Ο ρόλος της τριδιάστατης ηχωκαρδιογραφίαςστην ποσοτικοποίηση και αντιμετώπιση της

ανεπάρκειας μιτροειδούς

Κωνσταντίνος Παπαδόπουλος

Επιμελητής Α΄ Καρδιολογίας,

Νοσοκομείο Κοργιαλένειο – Μπενάκειο Ε.Ε.Σ.

Ποια η τρέχουσα θέση της τριδιάστατης ηχωκαρδιογραφίας στη διαχείριση των ασθενών με ανεπάρκεια της μιτροειδους βαλβίδας?

1. Βοηθά στην καλύτερη εκτίμηση της αιτιολογίας τηςπρωτοπαθούς μιτροειδικής ανεπάρκειας

2. Χρησιμοποιείται για την ποσοτικοποίηση της ανεπάρκειας μέσωτης 3D-PISA ή 3D – VC

3. Παρέχει χρήσιμες παραμέτρους για τον επεμβατικό καρδιολόγοπριν την επέμβαση και τον κατευθύνει σε ορισμένα στάδια τωνδιαδερμικών επεμβάσεων στη βαλβίδα

4. Το 1 και 3

5. Όλα τα ανωτέρω

MITRAL VALVE

3D Full Volume 3D Zoom

BUT....

MITRAL VALVE – 3D TTE

From LA perspective

From LV perspective

3D

ZOOM

MITRAL VALVE- 3DΤΕΕ

3D TEE in MV REGURGITATION

• Mainly in organic (primary) disease (degenerative, prolapse / flail, perforation, cleft, endocarditis)

• O’Gara P, et al. JACC Cardiovasc Imaging 2008;1:221–237

• Chandra S, et al.Circ Cardiovasc Imaging 2011;4:24–32

• Enriquez-Sarano, M et al. Lancet. 2009;373:1382-94.

Normal Prolapse Flail Functional MR

A. AETIOLOGY

Barlow’s Disease Deep slit/cleft posterior leaflet

Endocarditis Secondary MVR

FED (Prolapse / Flail valve)

B. EVALUATION / QUANTIFICATION of

MV REGURGITATION

2017 ESC/EACTS Guidelines for the management

of VHD. European Heart Journal 2017 38, 2739–86

Valve morphology

VC and PISA method correspond hemodynami-

cally to the EROA

2D VC and PISA reliable only in circular EROA

EROA is non-circular in most patients

Patients with Secondary MR have hemielliptic

ROA (Narrow in 4C and broad in 2C)

Systematic underestimation of true EROA with

2D VC and PISA

3D echocardiography is promising to overcome

the major limitations of 2D-based methods

Buck T, Plicht B. Curr Cardiovasc Imaging Rep. 2015;8:38

3D in MV Morphology

• Accurate assessment of the size, shape

and number of ROAs

• Increased accuracy of the estimation of

MR flow volume

• Regurgitant volume ( RV=VCA x VTI

MR)

• Good correlation with RV measured by

velocity-encoded CMR

• Cut off values 3D-VC for severity >41

mm2 - 60mm2

3D VENA CONTRACTA

-Kahlert P, et al. J Am Soc Echocardiogr. 2008;21:912–21.

-Thavendiranathan P, et al . J A C C 2012;60:1470–83

-Zeng X, et al . Circ Cardiovasc Imaging 2011;4:506–513

-Buck T, et al. Curr Cardiovasc Imaging Rep (2015) 8: 38

-Marsan, et al. JACC Cardiovasc Imaging. 2009;2:1245–52

3D VC

• No hemodynamic assumption of a

hemispheric shape of isovelocities

• 3D PISA: elongated / hemielliptic shape

• Can be obtained from RT3DE datasets

using PISA width, length, and radius for

the calculation of the hemielliptic PISA

surface by a specific formula

• New workstations measure PISA

automatically

• Cut off values >36-51 mm2

-Hyodo E, et al .JACC Cardiovasc Imaging 2012;5:669–676

-Thavendiranathan P, et al . J Am Coll Cardiol 2012;60:1470–1483

-Shanks M, et al . Circ Cardiovasc Imaging 2010; 3:694–700

-Zeng X, et al . Circ Cardiovasc Imaging 2011;4:506–513

3D PISA

• Complex dynamic changes of VCA size and shape

• Limited temporal and spatial resolution of 3D

color Doppler datasets

• Artifacts

• PISA formula too complex

• Significantly different Cut-off values of 3D VCA

and PISA proposed from studies to distinguish

between severe and non-severe MR

• 3D VCA seems to tend to larger values compared

to EROA from 3D PISA

• 3D VCA / 3D PISA not for clinical routine

application

• Further validation and studies evaluating their

clinical and prognostic value are needed

LIMITATIONS

-Buck T, et al. Curr Cardiovasc Imaging Rep

(2015) 8: 38

-Schmidt FP, et al. Int J Cardiovasc Imaging.

2014;30:1501–8.

