Real-Time 3D Interventional Echocardiography


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Intraprocedurally, TEE is used to initially guide transseptal puncture and to confirm optimal positioning of the delivery system. Optimal device placement is when the axis of the device aligns with the long axis of the LAA. Finally, at the end of the procedure, TEE is used to assess for changes in transmitral and pulmonary vein flow, along with potential complications including pericardial effusion, tamponade or device migration. However, many of these patients are considered inoperable due to significant surgical risk. The development of transcatheter aortic valve replacement TAVR gave high and intermediate risk patients an equally efficacious, but less invasive, option for valve replacement.

Specifically, echocardiography plays an essential role in the identification of patients with severe AS, sizing of the prosthesis, intraprocedural guidance, and the follow-up of prosthetic valve function. Two-dimensional and Doppler echocardiography remain the workhorses for the diagnosis of severe AS. TEE with Doppler is often less accurate due to difficulties with ultrasound beam alignment.


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However, TEE planimetry provides an alternative method for patients with suboptimal transthoracic echocardiography TTE evaluation. It correlates quite well with a continuity equation-derived valve area on TTE and with valve area derived from the Gorlin formula in the catheterization lab. This question is important, since undersizing can result in device embolization or significant paravalvular leak, an independent predictor of mortality after TAVR.

Concomitant TEE during the TAVR procedure aids in the placement of the valve, allows visualization of balloon aortic valvuloplasty, helps with sizing, identifies heavily calcified aortic annuli, identifies shallow coronary ostia origin, and provides rapid feedback to the interventionalist on complications. The general trend is to use TEE-guided TAVR placement during cases necessitating general anesthesia, and those with transapical, transaortic or subclavian approaches for image quality reasons.

A number of studies have shown that conscious sedation is becoming more prevalent with a transfemoral approach, and outcomes have been similar despite greater use of TTE over TEE. The interventionalist and echocardiographer should localize the prosthesis below the aortic annulus and monitor its relationship to the MV and left ventricular outflow tract. The team must also look for the prosthesis to assume its predicted circular shape in the short axis view.

TTE is performed at 24 hours, 30 days, and then at least annually after the procedure. Degenerative MV disease is the most common cause of mitral regurgitation MR. Most recently, a 5-year follow-up for durability was evaluated. Additionally, there were no differences in long-term survival, left ventricular function, or dimensions. Although surgery has superior outcomes, there is evidence that a percutaneous alternative is safe, improves heart failure symptoms, and left ventricular dimensions.

Identifying patients who meet the criteria for MitraClip starts with transthoracic echo imaging. Patients with these echo criteria included in the EVEREST cohort were more likely to have a successful intervention without the need for a recurrent procedure. Close collaboration between the primary operator and the echocardiographer is necessary to achieve successful placement.

Evaluation of the all pulmonary veins, in addition to all MR parameters, is invaluable to judge the success of the MitraClip procedure.

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TEE guidance begins with the transseptal puncture. Localization of the optimum position is posterior and superior in the septum with a height 3. The echocardiographer provides feedback on the proximity of the tip of this catheter and the wall of the left atrium. The MitraClip is directed to the left atrial appendage and then flexed downwards to the MV while using 3D imaging. A surgical view of the MV from a left atrial orientation allows positioning of the MitraClip perpendicular to the coaptation line and directly over the origin of MR, see Figure 4D. The device is advanced into the left ventricle using biplane imaging, preferably using a bicommissural view and long-axis view on the opposite plane, see Figure 4C.

The clip is positioned in the long-axis view to grab the anterior and posterior leaflets using 2D echocardiography. The flow convergence method is challenging, since it may overestimate MR when assessing multiple jets and underestimate MR in eccentric jets. A complete post-device evaluation should determine the presence of pericardial effusion, ventricular or leaflet perforation, and residual iatrogenic ASDs.

