Evolution of interventional imaging in structural heart disease

Figures

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  Figure 1. (A) 3D aortic annulus measurements by multiplanar reconstruction analyses. It allows for coronal and transverse plane reconstruction starting from 3D dataset. (B) Aortic root 3D static modelling, with the corresponding automated geometric measurements concerning with annular, sinus of Valsalva, sinotubular junction dimensions, and coronary ostia height. (C) Similarly to 3D transesophageal imaging, CT multiplanar reconstruction analyses show coronal, sagittal, and transverse planes adjusted to get the true cross-sectional plane of aortic annulus: the three markers identify the annular plane/virtual basal ring for transcatheter heart valve sizing (D). (E) Prosthetic valve implantation three-dimensional simulation by a static modelling in a case of bicuspid aortic valve (FEops simulation software).

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  Figure 2. Prolpase/flail of P2 scallop. (A and B) Mitral valve baseline evaluation by simultaneous biplane view without and with colour Doppler; evaluation of regurgitant lesion extension. (C) Different perspective of the same 3D dataset may allow a fine evaluation of mitral valve anatomy and regurgitant lesion. (D and E) 3D surgical view of mitral valve with different volume rendering display: true view rendering may allow for fine details of the anatomy of regurgitant lesion by changing light source orientation. (F) Galss view rendering. (G) Post-processing of mitral valve by multiplanar reconstruction. (H) Post-processing software evaluation allows for mitral valve reconstruction and parametric analysis.

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  Figure 3. Mitral valve annulus sizing by multiplanar reconstruction of transesophageal 3D dataset (A) and CT-scan dataset (B). (C) Multislice computed tomography (MSCT) evaluation of mitral valve annular calcifications (degree and extension) and spatial relationships with surrounding structures by multiplanar reconstruction analyses.

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  Figure 4. Transcatheter edge-to-edge repair. (A) 3D en-face view of fossa ovalis may allow for finest individuation of transseptal puncture site (asterisk). (B and C) Delivery system extrusion into the left atrium and navigation toward mitral valve plane by 3D overhead perspective of left atrium. (D) Trajectory and axial alignment of delivery system in relation with mitral valve plane, by simultaneous biplane view. (E) Device arms orientation evaluated on 3D surgical view of mitral valve. Leaflets capture and assessment of leaflet insertion by simultaneous biplane view (F) and 3D surgical view (G). 3D transparency rendering en-face view of the mitral valve with colour Doppler showing clearly the double orifice (H) and trivial residual regurgitation (I). Ao, aorta; DS, delivery system; LA, left atrium; LV, left ventricle; MV: mitral valve.

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  Figure 5. Neo left ventricular outflow tract assessment by multiplanar reconstruction of 3D transesophageal dataset (A) and MSCT dataset (B). (C) Simulation of prosthetic valve implantation by 3D modelling, is concordant with suitable TMVR procedure. (D) Intra-procedural guidance: the introduction of the sheath, wire, and delivery system transapically, is monitored by simultaneous biplane view, in order to properly evaluate the spatial position of the devices in terms of medial–lateral and anterior–posterior location (in particular, to exclude aorta and chordal engagement). Prosthetic valve deployment monitored by simultaneous biplane view (E) and 3D overhead perspective of left atrium (F).

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  Figure 6. (A) 2D mid-oesophageal view of left atrial appendage. (B) 3D true view en-face perspective of left atrial appendage orifice. (C) 3D lateral perspective of left atrial appendage with glass rendering: it may allow for an intuitive 3D perception of left atrial appendage morphology by creating a sort of ‘cast volume’. (D) Simultaneous biplane view of left atrial appendage. (E) Multiplanar reconstruction (MPR) allows for fine morphology assessment and orifice/landing zone measurement. (F) Left atrial appendage occlusion device deployed under simultaneous biplane view since 2D imaging ensures higher spatial and temporal resolution for fine monitoring of device positioning/sealing. (G) Right anterior oblique cranial fluoroscopic projection. (H) Left atrial appendage occlusion device position and sealing evaluation by in-live multiplanar reconstruction. RAO, right anterior oblique.

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  Figure 7. Tricuspid valve repair by leaflet approximation procedure monitored by 2D/3D transesophageal. (A) Baseline evaluation of tricuspid regurgitation by 2D mid-oesophageal inflow–outflow view with colour Doppler helps for spatial localization of reguritant jet/jets in terms of anteriority (marked by aortic valve) and posteriority. (B) The same mid-oesophageal view used as reference plane for simultaneous biplane view during intra-procedural monitoring, allows for fine positioning of the delivery system over the regurgitant lesion and helps in defining the trajectory over the TV plane. (C) Transgastric short axis view of TV is of utmost importance and discriminating in the patients screening process. It allows for proper device position over the regurgitant lesion and device arms orientation in relation with coaptation line. (D) TG simultaneous biplane view showing leaflets captured by the device. Proper leaflets insertion can be then confirmed by mid-oesophageal simultaneous biplane views (E). (F) Transgastric short axis view showing device realized in the antero-septal region with approximation of leaflets. (G) Final result assessment by mid-oesophageal simultaneous biplane view with…

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  Figure 8. Tricuspid valve repair by leaflet approximation procedure monitored by 3D intracardiac echocardiography. (A) Device with open arms just below the TV annular plane. (B) Leaflets inside the device arms. (C and D) Leaflets capture. (E) Residual regurgitation evaluated by simultaneous biplane view with colour Doppler. (F) Transvalvular gradient assessment by CW. Courtesy by Mani Vannan, Marcus Heart Vale Center, Piedmont Heart Institute, Atlanta.

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  Figure 9. Transcatheter TV replacement with CardioValve prosthesis. The device delivered and oriented over the valve plane evaluated by 2D mid-oesophageal view (A) and 3D overhead perspective of right atrium (B). (C) Mid-oesophageal simultaneous biplane view of the device pulled back toward TV, entrapping the leaflets. (D) 3D multiplanar reconstruction allows for fine evaluation of the leaflet grasping. Once the proper entrapment of the leaflet is confirmed the atrial portion of the device can be safely realized under mid-oesophageal simultaneous biplane view (E). Final result assessment of the prosthesis completely released, by 2D (F) and 3D (G) imaging with colour Doppler, showing no paravalvular leak and normal antegrade flow. ME, mid-oesophageal; RA, right atrium; PVL, paravalvular leak.

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  Figure 10. ICE intra-procedural monitoring of different transcatheter procedures. Transcatheter edge-to-edge mitral valve repair. final assessment by simultaneous biplane view without and with colour Doppler (A and B) and 3D en-face perspective from left atrium (left) and left ventricle (right) (C) through transparency volume rendering. Transcatheter valve-in-valve procedure. (D) Baseline evaluation of mitral bioprosthesis dysfunction by 2D and 3D imaging with and without colour Doppler. (E) Final assessment by 2D and 3D imaging with and without colour Doppler. Courtesy by Mani Vannan, Marcus Heart Vale Center, Piedmont Heart Institute, Atlanta. Left atrial appendage occlusion. (F) Initial device deployment (arrow). (G) Device deployed. (H) Device anchored finally released (arrow). MV, mitral valve; LA, left atrium; LV, left ventricle.

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  Figure 11. Fusion imaging in different transcatheter procedures. (A–E) Transcatheter edge-to-edge mitral valve repair. (F–I) Left atrial appendage occlusion. (J–N) Percutaneous mitral paravalvular leak closure.