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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3676_Библиотеки_им_академика_М_И_Перельмана
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Fig. 12.9 (a) Axial view of PSA (b) axial view of PSA—2-year follow-up (c) volume rendered (d) coronary angio-
gram showing coils
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12.10 Case 12.10
12.10.1 History
A 63-year-old female past medical history of
severe three vessel coronary artery disease (CAD)
and mixed valvular disease presented with progressive shortness of breath on exertion.
12.10.2 Findings
CCTA confirmed diagnosis of severe three vessel
CAD with patent bypasses by cardiac catheterization with mixed valvular disease with severe
mitral stenosis (Fig. 12.10a, b). Transesophageal
echo demonstrated mitral mean gradient of
10 mmHg as well as severe mitral regurgitation.
Also, patient had severe ascending aortic calcification shown on CCTA (Fig. 12.10c).
12.10.3 Diagnosis
Severe coronary artery disease, severe ascending
aortic calcification with severe symptomatic
mitral valvular disease: mitral stenosis, mitral
regurgitation.
12.10.4 Discussion
Three years prior to presentation, patient underwent coronary artery bypass to address her coronary artery disease. Due to patient’s severe
ascending aortic calcification and severe mitral
annular calcification, which extended into the
posterior left ventricular wall, only off-pump
coronary bypass was performed without surgical
correction of the mitral disease. In the 3 years
since the CABG, an attempt had been made to
treat her valvular congestive heart failure with
maximal medical therapy, but was unsuccessful.
She was evaluated by our Heart Team for additional therapeutic options.
After being evaluated by our Heart Team and
various other heart surgical programs, patient
was deemed inoperable due to the extent of aortic
calcification and the inability to cross clamp the
aorta. She was offered the option of a transcatheter aortic valve to be placed in the native mitral
position. The CT scan was used to plan the size of
the valve to be used as well as to define the pattern of mitral calcification. The left ventricular
outflow tract (LVOT) dimensions were also evaluated by the CCTA. LVOT obstruction can occur
with transcatheter implantation of an aortic valve
in the native mitral position.
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a
Fig. 12.10 (a) CCTA views showing heavy annular calcification of the mitral valve. (b) Sagittal MIP of mitral valve
(c) sagittal MIP of calcified ascending aorta
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12.11 Case 12.11
12.11.1 History
A 67-year-old female with progressive shortness
of breath on exertion.
12.11.2 Findings
Transesophageal echocardiography demonstrated severe para-valvular regurgitation of a
previously implanted surgical bioprosthetic
mitral valve.
CCTA was used to define the para-valvular
leak dimensions.
12.11.3 Diagnosis
Decompensated heart failure due to severe mitral
para-valvular regurgitation.
allows for sizing of the defect. It also allows for
determination of the proximity of important surrounding structures. Determination of the size of
the device to be used to close the leak can also be
facilitated by CCTA as demonstrated in
Fig. 12.11a. In this case, a large PDA Amplatzer
occlude device was used to close the leak
(Fig. 12.11b). Acquisition of a retrospective
gated CCTA allows for sizing of the defect’s
maximum dimensions (the sizes of the defect
changes during the cardiac cycle).
12.11.4 Discussion
In the planning of a percutaneous closure of a
para-valvular leak closure the use of CCTA
Fig. 12.11 (a) Sagittal MIP of mitral valve. (b) Volume
rendered
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Closure of the patent ductus arterio-
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Cardiac CTA: Electrophysiology
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John J. Lee, Rishi Anand, and Daniel Weitz
13
Cardiac computed tomography angiogram
(CCTA) has evolved from a simple structural
assessment tool to a key instrument used for
complex ablation procedures in clinical cardiac
electrophysiology. CCTA’s fast acquisition and
better image resolution allow for precise anatomic assessment that increases the efficacy and
safety of these procedures.
