:42

and what's really interesting about these views is where,

19:46

where the leaflets are located, where are the

19:50

angles located, et cetera.

19:52

So one of the things that I would tell you when it comes

19:55

to finding out where these are is always trying

19:59

to use your orientation

20:01

where you can see the three cost leaflets.

20:03

You can see your, uh, orientation

20:06

and I'll tell you, uh, terra recon has a very nice, uh,

20:11

protocol within their post-processing

20:13

and their workflow that automatically lines things up in a

20:17

three cusp view, an anterior view and a non cranial view.

20:21

And it'll provide you the, the angulations for this

20:25

for your report without any challenges.

20:28

Another way that you can do this is if you go

20:30

to fluoroscope, you see how you can see this cusp,

20:34

you wanna line this up to where you can first see

20:37

where the left, right

20:39

and non coronary coastal leaflets are aligned in plain

20:43

your nest orientation.

20:44

You're gonna want a simple overlap of the left of the right

20:49

and non coronary cusp.

20:50

That's another number that you're gonna need.

20:53

And last but not least, the deployment view is gonna be

20:56

where the right

20:58

and the left coronary cusps kind of come together, see that?

21:02

So it'll provide you that orientation

21:04

where these two overcome,

21:06

and that way you're able to mobilize

21:08

and assess those three leaflet costs in each one

21:11

of the orientations.

21:12

Okay, last

21:14

but not least, when you have the annulus, uh,

21:18

here in the landmarks I have it, it allows you

21:20

to make those traces.

21:21

The next set of measurements is, uh,

21:25

where the cusp leaflets are.

21:27

So you're going to measure the origin of the left coronary,

21:32

uh, artery from the plane where you are to the bottom

21:37

of the coronary artery.

21:38

That's where that measurement is made.

21:40

Usually I like to kinda tag along

21:43

and scroll around to be able to see it

21:45

and then find where that is.

21:47

At that same time, I encourage you to measure the sinus

21:50

of the left cusp to be able to get that measurement.

21:53

And same for the right, you wanna get the height

21:56

of the right coronary cusp

21:58

or the origin of the right coronary arties, as well

22:01

as the height of the sinus over salva on that right side.

22:06

Okay? Questions.

22:12

Okay? Once you have those measurements,

22:15

then you can start moving into some

22:17

of the other measurements that are equally important,

22:19

which is your synott tubular junction, your sinus diameters,

22:23

your mean diameters that are important to do that.

22:27

One thing that's different in TAVR cases different from

22:32

what we've seen in other cases is

22:34

where you measure the sinus of Valsalva measurements.

22:39

In TAVR cases, we do this sinus to commissural measurement

22:43

and sinus

22:45

to commissional measurements on each one of these three.

22:47

So I usually report these three

22:49

and provide a picture for it.

22:51

After that, then you start looking into your synott

22:54

tubular junction measurement.

22:56

And this is one where I usually like

22:58

to go off the plane if needed.

23:01

In this particular case, you can see

23:03

how I'm pretty much lined up with the same tubular junction,

23:05

so it makes it much easier for us to do.

23:08

But you make your measurements here

23:10

and then all the way through the abnormality,

23:13

and again, you document it.

23:15

And last but not least,

23:16

you get into the ascending aorta at the

23:18

widest dimensions for that.

23:20

And again, you want be in direction to the blood flow

23:23

or where the vessel is largest,

23:24

and you're gonna make that measurement as best as you can.

23:28

Okay? Okay, questions.

23:32

Now, what you're going to get

23:34

to next is you're gonna wanna have an assessment of the,

23:38

uh, of the vessel.

23:41

So in this particular case, you're gonna bring your, uh,

23:45

aorta measurements, your axial measurements,

23:48

and then bring it into this workflow.

23:50

There should be a TAVR workflow that allows you

23:52

to bring this into it and it will automatically do this.

23:57

No, right? Where you get to do this is

24:00

where the challenge sometimes occurs is getting into this

24:04

vessel and then getting terra recon to kind

24:08

of just give you the vessel of interest.

24:10

In this particular case, the aorta.

24:12

So if you press shift

24:14

and you go to measurements, right, it's going to do the,

24:19

uh, this, the aortas.

24:22

If you click this curve multiplayer reconstruction button,

24:26

it'll ask you, do you want me to do it manually

24:28

or do you wanna do it, uh, automatic?

24:32

So you can do auto, okay, present

24:37

and then list.

24:40

It's going to go through the list of these.

24:42

So let me see, um, lemme see this manual.

24:50

When you select manual scroll through here,

24:54

you're gonna come right on top and press the shift button.

24:59

Okay? And then automatically it's going

25:03

to start tracking this whole vessel.

25:06

So see here, come to

25:10

this view, start scrolling.

25:21

See? And

25:28

so now you can see how as it starts tracking this vessel,

25:33

it'll, it allows you to kinda edit the rotation

25:37

or adjust the points in the plane, et cetera,

25:40

and give you measurements.

