technique - heart · a +2 sd ultrasound, the poor resolution outside of a-----small depth of field...

Heart 1996;76:442-448

TECHNIQUE

Percutaneous transvenous intracardiac ultrasoundimaging in dogs: a new approach to monitor leftventricular function

L Jiang, N J Weissman, J L Guerrero, J He, A E Weyman, R A Levine, M H Picard

The CardiacUltrasoundLaboratory,Massachusetts GeneralHospital, HarvardMedical School,Boston,Massachusetts, USAL JiangN J WeissmanJ L GuerreroJHeA E WeymanR A LevineM H PicardCorrespondence to:Dr M H Picard, CardiacUltrasound Laboratory,Vincent-Bumham 5,Massachusetts GeneralHospital, Boston, MA02114, USA.Accepted for publication23 May 1996

AbstractObjective-To evaluate the feasibility andability of percutaneous transvenousintracardiac echocardiography (ICE) toimage the left ventricle (LV) and monitorits function from the right ventricular(RV) cavity.Methods-A 10 MHz catheter wasadvanced into the RV from the jugularvein and positioned along the septum atthe LV papillary muscle level in five dogs.The catheter was manipulated until a sta-ble catheter position along the septum,which provided on-axis images of the LV,was obtained. Different states of LV sizeand systolic function (n = 80) were cre-ated with dobutamine or esmolol, both inthe presence and absence of coronarystenoses. LV stroke area (cm2) obtainedby ICE was measured at the mid-ventricu-lar level and compared with stroke vol-ume (cm3) obtained simultaneously with atransaortic flow probe. LV end diastolic,end systolic, and stroke areas obtained byICE were also compared with thoseobtained by short-axis epicardialechocardiography.Results-In 96% of the stages, short axisimages of the LV could be obtained andmeasured by ICE. LV end diastolic, endsystolic, and stroke areas measured byICE were not significantly different fromepicardial echocardiographic values.Stroke area correlated with stroke volumein each dog (mean correlation coefficient0 79 (SEE 0.19) cm2) (P < 0.001).Conclusions-Percutaneous intracardiacultrasound imaging allows monitoring ofLV function from the RV with an accu-racy comparable to a short-axis epicar-dial echocardiogram. The present devicecan be used in closed chest experimentalstudies. With the development of lowerfrequency devices, this technique may bevaluable for continuous monitoring of LVfunction in patients in the intensive careunit or operating room.

(Heart 1996;76:442-448)

Keywords: intracardiac echocardiography; left ventric-ular function; monitoring; systolic function

Catheter-based ultrasound transducers cannow be positioned directly into cardiac cham-bers to give a clear delineation of the endocar-dial borders and other cardiac structures. Thisapproach can give accurate measurements ofventricular volume'-' and valve orifice.4Initially, these intracardiac echocardiography(ICE) images were obtained with high fre-quency (20 MHz) intravascular ultrasoundcatheters with a limited depth of field becauseof poor penetration of the sound beam. Thisrequired the catheter to be very close to thestructure of interest. Thus to image and mea-sure left ventricular structure and function, thecatheter had to be placed within the left ven-tricular cavity. With the introduction of lowerfrequency (10 MHz) ICE transducers, theresolution of structures at greater depthsimproved, resulting in the potential of imagingthe left ventricle from outside the chamber.56The purpose of this study was to evaluate thefeasibility of percutaneous transvenous intra-cardiac ultrasound imaging of the left ventriclefrom a position within the right ventricle andto determine the ability of this approach tomonitor left ventricular systolic function invivo.

MethodsEXPERIMENTAL MODELFive mongrel dogs with a mean (SD) weightof 28-4 (7 4) kg (range 17-38 kg) wereanaesthetised with pentobarbitone sodium(10 mg/kg intravenously) and mechanicallyventilated. Supplemental doses were given asneeded during the subsequent procedures tomaintain an adequate level -of anaesthesia. Theconcentration of inspired oxygen and ventila-tion rate were adjusted to keep blood gaseswithin the physiological range. A midline tho-racotomy was performed, the pericardiumincised, and the heart suspended in a pericar-dial cradle. An ultrasound flow probe(Transonic Systems, Ithaca, NY) was posi-tioned on the ascending aorta for continuousmeasurement of stroke volume.

