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3DRA in the Interstage:

When is it worth it?

Darren P. Berman, MD

Co-Director, Interventional Cardiology

The Heart Center

Nationwide Children’s Hospital

Associate Professor, Pediatrics

The Ohio State University

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None pertinent to this lecture

Disclosures

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Objectives

• Brief history of 3D-RA

• Describe how 3D-RA is done

• When & why consider 3D-RA in SV interstage patients

• Advantages & disadvantages

• Case examples

• 3D-RA utilization during interstage period

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Angiography in the Cath Lab

• Adult cath labs -- Single plane

• Congenital cath labs -- Biplane

•Imaging complex 3-D structures

• 2D biplane imaging

•Quantitative assessment

•Qualitative assessment

•‘Gold Standard’

•Interventions in the cath lab

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Why Do We Need 3DRA Then?

Why not image complex 3-dimensional structures in 3D?

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History of 3DRA

• First described in 2006

• Neurovascular procedures• Adjunct to subtraction angiography

• More sensitive in detecting subtle lesions

• Subsequently, described in the setting of real-time evaluation of• spinal interventions

• abdominal aortic aneurysm repair

• hepatic vascular chemoembolization

• PA/IVS case report

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3DRA in CHDKapins CEB et al. Use of Rotational 3D (3D-RA) in Congenital Heart Disease Patients: Experience with 53

cases. Rev Bras Cardiol Invasiva. 2010;18(2):199-203.

2010 – First series describing its use in CHD• 53 cases – various diagnoses

Results• 23%, 3D-RA revealed anatomic details not shown by 2D angiography

• 49%, 3D-RA findings were used to aid in treatment decisions

• Exposure to radiation was not statistically different from 2D angiography

• No complications related to 3D-RA

Conclusions• 3D-RA can provide additional useful information

• May reduce the number of angiograms needed during a case

• May limit patient exposure to radiation and contrast medium

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3DRA in CHDGlatz AC et al. Use of angiographic CT imaging in the cardiac catheterization laboratory for congenital heart

disease. JACC Cardiovasc Imaging. 2010 Nov;3(11):1149-57.

• Followed soon there after in the US in late 2010

• 41 caths; range of diagnoses

• RVOT/central pulmonary arteries; CPCs; pulm veins; distal PAs

• Results:

• 71%; Diagnostic-quality imaging

• 12 cases (29%), contributed to clinical outcomes

• Radiation dose was comparable to a biplane cineangiogram

• Conclusions:

• In certain cases, 3DRA provides additional anatomic detail

• Future work is needed to continue to define applications of this new

technology

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How It’s Done

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One 3D-RA200 degree rotational angiogram

•Automatically transferred to a dedicated 3D work

station

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One 3D-RA3D reconstruction

•Additional 3-5 minutes of image post-processing

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One 3D-RACross-sectional CT-like tomographic slices

3DRA -- Advantages• Single rotational angiogram 3D recon

• Assess complex 3D structure in 3D

• “Virtual” real time 3D assessment

• Determine best gantry angle for conventional angiography without taking multiple biplane angiograms

• Potential to reduce total # of angiograms

• Potential to reduce total contrast needed

• Single rotational angiogram cross sectional CT-like tomographic images

• Better understand relationship of PA’s to surrounding structures

• Better understand mechanism of stenoses

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Interstage Single Ventricle Patients: Fragile period

• Mortality 2-16%1

• Reintervention rate 18-37%2

• Increase pulmonary blood flow

• Improve systemic perfusion

• Improve venous mixing

• Urgently performed1Feinstein JA1, Benson DW, Dubin AM, et al. Hypoplastic left heart syndrome: current

considerations and expectations. J Am Coll Cardiol. 2012 Jan 3;59.2Galantowicz M, Cheatham JP, Phillips A, et al. Hybrid approach for hypoplastic left heart syndrome:

intermediate results after the learning curve. Ann Thorac Surg. 2008 Jun;85(6):2063-70.

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Catheterization RISk score for Pediatrics (CRISP)

Predicted incidence of SAE for

inter-stage single ventricle

patient:

Nykanen DG, Forbes TJ, Du W, et al. CRISP: Catheterization RISk score for

Pediatrics: A Report from the Congenital Cardiac Interventional Study

Consortium (CCISC). Catheter Cardiovasc Interv. 2016 Feb 1;87(2):302-9. doi:

10.1002/ccd.26300. Epub 2015 Nov 3.

