Preprocedural Planning Research Articles

A Comprehensive Review of Percutaneous and Surgical Left Atrial Appendage Occlusion.

Atrial fibrillation (AF) is the most common arrhythmia worldwide, and is associated with a significant risk of thromboembolic events. Left atrial appendage occlusion (LAAO) has emerged as a promising alternative for patients with contraindications or intolerance to anticoagulant therapy. This review summarises the current evidence, indications, and technical advancements in surgical and percutaneous LAAO. Preprocedural planning relies on various imaging techniques, each with unique advantages and limitations. The existing randomised clinical trials and meta-analyses demonstrate favourable results for both percutaneous and surgical LAAO. Postprocedural management emphasises personalised anticoagulation strategies and comprehensive imaging surveillance to ensure device stability and detect complications. Future focus should be put on antithrombotic regimens, investigating predictors of device-related complications, and simplifying procedural aspects to enhance patient outcomes. In summary, LAAO is presented as a valuable therapeutic option for preventing AF-related thromboembolic events, with ongoing research aimed at refining techniques and improving patient care.

How to improve patient outcomes following TAVI in 2024? Recent advances.

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of aortic stenosis, particularly among elderly patients. The world's first TAVI procedure was performed in 2002 by Professor Cribier. It was approved for clinical use in Europe in 2007, followed by approval in the United States in 2011. It has since been introduced into clinical practice throughout Europe, and there has been a remarkable increase both in the number of procedures and in the number of centers performing TAVI. Recent findings endorse its additional application in lower-risk populations, suggesting a transformative shift in the field of interventional cardiology. This review article thoroughly explores the recent advances and key considerations aimed at enhancing patient outcomes following TAVI. Key areas of focus include valve durability, paravalvular leak management, valve-in-valve procedures, and the implications and management of coronary artery disease in these patients. We highlight the importance of selecting valves with favorable hemodynamics, minimal coronary risk, and optimal durability, especially for younger, lower-risk patients. Paravalvular leak remains a significant concern; thus, pre-procedural planning and immediate corrective measures are crucial to mitigate its impact. The increasing need for valve-in-valve interventions underscores the importance of the strategic initial valve choice with a forward-looking perspective. Additionally, emerging strategies such as transcatheter leaflet laceration to prevent coronary obstruction during reinterventions, are examined. This review synthesizes current research and clinical practice, providing a roadmap for enhancing TAVI outcomes through technological advances and strategic procedural planning. The findings and recommendations presented aim to optimize long-term patient prognosis, ensuring that TAVI remains a leading solution for aortic stenosis in an increasing variety of patients.

Transcatheter Mitral Valve Intervention: Current and Future Role of Multimodality Imaging for Device Selection and Periprocedural Guidance.

Mitral regurgitation (MR) is a broadly diffuse valvular heart disease (VHD) with a significant impact on the healthcare system and patient prognosis. Transcatheter mitral valve interventions (TMVI) are now well-established techniques included in the therapeutic armamentarium for managing patients with mitral regurgitation, either primary or functional MR. Even if the guidelines give indications regarding the correct management of this VHD, the wide heterogeneity of patients' clinical backgrounds and valvular and heart anatomies make each patient a unique case, in which the appropriate device's selection requires a multimodal imaging evaluation and a multidisciplinary discussion. Proper pre-procedural evaluation plays a pivotal role in judging the feasibility of TMVI, while a cooperative work between imagers and interventionalist is also crucial for procedural success. This manuscript aims to provide an exhaustive overview of the main parameters that need to be evaluated for appropriate device selection, pre-procedural planning, intra-procedural guidance and post-operative assessment in the setting of TMVI. In addition, it tries to give some insights about future perspectives for structural cardiovascular imaging.

