 Good morning. I'm Stephanie Coulter and today we're going to speak on imaging in structural heart disease What does the interventionist need to know? So we're going to start by discussing three main Pillars of of structural heart disease for which we're conducting You know patient-centered trials and as part of a regular clinical medicine here at Baylor St. Luke's Medical Center and the Texas Heart Institute We do interatrial septal Closure devices left atrial appendage Exclusion devices and we're going to talk a little bit about valve disease and what opportunities are available so for interatrial septal defects a simple review reminds us that the most common type of interatrial septal defect is really the PFO which can be based on embryology and may be acquired due to atrial enlargement or acquired due to Interventional procedures as well but in the embryological type of interatrial septal defect the succundum is the most common and you can see pictures on both the left and the right Revealing the venosus type the succundum type the premium type An unroofed coronary sinus which is very rare The ASD Can be imaged very beautifully by trans esophageal echocardiogram and you can see there's evidence of a succundum ASD in this view on the left You'll see at the base of the heart the aorta as your landmark and you see the septum Primum above and a hole in the interatrial septum and on the right you can See again a defect in the center of the interatrial septum During part of the succundum septum and in another view you can with color Doppler You can see clearly that there is a good amount of flow From the left atrium into the right atrium which suggests that the left-sided filling pressures are higher than the right Which are common and are associated with over circulation of blood flow to the right heart Which leads to the manifestations of an ASD we can size the ASD by TE by 3d we can size an ASD as well by CTA or by MRI Real-time imaging in the cat lab is available only by TE and you can see that the defects here Have unique shapes some round some elliptoid some distorted and these distortions are related to the pressure differential That expose the interatrial septum to different forces Indication for interatrial septal intervention include ASD's and PFO's and in Asymptomatic children ASD should be closed if there's evidence of right-heart dilatation if the ASD measures more than five millimeters and If the child grows and there's no spontaneous closure in older patients hemodynamically significant ASD's are defined as a QPQ s greater than 1.5 These should be closed particularly if there is elevated pulmonary artery pressure or if there's pulmonary vasoreactivity due to Induced changes in the vascular bed due to pharmacologic challenges or if there are reversible changes on lung biopsy We also now have an indication for closing hemodynamically insignificant ASD's or PFO's or those with QPQ s less than 1.5 if the patients had a cryptogenic stroke The closure device that's most useful and most utilized is the amplacer device which is seen here, which is really Basically two discs and the measurements are on the right and the delivery catheter system is on the bottom left and it can be easily deployed from venous access and This is the respect trial which fed us with the proof that closure of a PFO or a small ASD Benefited patients who'd had a cryptogenic stroke in this landmark study There were 980 cryptogenic stroke patients aged 18 to 60 with a PFO And they were randomized to device closure versus medical management and followed for nearly six years and the endpoint was recurrent stroke There were low serious adverse event rates procedural Adverse risk were low at 2.4 percent And in the end there was a 45 percent reduction risk reduction In reducing recurrent ischemic stroke in those that had the closure device and a significant 2% relative risk reduction in favor of PFO closure for reducing recurrent cryptogenic stroke There was technical success in this study of 99 percent and 96 percent procedural Success and based on this trial the amplacer device was FDA approved for PFO closure During the interventional procedure the TE is useful for guidance because of its you know Advantages one their superior image quality to trans thoracic imaging You can use 3D techniques to evaluate the interatural septum. You can evaluate the anatomy. You can exclude thrombi and you can help the Interventional cardiologist or the interventional Radiologists I guess in some centers with device positioning and guidance and we can assess for Residual shunting at the end of the procedure of course the disadvantage for all TE procedures is that it requires esophageal intubation requires some additional sedation and The risks include aspiration and mainly esophageal trauma, which is really quite rare and reported to be less than one in 3000 Intubations so here is what a device looks like on FOS on the right and you can see The left atrial disc on the right protruding into the left atrium and the disc motion This slide shows a case that we actually had at our facility that was a transfer from an outside central Texas facility Where the patient had been previously treated for