intracardiac echocardiography in percutaneous pulmonary ... › apcash › 2014arc › dl ›...
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Role of Intracardiac Echocardiography
in Percutaneous Pulmonary Valve
Implantation
Qi-Ling Cao, MD.
Medical Director
Echocardiography & Research Lab.
Sidra Medical and Research Center
Doha, Qatar
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BACKGROUND • Percutaneous transcatheter replacement
of the pulmonic valve avoids mortality and
morbidity of multiple surgical reoperations.
• Cine angiography and Intracardiac echo
(ICE) have been employed during the
procedure to guide and assess the
implantation of pulmonary valve.
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• In Oct. 2000, Bonhoeffer reported the first clinical case of
a transcatheter PHV placement in a conduit between RV
and PA • In 2005, Hijazi report using SAPIEN THV implant in PA
homograft for a 16 yrs/old male, with ToF, s/p multiple
surgical repairs, homograft obstruction and significant PR • In May 2013, Dr. Hijazi report using VENUS transcatheter
self-expand pulmonary valve (P-Valve) in pulmonary
positionmfor patient who were status post ToF repair using
the trans-annular patch technique with significant pulmonary
regurgitation, and large PA&RVOT
Historical Overview
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PURPOSE
Demonstration of the role of ICE in
guiding the deployment of the
Pulmonary Valve and in evaluating
the valve function.
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AcuNav Catheter
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Intracardiac Echocardiography (ICE)
• 64 elements ultrasound tipped catheter
• Steering: 4 way in 2 planes
• Image modes: 2-D;
Color Doppler & DTI
Spectral Doppler: PW & CW
8.0F (2.5 mm),
5.5~10 MHz
Using 8F Sheath
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ICE for
Catheter Interventions
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TEE Images of Pulmonary Valve
• PV is in the far field, with lower quality 2DE image
• The blood flow passing PV is near 90º with echo beam
- bad for demo color Doppler flow
- unable to use PW and CW to measure gradient and
Assess valve competence.
Transesophageal Echocardiography
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ICE cath in RVOT
ICE Standard View for PV
MPA
RPA
LPA
PV
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Intracardiac Echocardiography
Normal Pulmonary Valve
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1. Cath hemodynamic assessment
of the valve and cine angiography.
2. ICE assessment pre, during and
post valve deployment.
A. Edwards SapienTM THV.
B. Melody Valve
C. Venus P-Valve
PROTOCOL
Rush University
Medical Center
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Edwards SapienTM Pulmonic Valve
Valve Size: Delivery Catheter:
A. 23 mm 22 Fr. Sheath
B. 26 mm 24Fr. Sheath
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Edwards SapienTM Pulmonic Valve
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Percutaneous Transcatheter Replace
Pulmonic Valve
Deploy a Stent Pre-Valve
a
A
b
B
c d
C D
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Edwards SapienTM Pulmonic Valve
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Percutaneous Transcatheter Replace
Pulmonic Valve Using Edwards PHV
A B C
a b c
D
d
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Melody Percutaneous Pulmonic Valve
Valve Size: 18 mm, 20 mm, 22 mm Delivery Catheter: 22 Fr. Sheath
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Rush University
Medical Center RCCSH
D RCCSD
Melody Percutaneous Pulmonic Valve
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Percutaneous Transcatheter Replace
Pulmonic Valve Using Melody PHV
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Percutaneous Transcatheter Replace
Pulmonic Valve Using Melody PHV
A B C D
a b c d
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Rush University
Medical Center
Transcatheter Placement PHV
Steps by ICE
A C E G
B D F H
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I K M O
J L N
Transcatheter Placement PHV
Steps by ICE
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ICE for Implantation of Pulmonary Valve
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VENUS P-Valve
• Structure (stent): Nitinol self-expandable
multi-level support frame • Integrated, unidirectional tri-leaflet porcine
pericardial tissue valve • The entire stent is covered (except the distal
cells) by porcine pericardium • The stent valve is a moderately radiopaque • Smaller delivery catheter
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Valve Size: Delivery Catheter:
Diameter: 16-32 mm 16-22 Fr. Seath
Length: 20 mm; 25 mm
30 mm; 35 mm
VENUS P-Valve
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VENUS P-Valve
RVOT View PA View
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Delivery Catheter
Slow/precise release
Fast release
14-22 Fr
Marker
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VENUS P-Valve
1
3
2
3 Markers
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VENUS P-Valve
Crimpier
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VENUS P-Valve
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Conclusion
Intracardiac Echocardiography
• ICE can be used successfully to assess
the function of the pulmonary valve pre &
Post intervention also guiding valve
implantation.
• We believe it is the best tool to assess the
PHV function after removal of all catheters
from across the valve
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Rush University
Medical Center
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