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Intra-cardiac Intra-cardiac EchocardiographyEchocardiography

August, 2007August, 2007

Xin Yang, MDXin Yang, MD

DefinitionDefinition

Defined as imaging from within the cardiac Defined as imaging from within the cardiac chambers and the major blood vessels.chambers and the major blood vessels.

It differs from intravascular ultrasonographic It differs from intravascular ultrasonographic imaging that refers to ultrasonographic imaging that refers to ultrasonographic navigation and visualization in small blood navigation and visualization in small blood vessels (usually coronary arteries). vessels (usually coronary arteries).

HistoryHistory

In the 1960s and 1970s, the use of ultrasound-In the 1960s and 1970s, the use of ultrasound-tipped catheters marked the advent of tipped catheters marked the advent of intracardiac ultrasonography.intracardiac ultrasonography.

The introduction of the intracoronary ultrasound-The introduction of the intracoronary ultrasound-tipped catheter in the 1980s made clinical tipped catheter in the 1980s made clinical intracardiac ultrasonography feasible. intracardiac ultrasonography feasible.

This initial use of intracardiac ultrasound in This initial use of intracardiac ultrasound in human beings was limited to imaging of a single human beings was limited to imaging of a single piezoelectric crystal on the tip of a 6F or 10F piezoelectric crystal on the tip of a 6F or 10F catheter. catheter.

InstrumentationInstrumentation

9F, 9-MHz, rotating element mechanical 9F, 9-MHz, rotating element mechanical catheter (Boston Scientific)catheter (Boston Scientific)– 360-degree 2-dimensional imaging on a 360-degree 2-dimensional imaging on a

transverse plane perpendicular to the transverse plane perpendicular to the transducer;transducer;

– radial field of view of approximately 5 cm in radial field of view of approximately 5 cm in depth producing high-resolution near-field depth producing high-resolution near-field images in cross section; images in cross section;

– limitations: it must be guided by a wire, and it limitations: it must be guided by a wire, and it lacks Doppler capabilities. lacks Doppler capabilities.


Steerable and deflectable ICE 8F and 10F Steerable and deflectable ICE 8F and 10F diagnostic ultrasound catheter (Siemens)diagnostic ultrasound catheter (Siemens)– 64-element vector phased-array transducer 64-element vector phased-array transducer

(5.5-10 MHz) with full Doppler capabilities (5.5-10 MHz) with full Doppler capabilities including color Doppler, tissue Doppler, and including color Doppler, tissue Doppler, and spectral Doppler;spectral Doppler;

– better depth penetration up to 12 cm for the better depth penetration up to 12 cm for the 10F catheter and 16 cm for the 8F catheter;10F catheter and 16 cm for the 8F catheter;

– Biplane fluoroscopy is recommended to safely Biplane fluoroscopy is recommended to safely advance the catheter to the desired position advance the catheter to the desired position without a guidewire without a guidewire

TechniqueTechnique

The catheter is interfaced to a standard The catheter is interfaced to a standard ultrasound platform.ultrasound platform.It is introduced by either a femoral or internal It is introduced by either a femoral or internal jugular approach. jugular approach. An 11F sheath is recommended to introduce the An 11F sheath is recommended to introduce the 10F catheter, which is 90 cm long. 10F catheter, which is 90 cm long. The 8F catheter can be introduced through an The 8F catheter can be introduced through an 8F sheath and has a 110-cm insertable length. 8F sheath and has a 110-cm insertable length.

TechniqueTechnique

The transducer can be positioned in three The transducer can be positioned in three locations:locations:– Inferior vena cavaInferior vena cava– Right atriumRight atrium– Right ventricleRight ventricle

The RA location is most useful for monitoring The RA location is most useful for monitoring invasive procedures as it visualizes the short invasive procedures as it visualizes the short axis aortic valve, tricuspid valve, mitral valve, axis aortic valve, tricuspid valve, mitral valve, RV, LV, interatrial septum, LA and left RV, LV, interatrial septum, LA and left pulmonary veins.pulmonary veins.