25:42

Uh, the interesting thing about this particular, uh,

25:46

workflow is it automatically does the tracings

25:49

and allows you to continue to edit things

25:51

by simply pressing shift

25:53

and giving you the option to change the vessel

25:56

as you're moving through.

25:57

So we put shift to this

26:01

and you put shift, build, track, track,

26:07

continue to track, and it lets you pick between the left

26:11

and right, right?

26:13

Then you show them the curve.

26:17

And then here, okay, rotate around.

26:21

Now if you get into this funny looking appearance

26:24

where it's like, I can't see, uh,

26:29

where the center lines are located,

26:31

you can simply erase all these measurements.

26:35

And what you want it to do is, uh,

26:39

you can do it one

26:40

or two clicks where it'll manually allows you to pick again

26:43

where, where the order comes from.

26:47

So again, from here to,

26:52

uh, I usually put it right before the page here,

26:57

and then it will, it will pretty much give you

26:59

that assessment.

27:01

So you can look at the center line if you not do it right,

27:06

but it should be able to get you that orientation.

27:09

So, okay, last

27:11

but not least, if that's still a problem,

27:14

you can always go within it, within it here on the tavr

27:18

and then through,

27:19

and try is always your ability to make the measurements

27:23

with your double orientation

27:27

and go from there.

27:29

Okay, we roll this measurement. Very.

27:34

Any other questions? Any other concerns?

27:45

Okay. All right.

27:47

We'll move on to the last

27:49

and most challenging case of week five.

27:53

Um, let's see.

27:57

So again, I'm gonna load this so we can kind of

28:02

see this anatomy and orientation.

28:05

This case is one for another TAVR case where,

28:10

uh, again, you have the task of measuring the aortic root

28:16

and the annulus measurements.

28:18

In this particular case, we

28:20

provided the, the phase only in Sicily to avoid you having

28:25

to do the entire ejection fraction measurements.

28:28

And more importantly, we did this case to kind

28:30

of get you familiarized with a fried leaflet.

28:33

Aortic valve. Again, we look at the anatomy, we see

28:36

how the valve open closes,

28:38

and more importantly, what are the measurements

28:40

that, that we need to do.

28:43

So again, if you have these, uh, measurements, you wanna

28:47

look at your location for where you put in the, the roots,

28:52

uh, angulations.

28:54

And the key thing is where this plane,

28:57

where the annular plane is, where the cusp

29:00

of the aortic annulus are located, that's

29:03

where you wanna line things up.

29:04

And you can see how as we scroll through the recon spaces,

29:09

you can see the tags of where these are, these need

29:12

to be right at the bottom of the crevices or,

29:15

or furrows, I guess would be the term for it.

29:19

Where this aorta is located.

29:21

Sometimes these aortas can be quite asymmetric

29:25

and, uh, uneven make it a little bit challenging to find

29:29

where those truly are.

29:30

But I wouldn't be too obsessed about making sure

29:34

that this left isn't right here

29:36

or this left isn't right there.

29:38

What matters is, as long as you are in, in a plane

29:41

where this is a nice circle

29:43

and you can assess the measurements, you'll be able

29:45

to get the widest and shortest dimensions

29:49

or that aortic route to get the,

29:52

the measurements that you need.

29:53

Okay? In regards to the assessment, again, you can go

29:58

through the entire recon automated ones

30:00

where it'll give you this, it has a three cusp view.

30:04

It'll give you these measurements.

30:05

Again, you can do that or you can do it manually from here.

30:09

Again, remember, you wanna have the left out, the right

30:12

and no coronary cusp overlap in a single plane.

30:16

See? So we want to see this two nicely overlapping.

30:21

And then last but not least, you're gonna want the left

30:24

and right to be overlapped.

30:26

So see right here and there you go.

30:29

See, and those are the measurements that you have.

30:32

See, they'll give you this, for example, no cranial,

30:34

no coddle view, and while technically it is correct,

30:38

this is impossible to align in, in the cath lab.

30:41

We just can't do that.

30:43

So that's why sometimes relying on the workflow can be

30:46

helpful, but sometimes it's not very helpful when you have

30:49

anatomy that's a little bit disoriented.

30:51

So that's why I wanted to show you those measurements.

30:54

So align them the three and overlap each one of those. Okay?

30:59

When you do get to the annulus, remember measure the highest

31:03

and largest dementia.

31:05

You can also inter recon embed anatomy.

31:09

So you can put the type of valves in the, in the case

31:14

and it should be able to kinda show you the,

31:17

the information that you want.

31:19

So let me see if I can get one

31:22

of these vows to kind of show it.

31:24

Okay? Um, no.

31:33

Okay. Maybe it's 'cause I'm doing it.

31:35

Um, it's quite the case.

31:44

Yeah, it's 'cause I'm loading it from that.

31:46

I'd have to do it from beginning.

31:48

But in your workstation, you should be able to, uh,

31:52

embed a geometry based on what you have without any issues,

31:57

meaning it will simulate what the valve will look like

32:00

by creating like an edge valve here

32:03

and provide you the measurements for the left

32:06

and the right coronary custom

32:08

and the measurements of how we would interact with this.

