The Expanding Role of Echocardiography in Interventional Cardiology


of the site of transseptal puncture, facilitating access to specific sites within the left atrium.55


Subsequently, ICE is used to determine


pulmonary vein anatomy and physiology prior to ablation, to assist and confirm catheter positioning, to confirm catheter tip–tissue contact and stability and to monitor for potential procedural complications such as the formation of microbubbles (indicating excessive tissue heating), pericardial effusion, thrombus formation and pulmonary vein stenosis.56–58


in ablative procedures for other cardiac arrhythmias.59–61


ICE has also been used with success Recent ASE


guidance recommends the use of ICE for radiofrequency ablation for AF.6


Some centres successfully use TEE (including 3D) to guide transseptal puncture (see Figure 4) and, in addition to fluoroscopy and computed tomographical reconstruction, to guide pulmonary vein ablation procedures for patients with AF, although this practice is much less common.25


Miscellaneous Pericardiocentesis


TTE determines the size and location of the pericardial effusion, factors important in deciding the site of approach and needle trajectory. Once the catheter is positioned in the pericardial space, its location can be confirmed by the injection of agitated saline.


Echocardiography is often used to guide needle pericardiocentesis, in addition to fluoroscopy, and may reduce procedure-related complications.62


Myocardial Biopsy


Echocardiography guidance enables greater choice of site for the biopsy and may reduce the risk of complications.63


TEE has


also been used in selected cases to guide biopsy of intra-cardiac and intra-vascular masses.65


Alcohol Septal Ablation


Alcohol septal ablation is performed in selected patients with symptomatic hypertrophic obstructive cardiomyopathy refractory to medical therapy.66


This technique involves the injection of ethanol into a septal perforator branch of the left anterior descending artery, causing localised infarction in the hypertrophied proximal ventricular septum. Echocardiography guidance is typically performed during the procedure with TTE, although TEE or ICE may be used as an alternative in some centres, with favourable results.66–68


The left


ventricular outflow tract and mitral valve anatomy and function are evaluated and the correct target septal perforator identified using echocardiography contrast injection to ensure perfusion of the


1.


Harper RW, Mottram PM, McGaw DJ, Closure of secundum atrial septal defects with the Amplatzer septal occluder device: techniques and problems, Catheter Cardiovasc Interv, 2002;57(4):508–24.


2.


Butera G, Romagnoli E, Carminati M, et al., Treatment of isolated secundum atrial septal defects: impact of age and defect morphology in 1,013 consecutive patients, Am Heart J, 2008;156(4):706–12.


3.


Butera G, Carminati M, Chessa M, et al., Percutaneous versus surgical closure of secundum atrial septal defect: comparison of early results and complications, Am Heart J, 2006;151(1):228–34.


4.


Brochu MC, Baril JF, Dore A, et al., Improvement in exercise capacity in asymptomatic and mildly symptomatic adults after atrial septal defect percutaneous closure, Circulation, 2002;106(14):1821–6.


5.


While myocardial biopsy is typically performed with fluoroscopy alone, some centres use adjunctive TTE or, in selected patients, even TEE or ICE.63,64


desired region of the septum prior to ethanol injection. The latter technique has been reported to affect interventional strategy in 15–20% of cases.69


results and monitoring for complications.


Left Atrial Appendage Device Occlusion Percutaneous left atrial appendage (LAA) occlusion devices are currently under development and undergoing evaluation in clinical trials. While preliminary data have shown LAA device occlusion to be safe and feasible, it is uncertain whether it will prevent thromboembolic stroke in patients with AF.70


The LAA occlusion


device is placed via a percutaneous transcatheter approach via a transseptal puncture to access the left atrium using fluoroscopic and TEE guidance. TEE is required to guide transseptal puncture, to size the ostium of the LAA to enable selection of the appropriate size ofocclusion device and to ensure optimal device placement and complete occlusion of the LAA. It also enables detection of complications. 3D TEE imaging enables excellent device visualisation with respect to the LAA.


Future Directions


It is likely that the exciting field of non-coronary cardiac intervention will continue to expand and evolve, necessitating advances in echocardiography technology to keep apace to support this development. Important advances will be seen in all the echocardiography modalities. Future developments that will further extend the role of ICE in the cardiac laboratory may include reduction in catheter size and improved catheter stability and handling, enhanced image quality and the development of realtime 3D imaging. Other potential advances include the integration of ICE into current electro-anatomical mapping systems and also coupling of ICE and ablative therapy into a single catheter.71


Recent development of a


neonatal TEE probe small and flexible enough to allow transnasal insertion in adults has a potential application in interventional cardiology. The transnasal approach, typically better tolerated by patients, may offer the distinct advantage of enabling some interventional procedures requiring TEE guidance to be performed without general anaesthesia. However, acceptable image quality and good patient tolerance with this application are yet to be demonstrated in scientific evaluations. It is likely that a single TTE transducer with integrated 2D and 3D capability will be available soon, and this will greatly aid workflow. Increases in processing power will lead to greater temporal and spatial resolution, further improving image quality. In addition, developments in software and workflow, taking into consideration the particular demands of procedural imaging, will also aid the interventional echocardiologist. n


Du ZD, Hijazi ZM, Kleinman CS, et al., Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial, J Am Coll Cardiol, 2002;39(11):1836–44.


6. 7. 8.


Silvestry FE, Kerber RE, Brook MM, et al., Echocardiography-guided interventions, J Am Soc Echocardiogr, 2009;22(3):213–31; quiz 316–217.


Cooke JC, Gelman JS, Harper RW, Echocardiologists’ role in the deployment of the Amplatzer atrial septal occluder device in adults, J Am Soc Echocardiogr, 2001;14(6):588––94.


Podnar T, Martanovic P, Gavora P, Masura J, Morphological variations of secundum-type atrial septal defects: feasibility for percutaneous closure using Amplatzer septal occluders, Catheter Cardiovasc Interv, 2001;53(3):386–91.


9.


Butera G, Chessa M, Bossone E, et al., Transcatheter closure of atrial septal defect under combined transesophageal and intracardiac echocardiography, Echocardiography, 2003;20(4):389–90.


10. Boccalandro F, Baptista E, Muench A, et al., Comparison of intracardiac echocardiography versus transesophageal echocardiography guidance for percutaneous transcatheter closure of atrial septal defect, Am J Cardiol, 2004;93(4):437–40.


11. Earing MG, Cabalka AK, Seward JB, et al., Intracardiac echocardiographic guidance during transcatheter device closure of atrial septal defect and patent foramen ovale, Mayo Clin Proc, 2004;79(1):24–34.


12. Hijazi Z, Wang Z, Cao Q, et al., Transcatheter closure of atrial septal defects and patent foramen ovale under intracardiac echocardiographic guidance: feasibility and


TTE or TEE also enables immediate evaluation of


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