Folie 1 - HCMC Pediatric Cardiology and Congenital Heart Disease ...
Folie 1 - HCMC Pediatric Cardiology and Congenital Heart Disease ...
Folie 1 - HCMC Pediatric Cardiology and Congenital Heart Disease ...
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>Congenital</strong> <strong>Heart</strong> <strong>Disease</strong>s, Atrial Septal Defect from A to Z,<br />
January 12-15, 2012, Ho Chi Minh City, Vietnam<br />
What the echocardiographer<br />
needs from the<br />
interventionalists<br />
Nina Wunderlich<br />
University Hospital Mainz, Germany<br />
Kardiologisches Zentrum Darmstadt, Germany
Development of structural heart<br />
diesease interventions<br />
• Pre- 2000:<br />
Balloon valvuloplasty<br />
Balloon septostomy<br />
Catheter ablation of SVT<br />
• Image guidance modality→<br />
Flouroscopy
Development of structural heart<br />
diesease interventions<br />
• Post- 2000:<br />
Device closure of PFO,ASD,VSD,PDA, PVL<br />
Catheter ablation of atrial fibrillation, VT<br />
Alcohol septal ablation for HOCM<br />
• Imaging guidance modality →Flouroscopy<br />
• plus ICE <strong>and</strong> 2DTEE<br />
• Early mapping systems
Development of structural heart<br />
diesease interventions<br />
• Last 3-5 years:<br />
Mitral valve repair<br />
Percutaneous aortic <strong>and</strong> pulmonic valve implantation<br />
Next generation devices for PFO/ASD closure<br />
LAA Occlusion devices<br />
• Image guidance modality→ Flouroscopy<br />
• plus 2D <strong>and</strong> 3D TEE, ICE<br />
• Advanced mapping systems,<br />
• Flouroscopy overlay on 3D CTA, MRA,<br />
<strong>and</strong> angio reconstructions
Development of structural heart<br />
diesease interventions<br />
• Future:<br />
Percutaneous valve replacement with a variety of<br />
mechanical <strong>and</strong> biological valve types<br />
Repair of all valves<br />
Biodegradable closure devices<br />
Myocardial regenerative therapies (intramyocardial delivery)<br />
Device closure of all LV aneurysms <strong>and</strong> pseudoaneurysms<br />
Shunts for complex CHD<br />
• Image guidance modality→<br />
• Advanced 3D technologies<br />
• 3D imaging wedded to robotic navigation<br />
• Advanced ICE imaging<br />
• ….
Future…<br />
A model made from CTA data<br />
Prototype made of soft material that mimics heart tissue allows to<br />
create a“ training“ model prior to challenging SHD interventions<br />
3D Research lab, University of Colorado
Evolution of structural heart interventions<br />
Structural <strong>and</strong> congenital heart disease cases per year<br />
Cubeddu et al, J INVASIVE CARDIOL 2009;21:478–482
T.Feldman<br />
Cath & Interventions 2011
What is different in structural heart<br />
disease interventions?<br />
• Vascular interventions<br />
→ are performed in a well- defined space of small<br />
branching vascular trees<br />
→ flouroscopy is normally sufficient<br />
• Structural interventions involve navigation in open 3D<br />
space (Relatively large cardiac chambers)<br />
→2D technologies are limited in the visualization of<br />
complex 3D structures<br />
• Interaction with moving targets (heart valves, catheters,<br />
wires, devices..)<br />
→Difficult visualization in one plane
Why is imaging more difficult in<br />
structural heart disease?<br />
• It`s all soft tissue<br />
• Angiograpy does not work<br />
<strong>and</strong> / or requires large<br />
amounts of contrast agents
Why do structural interventions fail?<br />
•Imaging<br />
•Imaging<br />
•Imaging<br />
• Rarely device failure , lack of operator skills, lack of training
Why should we use echocardiography?<br />
• Echocardiography has some major<br />
advantages over other advanced imaging<br />
modalities (MRI,CTA)<br />
Echocardiography is mobile<br />
– can be recorded at the bedside, in the cath lab, in<br />
the cardiovascular intensive care unit, in the<br />
emergency room-indeed, any place that can<br />
accommodate a wheeled cart<br />
Echocardiography is „real time“<br />
– allows for the “live” performance of imaging<br />
immediately before, during, <strong>and</strong> after a procedure
…therefore it makes sense to<br />
involve an<br />
echocardiographer in SHD<br />
interventions….
Why do we need an<br />
interventionalist?<br />
This is obvious…..<br />
No interventionalist..<br />
…… no procedure
Why do we need an interventionalist<br />
<strong>and</strong> an echocardiographer?<br />
The challenging visual-spatial <strong>and</strong><br />
technical tasks are the reason<br />
why SHD interventions requires a<br />
team including experts in<br />
echocardiography <strong>and</strong> advanced<br />
imaging
We`ll end up to have<br />
two main actors…..
