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• W2149484477 abstract "HomeCirculationVol. 132, No. 14Image Fusion Guided Device Closure of Left Ventricle to Right Atrium Shunt Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBImage Fusion Guided Device Closure of Left Ventricle to Right Atrium Shunt Elena K. Grant, MBChB, Anthony Z. Faranesh, PhD, Russell R. Cross, MD, Laura J. Olivieri, MD, Karin S. Hamann, RNC, Kendall J. O’Brien, BA, Michael S. Hansen, PhD, Mary T. Donofrio, MD, Robert J. Lederman, MD, Kanishka Ratnayaka, MD and Michael C. Slack, MD Elena K. GrantElena K. Grant From Department of Cardiology, Children’s National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children’s Heart Program, Baltimore, MD (M.C.S.). Search for more papers by this author , Anthony Z. FaraneshAnthony Z. Faranesh From Department of Cardiology, Children’s National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children’s Heart Program, Baltimore, MD (M.C.S.). Search for more papers by this author , Russell R. CrossRussell R. Cross From Department of Cardiology, Children’s National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children’s Heart Program, Baltimore, MD (M.C.S.). Search for more papers by this author , Laura J. OlivieriLaura J. Olivieri From Department of Cardiology, Children’s National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children’s Heart Program, Baltimore, MD (M.C.S.). Search for more papers by this author , Karin S. HamannKarin S. Hamann From Department of Cardiology, Children’s National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children’s Heart Program, Baltimore, MD (M.C.S.). Search for more papers by this author , Kendall J. O’BrienKendall J. O’Brien From Department of Cardiology, Children’s National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children’s Heart Program, Baltimore, MD (M.C.S.). Search for more papers by this author , Michael S. HansenMichael S. Hansen From Department of Cardiology, Children’s National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children’s Heart Program, Baltimore, MD (M.C.S.). Search for more papers by this author , Mary T. DonofrioMary T. Donofrio From Department of Cardiology, Children’s National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children’s Heart Program, Baltimore, MD (M.C.S.). Search for more papers by this author , Robert J. LedermanRobert J. Lederman From Department of Cardiology, Children’s National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children’s Heart Program, Baltimore, MD (M.C.S.). Search for more papers by this author , Kanishka RatnayakaKanishka Ratnayaka From Department of Cardiology, Children’s National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children’s Heart Program, Baltimore, MD (M.C.S.). Search for more papers by this author and Michael C. SlackMichael C. Slack From Department of Cardiology, Children’s National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children’s Heart Program, Baltimore, MD (M.C.S.). Search for more papers by this author Originally published6 Oct 2015https://doi.org/10.1161/CIRCULATIONAHA.115.013724Circulation. 2015;132:1366–1367A 16-year-old boy with a double-outlet right ventricle, D-malposed great vessels, and a subpulmonary ventricular septal defect status-post surgical ventricular septal defect patch closure and arterial switch procedure at 2 months of age, reported progressive exercise intolerance. He was found to have moderate right atrial enlargement, mild dilation of right and left ventricles, and a persistent residual left ventricle to right atrium (LV-RA) intracardiac shunt on echocardiographic assessment (similar physiology to a Gerbode-type defect; Figure A and Movie I in the online-only Data Supplement). Cardiac MRI delineated the LV-RA shunt (steady-state free precession cine; Figure B and Movie I in the online-only Data Supplement), with an estimated Qp:Qs of 1.4:1 (velocity-encoded MRI). Cardiac MRI–derived left-ventricular end-diastolic volume was 132 mL/m2 (z score = +3.6) with normal ejection fraction of 55% and right-ventricular end-diastolic volume was 136 mL/m2 (z score = +2.2) with an ejection fraction of 45%.1 Given his symptoms and progressive right heart dilation, he was referred for percutaneous device closure.Download figureDownload PowerPointFigure. Image fusion guided device closure of left ventricle to right atrium shunt. A, Preintervention transthoracic echocardiogram, 4-chamber view in color-compare mode showing left ventricle to right atrium (LV-RA) shunt (white arrow). B, Preintervention steady-state free precession cardiac MRI (Siemens 1.5 Tesla) with noncontrast angiographic sequences, assisted by respiratory compensation and ECG-based cardiac gating. The MRI shows right heart enlargement and LV-RA shunt (white arrow). The defect diameter is 3 mm and velocity-encoded MRI Qp:Qs is 1.4:1. C, The baseline conventional left ventriculogram shows the LV-RA shunt (white arrow). D, XFM (x-ray fused with MRI) overlay baseline left ventriculogram (blue=right atrium, light pink=left ventricle, dark pink=LV-RA shunt) highlights the intracardiac shunt. E, Following XFM-guided wire crossing of the LV-RA defect, this panel shows XFM-guided defect closure with a muscular