Post on 20-Aug-2020
3D and 4D Imaging of the Aortic Root
3D and 4D Imaging of the Aortic Root
Dominik FleischmannDepartment of Radiology
Stanford University
Dominik FleischmannDominik FleischmannDepartment of RadiologyDepartment of Radiology
Stanford UniversityStanford University
20th Annual Summer Practicum, Masters in Body ImagingJackson Lake Lodge, Moran, Wyoming
August 8-11, 2010
Research support: Research support: General ElectricGeneral ElectricSpeaker's board: Speaker's board: BraccoBracco
SiemensSiemens
Conflicts of Interest DisclosureConflicts of Interest Disclosure
Dominik FleischmannDepartment of Radiology
Stanford University
Dominik FleischmannDominik FleischmannDepartment of RadiologyDepartment of Radiology
Stanford UniversityStanford University
20th Annual Summer Practicum, Masters in Body ImagingJackson Lake Lodge, Moran, Wyoming
August 8-11, 2010
Progressive root enlargement (Marfan's)Progressive root enlargement (Marfan's)
Jan '04
24 mm
45 mm
30 mm
Nov '04
28 mm
47 mm
32 mm
Sep '05
29 mm
49 mm
33 mm
with ECG gating
3D and 4D Imaging of the Aortic Root3D and 4D Imaging of the Aortic Root
Learning Objectives / OutlineLearning Objectives / Outline
••Technique: Technique: 'gated chest' CT'gated chest' CT
••Surgical anatomy of thoracic aortaSurgical anatomy of thoracic aorta
••Clinical Clinical prepre-- and postop. imaging and postop. imaging inin
-- Marfan's diseaseMarfan's disease
-- Bicuspid aortic valve disease / aneurysmBicuspid aortic valve disease / aneurysm
Aortic Root Aneurysms Aortic Root Aneurysms
Etiology and associated conditionsEtiology and associated conditions
••genetic genetic (congenital wall defect)(congenital wall defect)
Marfan's Marfan's Bicuspid aortic valveBicuspid aortic valve
••atherosclerotic atherosclerotic
••chronic dissection chronic dissection
••infectious infectious ('mycotic', syphilis)('mycotic', syphilis)
••vasculitisvasculitis••postpost--traumatictraumatic rarerare
veryverycommoncommon
Aortic Root Aneurysms (TAA)Aortic Root Aneurysms (TAA)
Etiology and associated conditionsEtiology and associated conditions
congenital (intrinsic, defect of aortic wall):congenital (intrinsic, defect of aortic wall):
Marfan'sMarfan's FBNFBN--11 gene gene fibrillin= extracell.matrix fiber fibrillin= extracell.matrix fiber regulates TGFregulates TGF--ββ
Bicuspid AVBicuspid AV fibrillin, fibrillin, MMP 2MMP 2
EEhlershlers--DanlosDanlos--IVIV COL 3A1COL 3A1 gene (procollagen gene (procollagen IIIIII))
LoeysLoeys--DietzDietz TGFBR1TGFBR1 or or TGFBR2TGFBR2 genegene
TGF: transforming growth factor, MMP: matrix metalloproteinase; TGF: transforming growth factor, MMP: matrix metalloproteinase;
(0.01(0.01--0.02 %)0.02 %)
(1(1--2 % prevalence)2 % prevalence)
BAV diseaseBAV disease(bicuspid aortic valve disease)(bicuspid aortic valve disease)
Prevalence Prevalence 11--2%2%
Complications (>33%)Complications (>33%)
•• valve degeneration valve degeneration and stenosisand stenosis
•• endocarditisendocarditis
•• aortic root dilatation aortic root dilatation (50% of young pts.) (50% of young pts.)
