1 Introduction

3D rotational angiography (3DRA) is an evolving technique that delivers computed tomographic imaging at the heart catheterization suite. A 180 º rotation of the frontal plane during an interval of 4–7 s produces a rotational angiography (RA) when contrast is injected simultaneously with vendor-specific differences in the post processing.

Fig. 38.1
figure 1

3DRA workflow

Full size image
Fig. 38.2
figure 2

3DRA acquisition

Full size image
Fig. 38.3
figure 3

3DRA: Fusion with previous CTA

Full size image
Fig. 38.4
figure 4

Case 1: Coarctation stenting

Full size image
Fig. 38.5
figure 5

Case 2: CoA dissection

Full size image
Fig. 38.6
figure 6

Case 3: Bifurcation stenosis

Full size image
Fig. 38.7
figure 7

Case 4: Sano shunt stenosis. HLHS, Norwood I, 5 mm Sano shunt. 3 days post-op: oxygen saturation 50–60%

Full size image
Fig. 38.8
figure 8

Case 4: Sano shunt stenosis. 3D visualizing of entire anatomy and guidance of stent implantation

Full size image
Fig. 38.9
figure 9

Case 5: LPA stenosis in TCPC. 3D visualizing of entire anatomy and guidance of airway interrogation

Full size image
Fig. 38.10
figure 10

Case 6: PPVI “entire heart protocol”

Full size image
Fig. 38.11
figure 11

Case 6: PPVI “interrogation protocol”

Full size image
Fig. 38.12
figure 12

Case 6: PPVI based on 3DRA

Full size image
Fig. 38.13
figure 13

Case 7: 3DRA in complex PPVI

Full size image
Fig. 38.14
figure 14

Case 8: Complex PA VSD. A 3-year-old child with PA VSD after Melbourne shunt, unifocalization, multiple stent interventions, and implantation of Contegra valve during correction, severe distal MPA, and bifurcation stenosis post surgery

Full size image
Fig. 38.15
figure 15

3DRA conclusion

Full size image

2 Rotational Angiography

In a historic publication, Professor Schad/Stuttgart (Schad 1964–1966) demonstrated the value of rotational angiographies in congenital heart disease with the patient being fixed in a cradle and moved around the static C-arm. It took 40 years until complex algorithm (Kehl/Vogt, Frauenhofer 1999) allowed for computed conversion of the single rotational frames into stacks known from CTA or MRA.

3 Status Quo of 3DRA

The current systems use integrated workstations to automatically calculate and 3D reconstruct the scanned tissue within 10–20 s after rotation. The principle of contrast distribution in 3DRA is different from conventional angiography (CA) with a complex workflow including optional rapid pacing (Fig. 38.1), breath holding, and injection of diluted contrast simultaneously at multiple locations during 5–7 s. Post processing of the 3DRA dicom data is similar to CTA or MRA and allows for scissoring to hide irrelevant structures, threshold adaptation to visualize a specific range of Hounsfield units, use clipping planes and MIP views to measure, and virtually fly through anatomic structures. Projection of the post-processed 3D image to the CA screen enables for road mapping to guide complex procedures without the need for sequential localizing angiographies. Typical indications for 3DRA are aortic arch (AoS) stenosis, pulmonary artery or vein stenosis (PAS, PVS), interventions in pulmonary atresia (PA VSD), pulmonary valve implantation (PPVI), and interventions in single ventricle (SV) stages I–III.

4 Multimodality

Previous CTA, MRA of 3DRA dicom data can be imported – the so-called merge or fusion – to generate overlay visualization and sometimes can substitute a 3DRA. Anatomical annotation of those data is based on bone structures.

5 Benefit of 3DRA

3DRA offers the ability to understand the entire anatomy in unrestricted angulations, thus delineating substrates not or hardly visible by CA. As with all kinds of new techniques, the benefit of 3DRA strongly depends on the user’s confidence and trust in the resulting images. A validated algorithm is essential covering contrast dilution and amount, injection locations, and timing as well as optimization of the systems radiation parameters. In an optimal setting, an “all in one run” scan can be performed with 0.5 mSv and a contrast amount equal to two CAs. In complex bi- and univentricular hearts, it will deliver information of the entire topography allowing for a safer procedure with less radiation and contrast compared to CA. Visualization of vessel-vessel as well as vessel-airway interaction will promote to defocus from the original target of the intervention and widen the horizon by identifying potential interactions to prevent complications. The following figures cover the workflow in general as well as its case-related adaptations in AoS, PAS, PVS, PA VSD, PPVI, and SV I–III.

The images demonstrated are derived from a Siemens’ syngo DynaCT with a biplane Artis zee system. The results reflect a 6-year period of use in congenital heart disease with use of 3DRA in 70% of all interventions. Toshiba, Philips, and GE offer comparable equipment.

In conclusion 3DRA is a tool available during catheter interventions which enables to visualize all intrathoracic structures and their interactions. It helps to guide complex interventions, reduce radiation and enhance safety. Improvements of the available 3DRA systems are necessary in terms of post processing, 3D roadmapping with biplane projection and automized correction for anatomic shift (Fig. 38.15).