Vitrea 2

version 4.0

CT Cardiac
EP Planning
User Guide

VPMC-8151B
 Vital Images, Inc. 2007
Protected by U.S. Patents 5,986,662; 6,130,671; 6,219,059; 7,031,504; Other Patents Pending in the U.S. and other countries.

VPMC-8151B Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

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VPMC-8151B
 Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

Table of Contents
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
HIPPA Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Licensing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Safety and Regulatory Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Caution Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Intended Use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Contact Us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
What is CT Cardiac EP Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
EP Planning Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CT Cardiac EP Planning Workflow Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Detailed CT Cardiac EP Planning Workflow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Loading a Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Selecting the Cardiac EP Planning protocol and preset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Performing an overall review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Create and export 3D models and images to the EP lab. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Edit if necessary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Performing Quantitative Measurements of the Left Atrium and Pulmonary Vein Anatomy . . . . . . . . . . . . 10
Demonstrate Esophageal Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Performing a FlyThrough review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Saving the 3D model compatible with Ensite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Creating and Saving Snapshots. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Creating Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Accessing the 3D model from the EnSite NavX System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Keyboard Shortcuts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

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 Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

Overview
The separately-licensed CT Cardiac EP Planning option for Vitrea software is a
post-processing software that facilitates faster and easier visualization of the left
atrium, pulmonary veins, and osteum.

HIPPA Compliance
Vital Images products comply with the Health Insurance Portability and
Accountability Act (HIPPA) of 1996.
It is your responsibility to comply with your organizations HIPAA policies.

Licensing
To use CT Cardiac EP Planning, you must be licensed for Cardiac Planning. The
Cardiac Planning license requires the Cardiac and Vessel Probe licenses.

Safety and Regulatory Considerations

PLEASE READ THIS SECTION CAREFULLY BEFORE USING VITREA.
The Safety and Regulatory Considerations section of the Basic Vitrea 2 User
Guide contains information that is essential for the safe, effective use of the CT
Cardiac EP Planning option. You must understand this information before using
this application.
For general Vitrea Safety and Regulatory Considerations, refer to the Safety and
Regulatory Considerations section of the Basic Vitrea 2 manual.

Caution Statements

It is essential that you read, understand, and follow the directions for Loading
a Study or Volume. Incorrect loading procedures could cause errors in image
orientation, scaling, or measurements.
You should review original DICOM slices for cross-checking. There is some
loss of detail when the data is converted to a surface representation.

Intended Use Cardiac EP Planning

Cardiac EP Planning is a post processing advanced visualization application that
is intended to be used for the analysis and assessment of the heart including the
atria, pulmonary veins, and coronary sinus. The application provides analysis
tools which include a number of display, quantitative measurement and 3D
model export capabilities for use with the St. Jude Ensite System. The

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Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

application can be used to aid trained physicians in the visualization and

assessment of cardiac anatomy.

User Guide
This manual is intended to be used by customers who have purchased the
separately-licensed CT Cardiac EP Planning option. It assumes a working
knowledge of Vitrea and familiarity with the concepts covered in the Basic
Vitrea 2 manual.

Contact Us
For general, non-technical support questions, contact us through our Web
site: www.vitalimages.com.
For customer technical support, contact us using one of the following
methods:
In the U.S., call the Customer Support line at 1.800.208.3005.
Outside the U.S., contact your Vital Images distributor.
Go to http://support.vitalimages.com/requestinfo.aspx and perform the
following steps:
a In the Destination field, select Technical Questions and Support
Issues.
b Fill out the rest of the form.
c Click Send.
Send an email to support@vitalimages.com.
To provide feedback about this document or other Vital Images product
documentation, send an email to feedback@vitalimages.com.

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 Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

What is CT Cardiac EP Planning

CT Cardiac EP Planning is an advanced post processing software to assess
anatomy of the left atrium and pulmonary veins for EP Procedure Planning. After
you complete the assessment and measurements, you can export the 3D model
to an EP navigation and mapping system (EnSite). The 3D anatomical model can
be used in planning the electrophysiology procedure or correlation with the
model generated during the procedure.

Pre-Procedure Planning
You can use EP Planning for assessing the pulmonary veins and for evaluating the
left atrium.

Post-Procedure Planning
You can also use EP Planning to diagnose complications and left atrial changes.

