Real-Time Magnetic Resonance–Guided Aortic Valve Replacement Using Engager Valve Bogdan A. Kindzelski, BS, Ming Li, PhD, Dumitru Mazilu, PhD, Timothy.

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Real-Time Magnetic Resonance–Guided Aortic Valve Replacement Using Engager Valve Bogdan A. Kindzelski, BS, Ming Li, PhD, Dumitru Mazilu, PhD, Timothy Hunt, BS, Keith A. Horvath, MD The Annals of Thoracic Surgery Volume 98, Issue 6, Pages 2194-2199 (December 2014) DOI: 10.1016/j.athoracsur.2014.09.017 Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Picture of the Medtronic Engager Valve showing the self-expanding nitinol frame, control arm, commissural posts, and bioprosthetic leaflets composed of bovine pericardial tissue. The Annals of Thoracic Surgery 2014 98, 2194-2199DOI: (10.1016/j.athoracsur.2014.09.017) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Magnetic resonance imaging of Medtronic Engager stented bioprosthesis. (A) Single coronal slice of the stented prosthesis with good visualization of markers. (B) Different orientation of a coronal slice of the stented prosthesis with visualization of the control arm. (C) Axial slice of the stented prosthesis. The Annals of Thoracic Surgery 2014 98, 2194-2199DOI: (10.1016/j.athoracsur.2014.09.017) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Medtronic Engager delivery device modification. (A) Modified delivery device with specific modifications. (B) Assembled delivery device, as it was used for real-time cardiovascular magnetic resonance experiments. (C), (D) Magnetic resonance images of modified delivery device without any indication of ferromagnetic artifact. (PEEK = polyether ether ketone; PTFE = polytetrafluoroethylene.) The Annals of Thoracic Surgery 2014 98, 2194-2199DOI: (10.1016/j.athoracsur.2014.09.017) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Preintervention representative cardiovascular magnetic resonance snapshots. These snapshots are taken in three different planes and show the location of coronary arteries, aortic annulus, and implanted delivery device within the apex. (A) Long-axis view showing right coronary artery and delivery device. (B) Long-axis view showing left coronary artery and delivery device. (C) Short-axis view with delivery device visible. The Annals of Thoracic Surgery 2014 98, 2194-2199DOI: (10.1016/j.athoracsur.2014.09.017) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Transapical transcatheter aortic valve replacement using real-time cardiovascular magnetic resonance guidance with stepwise deployment of the Medtronic Engager valve in a (A) parasagittal and (B) axial orientation. Tip of the delivery device is clearly visible (double arrow), along with the implanted valve within the aortic annulus (asterisk). The Annals of Thoracic Surgery 2014 98, 2194-2199DOI: (10.1016/j.athoracsur.2014.09.017) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Snapshots of parasagittal and axial cardiovascular magnetic resonance after real-time cardiovascular magnetic resonance–guided transcatheter aortic valve replacement procedure, showing proper valve placement in the aortic annulus in (A) parasagittal and (D) axial views. (B, C) Parasagittal and (E, F) axial views showing phase-contrast flow demonstrate proper flow through the prosthetic valve without any evidence of intravalvular or paravalvular regurgitation. The Annals of Thoracic Surgery 2014 98, 2194-2199DOI: (10.1016/j.athoracsur.2014.09.017) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Representative first-pass perfusion scan seen in three heart slices (from apical to basal position of the heart) after the real-time cardiovascular magnetic resonance –guided transcatheter aortic valve replacement procedure. Each image row represents a different time after venous injection of gadolinium diethylenetriamine penta-acetic acid. The heart appears well perfused, indicating proper valve placement with respect to the coronary ostia. The Annals of Thoracic Surgery 2014 98, 2194-2199DOI: (10.1016/j.athoracsur.2014.09.017) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 Radiographic and macroscopic pathology of Medtronic Engager in situ. (A) Radiographic confirmation of the valve position after valve implantation. (B) Necropsy confirmation of proper valve position within the aortic annulus. The Annals of Thoracic Surgery 2014 98, 2194-2199DOI: (10.1016/j.athoracsur.2014.09.017) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions