4411-20080514_1720_Room02_Sievert_Horst

7/31/2019 4411-20080514_1720_Room02_Sievert_Horst

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The new Cardiac ImagingThe new Cardiac Imaging

Techniques forTechniques forTranscatheterTranscatheterStructural Heart TherapiesStructural Heart Therapies

Horst Sievert, Nina Wunderlich,Horst Sievert, Nina Wunderlich,

Nico Majunke, KristinaNico Majunke, Kristina RenkhoffRenkhoff

CardioVascularCardioVascularCenter FrankfurtCenter FrankfurtFrankfurt, GermanyFrankfurt, Germany

Washington Hospital CenterWashington Hospital Center

Washington, DC, USAWashington, DC, USA

SJM Structural Heart Disease Symposium, 14th May 2008


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StockStock optionsoptions,,

StocksStocks

CardiokinetiCardiokinetixx, Access, Access ClosureClosure,,

VelocimedVelocimed,, CoAptusCoAptus,, LumenLumen

BiomedicalBiomedical,, MedicalMedical VenturesVentures

Consulting fees,Consulting fees,

Travel expenses,Travel expenses,

Study honorariaStudy honoraria

Abbott, Access Closure, AGA,Abbott, Access Closure, AGA,

AngiomedAngiomed, Boston,, Boston, CardioKinetixCardioKinetix,,CardioMEMSCardioMEMS,, CierraCierra,, CoherexCoherex,,

CoaptusCoaptus,, CordisCordis, CSI, Edwards,, CSI, Edwards,

EndoTexEndoTex, ev3,, ev3, FlowCardiaFlowCardia, Gore,, Gore,

Guidant,Guidant, InInvatecvatec,, Lumen Biomedical,Lumen Biomedical,KenseyKensey Nash,Nash, NDC, NMT, OAS,NDC, NMT, OAS,

OcclutechOcclutech,, OvalisOvalis,, PathwayPathway,, pfmpfm

PendraCarePendraCare PercardiaPercardia,, RemonRemon,, RoxRox

MedicalMedical,, SadraSadra,, SorinSorin,, SpectraneticsSpectranetics,,

St. Jude, Terumo, Topspin,St. Jude, Terumo, Topspin,

VelocimedVelocimed,, XtentXtent

HorstHorst

SievertSievert

RelationshipRelationshipCompanyCompanyPhysicianPhysician

namename

Conflict of Interest Statement


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StructuralStructural HeartHeart InterventionsInterventions

ValveValve

InterventionsInterventions

ValvuloplastyValvuloplasty MitralMitral valvevalve repairrepair ParavalvularParavalvularleaksleaks closureclosure ValveValve ImplantationImplantation

ShuntShunt ClosureClosure PatentPatent ductusductus closureclosure ASDASD-- ClosureClosure PFOPFO-- ClosureClosure VSDVSD--ClosureClosure FistulaFistula--ClosureClosure

OtherOthercardiaccardiacInterventionsInterventions DilatationDilatation//stentstent implantationimplantation

subsub-- undund supravalvularsupravalvular

stenosisstenosis DilatationDilatation//stentstent implantationimplantationofofcoarctationcoarctation

DilatationDilatation//stentstent implantationimplantationofofpulmonarypulmonary arteryartery-- andand veinvein--stenosisstenosis

LeftLeft atrialatrial appendageappendage closureclosure


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One fundamentalOne fundamental differencedifferencecomparedcompared toto coronarycoronary

interventionsinterventions isis

thethe importanceimportance ofof

imagingimaging


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ReasonsReasons forforfailurefailure in PCIin PCI We could see the lesion but could notWe could see the lesion but could not

cross with the wirecross with the wire

The wire was across but the balloonThe wire was across but the balloon

did not followdid not follow

The balloon was there and fully inflatedThe balloon was there and fully inflated

but thebut the stentstent was not flexible enoughwas not flexible enough SubacuteSubacute closure occurred becauseclosure occurred because

thethe stentstent was not fully expandedwas not fully expanded


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So PCISo PCI failurefailure

isis mostmost oftenoften relatedrelated toto

-- cathetercatheterequipmentequipment

-- andand maymay bebe lack oflack ofourourownown

cathetercatheterskillsskills

ItIt isis usuallyusually notnot aa problemproblem ofofimagingimaging


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WhatWhat areare thethe reasonsreasons forforproceduralproceduralfailurefailure inin structuralstructural heartheart interventionsinterventions??

ImagingImaging

ImagingImaging

ImagingImaging DeviceDevice issuesissues,, operatoroperatorfailurefailure, lack of, lack ofskillsskills


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SomeSome examplesexamples forfor

badbad imagingimaging


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Crossing the Aortic ValveCrossing the Aortic Valve

We all know how toWe all know how todo itdo it

But honestly, it isBut honestly, it ismore or less randommore or less random

probingprobing

This is in no wayThis is in no waycomparable tocomparable to

crossing a coronarycrossing a coronarystenosisstenosis!!

