A New 3D Window to the Heart: Clinical Utility and Pitfalls of mTEE - SD

Introduction to the Symposium

Hello everybody.

My name is Roberto Lang.

I'm the director of the Cardiac Imaging Laboratories here at the University of Chicago, and today, I'm very pleased to introduce this symposium on live 3D Transit of AGL Echocardiography.

And I'm gonna talk to you a little bit about the clinical benefits and some of the pitfalls of this techniques.

There's going to be another group of prominent physicians talking about this, the engineer, Mike Budzinski from Phillips, who helped develop this unbelievable trans of a dual probe, will be talking about the technical aspects of this probe.

Ivan Salal, also a physician and engineer working at Phillips will talk about the quantitative aspects in particular on the mitral valve that can be obtained from this probe.

And Greg Fisher from New York is going to be talking about how you use this information in order to do to take decisions on what to do in the operating room at the time of surgery with the use of this probe.

I hope you will enjoy this program very much.

A New 3D Window to the Heart: Clinical Utility and Pitfalls of the Matrix Transesophageal Echocardiographic Probe

I will be talking about a new 3D window to the heart, the clinical utility and pitfalls of the matrix transit of a geo echocardiographic pro.

Before I start, I would like to profusely thank my colleagues Lisa Zang and Lynn Weiner.

Without their support, we would not have been able to do a lot of this work.

Evolution of Echocardiography

Now, echocardiography has truly evolved over the last 50 years, and we have all witnessed the change going from M mode to 2D, which is now vastly used in many labs around the world, and the 3D echocardiography, which in reality is not a new technique.

The first papers on three dimensional echocardiography have been published approximately 20 to 30 years ago, and the initial papers have been vastly dealing with the idea of using A 3D as a reconstructive technique.

And only lately in the last 10 years, we have seen the advent of real time transthoracic echocardiography, and today we are extremely excited about presenting to you the initial work on a transesophageal echocardiography.

Now, nowhere have we seen the evolution of echocardiography more evident as what we have seen with the mitral valve.

This is a mitral valve that was captured by Dr. Inga ler using a mode approximately 50 years ago.

Then we saw the visualization of the mitral valve with the use of ammo echocardiography, which is still used today.

A two dimensional echocardiography is definitely used around the world every single day in every echocardiographic study done.

And about 20 years ago, we have seen the initial description introduction of Oph AAL 3D.

This is done with a gated acquisition technique, and you can see all of these striations, which are made every time the mechanical transducer is moved three degrees.

Approximately 10 years ago, Phillips introduced the first real time transthoracic echo machine, and here we are looking at the mitral valve as if we would be seeing it when we are in the apex of the left ventricle.

You can see that this truly is a pyramid of data and using simple equipment, we can turn it around and now we can visualize the mitral valve as if I would be in the left atrium Looking in.

And today we are going to present to you for the first time real time transit of a geo echocardiography.

If you see the difference between this mitral valve that you're seeing now with the first one acquired by Inga ler, you would have to conclude with me that echocardiography has truly evolved tremendously over the last 50 years for many years, as I was mentioning to you, A 3D echocardiography was acquired using this gated sequential acquisition in which we used a multiplane transducer in which we acquired images every three degrees.

These images were processed and reconstructed offline to obtain images like the one I'm showing you now.

This is an image of a de hiss St. Jude mitral ring in which you can see that this ring is maintained here by a suture.

And we're looking at the mitral valve behind that ring.

And all of this is seen as if I would be in the left atrium looking down into the mitral valve.

And this is another image acquired with this gated sequential acquisition technique.

This is a patient who underwent a very not successful mitral valve repair, in which we see the central jet of mitral regurgitation, which is colliding against the roof of the left atrium.

Despite the fact that these images actually look very nicely or look very nice, they actually take a long time to acquire.

They require multiple cardiac cycles, and that is the reason why we see these radial artifacts.

In order to look at these images, it requires lengthy offline processing for display and analysis.

And that is the reason why this technique was not truly embraced in clinical practice, but remained predominantly a research tool.

The Real-Time 3D Matrix Transesophageal Probe

In order to circumvent some of these limitations, we now see the real time three-dimensional echocardiographic methodology incorporated and miniaturized on the tip of a matrix T transducer.

