Part I: Z6Ms 4D Echo and Essential Clinical Applications

Summarize historical progression of 4D volume imaging Identify various clinical procedures that utilize 4D echocardiography Recognize the importance of volume imaging in device sizing as well as guidance for device placement during the procedure Select ► to continue Upon successful completion of this course you will be able to: 1 Orenstein, B. (2008). Ultrasound history. Radiology Today, 9(24), 2.  Retrieved from http://www.radiologytoday.net/archive/rt_120108p28.shtml   2 (n.d.) The history of ultrasound. Ultrasound Schools Guide. Retrieved  from: http://ultrasoundschoolsguide.com/history-of-ultrasound/   3 Vargas, A., & Massimiliano, M. (2010) Three-dimensional transesophageal echocardiography is a major advance for intraoperative clinical management of patients undergoing cardiac surgery: a core review. Anesthesia & Analgesia, 110(6), 1548-1573. 4 Lang, R., Goldstein, S., Kronzon, I., Khandheria, B., & Mor-Avi, V. (2016). ASE’s Comprehensive Echocardiography (2nd ed.) Philadelphia, PA: Elsevier Saunders.  5 De Backer, O., Piazza, N., Shmuel, B., Lutter, G., Maisano, F., Hermann, H., Franzen, O. & Sondergaard, L. 2014, Percutaneous transcatheter mitral valve replacement an overview of devices in preclinical and early clinical evaluation. Circulation: Cardiovascular Interventions, 7, 400-409. doi: 10.1161/CIRCINTERVENTIONS.114.001607   6 Bader, S., Lattouf, O., & Sniecinski, R. (2007), Transesophageal echocardiography of the Edge-to-Edge technique of mitral valve repair. Anesthesia & Analgesia, 105(5), 1231-1232. 7 Alfieri, O., & Denti, P. (2011), Alfieri stitch and its impact on mitral clip. European Journal of Cardiothoracic Surgery, 39(6), 807-808.          doi:10.1016/j.ejcts.2011.01.017   8 Keong, Y. (2014), Oct 08, Percutaneous therapy for valvular heart disease.  Medical Grapevine Asia. Retrieved from http://www.medicalgrapevineasia.com/mg/2014/10/08/percutaneous-therapy-for-valvular-heart-disease 9 Novuyoshi, M., Arita, T.,  Shirai, S., Hamasaki, N., Yokoi, H., Iwabuchi, M., Yasumoto, H. & Nosaka, H. (2009), Percutaneous balloon mitral valvuloplasty a review. Circulation, 119, 211-219. doi:10.1161/CIRCULATIONAHA.108.792.952 10  Chikwe, J., Walthe, A. &Pepper, J. (2004), The surgical management of mitral valve disease. British Journal of Cardiology, 11(1), 1-11. 11 Nkomo, V., Gardin, J., Skelton, T., Gottdiener, J., Scott, C., Enriquez-Sarano, M. (2006), Burden of valvular heart diseases: a population-based study. The Lancet, 368(9540), 1005-1011. doi: http://dx.doi.org/10.1016/S0140-6736(06)69208-8   12 Varadarajan, P., Kapoor, N., Bansal, R, & Pai, R. (2006), Clinical profile and natural history of 453 nonsurgically managed patients with severe aortic stenosis. The Annals of Thoracic Surgery, 82(6), 2111-2115.                                13 Future Market Insights, (2016)  Transcatheter heart valve replacement (TAVI) market: global industry analysis and opportunity assessment 2015-2025. Retrieved from http://www.futuremarketinsights.com/reports/transcatheter-heart-valve-replacement-tavi-market   14 Mack, M. (2012), Access for transcatheter aortic valve replacement. Journal of American College of Cardiology, 5(5), 487-488. doi: 10.1016/j.jcin.2012.03.009   15 Abdel-Wahab, M., Mehilli, J., Frerker, C., Neumann, FJ., Kurz, T., Tolg, R., Zachow, D., …..Richardt, G. (2014), Comparison of balloon-expandable vs self-expandable valves in patients undergoing transcatheter aortic valve replacement: the CHOICE randomized trial.  Journal of the American Medical Association, 311(15), 1503-1504. doi: 10.1001/jama.2014.3316      1877: Pierre and Paul-Jacques Curie discover piezoelectricity, which becomes the foundation of ultrasound imaging 1912: Ultrasound imaging develops 1950's: A-mode, B-mode, M-mode 1970-1980’s: Doppler and color flow 1990's: First developments in 3D and 4D ultrasound imaging Select ► to continue 1940's: Diagnostic ultrasound develops The large and cumbersome nature of the transducers was a barrier to widespread acceptance of 3D imaging. Select ◄ to go back   The first transducers were bulky, awkward tools but over time progressed to small, comfortable hand held devices. Over the past few decades, transducers returned to a more compact size and technological advancements help limit the use of additional modalities which can expose patients to harmful radiation and dyes. Current developments in fusion technology allow the interventionalist to view 4-dimensional echocardiography images on the same screen with fluoroscopy imaging during interventional procedures. This type of fusion provides real-time guidance permitting visualization of anatomy from different and multiple perspectives, marking of landmarks and labels, as well as changing the opacity of the fused image. This method of imaging helps increase understanding of anatomic relationships between images.4   Select ► to continue What is the difference between 3D and 4D? There is a significant distinction.   Initially 3-dimensional volumes were stitched together and viewed out of sync with the live heart function. 4-dimensional echo demonstrates valve structure and mobility as well as ventricular function and wall motion, all in real time.3   3-dimensional volume imaging provides a reconstruction in 3 dimensions in place of the traditional 2-dimensional imaging planes. The fourth dimension is time. It is the 3-dimensional reconstruction in real time.   