3D echocardiography plays an important role in assessing and intervening in valve diseases. It can evaluate valve anatomy in detail, guide interventional procedures such as MitraClip and balloon valvuloplasty, and monitor outcomes. Real-time 3D TEE is especially useful for quantifying mitral regurgitation and measuring the mitral valve area during balloon valvuloplasty. 3D imaging also helps with patient selection and guidance for transcatheter aortic valve implantation.

1. SIÊU ÂM TIM 3D TRONG ĐÁNH GIÁ VÀ CAN
THIỆP CÁC BỆNH LÝ VAN TIM
TS.BS.NGUYỄN THỊ THU HOÀI
VIỆN TIM MẠCH QUỐC GIA VIỆT NAM

2. 4D echocardiography, history and actual performance. How to
implement it to your routine echo lab

3. 3D Echocardiography 2015: State of the Art
• LV Volume, Mass, radial, longitudinal, twist, torsion
• AS TAVI, preinterventional, intra-, postprocedural, complications
• MR differential diagnosis MitraClip®, Cardioband ®, parav. leak
• LAA preinterventional, intraprocedural
• ASD preinterventional, intraprocedural
• TR preinterventional, intraprocedural
TEE: AS diagnosis quantitative
TTE: Pacemaker leads
TTE and TEE: AC

4. LỰA CHỌN VÀ ĐÁNH GIÁ BỆNH NHÂN KẸP
SỬA VAN HAI LÁ QUA DA MITRACLIP -
CẬP NHẬT VỀ VAI TRÒ CỦA SIÊU ÂM TIM 3D
QUA THỰC QUẢN 3D
Select and assess patients for MitraClip:
Update on the roles of 3D TEE

5. Echocardiography is a key modality for MR
Etiology
Severity
Symptom
LV function
Echo
Echo
I nterviewing
Echo
2

12. Mitral Valve Anatomy
l Leaflet
l Annulus
l Chordae
l Papillary muscle

13. MitraClip anatomical patient selection
considerations
• Moderate to severe MR
(Grade 3 or more out of 4 grades)
• Pathology in A2-P2 area
• Coaptation length > 2 mm
(depending on leaflet mobility)
• Coaptation depth < 11 mm
• Flail gap < 10 mm
• Flail width < 15 mm
• Mitral valve orifice area > 4cm2
(depending on leaflet mobility)
• Mobile leaflet length > 1 cm
Recommended criteria1
1. The current patient considerations are based on EVEREST II and
commercial European experience to date. The MitraClip Patient
Selection Coniderations document has been endorsed by Expert
Opinion (Crossroads institute).
FMR
DMR

15. 1. Anatomic criteria.
2. Clinical criteria
EVEREST II: need to select patients with potential
clinical benefit.
How to identify suitable patients?

16. 1. Severe heart failure, despite optimal medical
therapy.
2. CRT non-responders.
3. Degenerative MR, denied for surgery.
4. Severe LV dysfunction, refractory to medical
therapy.
Patient groups in which significant
clinical benefits have been reported

18. Mitral valve suitability for Mitraclip

20. Ao
P1
P2
P3
LA perspective
Surgeon’s view
3D TEE Easy way
for understanding
the MV anatomy
4

21. Barlow’s MV with severe MR
and Bi-ventricular Failure Mild LV
at 2016/6)
AV
LAA IAS
Flail A2 & A3
Prolapse A1
Prolapse P3
VGHTPE-019

22. The changing appearance of the
MitraClip candidate:
Imaging is the key!

25. LAA
0°
45°
135°
AML
P2
P3
A2
P1
A2
P2
Bicommisure view
4ch
Long axis
2D TEE for the mitral valve
3

27. Siêu âm Doppler màu 3D

28. Quantification of MV prolapse
2D 3D analysis
Lateral Mediall
Anterior
Posterior
A
P
L M
L M A P
Gap
Left ventricle
Left atrium
0°: 4chamber
Width
Left atrium
Left ventricle
45°: Bi-commissure
Izumo, Shiota, et al. Am J Cardiol. 2013; 111:588-94. 15

29. Patient selection
Anatomical criteria (Functional MR)
Feldman, et al. J Am Coll Cardiol. 2009; 54:686-694. 18

30. 3D TEE
LV
LA
Ao
LV
LA
Ao
LA
LV
Ao
Lateral Medial
Anterior
Posterior
Evaluation of the tethering
3D analysis
19

31. 17
GEOMETRY AND DIRECTION OF MR JET
Jet width? Multiple jets?
Jet direction? Perpendicular?

