3D Hybrid Imaging for Structural and Congenital Heart Interventions in the Cath Lab

Figures & data

Table 1. Overview of advanced imaging options of major XRF vendors

	Philips Healthcare		Siemens Healthineers		GE Healthcare		Canon Medical
Systems	Allura Xper FD10/10 Allura Xper FD20/10 Allura Xper FD20 Azurion 5 Azurion 7		Artis Q Artis Q.zen Artis zee Artis zeego Artis pheno		IGS 3 × 0^a IGS 5 × 0^a IGS 6 × 0^a IGS 7 × 0^a		Infinix-i systems
3D technology	3D Rotational angiography	Cone-beam CT	3D Rotational angiography	Cone-beam CT	3DRotational angiography	Cone-beam CT	3D Rotational angiography	Cone-beam CT
Products	3DRA	XperCT	InSpace 3D	DynaCT	Innova 3D	Innova CT HD	3D-DA/3D-DSA	Low contrast imaging
Anatomy best visualized	Contrast filled	Soft tissue, bones and contrast filled tissues	Contrast filled	Soft tissue, bones and contrast filled tissues	Contrastfilled	Soft tissue, bones and contrast filled tissues	Contrast filled	Soft tissue, bones and contrast filled tissues
Acquisition time	80°/s (240 frames in 4 s)	80°/s (120 frames in 4 s) 80°/s (240 frames in 4 s) 24°/s (300 frames in 10 s) 24°/s (620 frames in 10 s)	40°/s (133 frames in 5 s)^b	40°/s (248 frames in 5 s)^b	40°/s (approx. 150 frames in 5 s)	40°/s (approx. 250 frames in 5 s) 28°/s (approx. 350 frames in 7 s) 16°/s (approx. 600 frames in 12 s)	80°/s (250 frames in 2.6 s) 80°/s (400 frames in 2.6 s) 80°/s (600 frames in 2.6 s)	25°/s (250 frames in 10 s) 26.7°/s (400 frames in 15 s) 30°/s (600 frames in 20 s)
Angular rotation (°)	240	240	200 2×220/360^c	200 2×220/360^c	200	200	210	210
Frame rate (fps)	30	30–60	26.6^d	49.6^d	30	50	100^d	25–30^d
Processing time	5 seconds (256^3)	< 1min	< 20s	< 20s	< 30s	< 1min
Spatial Resolution	256^3	256^3	256^3 (512^3)	256^3 (512^3)	512^3	512^3	256^3 (512^3)	256^3 (512^3)
Image integration	CT MR		CT MR PET-CT		CT MR PET-CT SPECT		CT MR

Notes. ^aX: 2 = 20×20 detector, 3 = 30×30 detector, 4 = 40×40 detector.

^bArtis Pheno can perform all 3D imaging acquisitions in 4s.

^cArtis Pheno can perform 360 degrees rotation.

^dEstimated based on acquisition time and angular rotation.

3DRA, 3D rotational angiography; CBCT, cone-beam CT; CT, computed tomography; MR, magnetic resonance; PET, positron emission tomography; SPECT, single positron emission CT.

Table 2. Overview of HI software tools of major XRF vendors for structural and congenital heart diseases

	Philips Healthcare		Siemens Healthineers		GE Healthcare
Tools	HeartNavigator	EchoNavigator	Aortic Valve Guide	TrueFusion	HeartVision 2
Image integration	CT	Echo (Philips CX50 or iE33, or Philips EPIC)	CBCT, CT	Echo (Acuson SC2000 Prime only)	CBCT, CT, MR, SPECT, PET
Image fusion	2D/3D matching of 3D volume with 2D XRF 3D/3D match with 3D XRF	Automatic fusion of 3D TEE with 2D XRF	2D/3D (2 2D XRF images > 30° apart) 3D/3D match with 3D XRF	Automatic fusion of 3D TEE with 2D XRF	2D/3D match with 2 orthogonal (AP, Lateral) 2D XRF shots 3D/3D match with 3D XRF
Image processing	Automatic segmentation: - Left ventricle - Aortic valve - Aorta - Coronary ostia	Demarcation of anatomical structures on echo	Automatic segmentation: - Aortic root - Coronary ostia - Aortic valve cusps Demarcation of landmarks	Demarcation of anatomical structures on echo	Automatic segmentation: - Left cavities (CT) - Left atrium (Innova 3D/CT HD) - Large structures (CT/Innova 3D/Innova CT HD)
Measurements	Automatic: Annulus: - Diameter - Perimeter - Area Aortic: - Diameters above annulus - Ostia heights - Sinus diameters		Annulus: - Diameter - Perimeter - Area	Automatic: Annulus: - Diameter - Perimeter - Area Aortic: - Root Sinotubular junction - Root Sinus of Valsalva	Automatic: Annulus: - Diameter - Perimeter - Area Aortic: - Diameters above annulus - Ostia heights - Sinus diameters
Roadmap + extra markers	Real-time 3D volume or outline overlay	Real-time 3D TEE overlay Demarcation of landmarks	Real-time 3D volume or outline overlay Demarcations of Cusp nadirs, coronary ostia markers and ascending aorta centreline Add circle of perpendicularity	Real-time 3D TEE overlay Demarcation of landmarks	Real-time 3D volume overlay Add landmark points and planning lines
Optimal X-ray angulation	Yes TAVI		Yes	Yes	Yes TAVI
Additional	Device selection and view planning Calcification distribution ascending aorta	Automatic tracking of TEE transducer position and orientation Automatic TEE field of view outline is displayed		Automatic tracking of TEE transducer position and orientation Automatic TEE field ofview outline is displayed

Note. 3DRA, 3D rotational angiography; CBCT, cone-beam CT; CT, computed tomography; MR, magnetic resonance; PET, positron emission tomography; SPECT, single positron emission CT; TAVI, transcatheter aortic valve implantation; TEE, transoesophageal echocardiography; XRF, single- and bi-plane cine angiography and fluoroscopy.

