Use of Intracardiac Echocardiography in Interventional Cardiology: Working With the Anatomy Rather Than Fighting It

Pulsed field ablation using a circular electrode array catheter in patients with atrial fibrillation: A workflow optimization study evaluating the role of mapping

Background

Pulsed field ablation (PFA) with a circular-electrode-array catheter (cPFA) has shown to be effective and safe. However, data on procedural workflow are limited.

Objective

to analyze the process of streamlining cPFA-procedures including evaluation of fluoroscopy versus 3D-map guidance and lesion characteristics.

Methods

Consecutive AF-patients underwent cPFA-based pulmonary vein isolation (PVI) in three phases (learning-phase-I: visualization of cPFA in 3D-map; phase-II: operator blinded to 3D-map with fluoroscopy-guidance only; phase-III: optimized mapping and ablation). Additionally, hemolysis-parameters were collected.

Results

A total of 35 patients (57 % paroxysmal-AF, age 63.4 ± 9.4 years) were enrolled: n = 10 phase-I, n = 15 phase-II, n = 10 in phase III. Total procedure and fluoroscopy time was 51.9 ± 9.4 and 6.7 ± 3.1 min, respectively. First-pass PFA isolation-rate was lowest in the fluoroscopy-only phase-II (I:86 %, II:81 %, III:100 %, p = 0.0079). Insufficient PV ablation with remaining conduction occurred mostly anterior (n = 8/15, 53 %) and at the carina (n = 4/15; 27 %). Following additional PFA, all 142 PVs (100 %) were acutely isolated.Procedure times between phase II and III did not differ (49 ± 8 vs. 46 ± 3 mins p = 0.23). Fluoroscopy times were longer in phase-II (phase-I: 5.8 ± 1.3, phase-II: 9.2 ± 2.9, phase-III: 3.8 ± 1.0 mins, p < 0.0001). No complications occurred. Pre- and post-ablation hemoglobin (14.4 ± 1.4 vs. 13.5 ± 1.2 g/dl, p = 0.0169) and LDH (188 ± 39 vs. 210 ± 29 U/l, p = 0.0007) were different.

Conclusion

The cPFA-catheter allows for fast and efficient PVI. A fluoroscopy-only approach creates distal PV ablation lesions that are associated with residual PV conduction along the carina and anterior antrum. However, with visualization and mapping, creation of wide antral ablation lesions is feasible without prolonging procedural duration.

Coronary Artery Injury Related to Catheter Ablation for Cardiac Arrhythmias - A Systematic Review

Catheter ablation is a widely used treatment modality for various cardiac tachyarrhythmias, including atrial and ventricular arrhythmias. Although it is generally considered safe, the procedure carries potential complications, with coronary artery injury being one of the most significant. The aim of this systematic review was to assess the incidence, mechanisms, contributing factors, diagnostic strategies, and preventive measures related to coronary artery injury in patients undergoing catheter ablation, including radiofrequency catheter ablation, cryoablation, and pulsed-field ablation.

Successful Transseptal Puncture of Giant Atrial Septal Aneurysm With a Novel Transseptal Guidewire

Atrial transseptal puncture is a fundamental maneuver in electrophysiological intervention, and atrial septal aneurysm (ASA) is a common cause of failure of transseptal puncture. We report a rare case of ASA in a patient with atrial fibrillation in which the conventional transseptal puncture method failed despite the guidance of intracardiac ultrasound and was completed by a novel atrial septal puncture guidewire, and double septal puncture was completed. Giant ASA is rare and is 1 of the major causes of unsuccessful atrial septal puncture, even under the guidance of intracardiac echocardiography. The new Accusafe guidewire (Synaptic Medical) should be the initial selection of transseptal puncture rather than a conventional transseptal puncture tool when encountering similar anatomic abnormalities of the atrial septum.

Novel Intracardiac Ultrasound Images Developed on a Cardiac Ultrasound Simulator and Validated in Live Horses

INTRODUCTION

Ultrasonographic guidance of catheter-based interventions in horses is based primarily on transthoracic echocardiography (TTE). Intracardiac echocardiography (ICE) has the potential to provide detailed imaging of specific cardiac regions. Insight and training in echocardiographic guidance can be acquired using an echocardiography simulator.

HYPOTHESIS/OBJECTIVES

Use an echocardiography simulator for horses to determine specific ICE views for catheter-based interventions and validate these in live horses.

ANIMALS

Six adult healthy experimental horses.

METHODS

Observational study. An echocardiographic phantom based on a three-dimensional computer model of the equine heart was used. This phantom was positioned in a water tank, allowing simultaneous TTE and ICE catheter introduction. Novel ICE images from within the thoracic inlet and right atrium were determined on the ultrasound simulator, with TTE as back-up modality to determine ICE catheter position in the simulator if necessary. Images were validated in six horses, with adaptations to catheter manipulations where needed.

RESULTS

Novel ICE images developed on the ultrasound simulator could be replicated in live horses, with no changes in catheter manipulations. These views allowed visualization of the tributaries of the cranial vena cava, both atria, pulmonary veins, aorta, and pulmonary artery.

CONCLUSIONS AND CLINICAL IMPORTANCE

The ultrasound simulator was useful in developing additional ICE images in order to understand echocardiographic anatomy. This simulator creates possibilities for ICE diagnosis of specific cardiac conditions and further development of ICE-guided catheter-based interventions in horses. The ultrasound simulator can be helpful for providing echocardiographic training and reduction of experimental animal use.

The use of cardiac imaging in patients undergoing atrial fibrillation ablation

Cardiac imaging (CI), including echocardiography, multidetector computed tomography (MDCT), and cardiac magnetic resonance (CMR), is gaining increasing interest to aid atrial fibrillation (AF) ablation procedures, from pre-procedural planning to intra-procedural guidance. Transthoracic echocardiography is widely used for imaging, especially for preprocedural assessment, while transesophageal and intracardiac echocardiography (ICE) are used for intraprocedural guidance during transseptal puncture. Cardiac MDCT, leveraging its high spatial resolution, offers a detailed anatomical visualization of cardiac chambers and adjacent structures; moreover, left atrial wall thickness assessed by MDCT may guide radiofrequency energy titration to enhance procedural safety and efficiency. At the same time, CMR allows for detailed myocardial tissue characterization and the detection of fibrosis. ICE, MDCT, and CMR also permit intra-procedural image integration with electroanatomical maps, allowing to be aware of a greater amount of intra-procedural real-time information regarding the anatomy and the local characteristics of the tissue in contact with the ablation catheter. One of the primary objectives of performing CI-aided AF ablations is to increase procedural safety and to permit more personalized procedures, according to the characteristics of each patient. This review offers a comprehensive overview of the current applications of CI during the different phases of AF ablation and explores the potential future applications of CI in this context.