In this slide, you can see the two transducers, an omni three and a matrix, and you can see that the dimensions are virtually identical.

And this transvaal probe can provide you with live 3D imaging.

It can do it in three different modes and live 3D mode, which actually uses a narrowed pyramid, a zoom mode, which is predominantly used to look at the valves in a full mode, which is used in order to get information on left ventricular volumes.

The data acquisition is very simple.

If you know how to do a three TEE, you can able to acquire this data.

This is a simulation in which we can see an acquisition of the mitral valve in an apical view.

We set a regions of interest in the apical four, in the apical two in this patient with a Barlow syndrome.

You press a button and you get this 3D acquisition.

It's always important to display this image with the aortic valve.

On the top, you see the anterior and posterior mitral valve.

This is actually the surgical view in which we can very nicely display the different scallops of the anterior mitral valve on top and the posterior mitral valve, P one, P two, and P three.

In the bottom of the image, this display corresponds to the surgical view of the mitral valve.

This is the images that the surgeon which obtain in operating room.

And you can see how clearly we can now communicate with the surgeons regarding the different scallops that are seen in a normal mitral valve.

So this is an example of a normal mitral valve as visualized from the left atrium on the left and from the left ventricle on the right, this is a 3D zoom acquisition, and it put this slide just to give you the idea that this, we are acquiring now a pyramid of data.

This pyramid of data can be mobilized easily.

You can see that now we're gonna be looking at the mitral valve from the left ventricle looking up, so we can see the underside of the mitral valve.

Clinical Experience with Mitral Valve Imaging

Now, we have done a lengthy study here at the University of Chicago and have had the opportunity to image approximately 400 patients using this type of technology.

And let me tell you that these beautiful images can be obtained in our experience in about an A two or the anterior scallops can be visualized with this degree of quality in approximately 90% of consecutive patients, whereas the posterior scallops can be acquired with this quality of visualization in approximately 82% of the patients.

This is a patient with a mitral stenosis, and you can very nicely see with a lot of detail the fusion of both the medial and lateral commissures.

Now this is a slide that I have obtained by Dr. Hanian and Dr. Brochet from Piat Hospital in Paris.

And this corresponds to a image using the live 3D TE probe during a percutaneous balloon mitral valvuloplasty using an INO wave balloon.

And you can very nicely see this balloon as it is introduced and inflated in the center of a mitral valve with the idea of splitting both commissures.

Let me show you this now in real time.

You can see this in balloon is introduced, balloon is dilated in order to obtain splitting of both commissures.

Surgical Pre-Planning and Intraoperative Applications

Let me briefly show you an example because I strongly believe that this new probe will become the standard for imaging of the mitral valve in the operating room with the idea of performing pre-planning of mitral valve surgery.

This is a patient that has a P two P three flail mitral valve with a at least mildly severe mitral regurgitation.

Please note on the image on the right this area of flow convergence in and the very nicely and distinctively seen p in area of vena contractor, you can see the 3D image.

This is what would've been shown to the surgeon.

You can very nicely see this flail structure here between P two and P three.

And you can see on the image on the right what the surgical findings were in this particular patient.

You can very nicely see the correspondence of the anatomic site.

This information, of course, is very helpful to the surgeon and as will be shown in this symposium, these types of images can be very nicely quantitated with a software developed by Dr. Algo and associates from Phillips.

And this is just an example in which we can have a parametric display of the mitral annulus, the, and the area of the prolapse occupying the P two and P three aspects of the placebo mitral valve.

This patient underwent successful surgery with a mitral valve repair with a quadrangular resection and the introduction of a ring, which you can very nicely see in these biplane images of the mitral valve.

This U-shaped ring can very nicely seen both from the left atrium and the left ventricle.

And if you look carefully, you can see in this left ventricular view that there is a small area of micro coaptation in the area that corresponds to the apex of a mitral valve.

So we can actually sort of immediately communicate with a surgeon and tell him that this repair looks good.

But there is this problem of micro coaptation.

You can very nicely see now with three dimensional color doppler that there is a small area of mitral regurgitation that is truly present in the same area of this area of my coaptation.

