Transcatheter interventions for structural heart disease (SHD) represent an exponentially growing field, which has expanded beyond established procedures such as balloon mitral valvuloplasty and alcohol septal ablation to technology-driven valvular procedures such as transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve repair (TMVR). These percutaneous procedures, along with their rapidly evolving technology, present new challenges and opportunities for the interventional echocardiographer.
Although the traditional perioperative space requires a comprehensive transesophageal echocardiography (TEE) exam at baseline, echocardiographic imaging during cardiac surgery is often sporadic. The perioperative imager will be required to present and confirm the initial pathology and identify the underlying mechanism of disease (e.g. primary chronic mitral regurgitation with prolapse of a mitral valve leaflet). Once the surgical procedure is complete, the echocardiographic assessment will be repeated but often remains focused around the actual surgical procedure. This is very different in the interventional catheter laboratory or the hybrid operating room. Here, the interventionalist depends on continuous procedural guidance paired with unambiguous and ongoing communication, at times for many hours. This not only requires expert imaging skills and familiarity with all relevant echocardiographic modalities but also unique dynamic team skillsets.
In line with the new strategic goals of the ASE, the Council on Perioperative Echocardiography (COPE) recognizes the opportunity for ASE to take the educational lead in this growing patient care industry that will mutually benefit our patients and the profession. Structural heart valve teams which encompass multiple specialties are forming worldwide. Often they include interventional cardiologists, cardiac surgeons, cardiac anesthesiologists, cardiologists, sonographers, interventional radiologists, and epidemiologists/researchers. The ASE aims to attract all users of ultrasound by creating quality and value. Regardless of their specialty, echocardiographers asked to image in the structural heart environment deserve to be equipped with up-to-date guidelines, educational opportunities including LIVE case demonstrations, online webinars, didactic “how to” lectures, and illustrations. To exemplify the educational need and to illustrate the utility of real-time two- and three-dimensional transesophageal echocardiography (2D and 3D TEE) in the SHD domain, we will briefly highlight their use during TMVR.
TMVR using the MitraClip ® system (Abbott, Inc., Menlo Park, CA, USA) has emerged as a feasible treatment option for patients with severe, symptomatic, degenerative MR determined to be at prohibitive risk for MV surgery. During the intervention, TEE is critical in guiding safe transseptal puncture, advancement of the delivery system, and MitraClip ® positioning. The MitraClip ® has to be positioned perpendicular to the line of coaptation of the MV leaflets and ideally in the center of the regurgitant orifice and regurgitant jet. During and following leaflet capture, the extent of leaftlet insertions and initial stability need to be assessed. After clip deployment, 2D and 3D TEE are used to evaluate clip stability, coaptation surface length, residual MR, and mitral orifice area ( Figure 1 ). In addition the presence of complications such as possible leaflet detachment from the MitraClip ® , entanglement in the chordal apparatus, cardiac rupture (tamponade), and large postprocedure iatrogenic atrial-septal defect should be excluded. Of note, fluoroscopy and biplane or 3D-TEE imaging remain complementary imaging modalities during percutaneous MV repair while TEE is essential throughout the entire procedure. There are many other procedures in the SHD domain that also heavily depend on echocardiographic guidance, and this list is growing. These procedures include, but are not limited to transcatheter MV replacement, valve-in-valve procedures, paravalvular leak closures, and left atrial appendage occlusion.