a PFO? Which was thought to be the cause of their interatural shunting and a PFO closure device was applied to the patient But lo and behold the shunting did not end TEE done here in our facility demonstrates a superior venosis defect and surgical Intervention was required at which time two branches of the right-sided pulmonary veins were anonymously Shunted into the SVC So these veins had to be re Allocated to the left atrium and the venosis defect closed So in fact if more careful imaging of the interatural septum had been done The patient probably wouldn't have needed the PFO closure device that you see on the right side of the screen this patient underwent The surgery as I said and then this slide actually shows a little bit of residual Color abnormality abnormalities around the interatural septal device Which is common because the interatural septal occluder device is a bulky device and it causes color Abnormalities which are not related to a recurrent or a residual hole when you look at intra cardiac Contrast injections so we also are a big center for left atrial appendage exclusion and We are using currently the watchman and we also are using the lariat device and the lariat device was developed here at the Texas Heart Institute under the direction really of doctors Billy Cone and Abdi Rasak and I think we've done the largest Series at in the world today using the lariat and I'm going to explain it as we go so during these procedures the Imaging is quite important Pre-procedurally we look at the left atrial appendage shape Documenting whether or not there's a large chicken wing or they're not it's a windsock We can make very detailed measurements of left atrial appendage size And we can make sure there's no thrombus in the left atrium or in the left atrial appendage Inter-procedurally we are there doing TE guidance To help with the transeptal puncture and for real-time imaging during device placement We assess the position of the device we look for complications including pericardial effusion and importantly We do follow-up Surveillance of these devices before we withdraw the anticoagulation to look for success of closure Looking for residual flow and we are also looking for residual post closure thrombus on the device Which in the watchman is currently thought to occur in about two and a half percent of the cases So this is a case of a TE pre Watchman and you can see on the scan on the left We are measuring the left atrial appendage at the waist where the device will sit and and at its depth and On the right side as well by x-plane technology is very helpful because you can get one picture you can get two pictures at one time and And shorten the length of your exposure into the cath lab Here you can see that There's a biplane picture again of the interatrial septum and we use this biplane imaging to help the interventionalists Puncture the interatrial septum and the goal is to puncture the septum both inferiorly and posteriorly So that there'll be plenty of room to maneuver into the left atrium So you can get the device across the watchman looks like this on the left it looks like a little parachute and we lodged that into the left atrial appendage and It sits should be flush With the os of the appendage and it should form clot on the back side of it and Exclude the appendage so blood clots can no longer form in the appendage this slide shows the post or Intra positioning of the watchman and on the left you can see the watchman with the catheter still Attached to the center of the watchman and we're imaging to make sure there's no residual flow on either side and in real-time Imaging on the right you can see that there's no color flow on either side of the watchman So it appears to be pretty well placed and Here you can see post procedural imaging on the left shows a very successfully deployed watchman and on the right You can see the residual interatrial septal defect which is common and which should spontaneously close over time And it's important to do follow-up imaging and this was a follow-up imaging done a month after the insertion of the watchman and you can see evidence of a thrombus with a long sinewy tail in The first image and in the second image the patient was antiqued kept on the anticoagulation And and follow-up imaging The thrombus went away. So this patient was maintained long-term on A NOAC which you know was kind of contra the reason for getting a watchman But it's a rare complication only two and a half percent But yields really of a good success rate at over 97 percent the Lariat system is another type of system for excluding the atrial appendage and This one literally causes permanent exclusion of the left atrial appendage because literally a lasso is threaded extra cardiac through the pericardium and that's what you can see on the the demonstration in a On the screen you can see a catheter is placed across the inter atrial septum And it has a magnet on it and that magnet enters the left atrial appendage From the inside of the heart and from the outside of the heart a pericardial tap is done dry and a catheter is positioned with the magnet near the lateral wall and the two magnets are attracted to one another and This