Technical Report of Radiofrequency Ablation of AVNRT with Persistent Left Superior Vena Cava: Success Relies on Basics

Background/Objectives: Persistent Left Superior Vena Cava (PLSVC) is a condition that may complicate the ablation of Atrioventricular nodal reentry tachycardia (AVNRT). We aimed to report technical experience in ablation under scuh clinical setting. Methods: 3D guided electrophysiological procedure was conducted and PLSVC was confirmed. Slow-pathway ablation for the AVNRT was performed and typical junctional rhythm during the ablation was observed. Results: Exactly the same AVNRT remained inducible after 10 radiofrequency applications, which was very likely because of suboptimal temperature increase due to lacking sustained stability/contact of the catheter given the PLSVC anatomy and the patient's deep respiration based on our observation during the RF applications. A non-steerable long sheath was introduced to achieve more firm contact of the ablation catheter, the slow-pathway was successfully ablated with just 1 application (seen immediately occurred, continuous typical junctional rhythms during ablation, and significantly better temperature during the ablation). Conclusions: PLSVC-related anatomical changes may destabilize ablation catheter making it difficult to establish sufficient energy delivery at the slow-pathway region and put forward the need for multiple ablations. Timely identifying such scenarios (e.g., insufficient stability, insufficient temperature) could help better plan/change the ablation technique or strategy to achieve better procedure outcomes. This technical report reminds us that typical junctional beats may not be the only determinant for successful ablation of the slow-pathway. The key to the solution often relies on basic ablation biophysics.

The Growing Role of Intracardiac Echo in Congenital Heart Disease Interventions

Advancements in congenital heart disease (CHD) care have significantly improved survival, leading to a growing population of adults with congenital heart disease (ACHDs). Many of these patients require ongoing interventions for residual defects, conduit or valve dysfunction, and arrhythmia management, often performed using transcatheter techniques. Imaging plays a critical role in ensuring procedural success and safety. Intracardiac echocardiography (ICE) has emerged as an essential imaging modality in ACHD interventions. With continuous technological advancements, ICE offers several advantages over transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE), including superior visualization, real-time guidance, and the ability to avoid general anesthesia. These benefits have made ICE the preferred imaging tool for many transcatheter procedures. This review explores the expanding role of ICE in ACHD interventions, highlighting its applications in structural and electrophysiological procedures. By enhancing procedural precision and reducing complications, ICE is transforming the management of ACHD patients, optimizing outcomes, and improving long-term care for this complex and growing population.

Role of ChatGPT in interventional cardiology

ABSTRACT

Since the development of Chat Generative Pre-trained Transformer (ChatGPT), its roles in health care and various medical specialties have been increasingly explored, showing significant potential in supplementing clinical approaches and management, as well as medical education and training for healthcare professionals. Furthermore, ChatGPT could have potential in the field of interventional cardiology, especially in aiding clinical decision-making, education and training. However, its role in interventional cardiology has yet to be comprehensively evaluated. This review aimed to evaluate existing literature on the potential of ChatGPT in interventional cardiology to better understand and utilise the platform for clinical decision-making, education and training in the future.

Multicenter Experience With a Novel Real-Time 3-Dimensional Intracardiac Echocardiography Catheter to Guide Interventional Cardiac Procedures

BACKGROUND

Recent technologies enable real-time 3-dimensional intracardiac echocardiography (ICE) with the advantages of 2-dimensional ICE and imaging capabilities of transesophageal echocardiography. The purpose of this study is to evaluate the real-world, multicenter safety and performance of a novel 3-dimensional ICE system in a variety of cardiac interventions used in standard clinical practice.

METHODS

This prospective, multicenter, observational, single-arm study enrolled patients who were scheduled for an invasive cardiac procedure involving guidance with ICE and followed until discharge or ≤48 hours postprocedure. Intracardiac imaging was performed with the 3-dimensional ICE catheter, VeriSight Pro (Philips Inc.). Fluoroscopy was used in all cases and transesophageal echocardiography was used in some cases. The primary safety end point was device-related adverse events. The primary efficacy end point included technical success, imaging success, and clinical success.

RESULTS

Between October 2021 and November 2022, 155 patients were enrolled and screened. Percutaneous interventions performed included atrial septal defect/patent foramen ovale closures, left atrial appendage occlusion, catheter ablations, and valve procedures. No adverse events were related to the device or procedure. The technical, imaging, and clinical success rates were 98.7% (95% CI, 95.4%-99.8%), 96.1% (95% CI, 91.8%-98.6%), 94.8% (95% CI, 91.8%-98.6%), respectively. Overall, the VeriSight Pro ICE image quality was assessed to be "acceptable" or greater in relation to reference image modality among 96.2% (149 of 155) of procedures.

CONCLUSIONS

VeriSight ICE imaging is safe and effective in the guidance of a wide variety of percutaneous cardiovascular procedures and has provided successful and high-quality imaging of cardiac structures.

Catheter Ablation of Atrial Fibrillation: Technique and Future Perspectives

Atrial fibrillation is the most common sustained cardiac arrhythmia with a significant impact on quality of life in terms of symptoms and reduction of functional status. Also, it is associated with an increased risk of mortality, stroke, and peripheral embolism. Catheter ablation for atrial fibrillation has become a well-established treatment, improving arrhythmia outcomes without increasing the risk of serious adverse events compared to antiarrhythmic drug therapy. The field has undergone significant advancements in recent years, yet pulmonary vein isolation continues to be the cornerstone of any atrial fibrillation ablation procedure. The purpose of this review is to provide an overview of the current techniques, emerging technologies, and future directions.

Tricuspid Valve Blood Cysts on Intracardiac Echocardiography

•Blood cysts are rare, typically solitary growths on the mitral valve. •Multiple imaging modalities exist to visualize intracardiac masses. •ICE has shown increasing utility in intervention. •ICE can provide excellent interrogation of intracardiac masses.

Central Venous Recanalization and Right Atrial Thrombectomy Using IVUS

Central venous occlusions (CVOs) of the systemic circulation are highly morbid, causing significant symptoms from venous congestion, venous thromboembolism (VTE) and impaired vascular access. Endovascular recanalization (EVR) has emerged as the treatment of choice for medically refractory nonthrombotic and thrombotic CVOs with Intravascular Ultrasound (IVUS) playing a pivotal role. Radial and side-firing IVUS catheters are used during central venous recanalization in the chest, abdomen and pelvis. The intraluminal ultrasonic view of a CVO shows dynamic details of pathology not obtained with conventional venography or cone-beam CT, allowing for a more accurate evaluation of clot burden, wall integrity, tumor invasion, occlusion length and luminal caliber. IVUS is also superb for guiding treatment of CVOs involving blunt and sharp recanalization, stenting, and mechanical thromboembolectomy (MTE) of VTE, especially high-risk free-floating thrombi (FFT) and clot in-transit (CIT) in the right atrium (RA). It most accurately assesses procedural endpoints, including successful intravascular traversal across an occlusion, adequate luminal gain after venoplasty and stenting, and complete clot extraction during thrombectomy. Moreover, this is all done without added contrast or radiation, which is paramount to reduce exposure during a challenging recanalization, especially in the aging hemodialysis population. Long-term data is now available that shows IVUS can enhance technical and clinical success and reduce complications during EVR. To achieve these benefits with IVUS interventionalists must be familiar with the available catheters and how to optimize and interpret the intraluminal images obtained. This paper will review the patient evaluation, indications, equipment, steps, challenges, complications, and outcomes for central venous recanalization (CVR) and RA thrombectomy with IVUS.

