Name: Anatomical Reconstructions of the Human Cardiac Venous System using Contrast-computed Tomography of Perfusion-fixed Specimens (Video) | JoVE Journal
Uploaded: 2013-04-18T09:00:00.000+00:00
Duration: 6 min 2 s
Description: Learn to generate 3D models of the human cardiac venous system using contrast CT scans of perfusion-fixed heart specimens. This method enables precise anatomical measurements for cardiac device design without patient exposure to radiation or contrast agents.

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5 minutes

We would like to acknowledge Dionna Gamble, Allison Larson, and Katia Torres for assistance with model generation and measurements, Monica Mahre for manuscript assistance, Gary Williams for technical assistance, Jerrald Spencer Jr. for assistance with the figures and the Fairview Imaging Services at the University of Minnesota. 
Funding was received from the Institute for Engineering in Medicine (University of Minnesota) and in part from a research contract with Medtronic Inc.

Procedure
Table 1 summarizes the materials used during the process. Figure 1 provides an overview of the process.
1. Specimen and Scan Preparation
<ol>
	<li>Obtain the isolated human hearts fresh and subsequently perfusion fix them in 10% buffered formalin in their end-diastolic state.</li>
	<li>Rinse the hearts to be scanned in water the day before scanning in order to remove the majority of the formalin.</li>
	<li>Before heading to the scanner, cannulate the coronary sinus (CS) vein within each heart with a venogram balloon catheter. Obtain access to the CS through either the superior or inferior vena cava under direct visualization or the use of videoscopes.</li>
	<li>Once in place, inflate the balloon of this venogram catheter to anchor the catheter in the CS.</li>
	<li>Place each heart within a sealable polymer container on top of a sponge that has been designed so that the heart can sit in its attitudinally correct anatomical position.</li>
</ol>
2. Computed Tomography Scans
<ol>
	<li>Position a given heart on the CT scanner bed as if a patient was lying supine and head first on the scanner.</li>
	<li>Connect the proximal end of the venogram catheter to an injector that contains two injection syringes: one for contrast and one for saline.</li>
	<li>Automatically inject 40 ml of contrast into the cardiac venous system at 5 ml/sec.</li>
	<li>CT scan the heart 8 sec after the contrast injection is initiated. Set the CT scan to 512 x 512 pixel resolution with 0.6 mm slice thickness.</li>
	<li>Automatically inject 40 ml of saline into the cardiac venous system at 5 ml/sec to flush out the contrast.</li>
	<li>Export the CT dicom images onto an external hard drive.</li>
</ol>
3. Reconstruction and Measurements
<ol>
	<li>Upload CT dicom images into Mimics Software.</li>
	<li>Generate a mask for the CT images that only contains pixels with high Hounsfield units to highlight only the contrast present in the heart.</li>
	<li>Remove contrast that has leaked into the chambers or diffused into the tissue so that the mask only contains the contrast within the major cardiac veins.</li>
	<li>Manually fill in air pockets within a given vein frame by frame.</li>
	<li>Generate a 3D object from the resultant mask.</li>
	<li>Smooth and wrap this object to eliminate rough geometries. Video 1 presents one of these 3D models rotating in space.</li>
	<li>Generate centerlines for each created 3D model.</li>
	<li>Using these centerlines, measure the arc length, branching angle, tortuousity (arc length/linear distance), and diameters for each major vessel in each heart. Our employed anatomical nomenclature is displayed in Figure 2.</li>
</ol>