INTRACARDIAC ULTRASOUNDA commercially available 10 MHz transducermounted on a 10 F catheter (CardiovascularImaging Systems, Sunnyvale, CA) was usedfor all intracardiac imaging. The catheter has a

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Percutaneous transvenous intracardiac ultrasound imaging in dogs: a new approach to monitor left ventricularfunction

Figure 1 Examples of intracardiac echocardiographic cross sectional images of the LVfrom the RVin diastole (upper left), and in systole (upper right).The bottom panels display tracings of endocardial borders to measure area. Arrow indicates catheter. LV, left ventricle; RV, right ventricle; S, systole; D,diastole.

fixed transducer at its tip with a mirror rotat-ing at 1800 rpm to produce a tomographicimage. The image has an axial resolution of0 30 mm, lateral resolution of 0 37 mm, anddepth of penetration of about 6 cm. The ICEcatheter was advanced through a 10 F intro-ducer sheath in the right internal jugular vein

Figure 2 Example of epicardial echocardiographic short axis image of the LV, with anICUS catheter (arrow) positioned along the interventricular septum. LV, left ventricle.

into the right ventricle and positioned alongthe interventricular septum. The position ofthe catheter was manipulated to obtain crosssectional images at the mid left ventricle inwhich both papillary muscles were imagedsymmetrically (fig 1). Once an optimalcatheter position was obtained, there was nofurther manipulation of the ICE catheter forthe duration of the experiment. Intracardiacechocardiographic images were continuouslyrecorded on 0 5 inch videotape.

EPICARDIAL ECHOCARDIOGRAPHYEpicardial echocardiographic imaging of theopen-chest preparation was performed toidentify the occurrence of wall motion abnor-malities. This was performed with the aid of awater bath for acoustical coupling and trans-ducer standoff. Short axis images of the leftventricle at the papillary muscle level wererecorded using an Interspec Apogee CX200echocardiograph (Interspec ATL, Ambler,PA) operating at 3-5 MHz (fig 2). In order toconfirm the accuracy of ICE measurements ofventricular area, measurements of LV dias-tolic, systolic, and stroke area (defined below)obtained nearly simultaneously by epicardialechocardiography were performed for onedog.

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4Jiang, Weissman, Guerrero, He, Weyman, Levine, Picard

Figure 3 Correlationsbetween ICUS andepicardial echo in themeasurement ofLVdiastolic (top), systolic(middle), and stroke area(bottom) for one dog. Theline of identity is shown.

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occluder the severity of the stenosis could bemodified and this was quantified by the degreeto which the hyperaemic response wasblunted. Degrees of stenosis were selectedwhich blunted coronary flow reserve withoutsignificantly decreasing baseline coronary

A flow. The dobutamine infusion in the settingof the coronary stenoses led to varying degreesof ischaemia and wall motion abnormality. Byusing different combinations of these threeinterventions, a total of 83 different haemody-namic states were created in five dogs. Duringeach stage, intracardiac cross sectional

Diastolic area echocardiographic images were recordedj j |simultaneously with the recording of stroke8 10 volume from the transaortic flow probe.

I2in) This experiment conformed to the guidingDrinci1les of the American Phvsiolooical

8 B ,,' Association and was approved by the subcom-mittee on research animal care at theMassachusetts General Hospital.

6 y O.83x + 0.1r =0.95SEE =0.36 , DATA ANALYSIS

Cross sectional intracardiac and epicardialecho images of the left ventricle were reviewed

4 - off-line in a random order independent ofA, A t ..knowledge of stroke volume, coronary stenosis

A , "E,,..status, dobutamine dose, or esmolol dose. The2 presence or absence of regional wall motion,,A ..abnormalities were independently noted for,a'A ..the epicardial and intracardiac images by an

Systolic area experienced echocardiographer (U). Because0 2 46I8 earlier studies showed a linear relation0 2 4 6 872 between stroke volume and area,78 these two

indices were calculated and compared. End5 -C, diastolic images were defined as those with theC ," largest LV cross sectional area and end systolic

images were defined as those with the smallest4 - y = 0.94x + 0.2 , LV cross sectional area. The endocardial bor-

r=0.93 A, ders of the mid-papillary level end diastolicSEE = 0-24 A, , and end systolic images for each stage were

