Cleveland Clinic Abu Dhabi Charts New Paths in 3-D Cardiac Imaging

When Cleveland Clinic Abu Dhabi opened its doors in early 2015, a key mission was to bring advanced specialty care to a region with unmet needs for deep subspecialty expertise and leading-edge equipment.

A prime example of how that mission’s being met is the work being done with three-dimensional (3-D) imaging in Cleveland Clinic Abu Dhabi’s Heart & Vascular Institute, which is applying technologies in ways that push boundaries in any region of the world. Two cases in point are profiled here.

1) Broadening preoperative 3-D echo use in mitral valve surgery

Although many U.S. medical centers employ 3-D transesophageal echocardiography (TEE) to some extent, 2-D TEE remains the standard of care for assessing mitral valve pathology. But Cleveland Clinic Abu Dhabi cardiologists have embraced more widespread use of 3-D TEE in patients prior to mitral valve surgery.

“In head-to-head studies of 3-D and 2-D echo, 3-D has performed far better in localizing disease, identifying the problem and predicting the outcome,” explains Cleveland Clinic Abu Dhabi cardiologist Nikolaos Tzemos, MD. “For these reasons, we now use 3-D TEE routinely on nearly 100 percent of patients scheduled for mitral valve repair or replacement surgery for stenosis or prolapse.”

In patients with mitral valve disease, the cardiologists have found 3-D imaging invaluable in helping determine whether a patient should undergo valve repair or replacement. This, in turn, enables them to direct patients to the most appropriate surgeon for their needs.

“Identifying whether the cause is secondary to the annulus or to leaf dysfunction is the most important use of this technology,” says Dr. Tzemos, “since knowing whether the valve can be repaired is critical. Whereas mitral valve repair has excellent outcomes, mitral valve replacement is a bit less successful over the long term.”

To evaluate the impact of the information obtained by 3-D TEE, Dr. Tzemos and colleagues conducted a clinical study in which the technique was used to evaluate all patients with mitral valve disease. In one group, imaging results were not disclosed until the day of surgery. In a second group, the results were disclosed in advance and used to determine whether the valve would be repaired or replaced. The findings were startling.

“We found that when the 3-D TEE findings were not disclosed, the choice of operation and surgeon were completely different than when we had the information,” says Dr. Tzemos. “Although our surgeons have ample experience in both procedures, two surgeons are particularly highly skilled in mitral valve repair. We found that many patients who qualified for repair had been assigned to a surgeon who primarily does replacements.”

These patients were subsequently reassigned to ensure that each received the optimal procedure.

While most centers that use 3-D echo employ the technique during the operation itself, these findings suggest its greatest value may lie in preoperative planning. “We feel it’s extremely important to perform 3-D imaging before surgery is scheduled, since the choice of procedure and surgeon depends on the results,” says Dr. Tzemos. “Directing patients to the most appropriate surgeon leads to better outcomes. Therefore, we now routinely perform 3-D TEE on nearly all mitral valve patients in order to direct them to the best expertise.”

2) Postinterventional 3-D printing

While 3-D printouts obtained from CT scans are increasingly used in planning and evaluating surgery for congenital heart defects, Cleveland Clinic Abu Dhabi cardiologists are taking the concept to a new level by using 3-D printouts to check the placement of pacemakers, implantable defibrillators and percutaneously implanted valves. In fact, they have a pilot study of the practice underway.

“We can see how a device is seated, or whether there’s a leak in the valve after transcatheter aortic valve replacement,” says the study’s initiator, Thomas Bartel, MD, Section Head of Interventional Cardiology at Cleveland Clinic Abu Dhabi. The image at the top of this post depicts a representative postinterventional 3-D printout following atrial septal defect closure.

Although the pilot study has just begun, Dr. Bartel is delighted with the detail revealed by the printouts, as demonstrated in an illustrated case report his team published recently in the European Heart Journal. “We feel this is contributing to quality improvement and the delivery of personalized medicine,” he says.