Practical Intracardiac Echocardiography in Electrophysiology

Practical Intracardiac Echocardiography in Electrophysiology. Jian-Fang Ren, Francis E. Marchlinski, David J. Callans, David Schwartsman.
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Added to Your Shopping Cart. Description Tremendous advances in intracardiac echocardiography ICE have coincided with the evolution of interventional electrophysiology. About the Author Dr. He has been a pioneer in using intracardiac ultrasound imaging for electrophysiologic applications. He has authored or co-authored over one hundred original manuscripts including seminal publications related to the use of intracardiac ultrasound imaging technology and catheter ablation of inappropriate sinus tachycardia and atrial fibrillation.

He has mentored over fifty trainees on the use of intracardiac echo and has lectured internationally on the subject matter. Table of contents Features Contributors. Imaging Technique and Cardiac Structures. Left Heart Transducer Position. David Schwartzman, MD 9. The best known example is the oval fossa on the interatrial septum, where transeptal puncture is easiest to perform 4. Other visible structures are vessels coronary arteries, the coronary sinus and valves 5.

Description

Valves can exist at the os of the coronary sinus, and in the coronary sinus figure 3 6. The latter can be an obstacle for diagnostic and pacing catheters. Other valves can be present, as an extension of the Eustachian ridge, and may lie over the entry of the inferior vena cava. Linear structures as the tendon of Todaro, the ligament of Marshall and the terminal crest can be identified as well 7,8.

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The latter structure is very echo-dense, and plays a role in the pathogenesis of arrhythmias. Some focal cristal tachycardias originate in it sometimes near the sinus node 9. The crista serves as a functional barrier between vena cava superior and inferior in isthmus dependent flutter The left atrium is now increasingly explored, and is shaped to a large extent by the pulmonary veins, sometimes with common ostia An important structure is the left atrial appendage.

Practical Intracardiac Echocardiography in Electrophysiology (eBook)

Doppler flow can be used to recognise these structures. Abnormalities in the ventricles aneurysms, clots can be seen. This technique becomes very easy with echo link 1. We have experience with both mechanical transducers and phased array. A small fossa can be recognised; tenting can be seen, and contrast may be used to facilitate the puncture 4. Catheter Positioning without fluoroscopy is an option 5.

Finding the os of the coronary sinus becomes possible. Atrial septal pacing above the oval fossa shortens the P-wave duration to a larger extent than pacing below the fossa Fluoroscopy is not a reliable tool to assess these differences.

ICE- section I - intracardiac Echo ( ICE )

Screening for clots and spontaneous contrast is as possible with intracardiac echo as it is with transesophageal echo, but has not been validated Flutter, also a macroreentrant tachycardia, uses the cavo-tricuspid bridge the isthmus in most cases, but occurs as well in post cardiac surgery situations and in congenital heart disease when the circuit is usually around a scar It is necessary to interrupt the conduction at an anatomical acceptable point.

The isthmus is highly variable, in shape, length, surface and thickness. This accounts for the failure of some procedures. While we have had difficulties in assessing the isthmus with a femoral approach using the ICE technique, a subclavian route was definitely better in assessing this structure 4.

Clinical applications of intracardiac echocardiography during diagnostic and int

Phased array technology showed to be reliable in the assessment of differences during systole and diastole, and reveals other pitfalls as pits, craters, ridges etc 5. Furthermore, in congenital heart disease, some malformations in access and structure can be assessed. It is clear that 3-dimensional echo will be much better than both the actual planar and scalar approaches to judge the cavo-tricuspid isthmus link 2. Integration of 3D echo with E. Segmental ostial catheter ablation and focal ablation when ectopic activity is present are now becoming widespread approaches for AF ablation.

Potentials are only detected when muscular sleeves are seen in the vein, which is feasible with the ICE technology Identification of the left and right upper and lower veins is very easy with a phased array catheter which yields a better vision of the left atrium from the right side Doppler signals can help to identify the atrial appendage. The presence of a common anthrum can be verified. Measurements can be performed, probably with more accuracy than with CT or MR, but certainly better than with venography The position of a lasso catheter can be better judged than with fluoroscopy Encircling of the pulmonary venous ostia can be simplified using an echographic approach 11, With the anatomic and electrical remodelling due to long standing AF, the underlying substrate becomes more important.

Linear lesions can play a role in compartimentalisation, and encircling becomes more or less linear. A difficulty inherent to the creation of linear lesions is the need for uninterrupted contact of the catheter with the endocardium, which may be helped by the use of linear catheters. Transversal view in the right atrium RA showing how the catheter is not well appositioned to the wall at the left and makes contact at the right ICE.

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Some investigators have used echo to assist in VT ablation, as it allows to see aneurysms, dyskinesia and dysplasia. This can help to avoid complications. That it is helpful in finding the right spot is not shown…. Since PV stenosis can be life-threatening, modifications to the procedure have been made, including use of different energy sources, such as irrigated or cooled tip ablation, and cryothermy.