<ol><li>Burkhardt, J. D., Wilkoff, B. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Interventional+electrophysiology+and+cardiac+resynchronization+therapy%3A+delivering+electrical+therapies+for+heart+failure%5BTitle%5D)+AND+%22Circ%22%5BJournal%5D)">Interventional electrophysiology and cardiac resynchronization therapy: delivering electrical therapies for heart failure.</a> Circ. 115, 2208-2220 (2007).</li>
<li>Lu, F. Cardiac resynchronization therapy. <a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=author%3aLu%2C+F+%22Handbook+of+cardiac+physiology+and+anatomy%22">Handbook of cardiac physiology and anatomy</a>. Iaizzo, P. , 2nd ed, Springer Science. New York, N.Y. 475-497 (2009).</li>
<li>Eggen, M. D., Swingen, C. M., Iaizzo, P. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Ex+vivo+diffusion+tensor+MRI+of+human+hearts%3A+relative+effects+of+specimen+decomposition%5BTitle%5D)+AND+%22Magn.+Reson.+Med%22%5BJournal%5D)">Ex vivo diffusion tensor MRI of human hearts: relative effects of specimen decomposition.</a> Magn. Reson. Med. 67, 1703-1709 (2012).</li>
<li>Manzke, R., Binner, L., Bornstedt, A., Merkle, N., Lutz, A., Gradinger, R., Rasche, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Assessment+of+the+coronary+venous+system+in+heart+failure+patients+by+blood+pool+agent+enhanced+whole-heart+MRI%5BTitle%5D)+AND+%22Eur.+Radiol%22%5BJournal%5D)">Assessment of the coronary venous system in heart failure patients by blood pool agent enhanced whole-heart MRI.</a> Eur. Radiol. 21, 799-806 (2010).</li>
<li>Abbara, S., Cury, R. C., Nieman, K., Reddy, V., Moselewski, F., Schmidt, S., Ferencik, M., Hoffman, U., Brady, T. J., Achenbach, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Noninvasive+evaluation+of+cardiac+veins+with+16-MDCT+angiography%5BTitle%5D)+AND+%22AJR.+Am.+J.+Roentgenol%22%5BJournal%5D)">Noninvasive evaluation of cardiac veins with 16-MDCT angiography.</a> AJR. Am. J. Roentgenol. 185, 1001-1006 (2005).</li>
<li>Gerber, T. C., Sheedy, P. F., Bell, M. R., Hayes, D. L., Rumberger, J. A., Behrenbeck, T., Holmes, D. R., Schwartz, R. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Evaluation+of+the+coronary+venous+system+using+electron+beam+computed+tomography%5BTitle%5D)+AND+%22Int.+J.+Cardiovasc.+Imaging%22%5BJournal%5D)">Evaluation of the coronary venous system using electron beam computed tomography.</a> Int. J. Cardiovasc. Imaging. 17, 65-75 (2001).</li>
<li>Jongbloed, M. R. M., Lamb, H. J., Bax, J. J., Schuijf, J. D., de Roos, A., vander Wall, E. E., Schalij, M. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Noninvasive+visualization+of+the+cardiac+venous+system+using+multislice+computed+tomography%5BTitle%5D)+AND+%22J.+Am.+Coll.+Cardiol%22%5BJournal%5D)">Noninvasive visualization of the cardiac venous system using multislice computed tomography.</a> J. Am. Coll. Cardiol. 45, 749-753 (2005).</li>
<li>Mao, S., Shinbane, J. S., Girky, M. J., Child, J., Carson, S., Oudiz, R. J., Budoff, M. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Coronary+venous+imaging+with+electron+beam+computed+tomographic+angiography%3A+three-dimensional+mapping+and+relationship+with+coronary+arteries%5BTitle%5D)+AND+%22Am.+Heart+J%22%5BJournal%5D)">Coronary venous imaging with electron beam computed tomographic angiography: three-dimensional mapping and relationship with coronary arteries.</a> Am. Heart J. 150, 315-322 (2005).</li>
<li>Muhlenbruch, G., Koos, R., Wildberger, J. E., Gunther, R. W., Mahnken, A. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Imaging+of+the+cardiac+venous+system%3A+comparison+of+MDCT+and+conventional+angiography%5BTitle%5D)+AND+%22AJR.+Am.+J.+Roentgenol%22%5BJournal%5D)">Imaging of the cardiac venous system: comparison of MDCT and conventional angiography.</a> AJR. Am. J. Roentgenol. 185, 1252-1257 (2005).</li>
<li>Schaffler, G. J., Groell, R., Peichel, K. H., Rienmuller, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Imaging+the+coronary+venous+drainage+system+using+electron-beam+CT%5BTitle%5D)+AND+%22Surg.+Radiol.+Anat%22%5BJournal%5D)">Imaging the coronary venous drainage system using electron-beam CT.</a> Surg. Radiol. Anat. 22, 35-39 (2000).</li>
<li>Tada, H., Kurosaki, K., Naito, S., Koyama, K., Itoi, K., Ito, S., Ueda, M., Shinbo, G., Hoshizaki, H., Nogami, A., Oshima, S., Taniguchi, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Three-dimensional+visualization+of+the+coronary+venous+system+using+multidetector+row+computed+tomography%5BTitle%5D)+AND+%22Circ.+J%22%5BJournal%5D)">Three-dimensional visualization of the coronary venous system using multidetector row computed tomography.</a> Circ. J. 69, 165-170 (2005).</li>
<li>Van de Veire, N. R., Schuijf, J. D., Sutter, J. D., Devos, D., Bleeker, G. B., de Roos, A., vander Wall, E. E., Schalij, M. J., Bax, J. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Non-invasive+visualization+of+the+cardiac+venous+system+in+coronary+artery+disease+patients+using+64-slice+computed+tomography%5BTitle%5D)+AND+%22J.+Am.+Coll.+Cardiol%22%5BJournal%5D)">Non-invasive visualization of the cardiac venous system in coronary artery disease patients using 64-slice computed tomography.</a> J. Am. Coll. Cardiol. 48, 1832-1838 (2006).</li>
<li>de Jong, P. A., Mayo, J. R., Golmohammadi, K., Nakano, Y., Lequin, M. H., Tiddens, H. A., Aldrich, J., Coxson, H. O., Sin, D. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Estimation+of+cancer+mortality+associated+with+repetitive+computed+tomography+scanning%5BTitle%5D)+AND+%22Am.+J.+Respir.+Crit.+Care+Med%22%5BJournal%5D)">Estimation of cancer mortality associated with repetitive computed tomography scanning.</a> Am. J. Respir. Crit. Care Med. 173, 199-203 (2006).</li>
<li>Martin, D. R., Semelka, R. C., Chapman, A., Peters, H., Finn, P. J., Kalb, B., Thomsen, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Nephrogenic+systemic+fibrosis+versus+contrast-induced+nephropathy%3A+risks+and+benefits+of+contrast-enhanced+MR+and+CT+in+renally+impaired+patients%5BTitle%5D)+AND+%22J.+Magn.+Reson.+Imaging%22%5BJournal%5D)">Nephrogenic systemic fibrosis versus contrast-induced nephropathy: risks and benefits of contrast-enhanced MR and CT in renally impaired patients.</a> J. Magn. Reson. Imaging. 30, 1350-1356 (2009).</li>
</ol>

