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pain symptoms. From a second trial, similar non-signifi cant but trending results were reported in the SCOT-Heart
trial with a hazard for coronary heart disease death or
nonfatal myocardial infarction of 0.62 (95% confi dence
interval: 0.38–1.01, p=0.053). Based on the SCOT-Heart
trial, there appears to be a trend toward improve outcomes
for CCTA and this requires further exploration but may be
due to the greater reported initiation of preventive medications that is frequently observed. Both of these trials
establish CCTA as equally effective as functional imaging
(Fig. 21.5 ) [ 49 ]. A second NIH- NHLBI- sponsored trial in
patients with CCTA-defi ned CAD is the I nternational
S tudy of C omparative H ealth E ffectiveness with M edical
& I nvasive A pproaches Trial which will enroll 8000
patients who will be randomized to invasive coronary
angiography-guided treatment as compared to prompt
medical therapy (without invasive coronary angiography).
These trials will and have demonstrably improved the
quality of evidence and provide important information to
guide selection of candidates and those who may or may
not receive a benefi t from testing with CCTA.
Conclusions
The evidence base on the clinical utility of CCTA has
grown substantially over the past few years. This evidence
emulates an important development and will be a path to
rationally guiding healthcare coverage decisions using
quality evidence from large registries and clinical trials.
Table 21.1 Stable ischemia heart disease trials
Sponsor Trial N= Endpoint
Suspected CAD AHRQ
R andomized e valuation
of patients with s table
angina c omparing
u tilization of diagnostic
e xaminations
4300 CAD death, MI, &
revascularization
RAN
a
vs. MPI
NIH-NHLBI
PRO spective
m ulticenter i maging
s tudy for e valuation of
chest pain trial
10,000 2.5 years death, ACS,
complications
RAN
a
vs. functional
testing
Known CAD NIH-NHLBI
I nternational s tudy of
c omparative h ealth
e ffectiveness with
m edical & i nvasive
a pproaches trial
8000 4–6 years CV death or MI Blinded CCTA to r/o
LM & normal
coronaries
Completion: 7/19
Source: www.rescuetrial.org , www.promisetrial.org , www.ischemiatrial.org [ 45 – 47 ]
a
RAN Randomization
0
0.2
0.4
0.6
0.8
1
1.2
PROMISE SCOT-HEART
Hazard Ratio
Hazard Ratio: 1.04
(95% CI: 0.83, 1.29)
p=0.750
Hazard Ratio: 0.62
(95% CI: 0.38, 1.01)
p=0.053
Fig. 21.5 Primary results
from the PROMISE and
SCOT-HEART trials revealing
that CCTA was equally
effective at near-term clinical
outcomes
21 Coronary Computed Tomographic Angiography for Detection of Coronary Artery Disease
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The upcoming large clinical trials can further refi ne our
evidence on the clinical utility of CCTA. The public and
private payer community has largely been unresponsive
to this evidence base and it may be that the evidence has
been amassed so rapidly and that their ability to maintain
current knowledge base has been slow to respond. Despite
this, certainly the evidence supports a re-evaluation of the
national and private payer policies for CCTA. This
author’s opinion on the quality of evidence with CCTA is
reported in Table 21.2 .
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Randomized clinical or controlled clinical trials
High quality: Multicenter registries Near-term outcomes Long-term outcomes
Diagnostic accuracy **** ***
Risk assessment ***** *****
ED *****
A total of 5 stars are available for this ranking
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© Springer International Publishing 2016
M.J. Budoff, J.S. Shinbane (eds.), Cardiac CT Imaging: Diagnosis of Cardiovascular Disease,
DOI 10.1007/978-3-319-28219-0_22
Cardiothoracic Surgery Applications:
Virtual CT Imaging Approaches
to Procedural Planning
Jerold S. Shinbane , Craig J. Baker , Mark J. Cunningham ,
and Vaughn A. Starnes
Abstract
Cardiovascular computed tomographic angiography (CCTA) has led to a paradigm shift in
planning and performance of cardiothoracic surgical procedures, providing information
essential to decisions regarding surgical intervention. As the operating room and interventional cardiology laboratory have evolved, merging into a hybrid space, CCTA has assumed
an essential role in determination of the optimal therapeutic modality and path of approach
for percutaneous, minimally invasive robotic and open surgical approaches in this setting.
