Conflict of Interests

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1 Introduction to Interventional Echocardiography Roberto M Lang, MD Tomtec Conflict of Interests Research Grants Philips Medical Imaging Research Grants Speakers bureau Advisory bureau 1

2 Structural Heart Disease: Definition Structural heart disease is a term first introduced by Martin Leon at the 1999 Transcatheter Cardiovascular Therapeutics meeting to provide an over-reaching term encompassing non-coronary cardiac disease processes and developing interventional techniques. U N I V E R S I T Y O F C H I C A G O N O N - I N V A S I V E C A R D I A C I M A G I N G L A B O R A T O R Y 2

3 Increased recognition of disease Advanced imaging techniques Catheter based techniques Devices Aging population Availability of new devices Advanced imaging needs U N I V E R S I T Y O F C H I C A G O N O N - I N V A S I V E C A R D I A C I M A G I N G L A B O R A T O R Y Steinberg D H et al. Eur Heart J Suppl 2010;12:E2-E9 U N I V E R S I T Y O F C H I C A G O N O N - I N V A S I V E C A R D I A C I M A G I N G L A B O R A T O R Y 3

4 Visualization of the Entire Catheter Thrombus Attached to Catheter Courtesy Dr Kronzon 4

5 Illumination Techniques Artificial Intelligence Fusion Imaging 3D Printing Virtual Reality Holography 5

6 Automated Cardiac Chamber Quantification Poor anatomic definition Images that interventionalists are familiar Single plane Good definition for catheters, wires and devices Radiation Exposure Good definition for, calcified and metallic structures Contrast Use U N I V E R S I T Y O F C H I C A G O N O N - I N V A S I V E C A R D I A C I M A G I N G L A B O R A T O R Y 6

7 Interventionalist are not used to echo persepctives Real Time 3D anatomic definition Worse definition of intracardiac catheters Visualization of structures in multiple planes Minimizes radiation exposure and increases safety Dependent on image quality Operators experience U N I V E R S I T Y O F C H I C A G O N O N - I N V A S I V E C A R D I A C I M A G I N G L A B O R A T O R Y FUSION IMAGING 7

8 Fusion imaging Fluoroscopic anatomy Mitral valve in RAO 30 Mitral valve in LAO 30 AL commissure AML AL commissure CS PML PM commissure PM commissure Fusion Imaging Fluoroscopic anatomy 8

9 FUSION IMAGING 3D Printing 9

10 Virtual Reality Computer-generated simulation of a threedimensional image that can be interacted with by a person using special electronic equipment (helmet with a screen inside or gloves fitted with sensors. Stenotic Bioprosthetic MV From LA From LV 10

11 Virtual Reality Virtual Reality 11

12 Virtual Reality VR & HM 12

13 Nobel Prize Laureate

14 3D Holography: Photographic technique that records the light scattered from an object, and then presents it in a way that appears 3D RealView Imaging Ltd. All rights reserved. Structural Heart Disease Treatment of Valvular heart Disease Mitral balloon valvuloplasty Edge to edge repair TAVR Treatment of Prosthetic Valve Malfunction Paravalvular leak closure Valve-in-valve 14

15 Mitral Stenosis Mitral Stenosis 15

16 PBMV in Mitral Stenosis PBMV in Mitral Stenosis PRE PBMV POST PBMV 16

17 Mitral Stenosis PRE POST Area: Pre = 1.4cm² Post = 1.9cm² 17

18 PRE POST Area: Pre = 1.2cm² Post = 1.6cm² Dehisced Mitral Valve 18

19 Dehisced Mitral Valve Dehisced Mitral Valve 19

20 A AV B Paravalvular leak identification LAA C D AV Catheter wire placement E AV Incorrect F Correct AV Successful closure with Amplatzer device Left atrial view Left ventricular view Percutaneous Repair of Prosthetic Mitral Valve Dehiscence 20

21 Percutaneous Repair of Prosthetic Mitral Valve Dehiscence Percutaneous Repair of Prosthetic Mitral Valve Dehiscence 21

22 Percutaneous Repair of Prosthetic Mitral Valve Dehiscence Percutaneous Repair of Prosthetic Mitral Valve Dehiscence 22

23 Percutaneous Repair of Prosthetic Mitral Valve Dehiscence Percutaneous Repair of Prosthetic Mitral Valve Dehiscence 23

24 Number of Leaks Percutaneous Repair of Prosthetic Mitral Valve Dehiscence 24

25 Percutaneous Repair of Prosthetic Aortic Valve Dehiscence Mitral Clip Steinberg D H et al. Eur Heart J Suppl 2010;12:E2-E9 25

26 Inter-atrial Septal Puncture Position and Orient Clip 26

27 Grasping the Leaflet Ventricular Side Atrial Side Alfieri Stich 27

28 Clip for a Cleft MV Clip for a Cleft MV Clip #1 28

29 Clip for a Cleft MV Clip #1 Clip for a Cleft MV Clip #2 29

30 Clip for a Cleft MV Clip #2 Valve in Valve 30

31 Valve in Valve Percutaneous MV Repair Direct annuloplasty Mitralign Guided Delivery Systems QuantumCor Coronary sinus annuloplasty Edwards Monarc Cardiac Dimensions Viacor PTMA Indirect annuloplasty St. Jude i-coapsys Ample PS3 Edge-to-edge evalve Edwards Mobius 31

32 Percutaneous MV Repair Percutaneous TV Repair Mitralign Concept Bi-caval valve implantation Forma Concept TriCinch Concept Transatrial Intrapericardic tricuspid annuloplasty concept 32

33 Aorta Normal Aortic Valve Anatomy AORTIC PERSPECTIVE LVOT PERSPECTIVE 33

34 Elliptical Aortic Annulus LVOT STJ AoA SOV Percutaneous Aortic Valves Edwards-Sapien ReValving R System CoreValve Bovine pericardium Tri-leaflet configuration Mounted on a 14 mm long x 23 mm or 26 mm diameter highly resistant stainless steel balloon expandable ste Single layer porcine pericardium Tri-leaflet configuration Nitinol frame self-expandable - Inflow: 26 and 29 mm 20 to 27 mm annulus Delivery system 18F 34

35 Aortic Balloon Valvuloplasty TAVR Deployment 35

36 Aortic Annulus Measurements NCC LCC RCC When: mid-systole: slightly larger and rounder Where: mid right coronary cusp and the edge of the commissures between the LCC and NCC from inner edge to inner edge Sinuses of Valsalva (End-diastole) Sino-tubular junction (End-diastole) Maximal diameter of the proximal Asc Ao (End-diastole) Leading edge to leading edge 36

37 Aortic Stenosis 37

38 LCC LCC 38

39 Paravalvular leak post-tavr -NO LEAK - PARAVALVULAR LEAK LVAD: Left Ventricular Assist Device A valuable option for patients with end stage systolic heart failure ~2000 LVADs are implanted annually in the United States alone It can serve as 1. Bridge to transplantation 2. Destination therapy 3. Bridge to recovery 3D CT reconstruction 39

40 Post-LVAD Aortic Insufficiency Transcatheter Aortic Valve Fusion Russo, Freed, Jeevanandam, Lang et al., Ann Thorac Surg Freed, Paul, Bhave, Lang et al., JACC Cardiovasc Interv

41 Transcatheter Aortic Valve Fusion Transcatheter Aortic Valve Fusion 41

42 Interventional Echocardiography Displays anatomy intuitively Pre-procedure assessment Intra-procedure guidance Post-procedure follow-up Bhave and Lang, Atlas of 3D Echocardiography, ed. Gill, in press 42