Transcatheter Aortic Valve Implantation in Challenging Anatomies

TANJA Rudolph, Heart and Diabetes Center North Rhine-Westphalia, Germany; and Carla Romina Agatiello, Hospital Italiano de Buenos Aires, Argentina, chaired a captivating session exploring the challenges associated with transcatheter aortic valve implantation (TAVI) in patients with complex aortic stenosis. The European Association of Percutaneous Cardiovascular Interventions (EAPCI) hosted the session during the 35th Annual EuroPCR Global Course held in Paris, France, between the 14th–17th of May. The primary objectives of the session were to evaluate and emphasise the importance of detailed CT imaging and pre-procedural planning in TAVI. Moreover, the session focused on how the selected valve and implant techniques in aortic stenosis can be tailored to individual patient anatomy.

Imaging Assessment of Fetal Cerebrovascular Anomalies.

Four distinct vascular anomalies can be seen to affect the brain on fetal imaging: vein of Galen malformations, non-galenic arteriovenous pial fistulas, dural sinus malformations, and intracranial venous malformations. These congenital disorders affect the arteries and veins of the developing brain and are rarely seen beyond the neonatal stage. The four fetal cerebrovascular anomalies are associated with quite disparate natural histories and prognoses. MRI plays a pivotal role in the evaluation of fetuses with these conditions due to its ability to definitively establish the diagnosis, to detect subtle parenchymal injuries, to delineate the course of abnormal vessels in detail and to some extent the nature of vascular flow, and to identify ischemic, thrombotic, and hemorrhagic complications. Recently, an investigational transurterine embolization procedure targeted at treating fetuses with vein of Galen malformations who are at high risk for neonatal decompensation has emerged as a promising alternative to expectant management and post-natal embolization, with imaging being used to identify suitable patients for the intervention and in pre-procedural planning. This manuscript reviews the essential imaging and clinical features of these four fetal neurovascular anomalies and underscores the practical aspects related to counseling, prognosis, and the multidisciplinary management of these entities.ABBREVIATIONS: ACVRL1= activin A receptor like type 1; b-SSFP=Balanced Steady State Free precession; DSM= Dural Sinus Malformation; Ephrin B4= Ephrin type-B receptor 4; icVM= Intracranial Venous Malformation; ITGB1= Integrin Subunit Beta 1; NOTCH1= Neurogenic locus notch homolog protein 1; PTPN11= Protein Tyrosine Phosphatase Non-Receptor Type 11; RASA1= RAS P21 Protein Activator 1; SSFSE= Single-shot fast spin echo; VOGM=Vein of Galen Malformation.

Desktop 3D printed anatomic models for minimally invasive direct coronary artery bypass

BackgroundThree-dimensional (3D) printing technology has impacted many clinical applications across medicine. However, 3D printing for Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) has not yet been reported in the peer-reviewed literature. The current observational cohort study aimed to evaluate the impact of half scaled (50% scale) 3D printed (3DP) anatomic models in the pre-procedural planning of MIDCAB.MethodsRetrospective analysis included 12 patients who underwent MIDCAB using 50% scale 3D printing between March and July 2020 (10 males, 2 females). Distances measured from CT scans and 3DP anatomic models were correlated with Operating Room (OR) measurements. The measurements were compared statistically using Tukey’s test. The correspondence between the predicted (3DP & CT) and observed best InterCostal Space (ICS) in the OR was recorded. Likert surveys from the 3D printing registry were provided to the surgeon to assess the utility of the model. The OR time saved by planning the procedure using 3DP anatomic models was estimated subjectively by the cardiothoracic surgeon.ResultsAll 12 patients were successfully grafted. The 3DP model predicted the optimal ICS in all cases (100%). The distances measured on the 3DP model corresponded well to the distances measured in the OR. The measurements were significantly different between the CT and 3DP (p < 0.05) as well as CT and OR (p < 0.05) groups, but not between the 3DP and OR group. The Likert responses suggested high clinical utility of 3D printing. The mean subjectively estimated OR time saved was 40 min.ConclusionThe 50% scaled 3DP anatomic models demonstrated high utility for MIDCAB and saved OR time while being resource efficient. The subjective benefits over routine care that used 3D visualization for surgical planning warrants further investigation.

