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Atlas of Cardiac Catheterization for Congenital Heart Disease 2019

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Published by UDH.library, 2021-03-18 04:24:41

Atlas of Cardiac Catheterization for Congenital Heart Disease 2019

Atlas of Cardiac Catheterization for Congenital Heart Disease 2019

376 S. Schubert and F. Berger

A. SEGMENTATION • IMPORT OF DICOM DATA (CT OR MRI)
(offline) • SEGMENTATION OF VESSEL STRUCTURES

B. PLANNING • PLACEMENT OF RING MARKERS FOR LANDMARKS OR LANDING
(offline) ZONE

• MEASUREMENTS (e.g. STENT LENGTH)
• BEST PROJECTION (STORED)

C. REGISTRATION • REGISTRATION OF 3D OVERLAY INTO 2D FLOUROSCOPY
(online) • CALIBRATION OF ALIGNEMENT

• LIVE GUIDANCE (3D TO 2D)
D. LIVE GUIDANCE

Fig. 43.1  Work Flow for the use of 3D overlay with the use of order to identify the best projection and visualization, which can be
VesselNavigator (Philips Healthcare): A. SEGMENTATION is done by saved for at the workstation. C. REGISTRATION is performed, if the
importing a 3D dataset (DICOM) into the workstation (CT of a com- patient is lying on the table with the use of fluoroscopy or angiography
plete thoracic scan of the heart and vessels and thorax and 3D MRI of and in the AP plane only. A difference of >30° is demanded in order to
the whole heart sequence are optimal). The targeted vessels are selected do the registration. This can be done from inside at the patients table or
with the mouse nearly automatically (aorta, pulmonary arteries, coro- outside at the workstation. D. LIVE GUIDANCE will start after steps
naries). B. PLANNING is then performed by using ring markers and A–C, where also re-calibration of the accuracy of the overlay is possible
small points for marking stenotic regions (landing zone) or landmarks during the whole examination
(branches, coronaries). Additionally the 3D dataset can be rotated in

43.3 C ASE: RPA Stenting 43.4 C ASE: CoA Stenting

Right pulmonary artery (RPA) stenting was performed in an A 35-year-old patient was treated for native and subatretic
8-year-old patient with pulmonary atresia with shunt pallia- coarctation of the aorta (CoA). Vessel navigator was used
tion and right ventricular to PA conduit placement. Several after import of an external CT scan (see Figs. 43.5, 43.6, 43.7
surgical and catheter interventions had been performed, but and 43.8.
RPA stenosis was reluctant to balloon dilatation or surgical
reconstruction. Actual MRI showed a residual RPA stenosis
with flow and size mismatch of left > right pulmonary arter-
ies including supravalvular stenosis at distal conduit anasto-
mosis (see Fig. 43.4 and Videos 4, 5 and 6).

43  3D Mapping: Live Integration and Overlay of 3D Data from MRI and CT for Improved Guidance of Interventional Cardiac Therapy 377
Fig. 43.2  Segmented vessel
for PPVI in a 13-year-old
patient with Contegra stenosis
in RAO 8° and cranial 47°.
Two rings are marking the
proximal and distal landing
zone for stent placement. 1
and 2 are marking LCA and
RCA (see Video 2)

Fig. 43.3 Percutaneous
Pulmonary valve (Melody)
implantation in a pre-stented
stenotic contegra with live
guidance by MRI based
image fusion (PA and Ao).
Blue rings act as marker for
the valve region. Left
coronary are marked by
0.014 inch wire

378 S. Schubert and F. Berger

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Fig. 43.4  3D overlay with pictures generated from MRI with seg- a 10 mm Powerflex balloon with a use of a 9 Fr long sheath (Cook
mented vessels (PA and Ao = yellow) during treatment of pulmonary Flexor). (c, d) Re-opening of the LPA ostium after stent placement with

branch stenosis. Green rings are marking the stenotic part in RPA and the use of a 4 mm coronary balloon and 8 mm Powerflex afterward
LPA ostium. (a, b) Stent implantation of a Mega LD (Ev3, 26 mm) on

43  3D Mapping: Live Integration and Overlay of 3D Data from MRI and CT for Improved Guidance of Interventional Cardiac Therapy 379

