Echocardiography-Fluoroscopy Fusion Imaging: Watchman Procedure and MItral Paravalvular Leak Closure

Hello man Shane. This presentation a series of images that will demonstrate the power of 3D echocardiographic imaging in guiding two real life procedures are continuous closure, left HL appendage. Using the watchman procedure as well as per Catania's closure of mitral para prosthetic leak. For this presentation these are my disclosures. And let's start with the real life case presentation, then 81 year old man with a progressive Disney on exertion over the preceding year. And this is what we know from his medical history. He has had persistent Angel fibrillation and he has had recurrent GI bleeds while taking warfrin. However, the anemia that it's chronic requiring frequent transfusion, could not be explained by JB the loan. As there was a hemolytic component in addition, he is status post bioprosthetic mitral valve replacement and it was a 29 millimeter Medtronic mosaic prosthesis of porcien type that was implanted surgically about eight years ago. And we also know that he has a series of comorbidities, including hypertension, diabetes, malladus, as well as a chronic obstructive pulmonary disease. So he was referred for a structural heart team with the two possibilities. One would be to reduce surgical mitral valve replacement with concomitant left HL appendage ligation in some search called fashion or to proceed with the possibility of a tool for Catania's procedures. With the left atrial appendage closure using WATCHMAN device and percutaneous closure of a para valvula mitral leak before we continue with the decision tree, we have to assess what's the risk for this patient regarding surgery because that will determine whether we take a surgical route or whether we take Percat Einius route and this is from his chart and you see that there is a series of risk assessment of which. The most important one is the risk score of mortality and his was a four point 8% or so. Just to give you a sense of scale, this is the score or the Society of Thoracic Surgeons score that was developed several years ago and this is the gamut of the risks from low risk to intermediate to high risk and prohibitive risk. And this is prom or predicted risk of mortality. And for our patient. You see, it's about four point 8% which is into intermediate range surgical risk, which is not to be taken lightly. To do really reduce surgery given his age, and as you see, there is a significant risk of mortality for redo surgery if you happen to be in Europe, you can use the euro score by. The idea is the same just to predict mortality and mobility from a procedure redo procedure in this patient so. Let's divide his. Medical history in two parts. Let's first discuss the HL fibrillation aspect. And let's image his left HL appendage using transistor for jail echocardiography and this appears as a 2D image. However it was drawn from a 3D echocardiographic image and represent simultaneous by plane view of the left Angel appendage. The left sided image represent a left HL appendage at the zero degree while the right sided image represent perpendicular. Orthogonal view in the 90 or 90 degrees in this case, and it's extremely important to have this capability of by plane imaging for all the procedures because simultaneously allows us to do 2 orthogonal planes in one image. And as you can see, left facial appendages well visualized. That is neither smoke nor thrombus in this left HL appendage. We can also turn the 3D aspect of it, and this is particular layout on the left hand side there are three images to represent long axis and the bottom one represents short axis. Each of these three images can be then be rendered as a 3D surface rendered image, and in this case on the right hand side in the big screen you see the rendering of the top left image and that represent left HL appendage. In the long axis we can also image the left facial appendage in the short axis and you can see we see the unfasten opening of the left HL appendage. It's orifice which is to the left of the mitral valve. In this view, we also between the left facial appendage and left upper pulmonary vein. We see what it's commonly referred as Coumadin rich, or the left HL Ridge that separates left HL appendage from the left upper pulmonary vein and at the top of image is the pulmonary. Artery. Now that's to be visualized. The left atrial appendage demonstrates it orifice as well showed that there is neither smoke nor thrombus in the left facial appendage. We can then proceed with the sizing. This left HL appendage in four Canonical views. Zero, 4590, and 135 degrees in each of these Canonical views, we measure the orifice diameter. It's a. Landing zone diameter as well as the depth of the left facial appendage in each of these views and based on this numbers that we obtained for four Canonical views, we can then determine what size of the WATCHMAN device we will need to implant in this patient, and these devices come in five sizes that are three millimeter apart. This is the five sizes. They start from 21 millimeters and go all the way up to 33 millimeters. And just to give you a sense of size, the 24 millimeter WATCHMAN device is roughly the diameter of a US quarter, or $0.25. Also, quarter of a Canadian currency. So now let's conclude from this part of assessment related to atrial fibrillation. We can say that anatomy of the left HL appendage is suitable for percutaneous closure using a 27 millimeter watchman device, and then this is image of a WATCHMAN device. It's a night Inal frame covered with the cloth that it's at the beginning, permeable to red blood cell and blood, but eventually will endothelia lies and successfully closed. The left atrial appendage and let's just review the steps of transcatheter closure of the left facial appendage using the watchman device. It starts with the transseptal puncture or transseptal cross, and it's a very important that is done in the posterior and inferior aspect of the fossil Vallis and you will see why that is important. It's probably one of the most important aspect of this procedure. After the Transseptal puncture is performed. Then a delivery