Table 3. Overview of optimized CBCT scan and contrast infusion protocols used for structural and congenital heart disease interventions

	Adult		Pediatric
Source	Numburi et al.^Citation10	Balzer et al.^Citation11	Peters et al.^Citation12	Haddad et al.^Citation13
XRF system	Siemens Axiom Artis	Philips Allura FD20	Siemens Artis zee	Toshiba Infinix-I
Scan duration (s)	5	5.2	5	4.1
Frame rate (frames/s)	60	60	30	25
Angular rotation(°)	220	210	200	206
Number of Projections (frames/scan)	235	312	248	-
Tube potential (kV)	Automatic (75–125)	120	Automatic	88 (< 30 kg) & 95 (> 30 kg)
Tube current (mAs)	Automatic (150–692)	Automatic (50–325)	Automatic (mean 118.4±104)	Automatic (25–55)
Detector entrance dose (µGy/X-ray pulse)	0.54	-	-	~0.13–0.22
Contrast infusion site	Aortic root	Left ventricle	Varying	Varying
Iodine concentration (mgI/mL)	370	350	300	-
Total volume (mL/kg) (contrast:saline)	(~1:1)	0.8 mL/kg (1:1)	(3:4)	1.6 mL/kg (1:2 for < 30 kg & 2:3 for > 30 kg)
Flow rate (mL/s)	10–15	14	2–14	-
Injection duration (s)	6–8	6	6	5–6
Scan delay (s)	1–2	1	1	1–2
Gating	Ungated	Ungated	Ungated	Ungated
Cardiac rhythm during imaging	RVP (200 bpm)	RVP (200 bpm)	RVP (180+ bpm)	RVP (140-180 bpm)

Note. The protocols are divided in adult and pediatric protocols, respectively focused on TAVI procedures and reducing radiation and contrast levels while maintaining good image quality. Bpm, beats per minute; RVP, rapid ventricular pacing; XRF, single- and bi-plane cine angiography and fluoroscopy.

Figure 1. Hybrid imaging during recanalization of a partial cavo-pulmonary connection of the left pulmonary artery. (A) 3D reconstruction of the pulmonary artery tree (yellow structure) and left ventricle (LV) with outflow tract (white structure). (B) 3D overlay of the pulmonary tree is used to introduce a guidewire into the left pulmonary artery. (C) Contrast injection in the pulmonary artery tree with the stent in place

Figure 2. Hybrid imaging during TAVI. (A) 3D reconstructed DynaCT of the aortic root using Aortic Valve Guide (Siemens Healthineers) shows automatically generated aortic centerline (marked yellow dotted line), a circle of perpendicularity (marked red line), and coronary ostia markers (blue and green markers). (B, C) The cusps markers (red dots) and circle of perpendicularity enable accurate prosthesis deployment at the correct annular height

Figure 3. Hybrid imaging during stent placement in a coarctation of the aorta. (A,B) 3D reconstruction of the left ventricle and aorta (white structure) and stent in the aortic arch (blue structure), respectively shown in the AP and LAO projections. (C) 3D overlay of the aortic arch with the stent in place. The 3D roadmap is used to provide targeted stent placement and avoid obstruction of the left common carotid and left subclavian arteries

Figure 4. Schematic overview of potential 3D overlay markings onto XRF to guide cardiac resynchronization therapy (CRT) and electrophysiology cardiac interventions. The blue markings show targets for pulmonary vein isolation. In yellow the phrenic nerve is depicted, passing along the epicardium of the left ventricle. In red an infarcted region is visualized with corresponding border zone marked in black. The orange region is showing the latest activated area along with the coronary venous tree depicted in white

Numburi UD , Kapadia SR , Schoenhagen P , et al. Optimization of acquisition and contrast injection protocol for C-arm CT imaging in transcatheter aortic valve implantation: initial experience in a swine model. Int J Cardiovasc Imaging . 2013;29(2):405–415. doi:10.1007/s10554-012-0075-8.

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Balzer JC , Boering YC , Mollus S , et al. Left ventricular contrast injection with rotational C-arm CT improves accuracy of aortic annulus measurement during cardiac catheterisation. EuroIntervention . 2014;10(3):347–354. doi:10.4244/EIJV10I3A60.

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Peters M , Krings G , Koster M , et al. Effective radiation dosage of three-dimensional rotational angiography in children. Europace . 2014;17(4):611–616. doi:10.1093/europace/euu207.

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Haddad L , Waller BR , Johnson J . et al. Radiation protocol for three-dimensional rotational angiography to limit procedural radiation exposure in the pediatric cardiac catheterization lab. Congenit Heart Dis . 2016;11:637–646. doi:10.1111/chd.12356.

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