No conflicts of interest declared.

Our laboratory is developing a library of perfusion-fixed heart specimens for various anatomical research studies. To date, we have over 240 preserved specimens. The specific methods we have used to prepare these specimens have been previously described3. The present study describes a novel methodology for mapping the human cardiac venous system and for the development of an anatomical database, which could be used for the design of cardiac devices employed within the vessels.
	<p class="jove_content...

anatomical reconstructions of the human cardiac venous system using contrast-computed tomography of perfusion-fixed specimens

Anatomical Reconstructions of the Human Cardiac Venous System using Contrast-computed Tomography of Perfusion-fixed Specimens

A detailed understanding of the complexity and relative variability within the human cardiac venous system is crucial for the development of cardiac devices that require access to these vessels. For example, cardiac venous anatomy is known to be one of the key limitations for the proper delivery of cardiac resynchronization therapy (CRT)1 Therefore, the development of a database of anatomical parameters for human cardiac venous systems can aid in the design of CRT delivery devices to overcome such a limitation. In this research project, the anatomical parameters were obtained from 3D reconstructions of the venous system using contrast-computed tomography (CT) imaging and modeling software (Materialise, Leuven, Belgium). The following parameters were assessed for each vein: arc length, tortuousity, branching angle, distance to the coronary sinus ostium, and vessel diameter.
	CRT is a potential treatment for patients with electromechanical dyssynchrony. Approximately 10-20% of heart failure patients may benefit from CRT2. Electromechanical dyssynchrony implies that parts of the myocardium activate and contract earlier or later than the normal conduction pathway of the heart. In CRT, dyssynchronous areas of the myocardium are treated with electrical stimulation. CRT pacing typically involves pacing leads that stimulate the right atrium (RA), right ventricle (RV), and left ventricle (LV) to produce more resynchronized rhythms. The LV lead is typically implanted within a cardiac vein, with the aim to overlay it within the site of latest myocardial activation. 
	We believe that the models obtained and the analyses thereof will promote the anatomical education for patients, students, clinicians, and medical device designers. The methodologies employed here can also be utilized to study other anatomical features of our human heart specimens, such as the coronary arteries. To further encourage the educational value of this research, we have shared the venous models on our free access website: <a href="http://www.vhlab.umn.edu/atlas" target="_blank">www.vhlab.umn.edu/atlas</a>.

