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The Clinical Utility of Dyna CT and Aortic Valve Guide Software in TAVR—The Prince Charles Registry
Abstracts CSANZ 2012 Abstracts
favourable short term prognosis in patients who present to hospital. While medical therapy is appropriate in asymptomatic patients, PCI is a safe and effective therapy for patients with ongoing ischaemia.
S177
430 Stent Usage Trends in Acute ST Segment Elevation Myocardial Infarction
http://dx.doi.org/10.1016/j.hlc.2012.05.439
M. Savage ∗ , E. Johnston, A. Incani, K. Poon, J. Crowhurst, M. Pincus, C. Raffel, D. Walters
429
The Prince Charles Hospital, Australia
Standardised Pre-hospital Notification of ST Segment Elevation Myocardial Infarction Patients by Ambulance Service Facilitates Achievement of Guideline Adherence at Three Tertiary Cardiac Centres
Introduction: Primary Percutaneous Coronary Intervention (PCI) for ST segment Elevation Myocardial Infarction (STEMI) has been shown to improve patient outcomes. In the elective PCI setting the decision regarding stent choice is often multi-factorial and patient dependent. However, in the acute STEMI setting, often a complete patient history is lacking. There have been a number of trials demonstrating safety of Drug Eluting Stents (DES) in the Primary PCI setting with reduced target lesion revascularisation rates. We sought to analyse the trend in DES usage for Primary PCI at our institution. Method: A retrospective analysis of 393 patients who underwent Primary PCI for acute STEMI over a four year period between January 2008 and December 2011 was performed and the type of stent/s used was recorded. Results: The total number of STEMI patients receiving Primary PCI did not differ each year (p < 0.001). The proportion of patients who received DES increased significantly from 9.3% vs 56.9% (p < 0.001), whilst the patients who received Bare Metal Stents (BMS) concomitantly decreased from 87.2% to 39.2% (p < 0.001). Patients who received balloon angioplasty did not differ over the four year period (p < 0.001). Conclusion: Analysis of stent usage in a large tertiary Primary PCI centre suggests a change in practice, with a shift towards preference for DES over BMS for primary PCI in acute STEMI. The trend is most likely due to improvements in DES stent technology and reduction of target lesion revascularisation rates as described in current literature.
S. Butterly 1,2,∗ , S. Rashford 3 , M. Dooris 4 , R. Jayasinghe 5 , P. Garrahy 1 1 Princess
Alexandra Hospital, Brisbane, Australia of Queensland, Brisbane, Australia 3 Queensland Ambulance Service, Brisbane, Australia 4 Royal Brisbane and Women’s Hospital, Brisbane, Australia 5 Gold Coast Hospital, Gold Coast, Australia 2 University
Background: Interventional cardiology services continue to have difficulty achieving published guidelines for timely primary percutaneous coronary intervention (PPCI) treatment of acute ST elevation myocardial infarction (STEMI). Additionally, most units continue to report door to balloon times rather than the recommended first medical contact (FMC) to device as a quality measure. From October 2011, standardised, pre-hospital notification directly to the on-call interventional cardiologist of suspected STEMI patients by the Queensland Ambulance Service (QAS) was available in southeast Queensland. We report the pre-hospital system response times during this initial phase of implementation at three tertiary cardiac hospitals – Royal Brisbane and Women’s Hospital (RBWH), Gold Coast Hospital (GCH) and Princess Alexandra Hospital (PAH). Population: QAS identified STEMI patients referred for PPCI, with pre-hospital notification, during the audit period (October 2011 to February 2012). Patients with prolonged resuscitation, contraindication to PPCI, intubation, previous coronary artery bypass surgery, resolution of ST segment elevation post initial treatment or cardiologist decision for medical management were excluded. FMC was defined as first diagnostic electrocardiogram. Results: Forty-one patients met inclusion criteria during the audit period. Audited times are outlined below.