6.2% - 36.8%

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Is 3DRA worth it? =

Is 3DRA worth the risk?

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Benefit of 3DRA

Improves

understanding of

anatomy

Guides intervention

Defines optimal

gantry angles for

2D imaging

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Barriers/Risks to 3DRA in Urgent

Interstage Catheterizations

• Increased radiation dose ?

• Increased contrast dose ?

• Increased procedural time ?

• Modify (decrease) stroke volume with RRVP

•Additional vascular access

•Possible clinical decline with pacing

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3DRA vs 2D Digital Angiography:Radiation Dose

Haddad L, Waller BR, Johnson J, et al.

Radiation Protocol for Three-Dimensional Rotational

Angiography to Limit

Procedural Radiation Exposure in the Pediatric

Cardiac Catheterization Lab. Congenit Heart Dis.

2016 Apr 14. doi: 10.1111/chd.12356.

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Uitlity of 3D-RA in SV patients

Additional value of three-dimensional rotational angiography

in the diagnostic evaluation and percutaneous treatment

of children with univentricular heartsFemke van der Stelt, MD; Gregor J. Krings, MD, PhD; Mirella C. Molenschot,

MD; Johannes M. Breur*, MD, PhD

Published 24 August 2018

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Methods and results:

Between January 2003 and March 2017, 140 patients

underwent 183 CAs and 107 3DRAs. 3DRA image

quality was superior to CA with fewer diagnostic

angiographies performed (p<0.001). Intervention rate

(p<0.001) and interventional success (p=0.03) were

higher with 3DRA, while complication rates were similar.

Mean radiation was lower in the 3DRA group, reaching

significance pre-PCPC. 3DRA was considered of

additional value in imaging of cardiovascular anatomy,

collaterals, stenoses, and vessel-vessel and vessel-

bronchi interactions.

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Barriers/Risks to 3DRA in Urgent

Interstage Catheterizations

• Increased radiation dose

• Increased contrast dose

• Increased procedural time

• Modify (decrease) stroke volume with RRVP

•Additional vascular access

•Possible clinical decline with pacing

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Transesophageal Pacing

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Case 1: Retrograde Aortic Arch Obstruction

• 3 month-old female

• HLHS (MA/AA)

• S/P Hybrid stage I

palliation

• Decreased RUE pulse

• TTE w/increasing gradient

across the retrograde

aortic arch

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3D Reconstruction

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Implantation of 4mm x12 mm Integrity

Coronary Stent

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Case #2: Sano Shunt

• 1 month-old male

• HLHS (AS/MS) s/p

Norwood operation with a

4 mm Gore-Tex Sano

shunt

• Progressive cyanosis

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3D Reconstruction

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Sano Shunt Angiogram

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Balloon Angioplasty with 3.5 mm x 15 mm

Quantum Maverick Balloon

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Post Procedural Angiogram

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Case #3: mBTTS

• 3 month-old male

• Complex SV s/p Norwood

operation with a 3.5 mm R

mBTT shunt

• Progressive cyanosis

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Case #4 – 6 day old F;

PA/VSD with single source PBF via PDA

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Case #5: Insufficient PBF

• 4 mo old male

• DORV, remote VSD,

pulmonary atresia

• s/p 3.5mm central

shunt

• Increasing hypoxia

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Case #6: PA/IVS, hypoplastic RV, RVDCC

• 1 week-old male

• S/P 3.5 mm Gore-Tex

modified BTT shunt

• Severe post-operative

cyanosis

• Severe cyanosis + inotropes

•Operator choice

•no 3DRA

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Selective Angiogram

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Implantation of a 3.5 mm x 18 mm

Integrity Stent

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Final Angiogram

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Summary

• Interstage SV patients are at high risk for morbidity and SAE

during cardiac catheterization

• There are perceived barriers and risks of 3D-RA

•Are just that – perceived 3D-RA is safe

• Wealth of information provided by a single 3D-RA

• More informed better decisions with how best to manage the

residual lesions we find

• Use of 3D-RA in this setting should be determined on an

individual basis