Let me now show you a patient that presents with a prolapse of the middle scallop of a posterior mitral valve leaflet.

You can not only see very nicely this area of the prolapse, but you can also see in this interrupted arrow the area of the ruptured cord.

And this is how you see this middle scallop of the posterior mitral valve leaflet prolapse from both the left atrium and the left ventricular aspects.

This patient also underwent a repair.

You can look at the integrity of the ring both from the left atrium and the left ventricle.

And these are the images that correspond in real time to this particular patient.

Let me show you that these are just some sort of nice examples in which we can nicely see a P one prolapse.

This is the PAP two prolapse with a ruptured cord.

This is a flail P three and this is a patient with Barlow syndrome with a large annulus with voluminous leaflets that are prolapsing in multiple segments.

Quantification of Mitral Valve Structures

There is now a very nice software these beautiful images can be easily quantified and Dr. Sgo is going to explain, but let me show you that we can obtain very nice data annular diameters.

We can actually quantify the annular height of the saddle shaped mitral valve.

We can nicely measure leaflet length.

We can look at leaflet surfaces, we can look at leaflet angles, and we also can look at the prolapse height and prolapse volume for patients with function regurgitation.

Measuring the tenting height and the tenting volume might also be extremely useful.

It is also now possible to measure this angle between the aortic orifice and the mitral plane.

The more acute this angle, the bigger the chances are that this patient will complicate after mitral valve repair with systolic anterior motion of the mitral valve.

Now look at the papillary muscles.

We can also quantify their position in 3D space.

Functional Mitral Regurgitation

Let me now present to you a patient with a dilated cardiomyopathy with functional mitral regurgitation.

In this particular case, the mitral regurgitation is caused predominantly by dilatation of a mitral valve annulus, a tation of a mitral valve leaflets. If you put the color, you can see that there is a jet of at least severe mitral reation with an area of flow convergence then can be nicely seen and quantified in these 2D biplane views of a mitral valve.

So let me just show you that with 3D we can indicate to the surgeon hereby seen by these red arrows, the areas in which there are leaflet mal cooptation.

Let me show you how we can very nicely see that in real time and we can direct the surgeon to try and predominantly repair these areas in which the mal coaptation is seen.

This patient actually had a geo formm ring placed and you can see that what happens here is that the interop posterior diameter is narrowed and also the posterior part of this ring is a elevated with the idea of trying to maintain the subtle shape of the mitral valve in this particular instance.

And this is how this geo formm ring looks in real time in this particular patient.

Imaging Prosthetic Valves

Another issue that can be very nicely imaged with this valve are a prosthesis, both mechanical, non mechanical prosthesis.

This is a mechanical St. Jude valve as visualized from the left atrium and from the left ventricle, we have had the experience of imaging approximately 60 to 80 of these patients.

And this will come in a forthcoming publication in which we really make the point that this will also become the modality of choice to look at these prosthesis.

Let me show you now an example of a thrombose bi leaflet mechanical prosthesis, and you can see nicely the lack of motion of both leaflets.

You can look here at the angle compared with a normal patient.

You can see that one of the leaflets is actually moving much less.

This is a bioprosthetic micro valve, which is stenotic.

These are still frames.

You can see with a lot of detail the three leaflets of this bioprosthesis.

And you can see that now in motion.

You can see this lack of opening of both the left atrium and left ventricular prosthesis.

And on the right you see the surgical specimens that belongs to this particular patient.

Paravalvular Leaks and Other Structures

Another area that is extremely important are the ability to look at the his mitral valves.

You can very nicely see the area of the hissin in a 3D format.

And of course, this type of information is can be useful both for the surgeon and also for the operator who might be trying to occlude this dehiscence from a percutaneous point of view.

Other areas of the heart that can be very nicely visualized with this technique is the interatrial septum.

Let me show you that in this particular instance, we can look at the area of the foraminal valet very nicely and these types of images can be obtained in approximately 90% of the patients.

Now this is an example of a patient with a patent for amino valet.

If you ever thought about how a patent for amino valet would look, particularly when you have this flap opening and closing, you can see this now in 3D, both from the left atrial and right atrial perspective.

