Department of Cardiology, University Medical Center, Utrecht, the Netherlands.
JACC Cardiovasc Imaging. 2013 Feb;6(2):238-48. doi: 10.1016/j.jcmg.2012.12.004.
The aim of this study was to determine whether pre-procedural analysis of multidetector row computed tomography (MDCT) scans could accurately predict the "line of perpendicularity" (LP) of the aortic annulus and corresponding C-arm angulations required for prosthesis delivery and impact the outcome of the procedure.
Optimal positioning of the transcatheter aortic prosthesis is paramount to transcatheter aortic valve replacement (TAVR) procedural success.
All patients referred for TAVR at our center underwent a routine pre-procedural MDCT scan. A 3-dimensional (3D) analysis using software dedicated to define the LP of the aortic annulus and the corresponding C-arm positioning was performed in 71 consecutive patients. In 35 patients, the results of the MDCT analysis were not available at the time of the procedure (angiography cohort). In that cohort the position of the C-arm was determined during the procedure using ad-hoc angiography. In 36 patients, the MDCT analysis was performed pre-procedure and results were available at the time of the procedure (MDCT cohort). In that cohort the position of the C-arm was derived from the MDCT analysis rather than by ad-hoc angiography.
Intraobserver and interobserver reproducibility of MDCT analysis to predict the LP of the aortic annulus were excellent (kappa = 1 and 0.94, respectively). Patient variations of the LP ranged >70°. Compared with the angiography cohort, the MDCT cohort was associated with a significant decrease in implantation time (p = 0.0001), radiation exposure (p = 0.02), amount of contrast (p = 0.001), and risk of acute kidney injury (p = 0.03). Additionally, the combined rate of valve malposition and aortic regurgitation was also reduced (6% vs. 23%, p = 0.03).
Automated 3D analysis of pre-implantation MDCT accurately predicts the LP of the aortic annulus and the corresponding C-arm position required for TAVR. With this approach, the implantation of the balloon-expandable prosthetic valve can be performed without an aortogram in the majority of cases and still be safe, with a low rate of valve malpositioning and regurgitation.
本研究旨在确定术前多层螺旋 CT（MDCT）扫描分析是否能准确预测主动脉瓣环的“垂直线”（LP）和输送假体所需的 C 臂角度，并影响手术结果。
经导管主动脉瓣置换术（TAVR）的关键是假体的最佳定位。
我们中心所有接受 TAVR 的患者均进行常规术前 MDCT 扫描。使用专门的软件对 71 例连续患者的 LP 和相应的 C 臂定位进行 3D 分析。在 35 例患者中，MDCT 分析结果在手术时不可用（血管造影组）。在该组中，C 臂的位置是在手术过程中使用专用血管造影确定的。在 36 例患者中，进行了 MDCT 分析并在手术时获得了结果（MDCT 组）。在该组中，C 臂的位置是从 MDCT 分析中得出的，而不是通过专用血管造影得出的。
MDCT 分析预测主动脉瓣环 LP 的观察者内和观察者间可重复性均较好（kappa 值分别为 1 和 0.94）。LP 的患者差异范围>70°。与血管造影组相比，MDCT 组的植入时间明显缩短（p=0.0001），辐射暴露量减少（p=0.02），造影剂用量减少（p=0.001），急性肾损伤风险降低（p=0.03）。此外，瓣膜位置不正和主动脉瓣反流的综合发生率也降低（6%比 23%，p=0.03）。
术前植入 MDCT 的自动 3D 分析能准确预测 TAVR 所需的主动脉瓣环 LP 和相应的 C 臂位置。通过这种方法，在大多数情况下，无需进行主动脉造影即可进行球囊扩张式假体瓣膜的植入，并且仍然安全，瓣膜定位不正和反流的发生率较低。
