advanced echocardiography in cath lab

1. WHAT YOU WILL SAY TO THE
INTERVENTIANIST AS ECHO MAN
IN CATH LAB
BY
HESHAM NAEIM,MD
CARDIOLOGY CONSULTANT
MCC, MEDINA

2. LAA CLOSURELAA CLOSURE
WITH ACP DEVICEWITH ACP DEVICE
2

3. 3

4. 4

5. 5

6. WHAT YOU WILL SAY TO THEWHAT YOU WILL SAY TO THE
INTERVENTIEMEST?INTERVENTIEMEST?
MAXIMUM MESSURED LAAMAXIMUM MESSURED LAA
DIAMETER IS 20MM, SO ADIAMETER IS 20MM, SO A
DEVICE SIZE OF 22-24MM ISDEVICE SIZE OF 22-24MM IS
SIUTABLE.SIUTABLE.
6

7. 7

8. YOUR SEPTAL PUNCTUREYOUR SEPTAL PUNCTURE
IS TOO ANTERIOR YOUIS TOO ANTERIOR YOU
SHOULD GO MORESHOULD GO MORE
POSTERIORPOSTERIOR..
8

9. 9

10. YOUR SEPTAL PUNCTUREYOUR SEPTAL PUNCTURE
IS TOO POSTERIOR YOUIS TOO POSTERIOR YOU
SHOULD GO MORESHOULD GO MORE
ANTERIORANTERIOR..
10

11. 11

12. EXCELLENT SITE FOREXCELLENT SITE FOR
SEPTAL PUNCTURE, GOSEPTAL PUNCTURE, GO
ONON
12

13. 13

14. 14

15. YOUR WIRE INSIDE LAA. IYOUR WIRE INSIDE LAA. I
CAN SEE YOUR BUBBLES.CAN SEE YOUR BUBBLES.
15

16. 16

17. YOUR DEVICE ATYOUR DEVICE AT
THE MOUTH OF LAATHE MOUTH OF LAA
17

18. 18

19. 19

20. 20

21. 21

22. 22

23. 23

24. 24

25. YOUR DEVICE IS IN A VERYYOUR DEVICE IS IN A VERY
GOOD POSITIONGOOD POSITION
*I CAN SEE BOTH PROXIMAL AND DISTAL*I CAN SEE BOTH PROXIMAL AND DISTAL
PORTIONS IN A GOOD POSITION.PORTIONS IN A GOOD POSITION.
*PROXIMAL PART IS WELL CUPPED.*PROXIMAL PART IS WELL CUPPED.
*NO CLOUR FLOW IN LAA.*NO CLOUR FLOW IN LAA.
*LUPV FLOW IS NORMAL.*LUPV FLOW IS NORMAL.
*NO PE SEEN.*NO PE SEEN.
**PLEASE RELEASE YOUR DEVICEPLEASE RELEASE YOUR DEVICE..
25

26. ASD CLOSUREASD CLOSURE
26

27. 27

28. 28

29. WE HAVE IAS ANEURYSMWE HAVE IAS ANEURYSM
WITH MULTIFENESTRATEDWITH MULTIFENESTRATED
SEPTUMSEPTUM
29

30. 30

31. WE HAVE GOODWE HAVE GOOD
SUPPORTIVE OSTIUMSUPPORTIVE OSTIUM
PRIMUM 1.5CMPRIMUM 1.5CM
31

32. 32

33. 33

34. I CAN SEE YOUR WIREI CAN SEE YOUR WIRE
INSIDE LAINSIDE LA
34

35. 35

36. YOYR DEVICE IS COMINGYOYR DEVICE IS COMING
36

37. 37

38. AORTIC POSITION IS OKAORTIC POSITION IS OK
BUT I AM NOT SUREBUT I AM NOT SURE
ABOUT THE POSTERIORABOUT THE POSTERIOR
RIM, WAIT ME PLEASE.RIM, WAIT ME PLEASE.
38

39. 39

40. OSTIUM PRIMUM IS NOTOSTIUM PRIMUM IS NOT
CATCHED, REPOSITIONCATCHED, REPOSITION
YOUR DEVICE PLEASEYOUR DEVICE PLEASE
40

41. 41

42. YOU ARE TRAPED IN AYOU ARE TRAPED IN A
SMALL HOLE OFSMALL HOLE OF
FENESTRATED TISSUE ,FENESTRATED TISSUE ,
GO OUT PLEASE.GO OUT PLEASE.
42

43. 43

44. 44

45. THE POSTERIOR RIM ISTHE POSTERIOR RIM IS
NOT CACTHED, THERE ISNOT CACTHED, THERE IS
MILD FLOW AT THE AORTAMILD FLOW AT THE AORTA
AND POSTERIORLY,AND POSTERIORLY,
REPOSITION PLEASE.REPOSITION PLEASE.
45