FMC to cardiologist contact FMC to door Door to first device FMC to first device
http://dx.doi.org/10.1016/j.hlc.2012.05.441 431 The Clinical Utility of Dyna CT and Aortic Valve Guide Software in TAVR—The Prince Charles Registry A. Incani ∗ , J. Crowhurst, K. Poon, M. Savage, C. Aroney, C. Raffel, D. Walters
All (h:mm)
In Hours (n = 22) (h:mm)
After Hours (n = 19)
p-Value (t-Test)
The Prince Charles Hospital, Australia
0:19 ± 0:14
0:20 ± 0:15
0:19 ± 0:13
0.58
0:43 ± 0:19 0:50 ± 0:27 1:33 ± 0:23
0:48 ± 0:18 0:44 ± 0:32 1:31 ± 0:26
0:37 ± 0:19 0:58 ± 0:18 1:35 ± 0:20
0.038 0.176 0.544
Background: Successful prosthesis placement in Transcatheter Aortic Valve Replacement (TAVR) demands accurate profiling of the plane of the aortic annulus. Dyna CT and Aortic Valve Guide (AVG) software automates this and provides the optimal angle in which to implant. We sought to analyse the utility of Dyna CT and AVG software in terms of device implantation optimisation, contrast use and radiation exposure. Methods: Two cohorts of patients were compared – Cohort A were implanted without Dyna CT/AVG and Cohort B with Dyna CT/AVG. Success of implantation
Conclusion: A collaborative, standardised, system of pre-hospital notification by QAS facilitates achievement of guideline-mandated times for STEMI patients in southeast Queensland. http://dx.doi.org/10.1016/j.hlc.2012.05.440
ABSTRACTS
Heart, Lung and Circulation 2012;21:S143–S316
S178
Abstracts CSANZ 2012 Abstracts
Heart, Lung and Circulation 2012;21:S143–S316
ABSTRACTS
Table 1. . Cohort A Contrast use (mL) Fluoroscopy time (min) Number of aortograms Acquisition number
282 27 1.9 23
± ± ± ±
99 10 1 12
Cohort B 245 19 1 11
± ± ± ±
p Value
83 7 0 5
<0.05 <0.05 <0.05 <0.05
Table 1. Aortic Annular Dimensions Based on the Cardiac Cycle. CT Annular Measurement Short diameter (mm) Long diameter (mm) Mean diameter (mm) Area (cm2 ) Circumference (mm) Eccentricitya a
Systole 20.8 26.6 23.6 4.7 78.5 21.3
± ± ± ± ± ±
2.24 2.84 2.3 0.8 8.2 8.0
Diastole 20.2 26.2 23.2 4.5 77.2 22.3
± ± ± ± ± ±
p Value
1.99 2.90 2.2 0.9 8.0 7.4
0.01 0.22 0.03 <0.01 0.01 0.28
1-Short diameter/long diameter.
was defined by prosthesis perpendicularity to the annular plane and by strut overlap and was given three predefined grades – excellent, satisfactory and poor. Contrast use, number of aortograms, fluoroscopy time and number of acquisition runs were also compared. Results: Cohort A comprised 23 CoreValve implants and Cohort B 13 CoreValve and 17 Edwards Sapien valves. Cohort A had 9 excellent, 12 satisfactory and 2 poor implants. This was statistically inferior to Cohort B which had 25 excellent, 5 satisfactory and 0 poor implants (p < 0.05). Table 1 summarises the comparison in mean contrast use and radiation exposure (expressed as mean ± 1 SD). Conclusion: Dyna CT and AVG software improved prosthesis placement yet also reduced contrast use and radiation exposure.
A. Willson ∗ , J. Webb, M. Freeman, R. Toggweiler, R. Binder, D. Wood, J. Leipsic
http://dx.doi.org/10.1016/j.hlc.2012.05.442
St Pauls Hospital, Vancouver, British Columbia, Canada
432
Background: Computed tomography (CT) provides three dimensional measurement of the aortic annulus which can be used for valve sizing in transcatheter aortic valve replacement (TAVR). Methods: 120 patients underwent CT prior to TAVR with a balloon expandable aortic valve. Valve sizing was by TEE annular diameter and clinical features. A theoretical CT based valve size was retrospectively determined by ensuring the nominal external valve area is greater than the CT annular area. The impact of CT sizing on valve selection and grade of paravalvular regurgitation by transthoracic echocardiography was assessed. Results: The mean aortic annular measurements were: TEE annular diameter 22.4 ± 1.8 mm, CT annular area 4.5 ± 0.9 cm2 and mean CT annular diameter 23.4 ± 2.3 mm. Using traditional TEE sizing the THV was undersized (external area of a fully expanded valve < CT annular area) in 33.3% (40/120). By using CT sizing criteria there was a trend towards using larger valves (Table 1). Eighty-five percent (34/40) of patients where CT suggested using a larger valve had mild or moderate paravalvular regurgitation (Table 1).
