Bài giảng Siêu âm tim 3D trong đánh giá và can thiệp các bệnh lý van tim – TS.BS. Nguyễn Thị Thu Hoài

Nội dung bài giảng trình bày lựa chọn và đánh giá bệnh nhân kẹp sử van hai lá qua DA Mitraclip; cập nhật về vai trò của siêu âm tim 3D qua thực quản 3D; kẹp sử van hai lá qua đường ống thông (Mitra Clip); can thiệp bệnh lý hở hai lá qua đường ống thông... Mời các bạn cùng tham khảo bài giảng để nắm chắc kiến thức.

SIÊU ÂM TIM 3D TRONG ĐÁNH GIÁ VÀ CAN

THIỆP CÁC BỆNH LÝ VAN TIM

TS.BS.NGUYỄN THỊ THU HOÀI

VIỆN TIM MẠCH QUỐC GIA VIỆT NAM

4D echocardiography, history and actual performance How to

implement it to your routine echo lab

3D Echocardiography 2015: State of the Art

• MR differential diagnosis MitraClip®, Cardioband ®, parav leak

• LAA preinterventional, intraprocedural

• ASD preinterventional, intraprocedural

LỰA CHỌN VÀ ĐÁNH GIÁ BỆNH NHÂN KẸP

SỬA VAN HAI LÁ QUA DA MITRACLIP

-CẬP NHẬT VỀ VAI TRÒ CỦA SIÊU ÂM TIM 3D

QUA THỰC QUẢN 3D

Select and assess patients for MitraClip:

Update on the roles of 3D TEE

Echocardiography is a key modality for MR

Mitral Valve Anatomy

l Leaflet

l Annulus

l Chordae

l Papillary muscle

MitraClip anatomical patient selection

considerations

• Moderate to severe MR

(Grade 3 or more out of 4 grades)

• Pathology in A2-P2 area

• Mitral valve orifice area > 4cm 2

(depending on leaflet mobility)

• Mobile leaflet length > 1 cm

1 The current patient considerations are based on EVEREST II and commercial European experience to date The MitraClip Patient Selection Coniderations document has been endorsed by Expert Opinion (Crossroads institute).

FMR

DMR

1 Severe heart failure, despite optimal medical

therapy.

2 CRT non-responders.

3 Degenerative MR, denied for surgery.

4 Severe LV dysfunction, refractory to medical

therapy.

Patient groups in which significant clinical benefits have been reported

Mitral valve suitability for Mitraclip

4

Barlow’s MV with severe MR

and Bi-ventricular Failure

Prolapse P3

VGHTPE-019

The changing appearance of the

MitraClip candidate:

Imaging is the key!

A2 P2

Bicommisure view 4ch

Long axis

2D TEE for the mitral valve

3

Siêu âm Doppler màu 3D

Patient selection

Anatomical criteria (Functional MR)

3D TEE

LV

LA Ao

LV

LA Ao

LA

LV Ao

GEOMETRY AND DIRECTION OF MR JET

Jet width? Multiple jets?

Jet direction? Perpendicular?

MitraClip step by step:

How to simplify the procedure

The procedure TSP

Triaxial System

Steerable Sleeve

Delivery Catheter

Guiding Catheter

MitraClip

Anatomic Consideration

Transseptal puncture

Bicaval Short-axis

Tips: Use X-plane wisely

VAI TRÒ CỦA SIÊU ÂM TIM 3D TRONG ĐÁNH GIÁ, HƯỚNG DẪN THỦ THUẬT VÀ THEO DÕI

BN NONG VAN HAI LÁ QUA DA

Hẹp Hai Lá

✓ Confirmation of diagnosis

✓ Quantitation of stenosis severity

✓ Consequences

✓ Analysis of valve anatomy

Echocardiography: Major role in decision making for mitral stenosis

Trans mitral valve gradient

Parasternal short-axis view

valve thickness (maximum and heterogeneity) commissural fusion

extension and location of localized bright zones (fibrous nodules or

calcification) Parasternal long-axis view

valve thickness extension of calcification valve pliability

subvalvular apparatus (chordal thickening, fusion, or shortening)

Apical two-chamber view

subvalvular apparatus (chordal thickening, fusion, or shortening) Detail each component and summarize in a score

Valve Anatomy

How to Grade Mitral Stenosis

✓ Normal MVA is 4.0-5.0 cm 2

✓ MVA >1.5 cm2 does not produce significant symptoms

✓ As severity increases, cardiac output decreases and fails to increase during exercise.

