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 ...
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<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!
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