intracardiac echocardiography in percutaneous pulmonary ... › apcash › 2014arc › dl ›...

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

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.

• 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

PURPOSE

Demonstration of the role of ICE in

guiding the deployment of the

Pulmonary Valve and in evaluating

the valve function.

AcuNav Catheter

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

ICE for

Catheter Interventions

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

ICE cath in RVOT

ICE Standard View for PV

MPA

RPA

LPA

PV

Intracardiac Echocardiography

Normal Pulmonary Valve

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

Edwards SapienTM Pulmonic Valve

Valve Size: Delivery Catheter:

A. 23 mm 22 Fr. Sheath

B. 26 mm 24Fr. Sheath

Edwards SapienTM Pulmonic Valve

Percutaneous Transcatheter Replace

Pulmonic Valve

Deploy a Stent Pre-Valve

a

A

b

B

c d

C D

Edwards SapienTM Pulmonic Valve

Percutaneous Transcatheter Replace

Pulmonic Valve Using Edwards PHV

A B C

a b c

D

d

Melody Percutaneous Pulmonic Valve

Valve Size: 18 mm, 20 mm, 22 mm Delivery Catheter: 22 Fr. Sheath

Rush University

Medical Center RCCSH

D RCCSD

Melody Percutaneous Pulmonic Valve

Percutaneous Transcatheter Replace

Pulmonic Valve Using Melody PHV

Percutaneous Transcatheter Replace

Pulmonic Valve Using Melody PHV

A B C D

a b c d

Rush University

Medical Center

Transcatheter Placement PHV

Steps by ICE

A C E G

B D F H

I K M O

J L N

Transcatheter Placement PHV

Steps by ICE

ICE for Implantation of Pulmonary Valve

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

Valve Size: Delivery Catheter:

Diameter: 16-32 mm 16-22 Fr. Seath

Length: 20 mm; 25 mm

30 mm; 35 mm

VENUS P-Valve

VENUS P-Valve

RVOT View PA View

Delivery Catheter

Slow/precise release

Fast release

14-22 Fr

Marker

VENUS P-Valve

1

3

2

3 Markers

VENUS P-Valve

Crimpier

VENUS P-Valve

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

Rush University

Medical Center