Francesco Fulvio Faletra

Atlas of Real Time 3D Transesophageal Echocardiography

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Tricuspid and Pulmonic Valves

Imaging of the tricuspid valve in real-time 3D TEE produces consistently suboptimal results. The reasons for this substantial failure are (a) the oblique plane of the valve in relation to the ultrasound pyramidal beams and (b) the thinness of the leaflets that makes it difficult to find the appropriate gain setting to remove noises but not structures. In Fig. 5.1a, a near perfect image of the base of the heart, seen from the atrial perspective, is obtained. But the image of the tricuspid valve is poor, and unlike the nearby mitral valve, part of the tissue at the base of the leaflets and along their free margins is missing because of the inadequate gain level. However, even a small increase in gain [in Figure 5.1b] causes noise that obscures both the mitral and tricuspid leaflets

Anatomy of the heart by multislice computed tomography

Preface. Acknowledgments. 1 Basic Principles ( Additional contributor: A. Mayer, MD ). 2 Location of the Heart: Body Planes and Axis. 3 Cardiac Planes. 4 The Right Heart. 5 The Left Heart. 6 The Cardiac Valves. 7 The Cardiac Septum. 8 Coronary Artery Anatomy ( Additional contributor: Giovanni Pedrazzini, MD ). 9 Coronary Vein Anatomy. 10 Coronary Artery Bypass Grafts ( Additional contributor: Stefanos Demertzis ). Index. A CD-Rom with video clips is included at the back of the book.

Real-Time 3D Interventional Echocardiography

Real-Time 3D Interventional Echocardiography - Libros de Medicina - Ecocardiografia - 129,99

Percutaneous Closure of Paravalvular Leaks

The presence of clinically significant paravalvular leak (PVL) that warrant repair ranges from 1 to 5% of patients with prosthetic valves and it is usually related to tissue friability, annular calcification, valve infection or technical factors. Surgical repair is the standard treatment for symptomatic PVL. Because of the increased risk of reoperation, there is tremendous interest in percutaneous closure of PVL. The accurate determination of the anatomical characteristics of the PVL (i.e. site, size and shape) is of paramount importance for proper selection of patients suitable for percutaneous closure, and the key for success of the procedure. 3D TEE appears to be the ideal technique for this purpose. In this chapter we will describe the normal 3D TEE appearance of mitral valve prostheses (both mechanical and biological), the 3D TEE imaging of mitral and aortic PVL, and, finally, the current role of 3D TEE during percutaneous PVL closure.

Closure of Patent Foramen Ovalis and Atrial Septal Defect

The atrial septum (AS) is bordered anteriorly by the aortic root and posteriorly by the posterior atrial walls. Because the left atrium is posterior and to the left of the right atrium, the plane of the AS is oriented obliquely and runs from a right posterior to a left anterior position. The best way to visualize the AS by ultrasound is by transesophageal echocardiography (TEE). However, two-dimensional (2D) TEE planes always intersect the septum perpendicular to its surface. Consequently, although this structure is anatomically a fibromuscular membrane dividing the atrial cavities, it is imaged as a linear structure, which may be thicker around the fossa ovalis (FO) and thinner at the level of the floor. Conversely, a unique quality of three-dimensional (3D) TEE is the ability to image internal surfaces of the heart from an en face perspective. Thus, both the left and the right sides of the AS can be visualized en face as they appear in anatomic specimens. The proximity of the transesophageal transducer to the AS (and the nearly perpendicular angle of incidence of the ultrasound beam), the use of transducers at higher frequencies, and, finally, the lack of interference from bones and lung allow the AS to be seen in 3D images of unprecedented quality. This chapter describes the acquisition of real-time (RT) 3D TEE images of the AS, the normal 3D TEE appearance of both left and right surfaces of the AS, the appearance of patent foramen ovalis (PFO) and secundum atrial septal defects (ASDs) on 3D TEE images, and, finally, the use of 3D TEE to guide percutaneous closure procedures for both PFOs and ASDs.

