Allan L. Klein, MD, FASE, FRCP (C), FACC, FAHA, and FESC

I was in New Orleans at the American Heart Association Meeting and attended a session on interventional echocardiography and structural heart disease. I was struck by the critical role that echo plays in the decision making of treating these diseases with percutaneous procedures. At one of the receptions, I got into a discussion with an interventionalist about how tricuspid valve disease is the “next new thing” in interventional cardiology, and he stressed the importance of echo in this new structural space. I mentioned that the ASE is very engaged with this area and recently organized a meeting entitled “Structural Heart Disease Forum: Intersection of Echo and Interventional Care.” This unique forum took place in Washington DC and brought together device companies (Abbott, Boston Scientific, Edwards, Medtronic, and St. Jude) with Echo companies (GE, Hitachi Aloka, Philips, Siemens, and Toshiba) and ASE thought leaders Drs. Asch, Gillam, Hahn, Lester, Little, Mackensen, Klein, Swaminathan, Weissman and ASE staff. For the first time, it brought together the structural heart and imaging industry and ASE experts in one-on-one sessions facilitating a productive meeting for all parties.

Why is this important in cardiology? There is an explosion of interest in structural heart disease including valvular heart disease and interventional cardiology, and echo is a crucial link between the two. Often, the device company works with the interventionist and cardiac surgeon while the imager works with the echo company, and now we were able to bring the parties together in the same room. It was like “speed dating,” and ASE is hopeful that long-term relationships will result from these meetings.

What is the utility of echo in this structural space? As people are aging with a lot of co-morbidities, there is a growing interest in treating valve disease as well as atrial fibrillation with percutaneous techniques without performing open heart surgery. Often, echo is vital in the pre, peri, and post-procedure phases of these techniques. The key areas where echo makes a substantial contribution include the following conditions: Aortic Valve ; 3-D TEE has an essential role in the evaluation of performing Transcatheter Aortic Valve Replacement (TAVR), however, there is an increasing trend of doing more TTE to assess for para-valvular leaks and pericardial effusion. TEE may be still very important in detecting immediate complications of the procedure such as annular rupture, tamponade, and coronary dissection. Mitral Valve ; The mitral valve space is growing with percutaneous mitral valve repair (MitraClip) and percutaneous mitral valve replacement. TTE is crucial for proper screening of patients with degenerative and functional MR. TEE guidance of the trans-septal puncture, positioning of the clip and leaflet capture is important in the success of the technique. Often the imager will be working hand in hand with the interventional cardiologist, and there could be more than one clip inserted in the mitral valve which could take several hours. Echo will increasingly play an important role in Transcatheter Mitral Valve Replacement in degenerated bioprosthetic valves as well as Transcatheter Mitral valve-in-valve or valve-in-ring procedures. Tricuspid Valve; There is increasing interest in percutaneous tricuspid valve repair in tricuspid regurgitation as well Transcatheter Tricuspid Valve Replacement in degenerative tricuspid valve replacements. Echo will be essential in screening and guiding tricuspid valve repairs and replacements in the future.

Other growth areas in the structural space will be closure of the left atrial appendage in atrial fibrillation and closure of para-valvular mitral valve leaks in mitral regurgitation, ventricular septal defects as well as PFO and ASD.

What is ASE doing in the structural disease space? As part of our strategic plan, ASE is making a major effort to recruit and assist new members in the structural space. Notable work in this area included doing a live demonstration course showing a MitraClip procedure and performing a valve-in-valve case at the Scientific Sessions in Seattle, a structural disease and echo symposium as part of Society of Cardiac Anesthesiology Echo week, a DVD highlighting the role of interventional echo and structural heart disease, and a future special edition of JASE featuring structural heart disease and echo. ASE guidelines may also make a significant impact on the decision making in the structural space since there have been recently updated guidelines on aortic stenosis, stress echo for non-ischemic indications (including valve disease), and valve regurgitation. ASE has helped establish a new interventional TEE code that is used for guidance, real-time image acquisition, documentation and interpretation during transcatheter intracardiac procedures.

What were the take home messages from the structural heart forum? There needs to be better communication between the device and echo companies at an earlier level in the development of the newer percutaneous valves and devices. New developments with fusion imaging of the echo, fluoroscopic and CT scan images may be important for the interventional cardiologist to lower the amount of radiation used during the procedures. It is clear from the discussions that the imager has to be an essential part of the valve team and be part of the decision making. Standardized echo protocols have to be established to provide more consistency between the echo images from different hospitals and to lower the variability of performing echoes. 3-D printing of valves may help in planning the procedures and providing education for the patients.

Clearly this structural heart disease forum between these device companies and echo companies is the start of a potential partnership (based on the speed dating), and ASE is wishing for further growth in this area with echo providing guidance in the decision making in the structural disease space.

Allan L Klein, MD, FASE, FRCP (C), FACC, FAHA, and FESC, is the Director of the Center for the Diagnosis and Treatment of Pericardial Disease and Staff Cardiologist at Cleveland Clinic and Professor of Medicine at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University.