Ο ρόλος της τριδιάστατης ηχωκαρδιογραφίας στην ποσοτικοποίηση και αντιμετώπιση της ανεπάρκειας μιτροειδούς

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1 Ο ρόλος της τριδιάστατης ηχωκαρδιογραφίας στην ποσοτικοποίηση και αντιμετώπιση της ανεπάρκειας μιτροειδούς Κωνσταντίνος Παπαδόπουλος Επιμελητής Α Καρδιολογίας, Νοσοκομείο Κοργιαλένειο Μπενάκειο Ε.Ε.Σ.

2 Ποια η τρέχουσα θέση της τριδιάστατης ηχωκαρδιογραφίας στη διαχείριση των ασθενών με ανεπάρκεια της μιτροειδους βαλβίδας? 1. Βοηθά στην καλύτερη εκτίμηση της αιτιολογίας της πρωτοπαθούς μιτροειδικής ανεπάρκειας 2. Χρησιμοποιείται για την ποσοτικοποίηση της ανεπάρκειας μέσω της 3D-PISA ή 3D VC 3. Παρέχει χρήσιμες παραμέτρους για τον επεμβατικό καρδιολόγο πριν την επέμβαση και τον κατευθύνει σε ορισμένα στάδια των διαδερμικών επεμβάσεων στη βαλβίδα 4. Το 1 και 3 5. Όλα τα ανωτέρω

3 MITRAL VALVE

4 MITRAL VALVE 3D TTE 3D Full Volume 3D Zoom BUT...

5 MITRAL VALVE- 3DΤΕΕ 3D ZOOM From LA perspective From LV perspective

perforation, cleft, endocarditis) O Gara

6 3D TEE in MV REGURGITATION A. AETIOLOGY Normal Prolapse Flail Functional MR Mainly in organic (primary) disease (degenerative, prolapse / flail, perforation, cleft, endocarditis) O Gara P, et al. JACC Cardiovasc Imaging 2008;1: Chandra S, et al.circ Cardiovasc Imaging 2011;4:24 32 Enriquez-Sarano, M et al. Lancet. 2009;373:

7 FED (Prolapse / Flail valve) Barlow s Disease Deep slit/cleft posterior leaflet Endocarditis Secondary MVR

2C) Systematic underestimation of true EROA with 2D VC and PISA 3D echocardiography is promising to overcome the major limitations of 2D-based

8 B. EVALUATION / QUANTIFICATION of MV REGURGITATION Valve morphology VC and PISA method correspond hemodynamically 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: ESC/EACTS Guidelines for the management of VHD. European Heart Journal ,

9 3D in MV Morphology

mm 2-60mm 2 -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.

10 3D VENA CONTRACTA 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 3D VC Cut off values 3D-VC for severity >41 mm 2-60mm 2 -Kahlert P, et al. J Am Soc Echocardiogr. 2008;21: Thavendiranathan P, et al. J A C C 2012;60: Zeng X, et al. Circ Cardiovasc Imaging 2011;4: Buck T, et al. Curr Cardiovasc Imaging Rep (2015) 8: 38 -Marsan, et al. JACC Cardiovasc Imaging. 2009;2:

3D PISA No hemodynamic assumption of a hemispheric shape of isovelocities 3D PISA: elongated

for the calculation of the hemielliptic PISA surface by a specific formula New workstations

jacc Cardiovasc Imaging 2012;5:669 676 -Thavendiranathan P, et al.

11 3D PISA 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 mm 2 -Hyodo E, et al.jacc Cardiovasc Imaging 2012;5: Thavendiranathan P, et al. J Am Coll Cardiol 2012;60: Shanks M, et al. Circ Cardiovasc Imaging 2010; 3: Zeng X, et al. Circ Cardiovasc Imaging 2011;4:

LIMITATIONS 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

12 LIMITATIONS 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 -Buck T, et al. Curr Cardiovasc Imaging Rep (2015) 8: 38 -Schmidt FP, et al. Int J Cardiovasc Imaging. 2014;30: Thavendiranathan P, et al. Circ Cardiovasc Imaging. 2013;6:125 33

C. MANAGEMENT OF MV REGURGITATION BEFORE and

Quantification Semi-automatic software for MV

planning and individualizing the approach to

Circulation 2013;119:314 329 -Chandra S, et al

13 C. MANAGEMENT OF MV REGURGITATION BEFORE and DURING (Transcatheter interventions) BEFORE MV Quantification Semi-automatic software for MV analysis (leaflets / annulus, anatomy and pathologies) A plethora of quantitative measurements Preoperative interventional planning and individualizing the approach to the patient. -Mor-Avi V, et al. Circulation 2013;119: Chandra S, et al Circ Cardiovasc Imaging 2011;4: Lang, R et al. J Am Coll Cardiol 2011;58:

MVQ Analysis IN PRIMARY MR A dynamic view of the valve similar to that seen

surgical repair or MitraClip Parameters: Exact location of abnormality

segments Length / Area (volume) of the prolapsed portion Tenting High (flail

14 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

15 MVQ Analysis IN SECONDARY MR Outcomes prediction in MV repair Guidance for surgical repair or MitraClip Parameters: -Annulus diameters area & circumference -Mitral Valve area -Tenting volume / height -Coaptation length / depth

NOVEL 3D AUTOMATED SOFTWARE FOR MV QUANTIFICATION

16 NOVEL 3D AUTOMATED SOFTWARE FOR MV QUANTIFICATION SURGICAL MV REPAIR ROLE of 3D TEE -Eibel S, et al. Int J Cardiovasc Imaging [Epub ahead of print] -Aquila et al. Medicine (2016) 95:49 -Aquila et al. Cardiovascular Ultrasound (2016) 14:17 Calleja A, et al. J Am Soc Echocardiogr 2015;28:

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

17 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 interventions 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 --Mahmood F, et al. JACC CVI 2015: Vukisevic, et al. 2017;45:

18 DURING 3d in Transcatheter Mitral Valve Repair (Mitral Clip) Faletra et al. JACC: CARDIOVASCULAR IMAGING ;7 :

19 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:

20 2. Mitral Clip Delivery System in the Left Atrium 3. Steering the mitral clip system toward the mitral valve

21 4. Opening the arm perpendicularly to the coaptation line 5. Capturing the leaflets This step is usually guided by 2D TEE because of its higher temporal and spatial resolution

22 6. Evaluating adequacy of the insertion of the leaflets into the clip 7. Clip deployment and withdrawal of the guide catheter

23 OTHER TRANSCATHETER PROCEDURES VALVE IN VALVE VALVE IN RING MV REPLACEMENT Courtesy of Hygeia Medical Center (K. Papadopoulos, M Chrysoheris)

24 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

25 CONCLUSIONS 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

26 Ποια η τρέχουσα θέση της τριδιάστατης ηχωκαρδιογραφίας στη διαχείριση των ασθενών με ανεπάρκεια της μιτροειδους βαλβίδας? 1. Βοηθά στην καλύτερη εκτίμηση της αιτιολογίας της πρωτοπαθούς μιτροειδικής ανεπάρκειας 2. Χρησιμοποιείται για την ποσοτικοποίηση της ανεπάρκειας μέσω της 3D-PISA ή 3D VC 3. Παρέχει χρήσιμες παραμέτρους για τον επεμβατικό καρδιολόγο πριν την επέμβαση και τον κατευθύνει σε ορισμένα στάδια των διαδερμικών επεμβάσεων στη βαλβίδα 4. Το 1 και 3 5. Όλα τα ανωτέρω

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