ICE at junction of inferior vena cava ICE at junction of inferior vena cava

and right atriumand right atrium

Comparison with other imaging Comparison with other imaging modalitiesmodalities

In comparison to fluoroscopy, ICE provides In comparison to fluoroscopy, ICE provides direct visualization of anatomical structures as direct visualization of anatomical structures as well as physiologic information.well as physiologic information.

In the event of procedural complications, such In the event of procedural complications, such as perforation and pericardial tamponade, those as perforation and pericardial tamponade, those can be immediately identified with ICE. can be immediately identified with ICE.

Pericardial effusion (PE) adjacent to free wall of left ventricle (LV)

Comparison with other imaging Comparison with other imaging modalitiesmodalities

When compared to TEE, several studies have When compared to TEE, several studies have demonstrated that the images obtained by ICE demonstrated that the images obtained by ICE were comparable. were comparable.

The near-field images obtained by ICE during The near-field images obtained by ICE during PFO and ASD closure were reported by one PFO and ASD closure were reported by one group to be superior to those obtained by TEE. group to be superior to those obtained by TEE.

Does not require prolonged sedation or general Does not require prolonged sedation or general anesthesia.anesthesia.

Other potential complications of TEE such as Other potential complications of TEE such as esophageal trauma are also avoided.esophageal trauma are also avoided.

Trans-septal punctureTrans-septal puncture

Transseptal puncture is often performed as part Transseptal puncture is often performed as part of various percutaneous procedures.of various percutaneous procedures.

The area of the fossa ovalis can be clearly The area of the fossa ovalis can be clearly visualized by using ICE. visualized by using ICE.

Orient the image so that the long axis of the IAS Orient the image so that the long axis of the IAS is perpendicular to the ultrasound beam.is perpendicular to the ultrasound beam.

Opposition of the needle against the IAS, with Opposition of the needle against the IAS, with resultant tenting of the septum, should be resultant tenting of the septum, should be visualized before puncture is attempted. visualized before puncture is attempted.

Trans-septal puncture Trans-septal puncture

Percutaneous PFO closurePercutaneous PFO closure

Direct visualization of the IAS by ICE can Direct visualization of the IAS by ICE can accurately define the morphology of the septum accurately define the morphology of the septum and help to exclude morphologic variations such and help to exclude morphologic variations such as a long PFO tunnel, convex IAS, and as a long PFO tunnel, convex IAS, and hypertrophic superior limbus, as well as the hypertrophic superior limbus, as well as the presence of other potential interatrial presence of other potential interatrial communications.communications.

During deployment of the closure device, ICE can During deployment of the closure device, ICE can be used to ensure that the IAS is completely be used to ensure that the IAS is completely between the left and right arms of the device, and between the left and right arms of the device, and that no residual shunt is present. that no residual shunt is present.

Percutaneous PFO closurePercutaneous PFO closure

Percutaneous ASD closure Percutaneous ASD closure

The size of the ASD can be determined using The size of the ASD can be determined using ICE.ICE.

ICE can also be used to inspect the septum ICE can also be used to inspect the septum before the closure, guide crossing the septum, before the closure, guide crossing the septum, ensure optimal position of the device, and ensure optimal position of the device, and exclude residual shunt and possible exclude residual shunt and possible complications. complications.

Percutaneous ASD closurePercutaneous ASD closure

Percutaneous balloon valvuloplasty Percutaneous balloon valvuloplasty

ICE can be used to guide proper positioning of ICE can be used to guide proper positioning of the balloon apparatus within the leaflets. the balloon apparatus within the leaflets.

It can also be used to measure the gradients It can also be used to measure the gradients across the valve as a measure of success, to across the valve as a measure of success, to grade the degree of insufficiency across the grade the degree of insufficiency across the valve to determine when to stop balloon valve to determine when to stop balloon inflations, and to exclude potential inflations, and to exclude potential complications.complications.

