Role of imaging in structural interventions
M. ChrissoherisAttending, THV Department
ROUND TABLE L Role of imaging in atrioventricular valves
Disclosures
- Proctoring activities for Abbott Vascular
I and the HYGEIA Hospital «Heart Team» have receivedresearch and/or travel grants and/or lecture fees from:- ABBOTT Vascular, Europe
HYGEIA Hospital Heart Team
Cardiologists: G. Kourkoveli, K Papadopoulos, A Halapas, M Chrissoheris, K Spargias
CT Surgeons: N Bouboulis, S Skardoutsos, A Tsolakis, S Pattakos
Anesthesiologist: C Nastoulis, I Nikolaou
Pediatric Cardiology: A Tzifa
Vascular Surgeons: I Belos, S Kaliafas
Radiologists: F Laspas, C Mourmouris
Electrophysiology: L Papavassiliou, S. Kourouklis, G Zervopoulos, T Apostolopoulos
Research Nurse: E. Dafnomyli
Daniel H. Steinberg et al. Eur Heart J Suppl 2010;12:E2-E9
Spectrum of Structural Heart Disease
Structural Heart Disease: Conditions for Successful Treatment
• Accurate assessment of nature of defect
• Patient selection
• Planning of procedure
• Precision and complication avoidance
– Guidance, monitoring, verification of success, early
identification of complications
• Patient follow up Imaging is Critical
“…Are there not twelve hours in the day? If anyone walks in the day, he does not stumble, because he sees the light of this world. But if anyone walks in the night, he stumbles, because the light is not in him.” (Jn. 11:9)
Structural Heart Disease: Role for Echocardiography
• Diagnosis
• Guidance during therapeutic interventions (Interventional Echocardiography)
Echocardiographic Modalities
• Transthoracic
• Intracardiac
• Transesophageal
• Tomographic imaging
• 3-Dimensional
• Doppler
– Color
– Spectral
• Speckle tracking
• Contrast (agitated saline)
Transthoracic Echocardiography
• Portable
• Non-invasive
• No radiation or contrast
• Anatomic– Tomographic and 3-
Dimensional imaging
• Physiologic information– Doppler
– Contrast
• Common denominator for all patients referred for evaluation is a comprehensive examination (incl’d. ventricular size / function, valvularfunction, intracardiacshunt determination, hemodynamic assessment)
Intracardiac Echocardiography (ICE)
• US probe inserted via transvenous access and advanced in right atrium Near field structures
• Under conscious sedation
• Variability in image acquisition
• Not standardized image planes
• Single use Cost
Transesophageal Echocardiography
• Superior image resolution
• Standardized imaging planes
• No interference with sterility during procedures Ideal for guidance during interventions
• Ability for real time 3-Dimensional imaging
Real Time 3-Dimensional Echo
Focused wide sector (3D-Zoom) Narrow sector (Live 3D)
Fusion Imaging: Fluoroscopy and Echo
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)
Atrial Septal Defects
• Type of defect
– Secundum, primum, venosum
– Coexistent pathology (e.g. anomalous pulmonary venous return)
• Hemodynamic impact
– Chamber size, function
– Shunt direction
– Qp/Qs calculation
– Pulmonary pressures
Atrial Septal Defects: Secundum
• Anatomy for Intervention
– Evaluation for rims
– Size, shape, complexity
• Transesophageal Echo
– Modality of choice
– Complemented by 3D
Arch Cardiol Mex 2012;82(1):37-47
Atrial Septal Defects: Secundum
• Anatomy for Intervention
– Evaluation for rims
– Size, shape, complexity
• Transesophageal Echo
– Modality of choice
– Complemented by 3D
Secundum ASD: TEE Evaluation for Closure Device
Arch Cardiol Mex 2012;82(1):37-47
Secundum ASD: Device Closure under Real Time 3D Echocardiography
Intraoperative
guidance
– Follow catheters
– Monitoring while
device is
positioned
– Accurate
positioning
– Residual shunt
Patent Foramen Ovale
• Common congenital abnormality (up to 35%)
• Associations with:
– Cryptogenic stroke, paradoxical thromboembolism, migraines, decompression illness, orthodeoxia)