The Role of Coronary CT Angiography in Chronic Total Occlusion Coronary Intervention

Context: The application of coronary computed tomography angiography (CCTA) is increasingly being recognized for its role in diagnosing and ruling out coronary artery disease (CAD). This editorial letter discusses the usefulness of CCTA in planning for chronic total occlusion percutaneous coronary intervention (CTO PCI). Evidence Acquisition: We searched for articles using Google Scholar and the PubMed Database. The keywords used were "Coronary CT Angiography (CCTA)," "Chronic Total Occlusion (CTO) intervention," "pre-procedural CTO PCI," and "post-CTO interventions." The articles included in the review were published between 2013 and 2023. Results: Regarding pre-procedural planning for the revascularization of chronic total occlusions (CTOs), there is significant interest in the ability of CCTA to visualize and analyze coronary atherosclerotic plaque. Additionally, CCTA can provide three-dimensional coronary vessel imaging. Following post-CTO intervention, CCTA is utilized to determine whether the formation of new channels and plaque remodeling will improve the chances of future successful interventions. Conclusions: CCTA allows for the precise assessment of anatomical features without invasive procedures, making the diagnosis of CAD easier. The technology is advancing rapidly, with new scanners offering higher resolution, better-quality images, and reduced radiation exposure.

Future of left atrial appendage interventions.

Percutaneous left atrial appendage occlusion (LAAO), currently recognized as a procedure with relatively low risk, is increasingly being adopted in clinical practice. However, due to the preventive nature of the procedure and the necessity to compare it with newer and safer oral anticoagulants, further optimization is required to address remaining challenges. These latter include acquiring comprehensive data on safety and efficacy, establishing standardized pre-procedural planning, and simplifying procedural process. Consequently, we have provided an overview that encompasses future opportunities for enhancing procedural safety and efficacy, thereby establishing LAAO as the mainstream strategy for stroke and systemic embolism prevention in patients with atrial fibrillation and absolute contraindications to anticoagulant drugs.

3D Printing of Subclavian Artery: Utility for Preprocedural Planning and Correlation With Subclavian Artery Percutaneous Vascular Interventions.

Three-dimensional (3D) printing for subclavian artery (SA) percutaneous vascular interventions (PVI) may allow superior understanding of patient specific complex anatomy and aid with preprocedural planning. Five patients with computed tomography angiography (CTA) of the neck who underwent SA PVI were queried retrospectively. 3D printing of aortic arch and great vessels was accomplished with 3D slicer software and painted with acrylic paint to highlight anatomic features. The aortic arch type and implications for preprocedural planning for SA interventions including complex chronic total occlusion (CTO) lesions were determined. Comparisons were made with SA angiograms and 3D-CTA. Of the 5 patients, type I (n = 2), type II (n = 1), and type III (n = 2) aortic arches were identified. Proximal and distal reference vessel size and total lesion length were determined using a digital millimeter caliper and correlated with intraprocedural balloons and stents. In 3D-printed models (3D-PMs) of patients with SA-CTO (n = 2), cap morphology (tapered vs blunt) and distal vessel filling were visualized, permitting optimal arterial access site selection for successful cap crossing. The vertebral arteries (VAs) were also 3D printed which further allowed the ability to delineate optimal stent deployment site (proximal or distal to VA), a common dilemma that is faced intraprocedurally. The 3D-PMs also allowed preprocedural precision in stent and balloon size and length, potentially leading to procedural efficiency and cost-effectiveness. 3D printing of aortic arch and great vessel anatomy for SA-PVI allows multiple procedure-related factors to be predicted in advance, translating to decrease in contrast volume, radiation time, procedure and fluoroscopic time, thereby improving procedure and cost efficiency.

Computational simulation model of transcatheter edge-to-edge mitral valve repair: a proof-of-concept study.