And with the use of contrast, you can see nicely these 3D bubbles, how they're passing from one atrial to the other, crossing the inter atrial septum.

This of course leads us to this patient who has a large os, osteo unds d We and others have used this modality to guide our partners who are trying to use different types of devices to close these atrial septal defects.

And this is an example of a patient and visualize with 3D after the positioning of an amp platter device.

This is how you see that in real time, both from the left atrium and from the right atrium.

And the view that I think is probably the most useful one is this view, which is called the sandwich view in which you can see the two plates of this amp platter device on both sides of the interatrial septum.

And we can actually get these type of pictures, we can communicate with the interventionalist and tell them that the placement of this device has been very nicely accomplished.

Left Atrial Appendage and Pulmonary Veins

These are some biplane views of the left atrial appendage.

The left atrial appendage can be also very nicely viewed.

With this matrix T probe, we can obtain an NFA view of the left atrial appendage in approximately 90% of the patients.

These views are also amenable to quantitation using Q lab.

And once you have this type of information, we can use this in order to assist our interventionists.

Were actually using this to put an left atrial appendage occlude device.

We have had the opportunity to validate these measurements against cardiac ct and 3D TEE is truly extremely accurate at measuring not only the different diameters of the mouth of the left atrial appendage, but also the depth of the left atrial appendage.

These are some biplane views of the left upper pulmonic vein with and without color.

And this technology is also extremely useful at visualizing the mouth of a left upper superior pulmonic vein.

This is the ridge separating the mouth of the left atrial appendage with a left upper superior pulmonic vein.

And this would be more in a longitudinal plane in which we see the left atrium, the ridge, and the left upper superior pulmonic vein.

And this is how you see these structures in real time.

Clinical Utility in Ablation Procedures

Now, how could these images be useful in a clinical setting?

This is an example of patient who underwent an ablation.

You can see that this patient has a dilated left atrial appendage with a lot of smoke.

You can see that there is a very dilated left upper superior pulmonic vein together with a presence of a thrombus in that particular type of situation.

And we have been working with our P colleagues.

This is a laal catheter.

You can see here the main pulmonic vein dividing into soup veins and how we use the 3D images in order to position our Lao catheter exactly in the position in which we want to perform the ablation.

Aortic and Tricuspid Valves

Now these are some beautiful images of the aortic valve, unlike what happens with a mitral valve.

Here we are not so lucky.

We can obtain beautiful image of the aortic valve one every five patients.

And the reasons why we are not as successful currently in visualizing the aortic valve is because the aortic valve is more anterior located because the ultrasound beam is slightly oblique.

And I think that we are gaining experience in the settings together with certain technical things that are coming that will allow us to visualize the aortic valve more frequently in a good way.

And the same actually would apply to the tricuspid valve.

These are some biplane views of the tricuspid valve, and you can see that it is possible to obtain very nice views of a tri leaflet a aortic valve, unfortunately similar to what happens with the aortic valve in a current state of development.

We actually can only see the tricuspid valve with this type of quality one every eight to nine patients.

Left Ventricular Assessment

This is an example of the use of this catheter using a full volume in order to visualize the left ventricle.

These types of images would allow us to quantify volumes and left ventricular ejection fraction.

These beautiful images can be obtained in approximately 77% of the time when you image these in consecutive patients.

And this allows us to quantify the left ventricle.

This is an example of a patient with an apical aneurysm and using again a Q lab.

It is possible to do accurate measurements of both volumes and also of regional wall motion.

Conclusion

So in conclusion, I think I have tried to convince you in this 20, 25 minutes that the Matrix T Pro provides you with unique views of the heart.

I think this modality will be rapidly become the gold standard for imaging of a mitral valve and will be used for preoperative planning of a mitral valve for the guidance of numerous percutaneous procedures and also for very novel quantitation of a mitral valve apparatus.

And not to forget about the ability of this new technique to also visualize prosthetic valves.

And in addition, as I showed you, this new technology provides you with unique views of the left atrial appendage and the pulmonic veins.

And these images again, will be extremely valuable in the guidance for ablation in cruder devices.

Techniques the same of course, would apply to the inter atrial septum.

With this, I would like to thank you very much for listening to this talk and I want to thank you again for your attention.