CCTA has particular signifi cance to planning of reoperation for coronary artery disease,
valvular heart disease, pericardial disease, congenital heart disease, cardiac masses, and
advanced heart failure. Communication of the data beyond the written report can be
achieved through images relevant for orientation and interventional approach. Review of
these virtual views with the multidisciplinary team is important for maximal application
and impact of this technology.
Keywords
Anomalous Coronary Arteries • Aortic Surgery • Cardiovascular Computed Tomographic
Angiography • Cardiothoracic Surgery • Computed Tomography • Congenital Heart Disease
• Coronary Artery Bypass Graft Surgery • Minimally Invasive Robotic Surgery •
Percutaneous Pulmonary Valve Replacement • Transcatheter Aortic Valve Implantation
Introduction
Cardiovascular computed tomographic angiography (CCTA)
has led to a paradigm shift in planning and performance of
cardiothoracic surgical procedures, providing information
essential to decisions regarding proceeding with surgical
intervention, facilitation of pre-surgical planning, and assessment for surgical effi cacy and sequelae. CCTA provides
a digitalized and individualized “Netter” illustration of the
relationships between thoracic skeletal, vascular, visceral,
and cardiac structures (Fig. 22.1 , Video 1). Full fi eld 3-D
reconstructions utilizing editing software enable visualization of multidimensional planes. Assessment of these views
is important for planning surgical access to target structures
while avoiding important vascular and visceral thoracic structures which may be in close proximity to the incisional plane.
J. S. Shinbane , MD, FACC, FHRS, FSCCT (*)
Division of Cardiovascular Medicine,
Department of Internal Medicine ,
Keck School of Medicine of the University of
Southern California , 1520 San Pablo Suite 300 ,
Los Angeles , CA 90033 , USA
e-mail: shinbane@usc.edu
C. J. Baker , MD, FACS • M. J. Cunningham , MD
Department of Surgery , Keck School of Medicine of the University
of Southern California , Los Angeles , CA USA
V. A. Starnes , MD
Cardiovascular Thoracic Institute, Department of Surgery ,
Keck School of Medicine of the University of Southern California ,
Los Angeles , CA USA
2 2
Electronic supplementary material The online version of this
chapter (doi: 10.1007/978-3-319-28219-0_22 ) contains supplementary
material, which is available to authorized users.
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392
The operating room and interventional cardiology laboratory have evolved, merging into a hybrid space utilized by a
multidisciplinary team of surgeons, interventional cardiologists and imagers. CCTA plays an essential role in decisions
and guidance for determination of the optimal therapeutic
modality and path of approach for percutaneous, minimally
invasive robotic and open surgical approaches in this setting.
Communication of the data beyond the written report can be
achieved through images relevant for orientation and interventional approach. Review of these virtual views with the
multidisciplinary team is important for maximal application
and impact of this technology.
Imaging Related to Surgery for Coronary
Artery Disease
CCTA has particular signifi cance to planning of re-operation
for coronary artery disease, as the number of prior operations
incrementally increases risk. At re-operation, the majority of
adverse events occur during sternotomy or pre-bypass dissection due to injury to bypass grafts and great vessels [ 1 , 2 ].
CCTA can visualize high risk sternotomy anatomy through
demonstration of structures coursing immediately posterior
to the sternum which may require special precautions
(Figs. 22.2 and 22.3 ). High risk features on CCTA include the
right ventricle or aorta less than 1 cm from chest wall and
coronary artery bypass grafts coursing across the midline less
than 1 cm from the sternum [ 3 ]. Pre-operative CCTA assess-
ment of the relationship of cardiovascular structures to the
sternum has been used to plan alternate approaches in patients
with high risk sternotomy anatomy, including: cancellation of
surgery, non-sternotomy incisional approach, deep hypother-
mic cardiac arrest, initiation of peripheral cardiopulmonary
bypass, and peripheral vascular dissection and exposure prior
to midline sternotomy [ 3 , 4 ]. Skeletal defects, traumatic
injury, metastatic disease, abscess, and osteomyelitis in the
sternum can also be identifi ed (Figs. 22.4 and 22.5 ).
