Two-Center Experience with Novel Image Fusion Software for 3D Guidance of Percutaneous Pulmonary Valve Implantation (PPVI)

Introduction: Recent advances in fusion software have enabled application of pre-intervention imaging, including computed tomography (CT) or magnetic resonance imaging (MRI) scans, to create a reliable roadmap for swift manipulation through complex cardiac anatomy. The aim of this study was to define the additional benefit of mapping for complex cardiac interventions.

Results: Vessel Navigator (Phillips Healthcare) was applied in 24 patients for planning (n = 5), suitability PA testing (n = 6) and PPVI (n = 14) between November 2015 and March 2016. The median age was 16 years (4.9–64 years); median weight was 46 kg (16.5–116 kg). Indications for PPVI were St.p. ROSS-procedure (n = 6), tetralogy of Fallot (n = 6), common arterial trunk (n = 5), pulmonary atresia (n = 3), double outlet right ventricle (n = 2) and Ebstein anomaly (n = 2). Twenty-two patients had a right ventricle-to-pulmonary artery conduit, three had patch repair only. Indications for PPVI were significant PS/PI. 3D roadmap was created from CT (n = 12) or MRI (n = 12) in all patients. Fusion with fluoroscopy images were acquired in 2 projections by angiography (n = 15), spine/vertebrae (n = 8), calcifications (n = 8) or artificial valves (n = 2) and was accurate in 20/24 patients. Landmarks were placed in all patients and in 5 patients re-adjustment was done during procedure due to distortion of the anatomy after introduction of a stiff wire or sheath. The median radiation dose was 4986 µGy*m2 (4773.3–24291 µGy*m2) and the median fluoroscopy time was 23.2 min (5.3–53.5 min).

Conclusion: 3D roadmap is a useful tool for guidance of PA-evaluation, PA-stenting and PPVI. Prior intervention proximal and distal parts or branches of valve region can clearly be marked by rings/markers and optimal angiographic projection can be nicely simulated. During intervention 3D overlay might improve 3D visualization in complex and overlapping anatomy. A reduction of radiation dose might be possible especially with use of MRI implementation.