SJM Structural Heart Disease Symposium, 14th May 2008

The new Cardiac Imaging Techniques for Transcatheter Structural Heart Therapies
Horst Sievert, Nina Wunderlich, Nico Majunke, Kristina Renkhoff
CardioVascular Center Frankfurt Frankfurt, Germany Washington Hospital Center Washington, DC, USA

Conflict of Interest Statement

Physician name Horst Sievert Company Abbott, Access Closure, AGA, Angiomed, Boston, CardioKinetix, CardioMEMS, Cierra, Coherex, Coaptus, Cordis, CSI, Edwards, EndoTex, ev3, FlowCardia, Gore, Guidant, Invatec, Lumen Biomedical, Kensey Nash, NDC, NMT, OAS, Occlutech, Ovalis, Pathway, pfm PendraCare Percardia, Remon, Rox Medical, Sadra, Sorin, Spectranetics, St. Jude, Terumo, Topspin, Velocimed, Xtent Cardiokinetix, Access Closure, Velocimed, CoAptus, Lumen Biomedical, Medical Ventures Relationship Consulting fees, Travel expenses, Study honoraria

Stock options, Stocks

Structural Heart Interventions

Valve Interventions
Valvuloplasty Mitral valve repair Paravalvular leaks closure Valve Implantation

Other cardiac Interventions

Dilatation/stent implantation sub- und supravalvular stenosis Dilatation/stent implantation of coarctation Dilatation/stent implantation of pulmonary artery- and veinstenosis Left atrial appendage closure

Shunt Closure
Patent ductus closure ASD- Closure PFO- Closure VSD-Closure Fistula-Closure

One fundamental difference compared to coronary interventions is

the importance of imaging

Reasons for failure in PCI

We could see the lesion but could not cross with the wire The wire was across but the balloon did not follow The balloon was there and fully inflated but the stent was not flexible enough Subacute closure occurred because the stent was not fully expanded

So PCI failure
is most often related to
- catheter equipment - and may be lack of our own catheter skills

It is usually not a problem of imaging

What are the reasons for procedural failure in structural heart interventions?

Imaging Imaging Imaging

Device issues, operator failure, lack of skills

Some examples for bad imaging

Crossing the Aortic Valve

We all know how to do it But honestly, it is more or less random probing This is in no way comparable to crossing a coronary stenosis! Forgive us, we don't see what we're doing

Aortic valve implantation

Positioning
- Imaging - Imaging - Imaging Guided by Fluoro only Other imaging does not help

PFO Closure
Device embolisation
- Why did it happen? - What did we miss?
Size of defect? Shape of defect? Rims? Relationship to surrounding structures?

Forgive us, we didn't see what we're doing

PFO Closure
Device erosion
- We don't really know why it happens in some patients - Problem of imaging

Why is imaging more difficult in structural interventions? It's all soft tissue Angiography does not work
- and / or would require large amounts of contrast dye

Which Imaging Techniques?

TEE CT

Fluoroscopy Guidance

ICE 3D Echo and TEE

MRI

Which Imaging Techniques?

TEE CT

Primary Fluoroscopy Guidance

ICE 3D Echo and TEE MRI

TEE
Widely used for structural heart interventions
ASD and PFO closure VSD closure Paravalvular leak closure Valve repair Valve implantation

You should have it available

- Even if some interventions can be performed without

TEE for ASD/PFOs and VSDs

Location of defect Rims? Additional defects? Eustachian Valve? Atypical tissue strings/membranes? Guidance of device implantation
- Device arms on the correct side?

Atypical ASD

Echo is the only way!

Membrane in LA

Only echo helps!

Simple straight forward ASD

but missed cranial rim

Multiple VSDs
Transposition of the large arteries
Multiple residual shunts after device closure Difficult on TEE Not clear on angio Not visible on CT and MRI

 and intracardiac echo?

TEE CT

Primary Fluoroscopy Guidance

ICE 3D Echo and TEE MRI

Intracardiac Echo ICE

Imaging almost as good as TEE
- Sometimes better
inferior part of the atrial septum

More convenient for the patient No need for sedation or GA No need for an echocardiographer The interventionalist has direct and immediate control over imaging

ICE: Two different Technologies

AcuNavTM 90 Sector Image

Ultra ICE (Boston) Radial 360 Imaging Plane

PFO Closure (AcuNav)

ICE Disadvantages
Additional venous access Some additional risk for intracardiac injury Echo probe may interfere with catheters/devices Sometimes difficult to keep the echo probe in a stable position Re-adjustment of the echo probe has to be done by the operator Extraordinary expensive

3D Echo?
TEE CT

Primary Fluoroscopy Guidance

ICE 3D Echo and TEE MRI

ASD Closure

2D

3D TEE nice views

ASD Closure

2D TEE

3D TEE nice views

ASD Closure

2D TEE

3D TEE
30 nice views

Mitral Valve
2D TEE
3D TEE

new views

Paravalvular Leaks
3D TEE allows views which are not possible with 2D

Courtesy Steven Goldstein

new views

Everybody is talking about CT and MRI

TEE CT

Primary Fluoroscopy Guidance

ICE 3D Echo and TEE MRI

Where does it really help in structural interventions?

Percutaneous Aortic Valve Implantation

MSCT/ Dual CT
Provides diameter of valve anulus Helps to calculate the best projection for valve implantation

The Percutaneous Aortic Valve Implant

MSCT/ Dual CT
Vessel narrowing Degree of calcification Luminal narrowing

Percutaneous Mitral Valve Repair Coronary sinus Circumflex relationship

Percutaneous Annuloplasty devices may compress Cx

LCX under CS 68% Tops et al. Circ 2007; 115: 1426-32

LCX over CS 32%

Distance between Coronary Sinus and Mitral annulus

Coronary sinus may be at the left atrial posterior wall rather than the mitral annulus
Tops et al. Circ 2007; 115: 1426-32

Coronary Sinus Approach for Mitral Valve Repair

Lessons learned

Early and late compression of the circumflex artery occurred despite use of CT The distance between mitral valve anulus and coronary sinus did not predict outcome

 and CT or MRI guidance in the cath lab?

TEE CT

Primary Fluoroscopy Guidance

ICE 3D Echo and TEE MRI

Jan 31, 2008

Questionnaire to 55 cath labs heavily involved in structural and congenital heart interventions Only 5 had used CT or MRI in the cath lab
- for research only - 4/5 have stopped completely

It seems to be that in daily practice nobody is currently using CT or MRI in the cath lab for structural interventions

Some comments from the most famous institutions

"We have the facility. We used it for coarct stenting, but we have stopped it" "We are not using anymore any of these modalities" "We dont (nor plan to) use it" "We will not have it in the new hospital either" "MRI in the cath lab is great! I allows you to easily convert a 30 min procedure into a 4 hour procedure"

Take Home Messages

Imaging is extremely important for structural and congenital heart interventions Currently we don't get the images we need If you start a program you have to have TEE ICE is helpful in special situations 3D echo and 3D TEE adds additional information by providing some additional views which are not possible with 2D echo CT and MRI
- are very useful for diagnosis and planning of some of the procedures - but not yet for guidance of the intervention