At the 2021 Pediatric and Congenital Interventional Cardiovascular Society Symposium, Shelby Kutty, Director of Pediatric and Congenital Cardiology at Johns Hopkins Medicine delivered the lecture," Right Ventricular Outflow Tract Imaging and Tools for Analysis" in the Transcatheter Pulmonary Valve Therapy session.
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Shelby Kutty, director of pediatric and congenital cardiology at Johns Hopkins, presents “Right Ventricular Outflow Tract Imaging and Tools for Analysis” during the Pediatric and Congenital Interventional Cardiovascular Society Symposium.
Click to Tweet mm. Yeah. Yeah. Good afternoon everyone. I'd like to thank Z and Damon for the invitation to speak in this parliamentary valve session. You need a valve replacement. We have staff going down to a nearby farm to look for a donor. That's not exactly how it's done in the world of France, scattered apartment radiotherapy. We do however, have a right of valves and decisions need to be made about which one is best and what size will fit the stock. Will review the imaging modalities to support this decision making, detailed assessment of the RVR for tract is important for successful transplanted appear er city and MRI are both excellent tools for demographic imaging and can show the critical details of this anatomy. Both city and um are yield comprehensive two dimensional data sets and display this information into the emerging place. The challenge after that is to select an atomic locations on an image which reflects the time in the cardiac cycle at which the measurements will provide the best guidance as illustrated here. Cross sectional measurements of their beauty Are made from two d. multi plane and reconstructed images using a double oblique method perpendicular to the main pulmonary artery. Of course, even that is an oversimplification because the heart is a moving structure. So accusations must integrate motion. Fortunately it's possible from the full cardiac cycle data provided by either a modern city or a time will solve the MRI to pick the correct face. Three dimensional images has shown here are an effective way for the intervention list to assimilate information as these images can be. The spatial relationships between the structures of interest and surrounding anatomy. The imagine protocols are straightforward for city retrospectively subjugating is suggested. However, this approach is associated with higher radiation doses with newer scanners. An adaptive sequential mode can give satisfactory data with less radiation. Other key points that you use a try physic contrast bowlers to optimize the pacification and use high quality reconstructions in Sicily and obviously which are the faces used for measurements of doubtful track. In addition to the standard RV function and be a fraction. The technical focus of the protocol is to obtain a 3D whole heart sequence and all we have to track specific cities with either modality, doubtful track is where we need the best an atomic data. This is accomplished through analysis of multiple slices orthogonal without for track to define the level of any obstruction that may be present. Appreciation of dynamic motion in the single plane to the images is essential for an atomic understanding and for device selection These cross sectional planes from a 3D reconstructed CD show the cycling and protracted. I made the changes Because of expansion and translational motion dimensions may increase by up 20-30% in Sicily. So systolic phase assessment can be critical for valve sizing for over our beauties come in a variety of configurations. So shape needs to be considered in the valve selection process. Our prototype conduits can be cyanotic and testified and they're an atomic relationship to the coronary arteries. May post compression risk with the device. City is quite sensitive for calcification. These reconstructed city images show variable degrees of calcification. The distance of left main and RC eight with our product is measured on cross sectional images has shown here but there are important considerations of tissue plane and mobility. So a single plane cross sectional imaging can our completely assessed the risk of coronary compression. This image illustrates how dynamic imaging on the right here is helpful as it displays the lady coursing the RVR project and posing risk. Yeah, rare colorado me. Such as the dual A lady in this patient with the rigid anterior chest wall can be picked up by demographic imaging diagnosing this anomaly is mandatory as it may represent a contra indication for outfront right standing. A number of devices are coming into clinical use although they are similar, they come in different sizes and different specifications. A center may be using more than one type so images must become comfortable with the structural features And the appearance of each one they may encounter. Cross sectional shape along their beauty is elliptical and north circular and there is dynamic transformation in shape during the cardiac cycle. The mood, the major access dimension of their lips diverges from that of the minor axis. The greater the potential forever. By under sizing of the device. If area based measurements are used using city data parameter based sizing with automated software tracking is therefore less susceptible to inappropriate underestimation. This wide illustrates 3D perimeter measurements performed with the center line starting in the right ventricle, along the outflow tract and through the roof of the verification. Across sexual measurements are obtained from three D. images at multiple levels as shown in this slide and the length of the potential landing zone. From the outflow tract to the bifurcation statement and the potential device fit is evaluated. This is an example of perimeter measurements in both faces. Sisterly in red and eisley in blue corresponding to maximum and minimum are really size from the device manufacturer cord lab for the FDA approved harmony device. The device needs to be bigger than our beauty at the proximal and distal ends and the central part of the device needs to be smaller. These graphic plots compare outflow tract parameter to device parameter along the length of the potential implant site and evaluate predicted over sizing or goodness of fit at the various implant locations. The green shading indicates an appropriately sized and good fitting device while the red shading on the left shows undersized device. This is software simulation of a different device in its landing zone that helps planning by showing an ideal delivery position. Yeah. In complex cases with unusual anatomy, the imaging data can be printed into a physical three D. Model but software based simulation has improved to the point that physical three D. Model is no longer routinely necessary at once, damaging tools can not only help for planning but also during the actual intervention. This is a biplane overlay That gives an augmented reality display not only in the 80 but also in the lateral planes. Alongside your routine forest topic display newer iterations of this will allow for respiratory motion compensation. In addition to the biplane overlay, as shown in these images, the role of demographic imaging does not end with the successful Valerie plantation. Follow up surveillance is important. Cities generally applies and the only follow up while MRI is preferable in the long term, although device related artifacts are often less problematic for city than for MRI. There is a role for artificial intelligence and the TPP our landscape. This is elegant will from the UK in which they have successfully validated AI and Digital Twin for our beauty predictive planning. Using patient data beyond automated analysis to improve decision making data from various sources could be fed as inputs into a deep neural network trained to predict various outputs. So in the future, with aI based integration of the large amounts of data. The images and interventional is collect. We may get more insights into measurements that provide the most reliable information regarding patient suitability and which specific patients derive the most or least benefit in summary cardiac CT and MRI offer high spatial resolution imaging and dynamic data for an atomic assessment to aid patient and device selection and follow up computational three D modeling and patient specific simulations are helpful for procedure planning, better standardization of the emerging protocols, measurements and reporting is critical to ensure quality and consistency within the costs and doesn't physicians predictive analytics may help bridge the gap from large, emerging data sets to optimal device selection. Many thanks to France and imaging for Tony and Tareq and friends and intervention, or jOHN and Mahad even for helping with this talk. Thank you for attention. Yeah.