Interventional Imaging Cases

Transcription

1 Interventional Imaging Cases Steven A. Goldstein MD Professor of Medicine Georgetown University Medical Center MedStar Heart Institute Washington Hospital Center Tuesday, October 10, 2017

2 DISCLOSURE I have N O relevant financial relationships

3 Management

4 Treatment Strategies for HCM No symptoms Symptoms Refractory Symptoms No rx? drug rx B-blockers Verapamil Disopyramide Combined B-blockers and Ca-blockers Refractory, Severe Sx Obstruction Myotomy-Myectomy??? DDD-pacing ETOH septal ablation Non-obstruction Transplant HCM121

5 Drug-Refractory HCM Therapeutic Options Surgery Dual-chamber pacemaker Septal Ablation

6 Alcohol Ablation

7 Alcohol Septal Ablation st procedure at Royal Brompton Since then >10,000 performed

8 HCM - Alcohol Septal Ablation Indications NYHA Class III nor IV* (*unresponsive to maximum medical treatment) LVOT gradient > 50 mmhg at rest (or with physiologic provacative maneuvers) 1 septal branch of LAD suitable for intervention

9 HCM - Alcohol Septal Ablation Selection Criteria Symptoms that interfere substantially with QOL despite optimal medical mgt Septal thickness 1.6 cm LVOT gradient 30 mm Hg at rest or 50 mmhg with provocation Accessible, appropriate septal perforator(s) Absence of intrinsic MV abnormality Absence of other conditions warranting cardiac surgery

10 HOCM - Alcohol Septal Ablation Echo Methods for Guidance Transthoracic echo Transesophageal echo (TTE) (TEE) Majority of centers WHC* Intracardiac echo (ICE) * Moderate sedation; NOT general anesthesia

11 HOCM - Alcohol Septal Ablation TEE Views Apical 4-chamber view (0 ) Longitudinal view ( ) Gastric short-axis view Deep transgastric view (for gradient)

12 Hypertrophic Cardiomyopathy Alcohol Septal Ablation Using intracoronary injection of an echo contrast agent, opacification of the strategic septal area can be delineated.

13 Alcohol Ablation of Septum in HCM Echo in Cath Lab During Procedure Transesophageal Transthoracic

14 HOCM - Alcohol Septal Ablation Echo Guidance During Procedure Myocardial Contrast Echo (Intracoronary Contrast) Goal: Delineate strategic portion of septum (perfusion territory of target septal perforator)

15 HCM - Alcohol Septal Ablation Similar to surgical myectomy, this procedure attempts to debulk the septum in the region where the LVOT obstruction occurs A localized myocardial infarction is created by injecting ethanol into the septal perforator that supplies the septal myocardium adjacent to the point of mitral leaflet (SAM)-septal contact

16 Alcohol Ablation of Septum in HCM Ethanol-induced infarction Nishimura and Holmes N Engl J Med 350:1320(2004)

17 HOCM - Alcohol Septal Ablation What to Evaluate Pre-Procedure Site and extent of septal hypertrophy Intracavitary gradient Localization of SAM-septal contact Mitral regurgitation (mechanism and degree)

18 "An important improvement of the new method in our opinion has been gained by the integration of echo monitoring" Faber, Seggewiss, et al Circulation 98:2415(1998)

19 % Patients Septal Ablation in HCM Contrast Echo Helps Improve Results p<0.01 p< No Contrast Contrast (n=30) (n=91) >50%reduction in LVOTG Clinical improvement Faber, Seggewiss Circulation 98:2415(1998)

20 HOCM - Alcohol Septal Ablation Echo Guidance During Procedure Assess Immediate Results Reduction of contractility/thickening of septum Elimination/reduction of SAM Elimination/reduction of gradient Elimination/reduction of mitral regurgitation

21 HOCM - Alcohol Septal Ablation Follow-Up (Post-Procedure Echo) LVOT gradient Mitral regurgitation Diastolic Filling Regression of hypertrophy LV function (especially septum)

22 HOCM - Alcohol Septal Ablation Echo Guidance During Procedure Myocardial Contrast Echo (Intracoronary Contrast) Goal: Delineate strategic portion of septum (perfusion territory of target septal perforator)

23 Alcohol Ablation of Septum in HCM Echo in Cath Lab During Procedure Transesophageal Transthoracic

24 Case 1

25 Case 2 MM - 61 year-old man

26 Case 3

27 Case 4

28 Case 5 BP - 69 year-old female Aborted RV papillary muscle perfused

29 Pericardiocentesis

30 Pericardiocentesis Using Subxiphoid Approach Old-Fashioned Way alligator clip to ECG

31 Echo-Guided Pericardiocentesis Gold-standard for management of effusions reguiring drainage Improves success rate Improves safety Reduces complication rate

32 Location of Needle Entry Chest wall (79%) Para-apical 67% L parasternal 6% L axillary 4% R parasternal 2% Posterolateral 0.2% n = 1,131 Unknown Subcostal Mayo Clinic: courtesy Seward/Khandheria

33 Needle Attempts for Access PC (%) n = 1,131 Number of needle attempts Mayo Clinic: courtesy Seward/Khandheria

34 Success and Complications of (Consecutive 1,131 procedures) Successful PC 1,097 (97%) Major complications 16 (1.4%) Death 1 Ventricular laceration 6 Intercostal vessel injury 1 Pneumothorax 6 Ventricular tachycardia 1 Infection 1 Minor complications 37 (3.3%) Mayo Clinic: courtesy Seward/Khandheria

35 Management of Cardiac Tamponade 1978 Blind pericardiocentesis 6% mortality, 50% morbidity Echo-guided centesis: n = 1,131 <0.1% mortality, <2% morbidity Mayo Clinic: courtesy Seward/Khandheria

36 Pericardiocentesis Call for Microbiology to tube 2 aerobic culture specimen bottles to the front desk # 205 Elevate HOB with 45 Chest prepped and draped Page echo stat to Cath Lab (7-6700) Sedate as ordered Closely monitor HR & BP Drop (2) 20cc syringes for labs Obtain CCU or ICU bed Patient may be sent to a 4 th floor cardiac bed if hemodynamically stable Complete blue FLUID lab slip with: Cell count (purple tube) 1 air tight 20 cc syringe (capped) Gram stain AFB smear and culture Aerobic, anaerobic cultures Fungal culture Cytology Glucose Total protein Albumin LDH Adenosine deaminase

37 Apical Approach

38 Apical-Lateral Approach

39 Case 1 JC - 55 year-old woman Contrast confirms

40 Case 2 EW - 80 year-old woman Apical approach

41 Not optimal pericardiocentesis site (apical)

42 Case 3 TJ - 71 year-old man Pericardiocentesis L-axillary approach

43 Not optimal pericardiocentesis site (subaxillarylateral))

44 Case 4 RD - 77 year-old man Massive pericardial effusion

45