Gila Perk

Guidance of Post Myocardial Infarction Ventricular Septal Defect and Pseudoaneurysm Closure

Left ventricular pseudoaneurysm and ventricular septal defect are rare but devastating complications of myocardial infarction. With medical treatment alone, the majority of patients will die from these complications. Until recently, the recommended treatment was surgical closure. These surgeries carried extreme risk due to abnormal hemodynamics, necrotic substrates and the comorbidities of these patients. Recently, trans-catheter closure was shown to be an acceptable alternative to open surgical intervention. 3D echocardiography identifies the location, size, and shape of the defect and can assess, guide, and follow up the closure procedure.

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.

The ‘thrombus’ that never was

A 72-year-old male presented with an ST-elevation myocardial infarction complicated by cardiogenic shock warranting placement of a left ventricular assist device (LVAD, Tandem Heart, Cardiac Assist, Inc., Pittsburgh, PA, USA) and an intra-aortic balloon pump. Eight hours after the LVAD placement, transthoracic echocardiogram revealed an echodense immobile structure filling the whole left ventricular cavity, diagnosed as a thrombus ( Figure …

Aortic dissection mimicking a massive pulmonary embolism

An 85-year-old patient presented after an abrupt change in mentation and was found to be hypotensive and hypoxic. Transthoracic echocardiogram (TTE) (see Supplementary data online, Video S1 ) revealed an underfilled, hyperdynamic left ventricle (LV), and a dilated right ventricle (RV) with an akinetic free wall. Pulmonary artery systolic pressure (PASP) was estimated …

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.

Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation has been introduced into the clinical arena as an alternative to traditional surgical aortic valve replacement for these high-risk patients. The anatomic suitability is decided by a number of imaging techniques including 2-dimensional transthoracic (2D TTE) and transesophageal (2D TEE) echocardiography, coronary and peripheral angiography, and computed tomography scanning from the aortic root to the common femoral artery. New insights into the anatomy of the aortic valve complex in the beating heart became possible with the rapidly increasing availability of 3-dimensional imaging techniques that have extended our concepts of the “in vivo” 3D morphology of the valve. A comprehensive understanding of the 3D anatomy of aortic root is of paramount importance for both interventionalists and experts in cardiac imaging. The purposes of this chapter are: to describe 3D TEE anatomy of normal aortic root ; to describe RT 3D TEE imaging of calcific aortic stenosis and, finally, to outline the debated role of 2D TEE and 3D TEE during the procedure.

Percutaneous Closure of the Left Atrial Appendage

Percutaneous occlusion of left atrial appendage (LAA) with specifically designed devices has been proposed for those patients with AF who are ineligible for or non-compliant with anticoagulation therapy.The left atrial appendage has a complex and extremely variable structure with a multi-lobulated configuration.Because the size of occlusion device is strictly dependent on the size and shape of LAA, understanding this complex anatomy has become of paramount relevance for interventionalists involved in percutaneous occlusion of the LAA.Three-dimensional TEE provides a 3D data set of LAA which can be cut and analyzed from a countless number of planes. Additionally, each plane can be observed from multiple perspectives, allowing a more precise assessment of the anatomy of the LAA. Furthermore, a long segment of catheter can be visualized in a single image and the tip of the catheter can be tracked during the procedure. In this chapter we describe the 3D TEE anatomy of the LAA and its role in percutaneous closure of LAA.

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.