Fig. 43.5  CT data as used for planning of the procedure in this patient aorta. Measurements (right) were performed, and landing zone length
with native CoA imported into VesselNavigator (left). Numerous col- (42 mm) and diameter (18 mm) of the stent were defined

lateral vessels can be seen connecting from dorsally into the descending

Fig. 43.6  Live guidance with the use of CT data was used. For calibra- clavian artery was then performed (right), and rings were placed in
tion, two angiographies in the descending aorta were used (left) and in order to define the landing zone for stent placement

a second 40° RAO projection. Passage over the CoA into the left sub-

380 S. Schubert and F. Berger

Fig. 43.7  Live guidance for 16 Fr-long sheath (Mullins, Cook) placement and implantation of a custom-made covered 10 zig CP Stent on a
22 mm Balloon-in-Balloon (BIB®) Catheter and with a length of 50 mm (NuMed)

Video 1  SEGEMENTATION is performed with the use of a 3D data-
set from MRI (3D of the whole heart), and the pulmonary artery is

selected by semiautomatic registration. On the right side, the MRI data

is still visible (MP4 8312 kb)

Video 2  Live guidance of PPVI with Melody into a pre-stenting (Max
LD (EV3) stent) valve region in RAO 5° with cranial 35°. A floppy

0.014 in. wire is marking the LCA. Overlay was implicated from MRI

data; see Figs. 43.2 and 43.3 (MP4 50133 kb)

Video 3  Segmentation of target vessels (blue) prior to intervention
with data achieved by MRI (3D of the whole heart). Right and left pul-
monary artery, conduit with distal stenosis, and aorta are selected and
visualized (blue). Coronary arteries are also selected, as they are far
away from the region of intervention. Movement of the dataset can be
used for achieving optimal angulation (MP4 4766 kb)

Video 4  LIVE Guidance during sheath placement (9 Fr Flexor sheath,
Cook) after segmentation and calibration. The three rings are marking each

of the pulmonary valve, RPA ostium, and LPA ostium (MP4 20692 kb)

Fig. 43.8  Angiographic result after covered CP stent implantation into Video 5  LIVE Guidance during balloon dilatation of the LPA ostium
a native CoA with the use of overlay by VesselNavigator from CT data. through the stent meshes of the Mega LD stent (26 mm) with the use of
an Atlas (Bard) 12 mm (MP4 25744 kb)
No residual gradient was measured
Video 6  LIVE Guidance during balloon dilatation of the RPA ostium
through the stent meshes of the Mega LD stent (26 mm) with the use of
an Atlas (Bard) 12 mm (MP4 13558 kb)

Part XI
Future Directions

Holography in Congenital Heart 44
Disease: Diagnosis and Transcatheter
Treatment

Elchanan Bruckheimer and Carmel Rotschild

44.1 Introduction Depth perception defines our ability to see an object,

comprehend its position in space, and interact precisely with

The heart is comprised of three-dimensional components that object. The object’s three dimensionality and distance

whose size, shape, and spatial interrelationships constantly are perceived owing to the capacity of the visual cortex to

change in an organized rhythmic fashion. The field of con- simultaneously combine multiple depth cues including bin-

genital heart disease encompasses the result of a disruption ocular stereopsis, convergence, and accommodation. Each

of the normal, but complex, three-dimensional internal anat- eye, since it has a different position in the head, views an

omy and functioning of the heart. The diagnosis and treat- object from a slightly different angle, and this disparity, ste-

ment of congenital heart defects demand a precise and reopsis, is employed by the brain as one of the cues for depth

profound understanding of this dynamic anatomy and are perception. Stereoscopy is a method which mimics stereop-

therefore heavily reliant on real-time imaging. The open-­ sis by presenting each eye with two slightly different ver-

heart surgeon has the benefit of comprehension and interac- sions of an image which, when combined in the brain,

tion with the real 3D anatomy; however this is usually static produce an illusion of depth. It is an illusion since all the

during open-heart surgery. The interventionalist wishing to points of light in the stereoscopic image are focused in a sin-

employ minimally invasive transcatheter techniques in the gular focal plane, whereas in a real object, these points arise

beating heart has to build a mental concept of the anatomy from multiple different planes, and true depth perception has

usually derived from 2D echocardiographic and fluoroscopic infinite focal planes (Fig. 44.1).