is the way that we use to guide the Lariat into the left around the left atrial appendage From the magnet inside the heart So you can see here that this ligation results in a permanent Transmural lesion and we think this is the reason that people that get the lariat Have sustained reduction in atrial fib burden long term So keys to successful left atrial appendage ligation is careful pre-procedural planning which includes both echocardiography and CTA pericardial access by careful Interventional cardiologists the proper placement of the endocardial magnet wire Orientation of the lariat and alignment of the snare over the left atrial appendage and then confirmation of closure We're going to move on to valvular disease and Valvular heart disease or structural heart disease is increasing with age for both Mitral and aortic disease and now it's considered to be at least nine and a half percent for patients or people Over 75 years of age So what do the interventionalists need to know from the imaging physician during taver and mitral clip? Well, in fact the imaging is the bread and butter of patient screening We primarily use the echocardiogram In an outpatient setting to identify patients who have significant aortic or mitral valve disease based on primary screening by the physical exam MRI and CT are complimentary techniques to evaluate both the structures involved and MRI certainly for quantification Purposes for taver. Dr. Crazier is going to speak about taver today, and I'm going to kind of Breeze past taver interventional imaging because it's pretty routine and we're doing about 15 tavers in our center every week We're pretty streamlined on the imaging for taver This certainly the interventional cardiologists use the fluoro Dr. Crazier and his colleagues here are doing tavers with very limited amount of Coronary dye and certainly that's beneficial to our patients. We are using gradients calculated by Doppler we identify stroke volume index and LVEF by echo In patients that have severe and symptomatic aortic stenosis. We're also looking as progress trial at Patients with moderate aortic stenosis and certainly we're using imaging to discern Trileaflet versus Bicuspid aortic pathologies for the mitral clip pre procedural screening is first performed by trans thoracic and then by trans esophageal echocardiogram the TE is required because detailed mitral anatomy is Required as well as measurement of the mitral valve annulus by 3d for plenometry the echo is also extremely beneficial for determining whether or not the etiology of the mitral regurgitation is primary or secondary and as I said before We have to determine the mitral valve area before we plan how to fix the valve because if the valve area is too small then Percutaneous Interventions are not going to work and finally we use the echocardiogram to quantify the severity of the mitral regurgitation here's a pretty picture of a taver and I'm going to move to mr. So mr. Is very common Increasing amounts of mr are found in our population and the pathophysiology of mr. Is such that it's a It's a circular Problem where you have a little bit of mr. That increases the load and the stress that causes muscle loss and damage and dysfunction to the left Fentrical which leads to dilatation of the left ventricle which leads to increasing levels of mitral regurgitation With one-year mortality for significant mr. Up to 57 percent medical management of mr. Defined by functional status or degenerative status on the left and on the right and You can see that the mortality In five years for medically managed mr. Is 50 percent So we're not doing a great job with therapies for mr Because many of the patients are not good surgical candidates. So for mitral clip technology. It started first with clipping organically abnormal or innately abnormal mitral Anatomy and you can see that with patients that have a flail leaflet or severe mr from degenerative mr Class three or four heart failure is associated with the mortality of up to 34 percent per year compared to those that have only class one Or two symptoms only four percent per year the mr. Severity also predicts progressive worsening prognosis in Patients that have functional mr. And heart failure and you can see here that the degree of mr. Increasing Decreases the likelihood of survival and increases the likelihood for mortality in Follow-up and this is data from the co-op trial the mitral clip is the only approved mitral device at this point And you can see on the left How it looks like a clip with arms and this is what the device looks like when you are Using it in the cath lab, and that's the delivery catheter and the device so in general the mitral clip requires a lot of detailed and Really kind of expert imaging in order to successfully complete the procedure the imaging is really really important And the imager has to be a companion to the interventional cardiologist to be effective you can see on the left that The first step of this procedure is to help guide the Transseptal puncture then we use the echo the TE to steer to the right Spot in the mitral valve, and we use both on-foss three-dimensional imaging as well as Two-dimensional explain imaging to see