A Novel Technique of Left Atrial Decompression Using Intracardiac Echocardiography Guidance in 2 Dogs With Advanced Degenerative Mitral Valve Disease

Left atrial decompression (LAD) using transseptal puncture followed by balloon atrial septostomy recently has been described as a palliative minimally invasive procedure in dogs with advanced degenerative mitral valve disease (DMVD). We report herein the first use of intracardiac echocardiography (ICE) guidance combined with 3-dimensional transesophageal echocardiography (3D-TEE) to ensure the safety of the LAD procedure from a caudal approach, as performed in humans, in 2 American College of Veterinary Internal Medicine (ACVIM) stage C and D DMVD dogs (Jack Russell Terrier and Cavalier King Charles Spaniel) with recurrent episodes of acute pulmonary edema. Both LAD procedures were successful, as confirmed by markedly decreased systolic left atrial pressures (17 and 25 mmHg vs. 42 and 80 mmHg before LAD, respectively). Both dogs remained free of left-sided congestive heart failure signs for 8 and 10 months, respectively. The addition of ICE guidance to 3D-TEE is feasible and valuable in medium-sized dogs for safe LAD procedures.

Ablation of ventricular tachycardia from right ventricular aneurysms in patients with arrhythmogenic cardiomyopathy guided by intracardiac echocardiography

BACKGROUND

The best approach for ablating ventricular tachycardia (VT) targeting right ventricular (RV) free wall aneurysms in arrhythmogenic right ventricular cardiomyopathy (ARVC) remains undefined.

OBJECTIVE

We aimed to describe the technical approach, safety, and long-term efficacy of endocardial ablation of VT originating from RV free wall aneurysms in ARVC patients.

METHODS

We identified ARVC patients with VT mapped to intracardiac echocardiography (ICE)-defined RV free wall aneurysms who underwent endocardial ablation targeting the aneurysmal area. RV free wall aneurysm on ICE was defined as an akinetic or dyskinetic area with diastolic bulging. The primary ablation end point was VT control, defined as freedom from any or multiple (>1) VT recurrences.

RESULTS

From 2012 to 2023, 14 ARVC patients underwent endocardial VT ablation within ICE-defined RV free wall aneurysms. The median age at first arrhythmia event was 55.5 years (interquartile range [IQR], 32.3-59.8 years). Pathogenic genetic variants were identified in 82% of the patients. Ablation inside the RV aneurysms during ICE monitoring used prolonged radiofrequency applications (median, 111 seconds; IQR, 81-180 seconds), with power titrated up to 29 W (IQR, 29-33 W) to achieve 10%-15% impedance drops. No steam pops occurred. VT noninducibility was achieved in 86% with no complications. During median follow-up of 4.3 years (IQR, 3.1-6.0 years), the primary end point was achieved in 13 patients (93%): 10 VT free and 3 with a single episode of VT.

CONCLUSION

Endocardial ablation targeting VT from ICE-defined RV free wall aneurysms in ARVC patients using prolonged radiofrequency applications is safe and effective, precluding the need for adjunctive epicardial ablation. Patients with aneurysm-dependent VT were typically older and carried pathogenic genetic variants.

Preclinical Experience Using 4D Intracardiac Echocardiography to Guide Cardiac Electrophysiology Procedures

INTRODUCTION

Intracardiac echocardiography (ICE) is an essential imaging modality for electrophysiology procedures, allowing intraprocedural monitoring, real-time catheter manipulation guidance, and visualization of complex anatomic structures. Four-dimentional (4D) ICE is the next stage in the evolution of the technology, permitting 360° rotation of the imaging plane, simultaneous multiplanar imaging, and volumetric acquisition, similar to transesophageal echocardiography (TEE). In this study, we report our experience with a novel 4D ICE catheter (NuVision, Biosense Webster) in structural electrophysiology procedures and difficult ventricular ablations in a swine preclinical model.

METHODS

7 Yorkshire swine underwent 4D ICE (NuVision, Biosense Webster) imaging procedures and anatomical shells of the RV, LV, and LA were created on the CARTO mapping system. Ablation was performed on the RV moderator band and LV papillary muscles under imaging guidance with the 4D ICE catheter. Additional ICE images were obtained of the LAA to simulate placement of a left atrial appendage occlusion (LAAO) device. Triphenyl tetrazolium chloride was administered before euthanasia and hearts were harvested, fixed in formalin, and sectioned.

RESULTS

CARTOSOUND reconstruction was completed using the novel multiplane imaging software platform, allowing for creation of anatomy with minimal movement of the ICE catheter. Maps generated were similar to 3D reconstruction acquired in pre-procedure CT. Ablation lesions were successfully delivered to the LV papillary muscles and RV moderator band with excellent correlation between gross pathology, electroanatomic mapping (EAM), and ICE images. 2D, multiplane, and 3D volumetric images were obtained of the LAA with minimal catheter movement to simulate use for an LAAO procedure.

DISCUSSION

Intracardiac ultrasound has become an essential tool in the electrophysiology lab, especially for visualization of intracardiac structures in real time. 4D ICE is the natural progression of this technology, adding features previously only seen on TEE probes. In this preclinical study, 4D ICE was used to create CARTOSOUND shells with less catheter manipulation, which could decease procedural times and potentially decrease complications related to frequent manipulation of the ICE catheter. It was also placed in the left atrium to acquire multiplane and 3D rendered volumes of the left atrial appendage (LAA) similar to what would be required for an LAA occlusion procedure. This could be used as an alternative to TEE in LAAO procedures, potentially improving procedural efficiency and negating the need for general anesthesia. Additionally, it was used for real-time ablation guidance, specifically directly on the RV moderator band and LV papillary muscles. Multiplanar imaging allowed for more accurate catheter visualization and localization when targeting these complex 3D intracavitary structures.

CONCLUSION

4D ICE is the next stage in evolution of an essential imaging modality for electrophysiology procedures. Integration within the electroanatomical mapping system software platform may provide additional value for guiding ablation of challenging intracavitary structures and is a novel feature of the NuVision catheter. Through promising, this technology is new and further clinical investigation will be required to determine the ideal applications for its use.

Structural Heart Imaging Using 3-Dimensional Intracardiac Echocardiography: JACC: Cardiovascular Imaging Position Statement

3-dimensional (3D) intracardiac echocardiography (ICE) is emerging as a promising complement and potential alternative to transesophageal echocardiography for imaging guidance in structural heart interventions. To establish standardized practices, our multidisciplinary expert position statement serves as a comprehensive guide for the appropriate indications and utilization of 3D-ICE in various structural heart procedures. The paper covers essential aspects such as the fundamentals of 3D-ICE imaging, basic views, and workflow recommendations specifically tailored for ICE-guided structural heart procedures, such as transeptal puncture, device closure of intracardiac structures, and transcatheter mitral and tricuspid valve interventions. Current challenges, future directions, and training requirements to ensure operator proficiency are also discussed, thereby promoting the safety and efficacy of this innovative imaging modality to support expanding its future clinical applications.

Intracardiac Echocardiography-Applications in the Electrophysiology and the Cardiac Catheterization Labs

Background. Intracardiac echocardiography (ICE) is routinely used in cardiac electrophysiology and catheterization labs. It plays a vital role in understanding cardiac anatomy, procedural planning, and early identification of complications. In this review, we describe the utility of ICE for procedures in the electrophysiology lab, including atrial fibrillation ablation, left atrial appendage occlusion device implantation, and cardiac implantable electronic device (CIED) extraction. Intracardiac echocardiography also helps in the identification of complications such as pericardial effusion, pulmonary vein stenosis, and left atrial appendage thrombus. Compared with traditional echocardiographic modalities such as transesophageal echocardiogram (TEE), ICE has equivalent image quality, requires less sedation, and possesses no risk of esophageal injury. The disadvantages of ICE include a learning curve and necessity for central vascular access.

