Ο ρόλος ης ριιάσ αηςηχωκαριοραφίας σηνποσοικοποίηση...
Transcript of Ο ρόλος ης ριιάσ αηςηχωκαριοραφίας σηνποσοικοποίηση...
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