THE UTRECHT COOKBOOK HOW TO DO 3DRA
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1 THE UTRECHT COOKBOOK HOW TO DO 3DRA 3DI3 CONFERENCE NATIONWIDE CHILDREN S, OCT Gregor Krings, Mirella Molenschot, Hans Breur Children s Heart Centre, University of Utrecht, The Netherlands
2 DISCLOSURES Edwards Medtronic Siemens Consultant Consultant ( 2016) Advisory Board
3 3DRA Cookbook Indication Radiation Workflow contrast, merge, post processing Cases Conclusion
4 3DRA during CATH-INTERVENTION Indication
5 3DRA Indications to perform safe, targeted intervention startup imaging anatomic interactions pre / post stenting strategy (Ao, PA, PPS, PPVI, SV Stage I-III) collaterals visualize high-flow / low-flow regions, Vessel-Vessel, Vessel-Airway for every intervention from 2 to 130 kg dissection / aneurysm, strut perfusion, side effects / interactions safe angulations platform but not in : radiation and contrast impossible for biplane angiography vas / vps / ASD / PDA to merge / use pre-cath CTA and MRA
6 3DRA during CATH-INTERVENTION Radiation
7 3DRA RADIATION Dosis Area Product (μgy/m 2 ) -75% 0,8 /frame r 2 = 0,7497 0,4 msv 1,5 /frame Calibration fault 1,6 msv Effective dose (msv)
8 3DRA during CATH-INTERVENTION Workflow
9
10 WORKFLOW 3DRA VENTILATION Long ventilation tubes Dead volume no problem Respiratory arrest
11 3DRA RAPID PACING? No Rapid Pacing With Rapid Pacing
12 WORKFLOW 3DRA RAPID PACING Electrode Bard 4Fr bipolar Pacing site: RA/RV/LA/LV oesophageal (TCPC, CVL 3DRA) Pacing rate: decrease RR by 50% start 160/min (160) increase +20/min (+10) up to 240/min AICD ready
13 WORKFLOW 3DRA CONTRAST Contrast 60% dilution Calculate ml/s amount per C.O. 10 kg 6 ml/s 20 kg 10 ml/s 40 kg 14 ml/s Xray delay! 3 kg 2 ml/s
14 3DRA CONTRAST four 2D angios biplane PCPC, 10kg one 3D angio (6ml/s per C.O.) PCPC LV AoAsc Collaterals 10ml 15ml 15ml 20ml VCS Anonyma LV Asc 15ml 15ml 36ml 15ml Total 60ml Total 81ml 60% 48ml pure
15 3DRA MULTIPLE CONTRAST LOCATIONS
16 3DRA MIP MIP 2D way to look at 3D imaging measurements in correct plane independent from post processing fake another tool in the ordinary 3D box
17 3DRA MERGE A B Merge Segmentation
18 3DRA OCCULT LPA
19 3DRA MERGE
20 3DRA HOLLOW FIGURE Treshhold : Ramp Trapezoid Clipping : 6 planes unlimited angulations Measure : In clipping plane
21 3DRA ROADMAP Roadmapping : Project 3DRA on A plane B plane? NO! Safe contrast revalidate position by control angio anatomic shift by stiff wires entrance in ostia made easy
22 3DRA during CATH-INTERVENTION Workflow Case related
23 3DRA MID AORTIC SYNDROME Spatial Resolution? every single intercostal artery visible!
24 3DRA WORKFLOW TOF PA VSD PPS
25 3DRA MINISCULE NATIVE PA 3 year and many Stents later Correction : VSD Patch, RV-PA Contegra
26 3DRA OCCULT LPA 3,5 kg, 3 1/2 month old Increase RVOTO 3DRA trc bcc sin 24ml RV 20ml 4ml/s 1s xray delay contrast 60%, rapid pacing RV 220/min
27 3DRA WORKFLOW PPVI
28 3DRA PPVI
29 3DRA PPVI Jesse krogt ppvi mov
30 3DRA PPVI, LUSORIC ARTERY but there is a small detail : never been able to swallow food nutritiation was always liquid
31 3DRA WORKFLOW SV Stage I Stage III Stage II
32 STAGE I 3DRA IN SV 2,2 kg cctga, PA cap shunt occlusion recanalisation Pacing 260/min Single location contrast
33 STAGE I 3DRA IN SV 2,2 kg cctga, PA cap shunt occlusion recanalisation Pacing 260/min Single location contrast
34 3DRA HLHS SANO SHUNT HLHS (3,2 kg) Norwood I, Sano shunt 5mm 3. d post op: 50-60% desaturation, NorAdr Biplane Angiography
35 3DRA HLHS SANO SHUNT
36 3DRA RCA RV FISTULA
37 3DRA THAT S IT?
38 CTA CMR 3DRA CATH INTERVENTION OLD 3DRA CFD ANALYSIS STATIC / DYNAMIC DEVICE PREDICTION ANSYS POST CATH : PREPARE 3D PRINT DICOM TECHNICAL STL MIMICS, ITK-SNAP
39 THE UTRECHT COOKBOOK : HOW TO DO 3DRA THANKS to : Aimee, Francisco, Lee, Mario, Sebastian, Shak, Tom, 3DI3 CONFERENCE The Utrecht Team : Mirella, Hans NATIONWIDE CHILDREN S, OCT Gregor Krings Children s Heart Centre, University of Utrecht, The Netherlands
40 3DRA is just another tool in your box Thank you for your attention!
41 CONCLUSION 3DRA IN SV workflow challenging not simple properly done multiple location injection rapid pacing visualization Pitfalls Cons entire anatomy (vessel - airway) helps to be aware of structures next to your focus washout (DKS, anonyma) heterogenic contrast density non dynamic information (wait!) Roadmapping (3D background) fixed
42 STAGE I 3DRA IN SV 3,6 kg HLHS, Sano shunt stenosis stenting Pacing 230/min Single location contrast
43 STAGE III 3DRA IN SV 40ml 40ml 56ml / 8ml/s Pacing 230/min (PM) Triple location contrast
44 STAGE III 3DRA IN SV Post Processing : make Airway visible
45 3DRA VSD
Additional Value of 3DRA in the Diagnostic Evaluation and Percutaneous Treatment of Children With Univentricular Hearts
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