Highlights of Transesophageal Echocardiography During Interventions for Adult Congenital Heart Disease

Significant advances in the diagnosis and treatment of congenital heart disease have transformed patient outcomes, leading to an expanding adult congenital heart disease population. Many of these adults require lifelong procedural interventions, frequently performed in catheterization labs under the guidance of echocardiography. This review explores the transesophageal echocardiographic aspect in key catheterization-based procedures.

Impact of moderate sedation on electrophysiology lab time for left atrial appendage occlusion using 4D-intracardiac echocardiography

INTRODUCTION

Left atrial appendage occlusion (LAAO) can be performed using diverse anesthetic approaches ranging from moderate sedation (MS) to general anesthesia (GA), and guided by intracardiac echocardiography (ICE) or transesophageal echocardiography (TEE). Prior studies have demonstrated shorter time in lab for heart rhythm procedures performed under MS. The objective of this study was to compare laboratory times, acute procedural outcomes and complication rates for LAAO procedures performed using MS and 4-dimensional ICE as opposed to GA.

METHODS AND RESULTS

This was a retrospective observational cohort study of 135 consecutive patients who were referred for LAAO to be performed with either GA or MS between June 2022 and April 2024. The primary endpoints were total laboratory time, procedure time, nonprocedure time, and fluoroscopy time. The secondary endpoints were stroke, peri-device leak (>5 mm), device-related left atrial thrombus, cardiovascular mortality, and all-cause mortality at 45 days and 6 months postprocedure, where data were available. The mean age of patients in the study was 78.8 ± 7.8 years and 64.4% were male with no difference between GA and MS. In the MS group, 4D-ICE was used for intraprocedural imaging in 95.5% of patients and 2 dimensional-ICE (2D-ICE) was used in 4.5% of patients. In the GA group, intra-procedural imaging was done using TEE in 51.5%, 2D-ICE in 32.4% and 4D-ICE in 16.2% of cases. Total laboratory time was significantly lower in the MS group compared to the GA group (68.3 ± 23.1 vs 117.1 ± 34.3 min; p < 0.001), due to shorter nonprocedure time (15.2 ± 9.1 vs 63.7 ± 22.0 min; p < 0.001), with no significant difference in procedure time and fluoroscopy time. There was no significant difference in complications at 45 days and 6 months postprocedure.

CONCLUSION

In this single center study, MS reduced total lab time by reducing nonprocedure time when compared to GA for LAAO, without affecting clinical outcomes.

Intracardiac echocardiography-guided biopsies for right-sided intracardiac tumors: An optimized diagnostic algorithm and case illustrations

Intracardiac tumors, though uncommon, necessitate a swift and accurate diagnosis for personalized treatment and prognosis estimation. While multi-modality imaging often determines the etiology of these cardiac masses, histological confirmation remains essential for definitive diagnosis and its specific treatment. Since cardiac tumors are often found in high-risk locations (ventricular free wall or atria), precision biopsy is paramount. The least invasive strategy would be to achieve this by means of endomyocardial biopsy (EMB); however real-time additional imaging is essential to reduce the risk of perforation/tamponade and to minimize sampling error. Intracardiac echocardiography (ICE) emerges as an excellent tool to achieve this goal preventing procedural complications and reducing the likelihood of sampling errors obtaining a definitive histopathological diagnosis in all cases. This paper outlines our diagnostic algorithm for optimal patient selection, details three illustrative cases, and elucidates the steps to acquire histopathology via percutaneous transvenous biopsy with ICE guidance in patients with right-sided cardiac tumors. Given the rarity of intracardiac tumors, we advocate these patients be managed by a dedicated multidisciplinary cardio-oncology team including an interventional cardiologist.

Intracardiac vs. transesophageal echocardiography guided transcatheter closure of patent foramen ovale and atrial septal defects

Transcatheter closure of atrial septal defects (ASD) and patent foramen ovale (PFO) can be performed with transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) guidance, but data comparing both modalities in contemporary practice is lacking. Using ICD-10 codes, patients who underwent transcatheter ASD/PFO closure between 2016 and 2020 using ICE or TEE in the Nationwide Readmissions Database (NRD) were identified. Propensity-score matching was performed to compare in-hospital adverse events, length of stay (LOS), cost, and 30-day non-elective readmissions. A total of 964 patients underwent ASD/PFO closure with ICE (38.3 %, n = 369) or TEE (61.7 %, n = 595) between 2016 and 2020. Propensity score matching yielded 327 patients in each group, which were well balanced. Median (IQR) age was 59.0 (46.0, 72.0) years and 54.7 % were female. No difference was observed in the rate of in-hospital major adverse events between groups. ICE guidance was associated with a lower median cost (ICE $20,140.1 (14,622.3, 25,027.0) vs TEE $20,740.4 (14,137.5, 33,045.3), p < 0.04). In conclusion, ICE guided ASD/PFO closure was associated with lower hospitalization cost without increasing in-hospital adverse events when compared with TEE guidance.

The use of Intracardiac Echocardiography in Catheter Ablation of Atrial Fibrillation

PURPOSE OF THE REVIEW

Intracardiac echocardiography (ICE) provides real-time, fluoroless imaging of cardiac structures, allowing optimal catheter positioning and energy delivery during ablation procedures. This review summarizes the use of ICE in catheter ablation of atrial fibrillation (AF).

RECENT FINDINGS

Growing evidence suggests that the use of ICE improves procedural safety and facilitates radiofrequency and cryoballoon AF ablation. ICE-guided catheter ablation is associated with reduced procedural duration and fluoroscopy use. Recent studies have examined the role of ICE in guiding novel ablation techniques, such as pulsed field ablation. Finally, the use of ICE allows for early detection and timely management of potentially serious procedural complications. Intracardiac echocardiography offers significant advantages during AF ablation procedures and its use should be encouraged to improve procedural safety and efficacy.

Intracardiac Echocardiography-Guided Percutaneous Mitral Balloon Commissurotomy: Technique and Early Experience

Background

Percutaneous mitral balloon commissurotomy (PMBC) is the gold standard for the treatment of patients with symptomatic rheumatic mitral valve (MV) stenosis and favorable valve morphology. Intracardiac ultrasound (ICE)-guided PMBC is an attractive alternative to standard transesophageal echocardiography guidance for simplification of procedure and avoiding general anesthesia.

Methods

We conducted a retrospective analysis of all ICE-guided PMBC cases at our institution between July 2020 and November 2023. Procedural success was defined as post-PMBC MV area ≥1.5 cm2; or an increase of ≥0.5 cm2 in MV area associated with echocardiographic mitral regurgitation (MR) that is ≤moderate post-PMBC. Six-month follow-up data were collected.

Results

We identified 11 subjects for whom ICE-guided PMBC was attempted. The mean age of the subjects was 61.7 (±12.1) years. All, but one, were females. Out of the 11 subjects, 2 did not undergo PMBC; one had baseline severe MV regurgitation identified on ICE, and the other developed a pericardial effusion following transeptal puncture that needed an urgent pericardial window. The protocol-defined procedural success was achieved in all nine patients who underwent PMBC. Post-PMBC mean MV gradient was 4.4 (±2.0) as compared to 11.1 (±2.9) mmHg at baseline. At 6-month follow-up, 8 of the 9 patients had ≤New York Heart Association class II symptoms.

