Download 3D Echo and Fusion imaging To Guide Transcatheter Procedures

When the interventionalist and the imager work together
3D Echo and Fusion imaging
To Guide Transcatheter Procedures
Itzhak Kronzon, MD, FASE, FACC, FAHA, FCCP. FACP
Director, Cardiac Imaging
Lenox Hill Hospital, New York, NY.
Professor Philips
of Cardiology, Hofstra NSHS/LIJ Medical School
Disclosures: Honoraria,
Stefano De Castro
1962-2012
 He was a superb doctor, an accomplished scientist and a great
teacher with thorough knowledge not only in cardiology,
but also in literature, poetry, politics, economy or any topic
that could arise during a conversation.
His warmth, eloquence, wisdom,
generosity and friendship are sorely missed.
He will never be forgotten
The heart is a 3D structure which should
be displayed in 3D
3D TEE is capable of demonstrating the entire
Intracardiac portions of catheters, wires
and devices
This improves the results and the safety of
Catheter based procedures
3D TEE can show findings not
seen on 2D TEE
73 year old female
 History of MV prolapse and severe MR with
congestive heart failure
 MV repair failed, and MVR with a bioprosthesis was
performed.The posterior valve leaflet and the papillary
muscle were retained . The posterior part of the prosthesis
was sutured to the leaflet.
 Post op the patient developed hemolysis requiring unit of
blood every month.
Prosthetic Valve Dehisence
“Double orifice MV”
Paravalvular leak (PVL)
No valvular MR
Transseptal, transapical or both
3D zoom LA perspective
Cathter in the leak
Closure device advanced
Device in place
PVL Closed
Results: No PVL, mild Valvular MR
Mild MR (valvular)
2 Weeks later
 The patient has severe hemolysis.
 Icteric
 SOB
 Hb 7.9 gr%
 LDH 5450
 Requires transfusion every week.
MR thru he bioprosthesis
Melody Valve (Medtronics)
Arteriovenous monorail
Valve in Valve
Valve in Valve
Melody prosthesis
Valve in Valve
Valve in valve initial inflating
Further inflating
Valve in valve in place
Wire in the Melody Valve
Final Result
Final results
Trace MR,
Mitral mean gradient 3mmHg
After PVL: Catheter across MV
Getting ready to perform Melody
implant
After PVL repair: Melody valve in valve
Replacement was attempted.
Are we ready to go home?
Melody valve flying in the LA
62 years old male with ASMI
Anterior LV pseudoaneurysm
Bloody pleural effusion
The aneurysm was entered by chest wall puncture,
and a catheter was advanced Across its neck
. It was snared by retrograde LV catheter
Catheter in pseudoaneurysm
Device delivered
Device in place
Minimal residual flow
Puncture closure Device
25 years ago the patient had coarctation repaired
Bicuspid aortic valve
Coarctation +Pseudoaneurysm
Pseudoaneurysm Neck
Catheter in neck
Partial List
Interventions in Structural Heart Diseases
Closure of shunts: ASD, VSD, PDA, Gerbode, Baffles
Closure of pseudoaneurysm: Ventricular, Aorta
Valvular Stenosis balloon dilation: MS,AS, PS, TS, Baffle stenosis
Valve replacement: AV, PV, MV, Valve in valve
Valve clipping: MR, TR
Vessel stenosis: Coarctation, pulmonary vein, SVC, peripheral PS
Closure of AV communcations – systemic, pulmonary
Closure of LAA
Guidance of EP – ablation
Removal of intracardiac masses.
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
RT 3D TEE
C CT
Dehiscence
RT 3D TEE
Fluoroscopy
RT 3D TEE
CT
Dehiscence occluded
• Multiple
images from a patient are registered and
overlaid or merged
•
Fused images may be created from multiple images
from the same imaging modality, or by combining
information from multiple modalities, such as Echo,
MRI, CT, PET and SPECT.
SPECT+
CCTA
[Slomka PJ and Baum RP, Eur J Nucl Med Mol Imaging 2009]
CCT – Fluoro Fusion in Apical puncture
LA
LV
PVL Closure
Interventionalist are not used to echo
persepctives
Real Time 3D anatomic definition
Worse definition of intracardiac
catheters
Visualization of structures in
multiple planes
Dependent on image quality
Minimizes radiation exposure and
increases safety
Operators’ experience
EchoNavigator
Key clinical functionality
60
TEE field of view (Ultrasound cone) as
outline in the X-ray
Markings in Echo, appear in X-ray for
context and guidance
Automated and intuitive link
between X-ray and Echo
Interrogate Echo data
from the table side
Echo image orientation automatically
follows the C-arm
Showing Echo from different anglees
simultaneously
EchoNav : TEE-Fluoro Fusion
61
Large mitral Paravalvular leaks
Large PVL
Segmentation with reconstruction
EchoNav LAA
Intellectual Disclosures
 The use of “Off-Label” approved devices
 This work would not have been possible without the “TEAM WORK” of:
Carlos Ruiz MD, PhD
 Howard Cohen MD
 Chad Kliger MD
 Vladimir Jelnin MD
 Itzhak Kronzon MD
 Gila Perk MD
 Robert Kumar MD
 Gregory Fontana MD
 Nirav Patel MD
 Konstadinos Plestis MD
 An amazing team of 5 SHD-CHD Cath Lab nurses, Cardiac Anesthesiologist, Cardiac
Surgery Intensivists
Thank you!
54 YO WOMAN, P/W SOB
 PMH
 Ebstein’s Anomaly
 s/p multiple dual chamber PPM implantations
 s/p percutaneous ASD repair ‘08
 s/p bioprosthetic TV replacement ‘09
 Pulm HTN
 Jehova Witness –refuses blood products
43year old female with large RA clot
Angiovac Aspiration System