Dr. Victoria Delgado
View the Slides from this session in ESC Congress 365
The number of percutaneous cardiac interventions has grown in the last years exponentially. Many patients with valvular heart disease and contraindications or high risk for conventional surgical procedures are currently referred for transcatheter valve implantation and repair interventions or paravalvular leak closure, therapies that have demonstrated to be safe, effective and to improve patients’ clinical outcomes. In addition, transcatheter left atrial appendage (LAA) closure has become a therapeutic alternative for patients at risk for cardioembolic events and contraindications for anticoagulation.
Furthermore, the efficacy of electrophysiological interventions such as ablation of atrial fibrillation and ventricular tachyarrhythmias has improved due to a better understanding of the arrhythmic substrate. Non-invasive cardiac imaging has played a major role in the development and success of these therapies. Particularly, technological innovations of 3-dimensional (3D) imaging modalities permitting accurate fusion of 3D anatomical (and functional) data onto fluoroscopy have helped to improve the safety and the success rates of these transcatheter therapies.
Jose Luis Zamorano, (Madrid,ES) summarized the relevance of accurate evaluation of patients with severe aortic stenosis who may be candidates for transcatheter aortic valve implantation and the procedural key steps. Using 3D transesophageal echocardiography (TEE), modern post-processing imaging tools can provide 3D anatomical models of the aortic valve and root and accurate measurements of the aortic annulus resulting in fast and improved aortic annulus sizing and selection of the prosthesis. These automated post-processing tools may reduce the interobserver variability and help to standardize the measurement of the aortic annulus, keep step in transcatheter aortic valve implantation. Furthermore, fusion of 3D TEE data and fluoroscopy permits accurate manipulation of the catheters and positioning of the transcatheter valve into the aortic root and improves communication between interventionalists and cardiac imagers.
Along the same lines, Ralph Stephan von Bardeleben, (Mainz, DE) discussed the importance of accurate assessment of left atrial appendage (LAA) with 3D TEE when evaluating patients for LAA closure. Evaluation of the morphology (single or multiple lobes) and dimensions of the ostium and landing zone of the LAA are key to selecting patients for this procedure. Compared with 2-dimensional TEE, 3D TEE provides more accurate and faster measurements of this structure. In addition, by displaying the 3D TEE data onto the fluoroscopy, the manipulation of the delivery catheters inside the left atrium and LAA is better guided and the procedure becomes safer.
Similarly, Giovanni La Canna, (Rodengo Saiano, IT) shared tips and tricks to maximize the success rate of transcatheter paravalvular leak closuring in patients with prosthetic mitral valves. By using 3D TEE and multidetector row computed tomography, the size, location and number of dehiscent parts of the sewing ring can be accurately visualized permitting precise selection of the procedural access (transseptal or transapical) and the size and type of closure device. Furthermore, 3D TEE is crucial during procedural guidance, accurately guiding the manipulation of the catheters and evaluating the results and immediately detecting potential complications such as device embolisation.
Finally, Karl-Heinz Kuck, (Hamburg, DE) has provided novel imaging modalities to characterize the pathophysiological mechanisms of atrial fibrillation and ventricular tachyarrhythmias, key aspects to select patients for catheter ablation techniques. Particularly, with the use of electrocardiographic information obtained with multiple electrode-vest and computed tomography or magnetic resonance imaging, the electrical activation of the left atrium can be analyzed. Rotors located at the pulmonary veins that initiate and perpetuate atrial fibrillation can be identified and accurately treated with catheter ablation later on at the cathlab. In addition, preliminary results on the use of nuclear imaging to identify ganglionated plexi that may trigger atrial fibrillation have been demonstrated feasible. The combination of these data with data obtained from computed tomography may help to guide specific ablation procedures of these structures. In addition, late gadolinium enhanced magnetic resonance is very important to characterize the left ventricular scar areas that are the anatomical substrate for ventricular arrhythmias. This imaging technique permits accurate planning of the ablation approach to use (endo- or epicardial) and to improve the therapeutic results.
Certainly, non-invasive imaging techniques have played a central role in the development of transcatheter therapies. In the future, fusion of these different imaging techniques will help to improve the communication between interventionalists and imagers and to improve the therapeutical success rate.
Innovation in interventional imaging
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