WHAT YOU WILL SAY TO THE INTERVENTIANIST AS ECHO MAN

IN CATH LABBY

HESHAM NAEIM,MDCARDIOLOGY CONSULTANT

MCC, MEDINA

LAA CLOSURE LAA CLOSURE WITH ACP DEVICEWITH ACP DEVICE

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WHAT YOU WILL SAY TO THE WHAT YOU WILL SAY TO THE INTERVENTIEMEST?INTERVENTIEMEST?

MAXIMUM MESSURED LAA MAXIMUM MESSURED LAA DIAMETER IS 20MM, SO A DIAMETER IS 20MM, SO A

DEVICE SIZE OF 22-24MM IS DEVICE SIZE OF 22-24MM IS SIUTABLE.SIUTABLE.

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YOUR SEPTAL PUNCTURE YOUR SEPTAL PUNCTURE IS TOO ANTERIOR YOU IS TOO ANTERIOR YOU

SHOULD GO MORE SHOULD GO MORE POSTERIORPOSTERIOR..

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YOUR SEPTAL PUNCTURE YOUR SEPTAL PUNCTURE IS TOO POSTERIOR YOU IS TOO POSTERIOR YOU

SHOULD GO MORE SHOULD GO MORE ANTERIORANTERIOR..

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EXCELLENT SITE FOR EXCELLENT SITE FOR SEPTAL PUNCTURE, GO SEPTAL PUNCTURE, GO

ONON

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YOUR WIRE INSIDE LAA. I YOUR WIRE INSIDE LAA. I CAN SEE YOUR BUBBLES.CAN SEE YOUR BUBBLES.

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YOUR DEVICE AT YOUR DEVICE AT THE MOUTH OF LAATHE MOUTH OF LAA

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YOUR DEVICE IS IN A VERY YOUR DEVICE IS IN A VERY GOOD POSITIONGOOD POSITION

*I CAN SEE BOTH PROXIMAL AND DISTAL *I CAN SEE BOTH PROXIMAL AND DISTAL PORTIONS IN A GOOD POSITION.PORTIONS IN A GOOD POSITION.*PROXIMAL PART IS WELL CUPPED.*PROXIMAL PART IS WELL CUPPED.*NO CLOUR FLOW IN LAA.*NO CLOUR FLOW IN LAA.*LUPV FLOW IS NORMAL.*LUPV FLOW IS NORMAL.*NO PE SEEN.*NO PE SEEN.

**PLEASE RELEASE YOUR DEVICEPLEASE RELEASE YOUR DEVICE..

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ASD CLOSUREASD CLOSURE

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WE HAVE IAS ANEURYSM WE HAVE IAS ANEURYSM WITH MULTIFENESTRATED WITH MULTIFENESTRATED

SEPTUMSEPTUM

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WE HAVE GOOD WE HAVE GOOD SUPPORTIVE OSTIUM SUPPORTIVE OSTIUM

PRIMUM 1.5CMPRIMUM 1.5CM

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I CAN SEE YOUR WIRE I CAN SEE YOUR WIRE INSIDE LAINSIDE LA

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YOYR DEVICE IS COMINGYOYR DEVICE IS COMING

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AORTIC POSITION IS OK AORTIC POSITION IS OK BUT I AM NOT SURE BUT I AM NOT SURE

ABOUT THE POSTERIOR ABOUT THE POSTERIOR RIM, WAIT ME PLEASE.RIM, WAIT ME PLEASE.

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OSTIUM PRIMUM IS NOT OSTIUM PRIMUM IS NOT CATCHED, REPOSITION CATCHED, REPOSITION YOUR DEVICE PLEASEYOUR DEVICE PLEASE

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YOU ARE TRAPED IN A YOU ARE TRAPED IN A SMALL HOLE OF SMALL HOLE OF

FENESTRATED TISSUE , FENESTRATED TISSUE , GO OUT PLEASE.GO OUT PLEASE.

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THE POSTERIOR RIM IS THE POSTERIOR RIM IS NOT CACTHED, THERE IS NOT CACTHED, THERE IS

MILD FLOW AT THE AORTA MILD FLOW AT THE AORTA AND POSTERIORLY, AND POSTERIORLY,

REPOSITION PLEASE.REPOSITION PLEASE.