As transcatheter mitral valve (MV) interventions are expanding and more device types and sizes become available, a tool supporting operators in pre-procedural planning and the clinical decision-making process is highly desirable. We sought to develop a finite element computational simulation model to predict the results of transcatheter edge-to-edge repair (TEER) interventions. We prospectively enrolled patients with secondary mitral regurgitation (MR) referred for a clinically indicated TEER. The 3D trans-oesophageal echocardiograms performed at the beginning of the procedure were used to perform the simulation. On the 3D dynamic model of the MV that was first obtained, we simulated the clip implantation using the same clip type, size, number, and implantation location that was used during the intervention. The 3D model of the MV obtained after the simulation of the clip implantation was compared with the clinical results obtained at the end of the intervention. We analysed the degree and location of residual MR and the shape and area of the diastolic MV area. We performed computational simulation on five patients. Overall, the simulated models predicted well the degree and location of the residual regurgitant orifice(s) but tended to underestimate the diastolic mitral orifice area. In this proof-of-concept study, we present preliminary results on our algorithm simulating clip implantation in five patients with functional MR. We show promising results regarding the feasibility and accuracy in terms of predicting residual MR and the need to improve the estimation of the diastolic MV area.

The correlation between left atrium voltage mapping and 3D late gadolinium enhancement cardiac magnetic resonance imaging findings in patients with known atrial fibrillation

Abstract Introduction The non-invasive cardiac magnetic resonance imaging-based late gadolinium enhancement (LGE-CMR) of the left atrium (LA) fibrosis distribution and degree can be utilized for preprocedural planning and real-time guidance of AF ablation. There is an ongoing discussion with somewhat conflicting results regarding the accuracy of LGE-CMR of the LA as compared with the invasive electroanatomical mapping (EAM). Earlier data mainly encompassed post-ablation patients with an EAM involving a relatively small number of acquired points. Aim To evaluate the accuracy of LGE-CMR-based LA fibrosis using the ADAS 3D LA software among ablation-naive AF patients as compared with EAM using the CARTO-3 navigation system. Methods Patients with non-permanent AF, naive to previous ablation/cardiac surgery, who underwent CARTO-based AF ablation with preceding LGE-CMR scan were selected for the study. The 3D substrate atrial maps were generated based on the LGE-CMR (CMR-fib) using the ADAS 3D LA software and the CARTO EAM (EAM-fib). A fibrosis threshold of 1.2-1.32 was established for the CMR-fib using the Image Intensity Ratio whereas a threshold of 0.2-0.5mV was applied for the EAM-fib. The two 3D-maps were assessed for fibrosis using anatomically synchronized quantitative point by point comparison. The EAM was set as the gold standard. Results The study included 26,777 points acquired from 17 patients (aged 65.8±7.92 yrs with 6 females and 10 paroxysmal AF cases). CMR-fib showed 22.0% of LGE, while the EAM-fib demonstrated 48.8% of low voltage areas. The CMR-fib vs. EAM-fib point by point comparison concluded with an agreement of 73.1% and interrater reliability of 0.45 (p&amp;lt;0.001). The sensitivity and specificity were 45.0% and 99.9%, respectively, while the PPV and NPV were 99.8% and 65.6%, respectively. The Area Under the Curve (AUC) was calculated as 72.4. Increase of the EAM-fib threshold for scar (to 0.5-1.5mV) led to a further decrease in the assessment diagnostic performance and the interrater reliability. The lowest agreement was tested in the LA roof segments and the higher in the inferoseptal and posterior walls. Conclusion The LGE-CMR underestimates the presence of scar as presented by the EAM, however, those detected are mostly accurate. The low sensitivity that was demonstrated between the two methods may be attributed to the lower spatial resolution of the CMR as well as the superficial subendocardial layer mapped by EAM as compared with the averaged transmural mapping of the CMR-fib. A follow-up larger-scale study is required to assess the accuracy of LGE-CMR-based assessment of fibrosis, considering various wall thicknesses and establishing the scar threshold on the ADAS software, particularly for ablation-naive patients.