• Agitated saline infusion for diagnosis
Otto C. The Practice of Clinical Echocardiography, 4th Edition
Patent Foramen Ovale
• Common congenital abnormality (up to 35%)
• Associations with:
– Cryptogenic stroke, paradoxical thromboembolism, migraines, decompression illness)
• Agitated saline infusion for diagnosis
J A C C : C A R D I O V A S C U L A R IMA G I N G V O L . 7 , N O . 3 , 2 0 1 4
PFO: Device Closure under Real Time 2D Echocardiography
Ventricular Septal Defects
• Type of defect
– Congenital (perimembranous, muscular, supracrystal, inflow)
– Post myocardial infarction
• Hemodynamic impact
– Chamber size
– Shunt direction
– Pulmonary pressures
– Qp/Qs calculation
Post MI VSD
Dan G. Halpern et al. Eur J Echocardiogr 2009;10:569-571
Ventricular Septal Defects
• Anatomy for intervention– Location
– Adjacent structures (aortic valve cusps, tricuspid valve)
– Sizing with multiplanar reconstruction
• Intraoperative guidance– Follow catheters
– Monitoring while device is positioned
– Accurate positioning
– Residual shunt
J A C C : C A R D I O V A S C U L A R I M A G I N G V O L . 6 , N O . 1 , 2 0 1 3
Ventricular Septal Defects
• Anatomy for intervention– Location
– Adjacent structures (aortic valve cusps, tricuspid valve)
– Sizing with multiplanar reconstruction
• Intraoperative guidance– Follow catheters
– Monitoring while device is positioned
– Accurate positioning
– Residual shunt
Dan G. Halpern et al. Eur J Echocardiogr 2009;10:569-571
Post MI Ventricular Septal Rupture
Circ Cardiovasc Interv. 2013;6:59-67.
Ventricular Pseudoaneurysms
• Complication of
myocardial infarction or
cardiothoracic surgery
• Contained rupture
• High risk for reoperation
• Feasibility of
transcatheter device
closure under 3D-TEE Circ Cardiovasc Interv. 2011;4:322-326.
Dysfunction of Prosthetic Valves
• Paravalvular Leak
• Degeneration of (bio) Prosthesis
Baseline Mitral Valve and 3D Color
Medial
AO
LAA
Posterior AO
PosteriorMedial
Medially located PVL with severe MR
Medial PVL Sizing using Vena Contracta Area
• Crescent shape• Vena Contracta 8x2mm
Access via PVL space
Diagnostic Multipurpose Catheter 6F, Terumo hydrophylic wire
Amplatz Duct Occluder 12x10mm
7F Delivery Catheter via PVL
Final Result
Dysfunction of Prosthetic Valves
• Paravalvular Leak
• Degeneration of (bio) Prosthesis
Baseline TEE
MG 8mmHg MVA 0.8cm2
Heart Team Assessment• Surgical re-do MVR and Tricuspid valve annuloplasty or replacement,
but patient was considered at high surgical risk / inoperable due to coexistent right heart failure, severe pulmonary hypertension and overall frailty
• Alternative: Implantation of a Sapien XT bioprosthesis within the degenerated Perimount in the mitral position
Thoracotomy Exposure of
Cardiac Apex
Valve in Valve with Sapien XT-29mm
Final Result
Mean Gradient 3mmHg
3D-TEE
MVA 2.57cm2
Diastole: LVOT area 1.92cm2
End-Systole:LVOT area 0.71cm2
Mitral VIV Complex: LVOT Interaction X-Plane at LVOT level shows interaction of VIV complex with LVOT during cardiac cycle
Recurrent mitral regurgitation after surgical annuloplasty
The Patient
• 80 year old female, NYHA IV
• CABG (3-vessel), MV repair (ring 32mm), TV repair (34mm ring) in 2015
• Recurrent severe MR (ERO 40mm2, RVOL 64ml)
• LVEF 35%, moderate TR, pulmonary hypertension sPAP 65mmHg
• Comorbidities: Chronic atrial fibrillation, diabetes mellitus II, transient
ischemic attacks
• Log Euroscore 43%, STS mortality 13.4%
• Decision for valve in ring via the transapical approach
Echocardiography:
Severe Mitral Regurgitation
Multidetector Computed Tomography
Note: Non-planar annuloplasty ring with highest points in the anteroposteriordirection and lowest points in the commissures
Valve in RingBalloon Expandable 29mm
Significant MR: What is the mechanism?