ForgiveForgive usus,, wewe don'tdon't seesee whatwhat we'rewe're doingdoing


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Aortic valve implantationAortic valve implantation

PositioningPositioning-- ImagingImaging

-- ImagingImaging

-- ImagingImaging

Guided by

Fluoro only

Other imaging

does not help


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PFOPFO ClosureClosure

DeviceDevice embolisationembolisation-- WhyWhy diddid itit happenhappen??

-- WhatWhat diddid wewe miss?miss?

SizeSize ofofdefectdefect?? ShapeShape ofofdefectdefect??

RimsRims??

RelationshipRelationship toto

surroundingsurroundingstructuresstructures??

ForgiveForgive usus,, wewe didn'tdidn't seesee whatwhat we'rewe're doingdoing


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PFOPFO ClosureClosure

Device erosionDevice erosion-- We don't really know why itWe don't really know why it

happens in some patientshappens in some patients

--Problem of imagingProblem of imaging


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Why is imaging more difficultWhy is imaging more difficultin structural interventions?in structural interventions?

It's all soft tissueIt's all soft tissue

Angiography does not workAngiography does not work-- and / or would require largeand / or would require large

amounts of contrast dyeamounts of contrast dye


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WhichWhich ImagingImaging TechniquesTechniques??

FluoroscopyFluoroscopy

GuidanceGuidance

TEETEE CTCT

MRIMRIICEICE

3D Echo and TEE3D Echo and TEE


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WhichWhich ImagingImaging TechniquesTechniques??

PrimaryPrimary


GuidanceGuidance

TEETEE CTCT

MRIMRIICEICE



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TEETEE Widely used for structural heartWidely used for structural heart

interventionsinterventions-- ASD and PFO closureASD and PFO closure-- VSD closureVSD closure

-- ParavalvularParavalvularleak closureleak closure-- Valve repairValve repair-- Valve implantationValve implantation

You should have it availableYou should have it available-- Even if some interventions can beEven if some interventions can be

performed withoutperformed without


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TEETEE forforASD/ASD/PFOsPFOs andand VSDsVSDs

Location of defectLocation of defect

Rims?Rims?

Additional defects?Additional defects?

Eustachian Valve?Eustachian Valve?

Atypical tissue strings/membranes?Atypical tissue strings/membranes?

Guidance of device implantationGuidance of device implantation

-- Device arms on the correct side?Device arms on the correct side?


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AtypicalAtypicalASDASD

Echo is the only way!


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Membrane in LAMembrane in LA

Only echo helps!


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butbut missedmissedcranialcranial rimrim

SimpleSimple straightstraightforwardforwardASDASD


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Multiple residualMultiple residualshuntsshunts afterafter

devicedevice closureclosure DifficultDifficult on TEEon TEE

NotNot clearclearonon

angioangio NotNot visiblevisible

on CT and MRIon CT and MRI

MultipleMultiple VSDsVSDsTranspositionTransposition ofofthethe largelarge arteriesarteries


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andand intracardiacintracardiac echo?echo?

PrimaryPrimary


GuidanceGuidance

TEETEE CTCT

MRIMRIICEICE



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IntracardiacIntracardiac Echo ICEEcho ICE

MoreMore convenientconvenient forforthethe patientpatient NoNo needneed forforsedationsedation ororGAGA

NoNo

needneed

forfor

anan

echocardiographerechocardiographer

TheThe interventionalistinterventionalist hashas directdirect andandimmediateimmediate controlcontrol overoverimagingimaging

ImagingImaging almostalmost as good as TEEas good as TEE-- SometimesSometimes betterbetter inferiorinferiorpartpart ofofthethe atrialatrial septumseptum


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ICE:ICE: TwoTwo different Technologiesdifferent Technologies

Ultra ICE (Boston)

Radial 360 Imaging Plane

AcuNavTM

90 Sector Image


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PFOPFO ClosureClosure ((AcuNavAcuNav))


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ICEICE DisadvantagesDisadvantages

Additional venous accessAdditional venous access Some additional risk forSome additional risk forintracardiacintracardiac injuryinjury Echo probe may interfere withEcho probe may interfere with

catheters/devicescatheters/devices Sometimes difficult to keep the echo probeSometimes difficult to keep the echo probein a stable positionin a stable position

ReRe--adjustment of the echo probe has toadjustment of the echo probe has tobe done by the operatorbe done by the operator Extraordinary expensiveExtraordinary expensive


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3D Echo?3D Echo?

