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Role Of Triple Fusion Multimodality Imaging In Alternative Transcatheter Hybrid Procedures
Luigi Pirelli, Chad A. Kliger, Sean R. Wilson, Carlos E. Ruiz, Gregory P. Fontana.
Lenox Hill Hospital, New York, NY, USA.

OBJECTIVE: Multimodality imaging techniques play a key role in planning and guiding alternative transcatheter hybrid procedures. The triple fusion of computed tomography (CT) and 2-D/3-D echocardiography with live fluoroscopy represents a novel imaging modality that enables better planning and conduct of hybrid cardiac procedures. Implementation and improvement of delivery technologies, devices and imaging modalities have rendered these interventions more accurate, precise and safe. The direct transaortic approach is an option for aortic valve deployment when extensive calcification or tortuosity involve the ileo-femoral vessels, or a transapical approach is not a safe alternative. Our objective was to assess the utility of fusion imaging technology for TAVR via the direct aortic approach.
METHODS: We studied a series of 11 patients (mean age 84.8 ± 5.3 years) who underwent direct transaortic aortic valve implantation using fusion imaging technology. The approach used to access the ascending aorta was an upper mini-manubriotomy. Self expandable valves were used in all cases. Preaquired CT was performed in all patients and fusion software technology was utilized to merge CTA and fluoroscopy. The merge of CT, echocardiography and fluoroscopy was utilized to assess the aortic wall and determine the optimal and safest access point for device delivery. This imaging merging technology also allowed defining the optimal angles and planes for valve deployment on the aortic annulus and the distance between the point of entry of the sheath in the ascending aorta and the valvular plane.
RESULTS: There were no intraoperative or hospital mortalities. The calcium score of the ascending aorta was 6584 ± 4240. Double aortic puncture was performed in 4 patients (37%) and transfemoral introduction of the pigtail in the remaining 7. The access distance to the valve and center line angulation was optimal for deployment in all cases. None of the patients experienced stroke or embolic event. Fluoroscopy time was 12.8 ± 2.9 minutes.
CONCLUSIONS: Triple fusion multimodality imaging technique is helpful in planning and executing alternative access hybrid cardiac procedures. It limits radiation time to the patients and provides an accurate mapping and guidance of the ascending aorta and aortic annulus, avoiding atheromatous and calcified plaques.

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