data displayed on a screen. In general, the surgeon’s under- Even the highest-quality stereoscopic image is confined

standing of the anatomy is more complete and intuitive than to one focal plane, and therefore interactions such as placing

that of the interventionalist even though they may be per- a device in the image, or manipulating the image with the

forming similar procedures, e.g., closure of an ASD secun- observer’s hand inside it, are not possible since the device or

dum. In an attempt to bridge that gap, high-quality 3D hand occupies multiple focal planes. In addition, the source

volumetric data acquisition systems such as 3D transthoracic of stereoscopic images is at a distance from the observer;

and transesophageal echocardiography, 3D rotational angi- however the overlapping of the images to create the 3D illu-

ography, CT, and MRI have been developed. However this sion occurs up close. When attempting to interact with the up

volumetric data is typically displayed on 2D screens which close 3D image, the eyes converge to focus on the hand or

restrict the image to a single plane of view, preclude interac- tool and lose their focus on the distant source, and the image

tion directly with the image, and hamper the perception of becomes blurred. This discrepancy between the convergence

depth. The development of a simple, accurate, and accessible depth cue and the distant focus creates a conflict in the brain

3D display for these data is a challenge, especially when often resulting in nausea. Recent attempts at enhancing the

attempting to display true depth. “image-anatomy” interaction and the operator’s experience

with stereoscopic displays include virtual reality (VR) and

augmented reality (AR). Although these methodologies may

E. Bruckheimer (*) provide a better understanding of the patient’s anatomy and
Section of Pediatric Cardiology, Schneider Children’s spatial relationship to the operator, they lack true depth per-

Medical Center Israel, Petach Tikva, Israel ception and cannot be used for accurate navigation within
e-mail: [email protected] the image.

C. Rotschild

Department of Mechanical Engineering, Technion, Haifa, Israel

© Springer International Publishing AG, part of Springer Nature 2019 383
G. Butera et al. (eds.), Atlas of Cardiac Catheterization for Congenital Heart Disease,
https://doi.org/10.1007/978-3-319-72443-0_44

384 E. Bruckheimer and C. Rotschild

Fig. 44.1 Stereoscopic
images of an object creating a
3D illusion of that object. The
observer is presented with
two slightly different images
of the same object which
overlap. The 3D illusion is
confined to one focal plane

Fig. 44.2  The same object in
Fig. 44.1 is projected as a
hologram that occupies 3D
space, as opposed to one
single focal plane. The fixed
coordinates and multiple focal
planes afford interaction with
and within the image at arm’s
reach of the observer

Holography, from the Greek for “whole” and “drawing,” interaction with and within the holographic image will simu-
is a methodology which creates an exact visual replication of late such interaction with and within the patients’ particular
an object in three physical dimensions including all the depth anatomy. Initial attempts at creating holograms in real time
cues, focal planes, and specific coordinates. The holographic in an actual clinical setting have been recently reported using
image occupies an actual space and can be likened to an the RealView 3D dynamic holographic display and interface
object created by a 3D printer where the material used to system [RealView Imaging, Yokneam, Israel]. The system
print is light. A high-quality hologram should be indistin- projects high-resolution 3D live holographic images “float-
guishable from the true object it represents (Fig. 44.2). ing in mid-air” without the need for any human-mounted
device, goggles, or a conventional 2D screen. The projected
Computer-generated holograms (CGH) of patients’ 3D 3D images appear in free space, allowing the user limitless
data could be useful in the clinical setting by providing the accessibility to the image affording direct and precise inter-
physician with a 3D image which is a true and spatially accu- action with and within the dynamic image. Therefore, a true
rate representation of the patient’s anatomy, having all the volumetric display based on current 3D acquisition modali-
visual depth cues. Since each point of light in the generated ties maintains the interventionalist’s advantage of a mini-
hologram is a distinct physical entity in real 3D space, it rep- mally invasive approach and provides “real” 3D dynamic
resents a precise anatomical coordinate in the patient, and

44  Holography in Congenital Heart Disease: Diagnosis and Transcatheter Treatment 385

anatomy similar or even better than that of the surgeon, since modalities that can be used to create holograms in the clini-
the surgeon sees static 3D surfaces, while the hologram can cal setting. Please note that holograms cannot be fully appre-
display the organ at different levels of transparency to the ciated on a 2D page, but need to be observed directly. [Videos
viewer and can be easily cropped and manipulated as of holograms shown here in the figures can be viewed at
required. www.realviewimaging.com]

