Clinical Value of 3D Echo: Volumes and Valves
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1 Clinical Value of 3D Echo: Volumes and Valves James D. Thomas, M.D., F.A.C.C. Cardiovascular Imaging Center Department of Cardiology Cleveland Clinic Foundation Cleveland, Ohio, USA Conflicts: None 3D2011:1
2 Lang et al. JASE 2012; 25: D2011:2
3 3D Echo Has Come a Long Way Bob Levine, Mark Handschumacher, MGH ~ D2011:3
4 Real-time 3D 3D2011:4
5 Critical Benefits of 3D Echo Quantification of cardiac chamber volumes and function Improved visualization of nonplanar structures within the heart 3D2011:5
6 3D Volume/Function Validation Study March, 2000 JACC 3D2011:6
7 EF by 3D 3DE vs MRI (EF) y = 0.98 x r = 0.98 p < SEE = EF by MRI 3D2011:7
8 Severe 4+ AR with Dilated LV 3D2011:8
9 3D LV Volume Normal LV Function 3D2011:9
10 Regional Wall Motion Abnormality 3D2011:10
11 Nine-Plane Visualization of 3D Echo Quantitation similar to MRI 3D2011:11
12 Nine-Plane Visualization of 3D Echo Contrast may improve quantitation 3D2011:12
13 3DE vs 2DE for LV EDV MRI Comparison Qin et al. JACC 2000; 36: D2011:13
14 3DE and MRI Handle Trabeculae Differently But very similar if trabeculae handle the same Mor-Avi et al. JACCi 2008;1: D2011:14
15 Conditions Where LV Volume/Function are Critical Cardiomyopathy Indications for ICD and BiV pacing Oncology Monitoring effects of chemotherapy Valvular heart disease Monitoring progression in aortic and mitral regurgitation 3D2011:15
16 Practical Barriers to 3D Echocardiography How to manage the workflow Extensive experience/comfort in 2D acquisition and review 3D acquisition and analysis are separate tasks: 1 or 2 sonographers? Is 3D software integrated into review software or separate? DICOM format only recently approved (but little penetration into the market now) 3D2011:16
17 Practical Barriers to 3D Echocardiography How to pay for this Currently no separate CPT code for 3D echo Most billing done under CPT s and D2011:17
18 Medicare Reimbursement Modality Tech Prof Total 2D echo D addon Bundled Actual 3D reimbursement averages ~$38 3D2011:18
19 Would Separate 3D Echo code be Beneficial? Not necessarily Imaging (and particularly echo) under intense scrutiny for rapidly rising utilization The pie is not getting bigger, so an increase in one piece will mean a decrease in another piece Comprehensive 3D echo code might lead to a devaluation in 2D reimbursement 3D2011:19
20 LA Volume Change 3D2011:20
21 l) LA Volume by 3D TTE Normal RVSP High RVSP 3D2011:21
22 Left Atrial Volume Change 3D2011:22
23 Comparison to MRI Estimates Good correlation with MRI estimates Bauer F et al J Am Soc Echocardiogr 2004;17:968 3D2011:23
24 RV Volume and Function 3D2011:24
25 3D2011:25
26 Severe Pulmonary Hypertension 3D2011:26
27 Critical Values for 3D Echo Quantification of cardiac chamber volumes and function Improved visualization of nonplanar structures within the heart 3D2011:27
28 Circulation 2003 (March 4): 107: D2011:28
29 Ischemic MR : 2 Jets Med Comm Lat Comm Lat Comm Kwan, et al, Circulation 2003: 107: D2011:29
30 Asymmetrical deformation of MV : Real Time 3D Echo med mid lat Medial Middle Lateral 3D2011:30
31 Regurgitant Orifice Area (cm 2 ) MV Tethering Predicts MR severity R 2 = R 2 = MV Tent area IMR DCM Mitral Tent area (cm 2 ) Kwan et al. Circulation 2003: 107: D2011:31
32 Functional mitral regurgitation Prolapse regurgitation ROA highly elongated in FMR, more focal in MVP atsumura Y, et al. Am Heart J 2008;155: D2011:32
33 32 yo Man with Fever X 1.5 years NCC vegetation 3D2011:33
34 63 yo Man Rheumatic MS Fishmouth MV 3D2011:34
