Intracardiac echocardiography: evolving use in interventional cardiology

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.

Routine use of a 3D mapping system in the ablation of supraventricular arrhythmias with as low as reasonably achievable X-ray exposure (AALARA): protocol for a prospective, observational, multicentre, multinational, open-label registry study

INTRODUCTION

The reduction of fluoroscopic exposure during catheter ablation of supraventricular arrhythmias is widely adopted by experienced electrophysiology physicians with a relatively short learning curve and is becoming standard of care in many parts of the world. While observational studies in the USA and some parts of Western Europe have evaluated the minimal fluoroscopic approach, there are scarce real-world data for this technique and generalisability of outcome in other economic regions.

METHODS AND ANALYSIS

The arrhythmias with as low as reasonably achievable X-ray exposure study is a prospective, observational, multicentre and multinational open-label registry study. Up to 700 patients undergoing catheter ablation for right-sided supraventricular arrhythmias (according to national guidelines) will be enrolled for the routine use of the EnSite Precision 3D mapping system. Participating sites are distributed in 13 countries from Central Eastern Europe, North and South Africa, the Middle East and the CIS (Commonwealth of Independent States), with different levels of expertise using minimal fluoroscopic exposure techniques. After electrophysiological procedure, patients will be followed up for 6 months either in-clinic or via telephone interview. Patients will be asked to complete a study questionnaire at enrolment and 6 months after the invasive procedure to assess quality of life changes secondary to the procedure. The study's primary objective is to describe ionising radiation exposure during catheter ablation when the EnSite Precision 3D mapping system is used in supraventricular tachycardia ablation. The study's secondary objective is to assess the safety and efficacy of this method. Furthermore, fluoroscopy timing, total procedure time, success rate and complications will be reported.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee at Mohammed Bin Khalifa Specialist Cardiac Centre (BDF/R&REC/2020-504) and the medical ethics committees of all participating sites. Participants will be required to provide informed consent before enrolment in the study. The study results will be published and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT04716270.

Intracardiac vs. transesophageal echocardiography for guiding transcatheter closure of interatrial communications: a systematic review and meta-analysis

Background

Transcatheter closure of atrial septal defect (ASD) and patent foramen ovale (PFO) is an established practice, and it requires monitoring and guidance. Both transoesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) can be used as guidance tools. However, the use of ICE and TEE in structural heart disease is controversial and the advantages and disadvantages of both for ASD and PFO closure need to be investigated. We did a systematic review and meta-analysis to compare the efficacy and safety of TEE and ICE for guiding transcatheter closure of ASD and PFO.

Methods

A systematic search of Embase, PubMed, Cochrane library, Web of Science was conducted from inception to May 2022. The outcomes of this study included average time for both fluoroscopy and the procedure, complete closure, length of stay at hospital and adverse events. This study was performed using mean difference (MD), relative risk (RR) and 95% confidence interval (CI).

Results

The meta-analysis was conducted with a total of 11 studies, involving 4,748 patients were included in meta-analysis, including 2,386 patients in the ICE group and 2,362 patients in the TEE group. The results of the meta-analysis showed that compared with TEE, ICE was shorter in time both fluoroscopy [MD: -3.72 (95%CI: -4.09 to -3.34) minutes, P < 0.00001] and the procedure [MD: -6.43 (95%CI: -7.65 to -5.21) minutes, P < 0.00001], shorter length of stay at hospital [MD = -0.95 (95% CI = -1.21 to -0.69) days, P < 0.00001], lower incidence of adverse events (RR = 0.72, 95%CI: 0.62 to 0.84, P < 0.0001), and the arrhythmia (RR = 0.50, 95% CI = 0.27 to 0.94, P = 0.03) and vascular complications (RR = 0.52, 95%CI = 0.29 to 0.92, P = 0.02) in ICE group were lower than those in TEE group. No significant difference in complete closure was found between ICE and TEE (RR = 1.00, 95% CI = 0.98 to 1.03, P = 0.74).

Conclusion

Under the premise of ensuring successful rate of complete closure, ICE can shorten time between fluoroscopy and procedure and length of stay at hospital, and there was no increase in adverse events. However, more high-quality studies are needed to confirm the benefits of using ICE in ASD and PFO closure.

Transesophageal echocardiography-guided implantation of totally implantable venous access devices via the internal jugular vein: retrospective analysis of 297 cases in pediatric patients

BACKGROUND

Accurately positioning totally implantable venous access device (TIVAD) catheters and reducing complications in pediatric patients are important and challenging. A number of studies have shown methods for locating the tip of the TIVAD catheter. We assessed the success and complications of TIVAD implantation guided by transesophageal echocardiography (TEE) via the internal jugular vein (IJV) for 294 patients in this retrospective study.

METHODS

From May 2019 to March 2021, 297 cases of TIVADs in our hospital were analyzed in this observational, non-randomized, single-center study. The position of the catheter tip under TEE and chest radiography and rates of periprocedural, early, and late complications were evaluated.

