The Development of New Imaging Standards for Preoperative Ross Procedure Evaluation

P0331 

Abstract Submission 

John Eisenga (1), William Brinkman (2), J. Michael DiMaio (3), Zuyue Wang (4), Kyle McCullough (5), Ghadi Moubarak (6), Sarah Hale (7), Justin Schaffer (8), Katherine Harrington (9), William Ryan (10), Amro Alsaid (4)

(1) Baylor Scott & White Research Institute, Plano, TX, (2) Baylor Scott & White Health, TX, (3) The Heart Hospital Baylor Plano, Dallas, TX, (4) Baylor Scott & White - The Heart Hospital, Plano, TX, (5) Baylor Scott and White Research Institute, Plano, TX, (6) N/A, N/A, (7) BSWH Research Institute, Plano, TX, (8) The Heart Hospital Baylor Plano, Plano, TX, (9) N/A, Plano, TX, (10) Baylor Scott and White The Heart Hospital, Plano, TX

John Eisenga    -  Contact Me
Baylor Scott & White Research Institute

*William Brinkman    -  Contact Me
Baylor Scott & White Health

*J. Michael DiMaio    -  Contact Me
The Heart Hospital Baylor Plano

Zuyue Wang    -  Contact Me
Baylor Scott & White - The Heart Hospital

Kyle McCullough    -  Contact Me
Baylor Scott and White Research Institute

Ghadi Moubarak    -  Contact Me
N/A

Sarah Hale    -  Contact Me
BSWH Research Institute

Justin Schaffer    -  Contact Me
The Heart Hospital Baylor Plano

Katherine Harrington    -  Contact Me
N/A

William Ryan    -  Contact Me
Baylor Scott and White The Heart Hospital

Amro Alsaid    -  Contact Me
Baylor Scott & White - The Heart Hospital

John Eisenga    -  Contact Me
Baylor Scott & White Research Institute

Objective: While, the Ross Procedure had seen decreased utilization due to concerns over long-term viability and operative risk, modern literature has demonstrated both the safety and efficacy of this surgery. As expert centers demonstrate the utility of this surgery in young patients with diseased aortic valves, the Ross procedure has seen a resurgence in popularity. Much has been written on the technical aspects and outcomes of the procedure, however little convention exists on preoperative imaging and assessment. As non-invasive imaging modalities have improved better information can be obtained regarding the right ventricular outflow tract. As a high-volume Ross center, we have established a preoperative imaging protocol for all patients being evaluated for Ross procedure to assess the RVOT for use as a homograft. We describe our novel approach to RVOT assessment below using four real world examples.

Methods: We have established a new institutional imaging protocol for patients being evaluated for the Ross procedure. Patients who are candidates for the procedure undergo preoperative 4D cardiac CTA. Optimal contrast timing is selected to allow simultaneous visualization (>220 HU) of the LVOT and RVOT. Contrast administration is visually inspected and the scan initiated once both sides have adequate attenuation or auto-triggered 5-6 seconds following the left atrium reaching the HU threshold. Reconstruction imaging of the aortic and pulmonic annulus are obtained and sized at peak systolic phases. Imaging reconstructions are performed and interpreted by a Level 3 Certified Advanced Cardiac Imaging Specialist. The aortic measurements include LVOT, aortic annulus (Diameters, area and perimeter), SOV, STJ and ascending aorta as well as coronary heights. The Pulmonic measurements include the PV annulus (diameter, perimeter and area) as well as the muscular cuff (3-5 mm below the PV annulus), and PA below the bifurcation.

Results: Patient ages were 36, 41, 48 and 61 years. Two patients were male and two were female. Average diameter of the pulmonic annulus in the four patients was 27.3 mm, 28.8 mm, 21.4 mm, and 25 mm. Perimeter of the pulmonic annulus was 90 mm, 93.1mm, 69.6 mm and 79.5 mm. Average diameter and perimeter of the aortic annulus were 23/73.8mm, 28.6/92.3 mm, 22.8/72.3mm, and 25.1/80.4 mm. Intraoperative measurement of the aortic annulus was obtained using a Freestyle sizer in each case. The annular measurements were 27 mm, 29 mm, 23 mm, and 27 mm. Three patients underwent a supported Ross, and one patient underwent tissue supported Ross procedure.

Conclusions: All four patients underwent successful Ross procedure. The pulmonary autograft was found to be properly sized and used successfully as an autograft in each of the four patients. Using 4D CTA reconstructions to assess the RVOT size during the evaluation for the Ross procedure is an easy adjunct to the process and appears to adequately size the RVOT for feasibility of use as an autograft. Being able to accurately and efficiently size the RVOT will likely provide a benefit for preoperative assessment and operative care for patients undergoing the Ross procedure. As this procedure experiences a resurgence of popularity it will be important to implement standardized quality measures and we believe 4D CTA with reconstructions can be an important part of the preoperative evaluation.

Aortic Root