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Antegrade Percutaneous Closure of Membranous Ventricular Septal Defect Using X-Ray Fused With Magnetic Resonance Imaging

Kanishka Ratnayaka, MD^_*,, Venkatesh K. Raman, MD, FACC^_*, Anthony Z. Faranesh, PhD^_*, Merdim Sonmez, MS^_*,,, June-Hong Kim, MD^_*, Luis F. Gutiérrez, PhD^_*, Cengizhan Ozturk, MD, PhD^_*,, Elliot R. McVeigh, PhD^_*, Michael C. Slack, MD, FACC^_*,, Robert J. Lederman, MD, FACC^_*,_*

^_* Translational Medicine Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
Cardiology Division, Children's National Medical Center, Washington, DC
Siemens Corporate Research, Princeton, New Jersey
Biomedical Engineering Institute, Bogazici University, Istanbul, Turkey

^_* Reprint requests and correspondence: Dr. Robert J. Lederman, Translational Medicine Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10, Room 2c713, MSC1538, Bethesda, Maryland 20892-1538 (Email: ledermar{at}nhlbi.nih.gov).

Objectives: We hypothesized that X-ray fused with magnetic resonance imaging (XFM) roadmaps might permit direct antegrade crossing and delivery of a ventricular septal defect (VSD) closure device and thereby reduce procedure time and radiation exposure.

Background: Percutaneous device closure of membranous VSD is cumbersome and time-consuming. The procedure requires crossing the defect retrograde, snaring and exteriorizing a guidewire to form an arteriovenous loop, then delivering antegrade a sheath and closure device.

Methods: Magnetic resonance imaging roadmaps of cardiac structures were obtained from miniature swine with spontaneous VSD and registered with live X-ray using external fiducial markers. We compared antegrade XFM-guided VSD crossing with conventional retrograde X-ray–guided crossing for repair.

Results: Antegrade XFM crossing was successful in all animals. Compared with retrograde X-ray, antegrade XFM was associated with shorter time to crossing (167 ± 103 s vs. 284 ± 61 s; p = 0.025), shorter time to sheath delivery (71 ± 32 s vs. 366 ± 145 s; p = 0.001), shorter fluoroscopy time (158 ± 95 s vs. 390 ± 137 s; p = 0.003), and reduced radiation dose–area product (2,394 ± 1,522 mG·m² vs. 4,865 ± 1,759 mG·m²; p = 0.016).

Conclusions: XFM facilitates antegrade access to membranous VSD from the right ventricle in swine. The simplified procedure is faster and reduces radiation exposure compared with the conventional retrograde approach.

Key Words: image-guided intervention • interventional magnetic resonance imaging • congenital heart disease • multimodality image fusion • heart septal defects • ventricular

Abbreviations and Acronyms   MRI = magnetic resonance imaging   SSFP = steady state free precession   XFM = X-ray fused with magnetic resonance imaging   VSD = ventricular septal defect

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