10 ο ΣΥΝΕΔΡΙΟ ΕΠΕΜΒΑΤΙΚΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ ΚΑΙ ΗΛΕΚΤΡΟΦΥΣΙΟΛΟΓΙΑΣ Σεπτεμβρίου 2017 Electra Palace Θεσσαλονικη

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1 10 ο ΣΥΝΕΔΡΙΟ ΕΠΕΜΒΑΤΙΚΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ ΚΑΙ ΗΛΕΚΤΡΟΦΥΣΙΟΛΟΓΙΑΣ Σεπτεμβρίου 2017 Electra Palace Θεσσαλονικη

2 Ηχωκαρδιογραφία στην ένδειξη-προετοιμασία, διενέργεια, παρακολούθηση ασθενών που υποβάλλονται σε διακαθετηριακές θεραπείες καρδιακών βαλβιδοπαθειών Κων/νος Παπαδόπουλος Καρδιολόγος Τμήμα Διακαθετηριακών βαλβίδων «ΥΓΕΙΑ»

3 Spectrum of Structural Heart Disease Daniel H. Steinberg et al. Eur Heart J Suppl 2010;12:E2-E9

4 Structural Heart Disease: Role for Echocardiography Diagnosis Guidance during therapeutic interventions (Interventional Echocardiography)

5 Structural Heart Disease and Catheter Based Intervention Closure of Intracardiac Shunts Atrial Septal Defects Secundum Patent Foramen Ovale Ventricular Septal Defects Congenital Post Myocardial Infarction Ventricular pseudoaneurysms Valvular Heart Disease Aortic Stenosis / Regurgitation Mitral Regurgitation Mitral Stenosis Prosthetic Heart Valve Dysfunction Degeneration Paravalvular Regurgitation Left atrial appendage closure Pulmonary vein ablation Other (patent ductus closure, coarctation of the aorta, congenital aortic / pulmonic stenosis)

6 Aortic Stenosis

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13 Imaging in TAVR

14 MDCT Allows for Full Assessment of valve and Vascular Access

15 MDCT: Aortic valve assessment Extent and location of aortic valve calcification May determine a noncircular deployment of the prosthesis

16 ECG gated with iv contrast Mid-systole for measurements Annulus Sizing by MDCT Diameters (min/max) Perimeter Derived diameter Area Derived diameter Calcium distribution on annulus

17 3D-Planimetry of the Aortic Valve Multiplanar reconstruction in mid systole Evaluate AV orifice at a plane perpendicular to the tip of the three cusps Use 3D zoom+live 3D mode Better assessment than 2D

18 3D-Evaluation of Aortic Annulus Multiplanar reconstruction at a level corresponding to the leaflet insertion points Virtual annulus of aortic valve

19 Selection of CoreValve 29mm prosthesis Valve in Valve: Annulus Sizing Comparison of 3D-TOE and MDCT 3D TEE : Aortic Root Multiplanar Reconstruction : Area of Annulus 530mm 2 MDCT : Aortic Root Multiplanar Reconstruction : Area of Annulus 492mm 2

20 Transcatheter Aortic Valve Replacement Echocardiographic Image Guidance not routinely used fluoroscopy and angiography suffice in majority of patients, except for Valve in valve for stentless bioprosthetic valves Native valve stenosis without significant calcification Echo for pre- and post procedure evaluation mandatory for assessment of final result and early detection of complications

21 Baseline X-Plane Imaging

22 TAVR - Valve in Valve: CoreValve 29mm positioning and release

23 Fusion Imaging in TAVR Simultaneous Echo and fluoroscopy imaging Soft tissue visualization Echo markers at annulus and ostia Reducing radiation exposure

24 Mitral Valve

25 THE MITRAL VALVE ANATOMY Anterior annulus Posterior annulus Anterior leaflet Chordae tendineae Posterior leaflet P1 A1 Anterior leaflet A2 P2 A3 P3 Lateral papillary muscle Medial papillary muscle Posterior leaflet The mitral valve apparatus includes the annulus, the leaflets, the chordae tendineae, and papillary muscles. The leaflets are normally asymmetric the anterior leaflet has a larger surface area, but occupies a smaller amount of annular circumference.

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27 3D ENFACE VIEW PUTTING YOUR UNDERSTANDING OF THE VALVE TOGETHER Lateral AML Severe A3/P3 prolapse PML Medial 3D provides a global view of MV leaflet anatomy Use 3D in conjunction with 2D to understand the valve, but not instead of 2D 3D may miss subtle leaflet abnormalities

28 LATERAL LATERAL Echo related valve anatomy Use of common anatomically based vocabulary reinforces clear communication ANTERIOR ANTERIOR Fossa MEDIAL MEDIAL POSTERIOR Salcedo, J Am Soc Echocardiogr, 2009 POSTERIOR

29 Mitral Regurgitation

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33 MVQ Analysis in DMR Evaluation of MV area, Annulus area, circumference Direct measurement of anatomic orifice area Exact location of abnormality Guidance for surgical repair or MitraClip

34 Functional MR Surgical Parameters 1. Annulus diameters 2. Annulus area & circumference 3. Mitral Valve area 4. Tending volume 5. Tending height 6. Coaptation length