where the grasping arms are and you can see that Following the spot once we get the leaflets gras we make an assessment about how hemodynamics have changed with the clip and then we look to see afterwards how successful we are what the gradients are and Here we can see that we use the TE to define the mitral valve anatomy before the procedure The plenimidered mitral valve area must be greater than four square centimeters by 3d plenimetry We look carefully to make sure that there are not large mitral valve clefts that there are no Vegetations and perforations which are exclusion criteria for mitral clip and we also look for Areas of abnormal calcification which would make clipping more difficult the TE is also useful to define Defendant of Lee what the etiology is whether it's primary or secondary And we look at the link of the leaflets because you're going to need enough Link of the leaflet to get into the clip and you need of at least a nine millimeter length of a leaflet particularly of the smaller posterior leaflet leaflet in order to make a good grab The width of the mr. Jet is important because it's going to help to define which kind of clip you're going to want to use and then we can measure the flail gap and a flail segment width and A gap less than 10 millimeters and a segment with less than 15 are ideal for clipping You can see here There's a 3d on phospho of the mitral valve which shows the aortic valve in the surgical position Which is so confusing to me as an echocardiographer and I've gotten used to it over time But you can see unfortunately for you know it seems backwards to us that the medial commissure is now lateral and the lateral commissure is now medial and This gives you the clock view with the enter leaflet on top and the poster leaflet on bottom It looks like a smiley face and here you can see that smiley face on an echocardiogram that I TE that I did this week and you can see that you've got the Two-dimensional images in a biplane Imaging plane on the left and then the 3d in the middle and you can see this is a relatively normal ish looking mitral valve and Again, you can do a lot of fancy imaging and I've shown you a technique that people are really kind of happy with called glass imaging Which may be useful in certain search of circumstances pre procedural hemodynamics are important and Assessment of the trans mitral gradient is important and looking at the pulmonary veins is also very important for the Assessment of mr. We quantify the mr In some cases by the ever is to criteria where you need at least three of the four or the color jet area of a Central jet is 30% of the left atrial area You look at the pulmonary veins to make sure that there is Cystallic flow reversal or blunting of that systolic flow to indicate significant hemodynamic Mitral regurgitation you measure the vena contract a width and hopefully it's greater than 0.5 a Regurgent volume needs to be at least 45 mils and in the US. We really kind of like 50 mils per beat Which should correspond with a regurgent fraction over 40% and a regurgent orifice at least greater than 0.3 and Hopefully near alert nearer to 0.4 mr. Comes in two types Really mr. Is incompetent mitral valve closure which leads to retrograde Cystallic flow from the left ventricle onto the left atrium and subsequently into the pulmonary veins Which is what causes pulmonary edema and it comes as a primary problem when the leaflet itself is diseased But the ventricle is not the problem in this case one leaflet is prolapsed or flail and It's usually a problem with a leaflet and the cordal structures or the sub-valvular apparatus Our secondary mr. Which is much more common is secondary to left ventricular dilatation Which is often related to ischemic heart disease But it's also very common in patients with non ischemic cardiomyopathy The common problem here is that the ventricle is the problem the ventricle is enlarged which displaces the Papillary muscles pulls on the cordae and pulls the mitral into an apically tethered position Which prohibits proper leaflet adherence and closure So here in this case on the left is a primary Mitral valve problem of the posterior leaflet and a secondary problem on the right and again The top left is the posterior mitral valve on the right the anterior mitral leaflet on The bottom left is a flail posterior leaflet with P1 cord rupture because you can see the aorta in that position and in the bottom right is a bi leaflet Myxomatous typical Barlow type mitral valve regurgitation patient so the criteria for mitral clip or are included here for Perfection but we really want to see patients with significant greater than moderate to severe regurgitation that are symptomatic with pre-existing co-morbidities that are that do not proclaim them from living at least a year To benefit from the reduction in MR. They patients are currently being Included if their surgical risk is prohibitive. So at this point for primary disease, you know some young people with Mitral regurgitation and a ruptured cord in their 30s. These people really should have very low STS scores and really should still go for an open or Robotic mitral valve repair, which has long-term durable outcomes, but