Computed tomography imaging in preprocedural planning of transcatheter valvular heart interventions.

Cardiac Computed Tomography (CCT) has become a reliable imaging modality in cardiology providing robust information on the morphology and structure of the heart with high temporal and isotropic spatial resolution. For the past decade, there has been a paradigm shift in the management of valvular heart disease since previously unfavorable candidates for surgery are now provided with less-invasive interventions. Transcatheter heart valve interventions provide a real alternative to medical and surgical management and are often the only treatment option for valvular heart disease patients. Successful transcatheter valve interventions rely on comprehensive multimodality imaging assessment. CCT is the mainstay imaging technique for preprocedural planning of these interventions. CCT is critical in guiding patient selection, choice of procedural access, device selection, procedural guidance, as well as allowing postprocedural follow-up of complications. This article aims to review the current evidence of the role of CCT in the preprocedural planning of patients undergoing transcatheter valvular interventions.

CCT‘S CRYSTAL BALL: PREDICTING CARDIOVASCULAR RISK IN AORTIC VALVE STENOSIS PATIENTS UNDERGOING VALVE REPLACEMENT

Abstract Background and Aims Currently, computed tomography cardiac imaging (CTCI) plays a fundamental role in the pre–procedural planning of degenerative–calcific aortic valve stenosis(AS) correction. However, its prognostic role in assessing mortality and major adverse cardiovascular events (MACE) has not been extensively explored. CTCI allows for the evaluation of coronary artery calcification(CAC), mitral annular calcifications (MAC), aortic valve calcifications (CVA), and thoracic aorta calcifications (CAT). The aim of our study was to assess whether the presence and extent of CAC, MAC, CVA, and CAT could influence non–cardiovascular mortality (NCM), cardiovascular mortality (CM), and MACE in patients undergoing valve replacement(VR). Materials and Methods We collected retrospectivelly clinical and instrumental data and reviewed CTCI using a semi–quantitative approach. CACs were classified according to the visual 2022 Coronary Artery Disease–Reporting and Data System. MACs were defined following the Guerrero et al. study, CVAs according to the Win Registry and CATs were assessed in the ascending aorta, aortic arch, and descending aorta according to the Vos classification. Results 244 patients(59% male, mean age 80.1±6.6 years), with 91% undergoing transfemoral VR, were enrolled(2016–2018). CM was significantly higher in patients with hypertension,cerebro/peripheral vascular disease, stage IV–V renal insufficiency and history of atrial fibrillation (p=0.012,p&amp;lt;0.001,p=0.005, p=0.034 and p=0.024, respectively). CM was also more pronounced in patients with STS SCORE≥6.7±5.2 and EuroSCOREII≥ 5.5±5.8(p=0.016 and p=0.037). Extensive CAC(p=0.019), a MAC score&amp;gt;7(p=0.051), moderate and severe AVC (p=0.029 and p=0.053) and TAC&amp;gt;270° in aortic arch(p=0.019) were linked to CM. In multivariate analysis, a high MAC score and the presence of moderate AVC persisted as risk factors for CM. The presence of a MAC score &amp;gt;7(p=0.006) and the extension of descending TAC &amp;gt;1.5 mm (p=0.034) were associated with an increased risk of NCM.The presence of extensive TAC (≥270°) measured in the aortic arch and descending aorta were associated with MACE (p=0.034 and p=0.0504 respectively). Conclusions CTCI emerges as a crucial tool for evaluating prognostic risk in patients undergoing VR for AS. This type of evaluation can assist clinicians in pre–procedural planning and patient management, allowing for better identification of high–risk patients and optimization of therapeutic strategies

Individualized Care Delivery for Children With Autism and Related Disabilities Undergoing Overnight Video Electroencephalography (EEG): One Hospital's Experience With a Coordinated Team Approach.