32:11

Again, that's not something that I do routine for native

32:15

TAVRs, but in valve in valves

32:16

where there's like a evaluation for a valve,

32:18

prosthetic valve that's failed

32:20

and we want to implant another valve,

32:22

I usually do include those measurements

32:24

as part of the evaluation.

32:25

So here again, consistency is key.

32:29

Left coronary height, left side, so Valsalva height, right?

32:32

Coronary height, right side.

32:34

So Valsalva height,

32:35

and that's the important measurements that you need to have.

32:39

Again, you get into the synott tubular junction

32:41

and the sinuses of Valsalva

32:44

and get those measurements made, like we said, from

32:48

this edge, with that edge from this commissure

32:54

to the next commissure.

32:56

Then last but not least, from here to here, okay,

33:02

by sending aorta and then we'd go from there.

33:05

Okay? Questions?

33:15

No, no questions, no concerns.

33:18

How long does it take you to read and have a study

33:23

To read a TAVR study that does do take a hot minute.

33:27

They do take a while.

33:28

Again, it really depends on, on what's,

33:31

what information you have, right?

33:34

If they're gonna give you a full cardiac cycle

33:38

where you have to read the entire ejection fraction,

33:41

annular route, all those things,

33:44

it's gonna take a lot more time than it is if you do it.

33:47

Um, under just the root measurements,

33:51

I will tell you in the United States, uh, this study builds

33:55

for two procedures, well, two procedures.

33:58

There's the cardiac component

34:00

and then the, the ct, abdomen, chest,

34:05

pelvis, vascular assessment study.

34:07

So these are one of the highest, more,

34:10

more revenue generating procedures.

34:12

But as you can imagine, the amount of time

34:14

that goes into reading this

34:15

and you know, all the extra cardiac findings

34:18

that are in the abdomen, uh, that,

34:20

that's just quite a bit of time.

34:22

So most institutions in the United States, they kind

34:26

of split this into two components

34:28

where the cardiologist will do the TAVR measurements

34:31

for the cardiovascular structures

34:33

and the radiologists will often do the

34:36

extra cardiac findings

34:38

or non nonvascular findings for the CT, chest,

34:42

abdomen, and pelvis.

34:43

And everybody gets, you know, you get paid a full CT chest,

34:46

abdomen, pelvis scan price,

34:48

and I get paid a full cardiac price

34:50

and then makes it more bearable in terms of workflow.

34:53

Now, if you happen to be in one of those cases

34:55

where you're in charge for reading a lot of that,

34:58

then you gotta really make it worth your time and,

35:01

and decision if that's something you want to do, uh,

35:05

routinely because this can be very, very,

35:08

very time consuming depending also on the software

35:12

that you're using, right?

35:15

Some softwares allow you to make this very, very easy to,

35:20

to kinda do

35:22

and allow it in a way that it's simple to do.

35:26

Other softwares make it so that it's very, very difficult

35:30

for you to get to the, to the areas that you wanna get and,

35:34

and pretty much make it a, a challenge

35:37

to be able to do that.

35:39

Uh, terra recon doesn't pay me money for me

35:41

to tell you they're the greatest thing on earth.

35:43

So I'll be very honest with you.

35:45

I personally don't like to use terra recon

35:47

for TAVR cases if I don't necessarily have to.

35:50

But again, a lot of it has to do with the experience

35:53

that I have with it and, and the training that I have.

35:56

There are some folks that are very savvy

35:58

with it at getting it to do you know, what it wants to do,

36:03

but I oftentimes find it that in order to get a really

36:07

high quality assessment from Terracon for the TAVR case,

36:11

you have to just be perfectly located and,

36:15

and go from there, right?

36:17

So you do this manual finish, there you go.

36:21

See, it gives it, it just likes to mess with you.

36:25

And then how it measures this threshold for like, you know,

36:30

is it accurate or not?

36:31

See, I have to click and scroll, click and scroll,

36:34

and you, you can imagine the level of, of frustration

36:38

that comes with this.

36:39

So this can be time consuming where it's much simple

36:43

to just sometimes do things yourself and,

36:47

and where you need to do, right?

36:48

So that's, that's what makes this a fun time.

36:52

Some people would say. Okay, any other questions?

37:01

And again, my advice to you when it comes to this TAVR cases

37:05

is to spend as much time as you can trying

37:09

to see if you can get the annualist dimensions.

37:12

No one's really going to care if you're, you know,

37:15

descending thoracic aorta was, you know, off

37:19

by three millimeters.

37:21

But those annulus measurements, the ones that we use

37:24

to size the valve, those are the most challenging ones

37:27

and they're the most important ones to get.

37:29

So always get into the habit of trying to be as accurate

37:32

and always see the feedback, right?

37:34

See if the device that you set recommended would fit

37:37

instead of being accurate.

37:39

And that's the only way that you're going to get consistent

37:42

with these and get expedient with these

37:44

because this can be quite, quite cumbersome and

37:47

and quite challenging.

37:48

Okay, any other questions? Any other concerns?

37:53

Of course, you guys have a good day. I'll see you next week.