3 - ,,\' manually traced (fig 1). LV stroke area (cm2)'t//Awas calculated as the difference between dias-

/4A, tolic and systolic areas.2

STATISTICAL ANALYSISIn each animal, LV stroke area measured by

,/' ICE was compared with LV stroke volumeStroke area (from the transaortic flow probe) by linear

o 'g regression analysis. Linear regression analysiso 1 2 3 4 5 was used to compare LV stroke area calculated

Epicardial 2D area (cm2 from ICE with LV stroke area measured byepicardial echo in one animal. The mean dif-ference between pairs of measurements was

RIMENTAL PROTOCOL calculated according to the method describedest the imaging capabilities of the right by Bland and Altman.9 Interobserver variabil-icular intravascular ultrasound catheter ity was expressed as the coefficient of varia-iage left ventricles of different sizes and tion, where the standard deviation of thees and with different degrees of systolic differences between 36 ICE area measure-tion, a variety of manoeuvres were per- ments (18 end diastolic and 18 systolic areas)ed to alter the haemodynamic state and made by two investigators (LJ, JH) wasventricular wall motion. Contractility divided by the mean value measured. To testaugmented and preload reduced with the intraobserver variability, the 36 ICE areatamine (5 to 40,g/kg/min). Esmolol measurements were repeated by the sameug/kg/min) was administered to reduce observer (LJ) after a two week interval.

global contractility and increase heart size.Varying degrees of coronary stenoses were cre-ated in the proximal left anterior descendingartery by a pneumatic occluder (Biomedicalproducts, Silver Springs, MD). With this

ResultsThe entire LV endocardial circumferencethroughout the cardiac cycle could be success-

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Diastolic areaA

3 - Mean difference = 0.33 (0-48) cm2

+ 2 SDIz.-

the experiment, providing real-time monitor-ing ofLV wall motion. Wall motion abnormal-ities (n = 26) were detected by ICE in allstages when they were present by epicardialechocardiography.

A A A LV AREAS: ICE VERSUS EPICARDIALAAI A ECHOCARDIOGRAPHYAAAAA A End diastolic, end systolic, and stroke area

---------------------------------A------- measurements by the ICE and epicardial-2 SD ultrasound correlated well (fig 3). The mean

differences between left ventricular area mea-surements by the two techniques were: enddiastolic area 033 (0-48) cm2, end systolicarea 0 35 (0 42) cm2, and stroke area -0-01

II |I (0 24) cm2 (fig4). Therewasno statistical dif-2 3 4 5 6 7 8 ference between the LV area measured by ICE

Epicardial echo (cm2) and epicardial echocardiographic techniques.

Systolic areaB

- Mean difference = 0.35 (0-42) cm2

+2SD_-----------------_------_ --__ --__-------

It A

- - - -2 SD

ICE STROKE AREA VERSUS FLOW PROBE STROKEVOLUMEThe relations between stroke area (ICE) andstroke volume (flow probe) for each dog areshown in fig 5. A linear relation was presentwith r values ranging from 0-72 to 087 (meanr = 0-82 (0 06) cm3; mean standard error =047 (016) cm2).

REPRODUCIBILITY OF ICE MEASUREMENTSInterobserver variability for ICE area measure-ments was 5'5% and the intraobserver vari-ability was 4-6%.

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Epicardial 2D area (Figure 4 Bland-Altman analysis ofLVdiastolic area, sj

intracardiac and epicardial echocardiogram. ICE, intracaepicardial.

fully imaged from thall five dogs in 80 c

stage was inadequateation and in two simages was not goccomplete endocardiatransvenous ICE irquality to allow meain 80 stages. OnceICE catheter remain

Discussion5 6 7 8 The miniaturisation of ultrasound transducers,c2[cm ) sparked the development of both catheter

based intravascular and intracardiac ultra-sound imaging. These high resolution, realtime images have been applied for the accurateevaluation of vascular structure and func-tion.'O11 However, with the standard high fre-quency transducers used for intravascular

A + 2 SD ultrasound, the poor resolution outside of a------------------------- small depth of field has limited their wide-A

spread application to intracardiac ultrasound.At A Thus, monitoring of LV function would

