Why is intracardiac echocardiography helpful? Benefits, costs, and how to learn

Thomas Bartel, Silvana Müller, Angelo Biviano, Rebecca T Hahn, Thomas Bartel, Silvana Müller, Angelo Biviano, Rebecca T Hahn

Abstract

Current interventional procedures in structural heart disease and cardiac arrhythmias require peri-interventional echocardiographic monitoring and guidance to become as safe, expedient, and well-tolerated for patients as possible. Intracardiac echocardiography (ICE) complements and has in part replaced transoesophageal echocardiography (TEE), including real-time three-dimensional (RT-3D) imaging. The latter is still widely accepted as a method to prepare for and to guide interventional treatments. In contrast to TEE, ICE represents a purely intraprocedural guiding and imaging tool unsuitable for diagnostic purposes. Patients tolerate ICE much better, and the method does not require general anaesthesia. Accurate imaging of the particular pathology, its anatomic features, and spatial relation to the surrounding structures is critical for catheter and wire positioning, device deployment, evaluation of the result, and for ruling out complications. This review describes the peri-interventional role of ICE, outlines current limitations, and points out future implications. Two-dimensional ICE has become a suitable guiding tool for a variety of percutaneous treatments in patients who are conscious or under monitored anaesthesia care, whereas RT-3DICE is still undergoing clinical testing. Continuous TEE monitoring under general anaesthesia remains a widely accepted alternative.

Keywords: Guiding tools; Intracardiac echocardiography; Peri-interventional imaging; Structural heart disease.

Figures

Figure 1
Figure 1
Home view showing the right heart, including the interventricular septum: the slightly anteflexed probe is positioned in the mid-right atrium. IVS, interventricular septum; RA, right atrium; RV, right ventricle.
Figure 2
Figure 2
Standard views for device closure of interatrial communications: (A) longitudinal view; (B) short-axis view. Ao, ascending aorta; ASD, secundum type atrial septal defect; IVC, inferior vena cava; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
Figure 3
Figure 3
Atrial septal defect device closure: (A) longitudinal view showing left-to-right shunt; (B) balloon sizing; (C) long sheath with wire inside; (D) opened left-sided disc in the left atrium; (E) release of right-sided disk in the right atrium; (F) ‘wiggle manoeuvre’; (G) short-axis view and (H) longitudinal view with the device in place. 1, left-sided disc; 2, right-sided disc; 3, stent; Ao, aorta; ASD, secundum type atrial septal defect; B, balloon; C, cable; D, device; LA, left atrium; LS, long sheath; RA, right atrium; SF, shunt flow.
Figure 4
Figure 4
(A) Atrial fibrillation ablation procedure with desired intracardiac echocardiography image of atrial septal ‘tenting’ visible at the time the transseptal needle is about to cross over from the right atrium into the left atrium. (B) Posterior view of a registered electroanatomic + intracardiac echocardiography map of the left atrium with the ablation catheter tip in the left inferior pulmonary vein. (C) The circle, representative of the ablation catheter tip in (B), confirms intracardiac echocardiography location in the left inferior pulmonary vein. ‘→’ in (A), ‘tenting’; ‘→’ in (B), ablation catheter tip; LA, left atrium; LIPV, left inferior pulmonary vein; RA, right atrium.
Figure 5
Figure 5
Longitudinal view in transcatheter valve implantation. ICEC, intracardiac echocardiography catheter; IVC, inferior vena cava; LV, left ventricle; RA, right atrium; SVC, superior vena cava; TAVI, transcatheter valve implantation; TCHV, transcatheter heart valve.
Figure 6
Figure 6
Procedural steps during transcatheter valve implantation: (A) native aortic valve and stenotic flow pattern; (B) crossing the valve with a wire; (C) predilatation (annulus denoted by yellow line); (D) moderate aortic regurgitation after predilatation; (E) crimped valve prosthesis mounted on a balloon, position too high for deployment; (F) moderate paravalvular leak after valve deployment; (G) short-axis view demonstrating small paravalvular leak; (H) transventricular view showing left ventricular function and ruling out pericardial haemorrhage. AV, aortic valve; AR, aortic regurgitation; B, balloon; BC, balloon catheter; LV, left ventricle; PV, prosthetic valve; PVL, paravalvular leak; PML, pacemaker lead; RV, right ventricle.
Figure 7
Figure 7
Ventricular septal defect device closure: (A) mid-oesophageal four-chamber transoesophageal echocardiographic view of ventricular septal defect; (B) same view as in (A) with a closure device deployed; (C) ventricular septal defect viewed by intracardiac echocardiography from right ventricular outflow tract; (D) same view as in (C) with closure device deployed yellow arrow, native defect; green arrow, closure device.
Figure 8
Figure 8
Patent ductus arteriosus device closure: (A) patent ductus arteriosus with shunt flow; (B) long sheath in place; (C) withdrawal of the partially opened closure device from the aorta into the patent ductus arteriosus; (D) no residual flow after patent ductus arteriosus device closure. Ao, aorta; CD, closure device; LS, long sheath; PA, pulmonary artery; SF, shunt flow.
Figure 9
Figure 9
Stent implantation in aortic coarctation: (A) implanted stent; (B) flow after implantation. The arrow shows direction of flow. Ao, aorta; S, stent.
Figure 10
Figure 10
MitraClip® implantation: (A) transgastric short-axis two-dimensional transoesophageal echocardiographic view; (B) en-face real-time three-dimensional transoesophageal echocardiographic view; (C) intracardiac echocardiographic view from the right ventricular outflow tract. ‘*’, double mitral valve orifice; ‘→’, clip.
Figure 11
Figure 11
Left atrial appendage device closure: (A) mid-oesophageal biplane transoesophageal echocardiographic view; (B) real-time three-dimensional transoesophageal echocardiographic view; (C) transatrial intracardiac echocardiographic view without closure device; and (D) with device being deployed.
Figure 12
Figure 12
Three-dimensional intracardiac echocardiography in transcatheter valve implantation: (A) native valve with pigtail catheter placed in the non-coronary cusp; (B) predilatation; (C) final positioning of the prosthetic valve; (D) systolic flow after deployment of the prosthetic valve. AS, access sheath in the right atrium containing a pacemaker lead; AV, aortic valve; BA, balloon; F, systolic flow throughout the prosthetic valve; NCC, non-coronary cusp; PT, pigtail catheter; PV, prosthetic valve; RA, right atrium.

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