Intracardiac echocardiography in congenital heart disease

Intracardiac echocardiography probe via oesophageal to guide percutaneous left atrial appendage closure procedure: a case series

Background

Left atrial appendage closure (LAAC) can be an alternative to oral anticoagulant therapy in patients with non-valvular atrial fibrillation, characterized by high risk of stroke (CHA2D2VASC ≥ two for men and CHA2D2VA2SC ≥ three for women) and high risk of bleeding (HASBLED = 3).

Case summary

We describe three case reports in which an intracardiac echocardiography probe was used via the oesophageal route as an alternative to traditional transoesophageal echocardiography (TEE) or ICE methods to guide LAAC. Guiding the procedure via conventional TEE, even if feasible, could be difficult in these patients due to different causes: one patient was affected by Brugada syndrome while the other two patients reported oropharyngeal abnormalities. For these reasons, we performed an alternative use of the ICE probe to guide the entire LAAC procedure.

Discussion

Currently, LAAC is performed using intracardiac or transoesophageal echocardiography. This alternative use of ICE probe via oesophageal (ICE-TEE) is reported in previous studies that describe the feasibility of this technique both in excluding the presence of thrombus in left atrial appendage before cardioversion and in guiding percutaneous foramen ovale closure. Therefore, the ICE probe has been used as an intraoperative transoesophageal echocardiographic probe to repair congenital heart disease in infants or children with oropharyngeal abnormalities.This case series reports the first use of ICE-TEE to guide the entire LAAC procedure, guaranteeing the visualization of all echocardiographic views needed to perform it. The present case series highlights the potential of ICE-TEE to safely perform both pre-procedural and intraoperative evaluations in LAAC procedure.

Intracardiac vs. transesophageal echocardiography for guiding transcatheter closure of interatrial communications: a systematic review and meta-analysis

Background

Transcatheter closure of atrial septal defect (ASD) and patent foramen ovale (PFO) is an established practice, and it requires monitoring and guidance. Both transoesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) can be used as guidance tools. However, the use of ICE and TEE in structural heart disease is controversial and the advantages and disadvantages of both for ASD and PFO closure need to be investigated. We did a systematic review and meta-analysis to compare the efficacy and safety of TEE and ICE for guiding transcatheter closure of ASD and PFO.

Methods

A systematic search of Embase, PubMed, Cochrane library, Web of Science was conducted from inception to May 2022. The outcomes of this study included average time for both fluoroscopy and the procedure, complete closure, length of stay at hospital and adverse events. This study was performed using mean difference (MD), relative risk (RR) and 95% confidence interval (CI).

Results

The meta-analysis was conducted with a total of 11 studies, involving 4,748 patients were included in meta-analysis, including 2,386 patients in the ICE group and 2,362 patients in the TEE group. The results of the meta-analysis showed that compared with TEE, ICE was shorter in time both fluoroscopy [MD: -3.72 (95%CI: -4.09 to -3.34) minutes, P < 0.00001] and the procedure [MD: -6.43 (95%CI: -7.65 to -5.21) minutes, P < 0.00001], shorter length of stay at hospital [MD = -0.95 (95% CI = -1.21 to -0.69) days, P < 0.00001], lower incidence of adverse events (RR = 0.72, 95%CI: 0.62 to 0.84, P < 0.0001), and the arrhythmia (RR = 0.50, 95% CI = 0.27 to 0.94, P = 0.03) and vascular complications (RR = 0.52, 95%CI = 0.29 to 0.92, P = 0.02) in ICE group were lower than those in TEE group. No significant difference in complete closure was found between ICE and TEE (RR = 1.00, 95% CI = 0.98 to 1.03, P = 0.74).

Conclusion

Under the premise of ensuring successful rate of complete closure, ICE can shorten time between fluoroscopy and procedure and length of stay at hospital, and there was no increase in adverse events. However, more high-quality studies are needed to confirm the benefits of using ICE in ASD and PFO closure.

Intracardiac echocardiography Chinese expert consensus

In recent years, percutaneous catheter interventions have continuously evolved, becoming an essential strategy for interventional diagnosis and treatment of many structural heart diseases and arrhythmias. Along with the increasing complexity of cardiac interventions comes ever more complex demands for intraoperative imaging. Intracardiac echocardiography (ICE) is well-suited for these requirements with real-time imaging, real-time monitoring for intraoperative complications, and a well-tolerated procedure. As a result, ICE is increasingly used many types of cardiac interventions. Given the lack of relevant guidelines at home and abroad and to promote and standardize the clinical applications of ICE, the members of this panel extensively evaluated relevant research findings, and they developed this consensus document after discussions and correlation with front-line clinical work experience, aiming to provide guidance for clinicians and to further improve interventional cardiovascular diagnosis and treatment procedures.

Intracardiac Echocardiography to Guide Mapping and Ablation of Arrhythmias in Patients with Congenital Heart Disease

Catheter ablation of arrhythmias in congenital heart disease can be a challenging undertaking with often complicated anatomic considerations. Understanding this anatomy and the prior surgical repairs is key to procedural planning and a successful outcome. Intracardiac echocardiography (ICE) adds complimentary real-time visualization of anatomy and catheter positioning along with other imaging modalities. In addition, ICE can visualize suture lines, baffles, and conduits from repaired congenital heart disease and forms a useful part of the toolkit required to deal with these complex arrhythmias.

The role of echocardiography in the management of adult patients with congenital heart disease following operative treatment

Treatment of congenital heart diseases has significantly advanced over the last few decades. Due to the continuously increasing survival rate, there are more and more adult patients with congenital heart diseases and these patients present at the adult cardiologist from the paediatric cardiology care. The aim of the present review is to demonstrate the role of echocardiography in some significant congenital heart diseases.

Intracardiac Echocardiography for Structural Heart and Electrophysiological Interventions

PURPOSE OF REVIEW

With an increasing number of interventional procedures performed for structural heart disease and cardiac arrhythmias each year, echocardiographic guidance is necessary for safe and efficient results. The purpose of this review article is to overview the principles of intracardiac echocardiography (ICE) and describes the peri-interventional role of ICE in a variety of structural heart disease and electrophysiological interventions.

RECENT FINDINGS

Both transthoracic (TTE) and transesophageal echocardiography have limitations. ICE provides the advantage of imaging from within the heart, providing shorter image distances and higher resolution. ICE may be performed without sedation and avoids esophageal intubation as with transesophageal echocardiography (TEE). Limitations of ICE include the need for additional venous access with possibility of vascular complications, potentially higher costs, and a learning curve for new operators. Data supports the use of ICE in guiding device closure of interatrial shunts, transseptal puncture, and electrophysiologic procedures. This paper reviews the more recent reports that ICE may be used for primary guidance or as a supplement to TEE in patients undergoing left atrial appendage (LAA) closure, interatrial shunt closure, transaortic valve implantation (TAVI), percutaneous mitral valve repair (PMVR), paravalvular leak (PVL) closure, aortic interventions, transcatheter pulmonary valve replacement (tPVR), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) closure. ICE imaging technology will continue to expand and help improve structural heart and electrophysiology interventions.