The following figures are examples of holographic images Acknowledgement  Conflict of interest: EB and CR are stockholders
created using the RealView system and demonstrate some of and employees of RealView Imaging.
the interactions that can be performed and 3D acquisition

ab

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Fig. 44.3 (a) Hologram created from a segmented cardiac CT showing open and rotated so that the pulmonary venous orifice of the left upper
the anterior right ventricle [red] and the posterior left atrium [gray]. The pulmonary vein is viewed en face. (d) Ablation points are simulated
directly on the image at the junction of pulmonary vein orifice to the left
finger is touching the left upper pulmonary vein and rotates the image atrial wall using a tool. These points were intuitively positioned at the
to the desired viewing angle. (b) The volumetric data of the left atrium exact anatomical position and depth creating a continuous and contigu-
ous line in a similar manner to painting directly on a 3D object
is isolated, and the atrium is rotated anteriorly prior to slicing as seen in
Fig. 44.3c. (c) The hologram of the left atrial volume has been sliced

386 E. Bruckheimer and C. Rotschild

Fig. 44.4  Dynamic color holograms created from volumetric data The aorta and fully deployed CoreValve seen from the ascending aorta.
simulated with the TAVIguide™ technology (FEops, Ghent, Belgium) Lower pane: The partially deployed CoreValve is seen by slicing into
of a virtually deployed CoreValve® wire frame (Medtronic, the ascending aorta, and the interaction with the native aortic leaflets, in
Minneapolis, MN, USA). The TAVIguide technology predicts how a blue, can be seen from any angle
certain TAVI device will interact with a specific patient. Upper plane:

Fig. 44.5  Static hologram created from volumetric data of 3D model Fig. 44.6  Bicaval bidirectional Glenn palliation in a 2-year-old patient:
of a fetus. The hologram is “floating” in mid-air above the palm of the Static hologram created in real time from an intra-procedure 3D rota-
tional angiogram using a Philips Allura Cath Lab System [Philips
observer Medical, Eindhoven, Netherlands]. Contrast was injected into the right
SVC and left arm [hand injection] simultaneously

Fig. 44.7  ASD secundum in a 16-year-old girl. Dynamic color holo- secundum is demonstrated from the left atrial aspect in the center of the
grams created in real time from intra-procedure 3D transesophageal septum. Lower pane: The ASD is closed by a septal occlude, and the
mitral valve is seen en face, while the observer holds the heart in his
electrocardiography using a Philips ie33 echocardiography system hand

[Philips Medical, Eindhoven, Netherlands]. Upper plane: The ASD

Integrating Imaging Modalities 45

Tilak K. R. Pasala, Vladimir Jelnin, and Carlos E. Ruiz

45.1 Introduction position of the catheters and wires. Additionally, the orienta-

tion of the images from various imaging modalities can be

Transcatheter interventions for congenital heart disease can different which poses an added challenge to the operator. A

be challenging and require not only the understanding of real-time integration of the imaging modalities with 3D

anatomy but a working knowledge of modern imaging information and live fluoroscopy provides a rapid recogni-

modalities. Fluoroscopy has poor characterization of non-­ tion and orientation of the cardiac structures during percuta-

radiopaque structures and has limitations in providing three-­ neous interventions. It can also improve the communication

dimensional (3D) spatial information. Similarly, between various members for the team while performing the

echocardiography by itself has limitations in detecting the procedure.

Electronic Supplementary Material The online version of this 387
c­ hapter (https://doi.org/10.1007/978-3-319-72443-0_45) contains sup-
plementary material, which is available to authorized users.

T. K. R. Pasala · V. Jelnin · C. E. Ruiz (*)
Structural and Congenital Heart Center, Hackensack University
Medical Center and the Joseph M. Sanzari Children’s Hospital,
Hackensack, NJ, USA
e-mail: [email protected];
[email protected]

© Springer International Publishing AG, part of Springer Nature 2019
G. Butera et al. (eds.), Atlas of Cardiac Catheterization for Congenital Heart Disease,
https://doi.org/10.1007/978-3-319-72443-0_45

388 T. K. R. Pasala et al.
Pre-acquired CTA CTA-Fluoroscopy Fusion

Fluoroscopy

Real-time Echo Echo-Fluoroscopy Fusion

Fig. 45.1  Integration of various imaging modalities. The pre-acquired rable scale for CTA-fluoroscopy fusion. Similarly, real-time integration
computer tomography angiography (CTA) data is post-processed with of echo with fluoroscopy (echo-fluoroscopy fusion) is used during pro-
cedures at various steps
advanced software tools and is overlaid on live fluoroscopy in a compa-

ab

Fig. 45.2  Case presentation. We present a case of a large muscular with predominantly left-to-right flow. (b) The continuous Doppler
VSD to demonstrate the benefits of integrated imaging. (a) The color shows a significantly elevated pulmonary pressure with a right ventric-
Doppler on the transthoracic echo (TTE) shows a large muscular VSD ular systolic pressure of 61 mmHg