Conclusions

ICE-guided PMBC appears to be feasible and safe. ICE-guided PMBC offers several advantages over transesophageal echocardiography guidance including improving patient comfort and eliminating the need for patient intubation and general anesthesia.

Enhancing boundary detection of radiofrequency ablation lesions through photoacoustic mapping

Atrial fibrillation (A-fib) is the most common type of heart arrhythmia, typically treated with radiofrequency catheter ablation to isolate the heart from abnormal electrical signals. Monitoring the formation of ablation-induced lesions is crucial for preventing recurrences and complications arising from excessive or insufficient ablation. Existing imaging modalities lack real-time feedback, and their intraoperative usage is in its early stages. A critical need exists for an imaging-based lesion indexing (LSI) method that directly reflects tissue necrosis formation. Previous studies have indicated that spectroscopic photoacoustic (sPA) imaging can differentiate ablated tissues from their non-ablated counterparts based on PA spectrum variation. In this paper, we introduce a method for detecting ablation lesion boundaries using sPA imaging. This approach utilizes ablation LSI, which quantifies the ratio between the signal from ablated tissue and the total tissue signal. We enhance boundary detection accuracy by adapting a regression model-based compensation. Additionally, the method was cross-validated with clinically used intraoperative monitoring parameters. The proposed method was validated with ex vivo porcine cardiac tissues with necrotic lesions created by different ablation durations. The PA-measured lesion size was compared with gross pathology. Statistical analysis demonstrates a strong correlation (R > 0.90) between the PA-detected lesion size and gross pathology. The PA-detected lesion size also exhibits a moderate to strong correlation (R > 0.75) with local impedance changes recorded during procedures. These results suggest that the introduced PA imaging-based LSI has great potential to be incorporated into the clinical workflow, guiding ablation procedures intraoperatively.

Comparison of Conventionally Performed and Intracardiac Echocardiography Guided Catheter Ablation of Atrioventricular Node in Patients with Permanent Atrial Fibrillation-A Retrospective Single-Center Study

Background: Atrioventricular node (AVN) ablation is an effective treatment for atrial fibrillation (AF) with uncontrolled ventricular rates despite maximal pharmacological treatment. Intracardiac echocardiography (ICE) can help with visualizing structures, positioning catheters, and guiding the ablation procedure. We compared only fluoroscopy-guided and ICE-guided AVN ablation regarding patients with permanent AF. Methods: Sixty-two consecutive patients underwent AVN ablation were enrolled in our retrospective single-center study (ICE group: 28 patients, Standard group: 34 patients). Procedural data, acute and long-term success rate, and complications were analyzed. Results: ICE guidance for AVN ablation significantly reduced fluoroscopy time (0.30 [0.06; 0.85] min vs. 7.95 [3.23; 6.59] min, p < 0.01), first-to-last ablation time (4 [2; 16.3] min vs. 26.5 [2.3; 72.5] min, p = 0.02), and in-procedure time (40 [34; 55] min vs. 60 [45; 110], p = 0.02). There was no difference in either the total ablation time (199 [91; 436] s vs. 294 [110; 659] s, p = 0.22) or in total ablation energy (8272 [4004; 14,651] J vs. 6065 [2708; 16,406] J, p = 0.28). The acute success rate was similar (ICE: 100% vs. Standard: 94%, p = 0.49) between the groups. Conclusions: In our retrospective trial, ICE-guided AVN ablation reduced fluoroscopy time, procedure time, and first-to-last ablation time. There was no difference in ablation time, total ablation energy, acute and long-term success, and complication rate.

Intracardiac echocardiography guided anatomical ablation of the arcuate ridge for drug refractory inappropriate sinus tachycardia

INTRODUCTION

Inappropriate sinus tachycardia (IST) is a common condition with frequently not tolerated beta-blockers or ivabradine and a high rate of complication in ablation strategy; we describe an alternative anatomical approach of sinus node (SN) modulation.

METHODS

This retrospective study describes a case series of 6 patients from two centers diagnosed with symptomatic IST undergoing SN ablation.

RESULTS

The mean age was 40.6 ± 13.9 years; five of the six patients were female, 100% of patients reported heart palpitations, and 66% reported dizziness, the average heart rate (HR) on a 24-h Holter was 93.2 ± 7.9 bpm. HR during the first stage of a stress test using a standard Bruce protocol was 150 ± 70 bpm, The average HR on 24-h Holter postablation was 75 ± 5.6 bpm, the sinus rate HR during stage 1 of a Bruce protocol exercise stress test was 120 ± 10 bpm.

CONCLUSION

This is the first case series reporting the acute and long-term results of a novel anatomical approach for SN modulation to treat IST targeting the arcuate ridge (AR) under intracardiac echography (ICE) guidance. The novel anatomic ICE-guided catheter ablation approach aimed to identify the earliest activation at the AR with an extension of RF lesions toward its septal region seems effective and safe to modulate the SN in symptomatic patients with IST refractory to medical treatment.

The Covert Impact of Chiari Network and Eustachian Valves on Stroke: A Scoping Review and Meta-Analysis

BACKGROUND

The role of Chiari network (CN) and Eustachian valves (EVs) in cardioembolic strokes is still unclear. There is inconsistency in the literature regarding clinical approach to these lesions to reduce stroke risk. We aimed to describe clinical presentation, neuroimaging and cardioimaging features, as well as management approaches for CN and EV in stroke context.

REVIEW SUMMARY

A systemic search was carried out using PubMed and Web of Science following PRISMA guidelines, Supplemental Digital Content 1 ( http://links.lww.com/NRL/A123 ). We retrieved 4 case-control studies, 2 cross sectional studies as well 8 case reports, with a total of 883 patients with a mean age of 44.6 years (±13.8). The combined prevalence of EV/CN in stroke-related patent foramen ovale (PFO) patients was 50% (95% CI: 31-68). With isolated prevalence for EV and CN of 43% (95% CI: 25-63), 18% (95% CI: 12-25), respectively. Patients with history of stroke had higher prevalence of EV/CN compared with controls odds ratio=2.45 (95% CI: 1.2-5, P <0.01). All case-control and cross-sectional studies defined EV/CN by transesophageal echocardiography or intracardiac cardiography. In the 8 case reports, 7 cases were diagnosed by transesophageal echocardiography, while only 1 case was diagnosed postmortem.

CONCLUSION

EV/CN are relatively common findings in stroke patients with PFO. While it appears that presence of EV/CN with a PFO increases the risk of cardioembolic stroke, they remain underrecognized. EV/CN should be considered as high-risk PFO features. There is a scarcity of research emphasizing their role in clinical decision making, especially PFO closure and antithrombotic therapy choice.