In the setting of initial surgery as well as re-operation for
obstructive coronary artery disease, the use of CCTA to defi ne
native coronary anatomy has limitations due to calcifi cation
of native coronary arteries and inability to defi ne collateral
fl ow; therefore invasive coronary arteriography remains the
gold standard. CCTA can be useful in assessing graft location
and graft patency (Fig. 22.6 ). CCTA may be useful prior to
recurrent coronary artery bypass graft surgery in situations
where cardiac catheterization was unable to completely
defi ne graft anatomy, particularly as to whether a graft was
occluded versus unable to be cannulated at cardiac catheterization. CCTA in unoperated as well as previously operated
settings can defi ne the location and patency of the left and
right internal mammary arteries (Fig. 22.7 ). Depending on
the fi eld of view, CCTA can assess for subclavian artery stenoses. Surgical clip artifacts may make assessment of grafts
more challenging, particularly at the anastomosis site with the
native coronary artery (Fig. 22.8 ). Aortic characteristics, such
as profound calcifi cation/porcelain aorta, are important for
surgical approaches requiring cross-clamping of the aorta or
implantation of saphenous vein grafts into the aorta.
Imaging Related to Surgery for Valvular
Disease
CCTA for Surgical Versus Percutaneous
Approach to Aortic Valve Disease
CCTA has become essential to decision-making and preplanning related to transcatheter aortic valve implantation
(TAVI), minimally invasive robotic or open surgical
approaches for aortic valve replacement. Percutaneous
approaches employ TAVI balloon-expandable and selfexpanding valves [ 5 – 7 ]. CCTA provides data for decisions as
to the feasibility of versus contraindication to TAVI access
routes for percutaneous valve deployment including transfemoral, transapical subclavian artery, or direct aortic
approaches [ 8 , 9 ]. CCTA imaged anatomy limiting a trans-
femoral or aortic route include peripheral arterial diameter
limitations based on catheter size, aortic tortuousity, high
risk atheromas, severe vascular calcifi cation, chronic dissections and aneurysms. CCTA related factors and potential
limitations for consideration of a transapical approach to
TAVI include the morphology and location of the left ventricular apex, alignment of the left ventricular axis to the left
ventricular outfl ow tract, signifi cant septal hypertrophy and
presence of ventricular thrombi.
Fig. 22.1 A 3-D reconstruction demonstrating the relationships
between thoracic skeletal, vascular, visceral, and cardiac structures
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Aortic annulus characteristics can also limit use of TAVI
and therefore require operative approaches in patients who
are otherwise candidates for surgery. CCTA is the gold standard for annular geometry, measurements and physiology for
assessment of valve sizing and potential contraindication to
a TAVI approach based on annulus size and morphology
(Fig. 22.9 ). The annulus is often ovoid rather than circular in
shape, and can have variation in cusp length, height and relation to the coronary artery ostia. Annular dynamic morphologic changes occur throughout the cardiac cycle with
assessment for the largest diameter preferable [ 10 ]. Potential
annular eccentricity and elasticity therefore make detailed
coaxial characterization and measurement of the annulus
essential for decisions as to a percutaneous versus surgical
approach and appropriate sizing of valves when TAVI is an
option. In plane aligned aortic annular measurements of
maximum and minimum diameter, area, and circumference
at the attachments of all three aortic cusps, “hinge points” in
a “virtual ring”, are essential for accurate assessment and
provide virtual orientation for the TAVI team. The optimal
fl uoroscopic view for coaxial deployment should be noted by
the RAO/LAO and cranial/caudal viewing angle of the “virtual ring” created by these “hinge points” [ 9 , 11 ].