sheath is passed into the left atrium and through the delivery sheet, a pigtail catheter is then advanced into the left Angel appendage and after that delivery sheet is also advanced into the left agile appendage, then an angiogram using iodinated contrast is done to see the appendage, RAM or the flora. Scopic imaging of the Left HL anatomy. After that it's preceded with the. Unsheathing of the device that is placed at the orifice of left Angel appendage and then the device is deployed in order to close the left HL appendage orifice and after we are satisfied with the position of the device inside the left atrial appendage. We then. Prepare to release the device. An additional angiogram is done to check for League simultaneous to color Doppler assessment on echocardiography and if we are satisfied with the position of the device the device is then released and then initially it's permeable to blood flow through the device and the flow through the device is normal. However Flow Para device is abnormal overtime. The device will Endothelia lies. And will become part of the normal structure of the heart. Let's start to implant in this particular patient and we will start with the transseptal puncture, which is essential part of this procedure. As I pointed out, it's extremely important to do transseptal puncture inappropriate portion of the integral septum, which will be in the inferior and the posterior aspect of the septum. But how do we communicate? Is echocardiographer's the position of? Anterior posterior superior inferior to an interventional list, and I think the biplane transducer fragile Eco view is extremely helpful. On the left hand side you see the short axis at the level of the OR Dick valve, which allows us to recognize the anterior and the posterior aspect of the interracial septum on the right side of the screen we see the orthogonal view, which is roughly the by cable view, which then allows us. To see the superior and the inferior aspect of the integral septum. And now the interventional list has a map to guide their transseptal apparatus toward the desired part of the septum, which will be posterior and inferior. And once we are satisfied that the location of the transseptal needle transseptal puncture is done and I will demonstrate you on the next image of a 3D transesophageal echocardiography, the importance of a posterior transseptal puncture. Here you see the UN fast view of the left HL appendage. On 3D transesophageal echocardiography in the position roughly about 10:00 o'clock you see the left edge Hill appendage in its long axis on the right side of the screen you see the intertial septum on the top of the image is the anterior septum, and at the bottom part is the posterior septum. And you see if you do the transseptal puncture in the posterior aspect of the integral septum, then the path goes directly into the left HL appendage. And this would not be the case had we done the transseptal puncture in the anterior septum, does it's important to be in the posterior and inferior aspect of the integral septum in order for this procedure to succeed? Now that we have done successfully transseptal puncture in the appropriate portion of the intertial septum, let's then go to Watchmen, deployement, and again, transversal for Jellicle Cardiography, particularly 3D echocardiography, is essential for the success of this procedure. Here we are looking at transistor for GL echocardiography, 3D surface rendered image at the level of the left atrium in, see in the right side of the image is the actual septum an taken at the moment? That we are passing delivery sheath over the wire through the integral septum toward the left upper pulmonary vein. Now that we passed the delivery sheet in the left atrium because to the next step and you see here that the sheet is in the left upper pulmonary vein over the wire and in the next step we will move from the left upper pulmonary vein into the ultimate target, which is the left HL. Appendage and here you can actually see how 3D echocardiography can provide exceptional guidance to an interventional list. To go right into the left HL appendage and minimizing risk of damage to any of the surrounding structure. Now that the delivery sheath is placed in the body of left HL appendage, we can start delivering the device and here you can see again in a by plane view side by side. Two orthogonal views of the left atrial appendage as it's being closed with the watchman device. So now the position is appropriate. The location of the device is appropriate and now will check for its appearance of 3D. We can look at the non fast view of the left HL appendage as it's closed with the WATCHMAN device in the middle of the image we see the watchman device that it's appropriately placed at the orifice of left agile appendage. Flush with the orifice without any shoulder and then now I'll show you Justin comparison what was at the baseline on the right hand side you see the left Angel appendage before it was closure. You see it's orifice and now on the left hand side you see when it's closed with the watchman device in the final stage. We will then check for Para Device leak using color Doppler echocardiography and I'll show you a representative view here and there is clearly no Para device leak. On any side of the device. So we are completely satisfied and there's a successful closure of left heel appendage with the WATCHMAN device. No party device watchman leak. That's what we want to see. And now on the right hand side you see images of the watchman device. It's night and all frame as well as a cloth on top of device. And it's this cloth that provides the sealed. So the guidance of the position of the seal inside the left facial appendage is extremely important by transesophageal echocardiography, as it is certains that will be no para device leak once the device is diploid. If you interested in all details of this procedure. My colleague and I, we have recently published a paper in the General American Society of Echocardiography. On left HL appendage. Lucian or exclusion procedures that includes WATCHMAN. All the details of the watchman procedure that I have just demonstrated.