ventricular septal defect occluder. The device is deployed in the defect and still attached to the delivery cable. F, The postintervention left ventriculogram with XFM overlay shows successful device closure of the LV-RA defect.Invasive hemodynamic assessment yielded Qp:Qs of 1.5:1 (Fick) and normal pulmonary vascular resistance. A 3-dimensional map of the cardiac chambers and LV-RA shunt was manually extracted from the cardiac MRI by using previously described techniques.2 Live x-ray (Figure C and Movie I in the online-only Data Supplement) was fused with this 3-dimensional MRI map (XFM; MR fusion and overlay, Siemens, Forchheim, Germany) with automatic correction for gantry and table position to guide closure of the LV-RA shunt with an Amplatzer Congenital Muscular VSD Occluder (St. Jude Medical, Minneapolis, MN). XFM roadmaps optimized gantry angle and simplified wire crossing of the defect without requiring additional iodinated contrast (Figure D through F and Movie I in the online-only Data Supplement). One month afterward, the patient was asymptomatic with greatly improved exercise ability. A transthoracic echocardiogram was performed 1 year postprocedure with the following results: no residual shunt, normal right atrial size (2D dimension = 3.9 cm versus 5.3 cm preprocedure), mildly dilated right and left ventricles (M-mode right ventricular diastolic dimension, 2.1 cm; left ventricular internal dimension end diastole, 5.4 cm; left ventricular internal dimension end systole, 3.6 cm versus preprocedure M-mode right ventricular diastolic dimension, 2.3 cm; left ventricular internal dimension end diastole, 5.0 cm; left ventricular internal dimension end systole, 3.1 cm) with normal biventricular systolic function.XFM simplifies complex interventions by providing 3-dimensional procedural guidance in the familiar x-ray working environment.2,3 It may also reduce radiation and contrast exposure.4Sources of FundingThis work is funded by the National Heart Lung and Blood Institute (HHSN268201500001C and Z01-HL006039).DisclosuresChildren’s National Medical Center and Siemens Medical have a master research agreement.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.115.013724/-/DC1.Correspondence to Elena K. Grant, MBChB, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2c713, MSC 1538, Bethesda, MD 20982. E-mail [email protected]References1. Buechel EV, Kaiser T, Jackson C, Schmitz A, Kellenberger CJ.Normal right- and left ventricular volumes and myocardial mass in children measured by steady state free precession cardiovascular magnetic resonance.J Cardiovasc Magn Reson. 2009; 11:19. doi: 10.1186/1532-429X-11-19.CrossrefMedlineGoogle Scholar2. Ratnayaka K, Raman VK, Faranesh AZ, Sonmez M, Kim JH, Gutiérrez LF, Ozturk C, McVeigh ER, Slack MC, Lederman RJ.Antegrade percutaneous closure of membranous ventricular septal defect using X-ray fused with magnetic resonance imaging.JACC Cardiovasc Interv. 2009; 2:224–230. doi: 10.1016/j.jcin.2008.09.014.CrossrefMedlineGoogle Scholar3. Glöckler M, Halbfaβ J, Koch A, Achenbach S, Dittrich S.Multimodality 3D-roadmap for cardiovascular interventions in congenital heart disease–a single-center, retrospective analysis of 78 cases.Catheter Cardiovasc Interv. 2013; 82:436–442. doi: 10.1002/ccd.24646.CrossrefMedlineGoogle Scholar4. Abu Hazeem AA, Dori Y, Whitehead KK, Harris MA, Fogel MA, Gillespie MJ, Rome JJ, Glatz AC.X-ray magnetic resonance fusion modality may reduce radiation exposure and contrast dose in diagnostic cardiac catheterization of congenital heart disease.Catheter Cardiovasc Interv. 2014; 84:795–800. doi: 10.1002/ccd.25473.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Nageotte S, Lederman R and Ratnayaka K (2020) MRI Catheterization: Ready for Broad Adoption, Pediatric Cardiology, 10.1007/s00246-020-02301-6, 41:3, (503-513), Online publication date: 1-Mar-2020. Grant E, Kanter J, Olivieri L, Cross R, Campbell‐Washburn A, Faranesh A, Cronin I, Hamann K, O'Byrne M, Slack M, Lederman R and Ratnayaka K (2019) X‐ray fused with MRI guidance of pre‐selected transcatheter congenital heart disease interventions, Catheterization and Cardiovascular Interventions, 10.1002/ccd.28324, 94:3, (399-408), Online publication date: 1-Sep-2019. Thackeray J (2019) Preclinical Multimodality Imaging and Image Fusion in Cardiovascular Disease Image Fusion in Preclinical Applications, 10.1007/978-3-030-02973-9_8, (161-181), . Basman C, Parmar Y, Kliger C, Jelnin V, Pasala T, Ruiz C and Kronzon I (2017) Fusion Imaging for Structural Heart Disease Interventions, Current Cardiovascular Imaging Reports, 10.1007/s12410-017-9436-y, 10:12, Online publication date: 1-Dec-2017. Grant E and Olivieri L (2017) The Role of 3-D Heart Models in Planning and Executing Interventional Procedures, Canadian Journal of Cardiology, 10.1016/j.cjca.2017.02.009, 33:9, (1074-1081), Online publication date: 1-Sep-2017. October 6, 2015Vol 132, Issue 14 Advertisement Article InformationMetrics © 2015 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.115.013724PMID: 26438770 Originally publishedOctober 6, 2015 PDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsComputerized Tomography (CT)Congenital Heart Disease" @default.
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