Background and Purpose: Children with developmental disabilities have increased risk of epilepsy and need for overnight video electroencephalographic (EEG) monitoring. However, video EEGs have historically been considered difficult to complete for this population. An autism support service at a pediatric tertiary care hospital implemented a coordinated team approach to help children with developmental disability tolerate overnight video EEGs. The project included completion of a caregiver-report preprocedure questionnaire that then was shared with the multidisciplinary team and used to create individualized care plans. The current study aims to describe rates of video EEG completion and need for lead placement under general anesthesia among children with autism and related disabilities who received these supports. Methods: Rates of video EEG completion and general anesthesia use were analyzed for children referred to the support service between April 2019 and November 2021. Results: A total of 182 children with developmental disability (mean age = 10.3 years, 54.9% diagnosed with autism) met inclusion criteria. 92.9% (n = 169) of children successfully completed EEG (leads on ≥12 hours). Only 19.2% (n = 35) required general anesthesia for video EEG lead placement. The majority (80.2%) of parents (n = 146) completed the preprocedure questionnaire. Video EEG outcomes did not differ based on completion of the questionnaire. Parent-reported challenges with communication and cooperation were associated with shorter video EEG duration and greater use of general anesthesia. Conclusions: These findings suggest that most children with developmental disability can complete video EEG with sufficient support. Preprocedure planning can identify children who would benefit from additional accommodations. Further research is necessary to clarify which supports are most helpful.

Minimalistic approach to left atrial appendage occlusion guided by cardiac computed tomography angiography.

To assess the feasibility and safety of the minimalistic approach to left atrial appendage occlusion (LAAO) guided by cardiac computed tomography angiography (CCTA). Ninety consecutive patients who underwent LAAO, with or without CCTA-guided, were matched (1:2). Each step of the LAAO procedure in the computed tomography (CT) guidance group (CT group) was directed by preprocedural CT planning. In the control group, LAAO was performed using the standard method. All patients were followed up for 12 months, and device surveillance was conducted using CCTA. A total of 90 patients were included in the analysis, with 30 patients in the CT group and 60 matched patients in the control group. All patients were successfully implanted with Watchman devices. The mean ages for the CT group and the control group were 70.0 ± 9.4 years and 68.4 ± 11.9 years (P = 0.52), respectively. The procedure duration (45.6 ± 10.7 min vs. 58.8 ± 13.0 min, P < 0.001) and hospital stay (7.5 ± 2.4 day vs. 9.6 ± 2.8 day, P = 0.001) in the CT group was significantly shorter compared to the control group. However, the total radiation dose was higher in the CT group compared to the control group (904.9 ± 348.0 mGy vs. 711.9 ± 211.2 mGy, P = 0.002). There were no significant differences in periprocedural pericardial effusion (3.3% vs. 6.3%, P = 0.8) between the two groups. The rate of postprocedural adverse events (13.3% vs. 18.3%, P = 0.55) were comparable between both groups at 12 months follow-up. CCTA is capable of detailed LAAO procedure planning. Minimalistic LAAO with preprocedural CCTA planning was feasible and safe, with shortened procedure time and acceptable increased radiation and contras consumption. For patients with contraindications to general anesthesia and/or transesophageal echocardiography, this promising method may be an alternative to conventional LAAO.

Inversion recovery and saturation recovery pulmonary vein MR angiography using an image based navigator fluoro trigger and variable-density 3D cartesian sampling with spiral-like order.

