TPES 2024: Dr Burkhard Mackensen "How to implement advanced TEE technologies in your practice"

good afternoon well for you it's good morning elari yeah so uh it is uh my pleasure to start the last session of our Symposium uh we left the best for the end state of thee art um session was curated by elar nlink it's my pleasure to introduce El Marie uh before I go to details of for education I must say it's the best thing which can happen to senior guys to see your traines growing and getting much better than than yourself and and elari you are topn fellow and and and then we work as a colleagues this was always pleasure to work with busy cases in know our ICU Echo elari nlink obtain her uh anesthesia training in South Africa in stellen BOS uh she did her Fellowship in kardak anesthesia ICU and te with us at Toronto General Hospital and subsequently she also finished Fellowship in critical care training um two years ago she moved to uh western Canada she's working currently in Kona General Hospital still uh have the same type of practice this which she had Toronto General Hospital and she curator and assembly excellent speakers so we are looking forward to to hear couple of lectures state-ofthe-art uh at the end all panelists will will join Q&A session elari floor is yours and see you thank you Mar and and Marcus it's really nice being here and joining you guys today and thank you so much for the invitation we've really enjoyed the Congress and uh I miss you guys on a daily basis I can tell you that so it gives me great pleasure to introduce our first Speaker Dr mckinon is the alj tour indal professor of anesthesiology and chair of the University of Washington department of anesthesiology and pain medicine in Seattle he also serves as the Director of Interventional echocardiography at the UW Medicine Heart Institute Dr mckinson is a practicing cardiothoracic anesthesiologist and a key member of the UW structural heart valve team as an internationally recognized expert in peroperative and Interventional echocardiography he intimately involved in multi-disciplinary efforts that aim to advance minimally invasive trans catheter cardiovascular care he has given numerous national International lectures on the role of 2D and 3D te in Interventional and structural heart disease and has published over 140 peer-review Journal articles and the author of 20 book chapters as a fellow of the American Society of echocardiography Dr mckinon is also the chair of the a industrial Relations Committee and the immediate pasture of cope thank you very much for joining us today we are really privileged to have you and we very much look forward to this lecture thank you it's my pleasure to come to you virtually I wish I could be in Toronto but but uh anyways um I have a lot planned I may have to stop somewhere in terms of time so I'll keep a close eye on it um I do some assessment of new developments on occasion mostly from an Imaging uh quality point of view with Phillips here are my objectives that you probably have in the program as well I'm going to focus on the Imaging acquisition software packages and how to get the best out of your 2D and 3D image also make some remarks about some of the um automative quantitative tools that we have uh I want to highlight first uh this important paper which is not a quick read it's 74 or so pages but it is unbiased of any Interventional tool or device that we implant into the heart and really lens itself for both peroperative and Interventional images because we're really screening patients for the structural heart valve team uh and they can go to either a surgical or an Interventional approach to start off I thought it's important now at the end of the meeting to realize that we can always strive for a better image now these are very good 3D images they don't always come out as good but we should always try intentionally to get the best out of our image acquisition and I can say myself there's always something I can do to improve my image in the first place here are four valves all on fuss as you see and if we turn this around we have the ventricular views or The lvot View on the left and then the rvot view for the ponic valve on the right hand side again we need to know how we looking at 3D structures because in the end we just have a 2d plane screen that we look at so rotation is key and that will come back as a topic here are some pathologies for the ortic valve in the Cent you have a bicuspid eortic valve with a lot of calcium and then on the right hand side eortic insufficiency when you take it to the Mito valve pathology there may be a romatic valve we don't see as many here but certainly other parts of the world romatic mitosis is quite prevalent on the right hand side a typical wide open mitro regurgitation in an A2 prolapse for the tricuspid valve we have now certainly in the Interventional space imaged the TripIt much more and we've learned a ton in addition in how to best image it and how to use our 3D and 2D tools I'll get to that hopefully towards the end for the pulmonic valve it's hard to image it in 3D well the one on the left has a very high frame rate it's going quite slow but you might discern all three C all three leaflets on the right hand side the utility of bip plane Imaging for a color flow assessment of pulmonary insufficiency now we' have come a long way I still um at times image in the peroperative space but I have my focus quite often to be fully transparent on the structural world with Interventional Echo as a cardio anesthesiologist but yeah we have come a long way from very mechanical valves uh to open heart repairs now they're done robotic in places and we certainly to provide a lot of Imaging ahead of time and then all the way to minimal invasive surgeries or even procane approaches such as the mitro Tia procedure now along with that the utilization of echo cardiography moving from paropa of echo to Interventional Echo has really been growing significantly you could say exponentially now again it starts with a good image if I have an image like this of a mital valve that is a mechanical