Congenital Heart Disease (CHD) is a birth defect or malformation of the heart which can impact the heart’s structure and function. According to the American Heart Association, nearly 36,000 babies are born with a heart defect each year. While CHD can affect both children and adults and can be life threatening, revolutionary advancements in diagnosis and surgery have made treatment and reparation of such defects possible. In 2008, over one million people with CHD had survived through adulthood.

Cardiac Catheterization is a non-surgical procedure that can be used for hemodynamic and angiographic evaluations of the structure and function of the heart, helpful in the diagnosis of CHD. Transcatheter interventions for treatment of CHD can also be performed using stents, coils, and other interventional devices.

Used in conjunction with the Toshiba Infinix-i cardiac systems, the Toshiba 3D-Digital Acquisition (3D-DA) software package allows physicians to view a three-dimensional perspective of a variety of vascular structures including the pulmonary arteries. 3D reconstruction is ideal for optimizing vessel-viewing angles prior to intervention, providing a better understanding of complex anatomy and helping to determine the proper size of interventional devices to be used for planning and treatment.

Case Study: 3D rotational angiography using 3D-DA software.

Technology: Toshiba Infinix CF-i Biplane cardiovascular cath lab using 3D-DA software.

Patient History: A 14 year old girl born with complex congenital heart disease (interrupted aortic arch, ventricular septal defect) required numerous surgical procedures beginning in early infancy which culminated in a Fontan procedure at age 4. Recently she began complaining of decreased exercise tolerance prompting a cardiac MRI which raised the possibility of a left pulmonary artery stenosis which had not been appreciated during previous cardiac catheterizations despite selective left pulmonary arteriography.

Diagnosis: During catheterization performed via a right femoral venous approach, selective 2D left pulmonary angiography failed to adequately demonstrate any stenosis. Due to the high degree of suspicion a 3D-DA was performed at 30f/s using a 206 degree rotation over a 5 second acquisition while holding respiration. Fifty milliliters of undiluted contrast were injected at a rate of 10 cc/sec to obtain the images shown in figure 1. Reconstruction took 35 seconds and post-processing took another 2 minutes to produce the images shown here. By rotating the reconstructed image 90% caudal (a view, not possible with standard angiography) physicians were able to clearly view the compression of the left pulmonary artery in a front to back orientation. Two overlapping Genesis XD stents were implanted across the area with 12 mm balloon and further dilated to 14 mm to obtain the image shown in figure 2.

In this particular case the use of 3D-DA greatly enhanced the ability to diagnose an important stenotic lesion which was undetected by 2D-DA despite multiple bi-plane acquisition imaging angles. Furthermore, using 3D-DA, post-intervention provided excellent imaging of the vessel stent interface and allowed for improved assessment of the result as well as any potential complication.

Figure 1: Pre-intervention 3D-DA of the branch pulmonary arteries in a child with a significant left pulmonary artery stenosis (arrow) after a Fontan operation. In a standard projection (LAO 21/caudal 7) the stenosis is difficult to appreciate (left), however, after rotating the image to a virtual angle (LAO 35/Cranial 71), the stenosis is clearly visible as shown by the arrow (right).

Figure 2: The same structure seen in the comparable views as above following implantation of two endovascular stents to enlarge the area. Note the excellent clarity and detail of the newly implanted stents and their relationship to the vessel wall.

Pre- (left) and post- (right) 3D-DA spins.

Images courtesy of Dr. Evan M. Zahn, M.D., Miami Children’s Hospital, Miami Florida

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