SHA24/062002

Ahmad Omran, MD, FACC, FESC, FASE Head, Non-Invasive Laboratory King Abdulaziz Cardiac Center National Guard – Riyadh Kingdom of Saudi Arabia

Saudi Arabia Experience of Interactive Case Discussion Intra operation 3D TEE

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10thth Gulf Heart Association Conference joinedwith withSHA SHA24 24 Joined February 13-16, 2013 Riyadh, Kingdom of Saudi Arabia

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Introduction Technical background, mode of acquisition 3D TEE in valvular heart disease 3D TEE in adult congenital heart disease 3D TEE in cardiac masses, disease of the aorta Limitations of 3D Echo, future directions

Why do we need another (D) in echo?

What is wrong with 2-D echo?

Because the heart is a 3D object!!

LA

RA RV

LV

No common language!!!!

“3D Echo is the tool for common language between Cardiac surgeon and Echocardiographer and now interventional cardiologist�

Base of the heart with atria removed, shows four cardiac valves

Hurst’s The Heart: 2004

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Introduction Technical background, mode of acquisition 3D TEE in valvular heart disease 3D TEE in adult congenital heart disease 3D TEE in cardiac masses, disease of the aorta Limitations of 3D Echo, future directions

3-D TEE probe

3D TEE probe

2D TEE probe

3D Echo: Modes of Acquisition 1. Simultaneous Multiplane mode (Xplane) imaging with two real time images in one screen 2. Live 3D ( single beat), narrow sector 3. Zoom mode (single beat), low frame rate 4. Full volume (4,7,10 beats stitched), higher frame rate but chance of artifact 5. Full volume colour (7,10,14 beats stitched), chance of artifact & narrow sector

81-year-old male with TAVI, X-plane mode (low FR)

Live 3D TEE, high FR (30Hz), narrow sector

Zoom mode, low FR (8fs)

Full volume mode, needs cropping

Crop till you drop!!!

Full volume color, lower FR, chance of stitch artifact

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Introduction Technical background, mode of acquisition 3D TEE in valvular heart disease 3D TEE in adult congenital heart disease 3D TEE in cardiac masses, disease of the aorta Limitations of 3D Echo, future directions

3D TEE in mitral valve disease

Surgeon's view of Normal MV

40-year-old male with normal mitral valve

LA

LV

LAA

LAA

Medial

Medial oblique view

AOV

Anterior oblique view

Medial

AMVL

PMVL

MV, LV side

Lateral

65-year-old male with severe posteriorly directed MR

Flail A2, 2 ruptured chorda

Posteriorly directed MR

45-year-old male with severe anteriorly directed MR Ruptured chorda

Flail p2

Anteriorly directed MR

42-year-old female presented to the ER due to hyperthyroidism and fast atrial fibrillation

3D TEE- Surgery Correlation AOV LAA

A1 A2

ALC

PMC A1 A3 A2

A3

Severe A2 & A3 prolapse

LV

Anteriorly directed MR

Inspection of leaflets and chorda

Dr Najim, 16-Jan-2011, KAMC

GoreTex replacement of chorda, adjustment, saline test

Sizing the annulus, insertion of # 28 Physio ll ring, final saline test

Post op assessment, no MR

47-year-old male presented to ER due to severe SOB

LV

LA

MR

Flail P2

Play with mitral valve

3D TEE- Surgery Correlation

P1 P1

P3

LarFlail P2 scallop

P3 P2

Anteriorly directed MR

1- Inspection of leaflets and chorda. 2- Quadrangular resection of P2.

3- Sliding plasty of P1 and P3. 4- Saline test. 5- GoreTex to A2.

6- #32 Physio ring

Dr Najim, 30-May-2010, KAMC

Trivial residual MR

39-year-old male with severe MS

PE

MV from LA side, smoke

Mitral orifice from LV side

MVA= 0.7 cm2

AOV RA

LA

Guiding the balloon in to mitral orifice

Balloon inflation

Balloon inflation, smoke

Post balloon, mitral orifice from LV side

MVA= 1.5 cm2

Pre- PMBV

Post PMBV

MVA= 0.7 cm2

MVA= 1.5 cm2

64-old-male with severe functional MR and LVEF of 25-35%. Normal coronary angiography

