Multi-modality imaging for percutaneous pulmonary valve implantation – getting serious about radiation and contrast reduction

Aim

We report the integration of fusion with MRI 3D reconstruction, 3DRA, and ICE to optimize contrast and radiation reduction in PPVI.

Case report

A 45 kg 11-year-old girl with a history of repaired tetralogy of Fallot was referred to our center with severe pulmonary regurgitation. She had a surgical pulmonary valve replacement with a 25 mm Sorin Mitroflow valve in 2012 (Sorin Group USA Inc, Arvada, Colorado). Routine surveillance TTE revealed significant stenosis of the bio-prosthetic valve with a peak instantaneous gradient of 90 mm Hg. Magnetic resonance imaging showed a severely dilated right ventricle (RV) with indexed end diastolic volume of 180 ml/m² and low normal systolic function (ejection fraction of 44%). Moderate regurgitation of the pulmonary valve bio-prosthesis was visualized (25% regurgitation fraction). There was congenital interruption of the inferior caval vein with drainage via azygous continuation to the superior caval vein. The coronary arteries were not well visualized. After discussion at a multi-disciplinary meeting, the patient was accepted for PPVI. Prior to the procedure, her MRI scan was imported and manipulated on a dedicated workstation (VesselNavigator, Philips Healthcare, Best, Netherlands) to highlight the target structures (Figure 1).
Under general anesthesia, an 8-Fr sheath was introduced into the right internal jugular vein. Stored fluoroscopic images in two projections were used for direct fusion of 2D fluoroscopy and 3D reconstruction (2D–3D registration, Figure 1 D) [4, 8]. A soft wire in the aorta together with a diagnostic catheter in the superior caval vein and the radiopaque ring of the bio-prosthesis served as references for alignment of the 3D reconstruction. A right heart hemodynamic evaluation, guided by the aligned 3D roadmap, confirmed the noninvasive imaging findings with near systemic RV pressure and a 50 mm Hg peak-to-peak gradient across the bio-prosthesis. After introduction of an Amplatz 0.035” Superstiff (Boston Scientific, Marlborough, Massachusetts) wire to the left lower pulmonary artery, a 22 mm Atlas Gold balloon (Bard Peripheral Vascular, Inc, Tempe, Arizona) was positioned across the bio-prosthetic valve. The balloon was inflated to 12 atm, and 3DRA was performed with simultaneous contrast injection in the left coronary artery (LCA) (Figure 2). After analysis of the rotational image and post-processing to generate multi-planar reformats and 3D...


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