The Use of Intracardiac Echocardiography and Other Intracardiac Imaging Tools to Guide Noncoronary Cardiac InterventionsIntracardiac Imaging ToolsCharacteristics of imaging systemsICEIntracardiac endoscopyElectroanatomic mapping systems and image integrationOther emerging invasive imaging techniquesUse of Imaging to Guide Selected Cardiac InterventionsImaging to guide transseptal catheterizationImaging during catheter ablation proceduresRole of ICE during cardiac interventions for structural heart diseaseImaging protocol for ASD and PFO device closureImaging protocol for pulmonary valvuloplasty and per-cutaneous pulmonary valve implantationImaging protocol for mitral valvuloplastyImaging during percutaneous LAA occlusionFuture of Invasive Imaging to Guide Noncoronary Cardiac InterventionsREFERENCESAPPENDIXSTATE-OF-THE-ART PAPERSThe Use of Intracardiac Echocardiographyand Other Intracardiac Imaging Tools toGuide Noncoronary Cardiac InterventionsSusan S. Kim, MD,* Ziyad M. Hijazi, MD,† Roberto M. Lang, MD,* Bradley P. Knight, MD*Chicago, IllinoisThe limitations of standard fluoroscopy have led to the development of improved imaging techniques to guidenoncoronary cardiac interventions. Imaging tools that are used in the interventional laboratory can be catego-rized as invasive and noninvasive. Noninvasive cardiac imaging tools include ultrasound, computed tomography,and magnetic resonance imaging. These modalities can generate high-resolution images of the heart and areincreasingly being used to guide cardiac interventions. Despite these advances, there remains a strong role forinvasive imaging tools in the interventional laboratories. Such invasive imaging tools include transesophagealechocardiography, intracardiac echocardiography, intracardiac endoscopy, and electroanatomic mapping sys-tems. Despite the risks inherent to the invasive nature of these tools, these modalities can provide excellentreal-time, detailed images that can be invaluable in guiding certain cardiac interventions. This review will pro-pose the features of an ideal intracardiac imaging tool, summarize the intracardiac imaging tools that are cur-rently available or under development to guide noncoronary cardiac interventional procedures, and suggest op-portunities for improvement. One opportunity in this field is to couple imaging systems directly with theinterventional devices themselves. The use of intracardiac imaging to guide select cardiac procedures includingtransseptal catheterization, catheter ablation procedures for arrhythmias, and percutaneous placement of car-diac valves and closure devices will also be discussed. Most of this review will be devoted to intracardiac echo-cardiography, which currently has the broadest number of applications. (J Am Coll Cardiol 2009;53:2117–28)© 2009 by the American College of Cardiology FoundationThe development of new percutaneous interventions forpatients with arrhythmias and structural heart disease isfueling an increasing demand for improved intracardiacimaging techniques to guide cardiac interventions.Historically, fluoroscopy has been the mainstay of imag-ing to guide cardiac procedures. However, there are severallimitations to the use of fluoroscopy: radiation exposure tothe patient and the physician, poor resolution of soft tissuestructures, and problems associated with the use of iodinatedcontrast agents. Because of these limitations, other imagingtechniques have been developed to guide cardiac procedures.Imaging tools in the interventional laboratory can be catego-rized as invasive and noninvasive. Noninvasive imaging toolsinclude ultrasound, computed tomography (CT), and mag-netic resonance imaging (MRI). These modalities can generatehigh-resolution images of the heart, and in the past have beenused effectively during the planning stages of an intervention.These imaging systems are now being brought directly to theinterventional laboratories. Surface echocardiography can beused to guide endomyocardial biopsies, systems that canacquire 3-dimensional (3D) CT images in the interventionallaboratory are under development, and real-time MRI can beused to guide peripheral vascular interventions and electro-physiology procedures (1).Invasive imaging tools in the interventional laboratory in-clude transesophageal echocardiography (TEE), intracardiacechocardiography (ICE), intracardiac endoscopy, and electro-anatomic mapping systems. Despite the additional risks inher-ent to the invasive nature of these tools, they can provideexcellent real-time, detailed images that are often invaluable inguiding cardiac interventions. This review will summarizeinvasive, intracardiac imaging tools that are currently availableor under development to guide noncoronary cardiac interven-tional procedures. Most of this review will be devoted to ICE,which currently has the broadest number of applications.Intracardiac Imaging ToolsCharacteristics of imaging systems. There are numerousfeatures that characterize the ideal intracardiac imaging tool;From the *Division of Cardiology, Department of Internal Medicine, University ofChicago, Chicago, Illinois; and the †Rush Center for Congenital and StructuralHeart Disease, Rush University, Chicago, Illinois. Dr. Lang receives equipment partsfrom and is on the Speakers’ Bureau of Philips. Dr. Knight is on the Speakers’ Bureaufor Biosense Webster related to the use of intracardiac echocardiography.Manuscript received September 12, 2008; revised manuscript received January 6,2009, accepted January 19, 2009.Journal of the American College of Cardiology Vol. 53, No. 23, 2009© 2009 by the American College of Cardiology Foundation ISSN 0735-1097/09/$36.00Published by Elsevier Inc. doi:10.1016/j.jacc.2009.01.071these features are summarized inTable 1. Each of the currentlyavailable intracardiac imagingtechnologies possesses some, butnot all, of these features. Ofcourse, the relative importance ofeach feature depends on the typeof procedure being performed.An ideal intracardiac imagingsystem would provide real-time,3D images of the inside of theheart displayed in a way thatwould be useful to the interven-tionalist to increase success andminimize risk. That systemwould ideally provide high-resolution images, account forcardiac motion, and allow theinterventionalist to easily acquirethe images and minimize relianceon a second operator. The imag-ing technology should be capableof providing both near- and far-field views: a near-field view
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