Transseptal Puncture LAA Closure with Watchman Device Watchman Procedure Watchman Device Sizes Left Atrial Appendage Conclusion WATCHMAN PROCEDURE Case Presentation STS Score Left Atrial Appendage Occlusion/Exclusion: Heart Valve Team Assessment WATCHMAN PROCEDURE 123Sonography Procedural Image Guidance with Transesophageal 146 Watchman comes in 5 dimeter sizes, with 3-mm diameter increments. 90 Lens Tern : Lens Temp: C8. Lens Temp: 40.10 C Lens Temp: 3. Lens Temp: 38.30 Lens Temp : 40.10 C Lens Temp: C Lens Temp: 38.30C Lens Temp: C9. Lens Temp: 40. 30 C Lens Temp: 40.106 C Lens Temp: 38.3 s Tern s Temp: Echocardiography Lens : 40.10 c Lens Temp: C Lens Tern 81-year-old man with 81-year-old man with 81-year-old man with Lens Temp: 40.30 C Lens Temp: C. Lens Temp: 40.30 c Lens Temp: 38.30C Lens Temp: 39.30' Lens Temp: 39. Lens Temp: 39.30 Lens Temp: 39.3 'IL-ens Tem : C Lens Temp: 40.30 C Lens Temp: 38.30 C Lens Ternp: 38.30 Anatomy of the left atrial appendage is suitable for Lens Tern Lens Temp: C. Lens Temp: C9. s Temp: July 17, 2018 Lens Temp: 38.30C Lens Temp: C 29 fps mm 22 vps R 22 vps IR Lens Temp: C Lens Temp: 40.30 C Lens Ternp: 38.30 Lens Ternp: 3&.3• Lens Temp: 3. Lens Temp: 40.10 C Lens Temnp: 38.30C Lens Ternp: 38.30C Lens Temp: 3&3• Temp: s Temp: eter 22 vps IR 0.37 m/s 0.37 29 fps I Temp: 4• 29 fps mm 29 fps / mm 23 fps 120 mm 29 fps / mmn 23 fps / 120 mm 36 fps/ 90 36 fps 190 16vps/R 16vps/R progressive dyspnea on exertion over the past year 29 fps I nyn 29 fps I mm 138/7 Transseptal Puncture STS Risk Score: Risk of Mortality: 4.837% Flow percutaneous closure using a 27-mm Watchman device 138/7 mmH 145/8 mmHg Disclosures 63 bpm Ge eral 66 bpm/Ge eral 23 fps 1120 m 23 fps 1120 mm 23 83 bpm I 75 bpm n Flow 73 bpm n Flow 83 bpm I Serge C. MD, Wad J. MD, Anthony MD, 23 fps 1 23 fps / 120 m os 94 89 bp 89 94 bp 89 bp 94 b 89 b 66 bpm / 138/7 Usgd to Nayigate: pm / eneral / eneral pm / eneral 146 68 bpm 24 68 bprn I 66 bprn 68 bprn 145/80 145/80 138173m Hg 138173m g Contrast may be injec 14 mmHg 145/8 mmHg pm / eneral pm I Genera' bpm I Genera bpm / Genera' mmHg 145/8 145/8 mmHg 13 m / eneral I Genera Genera Larry A. MD, and MD, PhD, and A. MD, and MD, PhD, and m Genera 14 mrnHg PA Referred to Structural Heart Team INF 1.39/ mmHg mmHg stablished Stablished 138,173 g 138/73 138/73 '38/'73 4.5M 4.5MHa 138/7 1 mmHg 38/7 mmHg 3817 mmHg Posterior and Inferior dB AH5.5MHzf dB H5.5M 1 -7 dB H5.5MHzf- dB dB .5MHz/ de H5.5M 1-7 dB H5.5MHz/ dB .5MHz/ d mmHg int0ktheLAA .5MHz H5.5M / -7 dB .5MHz 4.5MHz H5SM 1-7 dB PERSISTENT ATRIAL FIBRILLATION • PERSISTENT ATRIAL FIBRILLATION .5MHz/ dB 5MHz .6 de 5MHz/ dB .5MHz/ de Morbidity or Mortality: 30.935% 1 dB TEC. 1 TEC: 1 1 et: O dB ANT T .110ffset: dB 4.5MHa 4.5MHz 1 /Offset: dB a. 1/Offset: dB .110ffset: dB D :60dB D:60d D •60d ,LAA JLAA TEQ: 1 Offset: dB 1 / Offset: dB Offset: O d Offset: d -1 dB -13 dB -8 dB -8 dB o dB -1 dB TEO: 1 TEQ 1 TEO: 1 / TEQ 1 / 1 Offset: Offset: O dB -13 dB -: dB . 