A 66-year-old woman with severe mitral regurgitation was referred to our heart team to assess eligibility for mitral valve (MV) surgery (MVS). In MVS, injury to the left circumflex artery (LCX) is estimated to occur in up to 2.7% of the patients.1 The distance of the LCX to the MV (on average 3.1 ± 1.3 mm) is highly variable and is likely to determine the prevalence of this complication.1 Transesophageal echocardiography (TEE) is the modality of choice for MVS planning (Panel A and B).2 Computed tomography (CT) has been proposed as standard screening tool for MVS to determine the risk of LCX injury.3 We aimed to fuse the CT-derived LCX identification (Panel C) with TEE-derived MV views to improve the surgical planning of MVS in patients at high risk of injury.
Using Meshmixer (Autodesk), 3D Slicer (Slicer) and Elastix toolbox, TEE (General Electric) and CT scans (Siemens) were prealigned using the Procrustes algorithm, cropped, and subsequently aligned using Mutual information registration with an adaptive gradient descent optimizer.4,5 The LCX is segmented on CT and a MV reconstruction is made on TEE.
This initiative is the first to fuse CT and a TEE of the MV for the purpose MVS planning. The fused image (Panel D) provides synergistic information derived from both TEE and CT modalities. If, in routine screening on CT, the distance of the MV to the LCX is close, fusion of the LCX to TEE could be helpful to devise a surgical strategy for MVS..
We would like to thank F. Meijerink and S.A.J. Chamuleau for their support.
This study was approved by the local Human Research Ethics Committee (Amsterdam UMC). Informed consent was obtained.
Supplementary data is available at European Heart Journal online.
Supplementary Material
Contributor Information
Jelle Piet Man, Department of Cardiology, Amsterdam UMC, location AMC, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands; Netherlands Heart Institute, Moreelsepark 1, 3511 EP Utrecht, the Netherlands.
Berto Jorrit Bouma, Department of Cardiology, Amsterdam UMC, location AMC, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands.
Mark Johan Schuuring, Department of Cardiology, Amsterdam UMC, location AMC, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands; Netherlands Heart Institute, Moreelsepark 1, 3511 EP Utrecht, the Netherlands.
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