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Intracardiac Echo Guidance for Interventions of Structural Heart Diseases
S56
Ultrasound in Medicine and Biology
Volume 43, Number S1, 2017
commissurotomy, mitraClipping, atrial septal defect (ASD) device closure etc. There are some important tips and tricks. (1). For septal puncture, 2D echo may be better than 3-D echo. The optimal tenting sign should be managed to appear on the bicaval plane before protruding the puncture needle. If the tenting sign appears on a plane showing the right upper pulmonary vein, it indicates that the needle is pointing too posteriorly, increasing the risk of atrial wall perforation. Conversely, if the tenting sign appears on a plane showing the ascending aorta, it indicates that the needle is pointing too anteriorly, increasing the risk of aortic perforation. (2). Live 3D zoom mode is very convenient and better than 2D for monitoring ASD device deployment. (3). Fluoroscopy is still useful for monitoring some parts of the intervention procedures. If available, fusion imaging would be very convenient. (4). The duration of using color Doppler and 3-D echo should be kept short. Long duration tends to elevate the temperature of the TEE probe. (5). When using loop function, the time mode may be more desirable than the beat mode to prevent interruption of an important recording.
some echocardiography parameters such as projected aortic valve area during dobutamine stress echocardiography, global longitudinal strain (GLS) and calcium score of the aortic valve on multidetector computed tomography can be discriminate from true SAS to pseudo-SAS. However, there is a subset of patients with PLFLG-SAS, who deny any AS related symptom in the outpatient clinic. Many patients are older with limited physical activity. Thus, subjective symptomatic assessment is not accurate to determine whether the patient is truly asymptomatic. Following echocardiography parameters might be useful to select high-risk group of patients for future adverse outcome among patients with asymptomatic PLFLG-SAS. 1): LV mass index 2): GLS 3): left atrial volume index 4): Diastolic dysfunction grade 5): right ventricular function I will discuss the usefulness of these parameters for the risk stratification in asymptomatic patients with PLFLG-SAS.
T5-14-IN05
T5-14-IN08
Intracardiac Echo Guidance for Interventions of Structural Heart Diseases Qi-Ling Cao
Transesophageal Echo in Transcatheter Aortic Valve Implantation Toshinari Onishi Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
T5-14-IN06 Intracardiac Echo Guidance of Intervention Yun-Ching Fu China Medical University Children’s Hospital Interventional therapy for congenital and structural heart diseases has become more and more popular nowadays. Transesophageal echocardiography (TEE) has been successfully used for guiding the procedure but requires general anesthesia. Intracardiac echocardiography (ICE) uses a miniaturized ultrasound tipped catheter which is placed in the heart to obtain the image. Imaging with ICE has evolved from cross-sectional imaging using a rotating transducer (similar to intravascular ultrasound) to sector-based imaging using a phased-array transducer. Phased-array ICE has many advantages over rotational ICE including a greater frequency range, greater depth of field, steerability, and the possibility of acquiring Doppler and color flow imaging. With their steerability, phased-array catheters can be easily advanced and positioned through short sheaths rather than through long guide sheaths. The AcuNav (Siemens Medical) phased-array ICE was first introduced in Taiwan in December 2004. In our experience, ICE can provide excellent images for device closure of ASD, VSD, ruptured sinus Valsalva aneurysm and transseptal puncture eliminating the need of general anesthesia. T5-14-IN07 Echocardiographic Risk Stratification in Asymptomatic Patients with Paradoxical Low Flow Low Pressure Gradient Severe Aortic Stenosis Masaaki Takeuchi Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan After the introduction of paradoxical low flow low pressure gradient severe aortic stenosis (PLFLG-SAS) in 2007, there are still ongoing debates regarding pathophysiology, therapy and prognosis in PLFLG-SAS. Symptomatic patients with PLFLG-SAS are usually associated with worse outcome, even though the symptom is related to either AS itself or coexistent comorbidities, such as heart failure with preserve left ventricular ejection fraction (HFpEF). PLFLG-SAS has two phenotypes, including true SAS and pseudo-SAS. Surgical aortic valve replacement or transcatheter aortic valve replacement (TAVR) could be useful in the former, but not useful or even harmful in the latter patients. Recent studies have demonstrated
