Journal of the American College of Cardiology 2009 by the American College of Cardiology Foundation Published by Elsevier Inc Vol 53 No 23 2009 ISSN 0735 1097 09 36 00 doi 10 1016 j jacc 2009 01 071 STATE OF THE ART PAPERS The Use of Intracardiac Echocardiography and Other Intracardiac Imaging Tools to Guide Noncoronary Cardiac Interventions Susan S Kim MD Ziyad M Hijazi MD Roberto M Lang MD Bradley P Knight MD Chicago Illinois The limitations of standard fluoroscopy have led to the development of improved imaging techniques to guide noncoronary cardiac interventions Imaging tools that are used in the interventional laboratory can be categorized 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 are increasingly being used to guide cardiac interventions Despite these advances there remains a strong role for invasive imaging tools in the interventional laboratories Such invasive imaging tools include transesophageal echocardiography intracardiac echocardiography intracardiac endoscopy and electroanatomic mapping systems Despite the risks inherent to the invasive nature of these tools these modalities can provide excellent real time detailed images that can be invaluable in guiding certain cardiac interventions This review will propose the features of an ideal intracardiac imaging tool summarize the intracardiac imaging tools that are currently available or under development to guide noncoronary cardiac interventional procedures and suggest opportunities for improvement One opportunity in this field is to couple imaging systems directly with the interventional devices themselves The use of intracardiac imaging to guide select cardiac procedures including transseptal catheterization catheter ablation procedures for arrhythmias and percutaneous placement of cardiac valves and closure devices will also be discussed Most of this review will be devoted to intracardiac echocardiography which currently has the broadest number of applications J Am Coll Cardiol 2009 53 2117 28 2009 by the American College of Cardiology Foundation The development of new percutaneous interventions for patients with arrhythmias and structural heart disease is fueling an increasing demand for improved intracardiac imaging techniques to guide cardiac interventions Historically fluoroscopy has been the mainstay of imaging to guide cardiac procedures However there are several limitations to the use of fluoroscopy radiation exposure to the patient and the physician poor resolution of soft tissue structures and problems associated with the use of iodinated contrast agents Because of these limitations other imaging techniques have been developed to guide cardiac procedures Imaging tools in the interventional laboratory can be categorized as invasive and noninvasive Noninvasive imaging tools include ultrasound computed tomography CT and magnetic resonance imaging MRI These modalities can generate high resolution images of the heart and in the past have been From the Division of Cardiology Department of Internal Medicine University of Chicago Chicago Illinois and the Rush Center for Congenital and Structural Heart Disease Rush University Chicago Illinois Dr Lang receives equipment parts from and is on the Speakers Bureau of Philips Dr Knight is on the Speakers Bureau for Biosense Webster related to the use of intracardiac echocardiography Manuscript received September 12 2008 revised manuscript received January 6 2009 accepted January 19 2009 used effectively during the planning stages of an intervention These imaging systems are now being brought directly to the interventional laboratories Surface echocardiography can be used to guide endomyocardial biopsies systems that can acquire 3 dimensional 3D CT images in the interventional laboratory are under development and real time MRI can be used to guide peripheral vascular interventions and electrophysiology procedures 1 Invasive imaging tools in the interventional laboratory include transesophageal echocardiography TEE intracardiac echocardiography ICE intracardiac endoscopy and electroanatomic mapping systems Despite the additional risks inherent to the invasive nature of these tools they can provide excellent real time detailed images that are often invaluable in guiding cardiac interventions This review will summarize invasive intracardiac imaging tools that are currently available or under development to guide noncoronary cardiac interventional procedures Most of this review will be devoted to ICE which currently has the broadest number of applications Intracardiac Imaging Tools Characteristics of imaging systems There are numerous features that characterize the ideal intracardiac imaging tool Kim et al Intracardiac Imaging 2118 these features are summarized in Table 1 Each of the currently available intracardiac imaging AF atrial fibrillation technologies possesses some but ASD atrial septal defect not all of these features Of CS coronary sinus course the relative importance of CT computed each feature depends on the type tomography of procedure being performed FO fossa ovalis An ideal intracardiac imaging ICE intracardiac system would provide real time echocardiography 3D images of the inside of the LA left atrium atrial heart displayed in a way that LAA left atrial would be useful to the intervenappendage tionalist to increase success and MRI magnetic resonance minimize risk That system imaging would ideally provide highPFO patent foramen resolution images account for ovale cardiac motion and allow the PV pulmonary vein interventionalist to easily acquire RA right atrium atrial the images and minimize reliance RF radiofrequency on a second operator The imaging technology should be capable TEE transesophageal echocardiography of providing both near and farTSP transseptal puncture field views a near field view to provide sufficient detail of endoTTE transthoracic echocardiography cardial structures and the details 3D 3 dimensional of the intracardiac tools themselves and a far field view to provide perspective and orientation The imaging tool should not interfere with execution of the procedure and vice versa Use of the imaging tool should not require additional anesthesia Current intracardiac imaging tools are catheter based endocardial imaging systems that acquire and display images of the heart using a variety
View Full Document
Unlocking...