Table 2 presents the median anatomical parameters for the major cardiac veins for 42 human heart specimens. All heart specimens contained one posterior interventricular vein (PIV) and anterior interventricular vein (AIV). Some specimens contained more than one posterior vein of the LV (PVLV), postero-lateral vein (PLV), left lateral vein (LLV), and/or antero-lateral vein (ALV), while other hearts may not have had one or two of these specific veins present.
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The objective of this research is to recreate and then access the anatomy of the human cardiac venous system using 3D reconstructions generated from contrast-computed tomography scans.

A detailed  understanding of the complexity and relative variability within the human  cardiac venous system is crucial for the development of cardiac ...

The overall goal of this procedure is to generate 3D models of the human cardiac venous system for the development of an anatomical database that can be used for the design of cardiac devices employed within these vessels. This is accomplished by first preparing the human heart specimen by fixing it in its end diastolic state and cannulating the coronary sinus with a venogram balloon catheter. In the second step, contrast, CT images of the cardiac venous system are obtained during the final step.3D models are generated from the CT scans from which various anatomical measurements can be obtained. One of the main advantages of our technique over other methods, such as the in vivo assessment of cardiac venous anatomy, is that there are no exposure to a patient to contrast agents or radiation. We first had the idea for this method when we were originally mapping the cardiac venous system of these profusion fixed hearts using a micro scribe on the epicardial surface.However, this method had some limitations. It was limited by the amount of adipose tissue as well as it generated 2D models. The use of contrast cts for model generation overcomes these limitations As soon as they're obtained.Perfusion fix the freshly isolated human hearts in their end diastolic state in 10%buffered formin. Then on the day before scanning, rinse the hearts in water in order to remove the majority of the formin before heading to the scanner. Use a venogram balloon catheter to cannulate the coronary sinus vein within each heart through the inferior vena cava.Under direct visualization. Once in place inflate the balloon of the venogram catheter to anchor the catheter in the coronary sinus. Now, place each heart within a sealable polymer container on top of a sponge designed to support the heart in its attitudinally correct anatomical position.Begin by positioning the heart on the CT scanner bed as if a patient was lying supine and headfirst on the scanner. Then connect the proximal end of the venogram catheter to an injector that contains two injection syringes. One for contrast and one for saline.Now automatically inject 40 milliliters of contrast into the cardiac venous system at five milliliters per second. Eight seconds after the contrast injection is initiated CT scan the heart setting, scan to 512 by 512 pixel resolution with 0.6 millimeter slice thickness. Then flush out the contrast by automatically injecting 40 more milliliters of saline into the cardiac venous system.At five milliliters per second, export the CT DICOM images onto an external hard drive. Now upload the CT DICOM images into mimic software and generate a mask for the CT images that only contains pixels with high hounds field units. To highlight only the contrast present in the heart, remove any contrast that has leaked into the chambers or diffused into the tissue so that the mask only contains the contrast within the major cardiac veins.Then manually fill in the air pockets within a given vein frame by frame, and generate a 3D object from the resultant mask. Next smooth and wrap the mask to eliminate any rough geometries, and then generate center lines for each created 3D model. In order to minimize user variability in the generation of the 3D models, it's important that the user carefully follows the detailed protocol as well as has an observer check the model before generating the center lines.Finally, use the center lines to measure the arc length branching angle, tortuosity and diameters for each major vessel in each heart. In this table, the median anatomical parameters for the major cardiac veins for 42 human heart specimens are presented. All the heart specimens contained one middle cardiac vein and one anterior interventricular vein.Some specimens contained more than one inferior vein, inferior lateral vein, lateral vein, and or anterolateral vein. While other hearts may not have had one or two of these specific veins present in this movie, a representative 3D model can be observed rotating in space. Follow this procedure, one of the advantages is that you can use visualization with video scopes within the cardiac veins to assess the anatomy, validate the CT models, and also determine where various structures such as cardiac veins exist, which you can't see on CT After its development.This technique allows researchers in the field of biomedical engineering to explore the cardiac venous system and the development of cardiac devices that utilize these vessels. Ultimately, modeling and mapping of the human cardiac venous system will provide novel insights into the relevant anatomy to perform various clinical procedures.

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Learn to generate 3D models of the human cardiac venous system using contrast CT scans of perfusion-fixed heart specimens. This method enables precise anatomical measurements for cardiac device design without patient exposure to radiation or contrast agents.

Anatomical Reconstructions of the Human Cardiac Venous System using Contrast-computed Tomography of Perfusion-fixed Specimens

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