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Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

EP Planning Tools FIGURE 1. EP Planning Tools

TABLE 1. EP Planning Tools

Callout Description
Number
1 Clear - Click Clear to clear all vessels and segmentation.
Select - To probe an additional vessel, click Select and then
click the vessel. The vessel will be listed in the Vessel
Management list.
Extend - Click Extend and then click the vessel to extend the
highlighted vessel.
Edit - Select Edit to examine and edit the vessel centerline.
Show Vessel - Highlights the automatically selected vessels.
2 Vessel Type dropdown list - Select different types of vessels for
different algorithms associated with that vessel. The default is
Pulmonary.
3 The Vessel Management box displays the probed vessels.
Show All - Click Show All to display all probed vessels available
only when a vessel is not checked.
Rename - Click Rename to label the pulmonary veins, or double-
click the vessel in the Vessel Management that you want to
rename.
Delete - Click Delete to remove the selected vessel from the list.

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 Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

Callout Description
Number
4 LA and Pulm. Veins tab
Heart

LA and PV Only

LA and PV in Semi-Transp. Heart

Tinted LA and PV in Heart

5 Save 3D button - Select the Save 3D button to save the

anatomical model. This can be archived/exported to a CD from
the Study page.

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Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

CT Cardiac EP Planning Workflow Overview

Use CT Cardiac EP Planning to provide precise planning. For more information,
see the Detailed CT Cardiac EP Planning Workflow section.
1 Load a study
2 Select the Cardiac: EP Planning CT protocol and preset
3 Perform an overall review
Optional Create and export 3D models and images to the EP lab
4 Edit if necessary
5 Perform quantitative measurements of the left atrium and pulmonary vein
anatomy
6 Demonstrate esophageal location
7 Perform a FlyThrough review
8 Create 3D model
9 Create and save snapshots
10 Create report

Detailed CT Cardiac EP Planning Workflow

You may use the CT Cardiac EP Planning workflow steps independently or all
together.

Loading a Study To load a study:

1 From the Study Directory, open the study you want to view.
2 Select the series you want to view.
3 Select Load Volume, or right-click and select Load in Vitrea.

Selecting the Cardiac To select a protocol and preset:

EP Planning protocol 1 On the Gallery window, select the Cardiac: EP Planning CT protocol.
and preset When you select the Cardiac: EP Planning CT protocol, you will see an
approximate segmentation of the left atrium and the pulmonary veins in the
preset review windows and the segmentation progress indicated in the
progress bar.

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 Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

2 Select Pick next to the EP Planning 3D selection.

EP Planning 3D: When the Cardiac: EP Planning CT preset is selected, the

left atrium segmentation is started. After the algorithm has finished
processing, the left atrium and the pulmonary veins are displayed. The
pulmonary vein centerlines are automatically populated on the vessel
management list.
EP Planning FlyThrough PV: Select this preset to perform a FlyThrough
review.

Performing an overall To perform an overall review:

review 1 View the study in an appropriate format and perform a review.

NOTE LA and PV only is the default selection on the LA and Pulm. Veins tab.
You can also select the other options on this tab at any time.

2 Verify the automatically probed vessels are correct.

3 If you want to probe additional vessels, locate the vessel you want to probe in
2D or 3D view.
a On the Analysis tab, click Select.

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Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide
Create and export 3D
models and images to
the EP lab
Edit if necessary
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The cursor changes to a pointed finger.
b Click on the vessel to probe a vessel in the volume view, or you can probe
in the MPR planes. When probing in the volume view, the object visibility
should be set to either Heart or Tinted LA & PV in Heart.
To save data from CT Cardiac EP Planning into the St. Jude Ensite System:
Optional To save data from CT Cardiac EP Planning into the St. Jude Ensite
System, refer to Saving the 3D model compatible with Ensite on
page 14.
1 If the vessels are not probed correctly, click Edit on the Analysis tab.
2 Trim abnormal area off CPR (trimline).
3 Advance the end points in the Axial plane.
4 Deposit the new points in CPR view. Rotate in CPR view and check for
accuracy.
5 Click Edit to return to the present state.
6 If a portion of the atrium is not visible, perform the following steps:
a Check the Show seg on MPR box.
b Click Free.
c Click Include.
d Click Sculpt.
VPMC-8151B Detailed CT Cardiac EP Planning Workflow
 Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

Optional Rename the vessels.

