scan: : a new tool to analyse

Transcription

1 Gated CT-scan scan: : a new tool to analyse the shape of the aortic annulus. SEROUSSI SAFAR K, JONDEAU G, LANSAC E., SERFATY JM Bichat Hospital, U698, Paris, France

2 Anatomy: 3D + spatial resolution Retrospective EKG-gated helical acquisition max ma min ma Prospective EKG-gated helical acquisition max ma Table move Table move 0 ma X-ray on time Target Phase range 3 last cardiac beats taken into account

3 Coverage Heart: 4 blocks z x

4 SOMATOM Definition Flash Split-second thorax Conventional Technology DSCT Flash Spiral 321 Thorax: 5 s, breath hold Triple rule-out: 20 s, 20 msv Scan Thorax: 0.6 s, breath hold optional Scan 321 Triple rule-out: 0.6 s, < 5 msv Pediatric: > 4s, sedation Pediatric: < 1s, no sedation Whole body: > 10 s Whole body: 4 s 4D dynamic scans: 16 cm 4D dynamic scans: 48 cm

5 CTA basse dose CTA pour le suivi postopératoire Bénéfices idose Full Dose - FBP 70% Dose Reduction - idose 9.6 msv 2.8 msv 120 kv, 122 mas, 8.1 mgy 80 kv, 130 mas, 2.5 mgy 5 Courtesy Dr Dobritz, TU Munich, Germany

6 BICUSPID VALVE cuspide commissure Cuspides fusionnées raphé

7 SIEVERS CLASSIFICATION 1206 patients (304 bicuspidies) J. Thorac. Cardiovasc. Surg, 2007

8 TTE / TEE Difficult diagnosis if calcified valve, low echogeneicity Diagnostic accuray (Alegret et al, 2005) 174 patients (32 bicuspid) TTE: certain diagnosis for 56% bicuspid TTE + TEE: certain diagnosis for 98% bicuspid Little anatomical information Raphe excepted

9 MRI Non invasive (less than TEE) Cine sequence Se=100%/Sp=95% (Gleeson JMRI Oct 2008) Se= 75% et Sp=79% (Joziasse NethHeartJ. 2011) RAC Littleanatomicalinformation Raphe and flow excepted

10 Computed tomography Alkadhiet al. AJR 2010 Reference = surgery 47 bicuspid valves (34 surgery) 47 control Diagnosis : raphe + # cusps Type 0: Se/Sp 100/100 Type 1: Se/Sp 92/100

11 Heart fibrous annulus Yacoub, M. H. et al. Circulation 2004;109:

12 Tricuspid aortic annulus Sutton. Ann. Thorac. Surg 1995

13 Mesurement of the BASE of the AORTIC ANNULUS TTE, TEE, CT

14 Mesurement of the BASE of the AORTIC ANNULUS TTE, TEE, CT B D Aorta C Left atrium

15 Population : Prospectif, 45 patients avec RAC, ETT-ETO-Scanner Messika-Zeitoun, JACC 2010

16

17 Mesure de la base de l anneau Aortique ETT, ETO, Scanner A B D Aorta C Left atrium

18 Interleaflet triangle : H H

19 Location ofcommissures ANGULATION RAPHE

20 Anatomy of bicuspid valves on CT OBJECTIVES 1/ Describe bicuspid valve anatomy ( phénotypes) Raphe length Interleaflet triangle hight Location of commissures 2/ Diagnosis accuracy Gold standard : TTE+-TEE Control: tricuspid patients

21 MATERIAL AND METHOD Retrospective study, one center, inclusion 2007 to 2011 Gold standart for diagnosis of bicuspid valve: TTE alone or with TEE when needed Gold standart for raphe + or - : CT scan

22 MATERIEL AND METHOD: CT GE VCT 64 slices Prospective EKG 75% du cycle cardiaque si FC<75/min 40% du cycle cardiaque si FC>75/min Parameters : 100 kv / 600mA --> mgy.cm 90 ml d Iobitridol 350mg/ml Advantage Window 4.3

23 IMAGE ANALYSIS Diameters: base of the annulus, valsalva, tube RAPHE: number, length (small, long), location, calcification Interleaflet triangle length : H Commissure location : ANGULATION

24 POPULATION: results 60 bicuspid valves with both Echo + CT 97 matched control (age and sex) with CAD, thrombus, pericarditis. 9/60 bicuspid patients were removed from study (insufficient image quality on CT)

25 POPULATION: results Nb patients 7 (14%) type 0 44 (86%) type 1 94 control

26 ECHOCARDIOGRAPHY: results Type 0 Type 1 n 7 44 Ao Reg >2 Calcified AS p 3 (43) 12 (27) <0,001 3 (43) 29 (65) <0,001

27 ECHOCARDIOGRAPHY: results Necessary TEE : 27% Report: Diagnosis of type 0 or 1: 77% Location of raphe = 63% Discordance7 patients with tiny raphé on CT (not visalized on US)Raphe location (R-L): 5 patients

28 CT: DIAMETERS Bicuspid 51 Tricuspid 94 Annulus 27 (5) 24 (2) < Annulus (mm2) 619 (197) 470 (82) < Oval (%) 23 (18) 26 (8) NS STJ 34 (5) 27 (3) < Tube 43 (8) 31 (5) <0.0001

29 RAPHE (TYPE 1) Location R-L (84%) Calcified: 41% Length Tiny: 19 (43%) Long: 25 (57%)

30 HEIGHT of interleaflet triangle (H) T1 Bicuspidy Tricuspid p Mean H 9.94 (2.7) 10.1 (1.57) 0.29 Smallest H 4.5 (1.9) 8.9 (1.7) < Intermediate H 11 (3.3) 10.1 (1.6) 0.01 Highest H 14.4 (3) 11.4 (1.7) < SH/HH 32 (13) 78 (10) < SH/(IH+HH/ 2) 36 (12) 82 (11) < SH IH HH

31 SH HH X100 H

32 ANGULATION 180 T0B 180 (p<0.0001) T1B Tricuspid (p<0.0001)

33 CORRELATION BETWEEN RAPHE, H and ANGLE TINY Long p Smallest H 3.5 (1.5) 5.3 (0.4) 0,0004 Type 0 TINY Long Tricuspid p Angulation < /6 T1B with an angulation of 180 have a tiny raphe

34 CORRELATION BETWEEN H AND ANGULATION R2=0.16, p=0.02 ANGLE HEIGHT

35 DIAGNOSIS of BICUSPIDY with SH/HH P< AUC=0.995 Treshold: 58%

36 T1Bicuspidy

37 Tricuspid Aortic Valve Bicuspid aortic Valve with 1 raphe

38 CONCLUSION TYPE 1 bicuspidy has several phénotypes based on H, Angulation and Length of the raphe CONTINUUM between T0B, T1B small raphe, T1B long raphe and Tricuspid valves. CT Roadmap for surgery + differential diagnosis between bicuspid and tricuspid valves

39 CLINICAL IMPACT Roadmap for surgeons before surgery More complications for some of the phenotypes? A different technique depending on T1B anatomy? A additional surgery on commissures if its angulation > 160