35 29 yo Woman with Severe MR Cleft MV seen from LVOT 3D2011:35
36 >150 Front End Boards And Now It s in a TEE Shrinking Beamforming Electronics Compressed into Transducer Housing Further compressed into TEE Tip Electronics needed for 2500 Elements Higher density electronics New micro-beamforming architecture Novel interconnect scheme 3D2011:36
37 Which Is a Lot Easier Than the First Way TomTec approach ~1992 Breburda et al., JACC 1998;32: D2011:37
38 Normal aortic valve from aorta 3D2011:38
39 Normal mitral valve from LA 3D2011:39
40 3D2011:40
41 Left atrial appendage from LA 3D2011:41
42 Normal tricuspid valve from RA 3D2011:42
43 Bileaflet MVP (Barlow s mitral valve) 3D2011:43
44 Mitral valve with P2 flail from LA 3D2011:44
45 3D2011:45
46 Dehisced Geoform Ring 3D2011:46
47 Localizing Pathology Exploring 3D Datasets by Multiplanar Reconstruction Medial scallop flail 3D2011:47
48 Visualization of Aortic Valve Fibroelastoma on LCC 62 yo woman with TIA 3D2011:48
49 Guidance of Interventions Intraoperative echo MV repair, AV repair, myectomy, TV repair, congenital repairs Percutaneous interventions Mitral valve (balloon valvuloplasty, annuloplasty ring, leaflet clip) Aortic valve (balloon valvuloplasty, transfemoral or transapical AVR) Closure devices (PFO, ASD, VSD, paravalvular leaks) 3D2011:49
50 Pre Robotic Mitral Valve Repair Anterior leaflet perforation 3D2011:50
51 Robotic Surgical Instrumentation State-of-the-art robotic technology intuitive motion control of surgical instruments Surgeon in control Assistant has direct access 3D2011:51
52 Robotically-Assisted Mitral Valve Repair Mitral Valve Repair 3D2011:52
53 3DTEE in Intraoperative Echo Mitral valve with P3 flail, repaired with resection and annuloplasty 3D2011:53
54 Mitral Balloon Valvuloplasty efore During After 3D2011:54
55 Live 3D Guidance of TAVR Rapid pacing balloon inflation of bioprosthesis 3D2011:55
56 Post-Deployment Assessment Leaflet motion after PAVR 3D2011:56
57 MitraClip Placement LA side LV side 3D2011:57
58 After Two Clips Placed 3D2011:58
59 Patent Foramen Ovale Deploying PFO closure device 3D2011:59
60 Patent Foramen Ovale Testing PFO closure device with saline contrast 3D2011:60
61 52 yo Man with Large VSD After LAD MI Massive VSD with apical LV thrombus ourtesy of Roberto Lang, in press JACC D2011:61
62 52 yo Man with Large VSD After LAD MI 3.0 x 1.7 cm VSD with adequate rim ourtesy of Roberto Lang, in press JACC D2011:62
63 52 yo Man with Large VSD After LAD MI Retrograde approach to the defect, snaring wire in RV ourtesy of Roberto Lang, in press JACC D2011:63
64 52 yo Man with Large VSD After LAD MI #35 cribriform closure device in place ourtesy of Roberto Lang, in press JACC D2011:64
65 Percutaneous Closure of Paravalvular MVR Direct visualization of paravalular leak 3D2011:65
66 Percutaneous Closure of Paravalvular MVR Transseptal lasso catheter capturing retrograde wire through leak 3D2011:66
67 Percutaneous Closure of Paravalvular MVR Second deployment 3D2011:67
68 Left Atrial Appendage Occlusion Confirmation of device location 3D2011:68
69 Can We Calculate Strain in 3D??? Volumetric speckle tracking 3D2011:69
70 New era 3D Speckle Tracking 3D2011:70
71 Parametric Imaging by 3D Speckle Tracking Circumferential Strain Torsion 3D2011:71
72 46 subjects studied by 2D & 3D Timing of acquisition and analysis measured 2D & 3D strains compared Shorter Time for 3D STE Time 2D 3D p Acquisition 4.1± ±0.4 <0.001 Analysis 34.3±4 10.1±1.8 <0.001 Slight Differences in 2D and 3D Measurements Saito et al. JASE 2009; 22: D2011:72
73 3D Echo Has Come a Long Way! 3D2011:73
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