Penn Medicine cardiovascular imaging specialist Frank Silvestry, MD, discusses the role of interventional echocardiography and three new imaging options: 3D TEE, fusion imaging, and 3D ICE.
Related Links: Dr. Silvestry's physician profile
It's an honor to give this talk. I have nothing to disclose and no conflicts of interest. The analogy between inter operative cardiac surgical echo and interventional echo is the difference between a baseball pitcher and a catcher and an airplane pilot and a navigator. Whereas in inter operative cardiac surgery the person performing the T. E. Makes an assessment of the anatomy and suggestions about the operative approach. It's ultimately the cardiac surgeon that is going to be performing the procedure and then the inter operative echocardiography for assessing the results, much in the way a pitch is caught after it's thrown. But in interventional structural procedures it's much different and it's a more iterative process where every step is guided by both the pilot and the navigator working in tandem together to achieve the objectives in this case the flight. Now an interventional echocardiography needs to wear many hats and serve many roles and that includes the role of an echo technician and anonymous physiologist, a diagnostician, a navigator and a communicator. And we've learned valuable lessons about how each of these roles can be achieved in structural interventional procedures. Now there are three key new imaging options that I'd like to tell you about today. Three DTE really isn't new but it's become such a game changer that I wanted to underline its use and I do want to highlight the emerging role of fusion imaging and three dimensional inter cardiac echo as key new imaging options and structural heart disease. Three D. Trans esophageal echo is really still a game changer and the tip here is going to be not only to create great volumetric imaging of the structures of interest that could be helpful but also to learn to rely upon real time multi plane or reconstruction. This this facilitates excellent measurement abilities for example, as you can see here in the left atrial appendage included device and really gets us to drill in on the precise anatomy and allows us to deploy our device more effectively. Being able to see our catheter or advice and multiple planes and align the catheter multiple planes as obvious utilization. And so we've learned to rely upon the real time multiplayer reconstruction when deploying our devices. And this can be simple procedures like left atrial appendage include er or can be relatively more complicated procedures like trans catheter edge to edge repair or even um parallel to the league closure or trans catheter valve replacement. Now, future fusion imaging is really the newest kid on the block in terms of a neutral and it's an extension of two D. And three D. T. E. But here it's automatically fusing R. T. Images with live urus copy in real time for intuitive guidance of devices and procedures in space. And this allows us to either segment and outline cardiac structures on the floor. A Skopje were display the images that were getting on echo on Flora Skopje in a way that's anatomically and automatically tracked and paired together so that when the fluoroscope removes the echo images moves and we can even suggest Flora Skopje angles et cetera. Now, this has definitely given us some advantages in some procedures. For example, guiding trans septal puncture. Left atrial appendage include Urz and power value early closure. And we're learning its role in some of these other procedures like mitral valve repair with tear and mitral valve and valve procedures. Now, this is an example of fusion imaging of the para valvular legal closure here. We're looking at an aortic trans catheter valve replacement of Taber valve and there's a para valvular leak here. And what we've done is we've automatically segmented the left atrium left ventricle valve replacement and we've placed markers using echo that display on Flora Skopje simultaneously that allow the operator to visualize where we're seeing the leaks and where to cross and plug the hole. And we can use this as an adjunct. Certainly while we're crossing the defect, as well as positioning our devices in order to get better results with our trans catheter are valvular early closures. Similarly, we can use this for trans septal function here being used for tier in mitral valve repair. Trans catheter valve repair and idealized location of the transept was proposed and you can see how close we are with our trans septal as our guide wires going across into the left superior vein. In this case we can automatically segment the atrium and ventricle or we can superimpose our eco images on top of that here, you can see when tears being performed the alignment of the of the guide and the delivery catheter with the clip being ready to be opened prior to grasping. And here you can see a clip that's been placed already with the simultaneous display of two D. Information, color Doppler information and Flora Skopje all in the same image. And we can still see multi planar images on our eco as well. So this really gives us the best of both worlds multiple planes for guiding on echo simultaneously displayed on the floor. A Skopje for precise guidance in multiple modalities at the same time. So this really has the potential to be a game changer as well. And finally I'd like to highlight the potential role of three dimensional intra cardiac echo. There are two vendors that have this available via intra cardiac echo, the bio sense Webster New vision which uses the G. E. Platform and the phillips parasite which uses the phillips platform. Both of these offer a large volume two D, three D, both with an atomic and colour Doppler imaging. And this offers the possibility of creating T. E. Like images however, from an inter cardiac echo site. And there are small series that have demonstrated the use in E. P. And interventional procedures. This is one such procedure. Now these are images from the left atrium. So the inter cardiac catheter has been across the across the septum following the trans septal and now this is the catheter is placed in the left atrium for this kind of resolution. But you can see once again these are very T like images. We can see the guide catheter and we can see our in this case our watchman flex device being placed with T. E. Like images but from an intra cardiac echo site. So in summary, three D echo has become really critical for structural interventions and certainly has become standard of care for most of these interventions. And I would encourage everyone to learn how to use the multi planar reconstruction tools that are available live to get the most out of this technology. Fusion imaging is now finding its role in specific and complex intervention and the role of three D. Four D. Intra cardiac echo, which is now becoming available, will be defined with further work in both the ep and the structural space.
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