Contrast enhanced pulmonary vein magnetic resonance angiography (PV CE-MRA) has value in atrial ablation pre-procedural planning. We aimed to provide high fidelity, ECG gated PV CE-MRA accelerated by variable density Cartesian sampling (VD-CASPR) with image navigator (iNAV) respiratory motion correction acquired in under 4min. We describe its use in part during the global iodinated contrast shortage. VD-CASPR/iNAV framework was applied to ECG-gated inversion and saturation recovery gradient recalled echo PV CE-MRA in 65 patients (66 exams) using .15mmol/kg Gadobutrol. Image quality was assessed by three physicians, and anatomical segmentation quality by two technologists. Left atrial SNR and left atrial/myocardial CNR were measured. 12 patients had CTA within 6months of MRA. Two readers assessed PV ostial measurements versus CTA for intermodality/interobserver agreement. Inter-rater/intermodality reliability, reproducibility of ostial measurements, SNR/CNR, image, and anatomical segmentation quality was compared. The mean acquisition time was 3.58 ± 0.60min. Of 35 PV pre-ablation datasets (34 patients), mean anatomical segmentation quality score was 3.66 ± 0.54 and 3.63 ± 0.55 as rated by technologists 1 and 2, respectively (p = 0.7113). Good/excellent anatomical segmentation quality (grade 3/4) was seen in 97% of exams. Each rated one exam as moderate quality (grade 2). 95% received a majority image quality score of good/excellent by three physicians. Ostial PV measurements correlated moderate to excellently with CTA (ICCs range 0.52-0.86). No difference in SNR was observed between IR and SR. High quality PV CE-MRA is possible in under 4min using iNAV bolus timing/motion correction and VD-CASPR.

Long-term outcome of multilayer flow modulator in aortic aneurysms.

This retrospective study investigated the efficacy of endovascular treatment with multilayer flow modulators (MFMs) for treating aortic aneurysms in high-risk patients unsuitable for conventional treatments. Conducted from 2011 to 2019 at a single center, this retrospective observational study included 17 patients who underwent endovascular treatment with MFMs. These patients were selected based on their unsuitability for traditional surgical or endovascular procedures. The study involved meticulous pre-procedural planning, precise implantation of MFMs, and follow-up using CT angiography. The primary focus was on volumetric and flow volume changes in aneurysms, along with traditional diameter measurements. Moreover, the technical success and post-procedural complications were also registered. The technical success rate was 100%, and 30-day procedural complication rate was 17.6%. Post-treatment assessments revealed that 11 out of 17 patients showed a decrease in flow volume within the aneurysm sac, indicative of a favorable hemodynamic response. The median decrease in flow volume was 12 ml, with a median relative decrease of 8%. However, there was no consistent reduction in aneurysm size; most aneurysms demonstrated a median increase in volume for 46 ml and median increase in diameter for 18 mm. While MFMs offer a potential alternative for high-risk aortic aneurysm patients, their effectiveness in preventing aneurysm expansion is limited. The results suggest that MFMs can provide a stable hemodynamic environment but do not reliably reduce aneurysm size. This underscores the need for ongoing vigilance and long-term monitoring in patients treated with this technology.

Evaluating the diagnostic performance of non-contrast magnetic resonance angiography sequences in the pre-procedural comprehensive analysis of direct carotid cavernous fistula.

Endovascular treatment of direct carotid cavernous fistula (DCCF) requires invasive diagnostic cerebral angiography for diagnosis and planning; however, a less invasive modality like magnetic resonance angiography (MRA) can be useful, especially in high-risk cases. This single-centre study evaluated a newer MR angiography (MRA) sequence, silent MRA and the traditional time of flight (TOF) MRA for pre-procedural treatment planning of DCCF. All consecutive DCCF patients who underwent TOF, silent MRA and diagnostic cerebral angiography were included in the study. Angiographic features like rent size, location, draining veins and collateral communicating arteries were analysed and compared between the two MRA sequences, with digital subtraction angiography (DSA) as the gold standard. Fifteen patients were included in the study. TOF MRA exhibited better sensitivity (76.9% vs 69.2%) in identifying the rent location, correctly pinpointing the location in 93.3% compared to 73.3% with silent MRA. Both MRA sequences showed good agreement with DSA for primary sac and rent size. TOF MRA correctly identified 86.2% of 210 total venous structures compared to 96% by silent MRA. Silent MRA demonstrated higher sensitivity (90% vs 76%) and accuracy (87.69 vs 94.36) in visualisation of involved veins compared to TOF MRA. Arterial characteristics of DCCF like rent location and rent size were better assessed by TOF MRA. Although both MRA identified venous features, silent MRA correlated better with DSA irrespective of the size and proximity to the site of the fistula. Combining both sequences can evaluate various angioarchitectural features of DCCF useful for therapeutic planning.

