KEYWORDS: 3D image processing, Detection and tracking algorithms, 3D acquisition, Fluoroscopy, Reconstruction algorithms, X-rays, X-ray imaging, 3D modeling, Visualization, 3D image reconstruction
Minimally invasive catheter ablation procedures are guided by biplane fluoroscopy images visualising the interventional
scene from two different orientations. However, these images do not provide direct access to their
inherent spatial information. A three-dimensional reconstruction and visualisation of the catheters from such
projections has the potential to support quick and precise catheter navigation. It enhances the perception of
the interventional situation and provides means of three-dimensional catheter pose documentation. In this contribution
we develop an algorithm for tracking the three-dimensional pose of electro-physiological catheters in
biplane fluoroscopy images. It is based on the B-Snake algorithm which had to be adapted to the biplane and
in particular the asynchronous image acquisition situation. A three-dimensional B-spline curve is transformed
so that its projections are consistent with the catheter path enhancing feature images, while the information
from the missing image caused by the asynchronous acquisition is interpolated from its sequence neighbours. In
order to analyse the three-dimensional precision, virtual images were created from patient data sets and threedimensional
ground truth catheter paths. The evaluation of the three-dimensional catheter pose reconstruction
by means of our algorithm on 33 of such virtual image sets indicated a mean catheter pose error of 1.26 mm and
a mean tip deviation of 3.28 mm. The tracking capability of the algorithm was evaluated on 10 patient data
sets. In 94 % of all images our algorithm followed the catheter projections.
Various multi-center trials have shown that cardiac resynchronization therapy (CRT) is an effective procedure
for patients with end-stage drug invariable heart failure (HF). Despite the encouraging results of CRT, at least
30% of patients do not respond to the treatment. Detailed knowledge of the cardiac anatomy (coronary
venous tree, left ventricle), functional parameters (i.e. ventricular synchronicity) is supposed to improve
CRT patient selection and interventional lead placement for reduction of the number of non-responders.
As a pre-interventional imaging modality, cardiac magnetic resonance (CMR) imaging has the potential
to provide all relevant information. With functional information from CMR optimal implantation target
sites may be better identified. Pre-operative CMR could also help to determine whether useful vein target
segments are available for lead placement. Fused with X-ray, the mainstay interventional modality, improved
interventional guidance for lead-placement could further help to increase procedure outcome.
In this contribution, we present novel and practicable methods for a) pre-operative functional and anatomical
imaging of relevant cardiac structures to CRT using CMR, b) 2D-3D registration of CMR anatomy and
functional meshes with X-ray vein angiograms and c) real-time capable breathing motion compensation for
improved fluoroscopy mesh overlay during the intervention based on right ventricular pacer lead tracking.
With these methods, enhanced interventional guidance for left ventricular lead placement is provided.
Automatic segmentation is a prerequisite to efficiently analyze the large amount of image data produced by modern imaging
modalities, e.g., computed tomography (CT), magnetic resonance (MR) and rotational X-ray volume imaging. While many
segmentation approaches exist, most of them are developed for a single, specific imaging modality and a single organ. In
clinical practice, however, it is becoming increasingly important to handle multiple modalities: First due to a case-specific
choice of the most suitable imaging modality (e.g. CT versus MR), and second in order to integrate complementary data
from multiple modalities. In this paper, we present a single, integrated segmentation framework which can easily be
adapted to a range of imaging modalities and organs. Our algorithm is based on shape-constrained deformable models. Key
elements are (1) a shape model representing the geometry and variability of the target organ of interest, (2) spatially varying
boundary detection functions representing the gray value appearance of the organ boundaries for the specific imaging
modality or protocol, and (3) a multi-stage segmentation approach. Focussing on fully automatic heart segmentation, we
present evaluation results for CT,MR (contrast enhanced and non-contrasted), and rotational X-ray angiography (3-D RA).
We achieved a mean segmentation error of about 0.8mm for CT and (non-contrasted) MR, 1.0mm for contrast-enhanced
MR and 1.3mm for 3-D RA, demonstrating the success of our segmentation framework across modalities.