Percutaneous Balloon Mitral Commissurotomy

Percutaneous mitral commissurotomy (PMC) was one of the first catheter-based therapies for structural heart disease and has now become the treatment of choice for selected patients with rheumatic mitral stenosis. Inoue’s single-balloon technique has become the most popular method for performing PMC in most institutions today. The traditional tools of invasive cardiologist (i.e. fluoroscopy and hemodynamic pressure measurement) are inadequate for this procedure, and transoesophageal echocardiography (TEE) has become an essential component. Real time three-dimensional transesophageal echocardiography (RT 3D TEE) has greatly expanded the visualization of mitral stenosis. It provides detailed morphology of leaflets and commissures, and permits accurate planimetry of the valve. It is likely that RT 3D TEE will be used as a primary modality for guiding PMBV in the future. In this chapter we will describe the RT 3D TEE morphology of mitral stenosis, and how RT 3D TEE may add useful information in each stage of the procedure.

Closure of Post-AMI Ventricular Septal Defect

Ventricular septal defect (VSD) is a rare but deadly mechanical complication of acute myocardial infarction (AMI). Although significantly lower than with conservative management, in-hospital mortality after surgery remains as high as 47%, and dehiscence of the patch requiring a second operation is not infrequent because the sutures may teat out of the friable support around the defect. In todays era of percutaneous interventions, percutaneous closure is considered a valid alternative to surgical repair in patients with small to medium VSDs, since the occlusion device may provide a definitive treatment. Two-dimensional TTE/TEE color Doppler provides the most rapid diagnosis by demonstration of a discontinuity in the ventricular septum with left-to-right shunt. 3D TEE appears to be a very valuable tool in showing the defect as it anatomically is: a hole through the septum. In this chapter we describe 3D TEE anatomy of ventricular septum, 3D TEE imaging of post-AMI VSDs, and the current use of 3D TEE during percutaneous closure with catheter-based devices.

The Role of 3D TEE in Ablation Procedures

Complex ablations procedure might greatly benefit of an imaging technique capable of showing the anatomical details of the ‘terrain’ where the ablation takes place, guiding in real time catheter movements and continuously monitoring the catheter-tissue contact points during the energy delivery. Because 3D TEE provides high-resolution 3D images of the anatomy of the posterior structures of the heart (i.e. left and right atrium), at least in theory, this technique may have the potential to become a new, anatomy-driven navigational guide for ablation procedures. In this chapter we illustrate, normal 3D TEE anatomy of right and left atrial structures involved in ablation procedures and their anatomical variants, and then discuss the strengths and limitations of the technique during catheter ablation for typical atrial flutter and atrial fibrillation.

Catheter-Based Repair of Mitral Valve Insufficiency

Catheter-based percutaneous edge-to-edge repair using the MitraClip device (Abbott Vascular; Abbott Park, IL, USA) is a well-established, effective, and safe procedure that can be utilized in selected patients with mitral regurgitation (MR). The procedure mimics Alfieri’s surgical technique, bringing the anterior and posterior leaflets together from beneath the valve with a metallic stitch. Echocardiographic evaluation before the procedure is of paramount importance in defining the complex morphology of the valve and in detecting target leaflet lesion. Intra-procedural monitoring (i.e. delivery and placement of the clip) is usually performed under fluoroscopic and two-dimensional transoesophageal echocardiography. With the introduction of real-time three-dimensional transesophageal echocardiography (3D TEE), it appeared evident that the new technique would provide unique additional anatomical information both in selecting patients and guiding the procedure. In the selection of patients, the complex spatial structure of the valve is displayed as it actually is, allowing a precise assessment of the culprit as well as of secondary lesions. During the procedure, it has the unique ability to depict the “whole” scenario in which the procedure takes place in a single three-dimensional, real-time, easily understandable perspective. In this chapter we describe the normal mitral valve anatomy as displayed by 3D TEE, the 3D TEE pre-procedural characterization of valve morphology and the growing role of RT TEE in any individual steps of this complex procedure.