46. 46

47. 47

48. 48

49. 49

50. 50

51. 51

52. YOUR DEVICE IS WELLYOUR DEVICE IS WELL
POSITIONED, NOPOSITIONED, NO
RESIDUAL FLOW, OSTIUMRESIDUAL FLOW, OSTIUM
PRIMUM, AORTIC, IVC RIMPRIMUM, AORTIC, IVC RIM
ARE WELL CACTHED, MVARE WELL CACTHED, MV
IS OK, NO PEIS OK, NO PE
YOU CAN RELEAS YOURYOU CAN RELEAS YOUR
DEVICEDEVICE..
52

53. ASD SENT TO SURGERYASD SENT TO SURGERY
53

54. 54

55. 55

56. 56

57. I HAVE BORDERLINEI HAVE BORDERLINE
OSTIUM PRIMUM OF 0.9CM.OSTIUM PRIMUM OF 0.9CM.
WE CAN START WITH 38MMWE CAN START WITH 38MM
DEVICE.DEVICE.
57

58. 58

59. WE HAVE FENESTRATEDWE HAVE FENESTRATED
SEPTUM WITH DEFECTIVESEPTUM WITH DEFECTIVE
TISSUE ALL AROUND BYTISSUE ALL AROUND BY
3D3D
59

60. 60

61. REPOSITION PLEASEREPOSITION PLEASE
61

62. 62

63. YOUR DEVICE INSIDE RAYOUR DEVICE INSIDE RA
63

64. 64

65. I HAVE SMALL FLOW ATI HAVE SMALL FLOW AT
THE AORTA, CAN I CHECKTHE AORTA, CAN I CHECK
MV RELATION BY TTEMV RELATION BY TTE
65

66. 66

67. 67

68. THE AML IS HITTING THETHE AML IS HITTING THE
DEVICE WITH EVERY BEAT,DEVICE WITH EVERY BEAT,
I AM AFRAID FROM LONGI AM AFRAID FROM LONG
TERM EROSION OF AMLTERM EROSION OF AML
CAN WE TRY A SMALLERCAN WE TRY A SMALLER
DEVICE 34MM PLEASE.DEVICE 34MM PLEASE.
68

69. 69

70. 70

71. 71

72. RELATION OF THE DEVICERELATION OF THE DEVICE
TO MV IS OK BUT I HAVETO MV IS OK BUT I HAVE
CLEAR RESIDUAL SHUNTCLEAR RESIDUAL SHUNT
AT THE AORTAAT THE AORTA
QUESTIONING THEQUESTIONING THE
STABILITY OF THE DEVICESTABILITY OF THE DEVICE
WE WILL LEAVE THEWE WILL LEAVE THE
DEVICE FOR 2HOURS THENDEVICE FOR 2HOURS THEN
WE WILL REASSES BY TTE.WE WILL REASSES BY TTE.
72

73. 73

74. WE HAVE RESIDUAL FLOWWE HAVE RESIDUAL FLOW
AT THE AORTA AND IVC RIM,AT THE AORTA AND IVC RIM,
THE STABILITY OF THETHE STABILITY OF THE
DEVICE IS QUISTIONABLEDEVICE IS QUISTIONABLE
WE DECIDE TO REMOVE THEWE DECIDE TO REMOVE THE
DEVICE AND SEND THEDEVICE AND SEND THE
PATIENT FOR ELECTIVEPATIENT FOR ELECTIVE
SURGICAL CLOSURE.SURGICAL CLOSURE.
74

75. 75

76. 76

77. LAST 2 IMAGES ARELAST 2 IMAGES ARE
TAKEN BY DR NIZAM IN ORTAKEN BY DR NIZAM IN OR
AFTER SUCCESSFULAFTER SUCCESSFUL
SURGICAL CLOSURESURGICAL CLOSURE
77

78. TAVI CORETAVI CORE
VALVEVALVE
78

79. 79

80. 80

81. I HAVE LVOT 23.5CM ANDI HAVE LVOT 23.5CM AND
SINUS DIAMETER 30MM,SINUS DIAMETER 30MM,
26MM CORE VALVE WILL26MM CORE VALVE WILL
BE SUITABLEBE SUITABLE..
81

82. 82

83. 83

84. 84

85. I HAVE MODERATEI HAVE MODERATE
CENTRAL AR WITHCENTRAL AR WITH
VENACONTRACTA 0.43,VENACONTRACTA 0.43,
MILD MR, I GET PEAK PGMILD MR, I GET PEAK PG
0F 122MMHG IN TG AV LA0F 122MMHG IN TG AV LA
VIEWVIEW
85

86. 86

87. 87

88. 88

89. 89

90. 90

91. TAKE CARE BOTH AR ANDTAKE CARE BOTH AR AND
MR INCREASED ONEMR INCREASED ONE
GRADEGRADE
91

92. 92

93. 93

94. 94

95. 95

96. I HAVE MILD PARAVALVULARI HAVE MILD PARAVALVULAR
LEAK WITH VENACONTRACTALEAK WITH VENACONTRACTA
0.2CM WHICH FOR SURE LESS0.2CM WHICH FOR SURE LESS
THAN PREPROCEDURETHAN PREPROCEDURE
REGURGE.REGURGE.
MEAN PG 18MMHG FROM TGMEAN PG 18MMHG FROM TG
AV LA VIEW.AV LA VIEW.
MR CAME BACK TO MILD.MR CAME BACK TO MILD.
96