The shunt assessment should be done with 3D TEE, since it has proven to be more accurate in predicting size compared to 2D TEE, which underestimates diameter and area. At 1 year, reduction in MR and improvement in left ventricular dimensions were also comparable. This study argues that the MitraClip should be expanded to those patients with less ideal echocardiographic features.

However, those who did not meet the strict criteria were more likely to require an additional intervention due to recurrent MR. Catheter intervention with the assistance of echocardiography has created a suitable alternative for the closure of uncomplicated secundum ASD and PFO. The indications for ASD closure include right ventricular and atrial enlargement, evidence of paradoxical embolism, or documented orthodeoxia-platypnea, and may be considered when a significant shunt is present.

TTE with agitated saline is usually the initial step in the detection of atrial shunts and in assessing the hemodynamic consequences. There are a number of anatomical features that are required to confirm catheter closure suitability and device choice. There are several types of device available, and the presence of certain anatomical features will sway the use of one device over another.

Jude Medical when there is a deficient rim, since its softer disks may lead to less erosion. This image can then be rotated to view the septum from the right and left atrium, enabling us to appreciate the dynamic geometry in diastole and systole.

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The pre-assessment for a PFO should include size of the left and right atrial opening, total length of the PFO tunnel, the presence of aneurysm, and the location and extent of the Eustachian ridge and valve. The pre-assessment for ASD closure includes thickness of the secondary septum, rim size, and defect size. Once appropriate patients and devices are selected, 3D TEE can assist in the septal puncture from the oblique and lateral views, and in the case of ASDs it has been shown to provide better definition of septal anatomy and visualization of catheters.

From the oblique and lateral views, the guide catheter can be seen clearly crossing the IAS. While in this view, rotating from right to left creates a view of the catheter in the left atrium, allowing for disk expansion. A lateral perspective allows visualization of the right disk expansion, resulting in the IAS being sandwiched by two expanded disks, see Figure 5. The trend towards developing less invasive procedures for structural heart disease has led to an increased need for echocardiography support in the diagnosis of disease, sizing of devices, procedural guidance, and monitoring to determine the success or failure of procedures.

There is a high demand for improved spatial and temporal resolution via 2D and 3D imaging to meet these expectations. Evolving technology is expanding the role and improving the accuracy of 2D and 3D TEE and TTE in the rapidly-growing fields of structural cardiology and interventional echocardiography. Skip to main content. Radcliffe Cardiology. Search form Search this site.

Login Register. Roy Arjoon. Ashley Brogan. Lissa Sugeng. Login or register to view PDF. View eJournal. Order reprints. Interventional echocardiography, atrial septal defect closure, patent foramen ovale closure, MitraClip, transcatheter aortic valve replacement, left atrial appendage occlusion, WATCHMAN.

Roy Arjoon and Ashley Brogan have no conflicts of interest to declare. Box , New Haven, CT E: lissa. Received date. Accepted date. US Cardiology Review ;12 1 —7. Ashley Brogan and Roy Arjoon both contributed equally in writing this manuscript. Left Atrial Appendage Occlusion Approximately 2. Open in new tab Open ppt Open in new tab Open ppt Intraprocedurally, TEE is used to initially guide transseptal puncture and to confirm optimal positioning of the delivery system.

Fanari Z, Weintraub WS. Cost-effectiveness of transcatheter versus surgical management of structural heart disease. Cardiovasc Revasc Med ; 44—7. The changing face of interventional cardiology. Circ Cardiovasc Interv ; 5: —7. Training in structural heart interventions. J Am Coll Cardiol ; —8; discussion J Am Coll Cardiol ; e1— Risk of stroke or systemic embolism in atrial fibrillation patients treated with warfarin: a systematic review and meta-analysis. Stroke ; — Clinical Electrocardiography E-Book. Ary L. Paul Leeson. Osteotomies around the Knee.

Philipp Lobenhoffer. Hemodynamic Monitoring Made Incredibly Visual! Small Animal Orthopaedics. Daniel Lewis. July Michael J. Donald E. Mansoor Kassim. Comprehensive Atlas of 3D Echocardiography. Stanton K. Brian S.

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