Tips and Tricks of Transesophageal Echocardiographic Guidance During Cardiac Interventions

Abstracts The use of ICE in small children with atrial communications who undergo device closure of their defects provide better images of the atrial septum and the various stages of device closure. Specifically, the left atrium is better visualized using ICE. Cost effectiveness and comparison with TEE is also discussed. Symposium T5-14-IN01 Current Advancement of Transthoracic 3D Echocardiography for the Quantification of Left Chamber Parameters Masaaki Takeuchi Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan It has passed more than 20 years, since the first-generation transthoracic real-time 3D echocardiography came appeared in the clinical arena in 1998. Although the earlier day’s transthoracic 3D echocardiography (3DTTE) had limitations mainly due to large footprint of 3D transducer, lower temporal and spatial resolution, making its routine clinical use quite difficult, several studies have reported its accuracy for the quantification of left chamber parameters over 2D echocardiography against cardiac magnetic resonance imaging as a reference. With continuous advancement of ultrasound technology, quality of 3DTTE image has been much improved, and now, one-beat acquisition of the whole heart with high volume rate is possible in many ultrasound manufactures. 3DTTE expands its acquisition in not only patients with sinus beat but also those with irregular heart beat and those who cannot stop breath adequately. Although each ultrasound company has their own quantification software for the analysis of left ventricular (LV) volumes, ejection fraction and mass, manual tracing on the endocardial border causes measurement variabilities in different examiners and different institutions. The adoption of recently developed fully automated LV and left atrial (LA) quantification software with 3DTTE might be one potential solution to eliminate this problem. I will present the current status of fully automated software with 3DTTE for the assessment of LV and LA volumes. T5-14-IN02 The Added Value of 3D Echo to Assess RV Geometry and Function Luigi P. Badano, MD, PhD, FESC, FACC Department of cardiac, thoracic and vascular sciences, University of Padua School of Medicine, Padua, Italy Quantitative assessment of the right ventricle (RV) by conventional echocardiography is a challenging task due to its complex asymmetric geometry (limiting the ability to adequately visualize both inflow and outflow tracts in the same view), highly trabeculated endocardial borders, lack of precise anatomic landmarks, and unfavourable position of the RV in the chest. Furthermore, two-dimensional echocardiography (2DE) diameters of the RV vary significantly with minor rotation or tilting the transducer and may be inaccurate, leading to an under- or overestimation of RV size. Three-dimensional echocardiography (3DE) opened a new era in echocardiographic evaluation of the RV. 3DE allows to include all three parts of the RV (i.e. inflow, outflow and apical trabecular part) in the same dataset. RV acquisitions derived from stitching together consecutive multibeat volumes offer high temporal and spatial resolution. These data sets can be further analysed using dedicated software packages to obtain the mapping of the RV endocardial surface and to measure the RV volumes and function without using geometrical assumptions or approximations.

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Despite a slight underestimation, RV 3DE measurements closely correlate with RV volumes measured by cardiac magnetic resonance (CMR) and by volumetric thermodilution during cardiac catheterization both in children and adults. It’s worth stressing out that 3DE remains the only echocardiographic technique capable of a reliable calculation of RV EF from end-diastolic and end-systolic volume measurements. In the most recent meta-analysis aimed to explore the accuracy of different imaging modalities (2DE, 3DE, radionuclide ventriculography, computerized tomography- CT, gated single-photon emission CT, and invasive cardiac cineventriculography) for RV EF using CMR as reference method, 3DE has proven to be the most reliable technique, overestimating the RV EF only by 1.16% (range -0.59 to 2.92%). Normative data for 3DE RV volumes and EF including age, body size-, and sex-specific reference values based on large cohort studies of healthy volunteers is also available. Inclusion of the recommendations for 3D RV volumetric analysis in laboratories with appropriate 3D platforms and experience in the most recent edition of chamber quantification guidelines highlights the importance of 3DE in the assessment of RV. T5-14-IN03 Application of 3D Echo in the Diagnosis of Complex CHD Pang kunjing Director of department of pediatric ultrasound, Fuwai Hospital, Chinese Academy of medical sciences, National cardiac center, China Objective: to analyze the clinical value of three-dimensional echocardiography in the diagnosis of congenital heart disease by transthoracic three-dimensional echocardiography. Methods: Prospective using three-dimensional echocardiography in the diagnosis of 210 pre-operational cases of complex congenital heart disease, compared with the traditional two-dimensional ultrasound diagnosis results with surgical findings as the gold standard, the accuracy of the analysis of the characteristics and the diagnostic results of the three-dimensional ultrasound diagnosis method. Results:The diagnostic thinking of 3D echocardiography is different from that of two-dimensional echocardiography. Three dimensional thinking is more conducive to the three-dimensional understanding of the structure of the heart. For the cases of complex congenital heart disease with excellent twodimensional image, the results of three-dimensional ultrasound diagnosis were more accurate than two-dimensional ultrasound. Including the measurement of atrial and ventricular septal defect diameter, accurate assessment of cone structure of tetralogy of Fallot patients, judge the position relationship of ventricular septal defect and large arteries of double outlet right ventricle cases. For two dimensional images with poor quality, the quality of 3D images is worse and the diagnostic results have no advantage. For congenital valvular diseases, three-dimensional ultrasound has no advantage over 2D in the diagnosis of valvular structures because of the delicate structure of valves and the resolution limits of three-dimensional images. Conclusion: The establishment of diagnostic thinking of three-dimensional echocardiography is beneficial to the understanding of the spatial structure of congenital heart disease and to improve the accuracy of diagnosis. The resolution of the current three-dimensional echocardiographic diagnostic instrument is still limited by the acoustic window condition, and it is still difficult to achieve satisfactory imaging for the delicate structure of the heart valve. T5-14-IN04 Tips and Tricks of Transesophageal Echocardiographic Guidance During Cardiac Interventions Cheng-Wen Chiang Cardiovascular Center, Cathay General Hospital, Taipei, Taiwan Online transesophageal echocardiographic (TEE) guidance has become a useful and convenient technique for various structural heart disease interventions, e.g., interatrial septal puncture, balloon mitral

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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.

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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