Detailed CCTA annular characterization and measurements are essential to avoid undersizing or oversizing of the
valve relative to the annulus and avoidance of issues related
to the coronary artery ostia. Valve undersizing can lead to
valve embolization or perivalvular leak. CCTA characteristics, including the relationship of valve diameter relative to
average annular diameter, degree of aortic root calcifi cation,
angulation between the left ventricular outfl ow tract and the
ascending aorta, and eccentricity of the annulus, are factors
a
c
b
Fig. 22.2 Anomalous coronary arteries coursing in close proximity to
the sternum. Panel ( a ) A 3-D volume rendered view demonstrating the
sternum. Panel ( b ) A 3-D volume rendered view with the sternum
partially edited to demonstrate the anomalous coronary circulation
( arrow ). Panel ( c ) A 3-D volume rendered view demonstrating the rela-
tionship of the anomalous coronary arteries ( arrows ) to the sternum
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potentially predictive of post-procedure regurgitation [ 12 –
14 ]. CCTA aortic annular sizing algorithms developed to
modestly oversize the implanted valve have led to reduction
of perivalvular regurgitation [ 15 ]. Differences in individual
TAVI device characteristics and available sizes are also
important to decisions based on CCTA dimensions in order
to avoid signifi cant oversizing [ 16 ]. Valve oversizing can
lead to annular rupture. Additionally, moderate to severe
sub-annular left ventricular outfl ow tract calcium predicts
rupture [ 17 ].
Relationships and characteristics of the annulus in relation to the coronary artery ostia must be taken into account
with CCTA analysis. Defi nition of the quantitative relationship between the aortic annulus, aortic sinuses, sinotubular
junction and the coronary artery ostia are important in order
to avoid coronary artery compromise due to the device or
atherosclerotic plaque with valve deployment. If the annular
to ostial height is too small, the ostia could be covered by the
device. The extent and morphology of annular and sub-annular calcifi cation is important, as this atherosclerotic plaque
can embolize into or partially or completely obstruct the
coronary artery ostium [ 18 – 22 ]. Given the possibility of
these complications, CCTA cardiovascular relationships to
the sternum need to be noted for TAVI candidates, as the
need for emergent conversion to an open sternotomy surgical
approach is a potential scenario. TAVI can also lead to conduction abnormalities including high grade atrioventricular
block. CCTA fi ndings of deep valve placement relative to the
annulus, severe calcifi cation of the landing site, and prosthesis/patient mismatch have been associated with left bundle
branch block and high grade atrioventricular block
[ 23 – 28 ].
Multiple factors make CCTA assessment of the coronary arteries challenging in severe to critical aortic stenosis patients. Given the advanced age of many patients being
considered for TAVI, as well as the underlying pathophysiology of calcifi c aortic stenosis, signifi cant calcifi cation of
the coronary arteries is often present. From a CCTA image
acquisition standpoint, acute beta blockade and sublingual
nitroglycerin may be contraindicated as part of the CCTA
imaging protocol in patients with severe to critical aortic
Fig. 22.3 A 2-D axial view showing the right ventricle coursing
immediately posterior to the sternum
ab
Fig. 22.4 Sagittal views demonstrating traumatic injury to the chest. Panel ( a ) Demonstration of sternal fracture ( arrow ). Panel ( b ) Demonstration
of pneumopericardium ( arrow )
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stenosis, further limiting the ability to assess the coronary
arteries. In other aortic valve scenarios, such as chronic
severe aortic regurgitation, CCTA may be useful as an alternative to invasive cardiac catheterization prior to aortic valve
surgery in patients with low to intermediate risk of coronary
artery disease [ 29 ].
Endocarditis involving the aortic valve and aortic root can
potentially lead to a higher risk of complications with invasive cardiac catheterization due to large aortic vegetations,
aortic pseudo-aneurysms, and aortic root abscesses. CCTA
can defi ne the extent of infection through visualization of
abscesses, pseudo- aneurysms, fi stulas, the relationship of the
coronary arteries to these structures, and presence of coronary
artery disease (Figs. 22.10 , 22.11 , 22.12 , and 22.13 , Video 2)
[ 30 ]. As these patients are sometimes critically ill, heart rate
control may be diffi cult, but images may still be diagnostic.
Prosthetic valve function can be viewed similarly to fl uoroscopic views in order to assess mechanical valve motion as
well as the presence of thrombus/vegetation (Fig. 22.14 ).