Select Rename to label the pulmonary veins, or double-click the vessel in
the Vessel Management box that you want to rename.

NOTE The major pulmonary veins are automatically probed. They include
the Left Superior, Left Inferior, Right Superior and Right Inferior
pulmonary veins. They are given generic labels. For example, Vessel 1.

Once the veins are renamed, the new name appears in the Vessel
Management list and in the bottom right corner of the image.

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Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

Performing 1 Uncheck the Show Seg on MPR box.

Quantitative 2 Verify the Show Vessel box is checked.
Measurements of the 3 Verify LA and PV only is selected on the LA and Pulm. Veins tab.
Left Atrium and 4 Perform measurements using one of the following methods:
Pulmonary Vein Use Curved mode to perform measurements:
Anatomy
a Rotate the CPR view.
b Click Edit.

c Select the unlock button to switch it to locked to lock

the CPR and find a location of the ostium measurement.

d Right-click to open the right-click menu and select the ruler to

perform measurements.

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e Trim any incorrect contours.

Select the Oblique mode to perform manual measurements.

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Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

Demonstrate You can view the esophagus in one of the following ways:
Esophageal Location Click Heart from the LA and Pulm. Veins tab. Right-click and select

Window Level to window level the esophagus in. Verify the Show
Seg on MPR box is unchecked.

In the Axial view, trace free contours from top to bottom in the
esophagus. Click Surface from the Analysis tab. View the contour in 3D.

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 Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

Performing a You can perform a FlyThrough review using one of the following methods:
FlyThrough review
Perform FlyThrough using the EP Planning FlyThrough PV Preset:
1 From the Gallery tab, select Pick next to the EP Planning FlyThrough PV
preset.

NOTE All segmentation must be complete before performing the steps

below.
2 Locate the center of the atrium and click Crosshair.
3 Hold the Alt Point & Go key and click to the right side of the pulmonary vein
side.
4 Select the 180 key to look at the other side.
5 Use the Mouse roller or Nav Fwd key to perform a flythrough.

Perform FlyThrough using the EP Planning 3D Preset:

1 From the Gallery tab, select Pick next to the EP Planning 3D Preset.
2 Click Restore from the Analysis tab.
3 In the Axial view, scroll to the center of the atrium.

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Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

4 Select T to trim out half of the atrium.

5 Clear the Show Vessel box.

Saving the 3D model To save data from CT Cardiac EP Planning into the St. Jude Ensite System:
compatible with Ensite 1 Verify the model is complete.
If the model is not complete, perform vessel probe.

2 Select the Save 3D button . When the save is complete, a Save done
message displays at the bottom of the window.

NOTE The model is saved in the memory of the data set. If you make
adjustments and click Save 3D, it will overwrite the existing one.
a Select the Study Directory tab.

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 Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

b Highlight the series you are working in.

c Click Archive to CD/DVD.
d Verify EP files is selected.
e Insert a blank CD.
f Deliver the CD to the EP lab (physician or technologist using the EnSite
system).

Creating and Saving You save CT Cardiac EP Planning snapshots the same way you would for any other
Snapshots workflow in Vitrea.
Snapshots may be restored from the Study directory and from the Report page.
Snapshots may be restored on the same workstation or a different licensed
workstation.
For more information, see the Basic Vitrea 2 User Guide.

Creating Reports After you have generated desired images, you can create a report the same way
you would for any other study in Vitrea.
For more information, see the Basic Vitrea 2 User Guide.

Accessing the 3D model from the EnSite NavX System.

Refer to the EnSite System Instructions for Use for information on Accessing the
3D model.

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Vitrea 2 version 4.0 CT Cardiac EP Planning User Guide

Keyboard Shortcuts
You can use special function keys as shortcuts for common tasks.

TABLE 2. Basic Vitrea Function Keys:

Press... To rotate the volume...
F2 S-I Superior to Inferior
F3 I-S Rotate Inferior to Superior
F4 A-P Rotate Anterior to Posterior
F5 P-A Rotate Posterior to Anterior
F6 L-R Rotate Left to Right
F7 R-L Rotate Right to Left
F8 Oblique Rotate to MPR oblique orientation views
F9 Previous Previous loaded volume
F10 Next Next loaded volume
Ctrl + Z Undo Undo last action in Viewer window. Click more than
once to undo multiple actions.
Ctrl + Y Redo Redo last Undo in Viewer window.

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