anti atomically orientated valve and uh I wouldn't have enough information let's say one of the leaflets would be stuck then I could turn things around I happen to see the ortic valve which you know was not in the um not in the focus initially but now we actually see it quite well also but if I take that same piece of information and I place it into multiplan assessment I can very quickly assertain or convince myself that both leaflets are full moving and that there's should be good flow even though I have not added color flow talking about color flow normal washing Jets need to be recognized as well and again a multi-bead acquisition which we can do in a patient who is in a sinus rhythm will allow us to discern the washing Jets and actually figure out that there's not just two but actually up to three as you see in this image which I acquired with a GE device and you see there's six uh Jets three on each side um they're there to wash off thrombus or prevent thrombus formation now back to that initial paper that I shared and again the QR code is on the right upper corner but you can also freely get this off the American Society of echocardiography's web page when you look for guidelines and uh we we went pretty systematic and I I was mostly involved in the mitro section of this paper essentially mimicking here with my own images the carpenter classification just to be as comprehensive as possible and you see that 3D images now have made their way into guideline or standard recommendations talking about 3D if we enhance a 3D image and we include um the optimal Imaging modality and view view point that even is with the te probe now being in the stomach I can actually get a transgastric long AIS view like this and then turn it around and have a 3D image that gives me a lot of information about a b leaflet prolapse with the contraction of the papillary muscle and then to contrast that on the right hand side you see a secondary Mr Case where now all the cords are tethered um all the strings seem to be still attached there's no prolapse but there's a lot of tension tethering and tenting of this Mito valve there happens to be a Tava valve in place and the background for orientation the left appendage now if we take the 3D information to the next level we can on the one hand side on the left um use quantitative assessment tools that can be automated or can be relatively quick now just a few Mouse clicks not as tedious as maybe 10 years ago when we had to use a software called qab to go Point by point and really do a lot of clicking and and maneuvering until we would get a single an systolic image or quantification on the right hand side there's a postprocessing tool which I'll come back to in a moment but essentially it's a different way of displaying the same information not sure it adds much to this functional um case of a secondary Mr but uh in some instances of parav leaks or mitro regation for instance this will actually add quite a bit to this paper again uh highlighting Imaging tools the bip plane Imaging which comes as part of 3D is really a key tool to quantify and locate locate um the mitro regretation as you see it here so we move our bip plane uh tilt from right to left from the center of the valve through to A1 P1 and then on the left hand side to P3 and we also use 3D tools uh to basically calibrate our multi multimodal views including a Bic commmercial um View for the Mito valve um I'm not going to have much time to go into more quantification much of this quantification is in the process of being automated but for instance the important Vena contractor area which you see on the top level there is not yet automated to my knowledge um here I have brought to you I noted that there are um colleagues from liik who have participated in this meeting and I've been a faculty at this liik te master and I took the liberty to bring about a couple of examples of how I've used a multipler um tool to assess a patient's mitro regation you see there's a clear P2 prolapse but in order to bring out the maximum prolapse to then actually pursue this patient for a trans catheter tier edgo Edge repair I actually use the 3D image that I acquired ahead of time to illustrate both to the Interventional cardiologist as well as to the audience in this case how to best use my my cropping plane or my multiples in this case the red plane which is the right upper to bring out this prolapse now I can do even better if if I take a 3D color image and that's what you see here so essentially on the left hand side you see how I'm using different tools I'm optimizing the zoom and then I want to use a multipler tool so I actually go to a um 3D tool then I select multi view which is the Phillips term for the multiplane uh again all machines now have similar tools and then I lock these three planes so now my red green and blue planes are all locked to each other now I'm actually going to stop this image for a moment so that I can find out the maximum systolic Mr in this prolapse and there you have it so now I can use my cropping planes and essentially put the multiples into the very center of that Mr jet you see it here in a short axis you see it here in the right upper in the long axis and the left upper is going to be a commercial View and now I can make my new changes with the red plane going through this jet to really bring out the runoff of the Mr as well as the maximum which then actually means that I need to rotate as you see here with a track ball the plane for the red plane the right upper in order to optimally do so if I now hide the color I've now really discerned the maximum prolapse the maximum pathology and for instance if we do an edge to edge repair that would lead to a slight clocked orientation of a tier device be it an Edwards Pascal or a mitro clip device and I hope that uh that illustration makes a lot of sense I think Mye changes are important to really bring out the detail of pathology moving forward I'm going to go to another example of using multipler assessment to bring out the pathology perfectly now this first four chamber orientation