A System for Mixed-Reality Holographic Overlays of Real-Time Rendered 3D-Reconstructed Imaging Using a Video Pass-through Head-Mounted Display-A Pathway to Future Navigation in Chest Wall Surgery.

Background: Three-dimensional reconstructions of state-of-the-art high-resolution imaging are progressively being used more for preprocedural assessment in thoracic surgery. It is a promising tool that aims to improve patient-specific treatment planning, for example, for minimally invasive or robotic-assisted lung resections. Increasingly available mixed-reality hardware based on video pass-through technology enables the projection of image data as a hologram onto the patient. We describe the novel method of real-time 3D surgical planning in a mixed-reality setting by presenting three representative cases utilizing volume rendering. Materials: A mixed-reality system was set up using a high-performance workstation running a video pass-through-based head-mounted display. Image data from computer tomography were imported and volume-rendered in real-time to be customized through live editing. The image-based hologram was projected onto the patient, highlighting the regions of interest. Results: Three oncological cases were selected to explore the potentials of the mixed-reality system. Two of them presented large tumor masses in the thoracic cavity, while a third case presented an unclear lesion of the chest wall. We aligned real-time rendered 3D holographic image data onto the patient allowing us to investigate the relationship between anatomical structures and their respective body position. Conclusions: The exploration of holographic overlay has proven to be promising in improving preprocedural surgical planning, particularly for complex oncological tasks in the thoracic surgical field. Further studies on outcome-related surgical planning and navigation should therefore be conducted. Ongoing technological progress of extended reality hardware and intelligent software features will most likely enhance applicability and the range of use in surgical fields within the near future.

Coronary Artery Disease Assessment via On-Site CT Fractional Flow Reserve in Patients Undergoing Transcatheter Aortic Valve Replacement.

Purpose To examine the clinical feasibility of workstation-based CT fractional flow reserve (CT-FFR) for coronary artery disease (CAD) evaluation during preprocedural planning in patients undergoing transcatheter aortic valve replacement (TAVR). Materials and Methods In this retrospective single-center study, 434 patients scheduled for TAVR between 2018 and 2020 were screened for study inclusion; a relevant proportion of patients (35.0% [152 of 434]) was not suitable for evaluation due to insufficient imaging properties. A total of 112 patients (mean age, 82.1 years ± 6.7 [SD]; 58 [52%] men) were included in the study. Invasive angiography findings, coronary CT angiography results, and Agatston score were acquired and compared with on-site CT-FFR computation for evaluation of CAD and prediction of major adverse cardiovascular events (MACE) within a 24-month follow-up. Results Hemodynamic relevant CAD, as suggested by CT-FFR of 0.80 or less, was found in 41 of 70 (59%) patients with stenosis of 50% or more. MACE occurred in 23 of 112 (20.5%) patients, from which 14 of 23 had stenoses with CT-FFR of 0.80 or less (hazard ratio [HR], 3.33; 95% CI: 1.56, 7.10; P = .002). CT-FFR remained a significant predictor of MACE after inclusion in a multivariable model with relevant covariables (HR, 2.89; 95% CI: 1.22, 6.86; P = .02). An Agatston score of 1000 Agatston units or more (HR, 2.25; 95% CI: 0.98, 5.21; P = .06) and stenoses of 50% or more determined via invasive angiography (HR, 0.94; 95% CI: 0.41, 2.17; P = .88) were not significant predictors of MACE. Conclusion Compared with conventional CAD markers, CT-FFR better predicted adverse outcomes after TAVR. A relevant portion of the screened cohort, however, was not suitable for CT-based CAD evaluation. Keywords: CT, Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR), Cardiac, Coronary Arteries, Outcomes Analysis © RSNA, 2024 See also the commentary by Weir-McCall and Pugliese in this issue.