35 Modelling of Mitral Valve - MVQ

36 3D Vena Contracta Assymetric VC Measure VC area Cut off values for severity 60mm2 Assess assymetry index Assess regurgitant volume ( RV=VCA x VTI MR) Hyodo E, et al.jacc Cardiovasc Imaging 2012;5: Thavendiranathan P, et al. J Am Coll Cardiol 2012;60: Shanks M, et al. Circ Cardiovasc Imaging 2010; 3: Zeng X, et al. Circ Cardiovasc Imaging 2011;4:

37 3D Vena Contracta

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41 Transcatheter Mitral Valve Repair - MitraClip

42 The MitraClip Device Implant made of cobalt chromium Polyester-covered to promote healing MRI Safe to 3 Tesla Real-time positioning during procedure Surgically removable when required

43 The MitraClip principle Surgery Alfieri stich MitraClip

44 Strong Echo Team is Essential Echocardiographic Assessment is Critical for MitraClip! Patient Selection Determination of MR severity Analysis of valvular apparatus and LV responsible for MR Procedural Guidance Transseptal puncture guidance Steering and grasping of the Implant Determination of final result Post-procedural follow-up Determination MR severity Durability of Implant

45 MitraClip: Initial Inclusion Criteria (EVEREST studies) Valve geometry features: Coaptation length 2 mm, coaptation depth <11 mm, Flail gap <10 mm, flail width <15 mm Ventricle function/ geometry: Ejection fraction [EF] >25%, LV end-systolic diameter 55mm

46 MitraClip Suitability Location of pathology: Segment 2 vs. 1 or 3 Lack of calcification at leaflet tips in grasping area Valve area (>4cm 2 ) or at least >3.0cm 2 with good leaflet mobility Length of posterior leaflet (ideally >10mm) at least 7-10mm Coaptation depth (preferably <11mm) Normal thickness and mobility of leaflets or if restriction, only in systole (IIIb) MR with prolapse flail size <15mm, gap <10mm Boekstegers,-P; Hausleiter,-J, Baldus S, von Bardeleben RS, et al. Clin Res Cardiol 2013

47 Echocardiographic Parameters and MitraClip Outcomes J A C C : C A RD I O V A S C U L A R I N T E R V E NT I O N S, V OL. 7, N O. 4, :

48 The Enhanced TEE Protocol

49 TEE Assessment Focus on Mitral Valve leaflets and sub-valvular apparatus Determine Etiology: DMR vs FMR Leaflets: Flail, prolapse, restricted, cleft, etc. Chordal Relationships Papillary Muscles Jet Origin Location of Primary Jet Presence/Location of Secondary Jet LV function: EF and LV size LA size: MR acute vs. chronic Atrial Septum: ASD, PFO, fossa size, aneurysm, etc. Other: Intracardiac thrombus, vegetation, calcium, Rheumatic MV disease, etc.

50 Critical first step to entering the left atrium for left sided interventions Position of puncture depends on procedure e.g. for MitraClip, puncture at the high and posterior aspect of fossa ovalis Transeptal Puncture

51 Transeptal Puncture Observe tenting superiormid/posterior Cross fossa ovalis

52 Extra Stiff Guidewire towards Left Upper Pulmonary Vein

53 Steerable Guide Catheter in LA

54 Clip Delivery System in LA

55 Perpendicularity

56 Positioning for Leaflet Capture

57 Grasping of Leaflets

58 Final Double Orifice Mitral Valve

59 Echo Guidance in PASCAL

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62 PASCAL: Transition to Final Configuration

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64 Final 3D Zoom: Double Orifice Mitral Valve

65 Final Result 3D Narrow Sector Full Volume Fluoroscopy

66 Mitral Stenosis

67 Mitral Stenosis Diagnosis Multiplanar reconstruction for stenosis assessment Exclude left atrial thrombus prior to intervention Wilkins score for valvuloplasty

68 Mitral Stenosis Diagnosis Multiplanar reconstruction for stenosis assessment Exclude left atrial thrombus prior to intervention Wilkins score for valvuloplasty

69 Importance of correct measurement Zamorano J, et al. Eur Heart J 2004;25: Xie MX, et al. Am J Cardiol 2005;95: Sebag IA, et al. Am J Cardiol 2005;96:

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71 Mitral Stenosis: Percutaneous Balloon Valvuloplasty Intervention Follow catheters / balloon valvuloplasty / assess results / complications

72 Transcatheter Mitral Valve replacement (TMVR- TWELVE Valve)

73 Dual stent design Conformable Outer Stent engages the annulus providing fixation & sealing while isolating the inner stent from the dynamic anatomy Circular Inner Stent houses a 27 mm tricuspid bovine pericardium valve Flexible Brim aids imaging during delivery One valve size significantly reduces development & manufacturing complexity One implant platform regardless of delivery approach: trans-apical or trans-septal 90

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80 In Summary Echocardiography is the first stop imaging modality for accurate evaluation of structural heart disease Even more, it is an indispensable tool during transcatheter interventions for guidance and evaluation of the results Future developments will aim at fusion imaging to integrate echocardiography with other available imaging modalities

81 THANK YOU