Nonlinear beamforming for intracardiac echocardiography: a comparative study

Intracardiac echocardiography (ICE) enables cardiac imaging with a wide field of view, deep imaging depth, and high frame rate during surgery. However, strong sidelobe and grating lobe artifacts created by the ultra-compact transducer degrade its image quality, making diagnosis and monitoring of treatment difficult. Conventionally, aperture apodization algorithms are often used to suppress sidelobe and grating lobe artifacts at the expense of lateral resolution, which is undesirable in ICE. In this study, we present comparative results of the beamforming methods specifically in ICE application. We demonstrate and compare five nonlinear beamforming algorithms in ICE: nonlinear pth root delay and sum (NL-p-DAS), nonlinear pth root spectral magnitude scaling (NL-p-SMS), delay-and-sum with coherence factors (DAS + SCF), delay and sum with apodization (DAS + apodization) and delay and sum (DAS). Phantom and ex-vivo experiment compare the performance of each algorithm in static and dynamic conditions. DAS + SCF shows the best lateral resolution, and all four algorithms improve the image contrast and sidelobe suppression over conventional DAS. NL-p-SMS stands out for the best axial resolution and suppression of grating lobe artifacts. For motion tracking, NL-p-SMS shows better temporal resolution than other methods. Overall, all the beamforming algorithms other than DAS showed improved image quality. Among them, NL-p-SMS, which has a high temporal resolution, showed the potential for providing more accurate information regards movement tracking.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13534-024-00352-9.

Use of intracardiac echocardiography in vein of Marshall ethanol infusion for ablation of persistent atrial fibrillation

BACKGROUND

Few methods have been reported to demonstrate real-time effects during vein of Marshall (VOM) ethanol infusion in persistent atrial fibrillation (PeAF).

OBJECTIVE

This study was to evaluate the impact of left atrial (LA) monitoring using intracardiac echocardiography (ICE) during VOM ethanol infusion.

METHODS

Seventy-four consecutive patients with PeAF who underwent VOM ethanol infusion followed by radiofrequency (RF) ablation were included. Patients with findings on ICE consistent with echogenic streaming in the LA and with increased myocardial local echogenicity along the VOM area were placed into one group (group A) and those without into the other group (group B). Outcomes between the 2 groups were compared.

RESULTS

Forty-six patients (62%) were placed into group A. A new ethanol-induced low-voltage area in group A was larger than that in group B (8.5 cm2 [5.5-10.2 cm2] and 4.0 cm2 (2.4-6.3 cm2]; P < .001). The RF ablation time required to achieve MI block was reduced in group A patients (263.0 seconds [196.0-351.0 seconds] vs 417.0 seconds [315.0-709.5 seconds] in group B patients; P < .001). MI block was achieved in 46 patients (100%) via an endocardial approach in group A and 27 patients (96.4%) in group B (extra coronary sinus ablation in 4 patients). One patient developed clinically significant pericardial effusions and required pericardiocentesis in group B.

CONCLUSION

Presence of increased myocardial local echogenicity at the ridge and consistent echogenic streaming in the LA detected by ICE-based imaging during VOM ethanol infusion suggests increased ablated tissue in that region and lower RF ablation time during ablation for PeAF.

Comparison of Intracardiac Echocardiography Versus Transesophageal Echocardiography for Guidance During Transcatheter Aortic Valve Replacement

BACKGROUND AND OBJECTIVES

Evidence regarding the efficacy and safety of intracardiac echocardiography (ICE) for guidance during transcatheter aortic valve replacement (TAVR) is limited. This study aimed to compare the clinical efficacy and safety of ICE versus transesophageal echocardiography (TEE) for guiding TAVR.

METHODS

This prospective cohort study included patients who underwent TAVR from August 18, 2015, to June 31, 2021. Eligible patients were stratified by echocardiographic modality (ICE or TEE) and anesthesia mode (monitored anesthesia care [MAC] or general anesthesia [GA]). Primary outcome was the 1-year composite of all-cause mortality, rehospitalization for cardiovascular cause, or stroke, according to the Valve Academic Research Consortium-3 (VARC-3) definition. Propensity score matching was performed, and study outcomes were analyzed for the matched cohorts.

RESULTS

Of the 359 eligible patients, 120 patients were matched for the ICE-MAC and TEE-GA groups, respectively. The incidence of primary outcome was similar between matched groups (18.3% vs. 20.0%; adjusted hazard ratio, 0.94; 95% confidence interval [CI], 0.53-1.68; p=0.843). ICE-MAC and TEE-GA also had similar incidences of moderate-to-severe paravalvular regurgitation (PVR) (4.2% vs. 5.0%; adjusted odds ratio, 0.83; 95% CI, 0.23-2.82; p=0.758), new permanent pacemaker implantation, and VARC-3 types 2-4 bleeding.

CONCLUSIONS

ICE was comparable to TEE for guidance during TAVR for the composite clinical efficacy outcome, with similar incidences of moderate-to-severe PVR, new permanent pacemaker implantation, and major bleeding. These results suggest that ICE could be a safe and effective alternative echocardiographic modality to TEE for guiding TAVR.

The Fluoroless Future in Electrophysiology: A State-of-the-Art Review

Fluoroscopy has always been the cornerstone imaging method of interventional cardiology procedures. However, radiation exposure is linked to an increased risk of malignancies and multiorgan diseases. The medical team is even more exposed to X-rays, and a higher incidence of malignancies was reported in this professional group. In the last years, X-ray exposure has increased rapidly, involving, above all, the medical team and young patients and forcing alternative fluoroless imaging methods. In cardiac electrophysiology (EP) and pacing, the advent of 3D electroanatomic mapping systems with dedicated catheters has allowed real-time, high-density reconstruction of both heart anatomy and electrical activity, significantly reducing the use of fluoroscopy. In addition, the diffusion of intracardiac echocardiography has provided high anatomical resolution of moving cardiac structures, providing intraprocedural guidance for more complex catheter ablation procedures. These methods have largely demonstrated safety and effectiveness, allowing for a dramatic reduction in X-ray delivery in most arrhythmias' ablations. However, some technical concerns, as well as higher costs, currently do not allow their spread out in EP labs and limit their use to only procedures that are considered highly complex and time-consuming and in young patients. In this review, we aim to update the current employment of fluoroless imaging in different EP procedures, focusing on its strengths and weaknesses.

Intra-cardiac motion detection catheter for the early identification of acute pericardial tamponade during invasive cardiac procedures

Objectives

To develop and test an intra-cardiac catheter fitted with accelerometers to detect acute pericardial effusion prior to the onset of hemodynamic compromise.

Background

Early detection of an evolving pericardial effusion is critical in ensuring timely treatment. We hypothesized that the reduction in movement of the lateral heart border present in developing pericardial effusions could be quantified by positioning an accelerometer in a lateral cardiac structure.

Methods

A "motion detection" catheter was created by implanting a 3-axis accelerometer at the distal tip of a cardiac catheter. The pericardial space of 5 adult sheep was percutaneously accessed, and pericardial tamponade was created by infusion of normal saline. The motion detection catheter was positioned in the coronary sinus. Intracardiac echocardiography was used to confirm successful creation of pericardial effusion and hemodynamic parameters were collected.

Results

Statistically significant reduction in acceleration from baseline was detected after infusion of only 40 ml of normal saline (p < 0.05, ANOVA). In comparison, clinically significant change in systolic blood pressure (defined as >10% drop in baseline systolic blood pressure) occurred after infusion of 80 ml of normal saline (107 ± 22 mmHg vs. 90 ± 12 mmHg p = 0.97, ANOVA), and statistically significant change was recorded only after infusion of 200 ml (107 ± 22 mmHg vs. 64 ± 5 mmHg, p < 0.05, ANOVA).