ao. root aneurysmao. root aneurysm
Sievers et al.; J Thorac Cardiovasc Surg 2007;133:1226Sievers et al.; J Thorac Cardiovasc Surg 2007;133:1226--3333
Bicuspid aortic valve (BAV)Bicuspid aortic valve (BAV)
Classification (Sievers)Classification (Sievers)
BAV diseaseBAV disease(bicuspid aortic valve disease)(bicuspid aortic valve disease)
3D and 4D Imaging of the Aortic Root3D and 4D Imaging of the Aortic Root
Learning Objectives / OutlineLearning Objectives / Outline
••Technique: Technique: 'gated chest' CT'gated chest' CT
••Surgical anatomy of thoracic aortaSurgical anatomy of thoracic aorta
••Clinical focusClinical focus
pre and postoperative imaging pre and postoperative imaging
-- Marfan's diseaseMarfan's disease
-- Bicuspid aortic valve disease / aneurysmBicuspid aortic valve disease / aneurysm
EKG gated CTA of the ThoraxEKG gated CTA of the Thorax(16(16-- channel MDCT)channel MDCT)
'Gated Chest''Gated Chest'
••entire thoracic aorta entire thoracic aorta
••not thinnest not thinnest collimation (1.25mm)collimation (1.25mm)
••no betano beta--blockers, blockers, no subling. nitrono subling. nitro
••recon. 10 phases recon. 10 phases (0(0––90% of RR interval)90% of RR interval)
••no ECGno ECG--pulsing pulsing (constant mA)(constant mA)
Coronary CTACoronary CTA
••heartheart
•• thinnest collimation thinnest collimation (0.625mm) (0.625mm)
••betabeta--blockers, and blockers, and subling. nitrosubling. nitro
••recon. 1 diastolic recon. 1 diastolic phase (65% of RR) phase (65% of RR)
••ECG pulsing on ECG pulsing on (dose reduction)(dose reduction)
'Gated Chest''Gated Chest'
••entire thoracic aorta entire thoracic aorta
••not thinnest not thinnest collimation (1.25mm)collimation (1.25mm)
••no betano beta--blockers, blockers, no subling. nitrono subling. nitro
••recon. 10 phases recon. 10 phases (0(0––90% of RR interval)90% of RR interval)
••no ECGno ECG--pulsing pulsing (constant mA)(constant mA)
Coronary CTACoronary CTA
••heartheart
•• thinnest collimation thinnest collimation (0.75 mm) (0.75 mm)
••betabeta--blockers, and blockers, and subling. nitrosubling. nitro
••recon. 1 diastolic recon. 1 diastolic phase (65% of RR) phase (65% of RR)
••ECG pulsing on ECG pulsing on (dose reduction)(dose reduction)
EKG gated CTA of the ThoraxEKG gated CTA of the Thorax(16(16-- channel MDCT)channel MDCT)
s/ps/p Ross procedure (pulmonaryRoss procedure (pulmonary-- to aorta autograft)to aorta autograft)susp. leak/pseudoaneurysmsusp. leak/pseudoaneurysm
diastolediastole systolesystole
Advantages:Advantages:
••motionmotion--'free' (3D)'free' (3D) and and dynamic (4D)dynamic (4D)visualization of thor. aorta + aortic rootvisualization of thor. aorta + aortic root
••high 3D spatial resolution (0.5mmhigh 3D spatial resolution (0.5mm33))
"Gated Chest""Gated Chest"(16(16--slice CT, 64slice CT, 64--slice CT)slice CT)
Limitations:Limitations:
••temporal resolution (~165ms)temporal resolution (~165ms)
••lack of flow informationlack of flow information
••radiation dose (25radiation dose (25--50mSv*) 50mSv*)
*(~3*(~3--6 times of std.chest CT)6 times of std.chest CT)
DualDual--Source CTSource CT
(~85ms)(~85ms)
(8(8--15mSv)15mSv)allows ECGallows ECG--dose modulationdose modulation
58 yo woman58 yo woman
••abnormal valve (BAV?),abnormal valve (BAV?),••aneurysmal aortic rootaneurysmal aortic root••LV dilatation, lowLV dilatation, low--normal EFnormal EF
••53kg (117 lbs)53kg (117 lbs)••65 bpm heart rate65 bpm heart rate
24.7
cm
24.7
cm
Gated Chest, DualGated Chest, Dual--Source CTSource CT27.01 mGy, (667mGy*cm), [~11mSv]27.01 mGy, (667mGy*cm), [~11mSv]
100 kVp100 kVpECG pulsing ECG pulsing (30(30--70% of RR Interval)70% of RR Interval)
Gated Chest, DualGated Chest, Dual--Source CTSource CT27.01 mGy, (667mGy*cm), [~11mSv]27.01 mGy, (667mGy*cm), [~11mSv]
58 yo woman58 yo woman
100 kVp100 kVpECG pulsing ECG pulsing (30(30--70% of RR Interval)70% of RR Interval)
3D and 4D Imaging of the Aortic Root3D and 4D Imaging of the Aortic Root
Learning Objectives / OutlineLearning Objectives / Outline
••Technique: Technique: 'gated chest' CT'gated chest' CT
••Surgical anatomy of thoracic aortaSurgical anatomy of thoracic aorta
••Clinical focusClinical focus
pre and postoperative imaging pre and postoperative imaging
-- Marfan's diseaseMarfan's disease
-- Bicuspid aortic valve disease / aneurysmBicuspid aortic valve disease / aneurysm
Asce
ndin
g Ao
. Descending Ao.
Transverse Arch
Aortic Anulus
STJ*
* Sino-tubular Junction# Sinuses of Valsalva
Ao.
Roo
t
SOV#
Descending Aorta Descending Aorta
Transverse AortaTransverse Aorta
Ascending Aorta Ascending Aorta
Aortic RootAortic Root
••Sinotubular junctionSinotubular junction
••Sinuses of ValsalvaSinuses of Valsalvaaortic valveaortic valvecoronary ostiacoronary ostia
••Aortic anulusAortic anulus
Thoracic AortaThoracic Aorta
Surgical AnatomySurgical Anatomy
Normal diameter of thoracic aorta Normal diameter of thoracic aorta
AnulusAnulusnormal normal 2323--27mm27mm>27mm>27mm anuloaortic ectasiaanuloaortic ectasia
Thoracic aorta (incl. sinuses and STJ)Thoracic aorta (incl. sinuses and STJ)normal normal ageage--, sex, sex--, body size dependent, body size dependent'ectatic''ectatic' appears enlarged, but appears enlarged, but ≤≤4cm4cm>4.0 cm >4.0 cm aneurysm (root, asc., tra., desc.)aneurysm (root, asc., tra., desc.)