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YOUR DEVICE IS WELL YOUR DEVICE IS WELL POSITIONED, NO POSITIONED, NO

RESIDUAL FLOW, OSTIUM RESIDUAL FLOW, OSTIUM PRIMUM, AORTIC, IVC RIM PRIMUM, AORTIC, IVC RIM ARE WELL CACTHED, MV ARE WELL CACTHED, MV

IS OK, NO PEIS OK, NO PEYOU CAN RELEAS YOUR YOU CAN RELEAS YOUR

DEVICEDEVICE..52

ASD SENT TO SURGERYASD SENT TO SURGERY

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I HAVE BORDERLINE I HAVE BORDERLINE OSTIUM PRIMUM OF 0.9CM.OSTIUM PRIMUM OF 0.9CM.WE CAN START WITH 38MM WE CAN START WITH 38MM

DEVICE. DEVICE.

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WE HAVE FENESTRATED WE HAVE FENESTRATED SEPTUM WITH DEFECTIVE SEPTUM WITH DEFECTIVE TISSUE ALL AROUND BY TISSUE ALL AROUND BY

3D3D

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REPOSITION PLEASEREPOSITION PLEASE

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YOUR DEVICE INSIDE RAYOUR DEVICE INSIDE RA

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I HAVE SMALL FLOW AT I HAVE SMALL FLOW AT THE AORTA, CAN I CHECK THE AORTA, CAN I CHECK

MV RELATION BY TTEMV RELATION BY TTE

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THE AML IS HITTING THE THE AML IS HITTING THE DEVICE WITH EVERY BEAT, DEVICE WITH EVERY BEAT, I AM AFRAID FROM LONG I AM AFRAID FROM LONG TERM EROSION OF AMLTERM EROSION OF AMLCAN WE TRY A SMALLER CAN WE TRY A SMALLER DEVICE 34MM PLEASE.DEVICE 34MM PLEASE.

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RELATION OF THE DEVICE RELATION OF THE DEVICE TO MV IS OK BUT I HAVE TO MV IS OK BUT I HAVE CLEAR RESIDUAL SHUNT CLEAR RESIDUAL SHUNT

AT THE AORTA AT THE AORTA QUESTIONING THE QUESTIONING THE

STABILITY OF THE DEVICESTABILITY OF THE DEVICEWE WILL LEAVE THE WE WILL LEAVE THE

DEVICE FOR 2HOURS THEN DEVICE FOR 2HOURS THEN WE WILL REASSES BY TTE.WE WILL REASSES BY TTE.

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WE HAVE RESIDUAL FLOW WE HAVE RESIDUAL FLOW AT THE AORTA AND IVC RIM, AT THE AORTA AND IVC RIM,

THE STABILITY OF THE THE STABILITY OF THE DEVICE IS QUISTIONABLEDEVICE IS QUISTIONABLE

WE DECIDE TO REMOVE THE WE DECIDE TO REMOVE THE DEVICE AND SEND THE DEVICE AND SEND THE PATIENT FOR ELECTIVE PATIENT FOR ELECTIVE SURGICAL CLOSURE.SURGICAL CLOSURE.

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LAST 2 IMAGES ARE LAST 2 IMAGES ARE TAKEN BY DR NIZAM IN OR TAKEN BY DR NIZAM IN OR

AFTER SUCCESSFUL AFTER SUCCESSFUL SURGICAL CLOSURESURGICAL CLOSURE

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TAVI CORE TAVI CORE VALVEVALVE

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I HAVE LVOT 23.5CM AND I HAVE LVOT 23.5CM AND SINUS DIAMETER 30MM,SINUS DIAMETER 30MM,26MM CORE VALVE WILL 26MM CORE VALVE WILL

BE SUITABLEBE SUITABLE..

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I HAVE MODERATE I HAVE MODERATE CENTRAL AR WITH CENTRAL AR WITH

VENACONTRACTA 0.43, VENACONTRACTA 0.43, MILD MR, I GET PEAK PG MILD MR, I GET PEAK PG 0F 122MMHG IN TG AV LA 0F 122MMHG IN TG AV LA

VIEWVIEW

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TAKE CARE BOTH AR AND TAKE CARE BOTH AR AND MR INCREASED ONE MR INCREASED ONE

GRADEGRADE

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I HAVE MILD PARAVALVULAR I HAVE MILD PARAVALVULAR LEAK WITH VENACONTRACTA LEAK WITH VENACONTRACTA 0.2CM WHICH FOR SURE LESS 0.2CM WHICH FOR SURE LESS

THAN PREPROCEDURE THAN PREPROCEDURE REGURGE.REGURGE.