PrimaryPrimary


GuidanceGuidance

TEETEE CTCT

MRIMRIICEICE



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ASDASD ClosureClosure

2D 3D TEE

nice views


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2D TEE 3D TEE

nice views


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30


2D TEE 3D TEE

nice views


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MitralMitral ValveValve2D TEE2D TEE 3D TEE

new views


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new views

ParavalvularParavalvularLeaksLeaks3D TEE allows views which are not possible with 2D

Courtesy Steven Goldstein


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EverybodyEverybody isis talkingtalking aboutabout CT and MRICT and MRI

PrimaryPrimary


GuidanceGuidance

TEETEE CTCT

MRIMRIICEICE



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WhereWhere doesdoes itit reallyreally

helphelp inin structuralstructuralinterventionsinterventions??


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PercutaneousPercutaneousAortic Valve ImplantationAortic Valve Implantation

MSCT/ Dual CTMSCT/ Dual CT

Provides diameter of

valve anulus

Helps to calculate

the best projection

for valveimplantation


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TheThe PercutaneousPercutaneousAortic Valve ImplantAortic Valve Implant

MSCT/ Dual CTMSCT/ Dual CT

Vessel narrowingVessel narrowing

Degree ofDegree ofcalcificationcalcification

Luminal narrowingLuminal narrowing


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PercutaneousPercutaneous MitralMitral Valve RepairValve Repair

Coronary sinusCoronary sinus Circumflex relationshipCircumflex relationship

Tops et al. Circ 2007; 115: 1426Tops et al. Circ 2007; 115: 1426--3232

LCX under CS 68%LCX under CS 68% LCX over CS 32%LCX over CS 32%

PercutaneousPercutaneousAnnuloplastyAnnuloplasty devices may compressdevices may compress CxCx


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Tops et al. Circ 2007;Tops et al. Circ 2007;

115: 1426115: 1426--3232

Distance betweenDistance between

Coronary Sinus andCoronary Sinus and MitralMitral annulusannulus

CoronaryCoronary

sinus may besinus may be

at the leftat the left

atrialatrial posteriorposterior

wall ratherwall rather

than thethan the mitralmitral

annulusannulus


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CoronaryCoronary Sinus ApproachSinus Approach forfor

MitralMitral ValveValve RepairRepairLessonsLessons learnedlearned

EarlyEarly andand latelate compressioncompression ofofthethe

circumflexcircumflex arteryartery occurredoccurred despitedespite useuse

of CTof CT TheThe distancedistance betweenbetween mitralmitral valvevalve

anulusanulus andand coronarycoronary sinussinus diddid notnot

predictpredict outcomeoutcome

d CTd CT MRIMRI idid


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and CTand CT ororMRIMRI guidanceguidance

inin thethe cathcath lab?lab?

PrimaryPrimary


GuidanceGuidance

TEETEE CTCT

MRIMRIICEICE



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Jan 31, 2008Jan 31, 2008

Questionnaire to 55Questionnaire to 55 cathcath labs heavilylabs heavilyinvolved in structural and congenital heartinvolved in structural and congenital heartinterventionsinterventions

Only 5 had used CT or MRI in theOnly 5 had used CT or MRI in the cathcath lablab

-- for research onlyfor research only

-- 4/5 have stopped completely4/5 have stopped completely

It seems to be that inIt seems to be that in daily practicedaily practice nobody isnobody is

currently using CT or MRI in thecurrently using CT or MRI in the cathcath lab forlab forstructural interventionsstructural interventions


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SomeSome commentscomments fromfrom thethe

mostmost famousfamous institutionsinstitutions

""WeWe havehave thethe facilityfacility.. WeWe usedused itit forforcoarctcoarct

stentingstenting,,butbut wewe havehave stoppedstopped itit"" ""WeWe areare notnot usingusing anymoreanymore anyany ofofthesethese

modalitiesmodalities""

""WeWe dondontt ((nornorplan to)plan to) useuse itit""

""WeWe willwill notnot havehave itit inin thethe newnew hospitalhospital

eithereither"" "MRI in"MRI in thethe cathcath lablab isis greatgreat! I! I allowsallows youyou toto

easilyeasily convertconvert a 30 mina 30 minprocedureprocedure intointo a 4a 4

hourhourprocedureprocedure""


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Take HomeTake Home MessagesMessages Imaging is extremely important for structural andImaging is extremely important for structural and

congenital heart interventionscongenital heart interventions Currently we don't get the images we needCurrently we don't get the images we need If you start a program you have to have TEEIf you start a program you have to have TEE ICE is helpful in special situationsICE is helpful in special situations

3D echo and 3D TEE adds additional information3D echo and 3D TEE adds additional informationby providing some additional views which are notby providing some additional views which are notpossible with 2D echopossible with 2D echo

CT and MRICT and MRI-- are very useful for diagnosis and planning of some of theare very useful for diagnosis and planning of some of theproceduresprocedures

-- but not yet for guidance of the interventionbut not yet for guidance of the intervention

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