The most validated and commonly used TTE criterion is Wilkins Score:

✓ Severity and extent of leaflet calcification

Wilkins Score - Splitability score

An inverse relationship exists between the total splitability score and PMBV success, with the cutpoint of ≤8 reflecting best short- and long-term results

Wilkins score alone does not appear to be a good predictor of post-PMBV mitral regurgitation (MR), but rather the degree of commissural opening

Severity of MR before PMBV

TEE before PMBV is useful to screen for LA or LAA thrombus or dense spontaneous echo contrast, especially in A-fib.

Information of LA thrombus

Cli ni cal r esear ch

Non-i nvasi ve assessment of mi t r al valve ar ea dur i ng per cut aneous balloon mi t r al valvuloplast y: r ole

of r eal-t i me 3D echocar di ogr aphy

Echocar di ogr aphy Labor at or y of t he Hospi t al Cl ı´nico de San Carl os, Inst it ut o Cardiovascul ar, 28040 Madrid, Spain

bUni ver si t y Hospi t al of Chi cago, Chi cago, USA

Received 13 May 2004; revised 3 Sept ember 2004; accept ed 9 Sept ember 2004

See page 2073 f or t he edi t or i al comment on t hi s ar t i cle (doi : 10 101 6/ j ehj 2004 10 001)

Backgr ound In t he last decade, mult iple st udies depict ed discrepancies bet weenmit ral valvular orifice area (MVA) measurement s obt ained wit h t he pressure half -t ime(PHT) met hod and invasive met hods during t he immediat e post -percut aneous mit ralvalvuloplast y (PMV) period Our aim was t o assess t he accuracy of Real-Time 3D echo(RT3D) t o measure t he MVA in t he immediat e post -PMV period The invasively det er-mined MVA was used as t he gold st andard

Met hods and r esult s We st udied 29 pat ient s wit h rheumat ic mit ral st enosis f rom t wocent res (27 women; mean age 48 2± 11.3 years), all of which had underwent PMV.MVA was calculat ed bef ore and af t er PMV using t he PHT met hod, 2D echo planimet ry,RT3D echo planimet ry and invasive det erminat ion (Gorlin’ s met hod) The RT3D MVAassessment showed a bet t er agreement wit h t he invasively derived MVA bef ore and

in t he immediat e post -PMV period (Bland-Alt man analysis: Average dif f erencebet ween bot h met hods and limit s of agreement : 0 01 ( 0 31 t o 0 33) cm2 and

0 12 ( 0 71 t o 0 47) cm2) bef ore and immediat ely af t er t he PMV, respect ively.Conclusi ons RT3D is a f easible and accurat e t echnique f or measuring MVA in pat ient swit h RMVS It has t he best agreement wit h t he invasively det ermined MVA, part icu-larly in t he immediat e post -PMV period

c 2004 The European Societ y of Cardiology Published by Elsevier Lt d All right sreserved

Rheumat ic mit ral valve st enosis (RMVS) st ill remains an

import ant public healt h concern in developed count ries

When t here is f avourable mit ral valve anat omy, balloonvalvuloplast y has become t he procedure of choice.1 In

t he last decade, many st udies have demonst rat ed largediscrepancies in t he immediat e post -percut aneous mi-

t ral valvuloplast y (PMV) period bet ween mit ral valvularorifice area (MVA) measurement s obt ained using t hepressure half -t ime (PHT) met hod and t hose derived inva-sively in t he cat het erizat ion laborat ory Explanat ions f or

0195-668X/ $ - see f ront mat t er c 2004 The European Societ y of Cardiology Published by Elsevier Lt d All right s reserved

doi: 10 1016/ j ehj 2004 09 041

*Corresponding aut hor Tel : +34 913303290; f ax: +34 913303293.

E-mai l addr ess: j lzamorano@vodaf on e es (J Zamorano).

European Heart Journal (2004) 25, 2086– 2091

J Am Soc Echocardiogr 2003;16:841-9

European Heart Journal (2004) 25, 2086–2091

From LA From LV

RT3D echocardiography

Echocardiography in Percutaneous Aortic Valve Implantation

TEE in Percutaneous Aortic Valve Implantation

❖ Preliminary TTE assessment.

❖ TEE imaging and guided valve deployment.

❖ Early TTE assessment after device deployment.

Transoesophageal echocardiography evaluation

prior to TAVI

3D TEE view for the measurement of aortic annular dimension

Multi-slice detector computed tomography reconstruction of the aortic root

and ascending aorta

Multi-slice detector computed tomography assessing aortic valve anatomy

and calcification

TEE during valvuloplasty

TEE in Percutaneous Aortic Valve Implantation

During procedure

European Heart Journal - Cardiovascular Imaging

(2016) 17, 835

TEE during valve deployment

After procedure

TEE in Percutaneous Aortic Valve Implantation

THANK YOU VERY MUCH!