1 Offset: d 'Offset: d Offset: d 1 Offset: d Offset: O d Offset: dB 60 dB -13 dB DR: dB DR. dB D :60dB D : 60 dB 60 dB D : 60dB 60 dB 1 dB D : 60 dB • • D :56dB • D D :60dB E: R: de D : 60 dB -: dB Atrial the most common arrhythmia and is a risk factor for stroke. In this Echocardiography-Fluoroscopy Fusion Imaging: D :60dB • Recurrent Gl bleeds while on warfarin PROM 60 High / Sl High Low RISK HIGH RISK INTERMEDIATE HIGH RISK Speakers Bureau (Philips, Medtronic) 4342 0.37 article. autmrs describe role of two- and trarzesophageal echocardbgaphy • Redo surgical mitral valve replacement with LA appendage ligation Predicted E: PROHIBITIVE RISK M: E: Anterior Septum 9 M: DIP:O • M: DIP: O Chronic anemia requiring frequent transfusions in and assessment and intraprocedual gudmce ot percutaneous left atrial in and posgyocedual assessment and intraprocedwal guidance of percutaneous left atrial (STS-PROM < 4 (STS-PROM > 4 (STS-PROM 4-8 0/0) (STS-PROM (STS-PROM > 4 (STS-PROM < 4 (STS-PROM > 4 M: DIP: O Advisory Board (Siemens) Lhong Length of Stay: 12.076% Long Length of Stay: 12.07% M: DIP: T Risk of Mortality of .0/T:3 Atrial Watchman Procedure Watchman Device Sizes apperxiage a-AA) occlusion procedues. advances haw been made in the of systerwc aps»rxiage a-AA) occlusion procedues. recent advances haw been made in the of systerwc 21 27 24 21 33 30 Color— Transseptal Puncture Windsock COV 3.3MHz with the oral anticoaWlmts. theæ medications •with a sonificant risk vs. CDV 3.3MHz Septum Se*tum mm mm Lupu are in many patients. Because thromboemboågn in atrial relation typically arises from are in mmy patients. Because thromboemboågn in atrial fi&illation typically arises o dB -1 dB MV << Posterior Septum o dB • BIOPROSTHETIC MITRAL VALVE REPLACEMENT ttvombi originatng the LAA surgical arxi percutaneous LAA excluson/occlusion twtniques have been • Percutaneous interventions : 21M: 3 .21 M: 3 LAA devised as alternatives to systerwc anticoagulation. Currently, svgical LAA exclwim typically performed : 1 'PCI .11Pr:1 : 1/Pr:l : 1/Pr:1 • 29-mm Medtronic Mosaic porcine prosthesis as an to other cardiac surgical procedures. w•hÉh Emits of patmts. Recently. Left Atrial Appendage several percutaneousty delivered devices LAA from systernic have been devel- Muhamed Sarié MD, PhD, MPA • Surgically implanted 8 years ago oped. Of have been shown clinicd trials to risk oped. Of have been shown clinicd trials to reduce risk oce Director of Noninvasive Cardiology I Echo Lab OR e Health Our Patient Associate Professor of Medicine both an erriocardial a pericardial (epZardia0 approach. such as the Lariat procedue. In the Watchman 4.837% procedwes. a transseptalty delivered strwtwe cornposed of nitinol is placed in ttw LAA Prolonged Ventilation: 17.185% • COMORBIDITIES COMORBIDITIES Muhamed Saric, MD PhD the LAA In the Lariat a is created US QUARTER No Para-device Watchman Leak Post Watchman USA. C it' Jwn JWn C it' Hypertension, diabetes, COPD Diameter ligation ot the LAA (J Am Soc Echocardioy 2018;31 :454-74.) Associate Professor 24 mm NYU Langone Health, New York 16 NYU DIVISION OF CARDIOLOGY 25