45  Integrating Imaging Modalities 389

ab

Fig. 45.3  Cardiac computer tomography angiography (CTA)—post-­ specific colors by using “model-based” segmentation method. (b)
processing. The acquisition of CT requires expertise and can be Specialized software (Heart Navigator, Philips Healthcare, Inc.) are
used to build a 3D model of the heart. The white arrow is pointing at the
obtained by using helical CT, multi-row detectors (MDCT), and ECG ventricular septal defect reconstructed from the CT images with its
gating. (a) The standard CT images with anatomical planes (axial, sag- exact size, shape, and precise location

ittal, and coronal) are shown. Various cardiac structures are coded with

a bc

Fig. 45.4  Cardiac computer tomography angiography—virtual planning. Virtual devices (white arrows) are placed at the position of the ventricu-
lar septal defect to make decisions on the size and shape. Additionally, the interaction with surrounding structures can be examined

Video 1  Cardiac computer tomography angiography—virtual planning. Virtual devices (white arrows) are placed at the position of the ventricular
septal defect to make decisions on the size and shape. Additionally, the interaction with surrounding structures can be examined (MP4 59345 kb)

390 T. K. R. Pasala et al.

Fig. 45.5  Registration of c
processed CT data over
fluoroscopy. Registration is
the process of orienting
post-processed CTA images
on live fluoroscopy. It is
achieved by manually
adjusting any segmented
radiopaque structures, in the
above example prosthetic
valves (in yellow), to the
same structures on
fluoroscopy. Two orthogonal
planes (RAO 45° and LAO
45°) are used adjust manually.
After the desired position is
achieved, the 3D model of the
cardiac structures is overlaid
which will follow the C-arm.
In the case of lack of usable
radiopaque structures,
aortogram is performed to aid
in the registration process

ab

Fig. 45.6  Registration using TEE probe for echo-fluoroscopy fusion. and the probe is displayed in green color confirming successful regis-
A small window with the TEE probe is displayed on the bottom left of tration. (b) An exclamation mark is seen, and the probe is displayed in
white/transparent color suggesting that the registration is timed out. (c)
the echo-fluoroscopy fusion display. When the TEE probe is seen on the
An X mark is seen with the probe displayed in red color suggesting an
X-ray field, specialized software (Echo Navigator, Philips Healthcare,
Inc.) can perform registration automatically. (a) A check mark is seen, unsuccessful registration

45  Integrating Imaging Modalities 391

ab

cd

Fig. 45.7  Display of hemodynamic and integrated imaging during Live fluoroscopy is shown with catheters and wires. (d) CTA-­
procedures. Operators can have comprehensive information displayed fluoroscopy fusion is shown. A three-dimensional model of the heart
on the screen. (a) Live hemodynamic data is displayed on the upper left. with relevant cardiac structures is fused to fluoroscopy. The windows
(b) Echo-fluoroscopy fusion is shown where relevant information from can be changed per operator preference
transesophageal echocardiography (TEE) are fused to fluoroscopy. (c)

392 T. K. R. Pasala et al.

Fig. 45.8  CTA-fluoroscopy fusion—crossing ventricular septal defect. Fig. 45.9 CTA-fluoroscopy fusion—creating arterial-venous (AV)
Fusion of the CTA with live fluoroscopy shows a 3D model of the heart rail. An AV rail is created to support the delivery of device. The left
overlaid over the fluoroscopy during the procedure for guidance. ventricle is seen in blue, aorta in orange, and pulmonary arterial system
Segmentation of the heart is visible, but it is dimmed to avoid blocking in red color. The retrograde guidewire (white arrows) crossing the VSD
the view of the wires. A circular marker at the position of the ventricular is advanced and positioned in the left pulmonary artery. Then, a 6F JR4
septal defect (VSD) helps the operator in steering the guidewire. The guide catheter with an 18 × 30 mm Ensnare system (black arrows) is
guidewire (small white arrows) is seen crossing the ventricular septal advanced through the right internal jugular vein. The retrograde guide-
defect (VSD) retrograde from the aorta. The guidewire is inserted into wire is snared and externalized creating an AV rail
the right ventricle through the VSD (large white arrow)

