![Page 1: Interventional Imaging Cases · Interventional Imaging Steven A. Goldstein MD Professor of Medicine Georgetown University Medical Center MedStar Heart Institute Washington Hospital](https://reader034.vdocuments.net/reader034/viewer/2022042120/5e9a8cd0d6cc067d614b80b3/html5/thumbnails/1.jpg)
Interventional Imaging
Steven A. Goldstein MD
Professor of Medicine
Georgetown University Medical Center
MedStar Heart Institute
Washington Hospital Center
Tuesday, October 10, 2017
Cases
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DISCLOSURE
I have N O relevant
financial relationships
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Management
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No symptoms
Symptoms
Refractory Symptoms
Refractory, Severe Sx
Non-obstructionObstruction
No rx
? drug rx
??? DDD-pacing
ETOH septal ablation
B-blockers
Verapamil
Disopyramide
Combined B-blockersand Ca-blockers
Myotomy-Myectomy Transplant
Treatment Strategies for HCM
HCM121
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Drug-Refractory HCM
Therapeutic Options
Surgery Dual-chamber
pacemaker
Septal
Ablation
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Alcohol Ablation
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Alcohol Septal Ablation
• 1994 – 1st procedure at Royal Brompton
• Since then >10,000 performed
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HCM - Alcohol Septal Ablation
Indications
• NYHA Class III nor IV*
• LVOT gradient > 50 mmHg at rest
• ≥ 1 septal branch of LAD suitable for intervention
(*unresponsive to maximum medical treatment)
(or with physiologic provacative maneuvers)
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HCM - Alcohol Septal Ablation
Selection Criteria
• Symptoms that interfere substantially with
QOL despite optimal medical mgt
• Septal thickness ≥ 1.6 cm
• LVOT gradient ≥ 30 mm Hg at rest or ≥ 50
mmHg with provocation
• Accessible, appropriate septal perforator(s)
• Absence of intrinsic MV abnormality
• Absence of other conditions warranting
cardiac surgery
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HOCM - Alcohol Septal Ablation
Echo Methods for Guidance
• Transthoracic echo
• Transesophageal echo
• Intracardiac echo
(TTE)
(TEE)
(ICE)
Majorityof
centers
WHC*
* Moderate sedation; NOT general anesthesia
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HOCM - Alcohol Septal Ablation
TEE Views
• Apical 4-chamber view (0°)
• Longitudinal view (120-130°)
• Gastric short-axis view
• Deep transgastric view (for gradient)
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Using intracoronary injection of an echo
contrast agent, opacification of the
strategic septal area can be delineated.
Hypertrophic Cardiomyopathy
Alcohol Septal Ablation
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Transesophageal Transthoracic
Alcohol Ablation of Septum in HCM
Echo in Cath Lab During Procedure
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HOCM - Alcohol Septal Ablation
Echo Guidance During Procedure
Myocardial Contrast Echo
(Intracoronary Contrast)
Goal: Delineate strategic
portion of septum
(perfusion territory of target
septal perforator)
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HCM - Alcohol Septal Ablation
Similar to surgical myectomy, this procedure
attempts to debulk the septum in the region
where the LVOT obstruction occurs
A localized myocardial infarction is created by
injecting ethanol into the septal perforator that
supplies the septal myocardium adjacent to
the point of mitral leaflet (SAM)-septal contact
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Ethanol-induced
infarction
Alcohol Ablation of Septum in HCM
Nishimura and Holmes N Engl J Med 350:1320(2004)
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HOCM - Alcohol Septal Ablation
What to Evaluate Pre-Procedure
• Site and extent of septal hypertrophy
• Intracavitary gradient
• Localization of SAM-septal contact
• Mitral regurgitation (mechanism and degree)
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"An important improvement of the new
method in our opinion has been gained
by the integration of echo monitoring"
Faber, Seggewiss, et al
Circulation 98:2415(1998)
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0
20
40
60
80
100
>50%reduction Clinical
No Contrast
Contrast
Septal Ablation in HCM
Contrast Echo Helps Improve Results
p<0.01 p<0.05
(n=30)
(n=91)