Imaging techniques try to identify patients who may respond to cardiac resynchronization therapy (CRT). However, it
may be clinically more useful to identify patients for whom CRT would not be beneficial as the procedure would not be
indicated for this group. We developed a novel, clinically feasible and technically-simple echocardiographic
dyssynchrony index and tested its negative predictive value. Subjects with standard indications for CRT had echo preand
post-device implantation. Atrial-ventricular dyssynchrony was defined as a left ventricular (LV) filling time of
<40% of the cardiac cycle. Intra-ventricular dyssynchrony was quantified as the magnitude of LV apical rocking. The
apical rocking was measured using tissue displacement estimates from echo data. In a 4-chamber view, a region of
interest was positioned within the apical end of the middle segment within each wall. Tissue displacement curves were
analyzed with custom software in MATLAB. Rocking was quantified as a percentage of the cardiac cycle over which the
displacement curves showed discordant behavior and classified as non-significant for values <35%. Validation in 50
patients showed that absence of significant LV apical rocking or atrial-ventricular dyssynchrony was associated with
non-response to CRT. This measure may therefore be useful in screening to avoid non-therapeutic CRT procedures.
Knowledge of patient-specific cardiac anatomy is required for catheter-based ablation in epicardial ablation
procedures such as ventricular tachycardia (VT) ablation interventions. In particular, knowledge of
critical structures such as the coronary arteries is essential to avoid collateral damage. In such ablation
procedures, ablation catheters are brought in via minimally-invasive subxiphoid access. The catheter is
then steered to ablation target sites on the left ventricle (LV). During the ablation and catheter navigation
it is of vital importance to avoid damage of coronary structures. Contrast-enhanced rotational X-ray
angiography of the coronary arteries delivers a 3D impression of the anatomy during the time of intervention.
Vessel modeling techniques have been shown to be able to deliver accurate 3D anatomical models
of the coronary arteries. To simplify epicardial navigation and ablation, we propose to overlay coronary
arterial models, derived from rotational X-ray angiography and vessel modeling, onto real-time X-ray
fluoroscopy. In a preclinical animal study, we show that overlay of intra-operatively acquired 3D arterial
models onto X-ray helps to place ablation lesions at a safe distance from coronary structures. Example
ablation lesions have been placed based on the model overlay at reasonable distances between key arterial
vessels and on top of marginal branches.
We present and validate image-based speckle-tracking calipers for quantification of tissue deformation and rotation
in dynamic cardiovascular phantom models. Lagrangian strain was computed from the change in distance
between caliper regions-of-interest (ROIs) positioned within the wall of a pulsatile phantom and compared with
reference measurements derived from cardiac CT imaging. In a torsion phantom, rotational tissue excursion
in a 2D plane was estimated and compared with reference values from CT-scan data. Tissue deformation and
rotation measurements correlated well with their respective reference measurements. Our algorithm is capable
of estimating strain and rotation from distinct tissue regions without requiring explicit cardiac border detection,
a step which can be especially challenging in patients with poor acoustic windows.
Interventional cardiac electrophysiology (EP) procedures are typically performed under X-ray fluoroscopy for
visualizing catheters and EP devices relative to other highly-attenuating structures such as the thoracic spine
and ribs. These projections do not however contain information about soft-tissue anatomy and there is a
recognized need for fusion of conventional fluoroscopy with pre-operatively acquired cardiac multislice computed
tomography (MSCT) volumes. Rapid 2D-3D integration in this application would allow for real-time visualization
of all catheters present within the thorax in relation to the cardiovascular anatomy visible in MSCT. We present a
method for rapid fusion of 2D X-ray fluoroscopy with 3DMSCT that can facilitate EP mapping and interventional
procedures by reducing the need for intra-operative contrast injections to visualize heart chambers and specialized
systems to track catheters within the cardiovascular anatomy. We use hardware-accelerated ray-casting to
compute digitally reconstructed radiographs (DRRs) from the MSCT volume and iteratively optimize the rigid-body
pose of the volumetric data to maximize the similarity between the MSCT-derived DRR and the intra-operative
X-ray projection data.
