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