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Role of Intracardiac Echocardiography
in Percutaneous Pulmonary Valve
Implantation
Qi-Ling Cao, MD.
Medical Director
Echocardiography & Research Lab.
Sidra Medical and Research Center
Doha, Qatar
BACKGROUND • Percutaneous transcatheter replacement
of the pulmonic valve avoids mortality and
morbidity of multiple surgical reoperations.
• Cine angiography and Intracardiac echo
(ICE) have been employed during the
procedure to guide and assess the
implantation of pulmonary valve.
• In Oct. 2000, Bonhoeffer reported the first clinical case of
a transcatheter PHV placement in a conduit between RV
and PA • In 2005, Hijazi report using SAPIEN THV implant in PA
homograft for a 16 yrs/old male, with ToF, s/p multiple
surgical repairs, homograft obstruction and significant PR • In May 2013, Dr. Hijazi report using VENUS transcatheter
self-expand pulmonary valve (P-Valve) in pulmonary
positionmfor patient who were status post ToF repair using
the trans-annular patch technique with significant pulmonary
regurgitation, and large PA&RVOT
Historical Overview
PURPOSE
Demonstration of the role of ICE in
guiding the deployment of the
Pulmonary Valve and in evaluating
the valve function.
AcuNav Catheter
Intracardiac Echocardiography (ICE)
• 64 elements ultrasound tipped catheter
• Steering: 4 way in 2 planes
• Image modes: 2-D;
Color Doppler & DTI
Spectral Doppler: PW & CW
8.0F (2.5 mm),
5.5~10 MHz
Using 8F Sheath
ICE for
Catheter Interventions
TEE Images of Pulmonary Valve
• PV is in the far field, with lower quality 2DE image
• The blood flow passing PV is near 90º with echo beam
- bad for demo color Doppler flow
- unable to use PW and CW to measure gradient and
Assess valve competence.
Transesophageal Echocardiography
ICE cath in RVOT
ICE Standard View for PV
MPA
RPA
LPA
PV
Intracardiac Echocardiography
Normal Pulmonary Valve
1. Cath hemodynamic assessment
of the valve and cine angiography.
2. ICE assessment pre, during and
post valve deployment.
A. Edwards SapienTM THV.
B. Melody Valve
C. Venus P-Valve
PROTOCOL
Rush University
Medical Center
Edwards SapienTM Pulmonic Valve
Valve Size: Delivery Catheter:
A. 23 mm 22 Fr. Sheath
B. 26 mm 24Fr. Sheath
Edwards SapienTM Pulmonic Valve
Percutaneous Transcatheter Replace
Pulmonic Valve
Deploy a Stent Pre-Valve
a
A
b
B
c d
C D
Edwards SapienTM Pulmonic Valve
Percutaneous Transcatheter Replace
Pulmonic Valve Using Edwards PHV
A B C
a b c
D
d
Melody Percutaneous Pulmonic Valve
Valve Size: 18 mm, 20 mm, 22 mm Delivery Catheter: 22 Fr. Sheath
Rush University
Medical Center RCCSH
D RCCSD
Melody Percutaneous Pulmonic Valve
Percutaneous Transcatheter Replace
Pulmonic Valve Using Melody PHV
Percutaneous Transcatheter Replace
Pulmonic Valve Using Melody PHV
A B C D
a b c d
Rush University
Medical Center
Transcatheter Placement PHV
Steps by ICE
A C E G
B D F H
I K M O
J L N
Transcatheter Placement PHV
Steps by ICE
ICE for Implantation of Pulmonary Valve
VENUS P-Valve
• Structure (stent): Nitinol self-expandable
multi-level support frame • Integrated, unidirectional tri-leaflet porcine
pericardial tissue valve • The entire stent is covered (except the distal
cells) by porcine pericardium • The stent valve is a moderately radiopaque • Smaller delivery catheter
Valve Size: Delivery Catheter:
Diameter: 16-32 mm 16-22 Fr. Seath
Length: 20 mm; 25 mm
30 mm; 35 mm
VENUS P-Valve
VENUS P-Valve
RVOT View PA View
Delivery Catheter
Slow/precise release
Fast release
14-22 Fr
Marker
VENUS P-Valve
1
3
2
3 Markers
VENUS P-Valve
Crimpier
VENUS P-Valve
Conclusion
Intracardiac Echocardiography
• ICE can be used successfully to assess
the function of the pulmonary valve pre &
Post intervention also guiding valve
implantation.
• We believe it is the best tool to assess the
PHV function after removal of all catheters
from across the valve
Rush University
Medical Center