Conclusions

An intra-cardiac motion detection catheter is highly sensitive in identifying acute cardiac tamponade prior to clinically and statistically significant changes in systolic blood pressure, allowing for early detection and treatment of this potentially life-threatening complication of all modern percutaneous cardiac interventions.

3D Intracardiac Echocardiography for Structural Heart Interventions

Transcatheter structural heart interventions are expanding into more complex spaces including mitral transcatheter edge-to-edge repair, left atrial appendage occlusion, tricuspid transcatheter edge-to-edge repair, mitral/tricuspid valve-in-valve, and perivalvular leak closures. Transesophageal echocardiography (TEE), with concomitant fluoroscopy, has remained the gold standard for many of these interventions. Although three-dimensional intracardiac echocardiography has been used, applications were often limited to guidance for more "simple" procedures such as patent foramen ovale/atrial septal defect closure and/or intraprocedural adjunctive imaging guidance. However, patients with an excessive risk for general anesthesia or contraindications to TEE, including esophageal/gastric disease, cervical/thoracic spinal disease, or coagulopathies, have limited options.

Intracardiac Echocardiographic Guidance for Structural Heart Procedures: Current Utility as Compared to Transesophageal Echocardiography

Over the past decade, engineering advances in intracardiac echocardiography (ICE) have improved the ability of an imager or interventionalist to guide not only interatrial septal procedures but now commonly left atrial appendage, tricuspid, and mitral procedures. When transesophageal echocardiography (TEE) is not possible because of anatomic limitations, ICE has proved a useful tool to safely complete structural interventions. ICE will play a growing, key role in structural interventions where anatomic factors strongly favor an intracardiac perspective or augment TEE when imaging is suboptimal.

Intracardiac echocardiography is a promising strategy for guiding closure of the left atrial appendage

Background and Aims

Percutaneous transcatheter left atrial appendage (LAA) closure (LAAC) is an effective approach for preventing ischemic stroke in nonvalvular atrial fibrillation patients. Intracardiac echocardiography (ICE), a new imaging modality, is a promising strategy for guiding LAAC. This review highlights the various strategies for ICE-guided-LAAC as an option for clinical policy.

Methods

A comprehensive literature search was conducted of PubMed, ScienceDirect, Ovid Web of Science, SpringerLink, and other notable databases to identify recent peer-reviewed clinical trials, reviews, and research articles related to ICE and its application in the guidance of LAAC.

Results

Various methods are used to evaluate the spatial structure and dimensions of the LAA. The main techniques for guiding LAAC are transesophageal echocardiography (TEE), cardiac computed tomography (CTA), and ICE. Among these techniques, the advantages of ICE typically include (1) multiangle and real-time assessment of intracardiac structure, (2) a reduction in procedural fluoroscopy, (3) reduced operation time and improved workflow in the catheterization laboratory, and (4) the avoidance of general anesthesia and the early detection of complications.

Conclusion

ICE is a promising strategy for the guidance of LAAC. Among the most advanced and recent technological innovations in cardiovascular imaging in general and volume imaging in particular, ICE offers greater efficacy and safety.

Lead management in patients undergoing percutaneous tricuspid valve replacement or repair: a 'heart team' approach

Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous trans-catheter tricuspid valve (TV) replacement and tricuspid trans-catheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a trans-venous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of 'jailing' a CIED lead at the time of a percutaneous TV intervention (lead fracture and risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this 'state-of-the-art' review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads, and advocate for including a lead management specialist as a member of the 'heart team' when making treatment decisions in patients TR and CIED leads.

Comparison of intracardiac vs. transesophageal echocardiography for "one-stop" procedures of combined radiofrequency catheter ablation and left atrial appendage closure with the Watchman device in the treatment of atrial fibrillation

Background and objective

This study aimed to assess the efficacy and safety of "one-stop" procedures that combined radiofrequency catheter ablation and left atrial appendage closure (LAAC) with the Watchman device under the guidance of intracardiac echocardiography (ICE) vs. transesophageal echocardiography (TEE) in patients with atrial fibrillation.

Methods and results

In this study, we prospectively enrolled patients who underwent "one-stop" procedures under the guidance of ICE (n = 193, 109 men, 65.02 ± 8.47 years) or TEE (n = 109, 69 men, 64.23 ± 7.75 years) between January 2021 and October 2022. Intraprocedural thrombus formation in the left atrial appendage (LAA) was observed in 3 (1.46%) patients in the ICE group and 15 (11.63%) patients in the TEE group (P < 0.05) before LAAC. Total fluoroscopy time and dose in the ICE group were less than those in the TEE group. The total "one-stop" turnaround time and LAAC procedure time in the ICE group were significantly shorter than those in the TEE group (P < 0.05). Postoperative esophagus discomfort, nausea and vomiting, and hypotension were more often seen in the TEE group (P < 0.001). There was no significant difference in matched cases between ICE and fluoroscopy measurements (P = 0.082). The TEE results related to LAAC and clinical events were similar between the two groups during the follow-up (P > 0.05).

Conclusion

The ICE-guided "one-stop" procedure was safe and feasible with less radiation exposure, shorter turnaround time, and fewer complications and intraoperative thrombus formations than the TEE group. ICE offered accurate measurements in the LAA dimension during LAAC. Echocardiography during the "one-stop" procedures was necessary to rule out the intraoperative thrombus.

Design and Validation of a Soft Robotic Simulator for Transseptal Puncture Training

OBJECTIVE

Transseptal puncture (TP) is the technique used to access the left atrium of the heart from the right atrium during cardiac catheterization procedures. Through repetition, electrophysiologists and interventional cardiologists experienced in TP develop manual skills to navigate the transseptal catheter assembly to their target on the fossa ovalis (FO). Cardiology fellows and cardiologists that are new to TP currently train on patients to develop this skill, resulting in increased risk of complications. The goal of this work was to create low-risk training opportunities for new TP operators.

METHODS

We developed a Soft Active Transseptal Puncture Simulator (SATPS), designed to match the dynamics, static response, and visualization of the heart during TP. The SATPS includes three subsystems: (i) A soft robotic right atrium with pneumatic actuators mimics the dynamics of a beating heart. (ii) A fossa ovalis insert simulates cardiac tissue properties. (iii) A simulated intracardiac echocardiography environment provides live visual feedback. Subsystem performance was verified with benchtop tests. Face and content validity were evaluated by experienced clinicians.

RESULTS

Subsystems accurately represented atrial volume displacement, tenting and puncture force, and FO deformation. Passive and active actuation states were deemed suitable for simulating different cardiac conditions. Participants rated the SATPS as realistic and useful for training cardiology fellows in TP.

CONCLUSION

The SATPS can help improve catheterization skills of novice TP operators.

SIGNIFICANCE

The SATPS could provide novice TP operators the opportunity to improve their TP skills before operating on a patient for the first time, reducing the likelihood of complications.

Intracardiac echocardiography-guided left atrial appendage occlusion: The path to independence

INTRODUCTION AND OBJECTIVES

Transesophageal echocardiography (TEE) has been the standard method for guiding left atrial appendage occlusion (LAAO) procedures. Recently, intracardiac echocardiography (ICE) has emerged as an alternative to TEE due to several advantages, particularly the avoidance of general anesthesia. This analysis aims to assess the safety, feasibility and efficacy of ICE-guided LAAO procedures.