Two main actors…
Why is collaboration is complex?<br />
• Interventionalists <strong>and</strong><br />
echocardiographers performing SHD<br />
need to have<br />
• Structural <strong>and</strong> spatial knowledge of<br />
cardiovascular anatomy <strong>and</strong> pathology<br />
• Training with unique navigational devices<br />
• Incorporation of new procedural skills<br />
• Familiarity with novel image guidance<br />
technologies
Why is collaboration is<br />
complex?<br />
• Interventionalist <strong>and</strong><br />
echocardiographers performing SHD<br />
need to have<br />
• Structural <strong>and</strong> spatial knowledge of<br />
cardiovascular anatomy <strong>and</strong> pathology<br />
• Training with unique navigational devices<br />
• Incorporation of new procedural skills<br />
• Familiarity with novel image guidance<br />
technologies
Why is collaboration complex?<br />
Courtesy to Steffen Bagenda<br />
• Unlike surgeons interventionalists do not<br />
have the advantage of learning anatomy in<br />
the setting of open heart surgery
Why is collaboration complex?<br />
…The interventionalist has to rely heavily on images
Why is collaboration complex?<br />
…The interventionalist has to rely heavily on<br />
images
Why is collaboration is<br />
complex?<br />
• Interventionalist <strong>and</strong><br />
echocardiographers performing SHD<br />
need to have<br />
• Structural <strong>and</strong> spatial knowledge of<br />
cardiovascular anatomy <strong>and</strong> pathology<br />
• Training with unique navigational devices<br />
• Incorporation of new procedural skills<br />
• Familiarity with novel image guidance<br />
technologies
Why is collaboration complex?<br />
• The interventionalist must learn new procedural<br />
skills <strong>and</strong> gain familiarity with novel<br />
navigational <strong>and</strong> therapeutic devices
Why is collaboration complex?<br />
How to learn new procedural skills?<br />
• Simulation -based training →<br />
simualtors are designed to familiarize<br />
operators with various aspects of<br />
catheter based procedures (i.e.<br />
anatomy, imaging modalities etc)<br />
• Interventional cardiology meetings<br />
• In future? → training with prototype<br />
models
Why is collaboration is<br />
complex?<br />
• Interventionalist <strong>and</strong><br />
echocardiographers performing SHD<br />
need to have<br />
• Structural <strong>and</strong> spatial knowledge of<br />
cardiovascular anatomy <strong>and</strong> pathology<br />
• Training with unique navigational devices<br />
• Incorporation of new procedural skills<br />
• Familiarity with novel image guidance<br />
technologies
Why is collaboration complex?<br />
• Although complex moving 3D structures (heart valves ,<br />
chamber defects…) can be imaged with 2D crosssectional<br />
ultrasound images they require to mentally<br />
integrate the slice images into the context of a 3D<br />
object…<br />
X-plane
Why is collaboration complex?<br />
…challenges in imaging: aquisition <strong>and</strong> interpretation
Why is collaboration complex?<br />
• Delivery catheters, wires, devices, targets are<br />
often difficult to visualize simultaneously in a<br />
single cross sectional view<br />
We see the MitraClip, but not the mitral valve….
Why is collaboration complex?<br />
patient…?<br />
..uncomplaining?<br />
… As a result a significant amount of time is spent<br />
searching for the optimal view
Why is collaboration complex?<br />
A new thing to cope with…<br />
• In 2007 Philips Healthcare released the Live 3 D TEE<br />
iE33 Echo system which enables viewing of 3D image<br />
data in a variety of graphical display modalities….<br />
Full volume Live 3D Zoom Live 3D Thick slice Full volume+ colour
Why is collaboration complex?<br />
A new thing to cope with…<br />
Challenges in imaging: aquisition <strong>and</strong> interpretation becomes even more complex…
Why is collaboration complex?<br />
A new thing to cope with…<br />
• New views render additional information….<br />
• „enface“ views of cardiac structures <strong>and</strong> defects<br />
X-plane 3D view RA
Why is collaboration complex?<br />
A new thing to cope with…<br />
• 3D imaging facilitates the manipulation <strong>and</strong> alignment of<br />
the MitraClip to the mitral valve orifice, thereby<br />
increasing the odds of achieving procedural success
Why is collaboration complex?<br />
The echocardiographer has to provide 3D image data that are<br />
most appropriate <strong>and</strong> useful to the interventionalist <strong>and</strong><br />
improve the process of orientation …
Why is collaboration complex?<br />
…but it is up to the interventionalist to register the<br />
results of the 3D images in the 3D space of the<br />
patients heart
Why is collaboration complex?<br />
A new thing to cope with…<br />
• Implementation of 3D imaging involves…<br />
– gaining familiarity with the equipment<br />
– learn to aquire st<strong>and</strong>ardizing views<br />
– dissecting every intervention into a series of<br />
steps, each requiring a unique visual<br />
guidance solution<br />
– Communication between the<br />
echocardiographer <strong>and</strong> the interventionalist
Interventionalists <strong>and</strong><br />
Echocardiographers<br />
speak different<br />
languages …
Why is collaboration complex?<br />
A new thing to cope with…
Different angles...<br />
take it as a start giving people the possibility to see<br />
things from a different angle
Conclusion:<br />
What the echocardiographer needs<br />
(wants) from the interventionalist<br />
• The interventionist<br />
• … has to be physically present..<br />
• … has to have good structural <strong>and</strong> spatial knowledge<br />
about cardiovascular anatomy <strong>and</strong> pathology<br />
• …has to be trained with the navigational devices used<br />
• …has to be familiar with novel image guidance<br />
technologies<br />
• …must be „on board“ <strong>and</strong> want the information 3D<br />
imaging can render
…treat your echo guy nicely
And the future?<br />
Will be even more complex….<br />
Multidimensional<br />
fusion <strong>and</strong><br />
integrated<br />
navigation<br />
systems<br />
Robotic navigation<br />
controls
Thank you for your<br />
attention!