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How to evaluate your patient for a structural intervention

Non-Invasive Imaging

This well-attended session covered a wide range of topics related to the optimal evaluation of a patient prior to planned percutaneous intervention.
The first topic was "Is this atrial septal defect suitable for closure"? presented by J.D. Kasprzak (Lodz, Poland). The presentation included anatomical consideration for differentiating patent foramen ovale and atrial septal defect with their respective indications for closure.
The issues of identyfing appropriate indications for closure as well as choosing the optimal technique were illustrated with numerous 2- and 3-dimensional echocardiogrpahic clips representing wide spectrum of atrial septal defect pathology. Special attention was paid to identification of less common variants such as multiple or fenestrated defects which is markedly facilitated by 3-D technology. The presentation covered also the potential complications related to inappropriate sizing or technique choice. During the discussion it was suggested that 3-dimensional transesophageal echocardiography may change the initial clinical decisions in as many as 20% of cases - and potentially limit the use of X-ray balloon sizing in all, according to the experience of several laboratories.
The problem of optimal percutaneous aortic valve sizing was presented by dr E. Schwammenthal (Tel Hashomer, Israel).
The speaker described potential errors resulting from inappropriate use of two-dimensional techniques, including cross-sectinoal echocardiography due to inabiliy to select maximum diameter of the left ventricular outflow tract. Computed tomographic assessment is current clinical standard, allowing for 3-D based measurements of actual diameter and circumference of the LVOT.
The technique for proper sizing was presented in detail. The presentation gave rise to discussion whether novel, radiation-free methods may provide equivalent accuracy and robustness of data. Three-dimensional transesophageal echocardiography appears as emerging competitor, although the advantage of CT is the ability to answer relevant questions regarding vascular size and calcifications.
The following percutaneous intervention discussed was MitraClip implantation - (E.Brochet, Paris France). This exciting new technology is a role model for interventional and imaging specialist teamwork. Transesophageal echocardiography, optimally with three-dimensional optiom, plays a critical role for appropriate measurements of the valve prior to intervention. Further, the monitoring of procedure itself requires specific echocardiographic skills which were presented in detail. The most important criteria for qualification and procedure-specific requirements were reviewed.
The next speaker, V. Delgado (Leiden, The Netherlands) discussed preprocedural evaluation and guidance of percutaneous left atrial appendage occluder implantation for stroke prevention. This excellent review emphasized the use of transesophagel echocardiography with correct sizing of the appendage orifice. Computed tomography might be considered as alternative for the ostium sizing and also better depiction of the cavity shape, which in select cases may appear unsuitable to accomodate the implant.
Three-dimensional transesophageal option may further optimize the measurements and helps in guiding transseptal puncture, allowing for online monitoring of catheter position to maximize safety.
Finally, ultrasound is a necessary tool for measuring residual appendage flow. Small leaks up to 3mm diameter appear acceptable and do not increase the occurrence embolic events.
The final speaker and co-chairman, Jose L. Zamorano Gomez summarized the session with the series of excellent cases illustrating possible scenarios of 3-dimensional ultrasound use in structural intervention laboratory.
This advanced and attractive session gathered a sizeable audience, thus confirming the growing cooperation of echocardiography specialists and interventional cardiologists and interest in high-quality education in the field.




How to evaluate your patient for a structural intervention

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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