What does the future hold for echo? Select ◄ to go back Replacement of regurgitant or stenotic valves has been standard practice for many years. In the case of mitral regurgitation, there is a focus to repair the valve if at all possible rather than replace it with an artificial valve. Studies show that long term outcomes, especially in aging populations, improve with repair of the valve rather than replacing it with a prosthetic.5  Select ► to continue This method of open heart surgical repair implants a prosthetic ring in the mitral annulus for stability and stiches the anterior and posterior mitral leaflets together at the point of perceived maximum regurgitation.6 While repair is the preferred option, until recently, the only method was surgical repair, which still requires an open heart procedure.  The first surgical repair, known as the Edge-to-Edge technique or Alfieri Stitch, was developed by Dr. Ottavio Alfieri in Italy in the 1990’s. 7   Select ◄ to go back The transcatheter approach to mitral valve repair developed in response to this growing need for an alternative to open heart surgery, with lower associated risks and better long term outcome than surgical repair.7 This minimally invasive approach to mitral valve repair is fast becoming the preferred alternative for degenerative mitral regurgitation, or MR, to high risk surgical repair in select populations.5 Select ► to continue People are now living longer lives due to improvements in healthcare. Many seniors with degenerative MR are living into their 80’s and 90’s and need an alternative solution to open heart surgery due to increased risk factors and comorbidities. Select ◄ to go back Before patients go in for a procedure, the clinician needs reliable information on which to base decisions. Proper evaluation and analysis of data lay the groundwork for which procedure the patient will undergo and when it will occur.  4D transesophageal echocardiography provides the clinician with a tool to evaluate valve structure, function, size, and degree of regurgitation and stenosis. Utilization of the eSie valves™ advanced analysis package provides data on annulus size, shape and valve function. The eSie PISA™ volume analysis produces a 4D color volume analysis of estimated regurgitant orifice area or EROA. These quantification tools utilizing 4-dimensional echocardiography may provide the clinician enough reliable information that the patient would not have to undergo further diagnostic testing which may expose them to harmful radiation and dyes. Select ► to continue Select ◄ to go back                                                    Part I ♥ 4D Echo and Essential Clinical Applications Select the play arrow to begin. Select ► to continue     Minimally invasive approaches are an alternative to open heart surgeries for mitral stenosis. Mitral stenosis still accounts for more than 10% of single native valve diseases in Western countries. It remains a prominent public health issue in developing countries, primarily as a result of rheumatic fever.9 While the role of transesophageal echocardiography has traditionally been to detect left atrial appendage thrombus prior to the procedure,9,10 technological advancements now place TEE in the procedure room or interventional suite, aiding the clinician with guidance of device deployment across the atrial septum, in addition to assessing gradients and quantifying regurgitation.10 Select ► to continue Mitral Stenosis Mitral Valve Stenosis (Narrow Valve) Image courtesy of Blausen Medical Communication, Houston, TX. Select ◄ to go back   In patients with limiting symptoms from mitral stenosis, the 10-year survival rate is only 10-15%.10  Relieving patient’s symptoms before they get to the severely limiting stages of mitral stenosis is an important step in their longevity. The need for alternative solutions for higher risk patients with limiting MS symptoms, led to the development of balloon valvuloplasty. The procedure was first attempted in 1982 in Japan and remains a viable option for patients with moderate to severe mitral stenosis.10 During a valvuloplasty procedure, a balloon catheter enters the heart, makes a small perforation in the interatrial septum and inflates after crossing the mitral valve. After about five seconds, regurgitation and gradient are reassessed. The process continues until reaching the point where the gradient is almost if not entirely eliminated, and the amount of regurgitation is not too great.10     Select ► to begin In 1993, 3D echocardiography involved multiple imaging planes to generate a 3D image. New developments in transducer technology bring true real-time, 3D, fully sampled, matrix array, transthoracic, and transesophageal transducers. This technology became the main imaging modality in structural heart disease as well as in the assessment of left and right ventricular function. Use of volume imaging starts with structural and functional assessment at the physician’s clinic and continues on to device guidance and implementation in the operating room and catheterization lab.  The MitraClip system developed by Abbott Laboratories out of Illinois has the most research and clinical use for transcatheter mitral valve repair. Europe approved use in 2008, Singapore in 2011 and the USA in 2013.8 The MitraClip device mimics the Edge-to-Edge technique by clipping the anterior and posterior mitral leaflets together. Image courtesy of Abbott Laboratories, Chicago IL During the procedure the patient may receive either general anesthesia or conscious sedation.  