here gives away that there's likely a P2 prolapse but this patient was interesting enough presented with an outside tte and outside Hospital t PE and there was a suggestion that P3 was involved in the prolapse and I'm going to show to you how I worked out that there was actually no issue in P3 now if you look at uh the onas view many of you who are quite vers will know that P2 is right here at the base of the postor leaflet but how far P2 reaches and how how much P1 or P3 or P1 are coming up above the annular plane we don't know exactly from this 3D view we also have a little bit of an issue with parallx now on the right hand side you see how I aligned the multipler uh option in order to show uh the prolapse quite well again in the right upper which is the red plane now if we go about and use bip plane Imaging and this is how how I think these outside cardiologists may have gotten onto a p three plaps is if we um if we turn our multiplane appropriately into the commers we may actually discern that there's no prolapse in P1 and there may be no prolapse in P3 and A3 so again this is a rotation we can do quite easily in a multipler assessment however if we use just bip plane Imaging as in indicated in the guideline paper that I shared with you we make come down in the center we may see P2 we may see P2 also quite well here in the um bip plane color image but if we now try to interrogate P1 and P3 so P1 is here we interrogating right here uh we see maybe at times there's something coming up but overall looks pretty good and we can assertain that there's no color flow going through P1 so we're good on that side how are however if we look at P3 still with the same multiplane angle and this is important so pay attention we have 65 right now I'm going to interrogate the medial aspect which should be P3 and what do I see I do see a prolapse that could be oh yeah I'm in P3 so therefore this is a P3 prolapse and do I see color come through yes I do so again the lack of rotation does not take into account that the valve often has a bit of a smiley face orientation so what we actually need to do is shown on this next one where I have changed the multiplane angle for the Bic commercial view off from the 65 which is the center to 35 now rotating and with that I can actually see that the leaflets are coming together and that there's no obvious posterior prolaps in this case so again uh this uh on the right hand side shows the optimal orientation with the commercial view now being at 35 on the left hand side however I'm still at 65 and you can easily see how the red line will still cut some of the P2 protops that right that reaches quite immediately in this um instance I hope this is helpful if we take a 3D model for that same valve we might also shed some additional light on it and again appreciate that the prolapse is predominant in P2 now I'm going to take this to another level in a different example this is actually from last week um I came a little late to the cast lab my one of my colleagues had already obtained a 3D image which you see on the left hand side and I looked at that 3D image and in and of itself it was quite confusing to be honest so I didn't even spend time on it I actually acquired my own images not with a frame rate as high as my colleague did but with a frame rate of a 2 beat acquisition frame rate was still only eight because of the large area of interrogation however if I play this uh what did I do I didn't only freeze the image in the maximum Mr but I also start to rotate and I'm using a tool where I have a little bit more transparency in terms of the um uh different planes that we're looking at in this 3D image and if I wrote this a little bit more I can really see what's happening meaning there is a P1 prolapse or maybe a lateral P2 prolapse that is involved in this particular regurgitation taking that to the next level I can do more rotation again emphasizing how how important it is to not just to quantify but to also observe what we have for pathology and I cannot do that if this image is moving quickly I need to freeze and then rotate that's very similar to a child very early childhood we take a tool into our hands and we need to hold it in order to really grasp the full extent of the shape and rotate it in front of our eyes that's what babies do when they get to know a new tool on the right hand side it's a very different color illustration I've increased the transparency of this modality so in this glass view I'm looking through the mo the tissues and I can really see where the um Mr is forming and which direction it's going um yet another case here just from from last week also this is a hokam case that we did a sesame procedure which is um essentially a percutaneous slicing of the interventricular septum underneath the ortic valve to allow for more flow in a Hokum case and I'm not showing the procedure but I thought the patholog G was remarkable where you see even in that four chamber view the septal Touch of that anti leaflet and the post leafl is trying to follow not coming quite along you have a typical mid to late systolic posteriorly directed Mr jet uh shown in a long axis view I can convince you that the Mr is mostly orientated posteriorly taking that to a multiplan assessment I have everything in one View and again I show the posterior director I see the forward flow that's highly agitated through the ortic valve indicating indicating Hokum and lvot obstruction now taking that 3D image if I have a 3D uh back to in a slicing tool I can um I can achieve a better understanding of where that sepal contact is happening in the lvot again I've carefully sliced through this lvot and I see the anti leaflet on top and I see the most of the impact and the obstruction comes about in this aspect of the lateral lvot right here again same information same 3D image it's but it's allowing us to quantify and locate exactly what's going on uh moving forward um to the um functional Mr cases um when we add a bigger 3D Volume again from transgastric we can also understand the pathology much better we see the tension on