------------------------- require the catheter to be positioned inside the-2 SD LV in close proximity to all walls.' This neces-

sity for direct introduction into the LV makesthe device impractical for monitoring LV func-tion in most clinical settings. With the devel-opment of lower frequency transducers,

4 5 6 resolution of structures at greater depths has(cm2) been demonstrated.5 6 Our study adds to this

observation by demonstrating that intracardiacystolic area, and stroke area for ultrasound imaging of the LV obtained with ardiac echocardiography; Epi,

10 MHz transducer by percutaneous intro-duction of the catheter into the RV, providesadequate visualisation and measurement of

Le right ventricular ICE in the LV cavity in this canine model.Af 83 stages. One systolic Reproducible, serial LV cross sectional area! because of cavity obliter- measurements could be obtained by this ICE;tages the quality of the imaging approach and were found to be similarAd enough to discern the to those obtained by epicardial echocardiogra-al borders. Otherwise, the phy. Furthermore, quantitative assessment ofmages were of sufficient left ventricular systolic function was possiblesurement of mid-LV area with these cross sectional images.optimally positioned, the In this study a single cross sectional arealed in position throughout change (stroke area) was measured and found

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to be linearly related to LV volume change(stroke volume). This relation has previouslybeen noted by transthoracic and trans-oesophageal echocardiography with correla-tions and errors in a similar range.78 Thesestudies suggest that visualisation and measure-ment of the LV at this level can provide an

estimate of overall LV function. Although thelong axis dimension must be measured whenabsolute ventricular volume is examined, pre-vious studies of ventricular dynamic geometryhave demonstrated that LV ejection is accom-plished primarily by inward motion along theshort axis of the ventricle and that shorteningin the long axis plane contributes to a lesser

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Figure S Plots showing correlations and regression linesbetween simultaneously measured ICUS-stroke area andstroke volume (flow probe) in each dog. Triangles, stageswith normal wall motion; circles, squares with abnormalwall motion.

degree in both normal and diseased ventri-cles.'2-'9 Our results accord with previous stud-ies and show that LV cross sectional areachange assessed by an ICE catheter in the RVcan be related to LV stroke volume.

In the present study, alterations in regionalwall motion were obtained by partially occlud-ing the left anterior descending artery andincreasing myocardial oxygen demand withdobutamine. Even in these ischaemic states,the linear relation between stroke area andstroke volume remained significant. In all ofthe dogs that we studied, ischaemia in theLAD territory resulted in a wall motion abnor-mality within the cross section image. If wallmotion abnormalities were restricted toregions outside this imaging plane (such as theinferior base or the apex of the LV), then mon-itoring only the mid ventricular level couldlead to an overestimation ofLV function and adecreased sensitivity to detect ischaemia.

Although a significant relation betweenstroke area and stroke volume was noted foreach animal, there was significant variability inthis relation from subject to subject. This vari-ability may reflect the wide range of heart sizesthat were studied (weights of the dogs rangedfrom 17 to 38 kg). Other investigators, using

Dog 18 r-

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transthoracic and transoesophageal echocar-diography, also observed a similar degree ofsubject to subject variability in this rela-tion.7 819 Thus although relative changes in LVfunction can be assessed within an individualsubject, these values cannot be converted to anabsolute stroke volume nor can direct compar-isons between different individuals be made.The technique nevertheless can be used to ful-fil its intended purpose: namely, monitoring ofchanges in ventricular function within a givenindividual.

Before the technique is applied clinically,several limitations must be considered. Theaccuracy of intracardiac ultrasound imagingwill be influenced by the ultrasound trans-ducer and the catheter placement. The 10MHz transducer we used in this study has areported penetration of about 6 cm. In ourexperimental model, the endocardial bordersof the LV were usually within 5 cm of the ICEcatheter and thus it visualised them with mini-mal distortion. This degree of penetration isprobably adequate for imaging the LV fromthe RV in small hearts such as those of infants,small children, and experimental preparations.A lower frequency transducer which providesgreater beam penetration will be required forapplication in the adult human heart.