-Thavendiranathan P, et al. Circ Cardiovasc

Imaging. 2013;6:125–33

C. MANAGEMENT OF MV REGURGITATIONBEFORE and DURING (Transcatheterinterventions)

BEFORE

-Mor-Avi V, et al. Circulation 2013;119:314–329

-Chandra S, et al Circ Cardiovasc Imaging 2011;4:24–32

-Lang, R et al. J Am Coll Cardiol 2011;58:1933–44

MV Quantification

Semi-automatic software for MV

analysis (leaflets / annulus, anatomy

and pathologies)

A plethora of quantitative measure-

ments

Preoperative interventional plan-

ning and individualizing the appro-

ach to the patient.

MVQ Analysis IN PRIMARY MR

• A ‘dynamic’ view of the valve similar to

that seen intraoperatively by the surgeon

• Outcomes prediction in MV repair

• Guidance for surgical repair or MitraClip

Parameters:

• Exact location of abnormality (Anterior /

Posterior leaflet / scallops 1,2,3

• Number of the prolapsed segments

• Length / Area (volume) of the prolapsed

portion

• Tenting High (flail gap)

• MV area, Annulus area, A-P / AL-PM diameter

• Direct measurement of anatomic orifice area

MVQ Analysis IN SECONDARY MR

-Annulus diameters area & circumference

-Mitral Valve area

-Tenting volume / height

-Coaptation length / depth

• Outcomes prediction in MV repair

• Guidance for surgical repair or MitraClip

Parameters:

SURGICAL MV REPAIR –

ROLE of 3D TEE

Calleja A, et al. J Am Soc Echocardiogr 2015;28:1083-92

NOVEL 3D AUTOMATED

SOFTWARE FOR MV

QUANTIFICATION

-Eibel S, et al. Int J Cardiovasc Imaging. 2017 [Epub ahead of print]

-Aquila et al. Medicine (2016) 95:49

-Aquila et al. Cardiovascular Ultrasound (2016) 14:17

--Mahmood F, et al. JACC CVI 2015:226 – 3 1

- Vukisevic, et al. 2017;45:508-519

3D PRINTING

Patient-specific 3D-printed anatomical

models of intracardiac structures using

3D echocardiographic data

- Haptic feel and true 3D perspective

- Potential applications in cardiac inter-

ventions and surgery for:

> developing a superior surgical plan well

before the first incision

> designing task trainers, patient-specific

annuloplasty devices, and prosthetic

heart valves.

- Currently, technological limitations

- 3D printed valvular models for education

3d in Transcatheter Mitral Valve Repair (Mitral Clip)

DURING

Faletra et al. JACC: CARDIOVASCULAR IMAGING 2 0 1 4;7 : 2 9 2 – 3 0 8

1. Transeptal Puncture

- At the high and mid / posterior aspect of fossa ovalis

- Observe “tenting” at this site and cross the F.O.

Faletra et al. JACC- CVI 2014;7: 292-308

2. Mitral Clip Delivery

System in the Left Atrium3. Steering the mitral clip system

toward the mitral valve

4. Opening the arm perpendicularly

to the coaptation line

This step is usually guided by

2D TEE because of its higher

temporal and spatial resolution

5. Capturing the leaflets

6. Evaluating adequacy of the

insertion of the leaflets into the clip7. Clip deployment and

withdrawal of the guide catheter

VALVE IN VALVE

Courtesy of Hygeia Medical Center

(K. Papadopoulos, M Chrysoheris)

VALVE IN RING MV REPLACEMENT

OTHER TRANSCATHETER PROCEDURES

LIMITATIONS

• Training is required for both image acquisition and analysis

• Time consuming

• ‘Off line’ study

• Not well validated automatic software for MV analysis

• Relatively low inter- and intra-observer reproducibility of

manual measurements

• Low spatial and temporal resolution

• Artifacts

3D (TEE) ECHOCARDIOGRAPHY

• Superior visualization of the MV anatomy and morphology,

• Better assessment of the aetiology of primary MVR

• Quantification of MV regurgitation (3DVC-3DPISA) is not

recommended yet for clinical routine application

• Plethora of quantitative measurements of the MV for preoperative

interventional planning

• Useful guide for the interventionist in some stages of the procedure

CONCLUSIONS

Ποια η τρέχουσα θέση της τριδιάστατης ηχωκαρδιογραφίας στη διαχείριση των ασθενών με ανεπάρκεια της μιτροειδους βαλβίδας?

1. Βοηθά στην καλύτερη εκτίμηση της αιτιολογίας τηςπρωτοπαθούς μιτροειδικής ανεπάρκειας

2. Χρησιμοποιείται για την ποσοτικοποίηση της ανεπάρκειας μέσωτης 3D-PISA ή 3D – VC

3. Παρέχει χρήσιμες παραμέτρους για τον επεμβατικό καρδιολόγοπριν την επέμβαση και τον κατευθύνει σε ορισμένα στάδια τωνδιαδερμικών επεμβάσεων στη βαλβίδα

4. Το 1 και 3

5. Όλα τα ανωτέρω