% P
ati
en
ts
in LVOTG
70
9286
97
improvement
Faber, Seggewiss Circulation 98:2415(1998)
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HOCM - Alcohol Septal Ablation
Echo Guidance During Procedure
Assess Immediate Results
• Reduction of contractility/thickening of septum
• Elimination/reduction of SAM
• Elimination/reduction of gradient
• Elimination/reduction of mitral regurgitation
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HOCM - Alcohol Septal Ablation
Follow-Up (Post-Procedure Echo)
• LVOT gradient
• Mitral regurgitation
• Diastolic Filling
• Regression of hypertrophy
• LV function (especially septum)
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HOCM - Alcohol Septal Ablation
Echo Guidance During Procedure
Goal: Delineate strategic portion of septum
(perfusion territory of target septal perforator)
Myocardial Contrast Echo
(Intracoronary Contrast)
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Transesophageal Transthoracic
Alcohol Ablation of Septum in HCM
Echo in Cath Lab During Procedure
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Case 1
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MM - 61 year-old man
Case 2
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Case 3
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Case 4
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Case 5
BP - 69 year-old female
Aborted RV papillary muscle perfused
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Pericardiocentesis
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Pericardiocentesis Using Subxiphoid Approach
“Old-Fashioned Way” alligator clip to ECG
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Echo-Guided
Pericardiocentesis
• Gold-standard for management of
• Improves success rate
• Improves safety
• Reduces complication rate
effusions reguiring drainage
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Location of Needle Entry
Subcostal
Chest wall (79%)
Unknown
Para-apical 67%
L parasternal 6%
L axillary 4%
R parasternal 2%
Posterolateral 0.2%
n = 1,131
Mayo Clinic: courtesy Seward/Khandheria
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Needle Attempts for Access
PC
(%)
Number of needle attemptsn = 1,131
Mayo Clinic: courtesy Seward/Khandheria
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Success and Complications of
(Consecutive 1,131 procedures)
Successful PC 1,097 (97%)
Major complications 16 (1.4%)
Death 1
Ventricular laceration 6
Intercostal vessel injury 1
Pneumothorax 6
Ventricular tachycardia 1
Infection 1
Minor complications 37 (3.3%)
Mayo Clinic: courtesy Seward/Khandheria
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Management of
Cardiac Tamponade
• 1978 Blind pericardiocentesis
• 6% mortality, 50% morbidity
• Echo-guided centesis: n = 1,131
• <0.1% mortality, <2% morbidity
Mayo Clinic: courtesy Seward/Khandheria
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Pericardiocentesis
• Call 7-6146 for Microbiology to tube
2 aerobic culture specimen bottles to
the front desk # 205
• Elevate HOB with wedge @ 45°
• Chest prepped and draped
• Page echo stat to Cath Lab (7-6700)
• Sedate as ordered
• Closely monitor HR & BP
• Drop (2) 20cc syringes for labs
• Obtain CCU or ICU bed
• Patient may be sent to a 4th floor
cardiac bed if hemodynamically
stable
• Complete blue FLUID lab
slip with:
• Cell count (purple tube)
• 1 air tight 20 cc syringe
(capped)
• Gram stain
• AFB smear and culture
• Aerobic, anaerobic cultures
• Fungal culture
• Cytology
• Glucose
• Total protein
• Albumin
• LDH
• Adenosine deaminase
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Apical Approach
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Apical-Lateral Approach
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Case 1JC - 55 year-old woman
Contrast confirms
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Case 2EW - 80 year-old woman
Apical approach
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pericardiocentesis
site (apical)
Not optimal
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Case 3TJ - 71 year-old man
Pericardiocentesis
L-axillary approach
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pericardiocentesis
site (subaxillary-
lateral))
Not optimal
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Case 4RD - 77 year-old man
Massive pericardial effusion
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