Catheter position and stability within theRV will influence the ability to obtain a trueshort axis image of the LV suitable for moni-toring systolic function. Earlier studies showedthat catheters positioned with a 30 degreedeviation from the long axis of a circular vesselresult in imaging planes which yield ellipticalrather than circular cross sections of the vesselwith up to a 20% overestimation of lumenarea.2021 In our study, using jugular venousaccess, we could always stabilise the catheterin an orientation parallel to the long axis of theLV to obtain representative cross sectionalimages of the LV. An ultrasound catheter witha steerable tip would further improve the easeof obtaining accurate short axis images of theLV.22 In addition, the catheter remained in aconstant stable position with limited need formanipulation. This may be due, in part, to ananchoring effect of the heavily trabeculatedright side of the septum. Both the optimalpositioning and stability of the ICE catheterwere possible with an internal jugularapproach. Unfortunately, the current 10French catheter size is impractical for routineclinical application.The present device allows adequate imaging

and measurement of left ventricular functionin experimental preparations. With modifica-tions to the current equipment, potential clini-cal applications include monitoring of LVfunction in patients in the intensive care unitor operating room and for improved assess-ment of myocardial contrast. With the integra-tion of automatic border detection and thistechnique, continuous on-line monitoring ofLV systolic function and pressure-area rela-tions should be obtained.2324

Intracardiac ultrasound imaging of the LVobtained by percutaneous introduction of thecatheter into the RV provides adequate images

of the LV cavity in this canine model.Detection of regional wall motion abnormali-ties are possible when they occur within theimaging plane. Measurements of the cross sec-tional area of the LV by this ICE approachcorrelate well with stroke volume, providingquantitative information which can be usedduring serial examinations to assess changes inLV systolic function. With the development ofsmaller catheters with lower frequency trans-ducers to allow a greater penetration and withautomated border detection this techniquemay be a valuable clinical method for continu-ous monitoring of LV function.We thank Dr Bernard J Gersh for his helpful comments.

1 Fisher JP, Wolfberg CA, Mikan JS, Kieman FJ, Fram DB,McKay RG, et al. Intracardiac ultrasound determinationof LV volumes: in vitro and in vivo validation. JAm CollCardiol 1994;24:247-53.

2 Chen C, Guerrero JL, Vazquez de Prada JA, Padial LR,Schwammenthal E, Chen MH, et al. Intracardiac ultra-sound measurement of volume and ejection fraction innormal, infarcted, and aneurysmal left ventricles usinga 10-MHz ultrasound catheter. Circulation 1994;90:1481-91.

3 Vazquez de Prada JA, Padial LR, Chen MH, Chen MH,Jiang L, He J, et al. Assessment of right ventricular vol-ume using a new 10 MHz intracardiac ultrasoundcatheter: an in vitro validation study (abstract).Circulation 1993;88:I-160.

4 Jiang L, de Prada JV, He J, Padial LR, Fallon JT, King ME,et al. Quantitative assessment of stenotic aortic valve areausing intravascular echocardiography: in vitro validation(abstract). Circulation 1993;88:I-103.

5 Schwartz SL, Pandian NG, Hsu TL, Weintraub A, CaoQL. Intracardiac echocardiographic imaging of cardiacabnormalities, ischemic myocardial dysfunction, andmyocardial perfusion: studies with a 10 MHz ultrasoundcatheter. JAm Soc Echocardiogr 1993;6:345-55.

6 Schwartz SL, Pandian NG, Crowley R, Kumar R.Intracardiac echocardiography without fluoroscopy:potential of a balloon-tipped, flow-directed ultrasoundcatheter. Am HeartJ 1995;129:598-603.

7 Gorcsan J III, Gasior TA, Mandarino WA, Deneault LG,Hattler BG, Pinsky MR. On-line estimation of changes inleft ventricular stroke volume by transesophageal echo-cardiographic automated border detection in patientsundergoing coronary artery bypass grafting. Am J Cardiol1993;72:721-7.

8 Gorscan J III, Lazar JM, Romand J, Pinsky MR. On-lineestimation of stroke volume by means of echocardio-graphic automated border detection in the canine leftventricle. Am HeartJ7 1993;125:1316-23.

9 Bland JM, Altman DG. Statistical methods for assessingagreement between two methods of clinical measure-ment. Lancet 1986;i:307-10.

10 Tobis JM, Mallery J, Mahon D, Lehmann K, Zalesky P,Griffith J, et al. Intravascular ultrasound imaging ofhuman coronary arteries in vivo. Circulation 1991;83:913-26.