KEYWORDS: Image segmentation, Heart, Atrial fibrillation, Data modeling, Magnetic resonance imaging, 3D modeling, X-ray imaging, Veins, Data acquisition, 3D acquisition
Catheter-based ablation in the left atrium and pulmonary veins (LAPV) for treatment of atrial fibrillation
in cardiac electrophysiology (EP) are complex and require knowledge of heart chamber anatomy. Electroanatomical
mapping (EAM) is typically used to define cardiac structures by combining electromagnetic
spatial catheter localization with surface models which interpolate the anatomy between EAM point locations
in 3D. Recently, the incorporation of pre-operative volumetric CT or MR data sets has allowed for more detailed
maps of LAPV anatomy to be used intra-operatively. Preoperative data sets are however a rough guide
since they can be acquired several days to weeks prior to EP intervention. Due to positional and physiological
changes, the intra-operative cardiac anatomy can be different from that depicted in the pre-operative data.
We present an application of contrast-enhanced rotational X-ray imaging for CT-like reconstruction of 3D
LAPV anatomy during the intervention itself. Depending on the heart size a single or two selective contrastenhanced
rotational acquisitions are performed and CT-like volumes are reconstructed with 3D filtered back
projection. In case of dual injection, the two volumes depicting the left and right portions of the LAPV are
registered and fused. The data sets are visualized and segmented intra-procedurally to provide anatomical
data and surface models for intervention guidance. Our results from animal and human experiments indicate
that the anatomical information from intra-operative CT-like reconstructions compares favorably with preacquired
imaging data and can be of sufficient quality for intra-operative guidance.
Image-guided therapy for electrophysiology applications requires integration of pre-procedural volumetric imaging
data with intra-procedural electroanatomical mapping (EAM) information. Existing methods for fusion of
EAM and imaging data are based on fiducial landmark identification or point-to-surface distance minimization
algorithms, both of which require detailed EAM mapping. This mapping procedure requires specific selection
of points on the endocardial surface and this point acquisition process is skill-dependent, time-consuming and
labor-intensive. The mapping catheter tip must first be navigated to a landmark on the endocardium, tip contact
must be verified, and finally the tip location must be explicitly annotated within the EAM data record. This
process of individual landmark identification and annotation must be repeated carefully >50 times to define
endocardial and other vascular surfaces with sufficient detail for iterated-closest-point (ICP)-based registration.
To achieve this, 30-45 minutes of mapping just for the registration procedure can be necessary before the interventional
component of the patient study begins. Any acquired EAM point location that is not in contact with
the chamber surface can adversely impact the quality of registration. Significantly faster point acquisition can be
achieved by recording catheter tip locations automatically and continuously without requiring explicit navigation
to and annotation of fiducial landmarks. We present a novel registration framework in which EAM locations
are rapidly acquired and recorded in a continuous, untriggered fashion while the electrophysiologist manipulates
the catheter tip within the heart. Results from simulation indicate that mean registration errors are on the order
of 3-4mm, comparable in magnitude to conventional registration procedures which take significantly longer to
perform. Qualitative assessment in clinical data also reflects good agreement with physician expectations.
This work presents an integrated system for multimodality image guidance of minimally invasive medical procedures.
This software and hardware system offers real-time integration and registration of multiple image streams with
localization data from navigation systems. All system components communicate over a local area Ethernet network,
enabling rapid and flexible deployment configurations. As a representative configuration, we use X-ray fluoroscopy
(XF) and ultrasound (US) imaging. The XF imaging system serves as the world coordinate system, with gantry geometry
derived from the imaging system, and patient table position tracked with a custom-built measurement device using linear
encoders. An electromagnetic (EM) tracking system is registered to the XF space using a custom imaging phantom that
is also tracked by the EM system. The RMS fiducial registration error for the EM to X-ray registration was 2.19 mm,
and the RMS target registration error measured with an EM-tracked catheter was 8.81 mm. The US image stream is
subsequently registered to the XF coordinate system using EM tracking of the probe, following a calibration of the US
image within the EM coordinate system. We present qualitative results of the system in operation, demonstrating the
integration of live ultrasound imaging spatially registered to X-ray fluoroscopy with catheter localization using
electromagnetic tracking.