The interventionalist threads a catheter through the vein entering the heart through the inferior vena cava. The catheter punctures the atrial septum creating a small perforation which allows for catheter positioning across the mitral valve. The device deploys, clipping the leaflets together, limiting regurgitation.8 Click the icon below to watch the MitraClip procedure.     Courtesy of Abbott Laboratories, Chicago IL Watch the MitraClip Procedure   Select the play arrow to begin. When complete, select the X in the upper-right corner to close the window and continue. This high risk demographic may benefit from transcatheter aortic valve replacement or implantation, known as TAVR/TAVI, in which knowing the true shape and size of the aortic annulus means less risk of device-patient mismatch. eSie valves analysis of the aortic valve allows the clinician to produce a model of the valve and annulus which facilitates device sizing and may improve patient outcomes.   The TAVR/TAVI procedure is a transcatheter approach to aortic valve replacement. Over 300,000 patients around the world have undergone TAVR/TAVI interventions with Europe being the largest market for the procedure.   Either general anesthesia or conscious sedation keeps the patient comfortable while the interventionalist floats a catheter through the chosen access point, across the aortic valve (either transfemoral, transaortic or transapical). Depending on the type of stent valve used, a balloon may be used to inflate and expand the artificial valve over the native valve leaflets. Image courtesy of Edwards Lifesciences LLC, Irvine, CA.Edwards, Edwards Lifesciences, Edwards SAPIEN, SAPIEN, SAPIEN XT and SAPIEN 3 are trademarks of Edwards Lifesciences Corporation. Click ► to continue The following pages discuss minimally invasive procedures for mitral valve repair and aortic valve replacement. Select ► to continue Utilizing 4D transesophageal ultrasound, clinicians gather real-time data and apply it to patient care. Many procedures for valve repair and replacement no longer require open heart surgery and 4D transesophageal ultrasound provides invaluable information for planning and guidance during these interventional procedures.   Select ◄ to go back Congratulations. You have completed Lecture 1 of the Z6Ms Advanced Course. Listed below are the key points that have been presented. Take time to review the material before you proceed to the final quiz. Download and print a copy of the Course Review.   Summarize historical progression of 4D volume imaging 4D is three dimensional ultrasound in real-time. The terms 3D and 4D are often used interchangeably Fusion between TEE 4D images and fluoroscopy aids in understanding anatomic relationships between images and also in device placement. Identify clinical procedures that utilize 4D echocardiography Research shows that maintaining the native leaflets if at all possible leads to improved long-term outcomes in aging populations. The MitraClip system is currently the most widely used method of transcatheter mitral valve repair. It has been approved for use in Europe since 2008, Singapore in 2011 and in the USA in 2013. The MitraClip device mimics the Edge-to-Edge technique by using a device deployed via a catheter to clip the anterior and posterior leaflets together. Mitral stenosis (MS) is decreasing but still accounts for 10% of single native valve diseases in Western countries. In developing countries, mitral stenosis is usually a result of Rheumatic Fever. Once symptoms become limiting from mitral stenosis, the ten year survival rate is only 10-15%.   Recognize the importance of volume imaging in device sizing and placement. In a valvuloplasty procedure, the inflation process continues until reaching the point where the gradient is almost entirely eliminated and the amount of regurgitation is not too great.  The eSie valves analysis package produces a model of the valve and annular configuration which aids in device sizing and reduces patient-device mismatch. eSie valves, eSie PISA,  and RES are trademarks of Siemens Medical Solutions, USA, Inc.   Select ◄ to go back                                                                                                        Select ►to continue               Aortic Stenosis As our loved ones are living longer lives, another prevalent valve disorder on the rise is aortic stenosis. For those with severe aortic stenosis or AS, medical treatment provides limited relief and many patients are not candidates for open heart surgery due to clinical status or comorbidities. Image courtesy of Blausen Medical Communication, Houston, TX.     Select ◄ to go back Select ► to continue Due to varying regulatory requirements, product availability varies from country to country. Some/all of the products and/or features referred to in this module may be available in your country. This course addresses an international audience of Healthcare customers and cannot consider all country-specific statistics, guidelines and regulations. It is your responsibility to understand the regulations for your country or regions. Images and graphics used in this tutorial are for educational purposes only. They may have been modified or compressed, and may not reflect the actual image quality of the system. Selecting the ► continues this course and you confirm that you have read and understood this disclaimer