Treatment indication (elective)Treatment indication (elective)
>4.5>4.5--5.0cm5.0cm (syndromic patients) (syndromic patients) >6.0 +cm>6.0 +cm (degenerative)(degenerative)rapid diameter increase (rapid diameter increase (>5mm/year>5mm/year))Ao. rootAo. root valve insufficiencyvalve insufficiency
••73 y/o retired RN73 y/o retired RNascending aortic aneurysmascending aortic aneurysm
MIP (thinMIP (thin--slab) centered at valveslab) centered at valve
anulu
s
anulu
s
sinus.of Vals.
sinus.of Vals.
sin.tub.
sin.tub.--junct.
junct.
asc.ao.asc.ao.
••3D thoracic Aorta3D thoracic Aorta•• VR (candyVR (candy--cane view)cane view)
••Measurements Measurements •• MIP (5mm) ~ aMIP (5mm) ~ a--pp•• MIP (5mm) ~ lat.MIP (5mm) ~ lat.•• (MPR othogonal)(MPR othogonal)
••Coronary AnatomyCoronary Anatomy•• VR VR
••Sinuses + valveSinuses + valve•• VR 'transparent' VR 'transparent' •• MinIP (inverted)MinIP (inverted)•• 3 Chamber view3 Chamber view
Interactive Visualization Interactive Visualization –– InterpretationInterpretation
3D and 4D Imaging of the Aortic Root3D and 4D Imaging of the Aortic Root
Learning Objectives / OutlineLearning Objectives / Outline
••Technique: Technique: 'gated chest' CT'gated chest' CT
••Surgical anatomy of thoracic aortaSurgical anatomy of thoracic aorta
••Clinical focusClinical focus
pre and postoperative imaging pre and postoperative imaging
-- Marfan's diseaseMarfan's disease
-- Bicuspid aortic valve disease / aneurysmBicuspid aortic valve disease / aneurysm
Asce
ndin
g Ao
. Descending Ao.
Transverse Arch
Aortic Annulus
STJ*
* Sino-tubular Junction# Sinuses of Valsalva
Ao.
Roo
t
SOV#
Aortic RootAortic Root
••AnuloplastyAnuloplasty
••Composite graftComposite graftnn Contains valveContains valvenn Coronary Coronary
reimplantationreimplantation
••Valve Sparing SurgeryValve Sparing Surgerynn Resect sinuses down Resect sinuses down
to valve insertionsto valve insertionsnn Preserve native valvesPreserve native valvesnn Coronary reimpl.Coronary reimpl.
Thoracic AortaThoracic Aorta
Surgical OptionsSurgical Options
41 yo man41 yo manMarfan'sMarfan's
anulusanulus
sinus.of Vals.
sinus.of Vals.sin.tub.sin.tub.--junct.
junct.
Valve Sparing Aortic Root ProceduresValve Sparing Aortic Root ProceduresTirone DavidTirone David-- I I ““ReimplantationReimplantation”” TechniqueTechnique
PREPRE--OPOP
VR (slab)VR (slab) VR VR (transparent blood)(transparent blood)
27 y/o man, Marfan's27 y/o man, Marfan's
Surgical Surgical procedureprocedurecoronary coronary
ostiumostium
valvevalveleafletsleaflets
coronary reiplantedcoronary coronary reiplantedreiplanted
POSTPOST--OPOP
27 year old man27 year old man
bicuspid aortic valve root bicuspid aortic valve root aneurysmaneurysm
valve prolaps with severe valve prolaps with severe aortic regurgitation and left aortic regurgitation and left ventricular dilatationventricular dilatation
Bicuspid Aortic ValveBicuspid Aortic Valve
Severe prolaps of R+L Severe prolaps of R+L -- leafletleaflet
Raphe 'L+R' leafletRaphe 'L+R' leaflet
Bicuspid Aortic ValveBicuspid Aortic Valve
Severe prolaps of R/LSevere prolaps of R/L--cuspcuspdue to rupture of commissural suspensory 'chord'due to rupture of commissural suspensory 'chord'
'L+R' sinus'L+R' sinusraphe/chordraphe/chord
3D and 4D Imaging of the Aortic Root3D and 4D Imaging of the Aortic Root
SUMMARYSUMMARY
••Technique: Technique: 'gated chest' CT'gated chest' CT
••Surgical anatomy of thoracic aortaSurgical anatomy of thoracic aorta
••Clinical focusClinical focus
pre and postoperative imaging pre and postoperative imaging
-- Marfan's diseaseMarfan's disease
-- Bicuspid aortic valve Bicuspid aortic valve
Thank you..Thank you..
DC Miller DC Miller RS MitchellRS MitchellM FischbeinM Fischbein
20th Annual Summer Practicum, Masters in Body ImagingJackson Lake Lodge, Moran, Wyoming
August 8-11, 2010