32. Pre-procedure
l Case selection is the key to success
l Avoid
n cleft
n PML length less than 7 mm
n Pre-existing MS
l Central position
n FMR: with coaptation (no gap)
n DMR: not large gap or large flail width
How to simplify the procedure

33. The procedure
TSP
Sterring Grasping
Triaxial System
Steerable
Sleeve
Delivery
Catheter
Guiding
Catheter
MitraClip

34. Anatomic Consideration

36. Transseptal puncture
Bicaval Short-axis
Tips: Use X-plane wisely

50. VAI TRÒ CỦA SIÊU ÂM TIM 3D TRONG ĐÁNH
GIÁ, HƯỚNG DẪN THỦ THUẬT VÀ THEO DÕI
BN NONG VAN HAI LÁ QUA DA

51. Hẹp Hai Lá

52. ✓ Confirmation of diagnosis
✓ Quantitation of stenosis severity
✓ Consequences
✓ Analysis of valve anatomy
Echocardiography: Major role in
decision making for mitral stenosis

54. Trans mitral valve gradient

55. Parasternal short-axis view
valve thickness (maximum and heterogeneity)
commissural fusion
extension and location of localized bright zones (fibrous nodules or
calcification)
Parasternal long-axis view
valve thickness
extension of calcification
valve pliability
subvalvular apparatus (chordal thickening, fusion, or shortening)
Apical two-chamber view
subvalvular apparatus (chordal thickening, fusion, or shortening)
Detail each component and summarize in a score
Valve Anatomy

56. How to Grade Mitral Stenosis
✓ Normal MVA is 4.0-5.0 cm2
✓ MVA >1.5 cm2 does not produce significant symptoms
✓ As severity increases, cardiac output decreases and fails to
increase during exercise.

57. The most validated and commonly used TTE criterion is
Wilkins Score:
✓ Severity and extent of leaflet calcification
✓ Leaflet thickening
✓ Leaflet mobility
✓ Subvalvular apparatus
Patient selection for PMBV

58. Wilkins Score - Splitability score
An inverse relationship exists between the total splitability score and PMBV success, with the
cutpoint of ≤8 reflecting best short- and long-term results.
Wilkins score alone does not appear to be a good predictor of post-PMBV mitral regurgitation
(MR), but rather the degree of commissural opening

59. Severity of MR before PMBV

60. TEE before PMBV is useful to screen for LA or LAA thrombus or dense spontaneous echo
contrast, especially in A-fib.
Information of LA thrombus

62. Clinical research
Non-invasive assessment of mitral valve area during
percutaneous balloon mitral valvuloplasty: role
of real-time 3D echocardiography
José Zamoranoa,
*, Leopoldo Perez de Islaa
, Lissa S
ugengb
, Pedro Cordeiroa
,
José Luis Rodrigoa
, Carlos Almeriaa
, Lynn Weinert b
, Ted Feldmanb
,
Carlos Macayaa
, Roberto M. Langb
, Rosana Hernandez Antolina
a
Echocardiography Laborat ory of t he Hospit al Clı́nico de S
an Carlos, Inst it ut o Cardiovascular, 28040 Madrid, S
pain
b
Universit y Hospit al of Chicago, Chicago, US
A
Received 13 May 2004; revised 3 S
eptember 2004; accepted 9 S
eptember 2004
S
ee page 2073 for the editorial comment on this article (doi:10.1016/j .ehj .2004.10.001)
European Heart Journal (2004) 25, 2086– 2091
J Am Soc Echocardiogr 2003;16:841-9
European Heart Journal (2004) 25, 2086–2091

63. From LA From LV
RT3D echocardiography

64. Echocardiography in Percutaneous Aortic Valve Implantation

65. TEE in Percutaneous Aortic Valve Implantation
❖Preliminary TTE assessment.
❖TEE imaging and guided valve deployment.
❖ Early TTE assessment after device deployment.

66. Transoesophageal echocardiography evaluation
prior to TAVI

67. 3D TEE view for the measurement of aortic annular dimension

68. Multi-slice detector computed tomography reconstruction of the aortic root
and ascending aorta

69. Multi-slice detector computed tomography assessing aortic valve anatomy
and calcification

70. TEE during valvuloplasty

71. TEE in Percutaneous Aortic Valve Implantation
During procedure

72. European Heart Journal - Cardiovascular Imaging
(2016) 17, 835
TEE during valve deployment

73. After procedure
TEE in Percutaneous Aortic Valve Implantation

74. THANK YOU VERY MUCH!