The Impact of the Cardiac Cycle on Aortic Annular Dimensions as Measured by Computed Tomography (CT) and the Implications for CT Sizing Criteria in Transcatheter Aortic Valve Replacement A. Willson ∗ , J. Webb, R. Gurvitch, M. Toggweiler, R. Binder, D. Wood, J. Leipsic
Freeman, S.
St Pauls Hospital, Vancouver, British Columbia, Canada Background: The affect of the cardiac cycle on aortic annular dimensions is poorly defined and is important for the development of CT sizing guidelines in transcatheter aortic valve replacement (TAVR). Methods: Systolic and diastolic CT derived aortic annular measurements (short diameter, long diameter, mean diameter, area and circumference) were recorded in 66 patients who underwent TAVR. A theoretical CT sizing chart was developed where the balloon expandable valve selected must have a nominal external area greater than the CT annular area. The impact of using systolic or diastolic annular measurements on CT based valve selection was assessed. Results: Mean annular diameter, area and circumference were on average significantly larger in systole than diastole (Table 1). There was no difference in annular eccentricity. Compared with systole, using diastolic measurements for CT sizing resulted in 20% (13/66) of patients receiving a smaller valve. Among these patients, the mean difference in annular area between systole and diastole was 0.87 ± 0.52 cm2 compared to 0.06 ± 0.6 cm2 (p < 0.001) for those patients whose valve size did not change between the cardiac cycle.
Conclusions: The aortic annulus is larger in systole than diastole. Systolic CT annular measurements should be used for CT sizing guidelines in TAVR. http://dx.doi.org/10.1016/j.hlc.2012.05.443 433 The Implications of CT Sizing on Valve Selection and Paravalvular Regurgitation in Transcatheter Aortic Valve Replacement Gurvitch, S.
Table 1. The Effect of Using CT Sizing Guidelinesa on Valve Selection Compared to TEE. Change in Valve size Downsize by 1 No change Upsize by 1 Total a
N (%)
Paravalvular Regurgitation Grade None/trivial N (%)
13 (10.8) 67 (55.8) 40 (33.3) 120
Mild
Moderate
Severe
10 (76.9) 37 (55.2) 6 (15.0)
2 (15.4) 0 (0) 26 (38.8) 3 (4.5) 24 (60.0) 10 (25.0)
0 0 0
53 (44.2%)
52 (43.3) 13 (10.8)
0
External area of a fully expanded valve > CT annular area.
favourable short term prognosis in patients who present to hospital. While medical therapy is appropriate in asymptomatic patients, PCI is a safe and effective therapy for patients with ongoing ischaemia.
S177
430 Stent Usage Trends in Acute ST Segment Elevation Myocardial Infarction
http://dx.doi.org/10.1016/j.hlc.2012.05.439
M. Savage ∗ , E. Johnston, A. Incani, K. Poon, J. Crowhurst, M. Pincus, C. Raffel, D. Walters
429
The Prince Charles Hospital, Australia
Standardised Pre-hospital Notification of ST Segment Elevation Myocardial Infarction Patients by Ambulance Service Facilitates Achievement of Guideline Adherence at Three Tertiary Cardiac Centres
Introduction: Primary Percutaneous Coronary Intervention (PCI) for ST segment Elevation Myocardial Infarction (STEMI) has been shown to improve patient outcomes. In the elective PCI setting the decision regarding stent choice is often multi-factorial and patient dependent. However, in the acute STEMI setting, often a complete patient history is lacking. There have been a number of trials demonstrating safety of Drug Eluting Stents (DES) in the Primary PCI setting with reduced target lesion revascularisation rates. We sought to analyse the trend in DES usage for Primary PCI at our institution. Method: A retrospective analysis of 393 patients who underwent Primary PCI for acute STEMI over a four year period between January 2008 and December 2011 was performed and the type of stent/s used was recorded. Results: The total number of STEMI patients receiving Primary PCI did not differ each year (p < 0.001). The proportion of patients who received DES increased significantly from 9.3% vs 56.9% (p < 0.001), whilst the patients who received Bare Metal Stents (BMS) concomitantly decreased from 87.2% to 39.2% (p < 0.001). Patients who received balloon angioplasty did not differ over the four year period (p < 0.001). Conclusion: Analysis of stent usage in a large tertiary Primary PCI centre suggests a change in practice, with a shift towards preference for DES over BMS for primary PCI in acute STEMI. The trend is most likely due to improvements in DES stent technology and reduction of target lesion revascularisation rates as described in current literature.
