Interventional Imaging

Steven A. Goldstein MD

Professor of Medicine

Georgetown University Medical Center

MedStar Heart Institute

Washington Hospital Center

Tuesday, October 10, 2017

Cases

DISCLOSURE

I have N O relevant

financial relationships

Management

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

Drug-Refractory HCM

Therapeutic Options

Surgery Dual-chamber

pacemaker

Septal

Ablation

Alcohol Ablation

Alcohol Septal Ablation

• 1994 – 1st procedure at Royal Brompton

• Since then >10,000 performed

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)

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

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

HOCM - Alcohol Septal Ablation

TEE Views

• Apical 4-chamber view (0°)

• Longitudinal view (120-130°)

• Gastric short-axis view

• Deep transgastric view (for gradient)

Using intracoronary injection of an echo

contrast agent, opacification of the

strategic septal area can be delineated.

Hypertrophic Cardiomyopathy

Alcohol Septal Ablation

Transesophageal Transthoracic

Alcohol Ablation of Septum in HCM

Echo in Cath Lab During Procedure

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)

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

Ethanol-induced

infarction

Alcohol Ablation of Septum in HCM

Nishimura and Holmes N Engl J Med 350:1320(2004)

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)

"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)

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)

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

HOCM - Alcohol Septal Ablation

Follow-Up (Post-Procedure Echo)

• LVOT gradient

• Mitral regurgitation

• Diastolic Filling

• Regression of hypertrophy

• LV function (especially septum)

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)

Transesophageal Transthoracic

Alcohol Ablation of Septum in HCM

Echo in Cath Lab During Procedure

Case 1

MM - 61 year-old man

Case 2

Case 3

Case 4

Case 5

BP - 69 year-old female

Aborted RV papillary muscle perfused

Pericardiocentesis

Pericardiocentesis Using Subxiphoid Approach

“Old-Fashioned Way” alligator clip to ECG

Echo-Guided

Pericardiocentesis

• Gold-standard for management of

• Improves success rate

• Improves safety

• Reduces complication rate

effusions reguiring drainage

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

Needle Attempts for Access

PC

(%)

Number of needle attemptsn = 1,131

Mayo Clinic: courtesy Seward/Khandheria

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

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

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

Apical Approach

Apical-Lateral Approach

Case 1JC - 55 year-old woman

Contrast confirms

Case 2EW - 80 year-old woman

Apical approach

pericardiocentesis

site (apical)

Not optimal

Case 3TJ - 71 year-old man

Pericardiocentesis

L-axillary approach

pericardiocentesis

site (subaxillary-

lateral))

Not optimal

Case 4RD - 77 year-old man

Massive pericardial effusion