Aortic stenosis (AS) has been the most common valvular heart disease in the past decades. Although surgical aortic valve replacement (SAVR) is a well-established therapy, transcatheter aortic valve implantation (TAVI) provides an alternative treatment option for inoperable and high surgical risk patients with symptomatic AS. Echocardiography plays an important role in procedural planning, device placement or deployment, and postprocedure follow up. Intra-procedural transesophageal echocardiography is recommended by the American Society of Echocardiography because of its incomparable ability to provide rapid and accurate information, to evaluate the early function of the bioprosthesis, to define the severity and location of paravalvular leakage, and to detect complications such as sudden worsening of MR, new left ventricular wall motion abnormalities, cardiac tamponade, and dissection or rupture of the aortic root. T5-14-IN09 Making TAVR Simple: TTE or TEE Guidance Yung-Tsai Lee, Wei-Hsian Yin, Jeng-Wei Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan In 2012, ACC recommended the TEE as a mandatory tool in TAVR procedure. However, in 2017, ACC changed their statement as the TEE was an alternative tool. Alain Cribier performed first in man TAVR in 2002 with general anesthesia and TEE. Thereafter, they stated the procedures were done by local anesthesia without TEE in most of their cases. Minimalized TAVR seems attractive method. There are some problems of TAVR remained to solve, such as paravalvular leakage and residual pressure gradient. But the TEE has complications, such as esophageal injuries or tracheal intubation. Newer generation of devices might decrease the complications and paravalvular leakage. Without TEE, TAVR could be done safely, but we might loss some details. T5-14-IN10 Transesophageal Echo in Mitral Valve Interventions Sunil Mankad Department of Cardiology, Mayo Clinic, Rochester, MN, USA 2D and 3D transesophageal echocardiography (TEE) has emerged as the gold standard in guiding a variety of mitral interventions in the
Ultrasound in Medicine and Biology
Volume 43, Number S1, 2017
commissurotomy, mitraClipping, atrial septal defect (ASD) device closure etc. There are some important tips and tricks. (1). For septal puncture, 2D echo may be better than 3-D echo. The optimal tenting sign should be managed to appear on the bicaval plane before protruding the puncture needle. If the tenting sign appears on a plane showing the right upper pulmonary vein, it indicates that the needle is pointing too posteriorly, increasing the risk of atrial wall perforation. Conversely, if the tenting sign appears on a plane showing the ascending aorta, it indicates that the needle is pointing too anteriorly, increasing the risk of aortic perforation. (2). Live 3D zoom mode is very convenient and better than 2D for monitoring ASD device deployment. (3). Fluoroscopy is still useful for monitoring some parts of the intervention procedures. If available, fusion imaging would be very convenient. (4). The duration of using color Doppler and 3-D echo should be kept short. Long duration tends to elevate the temperature of the TEE probe. (5). When using loop function, the time mode may be more desirable than the beat mode to prevent interruption of an important recording.
some echocardiography parameters such as projected aortic valve area during dobutamine stress echocardiography, global longitudinal strain (GLS) and calcium score of the aortic valve on multidetector computed tomography can be discriminate from true SAS to pseudo-SAS. However, there is a subset of patients with PLFLG-SAS, who deny any AS related symptom in the outpatient clinic. Many patients are older with limited physical activity. Thus, subjective symptomatic assessment is not accurate to determine whether the patient is truly asymptomatic. Following echocardiography parameters might be useful to select high-risk group of patients for future adverse outcome among patients with asymptomatic PLFLG-SAS. 1): LV mass index 2): GLS 3): left atrial volume index 4): Diastolic dysfunction grade 5): right ventricular function I will discuss the usefulness of these parameters for the risk stratification in asymptomatic patients with PLFLG-SAS.