Video 2  CTA-fluoroscopy fusion—crossing ventricular septal defect.
Fusion of the CTA with live fluoroscopy shows a 3D model of the heart
overlaid over the fluoroscopy during the procedure for guidance.
Segmentation of the heart is visible, but it is dimmed to avoid blocking
the view of the wires. A circular marker at the position of the ventricular
septal defect (VSD) helps the operator in steering the guidewire. The
guidewire (small white arrows) is seen crossing the ventricular septal
defect (VSD) retrograde from the aorta. The guidewire is inserted into
the right ventricle through the VSD (large white arrow) (MP4
59628 kb)

Video 3  CTA-fluoroscopy fusion—creating arterial-venous (AV) rail.
An AV rail is created to support the delivery of device. The left ventricle
is seen in blue, aorta in orange, and pulmonary arterial system in red
color. The retrograde guidewire (white arrows) crossing the VSD is
advanced and positioned in the left pulmonary artery. Then, a 6F JR4
guide catheter with an 18 × 30 mm Ensnare system (black arrows) is
advanced through the right internal jugular vein. The retrograde guide-
wire is snared and externalized creating an AV rail (MP4 153400 kb)

Fig. 45.10 CTA-fluoroscopy fusion—advancing delivery sheath.
Delivery sheath is introduced through the VSD (large white arrow) into

the left ventricle (small white arrows) using the AV rail and is advanced

into the aorta (Video 3)

45  Integrating Imaging Modalities 393

a b

cd

Fig. 45.11 . Echo-fluoroscopy fusion—advancing VSD closure probe. (d) The C-arm view where relevant TEE images are fused with
device. Different views of the 3D TEE are shown. (a) The “free view” live fluoroscopy. Echo-fluoroscopy fusion helps in controlling the posi-
tion of the delivery system into LV through the VSD. The VSD closure
allows the operator to cut the 3D reconstructed volume and perform device is seen inside delivery sheath along with the security wire going
360° rotation. (b) This view allows the echocardiographer to perform from the sheath to the aortic arch (Videos 2 and 3)
additional review. (c) This view coincides with the position of TEE

Fig. 45.12  CTA-fluoroscopy fusion—VSD closure device delivery.
The opened Amplatzer VSD closure device which is positioned at the
VSD (large white arrow) and still connected to the delivery wire.
Having the segmented VSD overlaid on fluoroscopy along with echo-­
fluoroscopy fusion aids the operator in positioning the VSD device

394 T. K. R. Pasala et al.

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Fig. 45.13  Echo-fluoroscopy fusion—confirmation of device posi- the positioning of the device with the help of echo-fluoroscopy fusion
tion. The most important functions of echo-fluoroscopy fusion are posi- (d). The left disc of the Amplatzer device (d, white arrows) is anchored
tioning the VSD closure device and confirming the device position. (a,
b, c) The 3D TEE images of the device are shown. These images aid in on the LV side, and the right disc is attached to the delivery wire. Echo-­

fluoroscopy fusion adds anatomical relevance to the fluoroscopic image

45  Integrating Imaging Modalities 395

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Fig. 45.14  Integrated imaging—final stages of VSD closure. The final Amplatzer VSD closure. (c) Live fluoroscopy showing the VSD device.
stage of the VSD closure procedure using integration of the different (d) CTA-fluoroscopy fusion showing the device that is still attached to
imaging modalities is shown. (a) Vitals of the patient. (b) Echo-­
the delivery wire. After a thorough assessment, the device is deployed,
fluoroscopy fusion showing the color Doppler overlay on fluoroscopy.
and its position and stability are checked (Videos 2 and 3)
The color Doppler demonstrates a mild residual flow around the

396 T. K. R. Pasala et al.

a

c

b

Fig. 45.15  Future direction—echo-CTA fusion. In the future, the inte- are seen in a patient with repaired endocardial cushion defect. The ori-
gration of processed CTA (a) and live echocardiography (b) has the gin of the two jets is seen on color Doppler (b, c). One of the jets is
potential to decrease the overall radiation dose and contrast use during
procedures. In the above image, two separate jets of mitral regurgitation originating from the lateral cleft of left-sided valve and the other from

the base of the left-sided valve due to dehiscence


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