The Essential Role of CT Planning and TEE Guidance to Optimize Device Deployment

Transcription

1 LAA Occlusion Therapy The Essential Role of CT Planning and TEE Guidance to Optimize Device Deployment John Carroll, MD University of Colorado Interventional 3-D Lab 3-D Research Lab for Interventions

2 Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Grant/Research Support Sale of Heart Models Consulting Fees/Honoraria Royalty Income Company Philips Health Care Atritech, AGA Medical/St. Jude Medical Philips Health Care and AGA Medical/St. Jude Medical Philips Health Care

3 Image-Based Planning and Guidance of LAA Occlusion Therapy Why so Important? Variable anatomy, complex 3D relationships, unique imagederived measurements, delivery systems and devices requiring size matching, and careful deployment with 3-D alignment Plus the potential problems due to poor imaging including long procedures with high radiation and contrast loads, residual leaks, and the risks of perforation, embolism, and more

4 Where is the Os of the LAA? What are the distances from the LAA Os to the mitral valve and warfarin ridge? What is orientation of the central axis of the proximal LAA relative to the plane of the interatrial septum? Adam Hansgen University of Colorado 3D Research Are the depth and dimensions of the landing zone of the LAA appropriate for the device? How many lobes does the LAA have? What is the shape and size of the LAA Os? What is the distance from the transseptal puncture site to the LAA?

5 Anatomical Considerations in LAA Occlusion Therapy What anatomies are suitable for device occlusion? What measurements and understanding of anatomy are needed for the device, delivery system, and deployment? LAA characteristics, transseptal puncture location, delivery catheter shape, and achieving optimal alignment of device in LAA What imaging modalities will provide these measurements to plan and the image guidance to execute?

6 2D Echo and Traditional Fluoroscopy/Angiography are Limited in Providing this Information Consider CTA and 3D TEE

7 LAA: Complex Anatomy P Su, K P McCarthy and S Y Ho. Occluding the left atrial appendage: anatomical considerations Heart 2008;94; ;

8 Heart Models from CT Angiography for SHD Interventions Circulation. 2008;117:

9 Digital Dissection to Make Physical Models with Variable LAA Anatomy LAA Inserts Whole Heart from CTA Whole Heart Minus LAA

10 Atritech Project for Physician Training Variable Lobes Large, Oval Os Average, Round Os, Bi-Lobe Average, Round Os

11 Device-Anatomy Mismatch

12 3D Catheter Shape and Fit to Anatomy Optimizing Transseptal Puncture Location Optimizing Alignment of Delivery Catheter and Landing Zone of LAA

13 CTA Planning for LAA Occlusion Current Patient selection: LAA shape and size Future Assess septum to LAA 3D path trajectory, optimal transseptal location, and optimal delivery catheter 3D shape Place a device in a model (physical or graphic) and see if and how it fits

14 Echocardiography for LAA Occlusion Therapy Pre-procedure patient selection Intraprocedure performance Transseptal puncture Optimizing viewing perspectives Optimizing device sizing and alignment of device-anatomy Assessment of results

15 Echo has Transformed Transseptal Puncture Safety Precision Ultrasound visualization for strategic transseptal puncture as required for LAA Occlusion How can ultrasound and fluoroscopic imaging during transseptal catheterization be further advanced?

16 Next Generation 3D Guidance of SHD Procedures We have RT 3D TEE visualization, but how to optimize its use? Make it interventional, integrated, and interactive

17 Assessment of Septum C-Arm and 3D TEE Concordance of Perspective and Surface Visualization Rotate Gantry

18 Combined Echocardiographic Fluoroscopic Guidance Trans-Septal Puncture (investigative software) Ultrasound and x-ray are registered The marker is placed on the ultrasound image at the desired puncture site Real-time Echo and fluoroscopic images used to place transseptal catheter at the marker Particularly useful for a strategic trans-septal puncture as required for LAA Occlusion

19 The Rotating 3D TEE Dataset The ability to vary the perspective despite a fixed location of probe improves depth visualization and understanding of anatomy/devices Is depth perception adequately created with pseudo-colorization? Truth in depth perception is the key to hand-eye coordination What in-room tools are needed to allow us to use 3D TEE better? (i.e. cropping, multiple views)

20 Echocardiographic Guidance of LAA Occlusion Echogenicity of wires, catheters, devices Is this en face view useful for LAA occlusion device deployment?

21 LAA Targeting and Integrating Fluoroscopy and Ultrasound (investigative imaging tool) Multiple simultaneous perspectives Placing marker in LAA Os Registration with x-ray making fluoroscopic guidance smart with soft tissue target Cropping of 3D to see inside LAA in fluoro concordant view

22 Conclusions Pre-Procedure CTA provides critical information for planning 3-D LAA anatomy: sizes, shapes Septum to LAA relationship Can be imported into cath lab for fluoro overlay Intraprocedure 2D/3D TEE provides critical real-time images for procedure performance Placement of transseptal puncture Alignment of delivery system and monitoring device deployment Assessment of results and troubleshooting Integrated, interventional, and interactive 3D TEE registered with fluoroscopy may further enhance image guidance of LAA occlusion interventions