Percutaneous balloon valvuloplastyPercutaneous balloon valvuloplasty

Cardiac biopsy Cardiac biopsy

Cardiac tumors can be well visualized using ICE, Cardiac tumors can be well visualized using ICE, allowing for accurate tissue sampling.allowing for accurate tissue sampling.

In addition, potential complications can be In addition, potential complications can be identified immediately.identified immediately.

Radiofrequency Ablation of A FibRadiofrequency Ablation of A Fib

ICE guides trans-septal puncture.ICE guides trans-septal puncture.It also delineates abnormal anatomy.It also delineates abnormal anatomy.It has been demonstrated that both catheter It has been demonstrated that both catheter position and stability can be evaluated more position and stability can be evaluated more accurately by ICE when compared with accurately by ICE when compared with traditional methods.traditional methods.It also allows sizing and positioning of PV It also allows sizing and positioning of PV mapping catheters, measurement of PV ostial mapping catheters, measurement of PV ostial diameters, and continuous monitoring of PV diameters, and continuous monitoring of PV Doppler flow velocities. Doppler flow velocities.


Other complications related to ablation, such as Other complications related to ablation, such as pericardial effusion, perforation of the aorta, and pericardial effusion, perforation of the aorta, and thrombus formation, can be recognized early thrombus formation, can be recognized early and prevented by use of ICE. and prevented by use of ICE.

An additional potential complication of ablation in An additional potential complication of ablation in the LA is the development of a fistula between the LA is the development of a fistula between the LA and the esophagus which can also be the LA and the esophagus which can also be detected by ICE.detected by ICE.

Catheter Ablation of Atrial Flutter Catheter Ablation of Atrial Flutter

The anatomic thickness of the RA isthmus, the The anatomic thickness of the RA isthmus, the diameter of the RA, and thickness of the RA free diameter of the RA, and thickness of the RA free wall can all be measured by using ICE. wall can all be measured by using ICE. These measurements are critical for These measurements are critical for constructions of complete bidirectional block by constructions of complete bidirectional block by radiofrequency energy in the isthmus between radiofrequency energy in the isthmus between the tricuspid annulus and inferior vena cava. the tricuspid annulus and inferior vena cava.

Placement of a Pacing Catheter in Placement of a Pacing Catheter in the Coronary Sinus the Coronary Sinus

ICE can be used during this procedure for ICE can be used during this procedure for visualization of the coronary sinus anatomy. visualization of the coronary sinus anatomy.

This has the potential of facilitating coronary This has the potential of facilitating coronary sinus lead placement, while reducing sinus lead placement, while reducing fluoroscopy time and rate of possible fluoroscopy time and rate of possible complications. complications.

Placement of a Pacing Catheter in Placement of a Pacing Catheter in the Coronary Sinusthe Coronary Sinus

LimitationsLimitations

The echo probe is single use only and therefore The echo probe is single use only and therefore considered an expensive addition to a considered an expensive addition to a procedure.procedure.Another limitation is the size of the original 10F Another limitation is the size of the original 10F catheter, which limits its use in small adults and catheter, which limits its use in small adults and children. children. Furthermore, a monoplane imaging catheter Furthermore, a monoplane imaging catheter does not provide a wide field of view in multiple does not provide a wide field of view in multiple planes, and therefore requiring manipulation of planes, and therefore requiring manipulation of the catheter to obtain additional views. the catheter to obtain additional views.

Future Advances in ICE Future Advances in ICE Technology Technology

Newer imaging modalities, including Doppler Newer imaging modalities, including Doppler tissue imaging and velocity vector imaging, are tissue imaging and velocity vector imaging, are now being investigated for use in combination now being investigated for use in combination with ICE.with ICE.Another future area of development is combining Another future area of development is combining the ICE catheter with an EP mapping catheter. the ICE catheter with an EP mapping catheter. Finally, efforts are being applied to the Finally, efforts are being applied to the development of ICE catheters with the ability to development of ICE catheters with the ability to generate 3-dimensional volumes that could be generate 3-dimensional volumes that could be reconstructed for improved visualization of reconstructed for improved visualization of intracardiac structures. intracardiac structures.

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