CCTA for Surgical Versus Percutaneous
Approach to Pulmonary Valve Disease
With the advent of percutaneous pulmonary valve replacement, surgical decision-making for pulmonary valve disease
must include assessment for the feasibility, risks and benefi ts
of each approach [ 31 – 34 ]. CCTA can be useful in imaging
many important decision-making factors including the size
and degree of calcifi cation of the pulmonary annulus, the
presence of anomalous coronary arteries, and the 3-D relationship of the coronary arteries to the pulmonary annulus
(Fig. 22.15 ) [ 35 ]. These factors are important to avoid com-
plications such as compression of the coronary arteries with
valve deployment, pulmonary regurgitation due to undersizing of the valve relative to the annulus, or conduit/annulus
rupture due to oversizing of the valve relative to the annulus.
The close proximity of anomalous coronary arteries or
enlarged right heart structures to the sternum are important
to identify in case emergent open surgical intervention is
required.
CCTA for Surgical Versus Percutaneous
Approach to Mitral Valve Disease
Research and clinical approaches to mitral valve disease
include a spectrum of options including percutaneous clipping of valve leafl ets, percutaneous mitral annuloplasty,
transcatheter mitral valve replacement, minimally invasive
robotic mitral valve repair or replacement, and open sternotomy mitral valve repair or replacement. Anatomic defi nition of the valve leafl ets, annulus, subvalvular apparatus,
relationship of the coronary arteries and cardiac veins to the
left atrioventricular groove, and presence or absence of coronary artery disease are important components of CCTA
analyses for decision-making and planning. Mitral annular
size and geometry factors including valve tenting, height
and tethering of the mitral leafl ets variability in number of
heads and insertions of the posterior papillary muscle, interpapillary muscle distance, mitral valve sphericity index,
intercommissural and septolateral distance , and anterior
and posterior circumference of the mitral annulus can be
Fig. 22.5 Sternal metastasis in a patient with aortic dissection
Fig. 22.6 A 3-D view showing a left internal mammary artery graft to
the left anterior descending coronary artery ( black arrow ), saphenous
vein graft to an obtuse marginal branch ( double black arrow ), saphe-
nous vein graft to a diagonal artery ( white arrow ), and saphenous vein
graft to the posterior descending artery ( double white arrow )
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assessed [ 36 – 38 ]. Mitral annular contour has a complex 3-D
non-planar saddle-shaped morphology. More simplifi ed,
planar measurements may be important to annular sizing for
valve implantation [ 39 ].
The presence of signifi cant aorto-iliac disease limiting
peripheral cardiopulmonary bypass as well as the extent and
location of mitral calcifi cation can limit minimally invasive
surgical approaches to mitral valve disease. CCTA can be
useful to determine a right thoracotomy robotic versus sternotomy approach based on the degree of mitral valve calcifi cation as well as the degree of aorto-iliac disease [ 40 , 41 ].
CCTA is also useful as an alternative to coronary artery catheterization in low to intermediate risk patients in preoperative decisions for robotic mitral valve repair [ 42 ].
Assessment of the 3-D spatial relationship of the circumfl ex coronary artery in the left atrioventricular groove and
the mitral annulus are important to the placement of the
sewing ring in mitral annuloplasty surgeries for mitral
regurgitation (Fig. 22.16 ) [ 43 ]. CCTA can assess the rela-
tionship of the coronary sinus / great cardiac vein, circumfl ex coronary artery and mitral annulus for novel
percutaneous mitral annuloplasty procedures utilizing the
cardiac vein system. There is great variability in these relationships, and segments where the circumfl ex coronary
artery courses between the coronary sinus/great cardiac
vein and the annulus can potentially compress the circumfl ex coronary artery [ 44 – 48 ].
Imaging Related to Surgery for Congenital
Heart Disease
In congenital heart disease, the multitude of individual
anomalies in the native state as well as palliative and corrective repairs in the operated state make the characterization of complete individualized anatomy in relation to the
thorax important for hybrid lab interventional, minimally
robotic and open surgical approaches. Decisions regarding
ab
Fig. 22.7 CCTA visualization of
the left ( a ) and right ( b ) internal
mammary arteries
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