METHODS

We performed a retrospective analysis of ICE-guided LAAO procedures, including a comparison of embolic and bleeding events with the predicted standard scores and a comparison with TEE-guided procedures.

RESULTS

A total of 88 patients underwent echocardiography-guided percutaneous LAAO (43 patients with TEE and 45 with ICE), mean age 74.9 years, 68.2% male. In the ICE-guided population, the technical success rate was 93% and the major complication rate was 8.8%. During follow-up, yearly stroke and major bleeding rates were 1.4% and 8.4%, respectively, compared to the 4.0% and 8.7% predicted by the CHA2DS2-VASc and HAS-BLED scores. In the TEE versus ICE analysis (similar baseline characteristics), no statistically significant differences were seen regarding technical success (95.3% vs. 93.3%), procedure-related complications (14.0% vs. 8.9%), device thrombus (2.3% vs. 0%), residual minor peridevice leaks (14.0% vs. 24.4%), one-year all-cause mortality (9.3% vs. 4.4%), stroke (9.3% vs. 2.2%) or major bleeding events (9.3% vs. 11.1%).

CONCLUSION

ICE-guided LAAO was a safe and effective therapeutic strategy in a high embolic and bleeding risk population, compared to the event rates predicted by the CHA2DS2-VASc and HAS-BLED scores. The ICE-guided procedure compared well to TEE-guided procedures regarding procedure feasibility, safety, and efficacy.

The Emerging Role of Intracardiac Echocardiography (ICE) in Left Atrial Appendage Closure (LAAC)

PURPOSE OF REVIEW

Intracardiac echocardiography (ICE) has emerged as a powerful imaging tool to guide percutaneous left atrial appendage closure (LAAC). Herein, we review an imaging protocol for ICE-guided LAAC and discuss the evidence for its use.

RECENT FINDINGS

Standardized imaging protocols have been proposed but have not been fully validated. ICE imaging yields similar procedural and clinical outcomes when compared to transesophageal echocardiography (TEE) to guide LAAC. Despite benefits of avoiding general anesthesia, TEE, and multiple physicians for LAAC procedures, ICE imaging remains under-utilized. Novel ICE catheters with 3D imaging capabilities may improve accuracy and efficiency of LAAC device implantation. ICE guidance is feasible, safe, and effective for LAAC. As the field evolves, further studies will be necessary to assess this technological advancement in imaging guidance.

Intracardiac Echocardiography Guidance Improves Procedural Outcomes in Patients Undergoing Cavotricuspidal Isthmus Ablation for Typical Atrial Flutter

Atrial flutter (AFL) represents a prevalent variant of supraventricular tachycardia, distinguished by a macro-reentrant pathway encompassing the cavotricuspid isthmus (CTI). Radiofrequency (RF) catheter ablation stands as the favored therapeutic modality for managing recurring CTI-dependent AFL. Intracardiac echocardiography (ICE) has been proposed as a method to reduce radiation exposure during CTI ablation. This study aims to comprehensively compare procedural parameters between ICE-guided CTI ablation and fluoroscopy-only procedures. A total of 370 consecutive patients were enrolled in our single-center retrospective study. In 151 patients, procedures were performed using fluoroscopy guidance only, while 219 patients underwent ICE-guided CTI ablation. ICE guidance significantly reduced fluoroscopy time (73 (36; 175) s vs. 900 (566; 1179) s; p < 0.001), fluoroscopy dose (2.45 (0.6; 5.1) mGy vs. 40.5 (25.7; 62.9) mGy; p < 0.001), and total procedure time (70 (52; 90) min vs. 87.5 (60; 102.5) min; p < 0.001). Total ablation time (657 (412; 981) s vs. 910 (616; 1367) s; p < 0.001) and the time from the first to last ablation (20 (11; 36) min vs. 40 (25; 55) min; p < 0.01) were also significantly shorter in the ICE-guided group. Acute success rate was 100% in both groups, and no major complications occurred in either group. ICE-guided CTI ablation in patients with AFL resulted in shorter procedure times, reduced fluoroscopy exposure, and decreased ablation times, compared to the standard fluoroscopy-only approach.

Zero-Fluoroscopy Catheter Ablation of Supraventricular Tachycardias in the Pediatric Population

Catheter ablation (CA) of supraventricular tachycardias (SVTs) is conventionally performed with the aid of X-ray fluoroscopy. Usage of a three-dimensional (3D) electro-anatomical mapping (EAM) system and intracardiac echocardiography (ICE) enables zero-fluoroscopy ablation, eliminating the harmful effects of radiation. We retrospectively analyzed the feasibility, effectiveness and safety of zero-fluoroscopy radiofrequency and cryoablation of various types of SVTs in pediatric patients. Overall, in 171 consecutive patients (12.5 ± 3.9 years), 175 SVTs were diagnosed and 201 procedures were performed. The procedural success rate was 98% (193/197), or more precisely, 100% (86/86) for AVNRT, 95.8% (91/95) for AVRT, 94.1% (16/17) for AT and 100% (2/2) for AFL. No complications were recorded. Follow-up was complete in 100% (171/171) of patients. During the mean follow-up period of 488.4 ± 409.5 days, 98.2% of patients were arrhythmia-free with long-term success rates of 98.7% (78/79), 97.5% (78/80), 100% (13/13) and 100% (2/2) for AVNRT, AVRT, AT and AFL, respectively. Zero-fluoroscopy CA of various types of SVTs in the pediatric population is a feasible, effective and safe treatment option.

Catheter navigation by intracardiac echocardiography enables zero-fluoroscopy linear lesion formation and bidirectional cavotricuspid isthmus block in patients with typical atrial flutter

INTRODUCTION

One of the most helpful aspects of intracardiac echocardiography (ICE) implementation in electrophysiological studies (EPS) is the real-time visualisation of catheters and cardiac structures. In this prospective study, we investigated ICE-guided zero-fluoroscopy catheter navigation during radiofrequency (RF) ablation of the cavotricuspid isthmus (CTI) in patients with typical atrial flutter (AFL).

METHODS AND RESULTS

Thirty consecutive patients (mean age 72.9 ± 11.4 years, 23 male) with ongoing (n = 23) or recent CTI-dependent AFL underwent an EPS, solely utilizing ICE for catheter navigation. Zero-fluoroscopy EPS could be successfully accomplished in all patients. Mean EPS duration was 41.4 ± 19.9 min, and mean ablation procedure duration was 20.8 ± 17.1 min. RF ablation was applied for 6.0 ± 3.1 min (50W, irrigated RF ablation). Echocardiographic parameters, such as CTI length, prominence of the Eustachian ridge (ER), and depth of the CTI pouch on the ablation plane, were assessed to analyse their correlation with EPS- or ablation procedure duration. The CTI pouch was shallower in patients with an ablation procedure duration above the median (4.8 ± 1.1 mm vs. 6.4 ± 0.9 mm, p = 0.04), suggesting a more lateral ablation plane in these patients, where the CTI musculature is stronger. CTI length or ER prominence above the respective median did not correlate with longer EPS duration.

CONCLUSIONS

Zero-fluoroscopy CTI ablation guided solely by intracardiac echocardiography in patients with CTI-dependent AFL is feasible and safe. ICE visualisation may help to localise the optimal ablation plane, detect and correct poor tissue contact of the catheter tip, and recognise early potential complications during the ablation procedure.