CCTA has become integral in preparing for
left atrial-based electrophysiology (EP)
procedures, such as atrial fibrillation (AF) ablation. The cornerstone of AF ablation procedures
is application of radiofrequency energy in a wide
circumferential manner around the antrum of the
pulmonary veins. Prior to insertion of catheters
into the left atrium, it is essential to assess the
J.J. Lee, MD
Department of Medicine,
University of Miami at Holy Cross Hospital,
Fort Lauderdale, FL, USA
R. Anand, MD • D. Weitz, MD (*)
Electrophysiology Lab, Department of Cardiology,
Holy Cross Hospital, Fort Lauderdale, FL, USA
e-mail: daniel.weitz@gmail.com
number of pulmonary veins present, the presence
of common pulmonary vein antrums, and the
presence of potentially impending structures
such as left atrial diverticula and the presence of
cor triatriatum. In addition, in preparation for AF
ablation in patients who had previous left atrial
ablation, it is mandatory to assess for iatrogenic
pulmonary vein stenosis. Evaluation of these
structures is performed with volume rendering
into a three-dimensional (3D) reconstruction. 3D
CT images are reconstructed and vascular and
coronary structural images are segmented away
until pulmonary venous and left atrial anatomies
are isolated for a more focused evaluation.
The left atrial anatomy includes a venous portion that receives the PVs, which encloses a left
atrial dome, a vestibule that conducts to the mitral
valve, the left atrial appendage (LAA) and interatrial septum [1]. The left atrium (LA) is also
closely examined to assess for its size and for the
presence or the absence of thrombus [1, 2]. In
addition, the esophagus can be included in the 3D
rendering to note its proximity to the posterior
aspect of the pulmonary veins [2]; Avoidance of
direct energy application to areas abutting the
esophagus can prevent atrial-esophageal fistulas.
These images and the dataset are then translated to intra-procedure electro-anatomic mapping
© Springer International Publishing AG 2018
C. Smuclovisky (ed.), Coronary Artery CTA, https://doi.org/10.1007/978-3-319-66988-5_13
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systems, such as the CARTO mapping system
(Biosense Webster, Diamond Bar, CA, USA) and
the Endocardial Solutions, Inc. (ESI). By superimposing images from CCTA on the electroanatomical imaging created with the mapping
systems, it helps to precisely map PVs and guide
ablation catheters to target locations (i.e., the PV
angle of insertions, size) [3, 4]. These modalities
can in turn facilitate localization of anatomic
structures and track intracardiac instruments and
the ablation lesion set, effectively decreasing the
procedure and fluoroscopy time [2].
In addition to functions described above,
CCTA can be used to check for possible complications following EP procedures such as pulmonary vein stenosis. This chapter will use clinical
cases with images to demonstrate and further
explain CCTA application in EP procedures.
13.1 Case 13.1
13.1.1 History
13.1.2 Findings
The left atrium (LA) appears dilated measuring
in the range of 4.3 cm. There is no visualized
thrombus in the left atrial appendage (Fig. 13.1a).
There is a common trunk from the right upper
and middle lobes draining anterosuperiorly into
the left atrium. There is a draining venous trunk
from the right lower lobe into the inferoposterior
right side of the left atrium. There is a common
draining trunk from the left upper lobe into the
anterosuperior aspect of the left atrium and the
left lower lobe venous trunk draining into the
inferoposterior aspect of the left atrium
(Fig. 13.1b, c).
There is no pericardial effusion and no dilation of the aortic root or the pulmonary arterial
trunk.
A 72-year-old male with paroxysmal atrial fibrillation, despite being on propafenone 300 mg
three times a day and carvedilol 20 mg. CCTA
performed for pre-ablation planning.
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Fig. 13.1 (a) Volume rendered-left atrium (b) MIP axial-
superior vein (c) MIP axial-inferior vein (d) volume
rendered- left atrium (e) 3D fast anatomical mapping
(FAM) posterior anterior view (f) 3D FAM left anterior
oblique CT: Pre-Isolation (g) 3D FAM left anterior
oblique CT: Isolation (h) 3D FAM right CT
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Fig. 13.1 (continued)
g
h
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Fig. 13.1 (continued)
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