Cardiologists from the Structural and Congenital Heart Center and Cardiac Surgeons at Hackensack Meridian Hackensack University Medical Center/Hackensack Meridian School of Medicine have reported what is believed to be the very first patient with heart failure and a blood clot to undergo a minimally invasive transcatheter aortic valve replacement using CT (computed tomography) fusion imaging, a technique that employs two different imaging modalities. The report, “CT Fusion Imaging Guidance for Transcatheter Aortic Valve Replacement in a Patient with Left Ventricular Thrombus,”1 was published in the April 11, 2022, edition of the cardiology journal JACC: Cardiovascular Interventions.
“We believe this case is potentially groundbreaking because of its successful outcome and the fact that the presence of left-ventricle thrombus or blood clot has historically been considered to be a contraindication to transcatheter aortic valve replacement, an alternative to open-heart surgery to replace heart valves in patients with heart disease,” said Rahul Vasudev, M.D., the report’s lead author. “Although the nature of catheter manipulation in the left ventricle during the procedure cannot guarantee absence of contact with the blood clot, advances in imaging technology and embolic protection may allow transcatheter aortic valve replacement, if a surgical alternative is not possible, to be performed with greater safety in this setting.”
Elderly Patient with Obesity, High Blood Pressure and Artery Disease
The patient described in the published report was a 78-year-old man with a history of obesity, high blood pressure, and coronary artery disease. He came to Hackensack University Medical Center’s Heart & Vascular Hospital with worsening labored breathing on exertion and swelling in the lower extremities over three months. His imaging workup revealed severe stenosis of the aortic valve, left ventricular (LV) ejection fraction of 45 percent to 50 percent, and LV apical aneurysm with thrombus (an outpouching of the left ventricle with a blood clot). Ejection fraction is a measurement of the percentage of blood leaving the heart each time it contracts.
Cardiac catheterization showed severe coronary artery disease that was not amenable to minimally invasive procedures used to open clogged coronary arteries. He was started on anticoagulation with warfarin with planned follow-up.
The patient returned to the hospital six months later due to loss of consciousness from low blood pressure. Four-dimensional volume-rendered computed tomography (CT) images showed persistent left ventricle apical thrombus. The Heart & Vascular Hospital team elected to proceed with transcatheter aortic valve replacement (TAVR) given his high surgical risk, poor functional status, lack of response to anticoagulation, and hospitalization for fainting.
Because of the risk posed by the apical thrombus, TAVR with CT fusion imaging (CTFI) guidance and cerebral embolic protection was planned. “We believe this was the first case of TAVR with real-time CTFI to facilitate wire and catheter positioning to avoid disruption of the left ventricle thrombus,” said Tilak K. R. Pasala, interim director, Structural and Congenital Heart Disease Program. “CTFI requires high-quality CT acquisition and creating a 3-dimensional (3D) heart model using a CT post-processing technique called segmentation on special software. This 3D model is then married to fluoroscopy using a process called coregistration, which projects the model on fluoroscopy at appropriate scale and orientation,” said Vladamir Jelnin, M.D., director of Structural Heart CT Imaging.
“Fusion Imaging is extremely helpful in identifying the cardiac structures during catheter and wire manipulation, especially in complex structural heart interventions,” said Yuriy Dudiy, M.D., a cardiac surgeon involved in the procedure.
The patient had an uneventful hospital course; there was no evidence of cerebral or systemic embolization. He was discharged in a few days and was doing well at his one month follow up appointment.
For information about Hackensack Meridian Health’s cardiovascular services, visit https://www.hackensackmeridianhealth.org/services/cardiovascular/.
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1 Vasudev et al JACC: CARDIOVASCULAR INTERVENTIONS VOL. 15, NO. 7, 2022 TAVR With LV Thrombus APRIL 11, 2022:e77 – e79
”CT Fusion Imaging Guidance for Transcatheter Aortic Valve Replacement in a Patient With Left Ventricular Thrombus,” Rahul Vasudev, MD, Sayf Altabaqchali, MD, Yuriy Dudiy, MD, Michael Lim, MD, Vladimir Jelnin, MD, Tilak K.R. Pasala, MD
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