for those that have high STS scores for a mitral valve Replacement or repair or those that have porcelain aortas or hostile chest with radiation or severe pulmonary hypertension or Other pre-existing problems like cirrhosis or AIDS or severe dementia these patients really need to have a careful analysis the important thing too is that they need to be at goal-directed medical therapy and still have Symptoms and significant mitral regurgitation. So For secondary MR, you have to have moderate or severe MR According to the ASC guidelines Symptomatic MR persists despite as I said goal-directed medical therapy, but the EF is between 20 and 50 percent Okay, the stroke in systolic dimension needs to be less than 70 millimeters and a multidisciplinary team must be involved for the imaging you can see here on the very far right with the clip actually looks like and then you can see the echocardiographic view on the left and the fluoroscopic view on the right and The interventionalists will be watching both of the screen. So you need to have the echo TE images on the screen for the interventionalists and the first thing we're gonna watch is for the Transceptile puncture and here you can see an x-plane of the interatrial septum Which shows you a superior to inferior dimension and an x-plane which shows you an anterior and a posterior dimension and Again, you want to be inferior and slightly posterior in your puncture And you want to have about four to five centimeters of height from the puncture site as A distance to the mitral annular plane and this four to five centimeter Dimension gives should yield enough room to maneuver the device and to give you enough movement room to be able to steer The device toward the mitral valve appropriately as you can see here I've shown these beautiful 3d markers that can be applied to structures During a TE and then they can be followed in Subsequent imaging planes so that you always know what the structure is Very helpful in some of the technology For mitral valve clipping the transeptal again, you look at a bicable and a short axis view You measure the proper height from the annulus and you can assess whether or not your puncture site has been appropriately Directed for positioning you're gonna see in screen number one on the left an intercomissural two-chamber view looking at proper medial and lateral alignment and in Phase two you'll see the LV outflow track and again you look for anterior and posterior alignment So you can use 2d imaging to get to proper alignment or you can do a 3d on Foss view with a good amount of the atrial tissue and you can see where your catheter is diving Toward the mitral valve and align it in that regard and for clip positioning in this slide You can see on the left the clip arms are down and the 2d imaging in the x-plane of the clip At 60 degrees and x-plane you can see the grabber arms of the clips And you can see the mitral leaflets as they come down into the clip And that's how the interventionalist steers the guiding catheter system to the right position and the echocard The echocardiographer is certainly very involved because any motion of your wrist or of the probe will distort the imaging that the interventionalist is needing So it is a patient and time-consuming procedure you can see in three and four and four particularly you can see the on-foss view with the clip and its orientation and so the echocardiographer and The interventionalist can see you know what orientation You want to achieve In order to get the clip in the correct position based on the anatomy of the position of the patient and Here you can see the clip arms are perpendicular to the line of co-aptation The gripper arms are taken down the full length of both clip arms are visible at 180 degrees and the clip arms are available Once the clip is inserted you can assess to see whether or not the leaflet length is the proper length by echo views and Also by this on-foss tissue bridge view you can see where you've created, you know a Tissue bridge between the anterior and the posterior leaflet and you can also use this exact view to assess for regurgitation and it may be useful to help reposition the clip in order to get more Mitra regurgitation here is a clip case from this morning and a clip case from last week and The first five views on the left are from the clip last week and you can see the first two upper slides show significant Functional mitra regurgitation There's one clip in place and you can see that there's very Mitigated mitra regurgitation and a restriction of the motion at the clip and a very successful with one XTW clip The second case is done from this morning a functional mitra regurgitation patient that had left atrial pressure average in the middle 30s with V waves into the 70s the patient had torrential MR and pulmonary hypertension as expected the patient was quite symptomatic and The patient required two clips first lateral and then one medial and the left atrial pressure fell to 12 the mean gradient on the right went to 2.4 and Hemodynamically we thought it was a raging success and hopefully the patient will benefit Thank you so much for your attention and I appreciate the opportunity to present today