T5-14-IN05
T5-14-IN08
Intracardiac Echo Guidance for Interventions of Structural Heart Diseases Qi-Ling Cao
Transesophageal Echo in Transcatheter Aortic Valve Implantation Toshinari Onishi Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
T5-14-IN06 Intracardiac Echo Guidance of Intervention Yun-Ching Fu China Medical University Children’s Hospital Interventional therapy for congenital and structural heart diseases has become more and more popular nowadays. Transesophageal echocardiography (TEE) has been successfully used for guiding the procedure but requires general anesthesia. Intracardiac echocardiography (ICE) uses a miniaturized ultrasound tipped catheter which is placed in the heart to obtain the image. Imaging with ICE has evolved from cross-sectional imaging using a rotating transducer (similar to intravascular ultrasound) to sector-based imaging using a phased-array transducer. Phased-array ICE has many advantages over rotational ICE including a greater frequency range, greater depth of field, steerability, and the possibility of acquiring Doppler and color flow imaging. With their steerability, phased-array catheters can be easily advanced and positioned through short sheaths rather than through long guide sheaths. The AcuNav (Siemens Medical) phased-array ICE was first introduced in Taiwan in December 2004. In our experience, ICE can provide excellent images for device closure of ASD, VSD, ruptured sinus Valsalva aneurysm and transseptal puncture eliminating the need of general anesthesia. T5-14-IN07 Echocardiographic Risk Stratification in Asymptomatic Patients with Paradoxical Low Flow Low Pressure Gradient Severe Aortic Stenosis Masaaki Takeuchi Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan After the introduction of paradoxical low flow low pressure gradient severe aortic stenosis (PLFLG-SAS) in 2007, there are still ongoing debates regarding pathophysiology, therapy and prognosis in PLFLG-SAS. Symptomatic patients with PLFLG-SAS are usually associated with worse outcome, even though the symptom is related to either AS itself or coexistent comorbidities, such as heart failure with preserve left ventricular ejection fraction (HFpEF). PLFLG-SAS has two phenotypes, including true SAS and pseudo-SAS. Surgical aortic valve replacement or transcatheter aortic valve replacement (TAVR) could be useful in the former, but not useful or even harmful in the latter patients. Recent studies have demonstrated
Aortic stenosis (AS) has been the most common valvular heart disease in the past decades. Although surgical aortic valve replacement (SAVR) is a well-established therapy, transcatheter aortic valve implantation (TAVI) provides an alternative treatment option for inoperable and high surgical risk patients with symptomatic AS. Echocardiography plays an important role in procedural planning, device placement or deployment, and postprocedure follow up. Intra-procedural transesophageal echocardiography is recommended by the American Society of Echocardiography because of its incomparable ability to provide rapid and accurate information, to evaluate the early function of the bioprosthesis, to define the severity and location of paravalvular leakage, and to detect complications such as sudden worsening of MR, new left ventricular wall motion abnormalities, cardiac tamponade, and dissection or rupture of the aortic root. T5-14-IN09 Making TAVR Simple: TTE or TEE Guidance Yung-Tsai Lee, Wei-Hsian Yin, Jeng-Wei Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan In 2012, ACC recommended the TEE as a mandatory tool in TAVR procedure. However, in 2017, ACC changed their statement as the TEE was an alternative tool. Alain Cribier performed first in man TAVR in 2002 with general anesthesia and TEE. Thereafter, they stated the procedures were done by local anesthesia without TEE in most of their cases. Minimalized TAVR seems attractive method. There are some problems of TAVR remained to solve, such as paravalvular leakage and residual pressure gradient. But the TEE has complications, such as esophageal injuries or tracheal intubation. Newer generation of devices might decrease the complications and paravalvular leakage. Without TEE, TAVR could be done safely, but we might loss some details. T5-14-IN10 Transesophageal Echo in Mitral Valve Interventions Sunil Mankad Department of Cardiology, Mayo Clinic, Rochester, MN, USA 2D and 3D transesophageal echocardiography (TEE) has emerged as the gold standard in guiding a variety of mitral interventions in the