these cords there's up to 120 cords we can't see all of them but if you image from transgastric you have a good inter interrogation with a perpendicular uh scanning onto the chords and you get pretty good information as you see here in the short axis in 2D color compare I have a lot of information about the orientation of the jet or the footprint of the jet I don't even have to measure this out but I do see it's a typical elliptical shaped Mr Jet and then on the right hand side even from here I can get a good long axis and I see how the posterior leaflet is quite tethered in this particular instance taking a comprehensive Baseline te exam with a functional case uh to the next level we can then also use what is called a speckle tracking longitudinal strain unfortunately these um Clips don't seem to be playing automatically but I think you've all seen these types of examples and uh we've taken that piece of information to assess if patients that undergo induction of anesthesia is a simple intervention actually do suffer from a deterioration of their Global L longitudinal strain as a marker of functional um ability of the left ventricle and we've also looked at an intervention such as mitel tier here and didn't find um this is an abstract only wasn't the full data set quite yet at the time but again interesting how to how you can use a tool such as speckle tracking um longitudinal strain assessment uh to really look into things that we do as anesthesiologists or that we do as Interventional teams to a patient's heart and see how that affects it the graph in the center essentially shows in the conclusion that we didn't have any evidence that there was a significant impact um on either one of these interventions uh back to the quantitative aspect just briefly wanted to show you this software which is um assessing essentially quantitatively not only the diameters of a mitro Val anulus but also the the the movement over time as you see here in both of these graphs and there's not much happening meaning this might valve is already pretty much fixed there's not a lot of dynamic movement so if we take that information um back to um more quantifi quantitative approaches we can actually and this is a paper from a quite a few years ago where we looked at mitol love repair uh versus functional Mr and as you see on the right hand side annular displacement and annular distance as you see in the center bars is not that different between patients that actually have a mital anular plasty done to their primary Mr as opposed to those with functional Mr in the first place which could be important in a patient where maybe there's Mr in a setting of cabbage and your surgeon is asking should I add an annual plasty ring to this functional Mr patient MIT valve and if you already pick up with this um assessment tool that the anulus is more or less fixed or be dilated then the question is how much are you adding in a particular scenario like this um we took the 3D quantification with the vena contractor a little bit more to the next level in the context of MIT clip um interventions together with the Houston group just to show the simple um principle behind it you take the 3D image with the color and you cut carefully perpendicularly in the footprint if you will of the vena contractor area and you can quickly discern that a 2d assessment would just be a long axis diameter of .5 CM as opposed to a vena contractor area that seems to be quite large because again it's elliptical and if we look at the study without going into too much detail we used this approach in 155 available full data sets and we found that we have to be quite aggressive in our reduction of Mr based on the vena contractor area uh to prevent these patients from coming back to the hospital or having um having other interventions needed uh lastly very quickly wanted to touch on the TripIt valve before I close which means we have here an overview of what's happening in the TripIt space much before the mitro space we now have trans catheter replacement uh along with repair techniques but certainly still have surgical repairs as well and I'm going to go very quickly on these images again we need to be multimodal in our Imaging often using short axis and long axis used as you see it here but then importantly again utilizing a 3D image to ascertain exactly what's going on and for instance if we do an Nice Slice across the right ventricle we might be able to identify a papillary muscle that is associated with the anti leaflet right there or maybe more of a posterior leaflet Associated papillary muscle that comes into light right there again uh this is a additional information obtained from a 3D data set you can also plan a tier procedure for the tricuspid valve let's say you wanted to go between the sepal and anti leaflet you can orientate your red plane and then you have a pretty good grasping plane right there um finally uh second to last slide functional TR we assessed based on multiple systolic frames that the bulk of um TR is happening in the first third of CIS this was important work done together with um Terry's son who now works in Vancouver one of our many Canadian fellows that has come through our program uh to conclude I didn't have enough time to go into all of the standardized and automated um uh quantification tools but hopefully gave you an overview uh and remind you of the importance of getting the best possible image to then look into the pathology pause and freeze and rotate and then um the imaging technology is continuously evolving so it's good to um to push um the cardiovascular Specialists that come with the machines and help you to find out what's new on these platforms or what's embedded in the software that is not automatically maybe shared with us ultimately you need to be able to not only interpret the te image but also clearly communicate the pathology to your surgeons or Interventional cardiologists and uh with that I thank you for your attention I made some sourdough bread this morning and added the maple leaf I hope it came out okay it certainly tasted pretty good thank you