International Society For Minimally Invasive Cardiothoracic Surgery

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3 Dimensional Image Fusion Of Cardiac Cta And Fluoroscopy For Real Time Guidance During Minimally Invasive Lima To Lad Bypass Grafting
Moritz C. Wyler von Ballmoos, Ponraj Chinnadurai, Priya R. Kothapalli, Mahesh K. Ramchandani.
Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA.

OBJECTIVE: To demonstrate how advanced imaging technology with 3-dimensional fusion of cardiac CT angiography (CCTA) and fluoroscopy can be leveraged to precisely map the surgical incision and anastomotic site intra-operatively during minimally-invasive coronary artery bypass grafting. METHODS: A preoperative CCTA is fused with 2 simple fluoroscopy views (pa/lat) obtained with the patient positioned on the operating table. The fused images are then used to identify and map the LIMA and the anastomotic site directly onto the patient. The intra-operative mapping facilitates a small, anterior thoracotomy directly over the LAD target, which is chosen based on preoperative imaging. After completion of the anastomosis a completion angiography is performed with standard fluoroscopy. This confirms both the quality of the anastomosis as well as appropriate location thereof. RESULTS: We present a detailed, step-by-step approach to using advanced imaging technology available in every contemporary hybrid operating room for intraoperative guidance in cardiac surgery. Specifically, we outline the process of mapping both the LIMA and a prespecified target on the LAD for creating an anastomosis in a precise anatomic location. Information from the preoperative CCTA and conventional catheter angiography can be incorporated into the decision of where to create the anastomosis; with wider adoption and availability of CT-FFR this will allow to also consider hemodynamic information, in addition to anatomic features, when choosing the most appropriate anastomotic site. CONCLUSIONS: Our approach allows to plan preoperatively, resulting in highly precise incisions and create an anastomosis in a specific anatomic location, compared to the conventional approach of choosing a merely suitable target intraoperatively based on the surgeonís experience. The technology used for our imaging-based approach is widely applicable as it is part of the standard capabilities of any contemporary hybrid operating room.

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