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Intracardiac ultrasound also provides anatomic imaging of areas of special interest, for example, the Marshall ligament region or the lipomatous hypertrophy of the atrial septum. These hypertrophic structures can then be targeted for more aggressive energy delivery to create effective transmural PV isolation [ 25 ]. These anatomic variations are important in planning catheter ablation of AF.

Real-time visualisation of the LA and its adjacent structures is feasible and advantageous for online guiding of mapping and ablation catheters, not least because patients with AF often have atypical anatomical characteristics of the LA.

In patients with abnormal anatomy of the interatrial septum IAS especially e. The ICE-guided transseptal puncture can avoid potential life threatening complications including aortic puncture, pericardial tamponade, systemic arterial embolism, and perforation of the inferior vena cava [ 30 ]. Accurate visualisation of the fossa ovalis reduces the risk of complications.

The goal of transseptal access is to cross the septum in the posterior region of the fossa ovalis. The more anterior portions of the septum are depicted by views that display the aorta. An anterior puncture is not only less safe but also directs the catheters towards the mitral annulus, left ventricle, and the left atrial appendage.

This anterior approach can make manipulations of catheters for an AF ablation procedure difficult because of the posteriorly located ostia of the PVs. Preparing transseptal puncture a Brockenbrough-curved needle is inserted via a transseptal sheath and dilator system and advanced in the posterior region of the fossa ovalis Figure 1 b.

The first sign of a stable contact of the transseptal dilator at the IAS is tenting of the septum at this site. After successful puncture Figure 1 c , a coronary guide wire may be advanced into a left PV to stabilise the traverse of transseptal needle and sheath. After withdrawal of the Brockenbrough-curved needle a mapping or ablation catheter can be positioned in the LA via the transseptal sheath. Coronary guide wires and catheters can easily be visualised when entering the LA, which again helps to reduce fluoroscopy time. In many ablation procedures double transseptal access is needed and is eased by ICE.

After completing the ablation procedure, catheters and sheaths are retracted leaving residual atrial septal defects. Because of their small size such residual atrial septal defects after using 8F sheaths appear to be clinically insignificant and typically resolve completely in the course of a few months.


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Ablation of AF through PV isolation is a challenging procedure. Success and associated complication rates are largely dependent on the operator and equipment. Due to the complex and varying anatomy of the LA, the LA-PV junction, and the PVs, general anatomical landmarks and fluoroscopic imaging offer vague guidance for left atrial ablation procedures.

However, MRI has shortcomings associated with availability and costs, while cardiac CT causes additional radiation exposure for the patient and also requires contrast medium administration. The latter may be a problem in patients with chronic kidney insufficiency or hypersensitivity to contrast agents.

In addition, both modalities come with the disadvantage of time intervals between imaging and the ablative procedure itself, during which changes of anatomical conditions and shape of the LA may occur, potentially due to changes in intravascular fluid volume, which result in an alteration of left atrial volumes and shape. The procedure of CT or MRI data registration itself might be subject to inaccuracies [ 35 ], which may be more marked in patients with dilated LA [ 36 ].

Integration of ICE imaging into a 3D reconstruction of the LA and relevant adjacent structures, along with electroanatomic data obtained with the mapping or ablation catheter, is a key upgrade to the utility of ICE for an AF ablation. Real-time imaging ensures correct assessment of the positions of relevant structures, including the oesophagus, which can be accurately outlined and integrated into the model of the LA. This may help to avoid inadvertent heat trauma during ablation. Since the first reports of its use in humans [ 37 ], the CARTOSound system has been employed for guiding ablation procedures, including, but not limited to AF, ablation procedures [ 38 — 40 ].

Recording of only three ultrasound fans seems to be sufficient to exactly register the surface to a preprocedurally recorded CT or MRI [ 41 ]. The ablation procedure is subsequently guided by visualisation of the ablation catheter within the merged image, by intermittent fluoroscopy and continuous monitoring with ICE. Since ICE mapping can be performed from the right atrium, this approach involves shorter prothrombotic dwell time of catheters in the LA. Navigation of catheters is easier with potentially less fluoroscopy time [ 19 , 41 ]. Intracardiac ultrasound integration into 3D electroanatomic reconstruction of the LA provides reliable guidance for PV isolation.

Total procedural time was similar between these three groups, but MRI integration required more fluoroscopy time and a longer dwell spent in the LA. Importantly, there were no significant differences in AF recurrences among these groups. Intracardiac ultrasound image integration significantly reduces fluoroscopy time and dwell in the LA, a parameter linked to the procedure-associated risk of cerebrovascular complications, in comparison to MRI integration alone.

Intracardiac ultrasound with 3D reconstruction appears to be a safe and effective alternative to MRI and CT data registration, although randomized comparisons are lacking.