RESULTS

The implantation was successful in 242 (82.3%) cases which was in a proper position, and the results were consistent with those of postoperative chest radiography. A total of 72 complications were recorded. Of these, 1 case had a perioperative complication, 66 had early complications, and 5 had late complications after port implantation. The most common complications were local infection and catheter malposition, namely 10 (13.9%) cases of incision infection and 58 (80.6%) cases of catheter malposition. In total, 6 (8.3%) cases of port explantation were required.

CONCLUSION

Confirmation of proper TIVAD catheter positioning by TEE through an internal jugular approach in children was accurate and safe.

Zero-fluoroscopy approach for ablation of supraventricular tachycardia using the Ensite NavX system: a multicenter experience

BACKGROUND

Three-dimensional electroanatomic mapping systems have demonstrated a significant reduction in radiation exposure during radiofrequency catheter ablation procedures. We aimed to investigate the safety, feasibility and efficacy of a completely zero-fluoroscopy approach for catheter ablation of supraventricular tachycardia using the Ensite NavX navigation system compared with a conventional fluoroscopy approach.

METHODS

A multicenter prospective non-randomized registry study was performed in seven centers from January 2013 to February 2018. Consecutive patients referred for catheter ablation of supraventricular tachycardia were assigned either to a completely zero-fluoroscopic approach (ZF) or conventional fluoroscopy approach (CF) according to the operator's preference. Patients with atrial tachycardia were excluded.

RESULTS

Totally, 1020 patients were enrolled in ZF group; 2040 patients ablated by CF approach were selected for controls. There was no significant difference between the zero-fluoroscopy group and conventional fluoroscopy group as to procedure time (60.3 ± 20.3 vs. 59.7 ± 22.6 min, P = 0.90), immediate success rate of procedure (98.8% vs. 99.2%, P = 0.22), arrhythmia recurrence (0.4% vs. 0.5%, P = 0.85), total success rate of procedure (98.4% vs. 98.8%, P = 0.39) or complications (1.1% vs. 1.5%, P = 0.41). Compared with the conventional fluoroscopy approach, the zero-fluoroscopy approach provided similar outcomes without compromising the safety or efficacy of the procedure.

CONCLUSION

The completely zero-fluoroscopy approach demonstrated safety and efficacy comparable to a conventional fluoroscopy approach for catheter ablation of supraventricular tachycardia, and mitigated radiation exposure to both patients and operators.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03042078; first registered February 3, 2017; retrospectively registered.

Intracardiac Echocardiography for Structural Heart and Electrophysiological Interventions

PURPOSE OF REVIEW

With an increasing number of interventional procedures performed for structural heart disease and cardiac arrhythmias each year, echocardiographic guidance is necessary for safe and efficient results. The purpose of this review article is to overview the principles of intracardiac echocardiography (ICE) and describes the peri-interventional role of ICE in a variety of structural heart disease and electrophysiological interventions.

RECENT FINDINGS

Both transthoracic (TTE) and transesophageal echocardiography have limitations. ICE provides the advantage of imaging from within the heart, providing shorter image distances and higher resolution. ICE may be performed without sedation and avoids esophageal intubation as with transesophageal echocardiography (TEE). Limitations of ICE include the need for additional venous access with possibility of vascular complications, potentially higher costs, and a learning curve for new operators. Data supports the use of ICE in guiding device closure of interatrial shunts, transseptal puncture, and electrophysiologic procedures. This paper reviews the more recent reports that ICE may be used for primary guidance or as a supplement to TEE in patients undergoing left atrial appendage (LAA) closure, interatrial shunt closure, transaortic valve implantation (TAVI), percutaneous mitral valve repair (PMVR), paravalvular leak (PVL) closure, aortic interventions, transcatheter pulmonary valve replacement (tPVR), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) closure. ICE imaging technology will continue to expand and help improve structural heart and electrophysiology interventions.

Intra-cardiac echocardiography-guided stent implantation into stenosed superior vena cava in a patient with a history of contrast anaphylaxis

A 37-year-old patient, who suffered from a repeated superior vena cava (SVC) syndrome, was scheduled for stent implantation into SVC, but suffered from contrast anaphylaxis. To monitor the procedure, we used intra-cardiac echocardiography and successfully implanted a stent. Placing an intra-cardiac echocardiographic catheter in the main pulmonary artery and facing towards the right, we could readily visualize stenosis in the SVC and inflation of the stent. Also looking up from right atrium, we noted proximal obstruction of the stent and confirmed the relief of obstruction after additional balloon dilation. This report leads to new application of intra-cardiac echocardiography for intervention of structural and vascular diseases other than inter-atrial septum.

Comprehensive understanding of atrial septal defects by imaging studies for successful transcatheter closure

Transcatheter closure of atrial septal defects has become a popular procedure. The availability of a preprocedural imaging study is crucial for a safe and successful closure. Both the anatomy and morphology of the defect should be precisely evaluated before the procedure. Three-dimensional (3D) echocardiography and cardiac computed tomography are helpful for understanding the morphology of a defect, which is important because different defect morphologies could variously impact the results. During the procedure, real-time 3D echocardiography can be used to guide an accurate closure. The safety and efficiency of transcatheter closures of atrial septal defects could be improved through the use of detailed imaging studies.