97. FROM MY POINT OF VIEWFROM MY POINT OF VIEW
EVERY THING IS OK , NOEVERY THING IS OK , NO
NEED FOR BALLOONNEED FOR BALLOON
DILATION.DILATION.
WELL DONEWELL DONE
97

98. EDWARD TAVIEDWARD TAVI
98

99. 99

100. 100

101. 101

102. 102

103. 103

104. 104

105. TRACE PARAVALVULARTRACE PARAVALVULAR
LEAK, PG 4MMHG.LEAK, PG 4MMHG.
WELL DONE.WELL DONE.
105

106. HOCMHOCM
106

107. 107

108. 108

109. 109

110. 110

111. I HAVE PEAK PG OFI HAVE PEAK PG OF
25MMHG, WE CAN NOT25MMHG, WE CAN NOT
ABLATE ON THIS PG,ABLATE ON THIS PG,
PROVACATION SHOULD BEPROVACATION SHOULD BE
DONE.DONE.
111

112. 112

113. 113

114. 114

115. 115

116. 116

117. I HAVE MAXIMUMI HAVE MAXIMUM
PROVACATED PEAK PGPROVACATED PEAK PG
170MMHG.170MMHG.
POST ECTOPIC PGPOST ECTOPIC PG
122MMHG.122MMHG.
NOW WE CAN STARTNOW WE CAN START
SEARCHING THIS SEPTALSEARCHING THIS SEPTAL
BRANCHBRANCH
117

118. 118

119. YOU CATCH IT, THIS IS THEYOU CATCH IT, THIS IS THE
SEPTAL BRANCHSEPTAL BRANCH
SUPPLYING THE BASALSUPPLYING THE BASAL
ANTERIOR SEPTUMANTERIOR SEPTUM
INCLUDING THE CONTACTINCLUDING THE CONTACT
WITH AML.WITH AML.
119

120. 120

121. 121

122. 122

123. 123

124. 124

125. 125

126. 126

127. THERE IS PG 65 MMHG ANDTHERE IS PG 65 MMHG AND
POST ECTOPIC PG 70POST ECTOPIC PG 70
MMHGMMHG
IT IS DECREASED BUTIT IS DECREASED BUT
STILL WE HAVESTILL WE HAVE
SIGNIFICANT PGSIGNIFICANT PG
127

128. 128

129. 129

130. 130

131. THE PROXIMAL 8MM OFTHE PROXIMAL 8MM OF
THE BASAL SEPTUM STILLTHE BASAL SEPTUM STILL
MOVING BULGING TO LVOTMOVING BULGING TO LVOT
AND NOT OBASIFIED WITHAND NOT OBASIFIED WITH
DIE AS DISTAL PART.DIE AS DISTAL PART.
CAN WE SEARCH FORCAN WE SEARCH FOR
ANOTHER SEPTAL THATANOTHER SEPTAL THAT
MAY STILL SUPPLYING THISMAY STILL SUPPLYING THIS
AREA.AREA. 131

132. 132

133. 133

134. 134

135. 135

136. I HAVE PEAK PG AT PACEDI HAVE PEAK PG AT PACED
TACHYCARDIA 100 BMTACHYCARDIA 100 BM
15MMHG.15MMHG.
THIS IS VERY ACCEPTABLETHIS IS VERY ACCEPTABLE
RESULT.RESULT.
WE CAN STOP AT THISWE CAN STOP AT THIS
STAGE WELL DONE.STAGE WELL DONE.
136

137. 137

138. I TOOK HOME MASSAGEI TOOK HOME MASSAGE
-- I THINK WE SHOULD WAIT LONGERI THINK WE SHOULD WAIT LONGER
TIME TO ASSESS THE RESULTTIME TO ASSESS THE RESULT
BEFORE SEARCHING FOR ANOTHERBEFORE SEARCHING FOR ANOTHER
BRANCH.BRANCH.
-- NON OBACIFIED SEGMENT DOSENON OBACIFIED SEGMENT DOSE
NOT MEAN IT STILL HAVE BLOODNOT MEAN IT STILL HAVE BLOOD
SUPPLY.SUPPLY.
-- LOOK FOR SEGMENT KINESISLOOK FOR SEGMENT KINESIS
BEFORE LOOKING FOR THE PG.BEFORE LOOKING FOR THE PG.
-- COMPARE BASELINE IMAGE TOCOMPARE BASELINE IMAGE TO
POST ABLATION IMAGE.POST ABLATION IMAGE.
138

139. MV CLIPMV CLIP
139

140. THANK YOUTHANK YOU
140