S. Butterly 1,2,∗ , S. Rashford 3 , M. Dooris 4 , R. Jayasinghe 5 , P. Garrahy 1 1 Princess
Alexandra Hospital, Brisbane, Australia of Queensland, Brisbane, Australia 3 Queensland Ambulance Service, Brisbane, Australia 4 Royal Brisbane and Women’s Hospital, Brisbane, Australia 5 Gold Coast Hospital, Gold Coast, Australia 2 University
Background: Interventional cardiology services continue to have difficulty achieving published guidelines for timely primary percutaneous coronary intervention (PPCI) treatment of acute ST elevation myocardial infarction (STEMI). Additionally, most units continue to report door to balloon times rather than the recommended first medical contact (FMC) to device as a quality measure. From October 2011, standardised, pre-hospital notification directly to the on-call interventional cardiologist of suspected STEMI patients by the Queensland Ambulance Service (QAS) was available in southeast Queensland. We report the pre-hospital system response times during this initial phase of implementation at three tertiary cardiac hospitals – Royal Brisbane and Women’s Hospital (RBWH), Gold Coast Hospital (GCH) and Princess Alexandra Hospital (PAH). Population: QAS identified STEMI patients referred for PPCI, with pre-hospital notification, during the audit period (October 2011 to February 2012). Patients with prolonged resuscitation, contraindication to PPCI, intubation, previous coronary artery bypass surgery, resolution of ST segment elevation post initial treatment or cardiologist decision for medical management were excluded. FMC was defined as first diagnostic electrocardiogram. Results: Forty-one patients met inclusion criteria during the audit period. Audited times are outlined below.
FMC to cardiologist contact FMC to door Door to first device FMC to first device
http://dx.doi.org/10.1016/j.hlc.2012.05.441 431 The Clinical Utility of Dyna CT and Aortic Valve Guide Software in TAVR—The Prince Charles Registry A. Incani ∗ , J. Crowhurst, K. Poon, M. Savage, C. Aroney, C. Raffel, D. Walters
All (h:mm)
In Hours (n = 22) (h:mm)
After Hours (n = 19)
p-Value (t-Test)
The Prince Charles Hospital, Australia
0:19 ± 0:14
0:20 ± 0:15
0:19 ± 0:13
0.58
0:43 ± 0:19 0:50 ± 0:27 1:33 ± 0:23
0:48 ± 0:18 0:44 ± 0:32 1:31 ± 0:26
0:37 ± 0:19 0:58 ± 0:18 1:35 ± 0:20
0.038 0.176 0.544
Background: Successful prosthesis placement in Transcatheter Aortic Valve Replacement (TAVR) demands accurate profiling of the plane of the aortic annulus. Dyna CT and Aortic Valve Guide (AVG) software automates this and provides the optimal angle in which to implant. We sought to analyse the utility of Dyna CT and AVG software in terms of device implantation optimisation, contrast use and radiation exposure. Methods: Two cohorts of patients were compared – Cohort A were implanted without Dyna CT/AVG and Cohort B with Dyna CT/AVG. Success of implantation
Conclusion: A collaborative, standardised, system of pre-hospital notification by QAS facilitates achievement of guideline-mandated times for STEMI patients in southeast Queensland. http://dx.doi.org/10.1016/j.hlc.2012.05.440
ABSTRACTS
Heart, Lung and Circulation 2012;21:S143–S316
S178
Abstracts CSANZ 2012 Abstracts
Heart, Lung and Circulation 2012;21:S143–S316
ABSTRACTS
Table 1. . Cohort A Contrast use (mL) Fluoroscopy time (min) Number of aortograms Acquisition number
282 27 1.9 23
± ± ± ±
99 10 1 12
Cohort B 245 19 1 11
± ± ± ±
p Value
83 7 0 5
<0.05 <0.05 <0.05 <0.05
Table 1. Aortic Annular Dimensions Based on the Cardiac Cycle. CT Annular Measurement Short diameter (mm) Long diameter (mm) Mean diameter (mm) Area (cm2 ) Circumference (mm) Eccentricitya a
Systole 20.8 26.6 23.6 4.7 78.5 21.3
± ± ± ± ± ±
2.24 2.84 2.3 0.8 8.2 8.0
Diastole 20.2 26.2 23.2 4.5 77.2 22.3
± ± ± ± ± ±
p Value
1.99 2.90 2.2 0.9 8.0 7.4
0.01 0.22 0.03 <0.01 0.01 0.28
1-Short diameter/long diameter.