• Significant transvalvular regurgitation due to uncovered cell below the annuloplastyring near the lateral commissure
• Annuloplasty ring sits lower near the commissures and higher in the anteroposteriordirection (physio ring) Possibly contributes to MR from the lateral commissure
Post-dilatation 29mm balloon
Unsuccessful in decreasing MR grade
Valve in Valve (in Ring)29mm balloon expandable valve
Resolution of mitral regurgitation
Mitral Valve Dysfunction
• Mitral Regurgitation
• Mitral Stenosis
Functional Mitral RegurgitationLive 3D with Color Flow Doppler
Simultaneous X-Plane with Color
Degenerative MR : P2 Prolapse with ruptured chords
Simultaneous (X-Plane) Views Commissural and Long Axis with Color
Transeptal Puncture
• 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 under 2D TEE
Clip Delivery System in LA
Positioning for Leaflet Capture
Grasping of Leaflets
Final Double Orifice Mitral Valve
Case 1: PASCAL in patient with FMR
• 75 year old male, NYHA IV
• Coronary bypass surgery (1993, LIMA LAD, SVG Diagonal and OM)
• Echo: LV-EF 30%, severe FMR (ERO 1cm2) sPAP 70mmHg
• Stent Graft Abdominal Aorta (2011)
• Carotid artery disease, atrial fibrillation, pacemaker, mild kidney
disease
Baseline 3D Color: Severe MR
Baseline MR
Baseline MVQ analysis and MV area
Baseline MVQ analysis and MV area
PASCAL: Transition to Final Configuration
Final 3D Zoom: Double Orifice Mitral Valve
Final Result
3D Narrow Sector Full Volume Fluoroscopy
Final MV Orifice Evaluation
Medial 1.07cm2 Lateral 1.09cm2
Final 3D Color: Mild MR
Extubation in OR, fluoro time 22min, discharge home on day #4, clinically much improved at the 3 month follow up
Example of other evolving Transcatheter Mitral Valve Repair Technologies
Transcatheter Direct Annuloplasty: Cardioband
Transcatheter Chordal Implants
• Synthetic chords attached to LV myocardium and the leaflets for degenerative MR
J Am Coll Cardiol Intv 2011;4:1–13)
Neochord Implantation
Transcatheter Mitral Valve Implantation: Intrepid TWELVEFor Degenerative Mitral Regurgitation
• Conformable Outer Stent engages the annulus and leaflets providing
fixation & sealing while isolating the inner stent from the dynamic
anatomy
• Circular Inner Stent houses a 27 mm tricuspid bovine pericardium valve
• Conformable Brim aids imaging during delivery & subsequent platform
for healing
80
MEDTRONIC INTREPIDTM TMVIDUAL STENT DESIGN
CAUTION: INVESTIGATIONAL DEVICE. LIMITED BY FEDERAL LAW (USA) TO INVESTIGATIONAL USE. These tests may
not be indicative of clinical performance. These statements have not been evaluated by the FDA and are not
intended to represent claims of human clinical performance or serve as a substitute for medical judgment
• Variable stiffness along the height of the Outer Stent helps wedge the
implant – similar to a champagne-cork
• Outer stent engaging with, and conforming dynamically to, the annulus
• Circular inner stent isolated from the fixation and sealing
81
MEDTRONIC INTREPIDTM TMVIFIXATION AND SEALING
CT images from a human implantation Echo image from a human implantation – atrial view
CAUTION: INVESTIGATIONAL DEVICE. LIMITED BY FEDERAL LAW (USA) TO INVESTIGATIONAL USE. These tests may
not be indicative of clinical performance. These statements have not been evaluated by the FDA and are not
intended to represent claims of human clinical performance or serve as a substitute for medical judgment
• Radial interference, small cleats, frictional elements & tissue ingrowth
• Excellent healing response in longer term porcine and ovine studies
• Gross and histological evaluation of pre-clinical implants reveals the
implants are well integrated with the native tissue, with neo-endocardial
coverage
82
MEDTRONIC INTREPIDTM TMVIFIXATION AND SEALING
Chronic Porcine Pre-clinical Implants at 90 Days
Atrial View
Ventricular View
CAUTION: INVESTIGATIONAL DEVICE. LIMITED BY FEDERAL LAW (USA) TO INVESTIGATIONAL USE. These tests may
not be indicative of clinical performance. These statements have not been evaluated by the FDA and are not
intended to represent claims of human clinical performance or serve as a substitute for medical judgment
12-Month Follow-up: Stable Position & In-growth
MEDTRONIC INTREPIDTM TMVIRESULTS
83CAUTION: INVESTIGATIONAL DEVICE. LIMITED BY FEDERAL LAW (USA) TO INVESTIGATIONAL USE. These tests may