Lack of leaflets coaptation

Severe central MR

LV

2

1

2 jets of MR

Arms of clip are open, adjusting to the line of coaptation of mitral leaflets

Clip arms are perpendicular to the line

Clip is grasping the leaflets

Clip is released, double orifice MV from LA side

Double orifice MV from LV side

Trace residual MR

Pre MitraClip

Post MitraClip in cath lab

46-year-old male with history of inferior MI and severe ischemic MR, had CABG and MV repair 6 month ago

AOV LAA

TV

AOV

LAA

Dehiscence= 1.6 X 0.75 cm

MV from LV side

Color suppressed view

MR

Transvalvular MR Para-annular MR

Dr Najim, KACC, 09-Oct-2012

30-year-old female with severe SOB

Medial disc

FR 38Hz

Full volume, stitch artifact

Medial disc

FR 14Hz

Medial disc

Fps= 15

Medial Disc

54-year-old female with history of mechanical MVR

2 sites of paravalvular leak

3D TEE in aortic valve disease

Normal aortic valve with pocket-shaped semi- lunar cusps

LA

RA

LCC

NCC RCC RV

RCC RCC

LCC LCC

NCC NCC

Normal aortic valve, surgical view

67-year-old male with one month history of AOV endocarditis

RCC fenestration

MPR View of AOV and AI

Dr AlKhaldi, 29-May-2011, KAMC

Endocarditis of aortic valve, vegetation on LCC and fenestration of RCC

RCC fenestration

RCC

LCC, vegetation

3D TEE- surgery correlation

3D TEE in tricuspid valve disease

Surgical view of TV, compared with 3D TEE view

Anterior leaflet Posterior leaflet

Septal leaflet

3D TEE in pulmonic valve disease

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Introduction Technical background, mode of acquisition 3D TEE in valvular heart disease 3D TEE in adult congenital heart disease 3D TEE in cardiac masses, disease of the aorta Limitations of 3D Echo, future directions

29-year-old female with large secundum ASD

ASD= 2.5 X 2.6 cm

Amplatzer device from LA side

23-year-old cadet referred to our center due to cardiac murmur

Mitral valve from LV side

29-year-old female, treated as rheumatic valvular heart disease for many years

Trifoliate mitral valve

Cleft

MR

3D TEE- Surgery Correlation Cleft

Trifoliate Mitral Valve

Dr Arifi, 06-Nov-2010, KACC

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Introduction Technical background, mode of acquisition 3D TEE in valvular heart disease 3D TEE in adult congenital heart disease 3D TEE in cardiac masses, disease of the aorta Limitations of 3D Echo, future directions

38-year-old male with history of MI seven month ago in Syria, presented to our center due to multiple peripheral embolic events (patient had left leg amputation)

Dr Arifi, 02-Nov-2011, KAMC

68-old-female with palpitations

3D TEE- surgery correlation

Mass= 2.2 X 2.0 X 1.5 cm, about 7-8 gr

69-year-old female referred for pre- op clearance

Myxoma= 3.1 X 2.5 cm

79-old-male with type B aortic dissection

T F

T

F

F

T

F

T

49-old-male with history of car accident one week ago

? Clot

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Introduction Technical background, mode of acquisition 3D TEE in valvular heart disease 3D TEE in adult congenital heart disease 3D TEE in cardiac masses, disease of the aorta Limitations of 3D Echo, future directions

Limitation of 3D Echo • It is a new dimension! , a new technique !, a challenging learning curve !

• Poor spatial resolution especially in TTE • Low frame rate (temporal resolution) • Motion artifact (breath hold) • Stitch artifact in arrhythmia and cardiac motion • Limitation of color (narrow sector, stitch artifact) • No valid direct measurements on 3D images • It is a Transitional technique, therefore 2D confirmation is still needed

Mechanical MVR, Stitch Artifact

Brocken valve!!

3D Echo, future direction: Where we wish to go?

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Single beat acquisition Higher frame rate ( better temporal resolution) Better spatial resolution Automated cropping Wider color sector Direct three dimensional measurement To be less time consuming!!

Summary • 3D echo provides a new dimension in cardiovascular

imaging , it is a revolution in the field of echocardiography to assess cardiac pathology and guiding the appropriate intervention.

• 3D TEE creates a common language between cardiologist, cardiac surgeon and interventionist in the operating room and in the cath lab for decision making. • Like any other new technique, 3D Echo has its own limitations and needs further technical improvement.