A novel approach is presented which combines rotational X-ray imaging, real-time fluoroscopic X-ray imaging and real-time catheter tracking for improved guidance in interventional electrophysiology procedures. Rotational X-ray data and real-time fluoroscopy data obtained from a Philips FD10 flat detector X-ray system and are registered with real-time localization data from catheter tracking equipment. The visualization and registration of rotational X-ray data with catheter location data enables the physician to better appreciate the underlying anatomy of interest in three dimensions and to navigate the interventional or mapping device more effectively. Furthermore, the fused information streams from rotational X-ray, real-time X-ray fluoroscopy and real-time three-dimensional catheter locations offer a direct imaging feedback during interventions, facilitating navigation and potentially improving clinical outcome. With the technique one is able to reduce the fluoroscopic time required in a procedure, since the catheter is registered and visualized with off-line projection data from various view angles. We show a demonstrator which integrates, registers, and visualizes the various data streams. It can be implemented in the clinical work-flow with reasonable effort. Results are presented based on an experimental setup. Furthermore, the robustness and the accuracy of this technique have been determined based on phantom studies.
In carotid plaque imaging, MRI provides exquisite soft-tissue characterization, but lacks the temporal resolution for tissue strain imaging that real-time 3D ultrasound (3DUS) can provide. On the other hand, real-time 3DUS currently lacks the spatial resolution of carotid MRI. Non-rigid alignment of ultrasound and MRI data is essential for integrating complementary morphology and biomechanical information for carotid vascular assessment. We assessed non-rigid registration for fusion of 3DUS and MRI carotid data based on deformable models which are warped to maximize voxel similarity. We performed validation in vitro using isolated carotid artery imaging. These samples were subjected to soft-tissue deformations during 3DUS and were imaged in a static configuration with standard MR carotid pulse sequences. Registration of the source ultrasound sequences to the target MR volume was performed and the mean absolute distance between fiducials within the ultrasound and MR datasets was measured to determine inter-modality alignment quality. Our results indicate that registration errors on the order of 1mm are possible in vitro despite the low-resolution of current generation 3DUS transducers. Registration performance should be further improved with the use of higher frequency 3DUS prototypes and efforts are underway to test those probes for in vivo 3DUS carotid imaging.
With the introduction of ultra-fast cone beam scanners, cardiac CT
imaging has become feasible. In order to achieve excellent image
quality, cardiac phases must be found during which the heart is
quasi-stationary. Electrocardiogram (ECG) information does not
always correspond to the exact motion-state of the heart, and
there is high patient variability with respect to the motion
pattern. The clinician has to select stable phases manually
without an exact knowledge about the patient-specific motion.
Therefore, several high-resolution volumes corresponding to
different phases have to be reconstructed, which is an inefficient
task.
In this contribution, a simple and efficient image-based technique
is introduced which is able to deliver patient-specific stable
cardiac phases in an automatic fashion. For this purpose, a
low-resolution 4D data set is reconstructed in advance. The most
stable phases are derived from this 4D data set by calculating the
similarity between subsequent positions in the cardiac cycle.
Information about the patient-specific motion of the heart can be
determined. High-resolution reconstructions are shown at the
automatically predicted phase points corresponding to systole and
diastole. The images are superior to images reconstructed at other
phase points.
High resolution images of coronary arteries are reconstructed with the algebraic reconstruction technique (ART) applied to cone-beam CT cardiac imaging.
Due to the motion of the heart during the scan, only data belonging to the same phase of the heart cycle can be used in the reconstruction process. Currently, all known analytical image reconstruction algorithms for this problem are approximate and do not take the cone-angle fully into account.
ART models the scanner geometry exactly and does not suffer from large-cone angles, which is especially important with the current trend in CT to use detectors with more and more rows and larger cone-angles.
In this study, the influence of the cardiac weighting function on image quality is investigated.
Cardiac ART (CART) is used to reconstruct images from clinical data obtained with current 16-row CT scanners. The results are compared to an analytical reconstruction method.
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