not be indicative of clinical performance. These statements have not been evaluated by the FDA and are not
intended to represent claims of human clinical performance or serve as a substitute for medical judgment
MEDTRONIC INTREPIDTM TMVIRESULTS
84
12-Month Follow-up: Stable Position & In-growth
CAUTION: INVESTIGATIONAL DEVICE. LIMITED BY FEDERAL LAW (USA) TO INVESTIGATIONAL USE. These tests may
not be indicative of clinical performance. These statements have not been evaluated by the FDA and are not
intended to represent claims of human clinical performance or serve as a substitute for medical judgment
The Patient
• 78 year old female, NYHA IV
• Multiple hospitalizations for CHF decompensation
• Severe mitral valve regurgitation (4+) : Degenerative etiology
• Coronaries without stenosis
• Chronic lung disease, FEV1 1.03 l/min, bronchodilator use
• Prior cardiac surgery for removal of a left atrial myxoma (2011)
• Chronic atrial fibrillation, on anticoagulation
• Pulmonary hypertension • sPAP 60mmHg, dPAP 30mmHg, mean 42mmHg
• LE 42%, STS mortality 8.9%, STS morb/mort 46.3%
Baseline Color in X-plane View
Delivery catheter advancement
Valve Positioning
Opening of the device in the left atrium, viewed in 3D-zoom mode
Device positioning under rapid ventricular pacing
Final Result
Final 3D color without MR
Mitral Valve Dysfunction
• Mitral Regurgitation
• Mitral Stenosis
Mitral Stenosis
Diagnosis
• Multiplanar reconstruction for stenosis assessment
• Exclude left atrial thrombus prior to intervention
• Wilkins score for valvuloplasty
Mitral Stenosis
Diagnosis
• Multiplanar reconstruction for stenosis assessment
• Exclude left atrial thrombus prior to intervention
• Wilkins score for valvuloplasty
Novel RT-3D Echocardiographic Score for Mitral Balloon Valvuloplasty
• Mild MV involvement <8 points• Moderate MV involvement 8-13• Severe MV involvement ≥ 14
J Am Soc Echocardiogr 2010;23:13–22
Mitral Stenosis: Percutaneous Balloon Valvuloplasty
Intervention
• Follow catheters / balloon valvuloplasty / assess results / complications
Mitral Stenosis: Percutaneous Balloon Valvuloplasty
• Complicated mitral valvuloplasty with tear of the anterior leaflet and severe MR
J A C C : C A R D I O V A S C U L A R IMA G I N G V O L . 6 , N O . 1 1 , 2 0 1 3
Severe Mitral Valve Calcification
• 80 year old male, NYHA IV
• Comorbidities: Diabetes II, coronary artery disease PCI LCX (at age 64), pacemaker, lung Ca operated, prostate Ca, stroke, COPD, porcelain aorta
• Transcatheter aortic valve replacement (at age 77) for severe aortic stenosis Sapien XT 23mm
• Multiple hospitalizations for recurrent acute pulmonary edema
• Coronary artery disease (PCI LAD in 12/2015 and 9/2016)
• Moderately severe mitral stenosis and regurgitation, degenerative etiology
Severely degenerated mitral valve in 3D-Zoom
Mixed Mitral Valve Disease
Mixed Mitral Valve Disease
Mitral regurgitation and stenosis
Mitral Annulus Measurements
3D-Printing: Implantation of Sapien XT in model
MV
TV
Transapical Sapien 3-29mm Implantation in calcified mitral annulus
Final Result
Aortic Valve Pathology
• Stenosis
• Transcatheter aortic valve replacement
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
AVA 1.27cm2
3D-Planimetry: Bicuspid Aortic Valve
AVA 1.7cm2
3D-Evaluation of Aortic Annulus
Multiplanar reconstruction at a level corresponding to the leaflet insertion points Virtual annulus of aortic valve
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
J A C C : CARDI O V A SC U LAR IMAGI NG VOL. 8, NO. 3, 2015
Echocardiography During TAVR
Baseline X-Plane Imaging
Valve in Valve: Annulus SizingComparison of 3D-TOE and MDCT
3D TEE : Aortic Root MultiplanarReconstruction : Area of Annulus 530mm2
MDCT : Aortic Root MultiplanarReconstruction : Area of Annulus 492mm2
Selection of CoreValve 29mm prosthesis
TAVR - Valve in Valve: CoreValve 29mm positioning and release
TAVR - Valve in Valve: Final Result
Echocardiography post TAVR: Evaluation of Degree and Etiology of
Paravalvular Regurgitation
Severe Paravalvular Regurgitation: Incomplete expansion of the prosthesis
Valve not well apposed to the annulus
Calcium deposits not allowing stent frame to fully expand
Severe Paravalvular Regurgitation:Very low position
Tricuspid Valve Regurgitation
Severe Tricuspid Valve Regurgitation
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