11 Fitzgerald PJ, Ports TA, Yock PG. Contribution of local-ized calcium deposits to dissection after angioplasty: anobservational study using intravascular ultrasound.Circulation 1992;86:64-70.

12 Rushmer RF, Thal N. The mechanics of ventricular con-traction: a cinefluorographic study. Circulation 1951;4:219-28.

13 Hawthorne E. Dynamic geometry of the left ventricle. Am JCardiol 1966;18:566-73.

14 Bishop VS, Horwitz LD. Left ventricular transverse inter-nal diameter: value in studying left ventricular function.Am HeartrJ 1970;80:507-14.

15 Leshin SJ, Mullins CB, Templeton GH, Mitchell JH.Dimensional analysis of ventricular function: effects ofanesthetics and thoracotomy. Am J7 Physiol 1972;222:540-55.

16 Rankin JS, McHale PA, Arentzen CE, Ling D, GreenfieldJC, Anderson RW. The three-dimensional dynamicgeometry of the left ventricle in the concious dog. CircRes 1976;39:304-13.

17 Lewis RP, Sandler H. Relationship between changes in leftventricular dimensions and the ejection fraction in man.Circulation 1971;44:548-57.

18 Walley KR, Grover RM, Raff GL, Benge W, Hannaford B,Glantz SA. Left ventricular dynamic geometry in theintact and open chest dog. Circ Res 1982;50:573-89.

19 Appleyard RF, Glantz SA. Two-dimensions describe leftventricular volume change during hemodynamic tran-sients. Am J7 Physiol 1990;258:H277-84.

20 Chae JS, Brisken AF, Maurer G, Siegel R. Geometric accu-racy of intravascular ultrasound imaging. J Am SocEchocardiogr 1993;6: 158-65.

21 Mario CD, Madretsma S, Linker D. The angle of inci-dence of ultrasonic beam: a critical factor for image qual-ity in intravascular ultrasonography. Am Heart J 1993;125:442-8.

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22 Tardif JC, Cao QL, Schwartz S, Vannan M, Pandian N.Intracardiac echocardiography with a steerable lineararray device permits high resolution imaging of cardiacchambers and valves with an extended depth of field andthus left heart imaging from the right side. J7 Am CoilCardiol 1994;1A:484A.

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SHORT CASES IN CARDIOLOGY

Haemorrhagic bullae in a patient with lichensclerosus et atrophicus treated with streptokinase

Heather M Dunn, Raymond A Fulton

Altnagelvin AreaHospital,Londonderry,Northern IrelandH M DunnRA FultonCorrespondence to:Dr H M Dunn, CardiacUnit, Altnagelvin AreaHospital, Glenshane Road,Londonderry BT47 1SB,Northern Ireland.Accepted for publication30 April 1996

A 62 year old woman with no previous historyof cardiac disease was admitted with a 2 h 30min history of chest pain. The electrocardio-graph showed ST changes in the inferolateralleads in keeping with a diagnosis of acutemyocardial infarction. She had no recognisedcontra-indications to thrombolytic therapy.

Haemorrhagic builae in a patient with lichen sclerosus et atrophicus treated with streptokinase

She was treated with soluble aspirin (150 mg)and streptokinase (1 5 million units) followedby heparin infusion (1000 units per hour).On the day after admission the patient com-

plained of pain and swelling on the flexor sur-faces of both wrists and in the periumbilicalregion. On examination there were atrophicplaques on the wrists, umbilical region, andvulva. Haemorrhage had occurred into theseplaques with the formation of haemorrhagicbullae (figure). This significantly limitedmovement at the wrists. On questioning thepatient gave a long history of white patchesaffecting the flexor surfaces of the wrists, thevulva, and periumbilical region. A diagnosis oflichen sclerosus et atrophicus had been madeand the patient had previously noted minorbullae related to trauma. The heparin wasstopped and the patient was treated with simpleanalgesia.

Lichen sclerosus is an uncommon disease ofunknown aetiology presenting as small porce-lain-like shiny round macules which usuallyaggregate into atrophic plaques. Occasionallybullae, telangiectasia, and purpura may spon-taneously occur in the plaques. Treatmentwith streptokinase in this case caused the sud-den formation of painful haemorrhagic bullaein the pre-existing lichen sclerosus.

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