was defined by prosthesis perpendicularity to the annular plane and by strut overlap and was given three predefined grades – excellent, satisfactory and poor. Contrast use, number of aortograms, fluoroscopy time and number of acquisition runs were also compared. Results: Cohort A comprised 23 CoreValve implants and Cohort B 13 CoreValve and 17 Edwards Sapien valves. Cohort A had 9 excellent, 12 satisfactory and 2 poor implants. This was statistically inferior to Cohort B which had 25 excellent, 5 satisfactory and 0 poor implants (p < 0.05). Table 1 summarises the comparison in mean contrast use and radiation exposure (expressed as mean ± 1 SD). Conclusion: Dyna CT and AVG software improved prosthesis placement yet also reduced contrast use and radiation exposure.
A. Willson ∗ , J. Webb, M. Freeman, R. Toggweiler, R. Binder, D. Wood, J. Leipsic
http://dx.doi.org/10.1016/j.hlc.2012.05.442
St Pauls Hospital, Vancouver, British Columbia, Canada
432
Background: Computed tomography (CT) provides three dimensional measurement of the aortic annulus which can be used for valve sizing in transcatheter aortic valve replacement (TAVR). Methods: 120 patients underwent CT prior to TAVR with a balloon expandable aortic valve. Valve sizing was by TEE annular diameter and clinical features. A theoretical CT based valve size was retrospectively determined by ensuring the nominal external valve area is greater than the CT annular area. The impact of CT sizing on valve selection and grade of paravalvular regurgitation by transthoracic echocardiography was assessed. Results: The mean aortic annular measurements were: TEE annular diameter 22.4 ± 1.8 mm, CT annular area 4.5 ± 0.9 cm2 and mean CT annular diameter 23.4 ± 2.3 mm. Using traditional TEE sizing the THV was undersized (external area of a fully expanded valve < CT annular area) in 33.3% (40/120). By using CT sizing criteria there was a trend towards using larger valves (Table 1). Eighty-five percent (34/40) of patients where CT suggested using a larger valve had mild or moderate paravalvular regurgitation (Table 1).
The Impact of the Cardiac Cycle on Aortic Annular Dimensions as Measured by Computed Tomography (CT) and the Implications for CT Sizing Criteria in Transcatheter Aortic Valve Replacement A. Willson ∗ , J. Webb, R. Gurvitch, M. Toggweiler, R. Binder, D. Wood, J. Leipsic
Freeman, S.
St Pauls Hospital, Vancouver, British Columbia, Canada Background: The affect of the cardiac cycle on aortic annular dimensions is poorly defined and is important for the development of CT sizing guidelines in transcatheter aortic valve replacement (TAVR). Methods: Systolic and diastolic CT derived aortic annular measurements (short diameter, long diameter, mean diameter, area and circumference) were recorded in 66 patients who underwent TAVR. A theoretical CT sizing chart was developed where the balloon expandable valve selected must have a nominal external area greater than the CT annular area. The impact of using systolic or diastolic annular measurements on CT based valve selection was assessed. Results: Mean annular diameter, area and circumference were on average significantly larger in systole than diastole (Table 1). There was no difference in annular eccentricity. Compared with systole, using diastolic measurements for CT sizing resulted in 20% (13/66) of patients receiving a smaller valve. Among these patients, the mean difference in annular area between systole and diastole was 0.87 ± 0.52 cm2 compared to 0.06 ± 0.6 cm2 (p < 0.001) for those patients whose valve size did not change between the cardiac cycle.
Conclusions: The aortic annulus is larger in systole than diastole. Systolic CT annular measurements should be used for CT sizing guidelines in TAVR. http://dx.doi.org/10.1016/j.hlc.2012.05.443 433 The Implications of CT Sizing on Valve Selection and Paravalvular Regurgitation in Transcatheter Aortic Valve Replacement Gurvitch, S.
Table 1. The Effect of Using CT Sizing Guidelinesa on Valve Selection Compared to TEE. Change in Valve size Downsize by 1 No change Upsize by 1 Total a
N (%)
Paravalvular Regurgitation Grade None/trivial N (%)
13 (10.8) 67 (55.8) 40 (33.3) 120
Mild
Moderate
Severe
10 (76.9) 37 (55.2) 6 (15.0)
2 (15.4) 0 (0) 26 (38.8) 3 (4.5) 24 (60.0) 10 (25.0)
0 0 0
53 (44.2%)
52 (43.3) 13 (10.8)
0
External area of a fully expanded valve > CT annular area.