MEAN PG 18MMHG FROM TG MEAN PG 18MMHG FROM TG AV LA VIEW.AV LA VIEW.

MR CAME BACK TO MILD.MR CAME BACK TO MILD.96

FROM MY POINT OF VIEW FROM MY POINT OF VIEW EVERY THING IS OK , NO EVERY THING IS OK , NO

NEED FOR BALLOON NEED FOR BALLOON DILATION.DILATION.

WELL DONEWELL DONE97

EDWARD TAVIEDWARD TAVI

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TRACE PARAVALVULAR TRACE PARAVALVULAR LEAK, PG 4MMHG.LEAK, PG 4MMHG.

WELL DONE.WELL DONE.

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HOCMHOCM106

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I HAVE PEAK PG OF I HAVE PEAK PG OF 25MMHG, WE CAN NOT 25MMHG, WE CAN NOT

ABLATE ON THIS PG, ABLATE ON THIS PG, PROVACATION SHOULD BE PROVACATION SHOULD BE

DONE.DONE.

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I HAVE MAXIMUM I HAVE MAXIMUM PROVACATED PEAK PG PROVACATED PEAK PG

170MMHG.170MMHG.POST ECTOPIC PG POST ECTOPIC PG

122MMHG.122MMHG.NOW WE CAN START NOW WE CAN START

SEARCHING THIS SEPTAL SEARCHING THIS SEPTAL BRANCHBRANCH

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YOU CATCH IT, THIS IS THE YOU CATCH IT, THIS IS THE SEPTAL BRANCH SEPTAL BRANCH

SUPPLYING THE BASAL SUPPLYING THE BASAL ANTERIOR SEPTUM ANTERIOR SEPTUM

INCLUDING THE CONTACT INCLUDING THE CONTACT WITH AML.WITH AML.

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THERE IS PG 65 MMHG AND THERE IS PG 65 MMHG AND POST ECTOPIC PG 70 POST ECTOPIC PG 70

MMHGMMHGIT IS DECREASED BUT IT IS DECREASED BUT

STILL WE HAVE STILL WE HAVE SIGNIFICANT PGSIGNIFICANT PG

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THE PROXIMAL 8MM OF THE PROXIMAL 8MM OF THE BASAL SEPTUM STILL THE BASAL SEPTUM STILL MOVING BULGING TO LVOTMOVING BULGING TO LVOTAND NOT OBASIFIED WITH AND NOT OBASIFIED WITH

DIE AS DISTAL PART.DIE AS DISTAL PART.CAN WE SEARCH FOR CAN WE SEARCH FOR

ANOTHER SEPTAL THAT ANOTHER SEPTAL THAT MAY STILL SUPPLYING THIS MAY STILL SUPPLYING THIS

AREA. AREA. 131

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I HAVE PEAK PG AT PACED I HAVE PEAK PG AT PACED TACHYCARDIA 100 BM TACHYCARDIA 100 BM

15MMHG.15MMHG.THIS IS VERY ACCEPTABLE THIS IS VERY ACCEPTABLE

RESULT.RESULT.WE CAN STOP AT THIS WE CAN STOP AT THIS

STAGE WELL DONE.STAGE WELL DONE.

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I TOOK HOME MASSAGEI TOOK HOME MASSAGE- - I THINK WE SHOULD WAIT LONGER I THINK WE SHOULD WAIT LONGER TIME TO ASSESS THE RESULT TIME TO ASSESS THE RESULT BEFORE SEARCHING FOR ANOTHER BEFORE SEARCHING FOR ANOTHER BRANCH.BRANCH.-- NON OBACIFIED SEGMENT DOSE NON OBACIFIED SEGMENT DOSE NOT MEAN IT STILL HAVE BLOOD NOT MEAN IT STILL HAVE BLOOD SUPPLY.SUPPLY.-- LOOK FOR SEGMENT KINESIS LOOK FOR SEGMENT KINESIS BEFORE LOOKING FOR THE PG.BEFORE LOOKING FOR THE PG.-- COMPARE BASELINE IMAGE TO COMPARE BASELINE IMAGE TO POST ABLATION IMAGE.POST ABLATION IMAGE.

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MV CLIPMV CLIP139

THANK YOUTHANK YOU

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